Isolation, loss, stress and anxiety all came hand-in-hand with the COVID-19 pandemic. Now, their effects will continue to ripple through the community, experts say, as mental health cases rise.
Four times as many adults reported symptoms of depression and anxiety and the organizations and systems designed to provide for them are overburdened and still hamstrung by pandemic restrictions.
“We have seen dramatic changes over the last year with regards to patient need,” said Shane Lunsford, practice manager for the Department of Psychiatry at the Mountain Area Health Education Center. “We’re seeing increases across the board.”
“I think we’re seeing a lot of changes from the pandemic, and I also think we’re seeing changes from the numerous strains on the mental health system in general, and I think those are dovetailing,” said Dr. Dominique Huneycutt, psychologist with MAHEC.
People referred to MAHEC are talking about providers they had been seeing leaving their former agencies, which now can’t absorb new clients, aren’t offering individual therapies or taking insurance, she said.
Quarantining led to a major stressor for many: isolation.
That social isolation, Huneycutt said, isn’t great for anyone, but is particularly challenging for groups like young people and the elderly.
Research shows that extensive social isolation leads to mental and behavioral health disorders in both the short and long term, she said, and many schools went remote, not only removing students from friends, but removing them from services many children receive through schools.
Beside isolation, there’s loss.
Not only loss of family members who may have died to the pandemic – more than 13,400 in North Carolina – but loss of jobs, schools, friends and social connections, and stress of having been exposed to the virus and from having been ill from it, Huneycutt said.
Substance abuse issues have increased across the board, and some researchers are expecting a large spike in deaths by the end of the next decade due to mental health issues related to COVID-19, she said, including from increases in alcohol and drug use, even in accidental overdoses.
While the number of domestic violence, mental health and substance abuse cases hasn’t increased in Buncombe County, their severity has, said Rebecca Smith, Social Work Services Division Director and Foster Care and Adoptions Program Administrator for Buncombe Health and Human Services.
“The isolation, as well as the fear and anxiety around the impact to our ability to meet basic needs, I think those two things have dramatically impacted people’s mental health and their use of maladaptive coping strategies like substances to alleviate those stressors,” she said. “And those things have a ripple effect on people’s health and wellbeing, and that correlates a lot of times to neglect and abuse.”
Many people are relapsing, Smith said, people who have been in recovery and have children and had been able to move on successfully.
“We’re seeing a lot of them come back, relapses due to the stress of COVID,” she said. “Some are related to isolation and added stressors about being able to meet basic needs.”
The department is seeing a lot of anxiety and depression, and some of the more severe mental health issues like schizophrenia seem to be exacerbated, she said, as people haven’t been able to access the same level of care as meetings went virtual.
And it may be worse for frontline essential workers who dealt with the worst of the pandemic, especially frontline health care workers who may be showing symptoms of trauma, Huneycutt said, which will be exacerbated in those with existing mental health challenges.
She cited a study in Global Health Journal that found people infected with COVID-19 may face depression, anxiety, fatigue and post-traumatic stress disorder in the longer term and the health professionals who cared for them are at high risk of not only infection but also mental health problems.
“The high level of exposure of front-line health care workers to the virus and to COVID-19-related traumatic events, together with the need to make difficult decisions, puts them at particular risk of stress responses,” it reads. “Furthermore, health care workers showed more severe symptoms of post-traumatic stress following quarantine than did members of the general public.”
According to Centers for Disease Control data analyzed by the Kaiser Family Foundation, about four in 10 adults reported symptoms of anxiety or depressive disorder in a January 2021 CDC Household Pulse Survey, up from 1-in-10 between January and June 2019.
People aged 18-24 report an even higher rate of anxiety and/or depressive disorder at 56%, KFF reports, and compared to all adults, young adults are more likely to report substance abuse as well, at 25% compared to 13%, and have suicidal thoughts, at 26% compared to 11%.
Huneycutt said CDC data reports a significant increase nationally in visits to emergency rooms for potential suicides, especially among adolescent girls. The rate spiked by 22% for children in summer 2020 compared to summer 2019, she said.
It may be hard to say that’s entirely due to COVID, she said, but given the factors, it seems likely.
In MAHEC’s numbers, Huneycutt said they’re seeing anxiety disorders and a reaction to trauma or stress in highest frequency among the adult population.
