“The Science of Social Distancing: Part 2”
April 1 2020.
Excerpts relating to Mental Health: ( from the full transcript)
Presenter: Prof.Sandro Galea.
From COVID COVERSATIONS, National Academy of Medicine and American Public Health Association.
Dr. Sandro Galea, the Dean of Boston University’s School of Public Health. He’s an emergency medicine physician with expertise in epidemiology. And he’s a renowned expert on the mental health impacts of disasters, ranging from natural disasters like Katrina to human made disasters like wars, mass shootings and the 9/11 attacks. And Dr. Galea will speak with us about the mental health impacts of the COVID-19 crisis and how they might be mitigated.
Sandro Galea Very good, thank you for having me. And thank you National Academies and thank you to American Public Health Association for arranging this. In my 10 minutes I want to talk about mental health and COVID-19, and I ground my reflections in the observation that what is going on right now is a trauma. It is a global trauma. And, focusing on the US, it’s a national trauma.
This is a definition of a traumatic event that I have used for decades, really, a lot of my work I’ve studied trauma and mental health: “A traumatic event is an experience that causes physical, emotional, psychological distress, or harm. It is an event that is perceived and experienced as a threat to one’s safety or to the stability of one’s world.” This definition typically has been applied to more typical mass traumatic events like terrorist attacks or hurricanes or floods. But I think anybody can see that it applies equally to what is going on right now with COVID-19, both the pandemic itself, as well as the efforts to mitigate the pandemic.
When we understand this, I think we can ground a fair bit of our understanding in the literature of mass traumatic events. So I thought I would make seven points. I’m going to make seven points with just one data slide for each. And I’ll go through each one of them. Let me start this way.
Number one, is that prior evidence from a whole range of studies that have accumulated largely over the past quarter-century suggest that there is an increase in mental illness after traumatic events. After mass traumatic events. Much of that is in the mood anxiety disorders spectrum. Things like depression, anxiety, posttraumatic stress disorder, increase use of substances, alcohol, cigarette use, cannabis, as well as increase in behavioral disorders, things like domestic violence. I have just one slide to show you on this. This is from my research, after the 9/11 terror attacks. You see here, a map of the density of posttraumatic stress, leading out from where the World Trade Center was, which you’ll remember was at the south tip of Manhattan. And what I want to show you here -concentric circles with lower prevalence as you further out from 9/11, which was a consistent finding across many studies. The closer you are to the trauma, the higher the density of mental illness. And of course this is a trauma that is global and national. It’s not exactly clear where the epicenter is. The bottom line is, previous evidence suggests after traumatic events you’re going to have an increased incidence and severity of mental illness. That’s point 1.
Point 2 is that the emerging he emergent evidence after COVID-19 is that this is exactly what’s beginning to happen after COVID-19. Now, we are early in the epidemic, but there are a few papers that have been published in literature, most of them from Asia. And I just want to show you a couple of them. This is from one of them, which actually looked at the prevalence of anxiety, depression, and PTSD symptoms. What I want you to see is the prevalence of people -the blue bars are anxiety and depression, the red bars are PTSD, and the bars on the right are co-morbidities, any symptom of anxiety and depression, red is any symptom of PTSD, and the purple is both anxiety, depression and PTSD, at least one symptom. And about 50% of people in this one study had at least one symptom of anxiety, depression and PTSD. And when look at PTSD symptoms, you had 15 % of people had six PTSD symptoms, that’s in the red. The study wasn’t designed to come up with diagnostics for PTSD, anxiety and depression, but I think it gives us a clear indication early on that these symptoms are emerging.
The second other study uses the PHQ, which is a validated diagnostic instrument for depression, also looks at anxiety and some other symptoms of distress. But I highlighted in red, at the top right of this busy table, but I kept the table as it is, given that this is a science audience, And all I want to draw your attention to, and I hope you can all see, the table, is that there are columns here, the left, if you just look in my red circle, is Wuhan in China. The second is Hubei province outside of Wuhan. And he third column is outside of Hubei province. So that means you’re actually getting closer and closer to where there was more COVID-19. And if you just focus on PHQ depression, the rows are normal, mild, moderate, severe. And all I want you to see, is in the Wuhan column, you have more people who are severe and moderate, more severe than there are outside of Wuhan, more moderate than there were in Hubei outside of Wuhan. But then when you get to normal, you have more normal in Hubei outside of Wuhan. So in other words, early evidence, and these are really early studies, are that the closer that residents were to Wuhan, which was of course the first place there was COVID-19, the higher the likelihood of severe symptoms of depression. Which, if you think about it, is exactly the same as what I showed you about PTSD after 9/11. And then one other slide from a different study that came out, this looked at variables associated with, in this case, depression, and you can see there are multiple variables variables on the left. It’s a fairly typical graph. But all I want you to look at here is the bottom row. And the bottom row looks at social media exposure. And you see that social media exposure “frequently”, is associated with greater likelihood of depression and sometimes “a little bit less”, both of which are much more than less social media exposure. This, again is consistent with what we saw after the terrorist attacks and disasters in the past 20 years. This is beginning to behave like we’ve seen in the past two decades in studies of disasters and mass traumas, which suggests we are going to see a fairly predictable pattern of depression and PTSD throughout the country and the world. What is different about this event, of course, is the enormous geographic scope that it hits.
