UCI Podcast: Did COVID-19 cause a mental health pandemic?

Upheavals in family life, precarious job situations and, of course, the prospect of getting sick and even dying. The COVID-19 pandemic has produced significant stressors that have disproportionately affected women and people of color. At the same time, all this stress has prompted predictions of rising anxiety and depression.

Has the COVID-19 pandemic also created a mental health crisis? And how can we reduce the pandemic’s unequal impacts?

From the University of California, Irvine, I’m Aaron Orlowski. And you’re listening to the UCI Podcast. Today, I’m speaking with Tim Bruckner, a professor of public health at UCI.

Professor Bruckner, thank you for joining me today on the UCI Podcast.

Thank you, Aaron. It’s a pleasure to be here.

So at the beginning of the pandemic, there were predictions about a follow-on mental health pandemic. And a lot of folks are still worried about this, but has it happened has predicted?

There were a lot of popular media reports as well as editorials from scientific journals such as the BMJ that predicted this mental health pandemic, or a second wave of COVID-19 that would occur worldwide. This presumed pandemic ranges from predictions of a doubling in suicide rates, which would be a pretty extreme event, to rises in emergency room visits for psychiatric care, to perhaps less severe, but still important, increases in symptoms that are related to anxiety and depression. But interestingly, this was a surprise to me and to many, most of these predictions did not actually materialize.

So what has happened, then, if these severe predictions didn’t materialize?

So if we start in the U.S., we looked at various rigorous studies, so these aren’t ones that I’ve conducted. But in Massachusetts, during the strict state-at-home period in the spring 2020, there was no change in suicides relative to expected. You had other studies coming out in Japan and Greece and Austria. They had either no change in suicides or actually a decline in suicides during the first six months after COVID-19. Then you had other accumulating evidence in high-income countries that led the BMJ to actually write an editorial in late 2020, saying that pretty much the weight of evidence suggests that suicides in high-income contexts either did not change or actually fell slightly during the initial stages of COVID-19.

And then some work that I did in California shows that psychiatric emergencies didn’t really go above their expected levels. I mean, you had an overall decline in people seeking care in the ER. So, but once you control for that, there wasn’t much change. So that was unexpected. For anxiety and depression, it’s a little bit more nuanced. You have certain studies in the U.S. that are well done that show an acute increase in anxiety and depression, especially in March and April 2020, so right when the first societal restrictions occurred. Then it looks like, overall, there is a kind of return to pre-COVID levels the longer you move away from March and April. So it seems that there was this short-term rise that doesn’t seem to have been sustained afterwards. And that some of the work that I’ve done, actually with a good student of mine, Abhery Das, also suggests that there was this acute jump and then a gradual decline back to normal levels a few months after the first restrictions.

Well this sounds like really good news that this psychiatric pandemic hasn’t materialized, but why was there the prediction that it would in the first place? Why did a lot of people think that that would happen?

There’s a lot of good reasons why we thought there would be this kind of population-wide psychiatric pandemic. First we had, during the SARS 2003 outbreak, some evidence of slight increases in suicide. Also, you had the medical community that was really concerned that if you reduce the amount of routine health care that’s available to individuals, those who have existing mental health conditions, they might worsen when they don’t get routine care. Then you have certain subgroups of the population that are thought to be very sensitive to big changes in social interaction. So in particular, you think of teenagers who are already at risk of social isolation. And so school closures could really exacerbate any feelings of loneliness and isolation.

So we know from a lot of literature that losing a job is very stressful and increases your risk of suicide, especially among men. And so with this widespread economic disruption, you could imagine those that are financially unstable or those that lose their jobs would be highly likely to have depression, anxiety and other serious mental health issues. So that’s the kind of scientific literature that would lead us to that prediction on a more personal level, people like security and predictability. And when you have all this uncertainty about the future, that COVID brings, because we didn’t know how long it would last, we didn’t know how long the societal restrictions and economic reductions in activity would occur, this feeling of uncertainty, and also with school closures, that could really negatively affect your outlook.

And you personally have done a fair bit of research on how certain types of shocks affect health and mental health, such as the Great Recession and 9/11. So what kind of effect do those shocks tend to have on mental health? And then how is the COVID-19 pandemic different from those?

