Taking your 'mental health temperature' during COVID-19

You think you're doing OK when out of the blue it hits: a vague uneasiness—a nagging awareness that something isn't right. You're waking up in the middle of the night or you're snapping at your spouse. You miss people, but you don't call them. Fear, loneliness, uncertainty, or some other aspect of the pandemic—and the changes you've had to make—is getting to you.

You're not alone.

"There is a field called disaster psychiatry, and the COVID-19 pandemic falls within its purview," says Kimberly Yonkers, MD, a Yale Medicine psychiatrist. 9/11 is an example of another event that affected the mental health of many people and fits in this category, she says. But unlike 9/11, the pandemic directly affects everyone's lives and, for some, the threat feels even greater because there is no clear end in sight, and the trauma is compounded by financial stresses and the ongoing political divisions of the last several years, she says. "I think all of this is really having a profound mental health effect on the population," Dr. Yonkers says.

That's why mental health providers are concerned about everyone, including those who aren't in high-risk situations like health care workers or patients who have survived a serious case of COVID-19. In May, the U.S. Census Bureau released data revealing that one-third of Americans reported showing signs of clinical anxiety or depression. The data was based on a survey conducted in a one-week period that drew 42,000 respondents.

"Even if you are feeling fine in general, self-monitoring is very important," says Dr. Yonkers. "People need to check their emotional health every day by asking, 'How am I feeling? How is my mood? How is my energy? What can I do about it?'"

How the pandemic is affecting you

It may help for people to recognize that strong emotions aren't always a sign of a clinical diagnosis—in fact, they are a normal human reaction to acute stress resulting from a major external event, says Steven Marans, MSW, Ph.D., a child and adult psychoanalyst and chief of the Trauma Section at the Child Study Center.

When people feel threatened or their lives are altered in major, unwanted, and unanticipated ways, communication between the prefrontal cortex (the executive center of the brain) and the amygdala (the emotional processing center) may be disrupted, he says. This leads to the production of stress hormones that can cause distress in the body, as well as the mind. It may include increased heart rate; changes in respiration; muscle tension; irritability; disruptions in sleep, appetite, and concentration; and repetitive thoughts involving danger and helplessness.

Because each of us is in a different situation and our experiences and circumstances vary enormously, he says it may be helpful to identify what is bothering you the most (as opposed to trying to grapple with the pandemic as a whole).

"One common problem we're hearing about has been the loss of the normal routines of daily life," says Marans. "Major disruptions like this can undermine our normal capacities to regulate stress." Loss of social connection is another fear, he says. "Social connectedness is especially important because it can serve as a major protective factor when people are feeling most vulnerable."

Should you seek help?

For some people, the stressful feelings will resolve on their own; others may want to seek support from a psychologist or other mental health provider. But other people may find that their reactions persist and even grow worse, says John Krystal, MD, a Yale Medicine psychiatrist and a leading expert in such areas as alcoholism, post-traumatic stress disorder (PTSD), schizophrenia, and depression. You should consider seeking professional help if you find yourself overwhelmed by such symptoms as anxiety, exhaustion, fatigue, guilt, irritability, sleep problems, intrusive thoughts, and a reduced capacity to experience pleasure, he says.

"It will be important to recognize if someone is not bouncing back after the stresses and risks pass," Dr. Krystal says.

People who do not address their emotions in the short term could be putting themselves at risk for more serious potential long-term problems, such as PTSD, says Arman Fesharaki-Zadeh, MD, Ph.D., a Yale Medicine neuropsychiatrist. PTSD, which is more common in military veterans, is marked by hyper-vigilance, flashbacks, an intrusive recollection of certain memories, and nightmares, and can surface within weeks or years—or may take decades—after a severe trauma or life-threatening event.

Dr. Fesharaki-Zadeh believes PTSD would likely not develop as a response to the pandemic as a whole, but it could arise from a single traumatic experience during it. For instance, people have been traumatized by being told they no longer have a job, losing a loved one but not being able to grieve as they normally would, or (among some people who have had the virus) having flashbacks of frightening moments during the illness. "These things are happening to a lot of people, and I would not be surprised if the rate of PTSD increases," Dr. Fesharaki-Zadeh says.

What you can do to manage emotions

What may be a surprising bit of advice on preventing long-term mental health issues is to allow yourself to fully experience your uncomfortable emotions, overwhelming as they may feel. It's important to remain aware of your situation and—if you feel frightened—give yourself permission to feel that, says Dr. Fesharaki-Zadeh. "These are human emotions. They need to be out in the open," he says. "You can allow yourself to sit with uncomfortable feelings of being anxious, lonely, and fearful, and be compassionate to yourself in that moment."

