Why 'getting back to normal' may actually feel terrifying

Doctors are forecasting what some experts are now calling “the fourth wave” of the COVID-19 pandemic. Experts say the mental health impacts will be “profound and far-reaching,” likely outlasting the physical health impacts, and straining already-stretched mental health systems in the United States and worldwide.

While infections rage on in India and Brazil, case numbers in the U.S., Europe, and many other places have dropped dramatically and restrictions are lifting. But across the globe, many people are feeling lingering psychological effects from what has been a collective traumatic experience.

“The pandemic has produced a petri dish of psychological factors that may lead to emotional health problems: anxiety, brain fog, depression, and PTSD,” says Luana Marques, a psychologist and professor at Harvard Medical School. Symptoms of fatigue, exhaustion, and burnout are common, and stress can have long-lasting effects on brain physiology and function.

The 2021 World Happiness Report notes that “when the pandemic struck, there was a large and immediate decline in mental health in many countries worldwide." Prior research on disasters and pandemics shows that most people will rebound as we return to the office and school, spend time with friends and family, and lose our fear of infection. However, a sizable minority may confront new or long-term mental health issues.

The toll on our mental health 

Some 15 months of lockdowns, loneliness, Zoom calls, grief, illness, monotony, job loss, and economic hardship has caused “an extraordinary rise in anxiety and depression,” says Boston College developmental psychologist Rebekah Levine Coley. “The level of these disorders ... are unprecedented.”

During the pandemic’s first nine months, six times as many American adults reported mental health issues as in early 2019. This is according to U.S. Census Bureau data collected as part of the ongoing Household Pulse Survey, which is quantifying the social and economic effects of the coronavirus on U.S. households. As of February, of the nearly 1.5 million U.S. adults who participated in these surveys, 41.5 percent reported symptoms of anxiety or depression, similar to other countries that have tracked mental health.

Anxiety or depression manifest in many ways. Some can’t focus, are unproductive, or are utterly exhausted. Many are grieving the loss of loved ones. Others are lonely or unsure of what to do now that they’re vaccinated, or fearful about a variant evading vaccine protection and making them or their loved ones ill.

Researchers and clinicians report that people are sleeping poorly or forming unhealthy habits. One study found that acute social isolation sparks cravings similar to hunger, leading some people to eat more and gain weight; for some of them, the “quarantine 15” has become the “quarantine 30.” In one study 60 percent of people reported heavier drinking.

The inability to cope has sparked other, darker consequences. Soaring suicide rates in Japan prompted the appointment of a “minister of loneliness” in February. Suicide hasn’t spiked in the U.S. or Europe, but with many still in survival mode, trauma symptoms could manifest later.

The U.S. saw a sharp rise in other “deaths of despair” in 2020. Drug overdoses, mostly from fentanyl and other synthetic opioids, may have exceeded 90,000, up from 70,630 in 2019. While numbers had been climbing, that was the largest rise in two decades.

High risk groups for mental health 

Lockdown impacted people across the globe. But those who were most affected fall into a few categories, says Barbara Sahakian, a professor of clinical neuropsychology at the University of Cambridge. Just as some communities have shouldered more of the pandemic’s health disparities, the mental health impacts have hit some groups harder than others. Young adults, women, parents of young children, the less-educated, front-line medical workers, Black and Hispanic communities, as well as those who had pre-existing mental health issues are suffering more.

Overall, Sahakian’s research shows that people who managed to keep strong social connections “showed much less of a change towards negative, depressive cognitions.”

Financial pressure played a huge role on overall mental health, with lost jobs, increased hunger and some families facing eviction when bans are lifted. More than 2.3 million women have dropped out of the labor force, many unable to arrange childcare for kids not in school. “It doesn't matter how you slice and dice the data,” Marques says, “wealth is protective. You can stay home, hire help, you can feed your family.”

For kids learning remotely for extended periods—without peer relationships and school-based counseling and meals—the mental health toll has been catastrophic. “Emergency rooms and hospitals are now bulging with children and families in crisis,” says Christina Gurnett, a pediatric neurologist at St. Louis Children’s Hospital in Missouri. Their symptoms—from eating and sleep disorders to anger, anxiety, self-harm, and aggression—aren’t unique, but they are more common and severe. A Harvard study of 224 U.S. children aged seven to 15 found that two-thirds had clinically significant anxiety and depression symptoms—more than double that of 2019.

Young children, which some people have dubbed “bunker babies,” have had little social contact during a crucial development period. Teenagers who normally would be testing their independence and dating skills have been at home with their parents.

Front-line workers have been particularly hard-hit, Sahakian says, with overwhelming workloads while fearing contagion, compounded by the lack of safety equipment, as they witnessed unprecedented deaths for more than a year.

Sahakian also notes that, with difficulty accessing services and increased isolation, mental health also deteriorated for many with preexisting conditions.

The impact of COVID-19 on the brain

Infectious diseases, including COVID-19, can impact the brain, altering cognitive function and decision-making, causing both acute and chronic problems, says Maura Boldrini, a psychiatrist and neuroscientist at Columbia University Irving Medical Center in New York. “We’ve seen people coming to the hospital with symptoms that resemble depression, with hallucinations or paranoia” who were then diagnosed with COVID, she says. The disease also has caused major and minor strokes.

