As a psychiatrist, I don’t need much convincing that millions of people are suffering emotionally, as a consequence of the COVID-19 pandemic. (Most of us have our “war stories” to tell). For example, a recently released survey from the Centers for Disease Control found that from June 24-30, 2020, adults in the United States reported “considerably elevated adverse mental health conditions associated with COVID-19.”1 Using validated screening instruments, the CDC survey found that, overall, 40.9% of 5470 respondents reported an adverse mental or behavioral health condition, including those who reported symptoms of anxiety disorder or depressive disorder; trauma-related symptoms; new or increased substance use, or thoughts of suicide. The prevalence of symptoms of anxiety and depression were substantially higher than reported in 2019, and people with pre-existing (clinically diagnosed) psychiatric disorders reported an even higher prevalence of symptoms, compared with those without an established diagnosis.1 So, yes, many folks are indeed suffering.
All this has led many news outlets to declare a “mental health pandemic” or “secondary pandemic,” amidst the already devastating COVID-19 pandemic.2 I found about 145,000 results, searching the term, “mental health pandemic” on Google. Indeed, several respected mental health professionals have taken to using this linguistically awkward term.* And yet, while well-intentioned, the casual and colloquial use of the term “pandemic” is not warranted in this context.
Of course, I understand that the intention underlying the term is to highlight a worldwide upsurge in mental health issues and symptoms, which is certainly a valid concern. But problems often arise when we coopt terms from another medical discipline and apply them to psychiatry. For example, the same casual misuse of epidemiological terms was common in the popular press when referring to a supposed “epidemic” of psychiatric illness in the United States—even though no credible evidence ever supported that bogus claim.3,4 And this is more than a semantic quibble. The use or misuse of language can have powerful effects on the public’s beliefs and perceptions—witness the baneful effects of the “schizophrenogenic mother”5 or “chemical imbalance” tropes.6
To back up a bit: in epidemiology, an epidemic refers to an increase, often sudden, in the number of cases of a disease above what is normally expected in that population in that area. A pandemic refers to a disease epidemic that has spread over several countries or continents, usually affecting a large number of people.7 The critical term here is “disease,” and the critical point is that self-reported symptoms obtained from a screening survey do not establish the presence of a psychiatric disease, illness, or disorder. Many people can experience a new onset of—or an increase in—one or more symptoms of anxiety or depression, but not meet clinical criteria for a psychiatric disorder or “mental illness.”
Upon careful, clinical evaluation, such self-reported symptoms may or may not turn out to be a clinically significant disease or “mental illness.” The CDC report itself notes this limitation of its survey; ie, “. . . a diagnostic evaluation for anxiety disorder or depressive disorder was not conducted.”1
Consider the diagnosis of generalized anxiety disorder (GAD). According to the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the criteria for GAD require that symptoms be present for at least 6 months—so no one who responded to the CDC survey in June, 2020 would have met that criterion if their anxiety symptoms began, say, in March, 2020. Furthermore, DSM-5 criteria for nearly all the major disorders, including GAD, require that the person demonstrates “. . . clinically significant distress or impairment in social, occupational, or other important areas of functioning.”8
Merely experiencing an uptick in some symptoms of anxiety or depression does not necessarily mean that you have reached that distress-impairment threshold—much less, that you have a “mental disorder.” The difference between symptoms and disorder is not merely semantic. A formal, clinical diagnosis of a “mental disorder” has wholly different implications—medical, legal, and psychological—than those associated with, say, a normal or adaptive response to the stress and strain of the COVID-19 pandemic.
Indeed, the nebulous term “depression” may be misleading when considering many emotional reactions to the COVID-19 pandemic. I suspect—though I can’t prove–that many of the CDC survey respondents were reporting symptoms reflecting quite understandable demoralization and grief—and these are not mental disorders. On the contrary, as psychologist John F. Schumaker9 has elegantly put it, demoralization is “. . . an overarching psycho-spiritual crisis in which victims feel generally disoriented and unable to locate meaning, purpose, or sources of need fulfilment.” And grief, of course, is a normal, adaptive reaction to life’s “slings and arrows” and its manifold, painful losses.10
In my experience, only a careful clinical evaluation could distinguish profound demoralization and grief from major depressive illness, among the CDC survey respondents. Screening instruments like the four-item Patient Health Questionnaire (PHQ-4)—used in the CDC survey—simply can’t do the job.
