COVID-19 Q&A: Dr. Elizabeth Reichert on Depression, Anxiety, Risk for Suicide
It’s no surprise that a global pandemic would exacerbate feelings of stress and fear. What is needed is understanding of how to manage those feelings, how to recognize symptoms of clinical depression and anxiety, as well as when, how, and where to get help. Dr. Elizabeth Reichert provides this expertise as clinical assistant professor of Stanford Psychiatry and Behavioral Sciences, and Director of the Pediatric Anxiety and Traumatic Stress Clinic.
Are we seeing an increase in depression and anxiety since the beginning of the pandemic? New cases because of the virus, and/or recurrences of previously managed conditions?
Dr. Reichert: Prior to COVID-19, rates of anxiety and depression in the United States were high and among the most common mental health conditions. In 2017, nearly one in five adults in the U.S. reported having symptoms that met criteria for a diagnosis in the previous year and anxiety was the most common mental health disorder. Please see the NIMH website for additional prevalence rates.
The current pandemic has brought many significant changes to how we live each day; our routines have been disrupted, jobs lost, financial stressors incurred, schools and businesses closed, and widespread social distancing efforts to prevent spread and “flatten the curve.” In a matter of days our lives changed dramatically, contributing to a pervasive sense of uncertainty, loss, and isolation for many.
These factors combined increase risk for anxiety and depression. Unsurprisingly, we have seen a rise in levels of stress, anxiety, and depression. For individuals with prior mental health conditions, symptoms are being exacerbated, even among those with relatively stable conditions. A recent survey completed by the American Psychological Association provides additional insights into the increased stress levels during COVID-19.
How would you describe situational level of anxiety or stress over our current COVID-19 conditions, (considering the fear of contagion, uncertainty about the future, and social distancing) versus anxiety or depression that is clinical and perhaps debilitating, requiring treatment?
Dr. Reichert: During this unprecedented time of uncertainty and fear, and the steps we have had to take to reduce the risk of the virus spreading, such as shelter in place and social distancing, it is natural to feel increasingly worried, sad, afraid, and isolated. When we are faced with a crisis like this that threatens our health, safety, and life, experiencing fear and anxiety can be unavoidable, as they are the mind and body’s natural response to danger and uncertainty. Similarly, feelings of sadness, loneliness and grief are natural responses to loss and isolation.
Furthermore, many are experiencing changes in appetite, sleep, relationship difficulties, challenges with concentration and focus, irritability, frustration, boredom, and so on. There is a wide range of reactions that we expect to see in response to such an abnormal situation. The bottom line, it is ok not to “feel ok” or completely yourself right now.
While experiencing some of these feelings is to be expected, for some, treatment may be helpful. Sustained impact on one’s sleep, changes in appetite that lead to significant weight changes, and little/low motivation to engage in basic daily tasks are a good indication that stress is getting in the way of general functioning. Difficulties with concentration that impact one’s ability to meet obligations, withdrawn behavior such as difficulty getting out of bed or not responding to calls from family/friends, and ongoing daily worry that feels unmanageable or overwhelming, are also suggestive of difficulties that may require additional support. We recommend reaching out to your healthcare provider.
Individuals with pre-existing mental health conditions are especially vulnerable right now. We recommend monitoring symptoms, keeping in touch with your mental health provider or general practitioner and seeking help if you experience new or worsening symptoms.
Suicidal thoughts, urges to harm yourself, pervasive hopelessness or helplessness, and engaging in risky behaviors such as increased use of alcohol and substances that are impacting your life, are also indications that additional help is needed.
Here is additional information pertaining to common signs of depression, anxiety, panic attacks and risk for suicide.
Are there specific elements of the pandemic which trigger depression or anxiety? Are there different triggers for each?
Dr. Reichert: The elements that come to mind first are: uncertainty, loss, and social distancing. In one way or another, we are dealing with substantial social and community disruption, financial problems, and interruption to many aspects of our lives.
