Hits: 1

Data

We use city-by-month data on suicide records from November 2016 to October 2020, covering all suicide deaths among a total of 126 million citizens in Japan. The data are derived from suicide statistics published by the Ministry of Health, Labour, and Welfare, and they include information such as the number of suicides by age, gender, employment status, site, and day of the week55,56. The dataset includes 76,626 (monthly average 1,596) suicides in 1,848 cities (N = 88,512) with the average monthly suicide rate at 12.8 per million population. Males account for 68.2% of total suicides and male adults (between 20 and 69 years of age) contribute to about half of this total (50.2%) (Supplementary Table 1). Using these data, we assess how suicide rates vary before and during the pandemic.

We also use other datasets to supplement our analysis, including the number of COVID-19 infections, weather conditions, and macroeconomic conditions (that is, bankruptcy, unemployment rates, consumption index, and diffusion index). Details for these data are available in Supplementary Note 1.

DID model

A central empirical challenge to estimating the effect of COVID-19 on suicide rates is to disentangle the effect of the pandemic from the long-term suicide trend and its seasonality. On average, the suicide rate has declined by 6.4% from 2017 to 2019 (Extended Data Fig. 2; if data are extended, it declined by about 25% from 2013 to 2019). In addition, before the pandemic, the average suicide rate in February was 5.1% higher than that in January. These data imply that study design based on the before–after comparison could be problematic; if it compares the suicide levels before and during the COVID-19 outbreak29, the estimates might capture the seasonal trend (particularly between January and February); alternatively, if it compares the suicide level relative to past years in the same season26,27,28,30, the estimate might be confounded by a long-term ascending or descending trend.

The suicide trend and its seasonality also have to be accounted for at a disaggregated level, because they vary widely across locations (Extended Data Fig. 2). For instance, most regions had a declining suicide trend (Extended Data Fig. 2b1,c1), although it increased in some regions (Extended Data Fig. 2d1). Relatedly, we observe that the suicide rate in summer is higher in some locations (Extended Data Fig. 2b2), whereas this pattern is reversed in others (Extended Data Fig. 2e2). If we eliminate such location-specific trends and seasonality (we regress suicide rate on city-by-month and city-by-year fixed effects, and eliminate those effects), suicide patterns seem to be different from the observed trends (Extended Data Fig. 2a3–e3). These make the point that the time-series analysis, which compares national suicide trends, could easily generate biased estimates25,26,27,28,29,30,31. Instead, accurate estimation requires a quasi-experimental research design and harmonised data, by defining reasonable location-specific control conditions (counterfactual without the pandemic).

By leveraging our disaggregated but comprehensive dataset, we adopt the DID estimation with high-dimensional fixed effects. Our model is designed to overcome the empirical challenges. First, the model compared the difference in suicide rates before (November 2019 to January 2020) and during the virus outbreaks (February to October 2020) with the difference in the corresponding period in the previous three years (November 2016 to October 2019). Because the model focuses on the relative difference before and during the sudden pandemic within a year, the overall suicide level across years (the long-term suicide trend) is cancelled out. Second, we include city-by-month fixed effect and city-by-year fixed effect. These rich sets of fixed effects allow us to isolate the pandemic effects from the location-specific suicide trend and seasonality.

In particular, we specify the following model:

$$Y_{iym} = alpha mathrm{Treat}_y times mathrm{Post}_m + mu _{im} + gamma _{iy} + varepsilon _{iym}$$

(1)

where Y denotes suicide rates in city i in month m in year y (a year includes 12 months from November to October), and α is the parameter of interest, which denotes the impacts of the COVID-19 pandemic on suicide rates. Postm is a binary variable that takes the value 1 if periods of observations corresponded to months between February (when the COVID-19 outbreak became salient and the national government launched the nationwide anti-contagion policies) and October. It takes a value of 0 if periods correspond to months from November to January, regarded as the ‘pre-treatment’ period prior to the COVID-19 pandemic. Treaty takes the value 1 if the year is 2020 (November 2019 to October 2020) and 0 otherwise (November 2016 to October 2019). In this model, suicide trends between February and October from 2016 to 2019 serve as a control condition (counterfactual), after accounting for the level across years, with the assumption that we encounter only common shocks between the control and the treatment periods (during the pandemic).

We include city-by-month fixed effect and city-by-year fixed effect, denoted by μim and γiy, respectively. City-by-month fixed effect flexibly controls for month-specific shocks in each city, such as seasonality in the suicide rate, monthly local events or climatic conditions57,58. City-by-year fixed effect controls for year-specific shocks in each city, such as macroeconomic trends, industrial or population structural changes, or suicide trends.

Suicide trends during the pandemic could vary across periods depending on the size of the ongoing outbreak, people’s responses and the government’s health interventions. Specifically, Japan faced two large COVID-19 outbreaks (Supplementary Note 2), and we might expect the suicide trend to vary in each wave. Unlike the time-series interrupted analysis, the DID desings enables us to estimate the time-varying effects flexibly (see Supplementary Note 5 and Supplementary Fig. 4 for details). Therefore, we estimate:

$$Y_{iym} = alpha _f times mathrm{Treat}_y times mathrm{First}_m + alpha _s times mathrm{Treat}_y times mathrm{Second}_m + mu _{im} + gamma _{iy} + varepsilon _{iym}$$

(2)

where Firstm denotes the dummy variable, which takes the value 1 during months corresponding to the first outbreak (February to June) and Secondm takes the value 1 during months corresponding to the second outbreak (July to October). Similarly, we estimate how the suicide trends differ during the SOE (April and May 2020) and school closure (March and April 2020).

Our outcome variable of interest, suicide rate, is left-skewed and non-negative. Specifically, 58.7% of the city-by-month suicide rate takes a value of zero during our study period. Therefore, we use a Poisson-pseudo-maximum-likelihood estimator to specify equations (1) and (2) (refs. 59,60). The adjusted model for Eq. (2) can be written as:

$$Y_{iym} = exp [alpha _f times mathrm{Treat}_y times mathrm{First}_m + alpha _s times mathrm{Treat}_y times mathrm{Second}_m + mu _{im} + gamma _{iy}] times varepsilon _{iym}.$$

(3)

We use the package ppmlhdfe to estimate the regression, with options ‘weight’, ‘absorb’ and ‘cluster’ in STATA v.16 to implement all the Poisson regression analyses59. We report the estimated coefficient in the form of IRRs. For this estimation, the necessary condition for the existence of the estimates is non-existence of the ‘separated’ observations60. Therefore, such observations are excluded from the analysis. Note that because more than 95% of the city-by-month suicide rates among children and adolescents are zero, we aggregated the data to the prefectural level for this specific cohort.

We cluster standard errors at the city level to allow arbitrary correlation over time within the same city. Additionally, all the regressions are weighted by population in 2018 so that cities with larger populations are given greater weights. Intuitively, these weights help to estimate the impact of the event on an average person instead of on an average city.

Event-study approach

The assumption for the DID estimator to be valid is that the pandemic period (February to October) in 2020 and the same periods in 2016–2019 would have parallel trends in suicide rates in the absence of the pandemic. If this assumption were not satisfied, the estimated parameter would be biased because the results could be driven by systematic differences between the treatment and control groups rather than the event of interest. To assess whether the parallel trends assumption would be reasonable, we adopt the event-study approach by fitting the following equation37,61:

$$Y_{iym} = {mathrm{exp}}left[ {mathop {sum }limits_{k = – 3,,k ne – 1}^8 alpha _k({mathrm{Treat}}_y times {mathrm{Month}}_{m,k}) + mu _{im} + gamma _{iy}} right] times varepsilon _{iym}$$

(4)

where Monthm is 1 if the month corresponds to k, where k = −1 is set to be a month before the pandemic period (January). Intuitively, this casts the difference in suicide rates between 2020 season and 2016–2019 season in each month relative to k = −1; we expect the treatment group and control group to have a similar suicide rate before the disease outbreak becomes salient (k < 0) and we expect them to diverge after the outbreak (k ≥ 0).

Heterogeneity

We estimate the heterogeneity effects across different gender, age, job status, and geography. For age and gender, we re-estimate equation (3) by using suicide rate across gender and age groups (children and adolescents aged less than 20 years, the working-age population aged 20–69 years, and older adults aged 70 year or more). For job status, we use suicide rate among the employed, retired, unemployed, self-employed, housewives, and students.

For heterogeneous analysis across geography, we re-estimate equation (3) using the subsamples. We use city-level base suicide rate (measured from November 2016 to January 2020), base income per capita (measured in 2018), and base share of urban population (measured in 2018) to classify the samples, in that, if the variable in a city is above its median, the corresponding city is classified as a high-suicide-rate, a high-income, or an urban city. Similarly, we use the prefectural level COVID-19 prevalence (measured by total confirmed cases per million population in October 2020), mobility restrictions (measured by change in Google Community Mobility at workplaces from January 2020 to after February 2020) and economic shocks (measured by the changes in unemployment between October–December 2019 and April–September 2020). We use prefectural level data for the sample classifications because the city-level data are not available. The details of these data are described in Supplementary Note 1.

Placebo test

We perform a placebo test37,62 to investigate whether impacts of the pandemic on suicide rates are driven by either common time trends or common shocks across different periods, using the following procedure. Using the data from November 2016 to October 2019, we randomly allocate treatment status to a year in the same period (February to June for the first outbreak, and July to October for the second outbreak) in each city and estimate the treatment effects analogously to equations (3) and (4). These equations can be written as:

$$Y_{iym} = exp [alpha _f^p times mathrm{Pl}_mathrm{Treat}_y times mathrm{First}_m + alpha _s^p times mathrm{Pl}_mathrm{Treat}_y times mathrm{Second}_m + mu _{im} + gamma _{iy}] times varepsilon _{iym}$$

(5)

$$Y_{iym} = exp left[ {mathop {sum }limits_{k = – 3,,k ne – 1}^8 alpha _k^pleft( {mathrm{Pl}}_{mathrm{Treat}}_y times {mathrm{Month}}_{m,k} right) + mu _{im} + gamma _{iy}} right] times varepsilon _{iym}$$

(6)

where Pl_Treaty is 1 if the treatment status is allocated in both the equations. Then, we compare the placebo results to the real estimates. We repeat these procedures 1,000 times. If there is an event causing higher suicide incidence in a specific region in a pre-pandemic period (for example, cities in Tokyo prefecture in 2019 have unusually high suicide rates), our placebo results would include the spike in the estimated parameters. These results might imply that our main estimate is not driven by the disease outbreak, but by a random shock (or time trend) in some cities. We expect the placebo results (denoted by (alpha _f^p), (alpha _s^p) and (alpha _k^p)) to not be statistically different from zero.

Back-of-the-envelope calculation

To estimate the increased or decreased deaths from suicide during the pandemic, we estimate the following equation:

$$begin{array}{lll}widehat {mathrm{Suicide}},{mathrm{change}}{i,mathrm{treat,post}} &=& left( {widehat {alpha _f} times mathrm{Treat}_y times mathrm{First}_m + widehat {alpha _s} times mathrm{Treat}_y times mathrm{Second}_m} right)\&& times mathrm{Base},mathrm{suicide}{i,mathrm{treat,pre}}end{array}$$

(7)

where (widehat {mathrm{Suicide}},{mathrm{change}}_{i,mathrm{treat,post}}) denotes the predicted change in number of suicides in city i in the treatment year (2020) during the pandemic period (after February). This is computed by estimated coefficients ((widehat {alpha _f}) and (widehat {alpha _s})) derived by specifying equation (3) for the period during the first outbreak (Treaty × Firstm, 5 months) and second outbreak (Treaty × Secondm, 4 months), and number of base suicide deaths (Base suicidei,treat,pre). We then sum the changes in number of suicides in each city to compute change on the national scale.