Activities that are good for both body and mind help to lay a foundation that can make it easier for people to manage uncomfortable emotions, say the Yale Medicine psychiatrists. They have provided the following strategies:

• Control your exposure to the news. Set a limited time each day for checking the news. "If you are steeped in all this stuff and you're ruminating on it, you have to ask yourself where the line is between watching events and not being able to pull yourself away," says Dr. Yonkers. It may be impossible to avoid some negative news every day, but you can restrict your sources to objective news outlets that don't sensationalize what's happening.
• Practice mindfulness. This can be as simple as a three- to five-minute meditation each morning. Mindfulness meditation early in the day can lower levels of the stress hormone cortisol (which fuels the fight-or-flight instinct) when it is most elevated, says Dr. Fesharaki-Zada. "Mindfulness quiets down those areas of the brain that are overly active and constantly firing over time," he says. "It can do wonders if it is practiced on a consistent basis."
• Exercise to strengthen the brain: Any physical exercise helps, whether it's yoga, walking, or something else, as long as you do it each day. "The quantity is not nearly as important as the routine of doing it," says Dr. Fesharaki-Zada, who advises creating a routine, and possibly adding other elements to strengthen its effects. "I could talk for a half hour about the benefits of exercise as far as mood regulation. If you combine it with meditation, it's a very powerful cocktail."
• Keep a daily journal: Writing down the events of the day helps you to process them, Dr. Fesharaki-Zada says. He recommends finding a place where there are minimal distractions and writing as little or as much as you want, without judgment, ideally on a daily basis.
• Find ways to be social: Visit people when you can maintain a safe social distance, make phone calls, or schedule Zoom visits. Send cards and emails. Look for a safe way to volunteer your time or help someone in your community (volunteer organizations may have precautions in place). See if you can find someone to be with in a "buddy system" and check in regularly with that person.
• Do something you enjoy. Watch a movie, listen to music, go hiking, or do some other pleasant activity. "It's really managing stress that we're talking about," says Dr. Yonkers. "People manage stress by taking museum tours online or doing crossword puzzles or watching videos or cooking. You can't totally tune out the stress, but don't ruminate and dwell on it to the point where you can't get out of it."
• Get adequate sleep: Sticking to a sleep schedule helps reset the body's clock and supports falling and staying asleep. Consistent bedtime routines increase predictability and control. Avoid alcohol and caffeine before bed and focus on positive/calming thoughts before bed.

Everyone should be taking optimal care of their general health as well, says Dr. Krystal. "Aspects of a healthy lifestyle, such as a healthy diet, exercise, and re-engaging in meaningful activities also facilitate resilience."

If you are struggling, support is available

Some people may be more susceptible than others to mental health problems in the pandemic. People with a family history of addiction, anxiety, or depression, or a personal history of domestic violence, may be more at risk, as are people who have been exposed to COVID-19 or affected by losing their job or health insurance, for example. If feelings of sadness or other emotions are too much to manage on your own, it's important to reach out for help. "Counseling or formal treatment can be an essential part of resuming a full and rewarding life," says Dr. Krystal.

There are resources. The National Center for PTSD has a free app called COVID Coach that includes mindfulness exercises, mood trackers, and other tools.

The Yale Child Study Center provides the following information, developed by the trauma section, for parents and other adults:

• Understanding & Coping with Reactions in a Pandemic
• Spanish: Comprender y Lidiar con las Reacciones en una Pandemia
• Helping Children Cope with the COVID-19 Pandemic
• Spanish: Cómo Ayudar a los Niños a Lidiar con la Pandemia de COVID-19

If you need immediate help, the Centers for Disease Control and Prevention (CDC) recommends the following helplines:

• Substance Abuse and Mental Health Services Administration (SAMHSA) Disaster Distress hotline, 800-985-5990, or text TalkWithUs
• National Domestic Violence Hotline, 1-800-799-7233 (TTY: 1-800-787-3224)
• National Suicide Prevention Lifeline, 1-800-273-8255, or call 911.

The right support can set people on a better path, says Dr. Yonkers, who hopes one lesson people learn in the pandemic will be that they can reach out to a professional if they need one. "It's not a personal weakness if you're having a tough time now," she says. "A lot of people are."