A progression of relentless stress
At the core of this pandemic is relentless stress. When it began in early 2020, the pandemic ignited an acute stress reaction due to the fear of death and the oddness of being isolated at home. Aggravating the acute stress was the realization that life as we knew it suddenly disappeared and all business or social activities had come to a screeching halt. It was almost surreal when streets usually bustling with human activity (such as Times Square in New York or Michigan Avenue in Chicago) became completely deserted and eerily silent. In addition, more stress was generated from watching television or scrolling through social media and being inundated with morbid and frightening news and updates about the number of individuals who became infected or died, and the official projections of tens of thousands or even hundreds of thousands of fatalities. Further intensifying the stress was hearing that there was a shortage of personal protective equipment (even masks), a lack of ventilators, and the absence of any medications to fight the overwhelming viral infection. Especially stressed were the front-line physicians and nurses, who heroically transcended their fears to save their patients’ lives. The sight of refrigerated trucks serving as temporary morgues outside hospital doors was chilling. The world became a macabre place where people died in hospitals without any relative to hold their hands or comfort them, and then were buried quickly without any formal funerals due to mandatory social distancing. The inability of families to grieve for their loved ones added another poignant layer of sadness and distress to the survivors who were unable to bid their loved ones goodbye. This was a jarring example of adding insult to injury.
With the protraction of the exceptional changes imposed by the pandemic, the acute stress reaction transmuted into posttraumatic stress disorder (PTSD) on a wide scale. Millions of previously healthy individuals began to succumb to the symptoms of PTSD (irritability, hypervigilance, intrusive thoughts, avoidance, insomnia, and bad dreams). The heaviest burden was inflicted on our patients, across all ages, with preexisting psychiatric conditions, who comprise approximately 25% of the population per the classic Epidemiological Catchment Area (ECA) study.24 These vulnerable patients, whom we see in our clinics and hospitals every day, had a significant exacerbation of their psychopathology, including anxiety, depression, psychosis, binge eating disorder, obsessive-compulsive disorder, alcohol and substance use disorders, child abuse, and intimate partner violence.25,26 The saving grace was the rapid adoption of telepsychiatry, which our psychiatric patients rapidly accepted. Many of them found it more convenient than dressing and driving and parking at the clinic. It also enabled psychiatrists to obtain useful collateral information from family members or partners.
If something good comes from this catastrophic social stress that emotionally hobbled the entire population, it would be the dilution of the stigma of mental illness because everyone has become more empathic due to their personal experience. Optimistically, this may also help expedite true health care parity for psychiatric brain disorders. And perhaps the government may see the need to train more psychiatrists and fund a higher number of residency stipends to all training programs.
Quo vadis COVID-19?
So, looking through the dense fog of the pandemic fatigue, what will 2021 bring us? Will waves of COVID-19 lead to pandemic exhaustion? Will the frayed public mental health care system be able to handle the surge of frayed nerves? Will social distancing intensify the widespread emotional disquietude? Will the children be able to manifest resilience and avoid disabling psychiatric disorders? Will the survivors of COVID-19 infections suffer from post–COVD-19 neuropsychiatric and other medical sequelae? Will efficacious therapies and vaccines emerge to blunt the spread of the virus? Will we all be able to gather in stadiums and arenas to enjoy sporting events, shows, and concerts? Will eating at our favorite restaurants become routine again? Will engaged couples be able to organize well-attended weddings and receptions? Will airplanes and hotels be fully booked again? Importantly, will all children and college students be able to resume their education in person and socialize ad lib? Will we be able to shed our masks and hug each other hello and goodbye? Will scientific journals and social media cover a wide array of topics again as before? Will the number of deaths dwindle to zero, and will we return to worrying mainly about the usual seasonal flu? Will everyone be able to leave home and go to work again?
I hope that the thick dust of this 2020 viral asteroid will settle in 2021, and that “normalcy” is eventually restored to our lives, allowing us to deal with other ongoing stresses such as social unrest and political hyperpartisanship.