None of this is to minimize the mental health challenges posed by the COVID-19 pandemic. Individuals with established psychiatric diagnoses—for example, post-traumatic stress disorder, schizophrenia, or bipolar disorder—may be experiencing serious, pandemic-related exacerbation of their illness, and may require immediate treatment. There is also strong, emerging evidence that COVID-19 may lead to serious and enduring neurological complications.11 Care and treatment of these seriously affected individuals should be our priority. We must also carefully monitor the long-term psychological effects the COVID-19 pandemic may have on children and adolescents.12 Finally, we must remain vigilant regarding the enormous physical and emotional toll the COVID-19 pandemic is taking on our physicians, nurses, and other front-line health care workers.13
And let me be clear: the mere fact that someone may not meet full DSM-5 criteria for a “mental disorder” does not mean that the person is unworthy of professional attention, or undeserving of insurance coverage for, say, telemedicine counseling. We know, for example, that “subclinical” depression—ie, falling just short of full DSM criteria for major depression—can nevertheless be a disabling condition that needs treatment, and may respond to psychotherapy.14
So, no—the term, “mental health pandemic” is not really helpful or accurate. But that observation does not negate the distress and loneliness of so many who are enduring the COVID-19 pandemic, nor should it diminish our efforts at comforting and supporting them.
—————
*Ironically, the term “mental health pandemic,” understood in epidemiological terms, would mean something like “a worldwide outbreak of mental health!”
Dr Pies is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University; clinical professor of psychiatry, Tufts University School of Medicine; and editor in chief emeritus of Psychiatric Times® (2007-2010).
Acknowledgments: I wish to thank Dr Awais Aftab for his helpful comments on an earlier draft of this piece; and Ms. Grace Huckins for prompting my consideration of this issue.
Recommended reading:
Pies RW. Care of the Soul in the Time of COVID-19. Psychiatric Times. May 13, 2020. Accessed August 21, 2020. https://www.psychiatrictimes.com/view/care-soul-time-COVID-19
References
1. Czeisler MÉ , Lane RI, Petrosky E, et al. Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:1049-1057. DOI: http://dx.doi.org/10.15585/mmwr.mm6932a1
2. Gold J. Covid-19 Might Lead To A ‘Mental Health Pandemic.’ Forbes. Augues 6, 2020. Accessed August 21, 2020. https://www.forbes.com/sites/jessicagold/2020/08/06/COVID-19-might-lead-to-a-mental-health-pandemic/#333f0013706f
3. Pies RW. The Bogus “Epidemic” of Mental Illness in the US. Psychiatric Times. June 18, 2015. Accessed August 21, 2020. https://www.psychiatrictimes.com/view/bogus-epidemic-mental-illness-us
4. Pies RW. The Astonishing Non-Epidemic Continues. PsychCentral. October 5, 2017. Accessed August 21, 2020. https://pro.psychcentral.com/the-astonishing-non-epidemic-continues/
5. Johnston J. The ghost of the schizophrenogenic mother. Virtual Mentor. 2013;15(9):801-805. doi: 10.1001/virtualmentor.2013.15.9.oped1-1309.
6. Pies RW. Debunking the Two Chemical Imbalance Myths, Again. Psychiatric Times. August 2, 2019. Accessed August 21, 2020. https://www.psychiatrictimes.com/view/debunking-two-chemical-imbalance-myths-again
7. Center for Disease Control. Lesson 1: Introduction to Epidemiology. In: Principles of Epidemiology in Public Health Practice. October 2006; updated May 2012. Accessed August 21, 2020. https://www.cdc.gov/csels/dsepd/ss1978/lesson1/section11.html
8. American Psychiatric Association: Diagnostic & Statistical Manual of Mental Disorders, 5th ed. Washington, DC: American Psychiatric Publishing, Inc; 2013.
9. Schumaker J. The demoralized mind. New Internationalist. April 1, 2016. Accessed August 21, 2020. https://newint.org/columns/essays/2016/04/01/psycho-spiritual-crisis
10. Pies RW, Geppert CMA. Clinical depression or “life sorrows”? Distinguishing between grief and depression in pastoral care 1. Ministry. May 2015. Accessed August 21, 2020. https://www.ministrymagazine.org/archive/2015/05/depression
11. Heidt A. Dozens More Cases of Neurological Problems in COVID-19 Reported. Scientist. July 8, 2020. Accessed August 21, 2020. https://www.the-scientist.com/news-opinion/dozens-more-cases-reported-of-neurological-problems-in-COVID-19-67717
12. Harris NB. Children will pay long-term stress-related costs of Covid-19 unless we follow the science. Stat News. August 4, 2020. Accessed August 21, 2020. https://www.statnews.com/2020/08/04/children-long-term-stress-related-costs-COVID-19/
13. Kelly M. The Pandemic’s Psychological Toll: An Emergency Physician’s Suicide. Ann Emerg Med. Ann Emerg Med. 2020;76(3):A21-A24. [Epub ahead of print] 2020;doi:10.1016/j.annemergmed.2020.07.009
14. Cuijpers P, Koole SL, van Dijke A, et al. Psychotherapy for subclinical depression: meta-analysis. Br J Psychiatry. 2014;205(4):268-274. doi:10.1192/bjp.bp.113.138784
