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Johns Hopkins Pediatric

Gearing Up for COVID-19’s Mental Health Toll


Psychologist George Everly is no stranger to the emotional fallout disasters bring. For more than three decades, he’s been among the first responders to the psychological trauma caused by SARS, swine flu (H1N1 virus), Ebola, the World Trade Center attacks and Hurricane Katrina, among other crises. He’s also taught thousands of professionals and laypeople how to administer “psychological first aid,” using the Rapport, Assessment, Prioritization, Intervention and Disposition (RAPID) method he pioneered after 9/11. The intervention addresses people’s basic needs, stabilizes acute reactions, fosters coping and facilitates access to professional help.

But Everly says he’s never encountered anything as “psychologically toxic” as the COVID-19 pandemic. “Every crisis I’ve witnessed appeared to be different in nature and scope,” he says, “yet all followed a similar trajectory. This is true with the current pandemic, but it’s the most severe I’ve ever seen.” The COVID-19 pandemic ranks highest in every category on a rating scale he developed to evaluate the psychological toxicity of disasters (annotated below with his comments):

  1. Morbidity. “How dangerous is the event? How many will it injure and kill? The numbers are already staggering.”
  2. Duration. “This could go on for a long time. It’s very complicated because of the likelihood of a secondary wave of pandemic. The longer the impact of the event, the more toxic it is.”
  3. Ambiguity/Uncertainty. “This is, by far, the most toxic factor. We’re struggling to learn who’s most vulnerable, how the toxin makes you sick and transmission behaviors. The mixed messages we are receiving from leadership and scientific experts cause confusion.”
  4. Lack of emotional support. “Social support is the best predictor of resilience. “Unfortunately, quarantine has inadvertently eroded this protective factor.”

Given this new reality, Everly anticipates an uptick in psychological casualties — what he calls “the hidden pandemic.” The coronavirus has already caused tremendous anxiety, but at this point, he says, “we’re in ‘the honeymoon phase.’ People are ecstatic that things are opening up in 30 states. And that means there will likely be a false sense of security.”

Currently, Everly estimates that from 20% to 30% of Americans could benefit from some form of psychological intervention because of the pandemic. He expects those numbers to rise. Children and the elderly — as well as those with a history of mental illness — are the most vulnerable, he says, because they need a sense of safety and security, “which is less available to them.”

He recalls the initial reactions to the pandemic: confusion, shock, fear and denial. “Early behaviors demonstrated self-preservation, such as fleeing, hoarding and stigmatizing, which persist,” he says. At the same time, Everly cites the heroic reactions of support and altruism among emergency services and health care professionals, who are risking their physical and psychological well-being, and potentially that of their families.

Everly expects emotional distress to intensify as time goes on. Attitudes and behaviors will dictate the severity of what Everly calls the next probable reaction: the disillusionment phase.

“Some people will experience grieving, depression and anxiety. But even if things go perfectly with the pandemic,” says Everly, “they will be asking, ‘Why did this have to happen?’ They might also grieve because they lost loved ones or a job or sense of safety, or they may express fears about the potential for a new wave of coronavirus.”

Mental health professionals can expect to see a surge in patients with anxiety and depression as a result of the pandemic, says Everly. Preexisting problems such as substance use disorder, post-traumatic stress disorder and suicidal ideation, he adds, are likely to worsen.

Everly believes psychological intervention can lessen the effects of disillusionment. “But in the final analysis,” he says, “it’s about people helping people recover as a society, and the ambiguity factor makes this time especially challenging. I’m hearing two concerns repeatedly: ‘Is the pandemic going to come back? If so, what then?’ And, ‘Am I going to lose my job?’”

At the same time, Everly cautions mental health professionals to take care of their own emotional health. He recalls a recent conversation with a colleague at a New York hospital who admitted to feeling a sense of hopelessness that was overwhelming. “Seeing the refrigerated trucks for all the dead bodies made it seem like a war zone to him,” says Everly — a situation known as vicarious trauma.

The three greatest risks the pandemic brings, says Everly, include burnout (mental and physical exhaustion), vicarious trauma and depression. “Despair is not uncommon,” he says. “I’ve seen it in my career. I think if you go back to depression in terms of what we’re seeing, I would use the term feeling overwhelmed. I certainly hear breathtaking stories.”

Ultimately, says Everly, “We all need to be kind to ourselves. Structure family time — a complete diversion from work. Be compassionate to yourself and others. Practice mindfulness. Keep a journal, even if you just jot down the best and worst part of your day.” All these approaches, says Everly, can prove helpful in building resilience, whether you’re the clinician or the patient. “I really believe we can all come out of this stronger,” he says.

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