For rising sophomore Sabrina Perla, the coronavirus presented both physical and mental obstacles. When she tested positive for the virus mid-March, her mental and physical well-being became inextricably linked; after her hospitalization due to the infection, she experienced a manic episode that led to a bipolar disorder diagnosis.
Perla, who is majoring in business administration, was initially diagnosed with clinical depression and anxiety disorder and was prescribed antidepressants in late 2018, which she said were ultimately ineffective. Following her hospitalization, Perla, who also has attention-deficit/hyperactivity disorder, returned to Los Angeles from her home in New Jersey to access mental health services through Medicaid, a federal and state insurance program that helps cover health care costs for low-income individuals, since her therapist told her she had to be in California to continue meetings. She received an emotional support dog and new medication.
But even with these resources, Perla said quarantine has only made her mental health worse, making it difficult to maintain a routine and muster the motivation to follow through with daily tasks.
Perla’s experience is not uncommon. As the world lurched to a standstill as a result of the coronavirus pandemic, millions of people across the United States retreated into their homes. Nonessential businesses shuttered, recreation centers closed and colleges became near-ghost towns. With the mass cessation of activity, many people — particularly those with mental health disorders — lost access to vital coping mechanisms: face-to-face interactions with friends, distractions in the form of leisure pursuits and crucial tethers to their surroundings that encourage them to persevere.
“It’s been hard to stay home because I kind of need the social interactions to keep me going, keep me happy,” Perla said.
For students, whose college experience is ingrained with social gatherings — whether through parties, extracurricular activities or academic life — the abrupt end to most in-person interaction can exacerbate feelings of isolation and loneliness. A quarter of those between 18 and 25 have been diagnosed with mental illness, making young adults the group with the highest prevalence of mental illnesses, according to the National Institute of Mental Health.
“[Students are] totally cut off from the social interactions that are the fabric of college life, and that so often are the basis for people’s maturation and growth through the years of education,” said Columbia University clinical psychology professor Andrew Solomon in an interview. “So I see college communities as particularly vulnerable. I see it as a real responsibility for colleges to recognize this.”
Solomon wrote an op-ed about mental well-being during quarantine for The New York Times in April detailing how the lack of focus on the pandemic’s harmful mental health implications may contribute to a secondary epidemic if public health initiatives aren’t implemented to address the escalating crisis.
A new normal
After the L.A. County Department of Public Health enacted its safer-at-home order mid-March, USC Student Health, along with other health care facilities across the city, switched to TeleHealth visits for routine and wellness check-ins. Students have been encouraged to continue to take advantage of resources, including individual drop-in Let’s Talk … On Zoom! sessions, one-on-one appointments, group counseling and workshops.
With the switch to teletherapy, some of those at Student Health are now responsible for weekly workshops and talks on coping during the pandemic and maintaining healthy relationships and emotional connections, said Kelly Greco, assistant director of outreach and prevention services, clinical associate professor and faculty of the Department of Psychiatry and Behavioral Sciences at Keck School of Medicine of USC.
But some students have said they don’t feel comfortable taking advantage of these opportunities since they have moved online.
For Seanna Latiff, a rising junior majoring in art and cinema and media studies, the incentives to seek out treatment for mental health have decreased with the transition to TeleHealth services. Before the pandemic struck, Latiff had been utilizing the counselors’ walk-in hours because the in-person environment made her feel safe and cared for.
Perla, who is seeing both a USC therapist and an outside provider she was referred to by the Engemann Student Health Center, said counseling is no longer as accessible; because more people are now seeking professional mental health resources through the program, Medicaid’s resources are limited, meaning she connects with her non-USC affiliated therapist once a month instead of once a week. Although her counselor has made adjustments in an attempt to meet more frequently since her new diagnosis, she said therapy over the phone is awkward because of the lack of face-to-face interaction.
Sara Zuluaga Sierra, a rising junior majoring in non-governmental organizations and social change, said the pandemic has tested the adaptability of USC’s mental and physical health offerings.
Part of Zuluaga Sierra’s decision to stay in California rather than return to North Carolina was based on the increased access to mental and physical health practitioners in L.A. Some of these physicians were referrals from Student Health for treatment for major depressive disorder, generalized anxiety disorder and otherwise specified attention deficit disorder. In addition to outside physicians, Zuluaga Sierra said she has had mixed but overall positive experiences with Student Health services.
A secondary epidemic
Despite the TeleHealth adjustments undertaken by many offices across the country, including at Student Health, there is no adequate health care framework for dealing with psychological issues prompted by physical catastrophes such as pandemics, according to a 2011 study conducted by the RAND Corporation, a nonprofit global policy think tank. The stressors produced by the unprecedented coronavirus crisis, coupled with the need for self-imposed isolation, disrupts the normalcy of the human experience, Solomon said.