Reporting Summary

Further information on research design is available in the Nature Research Reporting Summary linked to this article.

Data

We use city-by-month data on suicide records from November 2016 to October 2020, covering all suicide deaths among a total of 126 million citizens in Japan. The data are derived from suicide statistics published by the Ministry of Health, Labour, and Welfare, and they include information such as the number of suicides by age, gender, employment status, site, and day of the week55,56. The dataset includes 76,626 (monthly average 1,596) suicides in 1,848 cities (N = 88,512) with the average monthly suicide rate at 12.8 per million population. Males account for 68.2% of total suicides and male adults (between 20 and 69 years of age) contribute to about half of this total (50.2%) (Supplementary Table 1). Using these data, we assess how suicide rates vary before and during the pandemic.

We also use other datasets to supplement our analysis, including the number of COVID-19 infections, weather conditions, and macroeconomic conditions (that is, bankruptcy, unemployment rates, consumption index, and diffusion index). Details for these data are available in Supplementary Note 1.

DID model

A central empirical challenge to estimating the effect of COVID-19 on suicide rates is to disentangle the effect of the pandemic from the long-term suicide trend and its seasonality. On average, the suicide rate has declined by 6.4% from 2017 to 2019 (Extended Data Fig. 2; if data are extended, it declined by about 25% from 2013 to 2019). In addition, before the pandemic, the average suicide rate in February was 5.1% higher than that in January. These data imply that study design based on the before–after comparison could be problematic; if it compares the suicide levels before and during the COVID-19 outbreak29, the estimates might capture the seasonal trend (particularly between January and February); alternatively, if it compares the suicide level relative to past years in the same season26,27,28,30, the estimate might be confounded by a long-term ascending or descending trend.

The suicide trend and its seasonality also have to be accounted for at a disaggregated level, because they vary widely across locations (Extended Data Fig. 2). For instance, most regions had a declining suicide trend (Extended Data Fig. 2b1,c1), although it increased in some regions (Extended Data Fig. 2d1). Relatedly, we observe that the suicide rate in summer is higher in some locations (Extended Data Fig. 2b2), whereas this pattern is reversed in others (Extended Data Fig. 2e2). If we eliminate such location-specific trends and seasonality (we regress suicide rate on city-by-month and city-by-year fixed effects, and eliminate those effects), suicide patterns seem to be different from the observed trends (Extended Data Fig. 2a3–e3). These make the point that the time-series analysis, which compares national suicide trends, could easily generate biased estimates25,26,27,28,29,30,31. Instead, accurate estimation requires a quasi-experimental research design and harmonised data, by defining reasonable location-specific control conditions (counterfactual without the pandemic).

By leveraging our disaggregated but comprehensive dataset, we adopt the DID estimation with high-dimensional fixed effects. Our model is designed to overcome the empirical challenges. First, the model compared the difference in suicide rates before (November 2019 to January 2020) and during the virus outbreaks (February to October 2020) with the difference in the corresponding period in the previous three years (November 2016 to October 2019). Because the model focuses on the relative difference before and during the sudden pandemic within a year, the overall suicide level across years (the long-term suicide trend) is cancelled out. Second, we include city-by-month fixed effect and city-by-year fixed effect. These rich sets of fixed effects allow us to isolate the pandemic effects from the location-specific suicide trend and seasonality.

In particular, we specify the following model:

$$Y_{iym} = alpha mathrm{Treat}_y times mathrm{Post}_m + mu _{im} + gamma _{iy} + varepsilon _{iym}$$

(1)

where Y denotes suicide rates in city i in month m in year y (a year includes 12 months from November to October), and α is the parameter of interest, which denotes the impacts of the COVID-19 pandemic on suicide rates. Postm is a binary variable that takes the value 1 if periods of observations corresponded to months between February (when the COVID-19 outbreak became salient and the national government launched the nationwide anti-contagion policies) and October. It takes a value of 0 if periods correspond to months from November to January, regarded as the ‘pre-treatment’ period prior to the COVID-19 pandemic. Treaty takes the value 1 if the year is 2020 (November 2019 to October 2020) and 0 otherwise (November 2016 to October 2019). In this model, suicide trends between February and October from 2016 to 2019 serve as a control condition (counterfactual), after accounting for the level across years, with the assumption that we encounter only common shocks between the control and the treatment periods (during the pandemic).

We include city-by-month fixed effect and city-by-year fixed effect, denoted by μim and γiy, respectively. City-by-month fixed effect flexibly controls for month-specific shocks in each city, such as seasonality in the suicide rate, monthly local events or climatic conditions57,58. City-by-year fixed effect controls for year-specific shocks in each city, such as macroeconomic trends, industrial or population structural changes, or suicide trends.

Suicide trends during the pandemic could vary across periods depending on the size of the ongoing outbreak, people’s responses and the government’s health interventions. Specifically, Japan faced two large COVID-19 outbreaks (Supplementary Note 2), and we might expect the suicide trend to vary in each wave. Unlike the time-series interrupted analysis, the DID desings enables us to estimate the time-varying effects flexibly (see Supplementary Note 5 and Supplementary Fig. 4 for details). Therefore, we estimate:

$$Y_{iym} = alpha _f times mathrm{Treat}_y times mathrm{First}_m + alpha _s times mathrm{Treat}_y times mathrm{Second}_m + mu _{im} + gamma _{iy} + varepsilon _{iym}$$

(2)

where Firstm denotes the dummy variable, which takes the value 1 during months corresponding to the first outbreak (February to June) and Secondm takes the value 1 during months corresponding to the second outbreak (July to October). Similarly, we estimate how the suicide trends differ during the SOE (April and May 2020) and school closure (March and April 2020).

Our outcome variable of interest, suicide rate, is left-skewed and non-negative. Specifically, 58.7% of the city-by-month suicide rate takes a value of zero during our study period. Therefore, we use a Poisson-pseudo-maximum-likelihood estimator to specify equations (1) and (2) (refs. 59,60). The adjusted model for Eq. (2) can be written as:

$$Y_{iym} = exp [alpha _f times mathrm{Treat}_y times mathrm{First}_m + alpha _s times mathrm{Treat}_y times mathrm{Second}_m + mu _{im} + gamma _{iy}] times varepsilon _{iym}.$$

(3)

We use the package ppmlhdfe to estimate the regression, with options ‘weight’, ‘absorb’ and ‘cluster’ in STATA v.16 to implement all the Poisson regression analyses59. We report the estimated coefficient in the form of IRRs. For this estimation, the necessary condition for the existence of the estimates is non-existence of the ‘separated’ observations60. Therefore, such observations are excluded from the analysis. Note that because more than 95% of the city-by-month suicide rates among children and adolescents are zero, we aggregated the data to the prefectural level for this specific cohort.

We cluster standard errors at the city level to allow arbitrary correlation over time within the same city. Additionally, all the regressions are weighted by population in 2018 so that cities with larger populations are given greater weights. Intuitively, these weights help to estimate the impact of the event on an average person instead of on an average city.

Event-study approach

The assumption for the DID estimator to be valid is that the pandemic period (February to October) in 2020 and the same periods in 2016–2019 would have parallel trends in suicide rates in the absence of the pandemic. If this assumption were not satisfied, the estimated parameter would be biased because the results could be driven by systematic differences between the treatment and control groups rather than the event of interest. To assess whether the parallel trends assumption would be reasonable, we adopt the event-study approach by fitting the following equation37,61:

$$Y_{iym} = {mathrm{exp}}left[ {mathop {sum }limits_{k = – 3,,k ne – 1}^8 alpha _k({mathrm{Treat}}_y times {mathrm{Month}}_{m,k}) + mu _{im} + gamma _{iy}} right] times varepsilon _{iym}$$

(4)

where Monthm is 1 if the month corresponds to k, where k = −1 is set to be a month before the pandemic period (January). Intuitively, this casts the difference in suicide rates between 2020 season and 2016–2019 season in each month relative to k = −1; we expect the treatment group and control group to have a similar suicide rate before the disease outbreak becomes salient (k < 0) and we expect them to diverge after the outbreak (k ≥ 0).

Heterogeneity

We estimate the heterogeneity effects across different gender, age, job status, and geography. For age and gender, we re-estimate equation (3) by using suicide rate across gender and age groups (children and adolescents aged less than 20 years, the working-age population aged 20–69 years, and older adults aged 70 year or more). For job status, we use suicide rate among the employed, retired, unemployed, self-employed, housewives, and students.

For heterogeneous analysis across geography, we re-estimate equation (3) using the subsamples. We use city-level base suicide rate (measured from November 2016 to January 2020), base income per capita (measured in 2018), and base share of urban population (measured in 2018) to classify the samples, in that, if the variable in a city is above its median, the corresponding city is classified as a high-suicide-rate, a high-income, or an urban city. Similarly, we use the prefectural level COVID-19 prevalence (measured by total confirmed cases per million population in October 2020), mobility restrictions (measured by change in Google Community Mobility at workplaces from January 2020 to after February 2020) and economic shocks (measured by the changes in unemployment between October–December 2019 and April–September 2020). We use prefectural level data for the sample classifications because the city-level data are not available. The details of these data are described in Supplementary Note 1.

Placebo test

We perform a placebo test37,62 to investigate whether impacts of the pandemic on suicide rates are driven by either common time trends or common shocks across different periods, using the following procedure. Using the data from November 2016 to October 2019, we randomly allocate treatment status to a year in the same period (February to June for the first outbreak, and July to October for the second outbreak) in each city and estimate the treatment effects analogously to equations (3) and (4). These equations can be written as:

$$Y_{iym} = exp [alpha _f^p times mathrm{Pl}_mathrm{Treat}_y times mathrm{First}_m + alpha _s^p times mathrm{Pl}_mathrm{Treat}_y times mathrm{Second}_m + mu _{im} + gamma _{iy}] times varepsilon _{iym}$$

(5)

$$Y_{iym} = exp left[ {mathop {sum }limits_{k = – 3,,k ne – 1}^8 alpha _k^pleft( {mathrm{Pl}}_{mathrm{Treat}}_y times {mathrm{Month}}_{m,k} right) + mu _{im} + gamma _{iy}} right] times varepsilon _{iym}$$

(6)

where Pl_Treaty is 1 if the treatment status is allocated in both the equations. Then, we compare the placebo results to the real estimates. We repeat these procedures 1,000 times. If there is an event causing higher suicide incidence in a specific region in a pre-pandemic period (for example, cities in Tokyo prefecture in 2019 have unusually high suicide rates), our placebo results would include the spike in the estimated parameters. These results might imply that our main estimate is not driven by the disease outbreak, but by a random shock (or time trend) in some cities. We expect the placebo results (denoted by (alpha _f^p), (alpha _s^p) and (alpha _k^p)) to not be statistically different from zero.

Back-of-the-envelope calculation

To estimate the increased or decreased deaths from suicide during the pandemic, we estimate the following equation:

$$begin{array}{lll}widehat {mathrm{Suicide}},{mathrm{change}}{i,mathrm{treat,post}} &=& left( {widehat {alpha _f} times mathrm{Treat}_y times mathrm{First}_m + widehat {alpha _s} times mathrm{Treat}_y times mathrm{Second}_m} right)\&& times mathrm{Base},mathrm{suicide}{i,mathrm{treat,pre}}end{array}$$

(7)

where (widehat {mathrm{Suicide}},{mathrm{change}}_{i,mathrm{treat,post}}) denotes the predicted change in number of suicides in city i in the treatment year (2020) during the pandemic period (after February). This is computed by estimated coefficients ((widehat {alpha _f}) and (widehat {alpha _s})) derived by specifying equation (3) for the period during the first outbreak (Treaty × Firstm, 5 months) and second outbreak (Treaty × Secondm, 4 months), and number of base suicide deaths (Base suicidei,treat,pre). We then sum the changes in number of suicides in each city to compute change on the national scale.

