This September 11 is different. Every year, Americans have remembered the largest terrorist attack on American soil by coming together – to read names, to pray, to hold hands.
But this year, one of the most trusted remedies for grief – togetherness – is not available because of the worldwide coronavirus pandemic. In New York City, even the twin columns of light that traditionally shine into the Manhattan sky on the anniversary will not appear this year. A spokesman for the National September 11 Memorial and Museum told the New York Times that the decision was made in order to avoid the health risks of a crew of nearly 40 people working closely together to install the lights.
One could argue that the pandemic, like 9/11, has changed everything.
Seven months into social distancing and stay-at-home orders, long after many Americans expected things to have returned to normal, the stress of the pandemic has taken its toll. A study published earlier this month in the Journal of the American Medical Association Network Open found that the prevalence of depression in April was three times higher nationwide than it had been before the start of social distancing.
The researchers conducting the survey, including lead author Catherine Ettman, noted that by mid-April, 42 U.S. states, accounting for 96% of the population, were under stay-at-home or shelter-in-place advisories. The crisis has touched nearly everyone.
“We found that over one quarter of Americans reported depression,” she said in a phone interview Wednesday. “This was a threefold increase from before COVID.”
Acute vs. chronic stressors
Dana Rose Garfin of the University of California at Irvine has studied populations linked to 9/11 and to the pandemic. She said this week, also in a phone interview, that the distinction between the two crises is clear.
“With 9/11 it’s an acute stressor,” she said. “It had a clear beginning and end. The pandemic is different because it’s chronic.”
“This is not just one event,” Ettman said. “This is COVID and fear and anxiety around COVID, as well as its dramatic consequences.”
Those consequences include loss of loved ones, loss of jobs, and in some cases loss of a sense of security. The study notes that the people most likely to be affected by depression were those who were lower income and had less than $5,000 in savings.
“The economic consequences of this moment,” Ettman said, “may perpetuate stressors. For example, stressors such as the death of someone close to you due to COVID, losing a job, having difficulty paying rent, having family problems, financial difficulties. Those were associated with higher rates of depression, and in fact people who had higher stressor scores were three times more likely to experience depression.”
Ettman added, “Stress is cumulative.”
In some ways 9/11 was easier to bounce back from because after a few hours of terror and more weeks of uncertainty, it seemed to be over. There was a distinctly defined time to heal.
“After 9/11, we did not see the high levels of pathology that we expected to see,” Garfin said. She was lead author on a long-term study of 9/11 effects published in 2018. “The thing about acute trauma is, it’s a little bit different. After it’s over there’s a natural healing process.”
“The pandemic is different because it’s ongoing,” Garfin continued. “It’s not giving people a chance to recover. The stress is unrelenting.”
And in some cases, stress brings the threat of self-harm. “Evidence shows that financial strain is linked to higher rates of suicidal ideation,” Ettman said.
Help is possible
While it is impossible to control stressful events, there are things communities and governments can do to help. For a start, meeting people’s basic needs, according to Dr. Ruth Shim of the University of California at Davis. In a companion piece to Ettman’s study, she wrote, “Because of the inadequate structure of safety net systems in the U.S., lack of employment can lead to increasing poverty, loss of health insurance, housing insecurity, and food insecurity. These social determinants have been exacerbated for many families and communities during the COVID pandemic.”
Shim argued that the study on mental health should remind Americans of the importance of investing in people’s basic needs – stable housing, unemployment benefits, access to healthy food and policies that prevent discrimination – as a first step toward managing mental illness.
Garfin had similar thoughts. “Always, the first thing you have to do is treat physical needs. ... And once you can get people stable with that, you can address their psychological stressors.” She said while it can be useful to reach out with psychological help to someone who has lost his or her job, the bottom line remains: “They need a job.”
Ettman said public health officials can do three things to help, particularly with people with fewer resources: Create awareness, by alerting people to the fact that they are at risk for depression and may in fact be suffering from it. Second, she said, “provide opportunities to screen people and identify those with poor mental health. Third, ensure that there are sufficient opportunities to seek treatment.”
If this doesn’t happen, Ettman and Garfin both warned, the impact on public health could be serious – and expensive.
A 2018 study from Penn State University found that a single poor mental health day – when a person describes their mental health as not good – in a month was associated with a 1.84% drop in a person’s income growth rate – and in rural areas, the average drop was 2.3%.
The same study found that the global economic cost of mental illness is expected to be more than $16 trillion over the next 20 years, which is more than the cost of any other noncommunicable disease. And that study was done before the pandemic had begun.
But there is hope. Ettman and Garfin agree that meeting people’s basic needs can go a long way toward preserving mental health.
“The best thing the country can do is create the healthiest conditions for people to live in,” Ettman said. “This would call for doubling down on our societal investment in supporting people through difficult times.”
More personally, Ettman said she hopes people will reach out for help if they need it. “If somebody is feeling depressed and they read this, I want them to know medical care can help.”
Garfin, too, offered encouragement. For those whose basic needs are met but whose mental health is suffering, she noted that exercise can provide relief, as well as spending time outdoors, doing good deeds for others, and using technology to connect with family and friends.
“Even though the tunnel is long, it really isn’t going to last forever,” she said. “If we all come together, we can get through it. We did that after 9/11. ... We don’t have any reason to think this will be any different.”
If you are struggling with depression or thoughts of suicide, contact the National Alliance on Mental Health for help or call the National Suicide Prevention Lifeline at 800-273-TALK (8255).