I’ve looked at a variety of shocks and I first want to point out that the field of disaster research would really differentiate a 9/11 terrorist attack from a Great Recession. In general, when we think of violent events in which there’s witnessing of violence and threat to security, that’s a little different than losing a job. When we kind of separate those out, in brief, when we look at 9/11, there were really acute mental health responses, increased anxiety and depression, and in the longer-term increased PTSD. I should point out, though, that the majority of people surveyed after 9/11 did not experience these symptoms. Moving to the Great Recession, that was a little different. So we had broader psychological distress and self-rated health that worsened overall. That tended to concentrate among people that had reported losing a job or having difficulty paying their mortgage.

And then suicides also rose slightly, especially among working age men. But what was actually interesting too, though, with the Great Recession, is that sometimes you had these countervailing effects. So individuals who reported job loss and troubles with paying their mortgage reported much more alcohol consumption, for example. But overall alcohol consumption decreased during the recession because many people might’ve curbed their consumption — ones that weren’t maybe directly affected in terms of losing their job. Because even during a Great Recession, when unemployment peaks at 8 or 9 percent, again, that means 90 percent of people who want to work are working. And so their behaviors might be a little different than the people that are directly losing their jobs.

And COVID is, in terms of how it differs from those, we’re still trying to figure it out. This is the first pandemic we’ve had of this magnitude since the 1918 flu. So we still have a lot to learn. But in general, you know, we have some severe societal restrictions. We have uncertainty about the future. We have economic impacts in terms of job losses and unemployment and restrictions on economic economic activity. So it’s kind of a mix of a lot of things. And obviously you have healthcare workers who are directly experiencing a lot of sickness and death. And then I’d say the majority of us are probably more affected, if we don’t know somebody who was directly affected by COVID, we are more affected by the societal restrictions or the economic hit on our jobs and our finances. And so I think in terms of the financial aspect, we might imagine it being somewhat like the Great Recession, but a key difference is that we’ve done a lot of societal relief, in terms of Trump’s $2 million relief bill in March. So there was a quicker societal economic response to COVID than, say, the Great Recession, which might have helped cushion some of the adverse mental health consequences.

Well and one of the pieces of evidence that has taken a look at how mental health has been affected during the pandemic is actually a study that you co-authored looking at survey results from Danish people in Denmark, and it was published in the journal BMC Public Health. You and some co-authors analyzed the survey results taken before the initial pandemic response, after it and then several months later. Is that right?

Right. And I was really fortunate to work on this project. I had two great colleagues in Denmark. The study design was pretty strong in that these researchers had been interviewing participants before COVID hit. And so they could look at mental health before and after COVID among the same individuals. So from a study design perspective, it was pretty strong. So they interviewed these adults and asked them a variety of questions. And what we found is that immediately after the shutdown, which was pretty severe in Denmark, measures of depression and self-reported stress actually went down among adults. The key benefits for the mental health improvements after COVID were among parents who were living with children at home. So this was a big surprise. And I was especially surprised given that my spring 2020 wasn’t like that. Two young daughters at home. They were being schooled remotely, and that was a big switch. So I had to balance my work and my home parental duties. So this was a really big shock to me.

So do you think that if you conducted a similar study here in the U.S., do you think you would get similar results? Or were there really unique factors at play in Denmark that you think contributed to those results?

I highly doubt that we could replicate the Danish studies in the U.S. I mean, I’d love to see a rigorous analysis of it, but the benefit that the Danes had, I think that we don’t have in the U.S., is that they did not have as strong work demands right after COVID hit. So parents were able to pivot to spending much more time at home without competing demands. I don’t know if that would be the case in the U.S. At least for me, and maybe others, work expectations didn’t really go down, even though we were faced with this new stressor. But yes, I think a longitudinal study to especially focus on parents with young children at home in the United States is warranted. Based on my anecdotal evidence and looking at media reports, I think we would have a very different picture in the U.S. compared to Denmark.

One of the things that is striking about all of this is how much the societal response to the pandemic seems to be influencing the outcomes for mental health. We talked about the economic response cushioning people financially, so that they didn’t have to deal with quite so many stressors on their finances. And then the strength of the social safety net in a place like Denmark, where parents didn’t have to go through as many demanding choices about work versus parenting. The lack of that social safety net in the United States might be playing a role in our response to the pandemic. So how do you think that these types of policies — this social safety net or a lack thereof — has led to inequitable suffering during the pandemic?