Reporting Summary

Further information on research design is available in the Nature Research Reporting Summary linked to this article.

Hits: 2

Photo by United Nations COVID-19 Response on Unsplash (cropped)

We don’t know if suicide rates in the U.S. have gone up since Covid-19 first spread around the country, but it’s not hard to find reports of people whose suicides seem indelibly linked to the pandemic.

There’s Dr. Lorna Breen, the ER physician in New York City who worked 18-hour days in the height of the pandemic’s first wave last spring, and then contracted the virus herself.

There’s Christian Robbins, a 16-year-old who killed himself a month into the pandemic in Washington, D.C. His father agonizes about the what-if’s: What if they hadn’t cancelled their family vacation? What if schools hadn’t closed? What if the pandemic had never happened?

And there’s Spencer Smith, a high school sophomore in Maine who died in early December. He left a note for his parents saying he felt stuck at home and disconnected from his friends.

Suicide doesn’t have a single cause. There’s usually a confluence of reasons, which can include mental illness, substance addiction, stressful life circumstances, biology, exposure to suicide, and numerous others. So, it would be simplistic to blame suicides on the pandemic alone. But the pandemic certainly isn’t helping.

Are Suicide Rates Increasing during the Pandemic?

Official statistics about suicide in the U.S. won’t come out for a while. Right now, on the cusp of 2021, statistics for 2019 were released only a week ago. (There was good news, too: The suicide rate dropped by 2.1%, the first decrease in 15 years. However, good news is relative. More than 47,000 people died by suicide in 2019.)

Early research findings about suicide during the pandemic are mixed. Some areas, such as the Pacific Northwest and New Mexico, found no increase in the pandemic’s first 6-7 months. However,  a study in Maryland found that the suicide rate almost doubled for Black people in the first few months of the pandemic, relative to the same time period during the prior three years. Paradoxically, the same study found that suicide rates dropped by nearly 50% for white people early in the pandemic.

Whether the pandemic is leading to more suicides or not, it’s creating conditions that increase suicide risk. At least 10 million Americans still have lost their jobs. This has left many millions of people without enough food, resulting in hours-long waits at food banks. Poverty has increased. An “eviction tsunami” is predicted once a national moratorium on evictions ends. It’s worth noting that poverty and unemployment are significant risk factors for suicide, as is homelessness.

The Perils of Social Isolation

Photo by Erik McLean on Unsplash

Perhaps the most dangerous side effect of the pandemic, besides the virus itself, is social isolation. Humans are social animals. We need conversation, touch, laughter, camaraderie. Zoom and phone calls are better than no connection at all, but they can’t nourish us in the same way as a face to face conversation, a hug, a literal pat on the back, a kiss, sex.

Staying at home and physically isolating from others has meant the obliteration of normal daily life. For many people, the new normal means not working at the office or going to school among their peers. If you’re taking care to protect yourself or others, the new normal has meant not going out to restaurants or the gym, not going home for the holidays, not seeing your friends in person.

To me, a United Nations photo captures, no doubt unintentionally, just how deadening isolation can be. A pill bottle encloses a solitary chair. The pill bottle is shut, devoid of fresh air.

Photo by UN Covid-19 Response on Unsplash

The image reminds me of Sylvia Plath’s infamous bell jar of depression. In her autobiographical novel, she compared her feelings of inner deadness to “sitting under the same glass bell jar, stewing in my own sour air.” (Sylvia Plath killed herself one month after The Bell Jar was published.)

The effects of isolation are so grave that experts worry it’s killing older adults, especially those in nursing homes who can’t receive visitors unless a wall and window separate them. Some nursing homes are taking creative measures to let human contact continue, like the one in Texas using “hugging booths” created by Boy Scouts.

Do You Feel Suicidal During the Pandemic?

Photo by UN Covid-19 Response on Unsplash

Even with the devastating effects of the pandemic, it’s important not to convey that suicide is the solution. It’s not. If you’re feeling despair or thinking of suicide, please call the National Suicide Prevention Lifeline at 800-273-8255 (TALK) or use other free resources listed here.  

And please, remember that things are constantly changing. The new vaccines will, as far as we know, get the pandemic under control. 

Remember the UN picture I mentioned of the empty chair inside a pill bottle? There are a couple others, too, and they’re more uplifting. Though they’re not explicitly suicide prevention ads, they certainly could be.

“BETTER DAYS ARE COMING,” one states, again and again.

“This isn’t forever. It’s just right now,” another states.

Photo by UN Covid-19 Response on Unsplash (cropped)

Often, it can sound like a superficial, trite reassurance to say your situation is temporary, when it might be anything but. But at the moment, as far as we know, the pandemic actually is temporary. The end of the pandemic is beginning, now that effective vaccines against Covid are being distributed. 

It’s true: This isn’t forever. It’s just right now.

Who’s to Blame for Isolation in the Pandemic?

As long as I’m bemoaning the toxic effects of isolation, I want to make something clear: This article is a lamentation, not a diatribe.

Many people look to others to blame for the isolation and other hardships wrought by the pandemic. I understand the desire to blame someone, anyone, who can be held accountable more than an invisible pathogen can.

Some people blame policymakers. One mother in Illinois is suing the governor and local school district for this very reason. She states her son Trevor Till killed himself in October because shutting down schools and extracurricular activities deprived him of the connections he needed to stay alive.

“He thrived on being busy… These kids NEED THEIR ACTIVITIES! IT IS WHAT HIGH SCHOOL IS ALL ABOUT….” she wrote in a Facebook post.

Trevor’s death, and others’ like his, are tragedies. At the same time, as harmful as isolation can be, I don’t see a way around it in a deadly pandemic of a novel virus. Even with widespread stay-at-home orders and restrictions on businesses worldwide, 1.8 million people had died of Covid by December 30, 2020. In the U.S., almost 348,000 people died of Covid in 10 months, compared to 328,000 deaths from flu or pneumonia in the previous 6 years.

Imagine how much longer the list of Covid casualties would be if fewer people had stayed home, if schools and businesses had remained open without restrictions, if travel had continued unabated. Millions of people would have died in the early months of the pandemic alone. Such an enormous number of deaths would have created even more grief, isolation, and disruption to the economy than those caused by the preventive shutdowns.

Knowing that it’s necessary to hunker down doesn’t make it any easier. It will still be many months before society fully reopens. This makes it all the more important that you connect with others and manage your stress if you’re waiting until it’s safe to resume your old ways of living.

Surviving Social Isolation

Photo by Edwin Hooper on Unsplash

Though targeted toward older adults, the journal article “Loneliness and Social Isolation during the Covid-19 Pandemic” contains a list of useful suggestions for people of all ages on how to cope with isolation during the pandemic.

• Use technology to stay connected. No doubt you’ve been doing this for months already. My mother, sisters, and our families have talked via Zoom every Saturday since March. We come from three different time zones; one sister’s in California, I’m in Colorado, and my mother and another sister are in Texas. Our kids (my mom’s grandkids) often join us. Before the pandemic, the last time we were all together was at my father’s funeral, in 2015.
• Structure every single day. Structure and routine can help fend off chaos, even if your routines all occur at home. It might not lessen your isolation, but it could help you to feel less anxiety.
• Keep up physical and mental activities. Remember, exercise doesn’t just help your body. It also improves mood and cognition.
• Get outdoors. After a few months of staying at home, I discovered my vitamin D levels were precariously low. The doctor prescribed pills with 50,000 units of vitamin D. Now, I take 2,000 units a day and make sure I take regular walks during peak periods of sunlight. (Fortunately, I live in Denver, an exceptionally sunny city.)
• Take care of your emotional health. Get therapy, if needed. (If you can’t afford it, check out this article.) Try out anxiety management tools like meditation and deep breathing. Ask friends and family for help if you need it.
• Reach out to older adults you know, and their caregivers. For that matter, also reach out to people you know who are parents of young children, health care providers, other essential workers, and anyone else who seems especially vulnerable to the stresses of the pandemic.

Questions for You about the Pandemic and Social Isolation

What have you done to cope with isolation and other stresses of the pandemic over the last year or so?

What has helped you to stay connected to others?

Please let us know your thoughts in the comments.

Want to join the conversation?

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Most people face mental health challenges at one point or another in their lifetime. Occasional grief, stress, and sadness are normal. But if you’re experiencing persistent or severe mental health challenges, it’s time to get help.

“Help is available,” advises Dawn Brown, director of information and engagement services at the National Alliance on Mental Illness (NAMI). “Whether you’re feeling unsafe or a situation begins to escalate into a crisis, reaching out for help is important.”

When should you get help?

The following symptoms might be signs of an underlying mental health condition:

• thoughts of hurting yourself or others
• frequent or persistent feelings of sadness, anger, fear, worry, or anxiety
• frequent emotional outbursts or mood swings
• confusion or unexplained memory loss
• delusions or hallucinations
• intense fear or anxiety about weight gain
• dramatic changes in eating or sleeping habits
• unexplained changes in school or work performance
• inability to cope with daily activities or challenges
• withdrawal from social activities or relationships
• defiance of authority, truancy, theft, or vandalism
• substance abuse, including alcoholism or use of illegal drugs
• unexplained physical ailments

If you’re thinking about hurting yourself or someone else, get help right away. If you have other symptoms on this list, make an appointment with your doctor. Once they’ve ruled out a physical basis for your symptoms, they may refer you to a mental health specialist and other resources.

Are you making plans to hurt yourself or another person? That’s a mental health emergency. Go to a hospital emergency department or contact your local emergency services right away. Dial 911 for immediate emergency help.

Suicide prevention hotlines

Have you been thinking about hurting yourself? Consider contacting a suicide prevention hotline. You can call the National Suicide Prevention Lifeline at 800-273-8255. It offers 24/7 support.

There are many types of healthcare providers who diagnose and treat mental illness. If you suspect you might have a mental health condition or need mental health support, make an appointment with your primary physician or a nurse practitioner. They can help you determine what type of provider you should see. In many cases, they can also provide a referral.

For example, they might recommend seeing one or more of the healthcare providers below.

Providers who prescribe medicine

Therapist

A therapist can help diagnose and treat mental health conditions. There are many different types of therapists, including:

• psychiatrists
• psychologists
• psychoanalysts
• clinical counselors

Therapists often specialize in certain areas, such as addiction or child behavioral issues.

Only some types of therapists prescribe medications. To prescribe medications, they need to be either a physician or nurse practitioner. In some cases, you may also see a physician’s assistant or a doctor of osteopathic medicine.

Psychiatrist

If your doctor suspects you have a mental health condition that requires medication, they might refer you to a psychiatrist. They often diagnose and treat conditions such as:

• depression
• anxiety disorders
• obsessive-compulsive disorder (OCD)
• bipolar disorder
• schizophrenia

Prescribing medications is often their primary approach to providing treatment. Many psychiatrists don’t offer counseling themselves. Instead, many work with a psychologist or other mental health profession who can provide counseling.

Nurse psychotherapist

Nurse psychotherapists generally diagnose and treat psychiatric disorders. They may also treat other health conditions.

Nurse psychotherapists have an advanced nursing degree. They are trained as clinical nurse specialists or nurse practitioners. Clinical nurse specialists can’t prescribe medications in most states. However, nurse practitioners can. They often use a combination of medications and counseling to treat patients.

Psychologist

If your doctor thinks you might benefit from therapy, they might refer you to a psychologist. Psychologists are trained to diagnose and treat mental health conditions and challenges, such as:

• depression
• anxiety disorders
• eating disorders
• learning difficulties
• relationship problems
• substance abuse

Psychologists are also trained to give psychological tests. For example, they might administer an IQ test or personality test.

