Anxiety as a Public Health Issue

••• As the Covid-19 pandemic unfolds, many of us are feeling the strain on our mental health. Some people feel […]

Anxiety as a Public Health Issue

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As the Covid-19 pandemic unfolds, many of us are feeling the strain on our mental health. Some people feel anxiety about getting laid off; others have to continue to work at grocery stores and delivery companies, or perform other essential services, sometimes without the protections they need to stay safe. Families are trying to balance caregiving with remote work. We all worry about someone we love getting sick or about getting sick ourselves. There’s also the sudden instability of it all, as the pandemic upends global systems that many took for granted. Meanwhile, the social distancing measures we are taking to slow the spread of the disease have meant weeks of confinement, which brings its own anxieties.

In our concern for the physical risks of this pandemic, it is easy to overlook the mental health burden many of us feel. We may even be inclined to minimize our anxiety, thinking that, compared with what Covid-19 can do to our bodies, its effect on our minds is a lesser concern.

This would be a mistake. Mental health is public health, and the mental health burden of the pandemic deserves as much attention as its physical toll. We are collectively experiencing a large-scale traumatic event. Anxiety is part of a larger family of mental health challenges — including depression and post-traumatic stress disorder (PTSD) — that are often consequences of such events. While there is much we have yet to learn about Covid-19, there is ample research documenting the link between similar large-scale collective traumas and mental health consequences. Wars, terror attacks, natural disasters, and past disease outbreaks have all been studied and can teach us about the near- and long-term mental health effects of catastrophic and destabilizing moments in time.

I have spent my career in public health studying such events and their mental health consequences. This work has taught me seven key points that can help us understand and mitigate mental health consequences during this pandemic, and in the months and years to come.

1. Evidence suggests an increase in mental illness after traumatic events.

Past collective traumas reveal an increase in mental health challenges across an entire population. After the September 11, 2001, terror attacks, for example, approximately one in 10 persons in the New York area likely met the full criteria for PTSD related to the attacks, and many more of them probably felt significantly increased anxiety in some form. Following the 2003 severe acute respiratory syndrome (SARS) outbreak, there was a high prevalence of psychological distress among quarantined populations, including higher levels of depression and PTSD. And nearly half of New Orleans residents suffered from anxiety and mood disorders in the wake of Hurricane Katrina. This data reflects the mental health burden of such events.

2. Emerging evidence from Covid-19 is consistent with the effects of previous traumatic events.

Covid-19 will likely be no different from these past traumas. We have already begun seeing data on the mental health burden of this pandemic. A recent study, for example, found a high prevalence of depression and anxiety associated with frequent social media exposure. This reflects another complicating factor of the outbreak: It is unfolding in the social media age. We are still learning how new technologies — with their potential to connect us but also to keep the crisis on our screens at every waking moment — are mediating the mental health effects of the pandemic.

3. Economic downturns compound mental health strains.

Income and health are closely linked — how much money we have is one of the best predictors of how healthy we are able to be. Consequently, when the economy suffers, so does public health. In a study of economic conditions and suicide rates in New York State that I coauthored, for example, we found that the predicted rate of suicide was lower when economic activity was at its peak than when it was at its nadir. The Great Recession, for its part, was linked with reduced self-rated health, including anxiety and psychological distress. Given the economic consequences we have already seen emerge from this pandemic — falling stocks, lost wages, and millions filing for unemployment — and the potential for even greater shocks down the road, including another depression, we would do well to prepare for the mental health costs.

4. Ongoing socioeconomic stressors can extend the window for developing mental health issues.

Traumatic events do not unfold in isolation, and neither do their mental health effects. They occur in a given socioeconomic context, which mediates the duration and intensity of their consequences. We saw this after Hurricane Katrina. The event itself created mental health concerns, but so did the economic fallout after the hurricane ended, for those who lost homes and jobs. All of these factors played a role in shaping PTSD risk well beyond the actual weather event, and especially for those who were most vulnerable to the sudden change in socioeconomic conditions.

While we cannot always prevent disasters, public health interventions can address the conditions that shape them. Poor health outcomes, both mental and physical, are a result of underlying conditions that public health officials track and try to mitigate. To diminish the consequences of known hazards — hurricanes, for example, or viruses — we need to build structures that foster better health outcomes, including provisions for safe housing, gender equity, livable wages, clean air, and drinkable water, among others. These are the pillars that create a healthy world.

5. Mental health is inseparable from physical health.

Although we often treat them as separate categories, mental and physical health are closely linked. Poor physical health can mean poor mental health, and vice versa. A study of PTSD and type two diabetes among women that I co-conducted found that women with the highest number of PTSD symptoms had a nearly twofold increased risk of developing type two diabetes compared to women without traumatic exposure. And the link between depression, trauma, and substance use is well documented — there are, for example, strong links between childhood trauma, PTSD, and substance use disorders. Generalized anxiety is associated with many poor health outcomes as well. These connections suggest how supporting mental health in this time of Covid-19 means acknowledging how underlying physical health challenges like chronic disease can contribute to mental health challenges like anxiety and PTSD.

6. Mental health consequences can be long term and lasting.

This pandemic will not last forever. Eventually, Covid-19 will run its course; a vaccine will be developed and distributed. Even if it never fully goes away, we will see the end of this period of acute crisis. However, the mental health effects of a traumatic event can last for many years — even a lifetime. In a study of psychopathology in postconflict Nimba County, Liberia, conducted nearly 20 years after primary conflict in the area, my coauthors and I found that the geographic patterns of PTSD were consistent with where fighting had taken place all those years before. Examples like this show the importance of having structures in place to support the mental health consequences that will emerge from this pandemic, in both the near and long term — from general anxiety all the way to full PTSD.

7. We can mitigate some of these consequences.

Most important: Because we know to a degree what’s coming, we don’t have to wait to start addressing mental health. We can take steps to mitigate anxiety, depression, and PTSD now. These steps include ensuring that professional mental health services are widely accessible via telemedicine and hotlines. Perhaps more ambitiously, and in what is an emerging effort in public health, online data tracking could be used to identify at-risk individuals and send them mental health resources the same way we now send targeted ads. Machine learning can be put to work here to leverage the unprecedented technological environment in which this crisis is unfolding into better health outcomes, rather than allowing it to simply exacerbate mental health challenges through the anxiety social media can sometimes amplify.

Beyond the importance of health care services and technology is the importance of building support to get us through these challenging times. We can support others’ mental health by finding ways to reach out to friends, family, neighbors, and people who may be especially vulnerable to Covid-19 or who are acutely feeling the loneliness that can accompany physical distancing.

Companies, too, can play a role in helping their employees with the same challenges. First, they can educate employees by talking about mental health, including making it clear that mental health symptoms are anticipated and expected during and after an event like this. They can make resources available for employees to talk about normal anxiety and sadness, and if the symptoms begin to impair daily functioning. They can also make sure that there are mental health service providers employees can reach out to if they are struggling with mental illness.

Ultimately, a society founded on support and built on compassion during challenging times is a strong one — one in which health, both physical and mental, can flourish.The Big Idea

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