While Solomon believes local and national governments’ focus on physical health is appropriate given the nature of the pandemic, he is wary of how mental health is often sidelined in public health conversations.
“I think people will come out of this whole thing … with very, very damaged psyches,” Solomon said. “Being depressed lowers the vitality of your immune response … So on a variety of fronts, this issue of mental health is dangerous to physical health. And of course, mental health is physical health, I mean, these are brain disorders.”
For Zuluaga Sierra, who has been diagnosed with autoimmune conditions, the connection between physical and mental health is personal. Before spring break, she asked Residential Education officials about housing accommodations for immunocompromised individuals. After being given an answer that outlined a case-by-case policy regarding who would be able to stay in campus housing for the remainder of the term, she wasn’t convinced of their concern.
“And as a person who is sick, we really tried to make it known that just because we’re sick, we’re not expendable,” Zuluaga Sierra said.
But as circumstances quickly evolved, contingency plans for campus residents changed dramatically as students were encouraged to return home, which, according to Zuluaga Sierra, was for the better.
Unlike students such as Zuluaga Sierra and Perla, who recognized the pandemic’s drastic toll on their mental and physical well-being, people without mental health disorders may be less adept at identifying the symptoms of mental illness and thus less likely to seek out professional help during this time, Solomon said. By contrast, people with preexisting mental health conditions may be more equipped to deal with the crisis because they may already have support networks and are familiar with the cyclical nature of disorders such as depression. At the same time, Solomon said navigating the detrimental mental health implications of quarantine when diagnosed with mental illness is not easy.
“There are many people who have had mental illness and who have struggled with depression and anxiety who are now going to have what gets called a double depression, in which, effectively, their underlying and ongoing struggle is kicked into much higher gear by these difficult and peculiar circumstances,” Solomon said. “And a lot will be people who think, ‘Oh, I thought I was climbing out of that, and now here I am back at the bottom of the pit again.’”
Rising junior Selin Yalcinkaya, who is diagnosed with mixed anxiety and depressive disorder and other specified feeding or eating disorder, said quarantine has stunted the improvement of her mental health.
“I would say sophomore year for me has been a lot of personal growth and like me kind of shedding bad habits,” said Yalcinkaya, who is majoring in theatre and psychology. “And I feel like since all of this, I’ve kind of taken a few steps backwards, which has been pretty frustrating.”
Yalcinkaya said ever since she’s returned home, she’s fallen back into harmful behavior, such as compulsive exercising and restricting food, as a coping strategy for her anxiety and depression. She said being at home reminds her of negative high school experiences and being around her family triggers additional stress.
“I think with quarantine, it’s been, you know, obviously everyone’s really stressed out,” Yalcinkaya said. “And so for me that’s kind of manifesting in really negative ways.”
For some students, such as Latiff, quarantining in L.A. was preferable to returning home, where a complicated living situation would exacerbate her generalized anxiety disorder. But with the lack of communication she received from USC about her guaranteed summer housing as an orientation adviser, Latiff grew increasingly nervous.
“I have a lot of anxiety right now about what’s going to happen to me a month from now, where I’m gonna end up,” Latiff said. “I’ve been reaching out to so many different [University] offices — getting zero responses back.”
Latiff said the silence she received from USC regarding her housing concerns reinforced her belief that the University consistently sidelines mental health. However, she said she understood the communication gap given the rapid way the University has had to adapt to emerging challenges.
For Yalcinkaya, USC’s mental health services have proved to be a saving grace. While she does not currently use the University’s mental health resources, she said her freshman-year Engemann therapist saved her life, counseling her through some of her lowest points that year. Student Health also helped her find an outside therapist that she currently talks with on the phone, although she admitted remote therapy is not as helpful because of the lack of in-person meetings.
“I feel like we’re kind of all suffering right now,” Yalcinkaya said. “I feel really unmotivated and uninspired, which then makes my mental health worse.”
Zuluaga Sierra’s experience paralleled Yalcinkaya’s, as she mentioned it felt isolating knowing other students on campus were able to complete tasks that she could not on a daily basis during the pandemic. With the majority of her professors conducting class as usual, she felt increasingly alone.
“The first two weeks were really bad. I was struggling a lot, mentally. I was in a very dark place,” Zuluaga Sierra said. “And my schoolwork was just like, not, it was not getting done … I was genuinely so depressed or so anxious that I could not rise up from my bed, much less look at a textbook or try to write a paper. And so that I think has been the most difficult part, especially because like a large part of my identity is based on being a really good student.”
For Dr. Steven Siegel, the Franz Alexander Chair in Psychiatry and professor and chair of psychiatry and the behavioral sciences at the Keck School of Medicine, mental health concerns have never been easier to address — even amid pandemic — as they have become less stigmatized throughout the years.