A psychologist can potentially help you learn to manage your symptoms through counseling or other forms of therapy. In some states (Illinois, Louisiana, and New Mexico), they can prescribe medicine. However, when they can’t, psychologists can work with other healthcare providers who can prescribe medications.

Providers who can’t prescribe medicine

Marital and family therapist

Marital and family therapists are trained in psychotherapy and family systems. They often treat individuals, couples, and families who are coping with marital problems or child-parent problems.

Marital and family therapists aren’t licensed to prescribe medication. However, they often work with healthcare providers who can prescribe medications.

Peer specialist

Peer specialists are people who’ve personally experienced and recovered from mental health challenges. They provide support to others who are going through similar experiences. For example, they may help people recover from substance abuse, psychological trauma, or other mental health challenges.

Peer specialists act as role models and sources of support. They share their personal experiences of recovery to give hope and guidance to others. They can also help people set goals and develop strategies to move forward in their recovery. Some peer specialists work for organizations as paid employees. Others offer their services as volunteers.

Peer specialists can’t prescribe medications because they aren’t clinical professionals.

Licensed professional counselor

Licensed professional counselors (LPCs) are qualified to provide individual and group counseling. They can have many titles, based on the particular areas they focus on. For example, some LPCs provide marriage and family therapy.

LPCs can’t prescribe medication because they’re not licensed to do so.

Mental health counselor

A mental health counselor is trained to diagnose and treat people coping with difficult life experiences, such as:

• grief
• relationship problems
• mental health conditions, such as bipolar disorder or schizophrenia

Mental health counselors provide counseling on an individual or group basis. Some work in private practice. Others work for hospitals, residential treatment centers, or other agencies.

Mental health counselors can’t provide medications because they’re not equipped with a license. However, many work with healthcare providers who can prescribe medications when needed.

Alcohol and drug abuse counselor

Alcohol and drug abuse counselors are trained to treat people with alcohol and drug addictions. If you’ve been abusing alcohol or drugs, they can help guide you on the path of sobriety. For example, they can potentially help you learn to:

• modify your behavior
• avoid triggers
• manage withdrawal symptoms

Alcohol and drug abuse counselors can’t prescribe medications. If they think you might benefit from medications, they might advise you to talk to your family doctor or nurse practitioner.

Veterans counselor

VA-certified counselors have been trained by the Department of Veterans Affairs. They offer counseling to military veterans. Many veterans return from service with injuries or stress-related illnesses. For example, you might come home with post-traumatic stress disorder (PTSD). If you’re a veteran, a VA-certified counselor can help you:

• learn to manage mental health conditions
• transition from military life to civilian life
• cope with negative emotions, such as grief or guilt

VA-certified counselors can’t prescribe medication. If they think you might need medication, they may encourage you to talk to your family doctor, nurse practitioner, or psychiatrist.

Pastoral counselor

A pastoral counselor is a religious counselor who is trained to provide counseling. For example, some priests, rabbis, imams, and ministers are trained counselors. They typically have a postgraduate degree. They often combine psychological methods with religious training to promote psycho-spiritual healing.

Spirituality is an important part of recovery for some people. If your religious beliefs are a pivotal part of your identity, you might find pastoral counseling helpful.

Pastoral counselors can’t prescribe medication. However, some develop professional relationships with healthcare providers who can prescribe medications when needed.

Social worker

Clinical social workers are professional therapists who hold a master’s degree in social work. They’re trained to provide individual and group counseling. They often work in hospitals, private practices, or clinics. Sometimes they work with people in their homes or schools.

Clinical social workers can’t prescribe medication.

If you start to experience symptoms of a mental health condition, don’t wait for them to get worse. Instead, reach out for help. To start, make an appointment with your family doctor or nurse practitioner. They can refer you to a specialist.

Keep in mind that it can sometimes be challenging to find a therapist who meets your needs. You might need to connect with more than one therapist before you find the right fit.

Consider these factors

Before you look for a therapist, you’ll want to know the answer to these questions:

• What type of a mental health support are you looking for?
• Are you looking for a healthcare provider who can offer therapy?
• Are you looking for someone who can prescribe medication?
• Are you looking for both medication and therapy?

Contact your insurance provider

If you have health insurance, call your insurance provider to learn if they cover mental health services. If they do, ask for the contact information of local service providers who accept your insurance plan. If you need support for a specific condition, ask for providers who treat that condition.

Other questions that you should ask your insurance provider include:

• Are all diagnoses and services covered?
• What are the copay and deductible amounts for these services?
• Can you make a direct appointment with a psychiatrist or therapist? Or do you need to see a primary care physician or nurse practitioner first for a referral?

It’s always a good idea to ask for the names and contact information of multiple providers. The first provider you try might not be the right fit for you.

Look for therapists online

Your family doctor, nurse practitioner, and insurance provider can help you find a therapist in your area. You can also look for therapists online. For example, consider using these databases:

Schedule an appointment

It’s time to book an appointment. If you’re reluctant to make the call, you can ask a friend or family member to call on your behalf. A few things to do:

1. If it’s your first time visiting a therapist, let them know that. They may want to schedule a longer appointment to provide more time for introductions and diagnosis.
2. If the first available appointment time is far in the future, take that appointment time but ask to be put on a waiting list. If another patient cancels, you might get an earlier appointment. You can also call other therapists to learn if you can get an earlier appointment with them.
3. While you wait for your appointment, consider looking for other sources of support. For example, you might be able to find a support group in your area. If you’re a member of a religious community, you might be able to get support from a pastoral counselor. Your school or workplace might also offer counseling services.

If you’re in a crisis and need immediate help, go to a hospital emergency department or call 911.

Find the right fit

Once you’ve met with a therapist, it’s time to reflect on whether they’re the right fit for you. Here are some important things to consider:

• How much education and professional experience do they have? Have they worked with other people going through similar experiences or coping with a similar diagnosis? They should be qualified to provide the services that they’re offering. Most of the providers discussed previously should have at least a master’s degree, or in the case of psychologists, a doctoral degree.
• Do you feel comfortable with them? What “vibe” do you get from them? The personal questions that your therapist asks you might make you uncomfortable sometimes, but that person shouldn’t make you feel uneasy. You should feel like they’re on your side.
• Do they understand and respect your cultural background and identify? Are they willing to learn more about your background and beliefs? Consider following NAMI’s tips for finding culturally competent care.
• What processes does the therapist expect you to follow to establish mental health goals and evaluate your progress? What kind of improvements can you expect to see? You may be more comfortable with one approach to providing care over another.
• How often will you meet? How hard will it be to get an appointment? Can you contact the therapist by phone or email between appointments? If you can’t see or talk to them as often as you need, another service provider might be better suited to you.
• Can you afford their services? If you’re concerned about your ability to pay for appointments or meet your insurance copays or deductibles, bring it up with your therapist when you first meet them. Ask if you can pay on a sliding scale or at a discounted price. Doctors and therapists often prefer to prepare for potential financial challenges in advance because it’s important to continue treatment without interruption.

If you feel uncomfortable with the first therapist that you visit, move on to the next one. It’s not enough for them to be a qualified professional. You need to work well together. Developing a trusting relationship is critical to meeting your long-term treatment needs.

Distance therapy can be conducted by voice, text, chat, video, or email. Some therapists offer distance therapy to their patients when they’re out of town. Others offer distance therapy as a stand-alone service. To learn more about distance counseling, visit the American Distance Counseling Association.

Many hotlines, online information services, mobile apps, and even video games are available to help people cope with mental illness.

Hotlines

Many organizations run hotlines and online services to provide mental health support. These are just a few of the hotlines and online services that are available:

An online search will turn up more services in your area.

Mobile apps

A growing number of mobile apps are available to help people cope with mental illness. Some apps facilitate communication with therapists. Others offer links to peer support. Still others provide educational information or tools to promote good mental health.

You shouldn’t use mobile apps as a replacement for your doctor or therapist’s prescribed treatment plan. But some apps might make a helpful addition to your larger treatment plan.

Free apps

• Breathe2Relax is a portable stress management tool. It provides detailed information on how stress affects the body. It also helps users learn how to manage stress using a technique called diaphragmatic breathing. It’s available for free on iOS and Android devices.
• IntelliCare is designed to help people manage depression and anxiety. The IntelliCare Hub app and related mini apps are available for free on Android devices.
• MindShift is designed to help youth gain insight into anxiety disorders. It provides information about generalized anxiety disorder, social anxiety disorder, specific phobias, and panic attacks. It also provides tips for developing basic coping strategies.
• PTSD Coach was designed for veterans and military service members who have PTSD. It provides information about PTSD, including treatment and management strategies. It also includes a self-assessment tool. It’s available for free on iOS and Android devices.
• SAM: Self Help for Anxiety Management provides information about managing anxiety. It’s available for free on iOS and Android devices
• TalkSpace seeks to make therapy more accessible. It connects users to licensed therapists, using a messaging platform. It also provides access to public therapy forums. It’s free to download on iOS and Android devices.
• Equanimity is a meditation app. It may help you develop a stress-relieving meditation practice. It’s available to download for $4.99 on iOS devices
• Lantern offers sessions designed to boost emotional well-being. It’s a subscription-based service. (Email customer support for current pricing.) Although the service is web-based, you can also download a free supplemental app for iOS devices.
• Worry Watch is designed to help users document and manage experiences with chronic worry, anticipatory anxiety, and generalized anxiety disorder. It’s available on iOS for $1.99.

Paid apps

For information about other mental health apps, visit the Anxiety and Depression Association of America.

Video game therapy

Video gaming is a popular leisure activity. Certain doctors also use video games for therapeutic purposes. In some cases, immersing yourself in virtual worlds might help you take a break from everyday anxieties.

A:

Answers represent the opinions of our medical experts. All content is strictly informational and should not be considered medical advice.

Some game designers have created games specifically geared toward mental health. For example:

• Depression Quest aims to help people with depression understand that they’re not alone. It also illustrates how the condition can affect people.
• Luminosity uses games to strengthen players’ cognitive abilities.
• Project EVO was designed to provide daily therapy to people with brain disorders, such as attention deficit hyperactivity disorder (ADHD) and autism.
• Sparx is a role-playing game. It strives to promote positive affirmations through interactions among players. It’s currently available only in New Zealand.
• SuperBetter aims to increase resilience. This is the ability to stay strong, motivated, and optimistic in the face of difficult obstacles.

Ask your doctor for more information about the potential benefits and risks of video gaming.

Whether you’re grieving the loss of a loved one or coping with mental illness, many nonprofit organizations offer support. Consider connecting with one of the organizations listed below. Or conduct an online search to find an organization in your area.

• Alliance of Hope for Suicide Loss Survivors provides support to suicide survivors. It also helps those who’ve lost a loved one to suicide.
• American Foundation for Suicide Prevention provides resources to people affected by suicide.
• Candle Inc. offers programs designed to prevent substance abuse.
• Child Mind Institute provides support to children and families coping with mental health and learning disorders.
• Children’s Health Council provides support services to children and families coping with a variety of mental health and learning disorders.
• Finding Balance is a Christian organization. It strives to help people develop a healthy relationship with food and weight.
• Hope of Survivors offers support to victims of clergy sexual abuse and misconduct. It also provides education to clergy and churches.
• Knights of Heroes Foundation runs an annual wilderness adventure camp for children who’ve lost their parents during military service.
• Mental Health America is dedicated to promoting good mental health among Americans. It promotes prevention, diagnosis, and treatment for people at risk of mental illness.
• National Alliance on Mental Illness promotes the well-being of Americans affected by mental illness. It offers education and support resources.
• National Child Traumatic Stress Network strives to improve care for children and youth who’ve been exposed to traumatic events.
• National Federation of Families for Children’s Mental Health promotes policies and services to support families of children and youth who are coping with emotional, behavioral, or mental health challenges.
• Treatment Advocacy Center promotes policies and practices to…

We include products we think are useful for our readers. If you buy through links on this page, we may earn a small commission. Here’s our process.

