Life as we knew it changed almost overnight with the onset of the coronavirus pandemic. To date, almost 100 million people have been infected with and approximately 2 million of those have died from the SARS-2-CoV 2019 virus (COVID-19). What’s not accounted for in these numbers, however, is how many people have been impacted by the pandemic without actually contracting the virus. For example, in addition to health issues related to the disease, the pandemic has caused substantial financial burden and hardship, housing insecurity, social isolation, grief and overall increased stress, among others. Given how transmissible and deadly the virus is, scientific efforts have been largely focused on vaccine development, and currently vaccines are beginning to be rolled out across the world. However, long after the virus has been controlled and heard immunity achieved, there will continue to be significant personal challenges stemming from the pandemic, including increases in anxiety, depression, post-traumatic stress disorder, suicide, addiction, and other chronic illnesses that have gone un- or under- treated during the pandemic.
When we think about the long-term, non-infection-related consequences related to COVID-19, three interrelated streams of outcomes appear to be most relevant: mental health, addiction, and health behaviors. As brief examples of how we hypothesized COVID-19 to uniquely influence these processes, we provide a conceptual framework to improve clinical practice to offset the likely long-term effects of the pandemic. First, COVID-19 is relatively novel and there is a lack of knowledge regarding long-term consequences of the virus. This creates an ideal opportunity to foster unhelpful thoughts about and fear of the unknown related to the virus and the future. As such, we expect there to be an increase in the onset, maintenance, and exacerbation of anxiety symptoms, which is already being reported. Additionally, given high rates of loss associated with COVID-19, as well as social isolation, COVID-19 can be considered as a potentially traumatic event, and it is possible that a high-risk segment of the population may respond to COVID-19 as a traumatic event. As with other large-scale traumatic events, we have witnessed increased efforts to attain control including monitoring news, stockpiling food and supplies, and maintaining constant vigilance. These are two examples of how COVID-19 may adversely impact mental health concerns.
Similarly, substance use is expected to both have an adverse impact on COVID-19 outcomes, as well as increase in response to the pandemic. As an illustrative example, cigarette smoking worsens respiratory symptoms associated with COVID-19, and recent research shows that, compared to non-smokers, smokers are more likely to receive ICU ventilator care in response to COVID-19. It is also important to recognize the stress-management function of smoking, and many people may turn to cigarettes to manage COVID-19 stress, particularly in the absence of social coping mechanisms. Similar models are thought to apply for alcohol and cannabis use, particularly given the ubiquitous availability of these substances. There has also been some early research that provides support for the negative reinforcement model of substance use, whereby substance use may actually increase susceptibly to COVID-19, exacerbate symptoms, and require more substance use to manage exacerbations in mood.
Finally, COVID-19 is likely to have a significant impact on sleep, physical activity, and chronic disease management. Sleep is critically important, because it provides a restorative function to the body as well as increases in immune functionality. COVID-19 has significantly disrupted sleep schedules due to many people working from home, increasing screen time and sedentary behavior, as well as decreases in social activities. Additionally, healthcare workers have been particularly affected, given the increase demands on the healthcare system, likely putting these individuals at higher risk for adverse COVID-19 consequences. Similarly, those with pre-existing chronic medical illness, (e.g., HIV), are likely to be at higher risk for COVID-19 related complications, that stems from decreased access to care for HIV, engagement in treatment for HIV, and prevention. It is currently unknown whether HIV specifically increases vulnerability to COVID-19, but people with HIV are considered immunocompromised and often suffer from other comorbidities, which could likely impact COVID-19 severity. This highlights the importance of pre-existing chronic illness management to mitigate the potential impact of COVID-19.
Of course, it is important to consider the societal impact of COVID-19, but it is also important to consider subgroups of individuals that are likely more vulnerable to the psychological, addictive, and health behavior consequences of COVID-19. First, healthcare professionals and first responders have experienced the brunt of the physical and emotional impact of COVID-19, and therefore have some of the highest levels of COVID-19 stress. This is likely contributing to elevated mental health concerns among this population. Further, economic adversity caused by COVID-19, including job loss, is associated with significantly increased stress, anxiety, depression, and suicide, and with little to no social interactions to mitigate the financial adversity, those that experienced the greatest losses are likely to experience long-term consequences. It is also important to consider racial/ethnic disparities that already exist in terms of COVID-19 and are likely to worsen. For instance, Black and Latinx individuals are dying at higher rates than White individuals due to health inequities. Specifically, lesser access to healthcare services, higher levels of poverty and unemployment, as well as more dense living conditions, can increase risk to COVID-19 as well as the overall stress burden of COVID-19. Additionally, in terms of the current pandemic, Asian American individuals are experiencing high rates of stigma and discrimination, likely increasing emotional distress and coping oriented substance use. Finally, among these identified high-risk groups, or the population at large, there may be individual difference psychological factors, such as emotion dysregulation or anxiety sensitivity, that may predispose someone to the negative psychological effects of COVID-19.
Armed with this conceptual understanding for the impact of the pandemic on psychological addictive, and health behavior problems in the short- and long-term, what is the next step? From a clinical scientist perspective, there is an urgent need for more research into understanding the substantial and long-term consequences of COVID-19. Clinicians need to consider the unique circumstances of COVID-19 contributing to exacerbations in psychological symptoms, addiction, and poor behavioral health outcomes. There will most certainly be a need for preventative and intervention efforts to manage the short-term and long-term impact of COVID-19 on these outcomes. Ultimately, concerted efforts are needed to understand the full gambit of COVID-19 consequences on well-being and learn to respond to these consequences in a flexible, tailored manner to improve overall health.
Zvolensky, M. J., Garey, L., Rogers, A. H., Schmidt, N. B., Vujanovic, A. A., Storch, E. A., … & O’Cleirigh, C. (2020). Psychological, addictive, and health behavior implications of the COVID-19 pandemic. Behaviour research and therapy, 134, 103715.
- What clinical considerations should be made when working with clients in the post COVID-19 pandemic era?
- Which groups may be particularly vulnerable to the negative psychological effects of COVID-19? Are there more groups that are being identified as vulnerable?
- Following the vaccine rollout and herd immunity, there is likely to be an even greater exacerbation of the psychological, addictive, and health behavior consequences of COVID-19. What role do mental health providers have in informing the public of these potential consequences? How might we, as a field, deal with even greater shortages in mental health providers, particularly at a time when the need may be greater than now?