For over a year, many of us within the medical community have been sounding the alarm about how the COVID-19 pandemic will impact the mental health of individuals across the United States in the long term. The percentage of adults who have reported symptoms of anxiety or depressive disorders throughout the past year has remained consistently high, with the latest data from the Census Bureau’s Household Pulse Survey showing that over 40 percent of the adults surveyed in January 2021 were still experiencing symptoms of these disorders. This is an increase of approximately 30 percentage points when compared to early 2019.
While we will likely begin to return to some semblance of normalcy as vaccination rates increase and new, more effective treatments become available, the psychosocial effects of the virus will linger long after the worst of the outbreak has been brought under control. Studies have found that elevated distress levels persisted among those who cared for patients with SARS and MERS for upwards of three years in the wake of those outbreaks. It is still far too early to understand the broader implications for the population in general, but it would be wishful thinking to presume that everyone will be able to simply process the events of the past year and healthily move on, especially those who became seriously ill. An Italian research team reported that over 30 percent of a sample of people who had been hospitalized with severe COVID infection and recovered met the diagnostic criteria for PTSD.
Anxiety, depression, and substance use disorders cannot be neutralized by a shot (or two) in the arm. These are complex and layered conditions that develop over time. More importantly, the longer these disorders are allowed to fester, the more entrenched they become.
What Needs to Happen
We need to help people. It’s really that simple. We need to perform outreach now to encourage those who need help to seek it. At the very least, we need to foster a more accepting environment by launching campaigns to eliminate stigmas about mental health. Dismantling them needs to be the highest priority because these stigmas can prevent individuals from engaging in earnest discussions about their mental health and, even worse, discourage them from seeking help.
Unfortunately, social stigma is not the only thing preventing individuals from seeking help. Issues like real or perceived cost, language, and distrust of mental health care workers are other barriers that can prevent help-seeking behaviors, and they tend to be the most difficult to overcome in the most vulnerable communities (i.e., the people who need help the most). Additionally, social media campaigns or other public service announcements may not reach everyone in this audience due to lack of internet access, inadequate familiarity with newer technologies, or physical impairment.
Of all populations, disadvantaged seniors probably face the most obstacles. Seniors are the most likely to face limitations in using new technologies that could be used to provide care or to potentiate help-seeking behaviors. This is a significant logistical hurdle. It is of particular concern due to the severity of the pandemic’s direct and indirect effects on many senior populations.
A Widow-Making Machine
In addition to suffering the lion’s share of COVID-related deaths (more than 80 percent in the U.S.), many seniors have experienced extended periods of isolation to maintain social distancing protocols. In some cases, this isolation was just a more extreme version of an already solitary lifestyle. In the U.S., an estimated 27 percent of adults over the age of 60 lived by themselves prior to the pandemic. In other cases, solitude was tragically and suddenly thrust upon them during the pandemic. An unfathomable number of seniors have lost spouses to COVID, and the impact has been particularly hard on older women because COVID is more fatal for men. The Global Fund for Widows characterized the disease as “a widow-making machine” in a report published last May.
There is no one factor that makes a person resilient to mental anguish following a traumatic experience like forced isolation or the death of a spouse, but strong social networks and the feeling of being connected certainly increase the probability that one will be able to successfully cope with catastrophe. Conversely, loneliness has not only been associated with worse overall mental health, but specific afflictions like depression, anxiety disorders, cardiovascular diseases, stroke, and pain disorders like fibromyalgia. Unfortunately, surveys have found that COVID has made older Americans lonelier.
This tragedy is compounded by seniors’ reluctance to voluntarily seek out psychiatric care. In their seminal paper on mental health treatment-seeking behaviors among older adults, Conner et al. (2010) found a “critically low intention to seek and engage in professional mental health services” among the study’s senior participants. The was especially pronounced among the study’s Black participants. Other studies have found similar disparities affecting non-White populations. Henry et al. (2020) reported that White patients receive care at a rate of approximately twice that of Hispanic and Black patients.
How do we perform effective outreach to seniors during the pandemic without using overly complicated and exclusionary technologies? How do we ensure that outreach is equitable?
A Simple Solution
There is at least one refreshingly simple thing we can do: Call them. A paper published in February by a team out of the University of Texas that was led by Dr. Maninder Kahlon found that clients of Meals on Wheels Central Texas who received regular calls reported lower levels of loneliness, anxiety, and depression than controls.
This study was conducted in July and August 2020 to better understand how the Meals on Wheels clients had responded to reductions in contact with others. Those who received the calls were predominately female (79 percent), living alone (56 percent), and had seen decreases in the amount of contact they were accustomed to due to COVID (66 percent). Racially, they were 22 percent Hispanic, 38 percent African American, and 43 percent White, and had a median age of 69.4 years. One hundred and seven participants remained in the program for the duration of the five-week study. Calls were scheduled at a time that was requested by participants. These calls were planned to be around 10 minutes in length but were allowed to go longer. During the first week of the study, the participants received five calls, and then were given the opportunity to choose the frequency of the calls between the range of two and five per week. No surprise, the majority opted for five calls per week.
What is so interesting about this paper is that those who called the participants were not credentialled physicians or therapists. They were volunteers who were given two hours of training in empathetic conversational techniques—defined as “prioritizing listening and eliciting conversation from the participant on topics of their choice.”
This is a program that can be replicated and deployed elsewhere at very little cost. (The 16 callers received a $200 stipend at the end of the study.) Furthermore, it employs a technology that the vast majority of seniors are capable of using. This study also highlights how we can reach potentially vulnerable individuals without seeming intrusive. By partnering with groups like Meals on Wheels and others who provide vital services to the community, we can have their representatives introduce the program to clients. If they hear about it from a trusted source, rather than a stranger, it is far more likely that they will be willing to take part in the program.
Finally, and perhaps most importantly, these calls can serve as a form of outreach to get the ball rolling for those who are struggling with mental health issues but are reluctant to seek help. Risk of embarrassment and internalized stigma are obstacles to seeking help from mental health professionals, but these same hesitancies may not apply to signing up for a program to receive a call from a volunteer. If these calls make the participant feel not only less lonely, but also less anxious or less depressed, they may encourage additional help-seeking behaviors.
Very few people will emerge from the pandemic without having suffered in some way. At least 30 million people in the U.S. have tested positive for COVID, and COVID was the third-leading cause of death in the U.S. in 2020 (behind only heart disease and cancer). These staggering numbers do not even begin to take into account the indirect effects of lockdowns, social distancing, and isolation. We need to develop or promote novel methods of outreach and to start taking proactive measures to bolster people’s mental health sooner rather than later, and we need to start implementing programs designed to help the most vulnerable among us now. As we have learned time and time again throughout this crisis, the longer we wait to take corrective action, the longer it will take to return to normal.