Andrew Solomon talks to Amy Goodman and Nermeen Shaikh of Democracy Now! about the loneliness, depression and anxiety precipitated by the COVID-19 pandemic. (This is a one-hour program; the segment featuring Andrew begins at 15:35.)
Excerpts from the transcript
The double crisis in mental health
When I talk about a double crisis, I’m talking about these two problems, one of which is that we are all afraid of the virus itself. It feels like the angel of death is waiting outside our front door. It feels like people we know are dying. We’re going into, many of us, some form of economic crisis. There’s a great deal that’s going wrong that’s specifically about the virus.
And then the other piece of the crisis is that the response to the virus is primarily to shelter at home and to shelter with a very limited group of people or alone, and the isolation is taking a terrible toll. Human beings are social animals. And being reduced, in effect, to either a very small circle of people, which can be stressful, or to total loneliness has additional adverse mental health consequences.
On disparities in access to mental health care
In general, people who are less economically privileged are less likely to have their mental health problems diagnosed or treated, less likely to have them diagnosed because the basis for diagnosing depression is often that you feel really terrible despite having quite a pleasant life. And if you have a very actively unpleasant life and you feel terrible all the time, you’re unlikely to recognize that the way you feel may be the result of or a symptom of mental illness, and instead you’ll think it’s merely commensurate with your circumstances.
But even for poorer people who are able to get a diagnosis, the lack of access to mental healthcare remains shocking in the United States. There was a Mental Health Parity Act that went through some years ago. It’s full of loopholes. It’s a sort of Swiss cheese of an act. And people who don’t have decent health insurance and who don’t have access to so-called higher-quality doctors and teaching hospitals and so on are likely, in most instances, to go untreated. They can call hotlines some of the time. They can sort of patch together little bits of response. But they aren’t going to get the kind of steady, focused treatment that might allow them to come away from their mental illness and to emerge better able to contend with the very real challenges they face in the world.
On the current financial crisis
It’s difficult to be dealing with the two primary components that affect everyone, which are fear of getting sick or of losing people you love, and the problem of negotiating isolation. But when you add to those two already-existing difficulties financial collapse and ruin, you’re in a really desperate place.
And there are obviously huge numbers of people who have no idea whether they’re going to be able to feed themselves over a longer-term period of time. You know, the jobs that have been lost are not all going to return the minute that the economy reopens. And the economy reopening is going to be a very bumpy and problematic process.
So, you have a huge number of people who are facing not only the kind of fantastical concerns of the virus itself and not only loss, but who are also looking at being deprived and possibly having lives in which they’ll never be able to afford anything again. And, of course, we don’t have a safety net in the United States. And that’s part of why the financial crisis generated so much trouble and such high rates of depression and even of suicide.
And I should say, in relation to suicide, that there is a tendency to think that physical health is an urgent problem right now and that mental health is a sort of luxury. But actually, there are many people who, because they have poor mental health, will be driven either to lives of desperation, that may continue to escalate, or to acts of suicide. I’ve already heard about people, who already had some degree of mental illness, who have found the isolation so difficult and the fear so overwhelming, that they have in fact ended up killing themselves. And so, that increasing rate of suicide reflects a very stark reality. And for people who are looking also at financial ruin, the temptations of suicide are terribly proximate.
On the variety of emotional responses to the pandemic
I would say that there are essentially four responses to the current situation. Some people are very emotionally robust and seem to be able to handle it relatively gracefully. Some people are having a bit more trouble and require what I think of as psychiatric first aid. They need to regulate their eating. They need to regulate their sleep. They need not to become complete news junkies 24 hours a day. They need, in a variety of other ways, to moderate their behavior.
Then there are people who have never experienced mental illness before, who are being pushed up into mental illness at this moment by the experiences they have. And there, we have to look at the very tricky thing, which is: How do we separate rational anxiety and distress from a clinical condition? And the line can be very blurry, and it varies from person to person.
And finally, we have the people who already had mental illness, who are now developing what I’ve called and many clinicians call a double depression, in which underlying depression and anxiety are suddenly now escalated to the complete crisis point, to the point where people are contemplating suicide, to the point where people are unable to function, to the point where people who have lost their jobs are unable to fill out the paperwork to get benefits that they may require. Those are people who have got really serious and problematic mental illness.
In terms of advice, you know, the best advice is that depression is, on the one hand, a terrible and overwhelming problem, and, on the other hand, quite a treatable problem. So if you’re able to access mental healthcare, you should do it. And you should understand that it isn’t a failure, and it doesn’t mean that you’ve collapsed unduly, and it doesn’t mean you can’t deal with stresses other people can deal with. If you’re suffering and you’re in anguish and you’re in pain, there are treatments available, and you should take advantage of them.
