How Is COVID Harming Our Mental Health?
Charlotte doctors, officials weigh pandemic’s damage—and try to stay well themselves
Even before the virus, Julia Prentice felt as if the world would end. She’d suffered from severe depression for years—a product, she says, of a “complicated family situation” as she grew up. She had managed it, though, even through her cross-country move with her husband, Edward, from the San Francisco Bay Area to Charlotte in March 2019. She’d found a new therapist as well, and it was after one especially intense session in December when an anxiety attack landed on her like a judgment.
As Prentice walked toward her car in the clinic parking lot, she suddenly began to cry and couldn’t stop. She couldn’t catch her breath and felt certain she would die. Prentice calmed herself enough to drive the short distance to her home in Ballantyne, but more anxiety attacks followed, and her therapist was booked for the next two weeks.
Through online research, Prentice discovered HopeWay, a nonprofit mental and behavioral health center in south Charlotte that opened in 2016. She stayed there as a patient for 10 days, then visited every day as an outpatient through February. By early March, she felt better. Her anxiety attacks largely ceased—just in time for the disruption and fear that COVID-19 ushered in.
Prentice worried about herself, as an asthmatic and, at 65, a member of a high-risk age group. She had planned to visit her 89-year-old mother—in assisted living in St. Petersburg, Florida, and suffering from dementia—on March 16. Now that was canceled, and Prentice worried about her, too. “There was an increase in anxiety, not to be unexpected,” she says. “I was more anxious and more depressed because I was cut off from my normal routine.”
Given her age and asthma, plus the general uncertainty about COVID, Prentice didn’t want to risk trips to the grocery store. Like most of us in late March, she stayed in her house, and the less she could leave the house, the less she wanted to. “There was very little structure at home,” she says. “I was doing pretty much nothing.” Depression crept back, coupled with anxiety about the present and future—an understandable response to a lethal pandemic but nothing Prentice wanted to test.
She got back in touch with HopeWay and learned that the center had set up a virtual connection to its Intensive Outpatient Program to accommodate patients under lockdown. She began a new round of therapy April 3, this time with a more clearly defined reason for her symptoms.
COVID, a potentially lethal physical threat, hammers at mental and behavioral health in ways that amplify and compound each other. People fear contracting the virus. They isolate themselves to reduce those odds, which worsens the depression and anxiety they already feel or, over time, induces it in people who’ve never felt it before. Isolation deprives people of companionship, a basic human need and one of the traditional and most effective ways to combat depression and anxiety.
The COVID lockdown led to job losses that deepen the mental strain and rob people of the means to get help. Even in families with no loss of income, members are in closer quarters than they’re used to, which elevates the likelihood of family squabbles and domestic violence, which add to the stress. To relieve it, some people retreat into alcohol and drug abuse, which also contributes to stress. The United States fractures along social, political, and racial lines as it approaches a monumental presidential election. Some Americans take health precautions in public; some don’t. No one knows when a COVID vaccine will be available, or at what cost, or how effective it might be. No one knows when, or whether, life will return to anything that resembles the lives we led before March.
In late June, the Centers for Disease Control conducted a nationwide survey of adults to determine the effects of COVID on mental health. Forty-one percent reported at least one condition, like depression or anxiety, created by the virus. More than 25 percent of respondents aged 18 to 24 reported having “seriously considered suicide” in the 30 days before the survey.
“The human psyche is just not built for stress over this long a period of time,” says Dr. James Rachal, the academic chair of the psychiatry department at Atrium Health in Charlotte. “I think what we’re going to see, the longer this illness goes on, is more and more cases coming in.”
As of September, physicians and public health officials in Charlotte and statewide were still trying to grasp how many people suffered from COVID-related mental health issues and, besides treating them as well as they could, what to do about it. It’s a difficult, perhaps impossible, task. State and county officials know only what hospitals, doctor’s offices, clinics, and in some cases law enforcement report to them, and they believe long months of lockdown have prevented or dissuaded people from seeking help. “I would love it—and people think we have it—if we had some sort of master data set that tells me everything that’s going on in Mecklenburg County,” says Dr. Raynard Washington, the county’s deputy health director. “We are seeing some impacts, but this could just be the tip of the iceberg. It could be the whole thing. I don’t know.”
