Extended Social Impact

The COVID-19 pandemic will have lasting social impacts that we are only beginning to fully recognize. These societal influences will be informed by the economic and psychological effects of COVID-19, and they will likely alter conventions, customs, and social life in the United States for years to come, especially if the virus becomes endemic. One could engage in an endless amount of speculation on the many potential changes to society, but this chapter will focus on how many Americans will likely experience lasting feelings of vulnerability that may make any return to “normal” extremely challenging and how tectonic cultural and economic shifts may affect crime rates, demographics, and even specific industries. Of particular concern is the exodus of highly skilled personnel from the medical field due to extreme physical and psychological fatigue brought on by long hours, witnessing innumerable deaths, and the sense of there being no respite in the near future. Additionally, loneliness may be a major problem for many in the short- and long-term, as they remain homebound for myriad reasons or otherwise struggle to adapt to the postpandemic world. There is no doubt that though the rift created by the pandemic between our past and the present will be difficult for many to bridge, many others may find it easy to adapt to the new world, or they may have even experienced positive changes in their individual circumstances. Sometimes being placed in a difficult situation forces us to make decisions that we would not otherwise choose out of comfort or fear of the unknown, but many may have finally forged ahead with a decision they had been unwilling to make prior to the pandemic, like moving to a new city, starting a new career, or ending a toxic relationship.

No Longer Impervious

There is a sense of unity and belief among most Americans that the events of 9/11 were a kind of wakeup call. The events that day reminded us that we are not invulnerable. For those of us in New York City, it was a harrowing experience akin to suddenly being tossed into a warzone. For those of us who worked in the hospitals that day, and the following weeks, it was the kind of thing for which no amount of training can ever prepare you. Even months later, colleagues were still struggling to make sense of what happened that day, as were Americans from thousands of miles away.

This is not to say that previous events had not shocked us to our core. The Oklahoma City bombing in 1996 and the Columbine school shooting 3 years later were both truly horrific events, but the impact that 9/11 had on the national psyche was different. The sense that the United States was somehow impervious to the hostilities engulfing many parts of the world disappeared overnight, leaving many of us feeling vulnerable, confused, and scared. People who watched the events unfold on their television screens and far away from the carnage in Lower Manhattan still experienced what are, according to DSM-5, the hallmark symptoms of trauma- and stress-related disorders: hypervigilance, avoidant behavior, reexperiencing the traumatic moment, and negative changes in thinking or mood.¹ It was a traumatic event and we walked away from the experience irrevocably altered. Some went on to be diagnosed with conditions like posttraumatic stress disorder (PTSD) or generalized anxiety disorder, but the vast majority of Americans eventually ceased to feel the persistent unease of existential dread and emerged into a new-normal.

The changes caused by the COVID-19 pandemic will no doubt be of similar magnitude because we have endured a consistent needling of our collective psyche for such an extended period of time. It already has created a paradigmatic shift in the way millions of Americans think of illness, and it is likely to change the way we think and talk about mental illness because the psychosocial and economic impacts, as well as the long-term effects of the disease, will be felt by a large segment of the population for years to come. Millions of people remained largely cloistered in their homes for over a year. As noted previously at the start of the second part of this book, adults and children have no doubt developed sleep problems, anxiety disorders, affective disorders, and trauma- and stress-related disorders throughout this time. Furthermore, to cope with these issues and disorders, many may have indulged in unhealthy habits that then turned into substance use disorders. Others may have developed health problems associated with excessive weight loss or weight gain. More importantly, there is also the
fact that an enormous number of people died and that there have been multiple individual days when more than 3000 people lost their lives due to complications from COVID-19. In mid-January 2021, the average number of people dying per day swelled to over 3400,² and by spring of 2021, it was estimated that more than 37,000 children lost at least one parent to COVID-19.³

In addition to its psychological impact, the lingering effects of the pandemic will also have wide-ranging economic implications. A World Economic Forum held 2 years prior to the pandemic estimated that mental health problems would cost $16 trillion in lost economic output between 2010 and 2030 globally.⁴ Again, these projections were made before the crippling, once-in-a-lifetime nightmare scenario that has now lasted for over 2 years and might persist far longer. Proposing an estimate to reflect the new reality is beyond my expertise, but I can say with certainty that avoiding the problem will only make it worse, and that “worse,” in this context, means a lower quality of life for millions of people and a greater burden to taxpayers, since public spending as a percentage of total spending for mental health services has held fairly constantly for the past decade at around 60% but was expected to increase even before the pandemic.⁵ The fact that Medicaid currently covers 74 million Americans, a figure that increased by 9.7 million between February 2020 and January 2021, would suggest that these costs will be even higher.⁶

It would be wrong to pathologize national experience in the wake of trauma, but it would also be wrong to simply ignore these issues and pretend like everyone is going to eventually wake up one day and be capable of going back to normal. Many of the old ideas we had about “normal” have been washed away by the pandemic, and we will emerge from this cataclysmⁱ with the need to create a new definition of normal. This is not something that we can individually shape or purposefully influence. It will gradually come into its own as new conventions, new mores, and new limitations on what constitutes acceptable behavior become adopted and people express how comfortable or uncomfortable they are with certain activities.

