April 24, 2020
The destabilizing effects of the coronavirus pandemic appear to be producing levels of anxiety that typically would suggest a need for mental health intervention and treatment, according to a survey developed by a population health researcher at Thomas Jefferson University in Philadelphia.
For weeks — and with no clear end in sight — life around the world has been disrupted in ways that are challenging both the survival and personal resilience of millions of people.
In the United States, where the impact of COVID-19 has become most severe, already 26 million Americans have filed for unemployment. And sometime Friday, the 50,000th person will have lost his or her life to the disease.
Sharon Larson is a research professor at the Jefferson College of Population Health. Her work examines the behavioral health impact of the coronavirus pandemic using a variety of methods that incorporate direct community feedback.
Late last month, Larson developed an anonymous, 64-question survey that captures demographic insight into the social and economic toll of the pandemic. Out of nearly 5,000 responses, the survey results represent approximately 100 ZIP codes in 30 states, with the majority of participation coming from the Philadelphia regional metropolitan area.
"When I first conceived of this survey, I was watching news 24/7 and hearing the counts of people who have the disease, how many people have died, how many were in the hospital," Larson said. "The onslought of the kind of information that we're getting and the way that information changes almost daily is anxiety-provoking."
Trained as a psychiatric epidemiologist, Larson decided to build questions into the survey that draw from the GAD-2, a screening tool for generalized anxiety disorder that's used in doctor's offices and hospitals across the country. While the GAD-2 is not diagnostic on its own, it often serves as a signal that patients may require clinical screening.
For general reference, the Anxiety and Depression Association of America estimates that each year about 40 million Americans, ages 18 and over, suffer from an anxiety disorder, or roughly 18.1% of the population. Though these disorders are highly treatable, only about 36.9% of those suffering receive treatment.
The preliminary findings from Larson's report point to a spike in the number of people experiencing anxiety symptoms to levels that would warrant treatment.
"About 40% of the folks who responded to our survey actually met that cut point that, in a clinical setting, would suggest it's time to look into this a little deeper and think about what additional kinds of support people need," Larson said.
The survey specifically asks, “Over the last two weeks how often have you been bothered by the following problems?" The two relevant questions are (1) "… feeling nervous, anxious or on edge?" and (2) "… not being able to stop or control worrying?"
The responses presented on the survey are, "not at all," "several days," "more than half the days," and "nearly every day." In escalating order, each of these responses is assigned a point value – — 0, 1, 2 or 3. When the point total for these two questions adds up to 3 or more, the individual is considered to have screened positive and may need additional conversation with a provider.
According to an early analysis of the survey, about 40% of all respondents had a score of "3" or higher, and those who appear most anxious are individuals between the ages of 30 and 60 years old.
Income also told an interesting story about "uncontrolled anxiety," based on preliminary findings.
|Uncontrolled Worry "Nearly Every Day"
"While portfolios of those in the highest income categories may have been impacted, these individuals are probably not experiencing many of the risks that worry those in the lowest income strata," Larson said.
To put the issue of anxiety in contrast, we asked Larson for preliminary data on those who responded that they were "not at all" worried nor experiencing uncontrolled anxiety. This was framed in relation to job changes or job loss as a result of the pandemic.
The majority of survey respondents, even those still working, reported feeling at least some elevated degree of worry in response to the coronavirus pandemic.
|Job Status Change from COVID-19
|Feeling Nervous "Not At All"
|Uncontrolled Worry "Not at all"
Larson's work is particularly focused on areas of differential access within vulnerable sub-populations, whether it's getting adequate food, health care, prescriptions, information or employment and financial security.
"Population health is interested really in what we should do to manage influxes of populations from one group or another," Larson said.
As evidence mounts that COVID-19 is more severely impacting black and Latino populations in the U.S., she hopes her research can drive community health needs assessments that will enable health systems to refine their strategies for treatment and prevention among these populations.
"I think this is a really great framework for gathering information from the community and giving voice back to people who normally don't get included in our data collection," Larson said. "We're trying to do that deeper dive and getting real feedback from the community, not just relying on electronic health records and census data."