What they know is alarming enough. In late July, the state Department of Health and Human Services announced that reports of depression and anxiety symptoms statewide had tripled, and that hospital emergency departments had reported a 15-percent rise in visits for opioid overdoses. That increase has wiped out many of the state’s gains over the years in combating opioid addictions, said Victor Armstrong, who directs the DHHS division that oversees mental health and substance abuse.
Moreover, he said, the effects of the pandemic have “highlighted preexisting health disparities” among North Carolinians—meaning that the poor and racial minorities, who struggled to gain access to limited resources before, struggle even more under COVID, in part because mental and behavioral health services tend to locate in affluent areas. The state and county maintain contracts with organizations that provide services to Medicaid patients and those with limited or no health insurance. They’re not enough.
“What we have always known is that behavioral health was under-resourced, and it was an under-resourced space before the pandemic,” Armstrong tells me in August. “We don’t have nearly enough funding in the behavioral health space. So to say that those organizations have all the resources they need, I would say absolutely not.”
The crisis has yielded a few unexpected benefits. As of early September, Mecklenburg County planned to use nearly $2 million in federal CARES Act funds to make behavioral health services available to the public regardless of ability to pay; the county will extend the services only until the end of 2020, but the program could serve as a blueprint for a similar county program in the future. Also, hospitals and private clinics have reported surprising results from an expanded use of virtual platforms as a substitute for in-person visits. Atrium’s no-show rate for mental and behavioral health services has dropped from close to 20 percent to about 5 percent, Rachal says. Mental health professionals still have backlogs, but in some cases, they’re seeing more patients under COVID than before.
Overall, though, the picture is bleak, and doctors and therapists can only guess at the long-term ramifications. And they have themselves to worry about: The number of Atrium employees who have sought mental health services through the company’s Employee Assistance Program, Rachal says, has more than doubled since spring.
Dr. Alyson Kuroski-Mazzei, HopeWay’s CEO and chief medical officer and the North Carolina Psychiatric Association’s president-elect, tells me she recently received a text from her 71-year-old father, who told her he’d never imagined anything like this. The holidays will be particularly hard on people, Kuroski-Mazzei says, “especially if they can’t be with family. Even my family was like, ‘Should we drive to Chicago to see our parents?’ My husband has an elderly mom, and he’s worried he might not see her again.
“The mental health system has been fragmented and challenged for so, so long, and now this is just on top of that,” she says. “We will continue to see a tsunami of mental health effects from this. It’s overwhelming.”
Jaren Doby has kept his psyche and body in shape by setting up a makeshift gym in his garage and sticking to a strict exercise regimen, which includes regular walks with his fiancée and their 8-year-old daughter. At 35, he’s been a therapist at Novant Health Psychiatric Associates in Huntersville for a little more than a year, long enough to register the difference between clients’ pre- and post-COVID emotional states. “Folks are afraid,” Doby tells me in August. “This is something they have never seen or experienced before.”
Exercise helps, he knows; so does time spent with loved ones. He’s found a way to combine the two. The Greensboro native has also reached out more than usual to his Alpha Phi Alpha fraternity brothers from UNC Greensboro, just to check in with them and see how they’re doing. Taking time to care for his own body and spirit “is everything to me,” he says. “It really is, and it keeps me in the position to continue to serve people.”
Doby is part of a team of 45 mental health providers divided among six Novant outpatient clinics in the Charlotte area. Like Atrium, Novant has leaned heavily on virtual services, which have helped them see more patients. But the hospital system caps therapists’ sessions at 40 per week, and Doby says everyone’s schedule is full—with established patients whose symptoms have returned and with new patients who struggle with symptoms for the first time.
