As many places start to look forward to life after the first wave of the coronavirus, another type of illness could be about to follow in its wake.
"We're going to have many more mental health issues as time goes on," said Dr. Rima Styra, a psychiatrist at Toronto's University Health Network and associate professor of psychiatry at the University of Toronto. "And people will refer to it as a mental health pandemic."
U.S. crisis centers already report being flooded with calls. The Well Being Trust, a foundation that focuses on mental health issues, predicts the pandemic could cause 75,000 "deaths of despair" from suicide or addiction.
Not everyone will have a problem, experts say. And there are ways for everyone to support people at risk.
But the past offers a warning. After the 2003 epidemic of SARS, or severe acute respiratory syndrome, studies in Hong Kong found 40% of the survivors had post-traumatic stress symptoms.
Styra was co-author of a study of 129 people quarantined in Toronto because of SARS. About 30% showed symptoms of post-traumatic stress disorder and depression. More time in quarantine was associated with more symptoms.
Yuval Neria, director of the PTSD program at the New York State Psychiatric Institute, said we're in uncharted territory in terms of predicting the current pandemic's effects.
"I don't think the mental health consequences will be limited to PTSD only," said Neria, who also is a professor in the department of psychiatry and epidemiology at Columbia University Medical Center in New York City. "In fact, I think we should expect other mental health problems, such as depression, anxiety, substance abuse and potentially increase in suicide. They are already there and kind of showing themselves."
Workers "who continue to serve us while we self-isolate at home" could be at particular risk. But, he said, "there is so much to learn here. It's a big unknown, and we badly need good research."
For example, he said, "being isolated for a long time, without social support, is very unique to this pandemic on a global scale." As is the wave of grief that will follow tens of thousands of deaths.
Neria, a combat veteran whose own experiences with war trauma guided his decision to research the topic, has studied how PTSD follows wars, natural disasters and events such as 9/11. The pandemic is like and unlike those.
"Disasters are usually limited to space and time. And there is an onset of a disaster – which may take some time – but there is an end," he said. "But I think viruses have their own way to inflict adversities on us. The threat is ambiguous. (It) is everywhere and nowhere. It's ongoing. It may take a long time."
Anxiety alone doesn't lead to PTSD. It is sparked by a trauma – a direct threat to life, such as an assault, exposure to war, or being treated in an intensive care unit. Symptoms may include flashbacks, nightmares and becoming hypervigilant or emotionally numb.
Neria said the crisis highlights the need to upgrade the entire mental health system. In particular, he said, doctors need better training in how to treat addiction, depression, PTSD and grief.
And while not everyone who experiences trauma gets PTSD, Neria said those at risk now are people who have high chances of being exposed to the virus, "especially frontline health care workers, first responders and COVID patients coming out of ventilators and ICUs."
Dr. Laura Hawryluck, lead author of the Toronto SARS study, understands the stresses too well. Like Styra, she treated patients during the SARS outbreak. Then as now, patients had to be isolated.
"And the thought of somebody who is desperately ill not having the support of people they love and not having those people around until perhaps the last moments of their lives is very hard emotionally on the health care team."
COVID-19 has brought more death in less time. Health care workers also must worry about protective gear and other vital supplies running out.
On top of that, Styra said, they worry about exposing loved ones to the virus as they continue to deal with aspects of everyday life made harder by the pandemic, from getting groceries to finding child care.
She said anyone with symptoms of a mental health crisis – high levels of anxiety, feeling tearful, having trouble sleeping – should seek help. (The Department of Veterans Affairs offers PTSD-related advice at ptsd.va.gov, as does the National Alliance on Mental Illness at nami.org.) Family members should keep an eye on loved ones as well, Styra said, and encourage them to seek aid if they need it.
Hawryluck encourages health care workers to try to maintain self-awareness and a support network. She also encourages them to seek help if they feel they are not able to cope.
"There's been a lot more support for health care workers and frontline workers and being called heroes and stuff like this" compared with SARS, said Hawryluck, an associate professor of critical care medicine at University Health Network/University of Toronto.
"We aren't used to this overwhelming support, and it means more than we can ever express."