Most people face mental health challenges at one point or another in their lifetime. Occasional grief, stress, and sadness are normal. But if you’re experiencing persistent or severe mental health challenges, it’s time to get help.

“Help is available,” advises Dawn Brown, director of information and engagement services at the National Alliance on Mental Illness (NAMI). “Whether you’re feeling unsafe or a situation begins to escalate into a crisis, reaching out for help is important.”

When should you get help?

The following symptoms might be signs of an underlying mental health condition:

• thoughts of hurting yourself or others
• frequent or persistent feelings of sadness, anger, fear, worry, or anxiety
• frequent emotional outbursts or mood swings
• confusion or unexplained memory loss
• delusions or hallucinations
• intense fear or anxiety about weight gain
• dramatic changes in eating or sleeping habits
• unexplained changes in school or work performance
• inability to cope with daily activities or challenges
• withdrawal from social activities or relationships
• defiance of authority, truancy, theft, or vandalism
• substance abuse, including alcoholism or use of illegal drugs
• unexplained physical ailments

If you’re thinking about hurting yourself or someone else, get help right away. If you have other symptoms on this list, make an appointment with your doctor. Once they’ve ruled out a physical basis for your symptoms, they may refer you to a mental health specialist and other resources.

Are you making plans to hurt yourself or another person? That’s a mental health emergency. Go to a hospital emergency department or contact your local emergency services right away. Dial 911 for immediate emergency help.

Suicide prevention hotlines

Have you been thinking about hurting yourself? Consider contacting a suicide prevention hotline. You can call the National Suicide Prevention Lifeline at 800-273-8255. It offers 24/7 support.

There are many types of healthcare providers who diagnose and treat mental illness. If you suspect you might have a mental health condition or need mental health support, make an appointment with your primary physician or a nurse practitioner. They can help you determine what type of provider you should see. In many cases, they can also provide a referral.

For example, they might recommend seeing one or more of the healthcare providers below.

Providers who prescribe medicine

Therapist

A therapist can help diagnose and treat mental health conditions. There are many different types of therapists, including:

• psychiatrists
• psychologists
• psychoanalysts
• clinical counselors

Therapists often specialize in certain areas, such as addiction or child behavioral issues.

Only some types of therapists prescribe medications. To prescribe medications, they need to be either a physician or nurse practitioner. In some cases, you may also see a physician’s assistant or a doctor of osteopathic medicine.

Psychiatrist

If your doctor suspects you have a mental health condition that requires medication, they might refer you to a psychiatrist. They often diagnose and treat conditions such as:

• depression
• anxiety disorders
• obsessive-compulsive disorder (OCD)
• bipolar disorder
• schizophrenia

Prescribing medications is often their primary approach to providing treatment. Many psychiatrists don’t offer counseling themselves. Instead, many work with a psychologist or other mental health profession who can provide counseling.

Nurse psychotherapist

Nurse psychotherapists generally diagnose and treat psychiatric disorders. They may also treat other health conditions.

Nurse psychotherapists have an advanced nursing degree. They are trained as clinical nurse specialists or nurse practitioners. Clinical nurse specialists can’t prescribe medications in most states. However, nurse practitioners can. They often use a combination of medications and counseling to treat patients.

Psychologist

If your doctor thinks you might benefit from therapy, they might refer you to a psychologist. Psychologists are trained to diagnose and treat mental health conditions and challenges, such as:

• depression
• anxiety disorders
• eating disorders
• learning difficulties
• relationship problems
• substance abuse

Psychologists are also trained to give psychological tests. For example, they might administer an IQ test or personality test.

A psychologist can potentially help you learn to manage your symptoms through counseling or other forms of therapy. In some states (Illinois, Louisiana, and New Mexico), they can prescribe medicine. However, when they can’t, psychologists can work with other healthcare providers who can prescribe medications.

Providers who can’t prescribe medicine

Marital and family therapist

Marital and family therapists are trained in psychotherapy and family systems. They often treat individuals, couples, and families who are coping with marital problems or child-parent problems.

Marital and family therapists aren’t licensed to prescribe medication. However, they often work with healthcare providers who can prescribe medications.

Peer specialist

Peer specialists are people who’ve personally experienced and recovered from mental health challenges. They provide support to others who are going through similar experiences. For example, they may help people recover from substance abuse, psychological trauma, or other mental health challenges.

Peer specialists act as role models and sources of support. They share their personal experiences of recovery to give hope and guidance to others. They can also help people set goals and develop strategies to move forward in their recovery. Some peer specialists work for organizations as paid employees. Others offer their services as volunteers.

Peer specialists can’t prescribe medications because they aren’t clinical professionals.

Licensed professional counselor

Licensed professional counselors (LPCs) are qualified to provide individual and group counseling. They can have many titles, based on the particular areas they focus on. For example, some LPCs provide marriage and family therapy.

LPCs can’t prescribe medication because they’re not licensed to do so.

Mental health counselor

A mental health counselor is trained to diagnose and treat people coping with difficult life experiences, such as:

• grief
• relationship problems
• mental health conditions, such as bipolar disorder or schizophrenia

Mental health counselors provide counseling on an individual or group basis. Some work in private practice. Others work for hospitals, residential treatment centers, or other agencies.

Mental health counselors can’t provide medications because they’re not equipped with a license. However, many work with healthcare providers who can prescribe medications when needed.

Alcohol and drug abuse counselor

Alcohol and drug abuse counselors are trained to treat people with alcohol and drug addictions. If you’ve been abusing alcohol or drugs, they can help guide you on the path of sobriety. For example, they can potentially help you learn to:

• modify your behavior
• avoid triggers
• manage withdrawal symptoms

Alcohol and drug abuse counselors can’t prescribe medications. If they think you might benefit from medications, they might advise you to talk to your family doctor or nurse practitioner.

Veterans counselor

VA-certified counselors have been trained by the Department of Veterans Affairs. They offer counseling to military veterans. Many veterans return from service with injuries or stress-related illnesses. For example, you might come home with post-traumatic stress disorder (PTSD). If you’re a veteran, a VA-certified counselor can help you:

• learn to manage mental health conditions
• transition from military life to civilian life
• cope with negative emotions, such as grief or guilt

VA-certified counselors can’t prescribe medication. If they think you might need medication, they may encourage you to talk to your family doctor, nurse practitioner, or psychiatrist.

Pastoral counselor

A pastoral counselor is a religious counselor who is trained to provide counseling. For example, some priests, rabbis, imams, and ministers are trained counselors. They typically have a postgraduate degree. They often combine psychological methods with religious training to promote psycho-spiritual healing.

Spirituality is an important part of recovery for some people. If your religious beliefs are a pivotal part of your identity, you might find pastoral counseling helpful.

Pastoral counselors can’t prescribe medication. However, some develop professional relationships with healthcare providers who can prescribe medications when needed.

Social worker

Clinical social workers are professional therapists who hold a master’s degree in social work. They’re trained to provide individual and group counseling. They often work in hospitals, private practices, or clinics. Sometimes they work with people in their homes or schools.

Clinical social workers can’t prescribe medication.

If you start to experience symptoms of a mental health condition, don’t wait for them to get worse. Instead, reach out for help. To start, make an appointment with your family doctor or nurse practitioner. They can refer you to a specialist.

Keep in mind that it can sometimes be challenging to find a therapist who meets your needs. You might need to connect with more than one therapist before you find the right fit.

Consider these factors

Before you look for a therapist, you’ll want to know the answer to these questions:

• What type of a mental health support are you looking for?
• Are you looking for a healthcare provider who can offer therapy?
• Are you looking for someone who can prescribe medication?
• Are you looking for both medication and therapy?

Contact your insurance provider

If you have health insurance, call your insurance provider to learn if they cover mental health services. If they do, ask for the contact information of local service providers who accept your insurance plan. If you need support for a specific condition, ask for providers who treat that condition.

Other questions that you should ask your insurance provider include:

• Are all diagnoses and services covered?
• What are the copay and deductible amounts for these services?
• Can you make a direct appointment with a psychiatrist or therapist? Or do you need to see a primary care physician or nurse practitioner first for a referral?

It’s always a good idea to ask for the names and contact information of multiple providers. The first provider you try might not be the right fit for you.

Look for therapists online

Your family doctor, nurse practitioner, and insurance provider can help you find a therapist in your area. You can also look for therapists online. For example, consider using these databases:

Schedule an appointment

It’s time to book an appointment. If you’re reluctant to make the call, you can ask a friend or family member to call on your behalf. A few things to do:

1. If it’s your first time visiting a therapist, let them know that. They may want to schedule a longer appointment to provide more time for introductions and diagnosis.
2. If the first available appointment time is far in the future, take that appointment time but ask to be put on a waiting list. If another patient cancels, you might get an earlier appointment. You can also call other therapists to learn if you can get an earlier appointment with them.
3. While you wait for your appointment, consider looking for other sources of support. For example, you might be able to find a support group in your area. If you’re a member of a religious community, you might be able to get support from a pastoral counselor. Your school or workplace might also offer counseling services.

If you’re in a crisis and need immediate help, go to a hospital emergency department or call 911.

Find the right fit

Once you’ve met with a therapist, it’s time to reflect on whether they’re the right fit for you. Here are some important things to consider:

• How much education and professional experience do they have? Have they worked with other people going through similar experiences or coping with a similar diagnosis? They should be qualified to provide the services that they’re offering. Most of the providers discussed previously should have at least a master’s degree, or in the case of psychologists, a doctoral degree.
• Do you feel comfortable with them? What “vibe” do you get from them? The personal questions that your therapist asks you might make you uncomfortable sometimes, but that person shouldn’t make you feel uneasy. You should feel like they’re on your side.
• Do they understand and respect your cultural background and identify? Are they willing to learn more about your background and beliefs? Consider following NAMI’s tips for finding culturally competent care.
• What processes does the therapist expect you to follow to establish mental health goals and evaluate your progress? What kind of improvements can you expect to see? You may be more comfortable with one approach to providing care over another.
• How often will you meet? How hard will it be to get an appointment? Can you contact the therapist by phone or email between appointments? If you can’t see or talk to them as often as you need, another service provider might be better suited to you.
• Can you afford their services? If you’re concerned about your ability to pay for appointments or meet your insurance copays or deductibles, bring it up with your therapist when you first meet them. Ask if you can pay on a sliding scale or at a discounted price. Doctors and therapists often prefer to prepare for potential financial challenges in advance because it’s important to continue treatment without interruption.

If you feel uncomfortable with the first therapist that you visit, move on to the next one. It’s not enough for them to be a qualified professional. You need to work well together. Developing a trusting relationship is critical to meeting your long-term treatment needs.

Distance therapy can be conducted by voice, text, chat, video, or email. Some therapists offer distance therapy to their patients when they’re out of town. Others offer distance therapy as a stand-alone service. To learn more about distance counseling, visit the American Distance Counseling Association.

Many hotlines, online information services, mobile apps, and even video games are available to help people cope with mental illness.

Hotlines

Many organizations run hotlines and online services to provide mental health support. These are just a few of the hotlines and online services that are available:

An online search will turn up more services in your area.

Mobile apps

A growing number of mobile apps are available to help people cope with mental illness. Some apps facilitate communication with therapists. Others offer links to peer support. Still others provide educational information or tools to promote good mental health.

You shouldn’t use mobile apps as a replacement for your doctor or therapist’s prescribed treatment plan. But some apps might make a helpful addition to your larger treatment plan.