At the time of the terrorist attacks of 9/11, Larson worked with the federal Agency for Healthcare Research and Quality.
One of the agency's key concerns that emerged from the event was whether depression in the U.S. would increase in the months that followed. Larson and her colleagues found a more multifaceted response in the population.
"Depression didn't necessarily skyrocket, but people's reports of serious mental health symptoms increased at that time," Larson said. "It was sort of generalized."
There are key differences between 9/11 and the coronavirus pandemic, but those varied findings seem likely to show up again.
"I don't think most of us are afraid of dying from coronavirus. It's the conditions of life that are causing people to be anxious" – Sharon Larson, Thomas Jefferson University researcher
"The thing that's different about the coronavirus pandemic is that it's long-acting," Larson said. "We had an event on 9/11. We had to deal with it, not to say that it didn't have long-lasting implications for some people, but for the nation, there was a moment in time when we sort of turned on the switch and continued on with our lives. This has affected people more globally across the United States. It feels like we don't know when that switch is going to happen."
The greatest similarity between the two crises is their powerful effect on the information economy. Media consumption plays a substantial role in shaping public perception, which is vitally important when the stakes become a matter of life or death.
About 92% of those who responded to Larson's survey said they were getting their information from television news, among other sources. Fewer people said they were turning to the CDC or the World Health Organization, but those who did actually reported higher levels of anxiety.
Larson considered that this is perhaps because these institutions are most strongly urging lifestyle changes, such as social distancing, that require unprecedented sacrifices of routine freedom. It's also true that, as in the case of the guidance on wearing masks, recommended practices are evolving as epidemiologists continue to study the behavior of SARS-Cov-2.
With a pivotal election approaching in November — an event that normally provokes social tension and clashing viewpoints — Larson emphasized that coronavirus information needs to maintain focus on community health, even as politics take center stage.
"We need to make sure that people are getting the right info," she said. "We've got to have clear, thoughtfully delivered information out there in a space where people can take it, believe it and trust it."
Larson has been in contact with population health researchers elsewhere in the U.S. to discuss collaborative efforts that will generate more public feedback on the crisis.
There is an expectation in Larson's field that the economic and health impacts of COVID-19 will have long-lasting effects on psycho-social and mental health..
One colleague in Michigan mused, "How do you treat a national post-traumatic stress disorder?"
Larson believes the answer will require looking deeper at the problems that arise from social isolation. How do they play out in different networks and households?
"When it's a parent, is it about not being able to have an adult conversation? They're stuck at home all day and had anticipated their child would be away at school for another couple of months," Larson said. "Is it about losing your job, or a change in how you work? Is it about not being able to take care of an elderly parent in a direct way?"
Researchers and mental health practitioners need to consider more closely how these issues are provoking anxiety, she said.
"I don't think most of us are afraid of dying from coronavirus. It's the conditions of life that are causing people to be anxious," Larson said. "I think we need to get much more real about that. Getting people to talk about what's causing the anxiety will help us understand and start thinking about solutions for that."
Telemedicine, which has become a lifeline for psychotherapy during the pandemic, will need to become a more widely adopted practice, Larson believes.
"From the standpoint of research, what would be the right amount of that kind of thing?" Larson wondered. "How many sessions might help someone get their anxiety under control?"
In the weeks and months ahead, Larson and her colleagues aim to publish their findings, share them with health departments and provide useful infographics for the public. The goal is to give communities a clearer sense of how COVID-19 creates pressure in people's lives, and in turn give policymakers the data they need to adapt to these challenges.
The findings on anxiety are jarring, but Larson believes it's yet another sign that society needs to continue the work of destigmatizing mental health issues.
"I think we need to remember that lots of us — 40% of respondents — are anxious to the point that if they were sitting in a doctor's office, the doctor would be saying, maybe we need to get you into some counseling, maybe there's some medication you can take. Have you tried meditation? Are you exercising?"