The virus pushes the immune system into overdrive, causing general inflammation. After recovery, some experience what’s become known as long COVID. The inflammation switch doesn’t turn off, similar to an auto-immune disease like lupus. Prolonged inflammation in the brain impacts communication between neurons and can kill them off.

Some have ongoing memory and concentration problems, loss of smell and taste, new-onset anxiety, depression, and even psychosis and seizures. The virus has caused changes in personality and behavior; some have committed suicide. Depending on the symptom, it’s affected 20 to 70 percent of patients. Nearly one-third developed PTSD.

“How long do these symptoms last? We don’t know,” Boldrini says.

Your brain on stress 

Humans are wired for survival. When we’re under threat, our “lizard brain”—the amygdala—reacts, adrenaline floods the bloodstream, and we’re ready to fight, flee, or freeze. But unlike most perils, the pandemic hasn’t ended.

Reactive fear became chronic stress, with our bodies still laden with cortisol and other stress hormones that are toxic to the brain, potentially inhibiting the production of new neurons and causing changes that trigger depression.

In this state, the emotionally reactive amygdala outcompetes the prefrontal cortex—the part of the brain charged with executive functions and decision-making. An MRI brain scan illustrates this well: In a traumatized patient, the amygdala glows brightly, while the prefrontal cortex is dimmer, indicating reduced functioning.

The prefrontal cortex also helps us survive—by reasoning and planning, says Judson Brewer, a psychiatrist and neuroscientist at Brown University. If we can't deal with uncertainty, we start to spin out into anxiety. “Think of anxiety as a fire,” he says. “When we can't predict the future, we get anxious. So 2020 was gasoline being thrown on the fire.” If we’re prone to worry, we worry more, making us feel like we're in always in danger, revved up in a way that's harmful, he says.

Some are suffering from what European psychologists Marcantonio Spada and Ana Nikčević dubbed “COVID-19 anxiety syndrome.” It’s characterized by coping behaviors “that can keep people locked into a state of continuous anxiety and fear,” with people afraid to go out, avoiding people and public places, and worrying constantly about themselves or others contracting the virus, Spada says.

Symptoms mirror other conditions, including obsessive-compulsive disorder and PTSD, and mimic the psychological consequences of living through war or disaster, both of which disrupt societies and bring great loss. After a year, Spada says, these habits may be hard to shed. Those who are under financial pressure, lack social support, or have a history of mental health issues are at higher risk.

Meanwhile, there’s a continuum of mental health that runs from thriving to severe depression and anxiety. Some of us are stuck somewhere in the middle, in a kind of psychological limbo, a state that psychologist Corey Keyes in 2002 characterized as “languishing.” Merriam-Webster defines languishing as “to be or become feeble, weak,” “to live in a state of depression or decreasing vitality,” or “to become dispirited.”

The challenge of reacclimating to normal life

With more people returning to work and schools, and businesses reopening, some people are bouncing back. But a significant number are not, struggling to reintegrate back into daily life: 33 percent of Americans reported mental health symptoms in April—more than 80 million people. In another U.S. poll, more than half of parents expressed concern about their children.

But this is just a snapshot; gauging the true toll will take years. Research shows that about 50 percent of us will quickly bounce back, but others may face challenges for some time. Marques notes that a decade after the September 11, 2001, terrorist attacks, 12 percent of first responders still had clinical PTSD symptoms. Three years after recovering from severe acute respiratory syndrome (SARS), another coronavirus, a quarter of survivors still had PTSD.

With 163 million COVID cases as of mid-May 2021 and billions impacted by the pandemic worldwide, the wave of people who may need mental health services could be a tsunami, Marques says. “In the U.S., we are at least doubling the people that need support, and we don't have the capacity, and globally, 90 percent of the people that need help don't get it.”

To address this current crisis, the U.S. American Rescue Plan, signed in March, included $4 billion for mental health and substance abuse services. It will fund everything from treatment and overdose prevention to training for health care personnel and first responders. But experts say there is a severe shortage of mental health providers, especially for kids.

Meanwhile, mental health still holds stigma. “I think we should be talking about brain health, not mental health so that people can start to remind themselves that the brain is actually an organ. Like the heart,” Marques says.

In addition to professional treatment, there are fairly simple, proven methods to deal with stress. Daily meditation seems to shrink the amygdala and thicken the pre-frontal cortex. Getting out into nature lowers cortisol levels. Exercise sparks emotional resilience, and for some, can be as effective as some medical treatments. Eating well and getting about seven hours of sleep is important. Social engagement is key. Unplug from the news and social media. Have weekly check-ins with kids to help them cope. A free, web-based program developed by Brewer, mapmyhabit.com, helps people chart their anxious habits as a first step towards change.

Marques and others note the need for a public health campaign that teaches people the basic science of stress and how to regulate emotion: that when they feel anxiety, the amygdala is activated, and there are ways to cool off the reactive brain and turn on the thinking brain.