Free apps

• Breathe2Relax is a portable stress management tool. It provides detailed information on how stress affects the body. It also helps users learn how to manage stress using a technique called diaphragmatic breathing. It’s available for free on iOS and Android devices.
• IntelliCare is designed to help people manage depression and anxiety. The IntelliCare Hub app and related mini apps are available for free on Android devices.
• MindShift is designed to help youth gain insight into anxiety disorders. It provides information about generalized anxiety disorder, social anxiety disorder, specific phobias, and panic attacks. It also provides tips for developing basic coping strategies.
• PTSD Coach was designed for veterans and military service members who have PTSD. It provides information about PTSD, including treatment and management strategies. It also includes a self-assessment tool. It’s available for free on iOS and Android devices.
• SAM: Self Help for Anxiety Management provides information about managing anxiety. It’s available for free on iOS and Android devices
• TalkSpace seeks to make therapy more accessible. It connects users to licensed therapists, using a messaging platform. It also provides access to public therapy forums. It’s free to download on iOS and Android devices.
• Equanimity is a meditation app. It may help you develop a stress-relieving meditation practice. It’s available to download for $4.99 on iOS devices
• Lantern offers sessions designed to boost emotional well-being. It’s a subscription-based service. (Email customer support for current pricing.) Although the service is web-based, you can also download a free supplemental app for iOS devices.
• Worry Watch is designed to help users document and manage experiences with chronic worry, anticipatory anxiety, and generalized anxiety disorder. It’s available on iOS for $1.99.

Paid apps

For information about other mental health apps, visit the Anxiety and Depression Association of America.

Video game therapy

Video gaming is a popular leisure activity. Certain doctors also use video games for therapeutic purposes. In some cases, immersing yourself in virtual worlds might help you take a break from everyday anxieties.

A:

Answers represent the opinions of our medical experts. All content is strictly informational and should not be considered medical advice.

Some game designers have created games specifically geared toward mental health. For example:

• Depression Quest aims to help people with depression understand that they’re not alone. It also illustrates how the condition can affect people.
• Luminosity uses games to strengthen players’ cognitive abilities.
• Project EVO was designed to provide daily therapy to people with brain disorders, such as attention deficit hyperactivity disorder (ADHD) and autism.
• Sparx is a role-playing game. It strives to promote positive affirmations through interactions among players. It’s currently available only in New Zealand.
• SuperBetter aims to increase resilience. This is the ability to stay strong, motivated, and optimistic in the face of difficult obstacles.

Ask your doctor for more information about the potential benefits and risks of video gaming.

Whether you’re grieving the loss of a loved one or coping with mental illness, many nonprofit organizations offer support. Consider connecting with one of the organizations listed below. Or conduct an online search to find an organization in your area.

• Alliance of Hope for Suicide Loss Survivors provides support to suicide survivors. It also helps those who’ve lost a loved one to suicide.
• American Foundation for Suicide Prevention provides resources to people affected by suicide.
• Candle Inc. offers programs designed to prevent substance abuse.
• Child Mind Institute provides support to children and families coping with mental health and learning disorders.
• Children’s Health Council provides support services to children and families coping with a variety of mental health and learning disorders.
• Finding Balance is a Christian organization. It strives to help people develop a healthy relationship with food and weight.
• Hope of Survivors offers support to victims of clergy sexual abuse and misconduct. It also provides education to clergy and churches.
• Knights of Heroes Foundation runs an annual wilderness adventure camp for children who’ve lost their parents during military service.
• Mental Health America is dedicated to promoting good mental health among Americans. It promotes prevention, diagnosis, and treatment for people at risk of mental illness.
• National Alliance on Mental Illness promotes the well-being of Americans affected by mental illness. It offers education and support resources.
• National Child Traumatic Stress Network strives to improve care for children and youth who’ve been exposed to traumatic events.
• National Federation of Families for Children’s Mental Health promotes policies and services to support families of children and youth who are coping with emotional, behavioral, or mental health challenges.
• Treatment Advocacy Center promotes policies and practices to…

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Mark É. Czeisler1,2; Rashon I. Lane, MA3; Emiko Petrosky, MD3; Joshua F. Wiley, PhD1; Aleta Christensen, MPH3; Rashid Njai, PhD3; Matthew D. Weaver, PhD1,4,5; Rebecca Robbins, PhD4,5; Elise R. Facer-Childs, PhD1; Laura K. Barger, PhD4,5; Charles A. Czeisler, MD, PhD1,4,5; Mark E. Howard, MBBS, PhD1,2,6; Shantha M.W. Rajaratnam, PhD1,4,5 (View author affiliations)

View suggested citation

Summary

What is already known about this topic?

Communities have faced mental health challenges related to COVID-19–associated morbidity, mortality, and mitigation activities.

What is added by this report?

During June 24–30, 2020, U.S. adults reported considerably elevated adverse mental health conditions associated with COVID-19. Younger adults, racial/ethnic minorities, essential workers, and unpaid adult caregivers reported having experienced disproportionately worse mental health outcomes, increased substance use, and elevated suicidal ideation.

What are the implications for public health practice?

The public health response to the COVID-19 pandemic should increase intervention and prevention efforts to address associated mental health conditions. Community-level efforts, including health communication strategies, should prioritize young adults, racial/ethnic minorities, essential workers, and unpaid adult caregivers.

https://d1bxh8uas1mnw7.cloudfront.net/assets/embed.js

Altmetric:

Citations:

Views:

Views equals page views plus PDF downloads

The coronavirus disease 2019 (COVID-19) pandemic has been associated with mental health challenges related to the morbidity and mortality caused by the disease and to mitigation activities, including the impact of physical distancing and stay-at-home orders.* Symptoms of anxiety disorder and depressive disorder increased considerably in the United States during April–June of 2020, compared with the same period in 2019 (1,2). To assess mental health, substance use, and suicidal ideation during the pandemic, representative panel surveys were conducted among adults aged ≥18 years across the United States during June 24–30, 2020. Overall, 40.9% of respondents reported at least one adverse mental or behavioral health condition, including symptoms of anxiety disorder or depressive disorder (30.9%), symptoms of a trauma- and stressor-related disorder (TSRD) related to the pandemic† (26.3%), and having started or increased substance use to cope with stress or emotions related to COVID-19 (13.3%). The percentage of respondents who reported having seriously considered suicide in the 30 days before completing the survey (10.7%) was significantly higher among respondents aged 18–24 years (25.5%), minority racial/ethnic groups (Hispanic respondents [18.6%], non-Hispanic black [black] respondents [15.1%]), self-reported unpaid caregivers for adults§ (30.7%), and essential workers¶ (21.7%). Community-level intervention and prevention efforts, including health communication strategies, designed to reach these groups could help address various mental health conditions associated with the COVID-19 pandemic.

During June 24–30, 2020, a total of 5,412 (54.7%) of 9,896 eligible invited adults** completed web-based surveys†† administered by Qualtrics.§§ The Monash University Human Research Ethics Committee of Monash University (Melbourne, Australia) reviewed and approved the study protocol on human subjects research. Respondents were informed of the study purposes and provided electronic consent before commencement, and investigators received anonymized responses. Participants included 3,683 (68.1%) first-time respondents and 1,729 (31.9%) respondents who had completed a related survey during April 2–8, May 5–12, 2020, or both intervals; 1,497 (27.7%) respondents participated during all three intervals (2,3). Quota sampling and survey weighting were employed to improve cohort representativeness of the U.S. population by gender, age, and race/ethnicity.¶¶ Symptoms of anxiety disorder and depressive disorder were assessed using the four-item Patient Health Questionnaire*** (4), and symptoms of a COVID-19–related TSRD were assessed using the six-item Impact of Event Scale††† (5). Respondents also reported whether they had started or increased substance use to cope with stress or emotions related to COVID-19 or seriously considered suicide in the 30 days preceding the survey.§§§

Analyses were stratified by gender, age, race/ethnicity, employment status, essential worker status, unpaid adult caregiver status, rural-urban residence classification,¶¶¶ whether the respondent knew someone who had positive test results for SARS-CoV-2, the virus that causes COVID-19, or who had died from COVID-19, and whether the respondent was receiving treatment for diagnosed anxiety, depression, or posttraumatic stress disorder (PTSD) at the time of the survey. Comparisons within subgroups were evaluated using Poisson regressions with robust standard errors to calculate prevalence ratios, 95% confidence intervals (CIs), and p-values to evaluate statistical significance (α = 0.005 to account for multiple comparisons). Among the 1,497 respondents who completed all three surveys, longitudinal analyses of the odds of incidence**** of symptoms of adverse mental or behavioral health conditions by essential worker and unpaid adult caregiver status were conducted on unweighted responses using logistic regressions to calculate unadjusted and adjusted†††† odds ratios (ORs), 95% CI, and p-values (α = 0.05). The statsmodels package in Python (version 3.7.8; Python Software Foundation) was used to conduct all analyses.

Overall, 40.9% of 5,470 respondents who completed surveys during June reported an adverse mental or behavioral health condition, including those who reported symptoms of anxiety disorder or depressive disorder (30.9%), those with TSRD symptoms related to COVID-19 (26.3%), those who reported having started or increased substance use to cope with stress or emotions related to COVID-19 (13.3%), and those who reported having seriously considered suicide in the preceding 30 days (10.7%) (Table 1). At least one adverse mental or behavioral health symptom was reported by more than one half of respondents who were aged 18–24 years (74.9%) and 25–44 years (51.9%), of Hispanic ethnicity (52.1%), and who held less than a high school diploma (66.2%), as well as those who were essential workers (54.0%), unpaid caregivers for adults (66.6%), and who reported treatment for diagnosed anxiety (72.7%), depression (68.8%), or PTSD (88.0%) at the time of the survey.

Prevalences of symptoms of adverse mental or behavioral health conditions varied significantly among subgroups (Table 2). Suicidal ideation was more prevalent among males than among females. Symptoms of anxiety disorder or depressive disorder, COVID-19–related TSRD, initiation of or increase in substance use to cope with COVID-19–associated stress, and serious suicidal ideation in the previous 30 days were most commonly reported by persons aged 18–24 years; prevalence decreased progressively with age. Hispanic respondents reported higher prevalences of symptoms of anxiety disorder or depressive disorder, COVID-19–related TSRD, increased substance use, and suicidal ideation than did non-Hispanic whites (whites) or non-Hispanic Asian (Asian) respondents. Black respondents reported increased substance use and past 30-day serious consideration of suicide in the previous 30 days more commonly than did white and Asian respondents. Respondents who reported treatment for diagnosed anxiety, depression, or PTSD at the time of the survey reported higher prevalences of symptoms of adverse mental and behavioral health conditions compared with those who did not. Symptoms of a COVID-19–related TSRD, increased substance use, and suicidal ideation were more prevalent among employed than unemployed respondents, and among essential workers than nonessential workers. Adverse conditions also were more prevalent among unpaid caregivers for adults than among those who were not, with particularly large differences in increased substance use (32.9% versus 6.3%) and suicidal ideation (30.7% versus 3.6%) in this group.

Longitudinal analysis of responses of 1,497 persons who completed all three surveys revealed that unpaid caregivers for adults had a significantly higher odds of incidence of adverse mental health conditions compared with others (Table 3). Among those who did not report having started or increased substance use to cope with stress or emotions related to COVID-19 in May, unpaid caregivers for adults had 3.33 times the odds of reporting this behavior in June (adjusted OR 95% CI = 1.75–6.31; p<0.001). Similarly, among those who did not report having seriously considered suicide in the previous 30 days in May, unpaid caregivers for adults had 3.03 times the odds of reporting suicidal ideation in June (adjusted OR 95% CI = 1.20–7.63; p = 0.019).