I first want to point out that there are some other fundamental reasons that we think there was a strong socioeconomic patterning and racial-ethnic patterning of the COVID pandemic in the U.S. that doesn’t have to do with the social safety net. Okay. So there are other fundamental aspects of American society that deserve careful scrutiny and examination. That said, there are other aspects related to the social safety net that I agree with you might have exacerbated these disparities. And I think in particular, when we look at how the American social safety net ranks relative to other high-income countries, especially for childcare and subsidizing childcare for young parents, as well as unemployment insurance benefits, we rank really poorly internationally. And so I think with respect to job protections, as well as to subsidizing childcare and valuing childcare as a key input to society, really working on those two things could have led to more financial security among these groups that could potentially buffer them from some of these adverse kind of societal restrictions and COVID related health issues.

Well and I think we should just point out — so in the U.S., which subgroups have suffered more from the pandemic? More layoffs, more precarious jobs, more childcare duties?

Speaker 2 (15:00):

Right, so the first thing I’d like to say is in terms of who got sick from COVID, that was a clear socioeconomic and racial-ethnic patterning. So you had especially Black Americans, Hispanic populations, more affected by COVID in terms of the infections and mortality. You also had lower income individuals, much more affected than higher income individuals across the United States. Now that’s in terms of COVID infection. Really a large fraction of the job losses concentrated among women. And the gendered patterning of people being put out of work or stopping work to take care of their children, or to help them school at home — it is such a strong gender pattern. This is again, disproportionately affecting lower income families and those communities of color. And so when the question arises, you know, how do we get back to a pre-COVID in terms of re-employing these individuals? I think one of the components is to really seriously look at subsidizing childcare and really affecting, having a positive impact on lower income families and potentially single-parent families as well.

So women have been exiting the workforce, whether pushed to do so to care for children, or they’ve been laid off. So what are the long-term consequences of that? If women do not reenter the workforce in significant numbers?

This is something that, you know, we have to wait a little bit more to really get a sense of whether women are going to come back once these other protections are available. It really remains to be seen. This is an open question. But in general, the optimistic estimate is that it would take a few years to get back to pre-COVID levels in terms of workforce participation by women and regaining the wages and the level of income that they had before COVID. So this could take awhile. Hopefully there would be political will and policies that could ease this transition. And then in my ideal world, you would also have unemployment protections and other valves in place in terms of childcare support, in which should another shock happen again, you don’t have this same pattern repeat itself.

You’ve mentioned a couple of different policy options for how to reverse this unequal response or treatment during the pandemic. Are there any other solutions that you think we need to implement?

The question of inequality is a really important one. I would want to say the answer of how much you decide to care about inequality is a real social question and it involves values and judgment and public health can inform political decisions. But ultimately, how much society cares about redressing inequality is often left to politicians and to civic engagement and to your voting, and to how you decide to import those values onto a political process. From a public health perspective, we are seeing some interesting moves toward really formally making equity a key indicator for health improvements and economic decisions.

So I’ll give you an example for COVID. California, when they had their tiered system about when you could move into more economic activity as a function of different COVID benchmarks — they had this tiered system that was really tied to meeting certain county-level COVID epidemiologic figures. So they had a positivity rate that had to be below a certain threshold. They had a hospitalization rate that had to be below a certain threshold. But then they added this interesting equity measure that had to be met in order for you to move to a less restrictive economic tier. And that was looking at certain cities within your county — they couldn’t have over, I think, a three-fold higher prevalence of COVID than the best performing city in your county. And so for Orange County, Santa Ana really ranked highly in terms of its COVID prevalence. And so Santa Ana could not have had higher than a three- or four-fold prevalence of COVID, if Orange County wanted to move to a less restrictive tier. And so the fact that the state of California made explicit that public health and other energies needed to be devoted to Santa Ana in order for the entire county to thrive, to me indicates that they are valuing equity as a measure, and as a focus for a lot of public health activity in order for the economy to move forward.

And the political decision making on that front is essentially matching the reality because if Santa Ana isn’t doing well, then none of us in the rest of the county are doing well, either.

It makes it very explicit acknowledgement that we’re all in it together. And that there are aspects of the Orange County economy that rely on Santa Ana, whether or not we physically go into Santa Ana or not — that we have this social and economic connection to the entire county and beyond the county.

Professor Bruckner, thank you so much for joining me today on the UCI Podcast.

It’s my pleasure. And thank you for your time.