A few weeks ago, a man I will call Manuel arrived at the hospital emergency room where I am a psychiatrist. I wasn’t treating patients sick with COVID, at least not in the traditional sense. Still, many of the crises I’ve been consulted for in recent months were brought on by the pandemic.
Here is Manuel’s story: He had moved in with his mom in 2018 to get sober from drugs and get his life back on track. He had just celebrated a year of sobriety and had a steady job waiting tables when his mother died last spring. Unable to afford her rent, he lost his housing, his sobriety, and then his job. The depression from his past, kept at bay by routine and purpose, returned. He fell back onto his previous path of living on the street and using drugs, and he knew right where it headed.
“If this is gonna be my life again,” he said to me, “it’s not worth living.”
Because of his suicidal thoughts, Manuel was one of 26 patients in the emergency department that day waiting for an inpatient psychiatric bed. Ongoing bed shortages and COVID outbreaks at the local psychiatric hospitals meant it was unlikely he would get one. And though inpatient psychiatric care was one of the only things I had to offer Manuel that day, the cause of his depression and suicidal thoughts was much more complex than a “chemical imbalance” that could be fixed with medication.
What he really needed was a residential substance use treatment program, but, as with inpatient psychiatric beds, COVID has worsened the pre-pandemic scarcity of such programs. Then he would need some transitional housing in a safe, drug-free environment—another rarity—until he could get his own place. To afford that, he’d need income. But he didn’t have a college degree, and his past work experience was limited to the restaurant industry, which isn’t hiring right now.
Hundreds of thousands of Americans have lost their jobs, slid further into poverty and debt, are facing homelessness, and have been cut off from their social support networks. Most are not developing a diagnosable mental illness, but their mental health is definitely worsening.
Others are more like Manuel—the tectonic shifts of 2020 have allowed their dormant mental illness to return. This includes the high school teacher whose contamination-related OCD symptoms are back in full force, the college student who moves back home with his parents and into the shadow of his teenage depression, the restaurant owner who loses her business and with it the medications for her bipolar disorder. For the millions of Americans who lived each day with a chronic mental illness before COVID, things have just gotten worse.
People’s mental health rests on the pillars of their social and family support networks, their housing, their access to health care, and their employment. Kick over one of those pillars, as COVID tends to do, and the whole thing topples down.
One survey that measured anxiety, depressive symptoms, stress-related disorders, and increased substance use during the pandemic found these issues occurred most often among young adults, unpaid caregivers, Black and Hispanic people, and those with lower levels of education. It’s not that these demographics have some predisposition to mental health problems. They are the people most likely to lose their jobs or housing because of COVID—or to contract the infection itself.
Treatment for a mental illness isn’t the solution. Of course medications and therapy can be very effective for diseases like schizophrenia or clinical depression, and I’d be disloyal to my profession if I downplayed their importance to people who need them. But when someone loses their ability to pay rent or buy food for their family because of our government’s failure to manage a pandemic, psychiatric care will have a minimal impact. Suggesting an antidepressant for them is like offering someone aspirin for their headache while repeatedly hitting them in the head.
What Manuel and so many others really need is help shoring those pillars back up. Financial stability is a basic pillar of mental health, one many people have lost with the widespread shutdowns. Poverty causes more than just stress about bills; it can lead to worse psychiatric outcomes, like depression, anxiety, and even schizophrenia.
Thanks to the pandemic, our government has paid out unprecedented amounts of stimulus money and unemployment payments to help people stay afloat. There’s good reason to believe this is also an investment in mental health. Research has shown that a universal basic income reduces depression and improves people’s ability to plan, learn, and concentrate by allowing their brain to focus on more than just survival. One study found that for each dollar increase of the minimum wage, suicides among adults without a college education went down by 3 to 6 percent. Americans have historically taken a “pull yourself up by the bootstraps” approach to climbing the socioeconomic ladder, but maybe the pandemic can change our attitude toward assistance, particularly given the initial success of many of these programs.
Housing is a crucial pillar of well-being and, right now, one of the most vulnerable. With unemployment rising, millions of Americans are behind on rent or mortgage payments. Shelters and other group living facilities can no longer safely house people in close quarters. Homelessness was already at an unacceptable level before COVID, and it’s expected to surge even further. Not having a home strains emotional well-being and exacerbates mental illness. It’s hard for Manuel to follow basic wellness advice—get eight hours of sleep, exercise regularly, and eat a healthy diet—while he’s sleeping in doorways. It’s harder still for him to stay sober, get to doctor’s appointments, and take medications on time.
Providing no-strings-attached housing to homeless people is a cost-effective way to improve quality of life, reduce alcohol and drug use, decrease suicidal thoughts, and help people with mental illness stick with their treatment. Unfortunately, noncontingent housing programs have been relatively scarce for years, but this is one thing COVID is changing for the better.
To curb viral spread, cities have moved people out of homeless shelters and off the street into motels. For once, there were few milestones or requirements they had to meet to have a roof over their heads (they just had to be potential viral vectors). Preliminary data has shown that not only did this slow infections, but it improved people’s mental health and made it more likely that they would then find permanent housing. Many states are considering making this a more permanent solution.
Also, while living on the streets is bad for your mental health, living in jail is worse. My patients with mental health and substance use disorders spend disproportionate amounts of their lives incarcerated. Overcrowded and underresourced in the best of times, jails during COVID are a pile of dry tinder waiting for a spark. This is also a place where the threat of the virus has prompted some positive changes: Concern about outbreaks led to decarceration efforts across the country, with the numbers of inmates in jails decreasing by about 25 percent last spring. Nonviolent offenders and people near end of their sentences were let out early; judges leveraged mental health and drug diversion programs as alternatives to arrest for minor infractions. People with mental health and substance use disorders were shunted to treatment instead of languishing in cells and losing their housing, their Social Security payments, and their place in line for treatment programs. Despite outcry, the anticipated wave of crime never materialized.
Not surprisingly, access to health care matters for mental health too, but a dire shortage of services makes help hard to find when you need it. Eighty percent of rural counties have no psychiatrist at all, and 94 percent have no community mental health facilities. The pandemic hasn’t created more providers, but it has made the ones we have easier to access. Telepsychiatry, well-suited for a specialty that rarely involves physical contact, became the norm for outpatient visits this past year.
Insurers granted temporary reprieves from billing hurdles for virtual visits; long-standing questions about privacy and security of online platforms were answered with sudden swiftness. And patients didn’t seem to miss the in-person interaction—many clinics that adopted telemedicine saw the number of cancellations and no-shows drop to nearly zero. Even when in-person visits are safe, telemedicine is a boon for patients with limited mobility or transportation issues, or who live in areas with no providers.
These modest accommodations, pieced together in haste and desperation, haven’t yet changed the world. Millions of Americans are still sleeping on the streets, living in poverty, spending months in jail, and finding themselves unable to get health care. The fabric of our socioeconomic support systems has been exposed as threadbare and inadequate. But like any good pilot study, the pandemic has shown us what we need and what is possible.
COVID has unveiled what people in my field have long known: Mental health is largely influenced by poverty, unemployment, isolation, incarceration, homelessness, and medical illness. Because of these connections, the same programs designed to curb viral spread and shore up the economy have had positive impacts on mental health too, making them an even more valuable investment. If the coronavirus and its far-reaching impacts have brought us one good thing, it’s how to start tackling our nation’s mental health problem.