But that goes back to our earlier point, which is that there are people who are in a good position to take advantage of the mental illness challenges by going to a good teaching hospital, by finding a good doctor and by taking medication and engaging in psychotherapy. And there are a lot of people for whom those things feel unavailable, and the prospect of trying to access them, even for people who theoretically should have some level of care, is completely overwhelming. So we need very much to try to support those populations.
On the potential for reducing stigma associated with mental illness
If we reduce the stigma attached to mental illness, that will be the elusive silver lining in the hideous cloud we find ourselves in right now. And I’m very hopeful that that may happen. I mean, the statistics that you read out at the beginning, that some 40% of Americans are now reporting mental health complaints, I think, is indicative. If 40% of Americans are experiencing this, it’s difficult for it to remain stigmatized in the way that it did when it was a lower percentage. But the percentage has always been higher than people believe. And I’ve sometimes called depression the family secret that everybody has.
I have found, over the years since I’ve started working on depression, people will say to me, “Oh, don’t you find that people sort of are laughing at you behind your back? Don’t you worry about the self-exposure that was involved in writing about your own experience with depression?” And my nearly universal experience is that everyone I meet says, “I’ve been so worried about my wife. She’s having a really difficult time,” or “My brother did such and such,” or “I myself have been in treatment, but I’m not sure I’m getting the right treatment,” that this is really all over the place and that it touches everyone.
Now it touches more than everyone. And in many countries, there have been real moves to respond to that. Even in China, which we don’t think of as progressive on mental health issues, when the virus surfaced in Wuhan, the government moved enormous numbers of mental health professionals to Wuhan to try to help people get through that trial and that trauma.
In the United States, we kept focusing on school closures and on all of these other things that are terribly important, but without giving any federal attention whatsoever to the mental health crisis. And so, I think that reinforces the stigma. I think if we had a president who was able to stand up and say, “This is affecting almost everyone, one way or another, directly or indirectly. It’s an absolute crisis. It requires attention and response,” that the stigma would evaporate relatively rapidly because of the sheer population numbers. As long as the government continues to ignore this problem, even though some state governments are responding to it, I think that the stigma remains and that people have a sense of failure.
But I often say to people, “In the first place, you should get treatment, because if you don’t, your condition might escalate, and you might end up killing yourselves. But in the second place, you should get treatment because right now you’re 37 years old, and you’re never going to be 37 years old again. And if you use up the next year feeling terribly depressed, you’re going to have years and years ahead of you of having to negotiate the aftermath of that depressive episode and having a possibly recurrent depression, and you’re going to have missed the year when you were 37 and when you really needed your resources to deal with isolation and to deal with losing people you love and to deal with financial crisis. And we can’t afford not to be at our strongest and best as we deal with those very real and immediate problems.”
On stress and despair
Dr. Lorna Breen, a top ER doctor who committed suicide, was a hero; we should all be breathless with admiration for somebody who was willing to work so hard in this area, in which, relatively speaking, there are still so few thanks, and who was willing to put herself on the line until she got to the point of that despair.
But, obviously, the despair itself is catastrophic and terrifying. I mean, mental health professionals are under pressure. Physical health professionals are actually seeing people die. People become doctors, by and large, because they want to help people and make them better. And here come these vast numbers of people for whom we can do virtually nothing. And instead of being able to help them and make them better, there’s a sort of vague effort to do some kind of palliative care as you watch them die in front of you and then pack them into big refrigerated trucks. The stress of it is enormous.
I would emphasize that there’s also a lot of stress for people like grocery store workers. There’s a lot of stress for people who are in any of the areas in which there’s a lot of exposure. And the stress is partly vulnerability to the illness.
And then I would add another layer, which is that we don’t really understand very well the full functioning of the coronavirus. There are people who have been dying of strokes that appear to be related to coronavirus. I would suggest that it’s possible that it also can have an effect, at least in some people, on mental health by having a direct organic effect on the brain.
It’s very nice that everyone opens their windows and bangs pots and pans in appreciation of healthcare workers in New York and in many other cities scattered around the country. It’s important that those people be acknowledged. But acknowledging them doesn’t take away from the desperation that you feel having something that’s so widespread and so untreatable.
On access to mental health care
We don’t have enough people in the field of mental healthcare. The people who are in the field of mental healthcare often deal with insurance that essentially requires that they see five or six patients an hour. You can’t understand what somebody’s mental health problems are in 10 minutes, much less figure out an appropriate means of treatment. There are a lot of people who come in saying that they have a mental health complaint, they’re given medication and sent home with it without any further conversation. If the reason that your mental health has escalated to this point is because of anxiety about being locked in and is because of loneliness and is because of fear of the illness and is for all of those other reasons, you need to be able to interact and exchange points of view about them and have someone who can sort out for you what constitutes a neurotic response and what constitutes serious mental illness and what constitutes a reasonable response to exactly what’s going on.
