As pandemic drags on, mental health must be monitored

As we move into yet another surge of COVID-19, the likelihood of remembering what was normal, and if we will “return” to normal, dims.

In the summer months there was a glimpse with low case rates and the opening of many venues once shuttered. Places of worship opened, people removed their masks, there was a return of the common cold (!), and with vaccinations people felt secure. However, the impact of COVID-19, the isolation, and daily living adjustments have taken a toll, in many ways unanticipated. With resurgence, resumption of “normalcy” fades (Figure 1)—and we all have experienced that those who are vaccinated can still contract COVID-19. Amid all this, our vulnerabilities are heightened.

As discussed in prior columns,1 the mental health toll of the pandemic cannot be understated. Baseline rates (2019) of symptoms of anxiety, depressive disorder, or both were 8.1%, 6.5%, and 10%, respectively. These have more than doubled during COVID. In a partnership with the Census Bureau, the National Center for Health Statistics collected the Household Pulse Survey to obtain information on the frequency of anxiety and depression symptoms. 

Using a modified version of the 2-item Patient Health Questionnaire and the 2-item Generalized Anxiety Disorder scale, they collected information on symptoms over the past 7 days. In the most recent data (July 21-August 2, 2021), 34% of women and 28% of men reported symptoms of anxiety or depressive disorder (Figure 2).

Indeed, from May 2020 to July 2021, the rates have been at least double these baseline rates. Furthermore, the rates are highest among our patients: 51% in 18- to 29-year-olds, 38.6% in 30- to 39-year-olds, and 32.8% in 40- to 49-year-olds (Figure 3). Those we care for are struggling with anxiety and depression at rates heretofore unseen.

Their children (our children too) are experiencing mental health issues. Among female adolescents there is a 34% relative increase in reporting recent suicidal thoughts.2 Emergency room visits for adolescent suicide attempts soared this past summer and winter, especially among girls, with a 22% spike for children aged 12 to 17 in summer 2020 and a 39% increase in the winter compared with 2019. During February 21 to March 20, 2021, suspected suicide attempt emergency department visits were 50.6% higher among girls aged 12 to 17 years than during the same period in 2019.3

The impact on physicians also is telling. Not only affecting practices, staffing, and income, COVID-19 has substantially affected physician well-being with 58% experiencing burnout compared with 40% in 2018.4 Personally, I have witnessed the impact on my fellow staff, with physicians opting for different career paths—moving to hospitalist positions, call-only positions, and/or leaving practice to afford more time with their families, decreased administrative burden, and less interest in academic pursuits. The time spent in isolation and the reflections of the pandemic have altered career paths and trajectories.

Similarly, training for medical students, with less time on labor and delivery and a lack of personal protective equipment hindering participation in cases, may have impacted our ability to recruit students into the field. Residents were recruited into residency programs without stepping foot into the buildings or meeting face-to-face. These same students had their training shortchanged by limited clinical interactions and training due to the pandemic. As we work to incorporate and overcome these issues, we all must recognize the impact on our specialty.

The Centers for Disease Control and Prevention, the American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine all now recommend the COVID-19 vaccine for pregnant, breastfeeding, and lactating women.5 However, it remains difficult to increase vaccination rates. We are seeing a surge in COVID cases in pregnant women, predominantly in those unvaccinated, with very serious implications for many, where we have had to manage them with prolonged ECMO or ventilation. As facilities mandate vaccination, we are bombarded with requests for exemptions for pregnant and lactating women—a conundrum as there is no medical indication for them not to be vaccinated. As a department we are holding strong to encourage vaccination and not sign these exemptions, but it is tiring.

As my children return to school (4 different schools and frames of reference, from third grade to medical school) I recognize how this pandemic has affected them and all of us. With optional masking in schools, children under 12 years of age are at heightened risk as they are not vaccinated. Looking forward, we must work together to understand the perspectives and stress others are experiencing, enhance our trainees’ experiences, and ensure optimal care for our patients.