The mental and emotional pressure cascades and touches everyone. “This is something that I’ve told anybody who’ll listen: We are so much better together,” he says. “Talk to each other. Utilize your supports. It is imperative—imperative—that we understand that it is only through togetherness and looking out for our fellow man and woman that we are able to get through this. We must stick together and support one another.”
A half-year of COVID has forced another realization for mental health professionals: The minimal, disjointed “system” doesn’t come close to meeting the need in a crisis this profound, and administrators and public officials have to make services more accessible and affordable. “When you’re going through a crisis,” Kuroski-Mazzei says, “you don’t want to wait three weeks to three months to see a psychiatrist.”
It’s far from clear what those changes might be. Doctors and administrators are still trying to manage the immediate crisis. It could be months before they have more reliable data. But in general, they expect a fresh wave of mental and behavioral health cases as people continue to live with heightened stress and isolation. Emergency doctors, nurses, and other front-line health care workers will need help managing the long-term strain and risk to themselves and their families. “And on top of that, we’re going to see a new crop of uninsured and underinsured folks because of the job market and the economy,” says Armstrong, a former Atrium vice president who began work at DHHS in March.
“I don’t think any of us went into this pandemic thinking that we would be where we are today. I know when I came into this role four or five months ago, I thought I would be, you know, probably in social isolation for 30 days, maybe six weeks. Who knew that five months later, we’d be where we are now? I do think that we’ll come out on the other side of this as a better behavioral health system. It’s just that there’ll be a lot of growing pains in getting there.”
The HopeWay virtual therapy, though welcome, limited what Julia Prentice and her fellow patients could do. On-site, they could realize the therapeutic benefits of exploring the 12-acre property; at home, Prentice had to adjust. HopeWay makes use of horticultural therapy, which gets patients outdoors to identify nearby plants and trees, a type of nature immersion. Under virtual therapy, HopeWay had patients explore at and near their homes. “That’s how they got us to be back in the mode of thinking about our lives,” she tells me.
Over the next 21 days, Prentice gradually felt like a healthier version of herself. She’s an artist and poet, but she’d never thought of art exclusively as a form of therapy. She began to paint in oil pastels, supplementing it with yoga and more therapy through a pair of online support groups. Structure helped; she no longer felt as if she was floating in the blackness of space. Her depression has eased, and she’s had only a couple of “very small” anxiety attacks since spring.
“I think my mental state is as good as it normally is,” Prentice tells me. “It’s just being impacted by the pandemic, in the situations that we’re in as a result of that. But I feel I’m in a very good space right now, and I do attribute a large part of that to the treatment at HopeWay.”
On April 27, three days after she stopped treatment, Prentice posted a poem, “Enter April,” to her WordPress site. Its concluding lines:
when will you exit, will i exit you?
a doozy of a month, this April
seems as long as a year—why?
there’s a pandemic, don’t you know—
and it’s not done yet …
She explains that in spring, time felt elongated, endless. “It was also a sense of, ‘Man, I could be ending myself,’ not necessarily in the sense of suicide, but in a sense of, ‘I’m just going to give up at this point; I don’t want to do anything because of the way this is all going.’ That was the sense then. It’s not so much the sense now.”
What is? “The sense now is that I have activities that I like to do. I have my connections with people, family and friends, and peer support, and I am enjoying the activities that I normally enjoy,” she says. “So this is a good thing. And I’m smiling right now.”
Greg Lacour is the senior editor for this magazine.
IF YOU NEED HELP
Charlotte-area organizations that can provide direct mental health services or referrals:
National Alliance on Mental Illness (NAMI) Charlotte: namicharlotte.org, 704-333-8218
HopeWay: hopeway.org, 844-HOPEWAY
Cardinal Innovations (for Medicaid and indigent patients): 704-939-7700; 800-939-5911 (crisis line)
Atrium Health 24-hour help line: 704-444-2400
Novant Health nurse care line: 800-718-3550