Discussion

Elevated levels of adverse mental health conditions, substance use, and suicidal ideation were reported by adults in the United States in June 2020. The prevalence of symptoms of anxiety disorder was approximately three times those reported in the second quarter of 2019 (25.5% versus 8.1%), and prevalence of depressive disorder was approximately four times that reported in the second quarter of 2019 (24.3% versus 6.5%) (2). However, given the methodological differences and potential unknown biases in survey designs, this analysis might not be directly comparable with data reported on anxiety and depression disorders in 2019 (2). Approximately one quarter of respondents reported symptoms of a TSRD related to the pandemic, and approximately one in 10 reported that they started or increased substance use because of COVID-19. Suicidal ideation was also elevated; approximately twice as many respondents reported serious consideration of suicide in the previous 30 days than did adults in the United States in 2018, referring to the previous 12 months (10.7% versus 4.3%) (6).

Mental health conditions are disproportionately affecting specific populations, especially young adults, Hispanic persons, black persons, essential workers, unpaid caregivers for adults, and those receiving treatment for preexisting psychiatric conditions. Unpaid caregivers for adults, many of whom are currently providing critical aid to persons at increased risk for severe illness from COVID-19, had a higher incidence of adverse mental and behavioral health conditions compared with others. Although unpaid caregivers of children were not evaluated in this study, approximately 39% of unpaid caregivers for adults shared a household with children (compared with 27% of other respondents). Caregiver workload, especially in multigenerational caregivers, should be considered for future assessment of mental health, given the findings of this report and hardships potentially faced by caregivers.

The findings in this report are subject to at least four limitations. First, a diagnostic evaluation for anxiety disorder or depressive disorder was not conducted; however, clinically validated screening instruments were used to assess symptoms. Second, the trauma- and stressor-related symptoms assessed were common to multiple TSRDs, precluding distinction among them; however, the findings highlight the importance of including COVID-19–specific trauma measures to gain insights into peri- and posttraumatic impacts of the COVID-19 pandemic (7). Third, substance use behavior was self-reported; therefore, responses might be subject to recall, response, and social desirability biases. Finally, given that the web-based survey might not be fully representative of the United States population, findings might have limited generalizability. However, standardized quality and data inclusion screening procedures, including algorithmic analysis of click-through behavior, removal of duplicate responses and scrubbing methods for web-based panel quality were applied. Further the prevalence of symptoms of anxiety disorder and depressive disorder were largely consistent with findings from the Household Pulse Survey during June (1).

Markedly elevated prevalences of reported adverse mental and behavioral health conditions associated with the COVID-19 pandemic highlight the broad impact of the pandemic and the need to prevent and treat these conditions. Identification of populations at increased risk for psychological distress and unhealthy coping can inform policies to address health inequity, including increasing access to resources for clinical diagnoses and treatment options. Expanded use of telehealth, an effective means of delivering treatment for mental health conditions, including depression, substance use disorder, and suicidal ideation (8), might reduce COVID-19-related mental health consequences. Future studies should identify drivers of adverse mental and behavioral health during the COVID-19 pandemic and whether factors such as social isolation, absence of school structure, unemployment and other financial worries, and various forms of violence (e.g., physical, emotional, mental, or sexual abuse) serve as additional stressors. Community-level intervention and prevention efforts should include strengthening economic supports to reduce financial strain, addressing stress from experienced racial discrimination, promoting social connectedness, and supporting persons at risk for suicide (9). Communication strategies should focus on promotion of health services§§§§,¶¶¶¶,***** and culturally and linguistically tailored prevention messaging regarding practices to improve emotional well-being. Development and implementation of COVID-19–specific screening instruments for early identification of COVID-19–related TSRD symptoms would allow for early clinical interventions that might prevent progression from acute to chronic TSRDs. To reduce potential harms of increased substance use related to COVID-19, resources, including social support, comprehensive treatment options, and harm reduction services, are essential and should remain accessible. Periodic assessment of mental health, substance use, and suicidal ideation should evaluate the prevalence of psychological distress over time. Addressing mental health disparities and preparing support systems to mitigate mental health consequences as the pandemic evolves will continue to be needed urgently.

Acknowledgments

Survey respondents; Kristen Holland, Emily Kiernan, Meg Watson, CDC COVID-19 Response Team; Mallory Colys, Sneha Baste, Daniel Chong, Rebecca Toll, Qualtrics, LLC; Alexandra Drane, Sarah Stephens Winnay, Archangels; Emily Capodilupo, Whoop, Inc.; The Kinghorn Foundation; Australian-American Fulbright Commission.

Corresponding author: Rashon Lane for the CDC COVID-19 Response Team, Rlane@cdc.gov.

1Turner Institute for Brain and Mental Health, Monash University, Melbourne, Australia; 2Austin Health, Melbourne, Australia; 3CDC COVID-19 Response Team; 4Brigham and Women’s Hospital, Boston, Massachusetts; 5Harvard Medical School, Boston, Massachusetts; 6University of Melbourne, Melbourne, Australia.

References

1. CDC, National Center for Health Statistics. Indicators of anxiety or depression based on reported frequency of symptoms during the last 7 days. Household Pulse Survey. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2020. https://www.cdc.gov/nchs/covid19/pulse/mental-health.htm
2. CDC, National Center for Health Statistics. Early release of selected mental health estimates based on data from the January–June 2019 National Health Interview Survey. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2020. https://www.cdc.gov/nchs/data/nhis/earlyrelease/ERmentalhealth-508.pdfpdf icon
3. Czeisler MÉ, Tynan MA, Howard ME, et al. Public attitudes, behaviors, and beliefs related to COVID-19, stay-at-home orders, nonessential business closures, and public health guidance—United States, New York City, and Los Angeles, May 5–12, 2020. MMWR Morb Mortal Wkly Rep 2020;69:751–8. CrossRefexternal icon PubMedexternal icon
4. Löwe B, Wahl I, Rose M, et al. A 4-item measure of depression and anxiety: validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population. J Affect Disord 2010;122:86–95. CrossRefexternal icon PubMedexternal icon
5. Hosey MM, Leoutsakos JS, Li X, et al. Screening for posttraumatic stress disorder in ARDS survivors: validation of the Impact of Event Scale-6 (IES-6). Crit Care 2019;23:276. CrossRefexternal icon PubMedexternal icon
6. Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2018 National Survey on Drug Use and Health. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration; 2018. https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHNationalFindingsReport2018/NSDUHNationalFindingsReport2018.pdfpdf iconexternal icon
7. Horesh D, Brown AD. Traumatic stress in the age of COVID-19: call to close critical gaps and adapt to new realities. Psychol Trauma 2020;12:331–5. CrossRefexternal icon PubMedexternal icon
8. Hailey D, Roine R, Ohinmaa A. The effectiveness of telemental health applications: a review. Can J Psychiatry 2008;53:769–78. CrossRefexternal icon PubMedexternal icon
9. Stone D, Holland K, Bartholow B, Crosby A, Davis S, Wilkins N. Preventing suicide: a technical package of policy, programs, and practices. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Injury Prevention and Control; 2017. https://www.cdc.gov/violenceprevention/pdf/suicideTechnicalPackage.pdfpdf icon

TABLE 1. Respondent characteristics and prevalence of adverse mental health outcomes, increased substance use to cope with stress or emotions related to COVID-19 pandemic, and suicidal ideation — United States, June 24–30, 2020

Mark É. Czeisler1,2; Rashon I. Lane, MA3; Emiko Petrosky, MD3; Joshua F. Wiley, PhD1; Aleta Christensen, MPH3; Rashid Njai, PhD3; Matthew D. Weaver, PhD1,4,5; Rebecca Robbins, PhD4,5; Elise R. Facer-Childs, PhD1; Laura K. Barger, PhD4,5; Charles A. Czeisler, MD, PhD1,4,5; Mark E. Howard, MBBS, PhD1,2,6; Shantha M.W. Rajaratnam, PhD1,4,5 (View author affiliations)

View suggested citation

Summary

What is already known about this topic?

Communities have faced mental health challenges related to COVID-19–associated morbidity, mortality, and mitigation activities.

What is added by this report?

During June 24–30, 2020, U.S. adults reported considerably elevated adverse mental health conditions associated with COVID-19. Younger adults, racial/ethnic minorities, essential workers, and unpaid adult caregivers reported having experienced disproportionately worse mental health outcomes, increased substance use, and elevated suicidal ideation.

What are the implications for public health practice?

The public health response to the COVID-19 pandemic should increase intervention and prevention efforts to address associated mental health conditions. Community-level efforts, including health communication strategies, should prioritize young adults, racial/ethnic minorities, essential workers, and unpaid adult caregivers.

https://d1bxh8uas1mnw7.cloudfront.net/assets/embed.js

Altmetric:

Citations:

Views:

Views equals page views plus PDF downloads

The coronavirus disease 2019 (COVID-19) pandemic has been associated with mental health challenges related to the morbidity and mortality caused by the disease and to mitigation activities, including the impact of physical distancing and stay-at-home orders.* Symptoms of anxiety disorder and depressive disorder increased considerably in the United States during April–June of 2020, compared with the same period in 2019 (1,2). To assess mental health, substance use, and suicidal ideation during the pandemic, representative panel surveys were conducted among adults aged ≥18 years across the United States during June 24–30, 2020. Overall, 40.9% of respondents reported at least one adverse mental or behavioral health condition, including symptoms of anxiety disorder or depressive disorder (30.9%), symptoms of a trauma- and stressor-related disorder (TSRD) related to the pandemic† (26.3%), and having started or increased substance use to cope with stress or emotions related to COVID-19 (13.3%). The percentage of respondents who reported having seriously considered suicide in the 30 days before completing the survey (10.7%) was significantly higher among respondents aged 18–24 years (25.5%), minority racial/ethnic groups (Hispanic respondents [18.6%], non-Hispanic black [black] respondents [15.1%]), self-reported unpaid caregivers for adults§ (30.7%), and essential workers¶ (21.7%). Community-level intervention and prevention efforts, including health communication strategies, designed to reach these groups could help address various mental health conditions associated with the COVID-19 pandemic.

During June 24–30, 2020, a total of 5,412 (54.7%) of 9,896 eligible invited adults** completed web-based surveys†† administered by Qualtrics.§§ The Monash University Human Research Ethics Committee of Monash University (Melbourne, Australia) reviewed and approved the study protocol on human subjects research. Respondents were informed of the study purposes and provided electronic consent before commencement, and investigators received anonymized responses. Participants included 3,683 (68.1%) first-time respondents and 1,729 (31.9%) respondents who had completed a related survey during April 2–8, May 5–12, 2020, or both intervals; 1,497 (27.7%) respondents participated during all three intervals (2,3). Quota sampling and survey weighting were employed to improve cohort representativeness of the U.S. population by gender, age, and race/ethnicity.¶¶ Symptoms of anxiety disorder and depressive disorder were assessed using the four-item Patient Health Questionnaire*** (4), and symptoms of a COVID-19–related TSRD were assessed using the six-item Impact of Event Scale††† (5). Respondents also reported whether they had started or increased substance use to cope with stress or emotions related to COVID-19 or seriously considered suicide in the 30 days preceding the survey.§§§

Analyses were stratified by gender, age, race/ethnicity, employment status, essential worker status, unpaid adult caregiver status, rural-urban residence classification,¶¶¶ whether the respondent knew someone who had positive test results for SARS-CoV-2, the virus that causes COVID-19, or who had died from COVID-19, and whether the respondent was receiving treatment for diagnosed anxiety, depression, or posttraumatic stress disorder (PTSD) at the time of the survey. Comparisons within subgroups were evaluated using Poisson regressions with robust standard errors to calculate prevalence ratios, 95% confidence intervals (CIs), and p-values to evaluate statistical significance (α = 0.005 to account for multiple comparisons). Among the 1,497 respondents who completed all three surveys, longitudinal analyses of the odds of incidence**** of symptoms of adverse mental or behavioral health conditions by essential worker and unpaid adult caregiver status were conducted on unweighted responses using logistic regressions to calculate unadjusted and adjusted†††† odds ratios (ORs), 95% CI, and p-values (α = 0.05). The statsmodels package in Python (version 3.7.8; Python Software Foundation) was used to conduct all analyses.

