From dining out at restaurants with her partner and relatives to attending book clubs with friends, Susan Kemp had an active social life before Covid-19. Since April, she’s only left her apartment near Stockholm five times, after experiencing a huge increase in social anxiety and germaphobia-based obsessive compulsive behaviours during the pandemic.
“It's like this extra stress makes me pass a breaking point that I was able to regulate better before,” says Kemp, a copywriter and part-time student in her thirties. She’s become petrified of taking public transport, more concerned about the cleanliness of cutlery and glasses and finds images of coronavirus cells triggering. “The main symptom is I start crying. I very much feel like I'm going to die, and then I cry one of those cries where your body and lungs feel sore afterwards,” she says. This is coupled with a strong disappointment that she’s “regressed” and a fear it could take years to get back on track when it comes to managing her OCD.
While plenty of us have become a little more anxious during Covid-19, Kemp’s experiences highlight that for some, the pandemic has either sparked or amplified much more serious mental-health problems. And psychologists are increasingly raising concerns these may linger in the longer term.
Steven Taylor, author of The Psychology of Pandemics, and professor in psychiatry at the University of British Columbia, argues that “for an unfortunate minority of people, perhaps 10 to 15%, life will not return to normal”, due to the impact of the pandemic on their mental wellbeing. Australia’s Black Dog Institute, a leading independent mental-health research organisation, has also raised concerns about “a significant minority who will be affected by long-term anxiety”. In the UK, a group of leading public health specialists recently warned in the British Medical Journal that “the mental health impact of the pandemic is likely to last much longer than the physical health impact”.
Learning from history
One reason psychologists are concerned about the potential long-term impact of Covid-19 is existing insights from previous pandemics and national emergencies.
The SARS global outbreak in 2003 was associated with a 30% increase in suicides in people over the age of 65. Strategies like quarantine that are necessary to minimise viral spread can have a negative psychological impact, such as causing post-traumatic stress symptoms, depression and insomnia. Job loss and financial struggles during a global economic downturn have been associated with a long-lasting decline in mental health.
“Historically, the adverse mental health effects of disasters impact more people and last much longer than the health effects,” explains Joshua C Morganstein, assistant director at the Centre for the Study of Traumatic Stress in Maryland, US. “If history is any predictor, we should expect a significant ‘tail’ of mental health needs that continue long after the infectious outbreak resolves.”
One key piece of research he points to is a 25-year retrospective review of the impact of the Chernobyl nuclear accident in Ukraine. Researchers found that two decades later, first responders had elevated rates of depression and post-traumatic stress disorder (PTSD). They also concluded that mental health effects were the most significant consequence of the disaster, which led to thousands of deaths and deeply damaged the region’s economy. Similarly, research suggests mental health problems, particularly psychological distress and PTSD, remained an issue for people who lost their homes during Hurricane Katrina in New Orleans, five years after the 2005 disaster. This was exacerbated among those who had poor mental health or a low income before the hurricane.
What long-term problems will be linked to Covid-19?
As for which mental health issues connected to the Covid-19 pandemic are most likely to last in the longer term, psychologists believe obsessive-compulsive disorder could be one of the main candidates.
Taylor explains that this could have a long-term impact, due to the fact that OCD arises from an interaction between genes and environmental factors. “For people with a genetic predisposition toward some forms of OCD (i.e. contamination obsessions and cleaning compulsions) the stress of Covid-19 is likely to trigger or worsen OCD,” he says. “Some of these people will become chronic germaphobes unless they receive appropriate mental health treatment.”
Alongside OCD, which is a manifestation of anxiety, “general anxiety is also a very important mental health issue to watch out for”, adds Yuko Nippoda, a psychotherapist and spokesperson for the UK Council for Psychotherapy. “There are many people who suffer from anxiety already in our modern society, but because of this deadly disease, people who tend to feel anxious more easily will continue to feel this and the condition might worsen,” she says. “Even when the Covid pandemic ends, some people might be over-anxious, because of the threat of a variant strain.”
Chronic loneliness brought on by social isolation or “a lack of meaning” in life during the pandemic is another major concern, says Nippoda. Some people have involuntarily found themselves with fewer close connections in the age of social-distancing and may find it challenging to rebuild their networks. Others deliberately withdrew from the outside world to feel “a sense of safety” and may become resistant to increasing their social interactions in the future, says Nippoda. “When people experience stress in the outside world, they can detach themselves from that world. Once they experience this detachment, it might be difficult for them to come out into the world and socialise with others.”
Meanwhile, the stress of living through Covid-19 is likely to have a greater ongoing mental toll on those who have had painful life experiences in the past. “It might trigger the memory of the trauma consciously and unconsciously, which can affect you. In this case, the mental health conditions can become long-term, as it can open the lid of the trauma,” explains Nippoda.
“I just have this constant fear of losing someone again,” says 35-year-old Lindsey Higgins from New York, who lost a partner to suicide in 2014 and has already experienced a resurgence in PTSD since the arrival of the pandemic. After several years of counselling, she felt like “life was moving forward”, but now finds herself “very nervous” every time her new partner leaves the house. “Obviously, you know, he's not going to die when he's out. But there's still that fear that something can happen, that he could get it [Covid-19] and get very sick. And it's the same with family and friends.”