Moving onto the third point, is that right now I’ve just talked about the mental health consequences of the COVID itself. We also have an economic downturn that is compounding the influence of the COVID, as you heard, and there are going to be ongoing stressors that are going to compound mental health as a result of the economic downturn. This is simply just a graph to remind us of what’s been going on with the economy. And I could spend an hour talking about the literature about the mental health link to economic downturns. This is just a very simple graph looking at economic indicators and likelihood of suicide. So on the X axis here, we have an index of economic indicators, and on the Y axis, you have the rate of suicide deaths in New York City. And as economic indicators get better, you see suicide rates go down. And this is pretty consistent across a range of literature. And I could show you economic indicators linked with a broad range of common mood anxiety disorders. I’m just showing suicide as a common point. So economic conditions will, themselves, have mental health consequences.
And a fourth point is, that a key part of this picture is, it’s not just that economic consequences are one time. They’re not just punctate events. What they are are ongoing stressors. One of the pictures forgotten after disasters, Typically, we tend to think of disasters as something that happens, they happen and then they’re over. But when you look carefully at the science on this, what matters to mental health is the stressors that go on into long-term after a disaster. And those stressors themselves influence the incidence and the trajectory of other mental illnesses. To make that point, I’m just going to show you one data graph. This is a graph of people with PTSD after Hurricane Katrina. So this is a survival curve, everybody on the left of the Y axis, essentially, had PTSD, and as you go forward in time, we have a couple of years here, is people have remission, either a natural remission or else throught treatment. but what you see here is two lines, the PTSD curve splits. There are two curves, one labeled “high stressors” and one labeled “low stressors.” And that the people who experienced other stressors, and here, in this study those stressors were things like having hard a time paying the mortgage, having a difficult time putting children in school, worried about one’s parents., which we all recognize are things that are going on right now. Those who had these stressors were likelier to have PTSD for longer. So, essentially ongoing life stressors are what drives the trajectory of mental illness after the initial insult happens.
Fifth point, we’re talking about mental health, and I was asked to speak about mental health, which I’m glad to do, but I do want to make the point that mental health is inseparable from physical health. When I talk about mental health, if you believe the argument that I’m making and if you are a reader of the literature that I’m reading that shows exactly what I’m suggesting is going to happen, you’re going to also realize that this mental health burden is going to be also a burden that will excentuate the physical health burden after this event. Let me show you just one graph to make this point. It is from a study that our group had done. This is What you see is people, age on the x axis, but what really matters is cumulative incidence of Type II Diabetes-if you look at the black line, which is the bottom line, these are people who never had traumatic events. What you see is, as you get older, your incidence of diabetes goes up with age. Nothing surprising there. But what I want you to see is that the slope of that line gets steeper and steeper, the more trauma and traumatic symptoms that people have experienced, until we get to this pink line, which is the steepest. These are people who have experienced trauma and have symptoms of PTSD. So the natural incidence of diabetes which goes up with age, that slope gets substantially steeper if you have experienced a trauma and you’ve had PTSD symptoms. That means that the mental health burden, after COVID, and after the consequences of COVID, that I am describing and we should expect to happen, is going to influence the burden of physical disorders after COVID. So that’s one way in which mental health is linked to physical health. And then I want to show a totally different slide just to make this point because I feel like this point has not been made in the public conversation. What this is, is the data from perhaps the most comparable recent incidents, SARS and Ebola.
This is a slide about Ebola. And what this slide shows, just focus on the bottom right, the green lines, which you see going up and down, are the Ebola epidemic. The bars are not Ebola at all. The bars are actually malaria, they’re the diagnosis of malaria, and deaths from malaria. What’s really interesting about this, if you just look at the bottom right, is that Ebola cases went up, malaria cases also went up, but then, Ebola cases after Ebola was resolved, malaria cases still went up and deaths from malaria went up. The reason I’m making this case is that what happens after these events is not just the mental health consequences, but the physical health consequences get worse, simply because our health systems are all focused on dealing with one specific subset of disorders, leaving open the whole ground for other physical conditions.
Sixth point. The mental health consequences, unfortunately, are long-term and lasting. I think right now our attention is all diverted on the urgency of COVID, and it is appropriate. COVID is a terrifying disease and it’s going to result in more than 100,000 deaths in the U.S. alone, which are deaths that we previously were not counting on. It is also important to remember that, unless, by the grace of God something changes, we will get through COVID. But the consequences, particularly mental health consequence, are long-term, and they’re going to be lasting for months and years after we’re over the acute part of the COVID epidemic.