So, it’s partly that we don’t have enough people in the field. It’s partly that it’s difficult to access the people in the field, even if you’re in a position in which your insurance covers it. It’s also that you have to be able to self-diagnose and be willing, despite the stigma that we talked about a moment ago, to go in and say, “I have a serious mental health problem, and I want to figure out how I can get better.” And making that assertion is already very difficult. And, of course, there are all of the people who, even if they could make that assertion, because of insurance problems and unemployment and so on, aren’t able to access mental healthcare at all.
Stress and isolation can be lethal
People dropping dead of coronavirus include all of the people who are dying because they end up committing suicide, like the brave doctor we just spoke about; the people who are dying because when you’re depressed, your immune system is depressed, as well, and people become more physically vulnerable to the virus; the people who are dying because when you have severe depression, your ability to take care of yourself dwindles, and people end up being careless and going out without a mask and standing too close to other people and so on and so forth; the people who develop touch deprivation, in which the absence of physical contact with other human beings pushes them over the edge and leads them into damaging behavior. So there are many, many ways in which this mental health problem becomes a serious one that can lead to destroyed lives and even to people dying — people dying of the virus who don’t even have it.
My own experience, historically, is that in 1994, a few years after my mother died, I developed a very acute and serious depression. I didn’t recognize it for what it was at the time. I was determined, because of the stigma, I suppose, that I would deal with this on my own. And I eventually reached the point at which I was almost unable to do anything, and I was lying in bed unable even to pick up the phone and ask for help. And then I finally realized something had to be done. And so I went, and I sought treatment. And then, like so many other people, I sought treatment, and I thought, “OK, I’m fine now,” and I went off the treatment, and I plummeted again. And I went back on treatment. Depression is a cyclical illness, and once you’ve acquired it, you’re likely to have episodes over and over again.
And what I would always say is that the opposite of depression is not happiness, but vitality. And it was vitality that I lost in those moments. It wasn’t that I felt sad all the time, though I did feel sad for a variety of reasons. It was that I no longer had the basic energy to go about the business of my life. I didn’t feel like I could get up, like I could cope with things, like I could go out, like I could talk to people. I found myself withdrawing more and more and more into the painful solitude of my own disturbed mind. And that tends to be what happens in depression.
And in this crisis, I think a lot of people start off having rational, reasonable fear and distress about what’s going on, and then it gets to the point where they are paralyzed. And they aren’t making themselves meals. And they either do nothing but sleep, or they can’t sleep at all. They do nothing but eat, or they can’t eat at all. They can’t bear the idea of exercise. They stop the even limited means of communication we have, by phone or by Zoom or by whatever people are using, and withdraw socially from their surroundings. Those would be some of the signs through which one could recognize the beginning of a depression. If you feel you’re not functioning well because of the way you feel, it may very well be depression. If you just feel upset, it may very well be a rational response to this tragic time.
The pandemic’s impact on children
The effect of isolation on children is enormous. My husband and I have a son who’s 11, who’s here with us in our quarantine that we’re living in. And I’m very much struck by the fact that the continuity of my friendships or of my husband’s lies, to a large extent, in verbal communication. And so, if we’re able to see and talk to our friends on Zoom and elsewhere, we can more or less feel that we’re keeping in touch.
The fabric of children’s friendships is in doing things together. And so, children who are deprived of the ability to do things together don’t have that much to say to one another when they call one another, and so their friendships themselves lose some of their fabric and substance. And the children are therefore missing not only some of the educational opportunities of school, but also the social situation of school. And I think if we do this for a year, and my son, who was 10 when we started, ends up being nearly 12 by the time that we’re finished, what are the modes of development that he will have missed?
Now, in addition to that, children are not stupid, and they can understand that this situation is unnatural and bizarre. Some children are able to put a good face on it; some children aren’t. It’s an enormous stress on them to recognize this. And the biggest stress on the children often is the condition of their parents. There was an experiment done, a study done, some years ago, in which a researcher named Myrna Weissman tried to determine what the best way was to treat childhood depression. And after trying 15 different things in a very large controlled study, the thing that was most effective in helping children was to treat their mothers. And so, the mental illness of parents bleeds over into the mental illness of children. Even just the stress and distress of parents bleeds over into the condition of children.
And now with this news that the disease may in fact be fatal for children or may make them very, very sick, contrary to what we previously heard, we have to isolate our children more, and we have to take more precautions. And we’re less likely to get back to school and less likely to go back to anything like what our children had come to experience as normal life. And that’s a very toxic situation psychologically, as well as an anxiety-producing one physically.
The U.S. National Suicide Prevention Lifeline is 1-800-273-8255.