Updated at 1:36 p.m. ET on May 22, 2020.
The word I keep hearing is deafness. Not necessarily an illness, but feeling uncomfortable. A kind of detachment from reality. Deb Hawkins, a tech analyst in Michigan, describes the feeling of being stuck at home during the coronavirus pandemic as “sleepwalking through my life” or “wading through a physical and mental quicksand.” Although she has been living in an “introverted sky” for two months – at home with her family, thankful that she is in good health – her brain disagrees. “I feel like I have two modes,” says Hawkins. “Hardly works and boils angrily.”
Many people are tied even deeper. Michael Falcone has been running an acupuncture clinic in Memphis, Tennessee for a decade. When he temporarily switched it off, his mental health was immediately impaired. “I immediately became depressed when I realized that my real purpose was to dissolve,” he says. He began to spend his days staring at his bookshelves. Falcone and I have been exchanging emails for weeks, and while his notes were full of bizarre thoughts about adapting to home life, one line contained a shocking line: “I have lost confidence in myself. I don’t know if I can actually justify taking up space and resources. “
[Read: All the things we have to mourn now]
After confirming with Falcone that he had no intention of harming himself, I recommended that he seek medical help. But given the unprecedented circumstances in which we all find ourselves, I’m not sure whether I underreacted or overreacted – or what exactly “help” should look like. The pandemic is a moment of historic loss: unemployment, isolation, stasis, financial devastation, medical suffering and hundreds of thousands of deaths worldwide. Crowds of people suddenly find themselves in a state like Falcone’s, feel lost, hopeless – in his words “depressed”.
Last month, Jennifer Leiferman, a researcher at the Colorado School of Public Health, documented a tidal wave of depressive symptoms in the United States. “The rates we see are just so much higher than normal,” she says. Leiferman’s team recently found that people in Colorado report poor mental health nine times more often than usual during the pandemic. About 23 percent of Coloradans have symptoms of clinical depression.
As a rough average during the life before the pandemic 5 to 7 percent of people met the criteria for a diagnosis of depression. Depending on how you define the condition, orders of magnitude more people do this. Robert Klitzman, professor of psychiatry at Columbia University, extrapolated from a recent one lancet Study in China to estimate that approximately 50 percent of the US population has depressive symptoms. “We are witnessing the psychological effects of massive illnesses and deaths,” he says. As a result, the social norm that defines depression and other conditions is changed. This essentially sheds the entire definition section.
[Amitha Kalaichandran: We’re not ready for this kind of grief]
Feelings of numbness, fainting and hopelessness are so common today that they are almost considered normal. What we see, however, is far less likely to actually increase brain disease than a number of circumstances that produce a similar neurochemical mix. This poses a diagnostic puzzle. Millions of people who show signs of depression now have to distinguish boredom from temporary grief over an illness. Those who google at home need to know when to see a doctor and when it’s safe to just bake more bread. In the meantime, doctors have to decide how best to treat people with new or worsening symptoms: to diagnose millions of people with depression or to more aggressively treat the social circumstances that are at the heart of so many ailments.
Clearly articulating the importance of medical depression is an existential challenge for the psychiatrist and for a country that does not provide health care for its population. If we fail, the second wave of death from this pandemic will not be caused directly by the virus. It will take the people who have suffered mentally from its reverberation.
Like COVID-19, depression takes an irregular course. There are some predictable patterns, but no two cases are exactly the same. Depression can seep away for long periods of time and then quickly become severe. Some people will hardly notice it, others will be extremely tested.
Andrew Solomon, the author of The Midday Demon: An Atlas of Depressiongroups people using four basic methods of how they respond to the current crisis. Two are straightforward. In the first case, they are people who rely on huge stocks of resilience and are doing really well. When you ask how you feel and say “eh, okay,” you actually mean it. In the second, at the other end of the line, people who already have a clinical diagnosis of major depression or a persistent version are known as Dysthymia. Her symptoms are currently at high risk of escalation. “They are developing what some clinicians call” double depression, “in which the underlying disorder is accompanied by a new layer of fear and grief,” says Solomon. Such people may need more medical care than usual and may even need to be hospitalized.