When we are anxious, we seek a need for safety, predictability, and control. And the riskier we believe something is the more anxious we feel about it. Everyone has different tolerance for risk. In a time that feels so out of control, with daily doses of uncertainty, our ability to tolerate or “sit with” the uncertainty and manage our anxious response can be compromised, increasing risk for an anxiety disorder.
Isolation, or limits in social contact, can have negative side effects that may impact mental health. As humans we thrive on connection with others; we are social beings. Loneliness is one of the biggest factors we are trying to combat right now. It can feel hopeless and can lead to increased feelings of isolation, which are risk factors for depression and anxiety.
We have all been impacted by loss in one way or another over the last few months. For some, it has been the devastating loss of a loved one or loss of health. For others, loss has been characterized by job loss and/or loss of income, loss of traditional rituals of grieving for a loved one and celebrations such as graduations or weddings, or even loss of the predictable routines of daily life. As we embark on the summer months, many are beginning to grieve the loss of summer plans – vacation plans, camps for kids, and more. Loss and subsequent grief, can bring sadness, fear, anger, and many other emotions that can feel very confusing.
What about for those who are already managing depression/anxiety. What are some elements of this pandemic that may trigger a recurrence?
Dr. Reichert: Similar to the previous question, uncertainty, loss, and social distancing are hard on everyone and especially those are already struggling with symptoms of depression and/or anxiety.
Some individuals who were already in treatment before the pandemic may be in a better position to cope, as one of the key goals of therapy for depression and anxiety is to build coping strategies (to manage worry, fear, and sadness). Treatment for anxiety, for instance, is not designed to make fear disappear. Instead, it cultivates ways to manage the fear and tolerate uncertainty. Being able to apply these skills to the current situation has been helpful for some. For others, the intensity of the current climate has contributed to an intensification, or resurgence, of symptoms inhibiting their ability to access previously learned skills.
What about the long-term aspect of this public health crisis that could make it particularly damaging for our psychological health? Can a situational bout of depression or anxiety, caused by the current pandemic, become a permanent challenge? And, is it possible for it to go away on its own when the stress or trauma has ended?
Dr. Reichert: I think it is fair to say that for some, we will see a sustained impact on mental health; whereas, for others, this will pass, and the current discomforts and stress will subside as the situation changes. It is likely that the mental health burden will continue to increase and those with previous mental health conditions will be at greater risk for longer term impact.
Specific to the impact of quarantine, a recent review by Brooks and colleagues (2020) found that “the psychological impact of quarantine is wide-ranging, substantial, and can be long lasting.” Posttraumatic stress symptoms, depression, confusion, and anger were among the reported negative psychological effects. Factors impacting the risk for mental health concerns included, longer durations of quarantine, frustration, boredom, inadequate supplies or information, fears of infection, financial loss and stigma.
More generally, research shows social isolation and loneliness are linked to poorer mental health (Leigh-Hunt et al., 2017). Job loss has also been found to be associated with increased depression, anxiety, distress and low self-esteem increasing risk for substance use and suicide (Paul & Moser, 2009). With the highest rates of unemployment since the Depression Era, it is fair to say that we are likely to see a sustained impact on mental health for many.
For those who are already managing depression/anxiety, what are keys to weathering COVID-19, and the related extenuating circumstances causing national and global stress? For those for whom depression/anxiety is a new experience, what should they know about managing it and expected outcomes?
Dr. Reichert: It is easy for us to get lost in worry about everything that is out of our control right now: how will the coronavirus impact me, my family, or those around me? What are the financial implications of this? What does the future hold? What will happen as states start re-opening? Or, what is to come as shelter-in-place orders are relaxed?
While these worries are completely understandable, they can become problematic if they are significantly impacting our daily life. Furthermore, engaging in behaviors to try and manage our worries, such as watching hours of news programming or repeatedly checking the news or washing one’s hands, may reduce our anxiety for the moment but impairs us from learning how to live with anxiety and tolerate some uncertainty. Regardless of whether we have struggled with anxiety or depression before, or these feelings are new to us, a guiding principle that can help us all cope effectively during this time is focusing on what we can control.