And just to make that case, I just want to show you some data from a study we had done in Africa. And all I want you to see here is, this is from a province in Liberia, and the dots here are areas where there was conflict. And that conflict was 25 years ago. Twenty-five years later we did a study, and the dark dots are the areas where there was high prevalence of PTSD. And really, all I want you to see, is that 25 years after, in an area where there was conflict, you can trace the path of trauma by looking at the PTSD in this one region in Africa, 25 years later, really, a quarter of a century later. So the echoes of these events goes on for a long time and the reason for it; It’s not just the initial trauma but the intitial trauma compounded by the stressors and compounded by the social and economic upheaval, which is exactly what we are seeing now with COVID.
So my last point, we can mitigate some of these consequences.
How do we mitigate some of these consequences?
Obviously, we could spend an hour talking about mitigation, but just four points:
Stepped care approaches; and
Improving social and economic conditions.
Briefly, one of the challenges we have, is that as a society we remain really, we are far behind in educating the public about mental health, de-stigmatizing mental health, making sure people come see providers in a timely way about mental health. And also normalizing mental symptoms. Normal anxiety adjustment reactions, normal sadness about being locked up in your house, it’s normal, it’s not necessarily pathological. But we don’t have that level of education that then allows us to screen people, screen the normal reaction from the pathological.
Number two, surveillance. Actually being able to monitoring mental health symptoms, being able to monitor the emergence.
Number three, stepped care approaches. Stepped care approaches means creating a system where we educate, we monitor, and refer to treatment only the people who need it. There’s a good, growing literature that stepped care is the way to deal with mass, large-scale traumatic events.
And number four, improving social and economic conditions, which, hopefully, now it should be clear why I’m saying that given how much social and economic conditions compound mental illness after traumatic events. This slide, here, what I want to show you, this is from a modeling study that we did. And what you see here, is, you can look at any of these, but just focus on the bottom right. The red line is stepped care approaches, and the purple line are usual care, without improving social and economic conditions. You can model the survival curve, the progression, of mental illness. And what you see is that the steepest decline, the most rapid resolution of mental illness is the red line. The red line is where we implement stepped care approaches coupled with improving social and economic conditions.
So, coming back to 7 points. The evidence does suggest we’re going to have a substantial increase in mental illness. The emerging evidence is consistent with that. This is going to be compounded by economic downturn and long-term, ongoing stressors. These mental health consequences also will compound physical health. They will last for a long time. You can mitigate some of these, but, ultimately, this is the next wave of the consequences of this pandemic that we have a responsibility to be prepared to deal with.
Thank you for having me.
DISCUSSION SECTION RESPONSES BY Prof.Sandro Galea.
Question 2 Thank you so much. Question for Dr. Sandro Galea. Could you speak to the anticipated short-and long-term impact on children and youth, in terms of mental health issues, and are there things that can be done now to try to mitigate those?
Answer 2: Sandro Galea That’s an excellent question. The children and youth are as susceptible to mental health symptoms as are adults. And everything I said applies to children as they do to adults. In many respects children are more susceptible and the current thinking I think, is that, most mental disorders are rooted in early in childhood and adolescence. In a book I edited years ago with several colleagues, we talked about the life course approach to mental disorders. The majority of mental disorders really start in childhood, and adolescence. The problem, when they start then, is they end up having implications throughout their life course. We know that people who have mental disorders that started in childhood and adolescence, will then go on to have a trajectory that is longer and more severe and it will intersect more with physical health and social and economic functioning. In terms of what can be done, the approaches are exactly what I outlined earlier, broadly, for children and for adults. It would be education. It would be screening. It would be making sure that care is available. And it would be making sure that the economic conditions and social conditions faced by their parents are dealt with. Some studies have shown that children of mothers who have depression, or mothers who have anxiety symptoms, those children are much more likely to have delayed social and developmental milestones, than mothers who are not depressed or don’t have anxiety syptoms. And so unfortunately, the implications of this for children, are serious. To my mind, the more we can do to mitigate these consequences both for children and for their parents, because that again affects the trajectory of the mental illness in children, it will yield enormous significance for us as a society in terms of return on investment. If we can invest now in mitigating these consequences.
Moderator: Dr. Galea, is there any evidence that sort of more broad scale population-based interventions might help? One of our people on the chat asked about mindfulness or other kinds of maybe broad-based interventions that could be done at the population level, or, alternatively, in low-resource areas?
Sandro Galea: There is literature on universal versus targeted interventions, and things like mindfulness are very difficult to deliver to millions of people, but they work much more in targeted ways. But probably, my read is that it is a combination of universal approaches, and targeted approaches to higher risk populations, that probably have the greatest yield. So I think it’s entirely reasonable to say the population level, we are going to aim for education about mental health, screening for mental health so that we can then direct people to needed, to more intensive, therapeutic approaches. And think of mitigating social and economic stressors as a form of treatment for mental illness. That’s at the population level. Than to say, for higher risk populations, which in particular cases may be children of those who are affected by COVID or its economic consequences, for those groups, led us train potentially lay workers, to deliver higher intensity approaches that can prevent or mitigate mental illness to higher risk groups. I think it is that kind of combination that we need to embrace collectively to minimize or reduce the mental health consequences of this event and the consequences of its consequences.