[Read: Dear Therapist writes to herself in her grief]
The remaining two groups form a gray area. A group is made up of millions of people who now have real depressive symptoms but will eventually return to baseline as long as their symptoms are treated. The people in this group desperately need basic measures that help to create routine and structure. This can include regulating sleep and eating, minimizing alcohol and other substances, exercising, avoiding obsessions with the news, and restricting other aimless habits that are easier to moderate in normal times.
The fourth group includes people who are starting to develop clinical depression. They are more than just a wellness program or a zoom with friends, they need formal medical intervention. They seemed fine in normal times and had enough resilience to deal with normal difficulties, but they always had a tendency to develop an open depression. Solomon describes this group as “hanging on the abyss of what could be considered pathological”. This can be particularly precarious because people in this condition – what some researchers call “subclinical depression” – have not previously dealt with depression and may not have the ability or resources to proactively seek treatment.
The earlier specific types of depression can be identified, the better people can be targeted for appropriate treatment. The mental health system has always had obstacles to recognizing people and helping them at an early stage – issues such as access to care and stigmatization in the search for them. In the midst of this pandemic, not only is the current number of psychiatrists insufficient to suddenly treat several times as many people as usual, but their basic diagnostic skills are also compromised by distance, volume, and confusing variables. “It takes considerable wisdom to find out who is in clinical condition and needs medication and therapy, and who is only stressed out in good mental health,” says Solomon. Clinicians train for years to understand this line, and to get people to one side or the other it usually takes long interviews to record every element of a person’s affect.
[Read: ‘ICU delirium’ is leaving COVID-19 patients scared and confused]
Even for people who manage to get in touch with doctors, subtleties in video calls are difficult to read, says Meghan Jarvis, a trauma therapist who has observed a range of responses to the pandemic, including depression. Usually, Jarvis may send one patient to the hospital each year to get a pathological response to trauma. She has had four people in hospital since March. Typically, she explains, depression symptoms are considered problematic if they persist six weeks after a traumatic event. The exact length is arbitrary, but is generally intended to help distinguish depression from periods of grief, for example after the death of a loved one. This distinction is largely useless in the pandemic. “I mean, we’ll all have that,” says Jarvis, “because we’ve been in this mode for more than six weeks.”
Now Jarvis and others need to develop new thresholds. Just as not everyone can go to hospital with a cough in the days of COVID-19, clinicians are working to identify and prioritize those who really need personal mental health attention. Jennifer Rapke, director of the inpatient consultation at Upstate Golisano Children’s Hospital in New York, has seen an increase in teenagers reporting suicidal thoughts and cases of self-harm. Therefore, she has carefully rejected the less severe cases to ensure that inpatient facilities are not overwhelmed. “We only see people who absolutely have to be here,” she says. In the meantime, those with milder, emerging cases sometimes remain in limbo. “The places we would normally send people to, the things we would set up to address depression or anxiety at an early stage – they don’t exist or they aren’t available,” says Rapke.
With fewer preventive and maintenance measures available, people in more severe conditions are more likely to come to hospitals. Extreme events such as self-harm and suicide are delayed during crises. First of all, it is logical to worry about the proximity of death or to be sad about the loss of loved ones. Any other reaction would be bizarre. However, our mind and body cannot endure this state for too long. The United States was slow to test for coronavirus, and COVID-19 cases piled up before we knew how common it was. Rapke and others are now preparing for a similarly delayed wave of severe depression – and for the difficult decisions they have to make about treatments.
The elusive definition of depression has always been a source of academic tension with serious consequences. Among the many challenges that the pandemic brings with it are the limitations of the ability of medicine to transform human suffering into a billable diagnostic code. Some people with symptoms of depression are told: “Everyone feels this way” or it is recommended to do breathing exercises if they urgently need medical help. Others are diagnosed with clinical depression that will change their life and self-image indefinitely if the problems are really cumbersome. The system has never been error-free, but its limitations are now significantly alleviated.