Overall, 40.9% of 5,470 respondents who completed surveys during June reported an adverse mental or behavioral health condition, including those who reported symptoms of anxiety disorder or depressive disorder (30.9%), those with TSRD symptoms related to COVID-19 (26.3%), those who reported having started or increased substance use to cope with stress or emotions related to COVID-19 (13.3%), and those who reported having seriously considered suicide in the preceding 30 days (10.7%) (Table 1). At least one adverse mental or behavioral health symptom was reported by more than one half of respondents who were aged 18–24 years (74.9%) and 25–44 years (51.9%), of Hispanic ethnicity (52.1%), and who held less than a high school diploma (66.2%), as well as those who were essential workers (54.0%), unpaid caregivers for adults (66.6%), and who reported treatment for diagnosed anxiety (72.7%), depression (68.8%), or PTSD (88.0%) at the time of the survey.

Prevalences of symptoms of adverse mental or behavioral health conditions varied significantly among subgroups (Table 2). Suicidal ideation was more prevalent among males than among females. Symptoms of anxiety disorder or depressive disorder, COVID-19–related TSRD, initiation of or increase in substance use to cope with COVID-19–associated stress, and serious suicidal ideation in the previous 30 days were most commonly reported by persons aged 18–24 years; prevalence decreased progressively with age. Hispanic respondents reported higher prevalences of symptoms of anxiety disorder or depressive disorder, COVID-19–related TSRD, increased substance use, and suicidal ideation than did non-Hispanic whites (whites) or non-Hispanic Asian (Asian) respondents. Black respondents reported increased substance use and past 30-day serious consideration of suicide in the previous 30 days more commonly than did white and Asian respondents. Respondents who reported treatment for diagnosed anxiety, depression, or PTSD at the time of the survey reported higher prevalences of symptoms of adverse mental and behavioral health conditions compared with those who did not. Symptoms of a COVID-19–related TSRD, increased substance use, and suicidal ideation were more prevalent among employed than unemployed respondents, and among essential workers than nonessential workers. Adverse conditions also were more prevalent among unpaid caregivers for adults than among those who were not, with particularly large differences in increased substance use (32.9% versus 6.3%) and suicidal ideation (30.7% versus 3.6%) in this group.

Longitudinal analysis of responses of 1,497 persons who completed all three surveys revealed that unpaid caregivers for adults had a significantly higher odds of incidence of adverse mental health conditions compared with others (Table 3). Among those who did not report having started or increased substance use to cope with stress or emotions related to COVID-19 in May, unpaid caregivers for adults had 3.33 times the odds of reporting this behavior in June (adjusted OR 95% CI = 1.75–6.31; p<0.001). Similarly, among those who did not report having seriously considered suicide in the previous 30 days in May, unpaid caregivers for adults had 3.03 times the odds of reporting suicidal ideation in June (adjusted OR 95% CI = 1.20–7.63; p = 0.019).

Discussion

Elevated levels of adverse mental health conditions, substance use, and suicidal ideation were reported by adults in the United States in June 2020. The prevalence of symptoms of anxiety disorder was approximately three times those reported in the second quarter of 2019 (25.5% versus 8.1%), and prevalence of depressive disorder was approximately four times that reported in the second quarter of 2019 (24.3% versus 6.5%) (2). However, given the methodological differences and potential unknown biases in survey designs, this analysis might not be directly comparable with data reported on anxiety and depression disorders in 2019 (2). Approximately one quarter of respondents reported symptoms of a TSRD related to the pandemic, and approximately one in 10 reported that they started or increased substance use because of COVID-19. Suicidal ideation was also elevated; approximately twice as many respondents reported serious consideration of suicide in the previous 30 days than did adults in the United States in 2018, referring to the previous 12 months (10.7% versus 4.3%) (6).

Mental health conditions are disproportionately affecting specific populations, especially young adults, Hispanic persons, black persons, essential workers, unpaid caregivers for adults, and those receiving treatment for preexisting psychiatric conditions. Unpaid caregivers for adults, many of whom are currently providing critical aid to persons at increased risk for severe illness from COVID-19, had a higher incidence of adverse mental and behavioral health conditions compared with others. Although unpaid caregivers of children were not evaluated in this study, approximately 39% of unpaid caregivers for adults shared a household with children (compared with 27% of other respondents). Caregiver workload, especially in multigenerational caregivers, should be considered for future assessment of mental health, given the findings of this report and hardships potentially faced by caregivers.

The findings in this report are subject to at least four limitations. First, a diagnostic evaluation for anxiety disorder or depressive disorder was not conducted; however, clinically validated screening instruments were used to assess symptoms. Second, the trauma- and stressor-related symptoms assessed were common to multiple TSRDs, precluding distinction among them; however, the findings highlight the importance of including COVID-19–specific trauma measures to gain insights into peri- and posttraumatic impacts of the COVID-19 pandemic (7). Third, substance use behavior was self-reported; therefore, responses might be subject to recall, response, and social desirability biases. Finally, given that the web-based survey might not be fully representative of the United States population, findings might have limited generalizability. However, standardized quality and data inclusion screening procedures, including algorithmic analysis of click-through behavior, removal of duplicate responses and scrubbing methods for web-based panel quality were applied. Further the prevalence of symptoms of anxiety disorder and depressive disorder were largely consistent with findings from the Household Pulse Survey during June (1).

Markedly elevated prevalences of reported adverse mental and behavioral health conditions associated with the COVID-19 pandemic highlight the broad impact of the pandemic and the need to prevent and treat these conditions. Identification of populations at increased risk for psychological distress and unhealthy coping can inform policies to address health inequity, including increasing access to resources for clinical diagnoses and treatment options. Expanded use of telehealth, an effective means of delivering treatment for mental health conditions, including depression, substance use disorder, and suicidal ideation (8), might reduce COVID-19-related mental health consequences. Future studies should identify drivers of adverse mental and behavioral health during the COVID-19 pandemic and whether factors such as social isolation, absence of school structure, unemployment and other financial worries, and various forms of violence (e.g., physical, emotional, mental, or sexual abuse) serve as additional stressors. Community-level intervention and prevention efforts should include strengthening economic supports to reduce financial strain, addressing stress from experienced racial discrimination, promoting social connectedness, and supporting persons at risk for suicide (9). Communication strategies should focus on promotion of health services§§§§,¶¶¶¶,***** and culturally and linguistically tailored prevention messaging regarding practices to improve emotional well-being. Development and implementation of COVID-19–specific screening instruments for early identification of COVID-19–related TSRD symptoms would allow for early clinical interventions that might prevent progression from acute to chronic TSRDs. To reduce potential harms of increased substance use related to COVID-19, resources, including social support, comprehensive treatment options, and harm reduction services, are essential and should remain accessible. Periodic assessment of mental health, substance use, and suicidal ideation should evaluate the prevalence of psychological distress over time. Addressing mental health disparities and preparing support systems to mitigate mental health consequences as the pandemic evolves will continue to be needed urgently.

Acknowledgments

Survey respondents; Kristen Holland, Emily Kiernan, Meg Watson, CDC COVID-19 Response Team; Mallory Colys, Sneha Baste, Daniel Chong, Rebecca Toll, Qualtrics, LLC; Alexandra Drane, Sarah Stephens Winnay, Archangels; Emily Capodilupo, Whoop, Inc.; The Kinghorn Foundation; Australian-American Fulbright Commission.

Corresponding author: Rashon Lane for the CDC COVID-19 Response Team, Rlane@cdc.gov.

1Turner Institute for Brain and Mental Health, Monash University, Melbourne, Australia; 2Austin Health, Melbourne, Australia; 3CDC COVID-19 Response Team; 4Brigham and Women’s Hospital, Boston, Massachusetts; 5Harvard Medical School, Boston, Massachusetts; 6University of Melbourne, Melbourne, Australia.

References

1. CDC, National Center for Health Statistics. Indicators of anxiety or depression based on reported frequency of symptoms during the last 7 days. Household Pulse Survey. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2020. https://www.cdc.gov/nchs/covid19/pulse/mental-health.htm
2. CDC, National Center for Health Statistics. Early release of selected mental health estimates based on data from the January–June 2019 National Health Interview Survey. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2020. https://www.cdc.gov/nchs/data/nhis/earlyrelease/ERmentalhealth-508.pdfpdf icon
3. Czeisler MÉ, Tynan MA, Howard ME, et al. Public attitudes, behaviors, and beliefs related to COVID-19, stay-at-home orders, nonessential business closures, and public health guidance—United States, New York City, and Los Angeles, May 5–12, 2020. MMWR Morb Mortal Wkly Rep 2020;69:751–8. CrossRefexternal icon PubMedexternal icon
4. Löwe B, Wahl I, Rose M, et al. A 4-item measure of depression and anxiety: validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population. J Affect Disord 2010;122:86–95. CrossRefexternal icon PubMedexternal icon
5. Hosey MM, Leoutsakos JS, Li X, et al. Screening for posttraumatic stress disorder in ARDS survivors: validation of the Impact of Event Scale-6 (IES-6). Crit Care 2019;23:276. CrossRefexternal icon PubMedexternal icon
6. Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2018 National Survey on Drug Use and Health. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration; 2018. https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHNationalFindingsReport2018/NSDUHNationalFindingsReport2018.pdfpdf iconexternal icon
7. Horesh D, Brown AD. Traumatic stress in the age of COVID-19: call to close critical gaps and adapt to new realities. Psychol Trauma 2020;12:331–5. CrossRefexternal icon PubMedexternal icon
8. Hailey D, Roine R, Ohinmaa A. The effectiveness of telemental health applications: a review. Can J Psychiatry 2008;53:769–78. CrossRefexternal icon PubMedexternal icon
9. Stone D, Holland K, Bartholow B, Crosby A, Davis S, Wilkins N. Preventing suicide: a technical package of policy, programs, and practices. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Injury Prevention and Control; 2017. https://www.cdc.gov/violenceprevention/pdf/suicideTechnicalPackage.pdfpdf icon

TABLE 1. Respondent characteristics and prevalence of adverse mental health outcomes, increased substance use to cope with stress or emotions related to COVID-19 pandemic, and suicidal ideation — United States, June 24–30, 2020

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WHAT IS PBIS?

Positive Behavioral Interventions and Supports (PBIS) is an evidence-based three-tiered framework to improve and integrate all of the data, systems, and practices affecting student outcomes every day. PBIS creates schools where all students succeed.

TIER 1

Tier 1 practices and systems establish a foundation of regular, proactive support while preventing unwanted behaviors. Schools provide these universal supports to all students, school-wide.

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TIER 2

Tier 2 practices and systems support students who are at risk for developing more serious problem behaviors before those behaviors start. These supports help students develop the skills they need to benefit from core programs at the school.

Learn More

TIER 3

At Tier 3, students receive more intensive, individualized support to improve their behavioral and academic outcomes. At this level, schools rely on formal assessments to determine a student’s need.

Learn More

WHAT IS PBIS?

Positive Behavioral Interventions and Supports (PBIS) is an evidence-based three-tiered framework to improve and integrate all of the data, systems, and practices affecting student outcomes every day. PBIS creates schools where all students succeed.

TIER 1

Tier 1 practices and systems establish a foundation of regular, proactive support while preventing unwanted behaviors. Schools provide these universal supports to all students, school-wide.

Learn More

TIER 2

Tier 2 practices and systems support students who are at risk for developing more serious problem behaviors before those behaviors start. These supports help students develop the skills they need to benefit from core programs at the school.

Learn More

TIER 3

At Tier 3, students receive more intensive, individualized support to improve their behavioral and academic outcomes. At this level, schools rely on formal assessments to determine a student’s need.

Learn More

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