Given the timeframe, she said, it’s likely those are impacts of the pandemic.
During the pandemic, KFF shows 35.8% of adults reported symptoms of anxiety disorder, 28.4% reported symptoms of depressive disorder and 41.1% showed symptoms of anxiety and/or depressive disorder.
Those rates jumped in the case of a job loss in the household. For those households that experienced a job loss since March 2020, 53.4% showed symptoms of anxiety and/or depressive disorder, KFF reports, compared to 31.8% in households that didn’t.
Rates of those symptoms also correlated to household income. The less a household makes, the higher its susceptibility to anxiety and depression.
Among people who said worry or stress related to the Coronavirus had a negative impact on their mental health, shares were greater among households with lower income.
In those with an income of less than $40,000, 56% said the Coronavirus had a negative impact on their mental health, 35% of which said it was a major negative impact.
In households making $40,000-$89,000, it was 51% and 21%, respectively, and for households making $90,000 and up, it’s 48% and 17%.
Rates of anxiety and/or depressive disorder symptoms also differ by race, with the KFF study showing some minorities and people of color with higher rates during the pandemic.
Non-white, non-Hispanic Americans had the highest rates, at 48.9%, followed by Black Americans, at 48%, Hispanic or Latinos at 46.3%, non-Hispanic white people at 40.9% and non-Hispanic Asian people at 33.1%.
The average for all adults studied was 42.4%.
“I think that this will have a generational impact, because this is a societal trauma that we all went through collectively,” Lunsford said.
And looking back through history, major trauma events have trickled down through generations, he said.
As depression, anxiety, alcohol and substance abuse and more increase across the board, they’re complicated by other pandemic challenges, Lunsford said, like people losing their jobs and with them their access to health insurance, health care and options like telehealth.
Early in the pandemic, providers were able to quickly pivot and meet many needs through telehealth, which had been eyed with apprehension beforehand, he said, not seeing the expected explosion of needs for service they expected.
But initially, they didn’t see the expected explosion of needs for service early in the pandemic.
Now that the country seems to be coming out of it, there’s been an increase in that demand, Lunsford said, specifically around child and elder abuse.
And as the country works to emerge from the pandemic needs are increasing, specifically around child and elder abuse, Lunsford said.
Smith, too, saw dips in demand early in the pandemic, but for the wrong reasons.
It was because kids weren’t in school where many cases of abuse or neglect get reported, and adults weren’t going to appointments, where doctors normally catch their problems.
Comparing fiscal year data shows not much change, Smith said, with monthly averages of child protective services intakes of 381 and 388 between July 2019-June 2020 and July 2020-June 2021, respectively.
But certain types of cases are increasing, she said, pointing out specifically children entering protective services through petitions, meaning they were in a crisis situation, which increased from 95 to 122.
She called it “a pretty drastic increase.”
The county is also seeing rates of adults entering protective services “skyrocket” in the last six months, Smith said.
In data shared by the county, 643 adult protective service reports have been screened into the county between January and June 2021, compared to 544 the previous six months, 542 between January and June 2020, and 651 in the last six months of 2019.
The stress that comes with all the different impacts from the pandemic, from medical issues, to employment issues, loss of wages and stability, lead to mental health crises and substance abuse, she said, including a loss of connection and relationships that directly correlate with resiliency.
In some cases, those are the parents of children that social workers end up seeing, Smith said.
‘It’s turning into a crisis across the state’
Adult cases are mostly doctors or other providers notifying DSS that an individual is in such bad shape they don’t have the capacity to make decisions for themselves and are self-neglecting and functionally disabled, Smith explained, resulting in DSS going to court for guardianship.
“We don’t take that lightly, and courts don’t either,” she said.
And with courts shutting down or moving to virtual-only for COVID-19 precautions, many cases aren’t moving, creating a backlog and a significant crisis, she said.
Foster homes, group homes and other facilities are also hesitant to accept children who may have been exposed to COVID-19 or need to be tested or quarantined, Smith said, which creates a huge stressor for staff, kids and families.
“It’s turning into a crisis across the state,” she said.
In some cases, children are sleeping in the Department of Social Services office, or in hotels, Smith said. Harder-to-place teenagers can be with DSS for two and three weeks at a time before they find placement, and sometimes it doesn’t work out and they end up right back with the county.