To venture a guess as to what these conventions will look like come 2023 or even late 2022 would be analogous to the science fiction writer from 1950 imagining what 2021 might be like. I am certain that most of it would be comically wrong, especially given the misplaced optimism of spring 2021, the impact of the Delta variant over the course of that summer, and the increasingly common belief that SARS-CoV-2 has become
an endemic virus. However, what I have noticed is that many people are recognizing in the pandemic not a newfound sense of vulnerability but a newfound sense of agency. Like Noah’s flood, and like all cataclysms, the pandemic destroyed the old world but has given birth to a new one. This is not to make light of the amount of death and pain and suffering that have taken place since the SARS-CoV-2 virus began spreading throughout our communities but to acknowledge that we are on the precipice of something new.

As I have said elsewhere, the pandemic has been kind of like a protracted night. Many of us spent this time cocooned in our thoughts and maybe reconsidered how we were living our lives and planned to make changes once the worst of it had passed. For some, this may have been a thought exercise akin to dreaming about how they might spend millions of dollars should they ever win the lottery. For others, these dreams are now turning into concrete action as they quit their jobs, start new businesses, leave behind stagnant relationships, and move to new homes. While there is no doubt that the COVID-19 pandemic has been a tragedy of Biblical proportions, and that millions of Americans will struggle with psychological and physiological postacute COVID-19 sequelae, as well as trauma- and stress-related disorders, many may see the aftermath as a time to make a new start and to take this as an opportunity to break out of old patterns and explore opportunities that may not have arisen otherwise.

It is worth bearing in mind that, prior to the pandemic, 83% of people in the United States were estimated to have gone through an experience that would satisfy criteria within DSM-5 for a traumatic event. However, PTSD prevalence for those individuals is a little over 8% or around 1 in 12.⁷ Many Americans may no doubt be awkward in their behavior, slightly avoidant, or even haunted by the experience of the pandemic. Similarly, many more may be vigilant, moody, or more anxious than they were before the pandemic. This does not mean that they have PTSD.

As psychiatrists, we need to avoid the urge to pathologize these symptoms and to help our patients recognize that these are common behaviors after stressful events and may not be indicative of mental illness. We need to stress the importance of talking about these feelings and processing them in a healthy way so that patients can emerge from the pandemic humbled but ultimately more well-adjusted. It has never been clearer that shutting oneself up and walling oneself in from the world can have deleterious consequences to mental health. We need to encourage patients and otherwise reluctant members of the public that now is the time to open up and talk about the difficulties they faced while coping with the effects of the pandemic.

The Return

It is impossible to say how quickly individuals will fully recover from the COVID-19 pandemic or when the majority of people will feel safe returning to public life without cumbersome restrictions on behavior. Still, it is worth noting that humans can be exceptionally resilient, even in the face of tremendous adversity, but this has been a truly novel event. Trying to estimate the number of people who will immediately bounce back and be able to resume somewhat normal social activities or, conversely, those who will not be comfortable resuming these activities is a matter of conjecture and not science.

Similarly, there simply have not been enough data accumulated to make more than an educated guess about how the pandemic and social distancing efforts will impact the prevalence of substance use disorders, anxiety, depressive, or trauma- and stressor-related disorders. Though these statistics from the American Psychological Association have already been mentioned, they bear repeating: During the pandemic, 23% of adults reported drinking more, 61% said that they have experienced undesired changes in weight, and 67% said their sleep patterns had been negatively impacted by the pandemic.⁸ While there is most certainly overlap between these three groups (excessive alcohol consumption can lead to weight gain and sleep problems), what is far more troubling is that these are not conditions that one heals from overnight. Alcoholism is not a phase that one casually wanders in and out of. For far too many people throughout the world, they will emerge from COVID-19 not only with anxiety disorders or depression but also trapped in a cycle of substance abuse, as well.

What is certain is that the process of acclimatizing to social situations is going to take more time for some people than others and that differences in comfort levels is perfectly natural. Some people have already fallen right back into the swing of things with minimal discomfort or awkwardness or changes to their prepandemic behaviors. Others are going to struggle to feel comfortable in social situations even if they live in a community with extremely high-vaccination rates and an extremely low number of COVID-19 cases. I do not think it is wise to try to put a limit on what constitutes a normal amount of time to readjust. We just need to show patience and encourage people to go at their own pace for the foreseeable future.

That said, we need to be empathetic to those who need support and who are struggling with anxiety disorders, affective disorders, and trauma- and stress-related disorders. An Italian study has found that
30% of patients with severe COVID-19 infection met criteria for PTSD,⁹ while a network cohort study using data from 69 million individuals, 62,354 of whom were diagnosed with COVID-19, found that as many as a third of patients are reporting neurological or psychiatric conditions between 14 and 90 days after COVID-19 diagnosis and that 5.8% of those patients received a first recorded diagnosis of a psychiatric disorder.¹⁰ For comparison, psychiatric disorder incidence during the same time period following diagnoses of other medical issues was far lower; this includes influenza (2.8%), other respiratory diseases (3.4%), skin infections (3.3%), cholelithiasis (3.2%), urolithiasis (2.5%), and fractures (2.5%).¹¹ A separate Italian study screened 402 adults with COVID-19 for psychiatric symptoms with clinical interviews and self-report questionnaires 1 month following hospital treatment for COVID-19 and found that 56% of those screened scored in the pathological range in at least one clinical dimension. This included reports of PTSD (28%), depression (31%), anxiety (42%), obsessive-compulsive disorder (20%), and insomnia (40%).¹²

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