Ongoing unemployment or loss of income (caused by the knock-on economic effects of the pandemic) may affect long-term wellbeing, too. Numerous pre-Covid-19 studies link these factors to depression, stress or suicidal thoughts. Recent polling data from the US found that more than half of those who were jobless or had their income reduced during the pandemic had already reported negative mental health impacts, with even higher rates amongst those on lower salaries.
Psychologists stress that the unprecedented nature and scale of the coronavirus crisis adds an additional layer of uncertainty compared to previous financial crises. Until there’s a global vaccine, it remains unclear when or even if some of the most badly-hit industries such as travel and entertainment will recover. Nippoda suggests this presents an especially challenging situation for people who “are not good at dealing with uncertainty” or struggle to handle situations they can’t control. “We are living in uncertain times at the moment. Some people even have fear towards uncertainty and the unknown. This fear can be prolonged.”
What we still need to learn
History will be the judge of how many of these warnings and predictions end up ringing true. Various bodies around the world have already created guidelines to address the issue. Earlier this year, the World Health Organization published recommendations for safeguarding mental health, and similar guidelines have been issued by government agencies in the US, UK and other countries. This month, the American Psychological Association published a report on the long-term stress-related impacts of the pandemic, and how people can better cope during this period of uncertainty.
Researchers are also gathering empirical data which they hope will provide a better grasp of the long-term mental health side effects of this unique crisis, and therefore how to manage it. Major UK studies are looking specifically at the mental health of patients hospitalised with Covid-19 and nurses working on the front line. In Sweden, researchers at the Centre for Psychiatric Research in Stockholm are conducting a year-long project involving more than 3,000 people with pre-existing mental health conditions, including depression, anxiety and OCD. An Australian nationwide survey by the Matilda Centre for Research in Mental Health in Sydney is measuring the impact of the pandemic on the ongoing mental health and wellbeing of the general population.
“There is concern that mental-health problems may rise or are rising, but this needs to be better understood,” says Nitya Jayaram-Lindström, operations manager for the Stockholm project. She says the Swedish research will focus on how much Covid-19 may have exacerbated existing mental health inequalities, how patients’ symptoms develop or change over the next year and which groups are worst affected. “We also want to understand factors that contribute to resilience, which is as important to understand as the risk factors.”
At the Centre for the Study of Traumatic Stress in Maryland, Joshua C Morganstein argues that these sorts of projects will be an essential resource for both healthcare providers and governments. “Health surveillance of various populations to better understand these aspects of risk is essential for us to provide interventions and plan for subsequent pandemic waves as well as future public health emergencies,” he says. “Stress is like a toxin, such as lead or radon. In order to understand it and how it is affecting a society, we need to know who is exposed, when, how much and what effects were caused by the exposure.” Although there is little data so far, Morganstein predicts that long-term studies are likely to further expose the wellbeing disparities across race, gender and income which have already been highlighted during the pandemic, and need to be taken into deeper consideration when developing future responses.
Resilience and hope
Despite ongoing concerns about the long ‘tail’ of mental health challenges caused by the impact of Covid-19, psychiatrists say it’s important to recognise there are some positive takeaways, too.
Taylor argues that while a significant minority may struggle long-term, the pandemic has highlighted high levels of resilience to stress in the wider population, alongside humans’ capacity to “bounce back” after catastrophic events. For instance, in Wuhan, where the pandemic first started and cases were brought under control after a strict 76-day lockdown and mass testing, the city staged a massive water-park music festival in August. Thousands of people crowded together shoulder to shoulder, with no masks and zero social distancing. Large gigs also returned in New Zealand after community transmission of the virus was curbed. These kind of events have taken place, Taylor reflects, despite a fatalistic mood at the start of 2020, when “many people doubted that life would return to normal, and some speculated about a grimly Dickensian post-pandemic world”. He believes that “similar events will likely occur elsewhere in the world when the pandemic is over”.
Psychotherapist Nippoda points out that for some people, the adverse circumstances of the pandemic have actually had a “remarkably positive impact” on their mental health, which may also be long lasting. The experience of lockdown, she argues, helped reduce anxiety levels or stop panic attacks among some who had high levels of stress in the outside world before the pandemic. This is because they felt a greater sense of freedom and safety by spending more hours at home. Although there is a risk of social isolation and loneliness for those who retreat too much, she says that this enforced time indoors has encouraged some to strive for a better work-life balance in the future or to “take their own pace in life” when it comes to socialising – by finding “their own comfort zone within the boundaries between indoors and outdoors”.
Others have used the era of social-distancing to declutter their homes, and "the new space within the home has been reflected positively within their mind, almost as if they were able to tidy up the complications in their head”, says Nippoda. Increased time for hobbies, especially making and doing things from scratch, is also thought to have provided a sense of satisfaction, fulfilment and stress-relief for many.
But these sorts of experiences ring hollow for people like germaphobe Susan Kemp in Stockholm who are still struggling to visualise an end to their more acute mental health challenges connected to the pandemic. “Clearly there needs to be some balance between being careful and being an absolute hermit that I’m not able to achieve,” she laments. “But I irrationally can't get over my fear. It's very hard these days to decide when I'm being rational and when I am not.”
“I find it really, really difficult to rebalance myself,” agrees American PTSD sufferer Lindsey Higgins, who says she’s unsure her symptoms will improve even if scientists develop a vaccine. “It is going to take time to distribute, and even longer to convince people they should even take the vaccine. Honestly, I'm not sure I'll ever really feel secure again.”