Keep routines as much as possible. Try to find activities on which you can anchor your day. Loss of our daily routine can make us feel more anxious and dysregulated. Having a schedule and things to look forward to can help contain anxiety. Impose structure similar to a normal work or school day, get dressed, eat breakfast and take regular breaks. Make sure to focus on consistent sleep-wake and meal times, as well as exercise and social engagement. Make a weekly schedule of tasks and try to keep weekday and weekend routines separate. Following a regular routine is important for everyone in the family.
Engage in self-care. Eat healthy, nutritious foods and drink plenty of water. Engage in daily hygiene practices. Exercise regularly; make efforts to continue (or increase) previous exercise commitments. Practice getting creative with ways to move your body – many gyms/studios are offering virtual classes or you can find free online activities via social media platforms. How we nourish our body and keep it moving can be extremely helpful in managing stress and regulating our mood.
Take breaks from listening to the news. The non-stop news coverage, email updates, and social media postings about COVID-19 can be exhausting and may take an emotional toll. Be mindful of your exposure. Limit to one hour or less a day. It is important to stay informed, however, if you are noticing an impact on your mood/stress, it may be time to limit.
Separate workspace from living space. If possible, create a workspace at home that is separate from everything else. This can help you stay organized and focused. Your workspace can be an office, a spare bedroom, a writing desk in the corner, the dining room table or any other space in the house. The goal is to have a designated workspace separate from your regular activities of daily living. Leaving this space when work is finished can help you physically and mentally transition from work to home life.
Stay connected. It is more important than ever to remain connected to others. FaceTime, Skype, phone calls and other social media platforms can be a great way to see loved ones and friends. Schedule a coffee break via FaceTime with a friend or colleague, turn phone calls into video calls, plan a “virtual happy hour”, or have Sunday family dinner together via FaceTime or Zoom. Get creative with ways to maintain face-to-face connections and be sure to make time to do so.
Ground yourself in the present moment. Take a moment to slow down and bring back a sense of mental and physical control by engaging your five senses: what do I see? What do I hear? What do I smell? What do I taste? What do I feel?
Be patient. With the recent “shelter in place” orders, many of us are having to juggle more responsibilities as the boundaries between work and life are more blurred than ever. Setting reasonable expectations as you make this transition are important. Be patient with yourself and your ability to manage. Take breaks when you can, reduce work requirements if/when possible, be open to shifting expectations and making adjustments with each new phase, and remember that tomorrow is always a new opportunity to try again.
Engage in activities that are in line with your values. Focus on actions that are meaningful and guided by your core values. Values might include respect, humor, kindness, patience, and courage. Dr. Russ Harris offers further guidance related to values-based actions and practical steps for responding to the current crisis.
A helpful guide for talking to youth about the current pandemic, and additional tools for self-care can be found here. See the resources below for additional guidance around ways to cope.
Are there any resources/links you’d like to recommend for either individuals suffering depression/anxiety, with questions about the condition, or for other health professionals?
Dr. Reichert: Below are some helpful links with resources for managing stress, anxiety and depression during this time. Additional links are provided for managing stressors related to parenting during a pandemic.
- The Anxiety and Depression Association of America (ADAA) resource list & free online group
- SAMSHA’s Tips for Social Distancing
- American Psychological Association’s (APA) COVID-19 resource page
- APA 7 research findings that can help cope with COVID-19
- National Child Traumatic Stress Network Guide for Taking Care of Yourself
- American Foundation for Suicide Prevention’s 5 Tips for Coping with Uncertainty
- Association for Cognitive and Behavioral Therapies Resource Page
Support for parents/families
- The Positive Parenting Webinar series is available here for parenting support during this time
- American Academy of Child and Adolescent Psychiatry (AACAP) Resource Page
- National Child Traumatic Stress Network’s Parent/Caregiver Guide to Coping
- Stanford’s Early Life Stress and Resilience Program
- Stanford Center for Youth Mental Health and Wellbeing (CYMHW)
- Child Mind Institute’s COVID-19 Resource Center