“It can be a cycle, so we’ve had to just adjust staffing,” Smith said, to make sure there’s basically 24/7 availability.
The county is working with community partners such as Vaya Health for placement solutions, and hoping for providers to begin opening up services, which they are starting to do, she said.
The high cost of isolation
The human body evolved to respond to threats in what’s known as fight or flight, Huneycutt explained.
In prehistoric times, if a tiger were threatening you, she said, you’d run, fight or freeze and hope it doesn’t get you.
“Our bodies still have that response,” Huneycutt said. “(It’s) not intended to be turned on for extended periods of time.”
That becomes exhausting, and the messages that it’s not safe outside and that normal things are dangerous tell the body to be on alert at all times, she said.
The anxiety system gets turned on, but without a place to go and without outlets like people to reassure you, she said. And in the height of the pandemic that may have even prohibited things like going for a walk, or hugging a family member.
Some may have had support networks in place, but some elderly people may have lost all of that as the country went into lockdown, Lunsford said, even “the mere fact of being able to get up and give someone a hug or a grandchild that comes up and says ‘I love you.'”
For children it can be especially impactful, Huneycutt said, and pandemic trauma is going to become an Adverse Childhood Experience, or ACE, which studies show increase risk for negative health and mental health consequences later in life.
“This is not a short-term problem,” she said. “This isn’t limited to mental health.”
Kids may be more withdrawn from friends and family, more prone to emotional outbursts and have a shorter fuse, Lunsford said, and suffer from isolation more without school, which serves as a constant in their lives and as their social network.
It’s going to take proactive investment of resources, Huneycutt said, all while mental health issues face stigma and the belief that there’s nothing that can be done, or that it’s each individual’s problem; but it can’t be each individual’s problem.
“The costs downstream if we don’t do something now are huge,” she said. “And I think mental health … gets a little bit of attention for a little while, then goes away until someone with a mental health condition does something that garners attention.”
The long-term costs will be pile up, she said, from increased mental health conditions and stress, to economic productivity lost, disability and suicide attempts.
“It’s a health condition,” Huneycutt said. “It is real.”
The nation’s mental health community is trying to be prepared for the upcoming needs, Lunsford said, but even before COVID-19, there was a shortage of mental health providers.
“It’s access to peripheral services really, where we struggle,” Smith said.
As those open up, hopefully they’ll start to see increased resilience and a decrease of the maladaptive coping strategies people have been relying on throughout the pandemic, like substances, she said.
And part of the solution is going to be using COVID relief dollars for individuals who need support for housing, employment and basic needs, Smith said.
“It’s that hierarchy of needs,” she said. “We have to meet basic needs so we can begin to work on social, emotional aspects of peoples’ lives.”
Help is out there.
“Number one, they’re not alone in this,” Lunsford said, on his message to folks struggling. “People all across the country are dealing with this same thing right now, that there is hope and there’s help and not to ignore it, to reach out.”
Huneycutt mentioned Asheville-based Resources for Resilience, which offers tools to help people self-regulate and connect with others, and encourages participants to take their training and strategies and share them with schools, agencies, organizations and communities.
MAHEC, while its Psychiatry Department is still growing, offers educational resources and the opportunity for employers or other groups to put together group programs for staff or employees, she said.
Vaya Health, at vayahealth.com, also provides help finding a health care provider and offers a 24/7 Access to Care Line at 1-800-849-6127.
People can call 211 to help find health and human services resources and can call 988 to reach the suicide prevention hotline.
To make an adult or child protective services report any time, day or night in Buncombe County, call 828-250-5800 for adult abuse and 828-250-5900 for child abuse.
For more, the CDC offers resources to help handle stress, and if you are in crisis, call:
National Suicide Prevention Lifeline: 1-800-273-8255 (English), 1-888-628-9454 (Spanish)
National Domestic Violence Hotline: 1-800-799-7233 or text LOVEIS to 22522
National Child Abuse Hotline: 1-800-422-4453 or text 1-800-422-4453
Derek Lacey covers health care, growth and development for the Asheville Citizen Times. Reach him at DLacey@gannett.com or 828-417-4842 and find him on Twitter @DerekAVL.