For most of human history, depression has not been treated with the same medical model as body diseases. People with mental illnesses were written off as morally bankrupt or simply “crazy”. It was only in the second half of the 20th century that the profession of psychiatry became a medical specialty and created systematic treatment approaches. The process of diagnosing a condition in psychiatry and clinical psychology will never be as simple and objective as saying whether a bone is broken or not. or whether a person had a heart attack. But it offers a common basic language for what a clinician means when he or she diagnoses a patient with something like depression. It also helps patients get the insurance coverage and health care they need.
Today, depression – the clinical condition also known as major depression – is defined by the American Psychiatric Association in its definition Diagnostics and statistics manual as a mood disorder.* * In order to be diagnosed, a person must have five or more symptoms almost daily, such as the following, for a period of two weeks: fatigue or loss of energy, feelings of worthlessness or inappropriate guilt, reduced physical activity, indecisiveness or difficulty concentrating; a decreased or increased appetite and a greatly reduced interest or pleasure in regular activities.
[Read: What you need to know about the coronavirus]
Experts are trained to identify exactly how much “loss of concentration” or “energy loss” is sufficient to qualify for a diagnosis, and the criteria are intentionally flexible enough to take into account the individual circumstances of the patient. But as the pandemic made clear, it is DSM-5 and the medical model as a whole does not offer the wealth of language to account for all of the nuanced ways in which people may look or feel depressed even when they do not need medical intervention. Well-intentioned attempts to standardize the diagnostic process have created an incorrect binary where you may or may not be a person with depression.
Outside of medicine, depression was most defined by metaphor. Sylvia Plath wrote: “The silence depressed me. It was not the silence of the silence. It was my own silence. “David Foster Wallace described depression as the feeling that” every single atom in every cell in your body is sick. “Even some clinical models use alternative ways to articulate despair beyond the conventional medical model. James Hollis, a psychodynamic Analyst and author of Life between worlds: finding resilience in changing timessays depression is sometimes the result of “intrapsychic tension”, a conflict between two areas of our psyche or identity. Hollis notes that the tension arises “when we are forced to get to know each other in a new way.”
Many Americans seem to experience something like this tension during the pandemic. People who define themselves through their work can lose basic self-confidence if this work disappears. At such moments, Hollis says, many people recede. Many also try to escape – be it by organizing a well-organized sock drawer, baking bread they don’t want, or scrolling endlessly through Instagram. Jarvis, the trauma therapist, sees similar tendencies to flee: “For someone to respond to a major global pandemic, I’m going to train really hardis just as pathological and dissociative as if you went to bed and didn’t get up for five days. “
[Read: America’s patchwork pandemic is fraying even further]
For people whose response to the pandemic leads from acute anxiety to general malaise, Jarvis recommends tackling deafness directly. It is treatable and not necessarily medication. First, she says, create regimes of simple tasks that add structure to the day. The approach works for Falcone, the acupuncturist. It starts with 30 minutes of stretching every day, no matter what. Then he goes for a walk with his dog, makes coffee and sits down to teach massage about zoom. Deb Hawkins, the tech analyst, sent me a list of things she does to help others and stay busy: she donated money for a few good causes and made an appointment to donate blood. She created a little social bubble and signed up for an online ballet class. She says her confidence is returning.
Small steps like this may not work for everyone, but they can help many in the subclinical field to mitigate a dangerous slide. As the medical system is already thin, it could take some time to build up its ability to care for people who will experience severe and persistent symptoms from the pandemic. As important as preventive behavior may be, human resilience has limits. These will be tested in the coming months.
The individual depression model should never target a significant percentage of a population. If the diagnosis appears to be so widespread, it is not the people or the entire medical system that are broken, but the social context. While many people will find ways to recalibrate their expectations and individual thresholds for enjoying the pandemic, Ultimately, the basic needs still have to be met. This means eliminating sources of fear, for example by ensuring financial, housing and food security. In Colorado, Leiferman’s group is one of those trying to curb the flood of depressive symptoms. “Our nation is under stress. It may be that more people need it [medical] Treatment, ”she says. “It may be that we as a population have to do more to reduce the stress.”
* * This article previously incorrectly stated that the DSM is published by the American Psychological Association.
Hear Jennifer Rapke join James Hamblin in an episode of Social distance, The AtlanticPodcast about experiencing a pandemic:
Note: We are not the author of this content. For the Authentic and complete version,
Check its Original Source