“Being in quarantine … might have an augmented negative impact in that people may already be quite isolated before this happened, and the few interactions that they may have, especially when you focus in on people with psychosis, are really their lifeline to feeling valued and valuable,” said Siegel, whose research focuses on those coping with psychosis and schizophrenia, which in different respects can both lead to loss of contact with reality and result in hallucinations or disrupted thought patterns. “It’s also their window into reality checks. And so, when that goes away, it can … reinforce some of their underlying fears that the world is a dangerous place or that they are alone.”
But for people who have never experienced mental illness, quarantine can foster the development of disorders such as post-traumatic stress disorder or depression, Solomon said.
A 2013 study published by the Society for Disaster Medicine and Public Health following the H1N1 outbreak found that of the 398 self-reporting parents that quarantined or isolated during the outbreak, a quarter met the criteria for PTSD.
“People are living in a state of fear, and they’re afraid for themselves,” Solomon said. “They’re afraid for colleagues. I mean, there are all of these people dying around them. And that’s terrifying.”
As health care providers, both Siegel and Greco recognize that their peers, other health care workers, parents and students who are the primary caregivers in their family find it difficult to balance caring for others along with maintaining their own mental well-being.
“What I say is reaching out for help is a sign of strength,” Greco said. “We are humans. COVID is something that is new to us. It is a time of uncertainty and great stress. And we have got to reach out to manage the stress with this — we cannot do this alone.”
Taking these groups into consideration, Keck Medicine and USC partnered to launch Care for the Caregiver, a program intended to ease the burdens that have surfaced for health care workers during the pandemic, by providing free housing, essential and comfort amenities and telehealth appointments with therapists from Student Health.
This program, along with past efforts to broaden access to mental health resources before the pandemic, has transformed the way Keck Medicine and USC will provide physical and mental health care in the future, Siegel said. Not only will TeleHealth continue to be an option for patients that may not be able to be seen in person, but the new student psychiatry practice on the fifth floor of Engemann will work in tandem to increase the University’s outreach and ability to see more patients on a long-term basis.
Both Greco and Siegel said this progress would have been nonexistent if professional advocates for mental health were left out of the conversation. At every level — not just discussions held by the University level — but by state politicians along with the Centers for Disease Control and Prevention and the World Health Organization have brought mental health to the forefront.
However, Solomon believes governments’ public health responses concerning the mental health implications of the outbreak have been lacking. Aside from general guidelines on how to manage stress amid the pandemic from NIMH and the CDC, large infrastructural change has failed to be implemented nationwide. Due to the economic effects of the outbreak, mental health providers have had to cut staff, reduce services or close entirely, according to a National Council for Behavioral Health survey of 880 community behavioral health care organizations.
“My concern is that in prioritizing physical health and largely overlooking mental health, what we’re going to achieve is a secondary epidemic that can be just as lethal and just as widespread as the initial one,” Solomon said.
Day by day
Given the isolating nature of quarantine, Solomon said it is of the utmost importance to maintain relationships and a semblance of routine during the pandemic, although the motivation to do so may be significantly decreased.
“Your lifeline is attachment to and connectedness to other people, and those are things that have to be sustained,” Solomon said. “Keep the essential emotional connections that you have and the friendships that are nourishing you alive, even though it takes a lot more effort to do it right now.”
Greco echoed this sentiment based on her previous talks with students and the research available on group involvement that demonstrates its beneficial effects on mental health.
“That sense of belonging is a key factor to thrive,” Greco said. “And so, you know, if you think about when you and I get stressed out, one of the first things a lot of us say is ‘So many people carried me through that. They carried me through the loss, the stress. They were there for me unconditionally.’”
During quarantine, people should take care of their basic needs by regulating their sleep schedules and their diet, avoiding excess alcohol, caffeine and drugs, Solomon said. He also said people should attempt to preserve a daily routine, which includes exercise and going outside for fresh air.
While some aspects of these routines may seem difficult to complete on a daily basis, Greco encouraged students to focus on easily achievable goals because the circumstances are more difficult to contend with.
“You know, it’s little things like going into the grocery store or just going out for a walk — they’re more stressful now these days and harder to do,” Greco said.
For Perla and Yalcinkaya, coping with the effects of outbreak means sticking to routines. Yalcinkaya sets aside time to play the guitar or go outside and spend time with siblings and friends on FaceTime, while each day Perla ensures she takes care of her dog and exercises.
“It’s OK to ask for resources, it’s OK to ask questions and it’s OK to not to be OK all the time,” Perla said. “A lot of people feel stressed, and maybe they feel things they’ve never felt before, but it’s important to take care of yourself and put yourself first during this time.”