Even when COVID-19 is beaten, the stress and depression of the pandemic will still be with us. How do we recover?

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The messages read like a country in the midst of a collective anxiety attack:

This is real. I know nothing feels real, but it is.

It is okay to cry. Life goes on.

It’s going to get worse before it gets better.

Since the first week of Canada’s coronavirus lockdown, Karen Blair, a professor of psychology at St. Francis Xavier University in Antigonish, N.S., has been collecting daily diaries from Canadians across the country. So far, more than 1,000 people have signed up – journalling, as Prof. Blair notes, is its own therapy. Among the questions posed in the study: What would you want yourself to know seven days ago? What question would you ask yourself seven days in the future? What’s your answer a week later? The responses have been variously wry, panicked and heartbreaking:

Q: Is it getting worse or better?

A: It’s worse. It’s a lot worse and getting even more worse.

Q: Did you get to say goodbye to grandpa?

A: No, he died before I got better.

Q: How stressed are you at work right now?

A: Holy shit, you have no idea.

The pandemic has brought about bleak and profound changes for which we had no time to prepare, while also denying us the comfort of friends and family to get through it. The usual balms – the refuge of a sunny park, a beer at the pub, family gatherings, maybe even summer itself – are all lost to us. A simple sidewalk stroll requires treating your neighbours (and yourself) like the zombie host of a contagious cloud of deadly virus.

The strain of unexpected deaths, physical distancing, lost jobs and closed businesses is taking its toll. Stress is rising, depression is deepening and anxiety is spiking. In an Angus Reid poll released in April, half of Canadians said their mental health had worsened during the pandemic. A survey by the Vanier Institute for the Family suggests one-third of us aren’t sleeping well (which frankly sounds optimistic). Distress hotlines are reporting escalating numbers of callers. An April survey of Canadians by the human-resources company Morneau Shepell found that self-reported measures of productivity and optimism had fallen steeply since the lockdown began.

That same Morneau Shepell report also suggested that nearly half of those surveyed thought we’d be on the other side of the pandemic by the end of June at the latest. Even the most hopeful among us would have to call that wishful thinking, but the longer the pandemic lasts, the more our coping skills will falter. And afterwards, we’ll still be picking up the pieces of a shattered economy.

Steven Taylor, a clinical psychologist and professor at the University of British Columbia, wrote a book predicting this very moment. The Psychology of Pandemics: Preparing for the Next Global Outbreak of Infectious Disease was published this past October, but only after it was first refused by his usual editor, who said no one would want to read it. In the book, Dr. Taylor lays out our current reality: closed schools and businesses, physical distancing, an abrupt halt to modern life. He also warned of what would follow the first wave of sickness and death: a tsunami of trauma and mental illness, one with long-term consequences.

But even he’s surprised by the level of Canadians’ collective stress. “I didn’t think the anxiety would be as pervasive and prevalent as it is now,” he says. Then again, “none of us have been through something like this before.”

Dr. Taylor has been doing his own study, tracking the mental health of nearly 7,000 Canadians and Americans via clinical surveys. The data is still coming in, but this week he co-authored a journal article on what’s being called COVID Stress Syndrome. Among the symptoms: heightened anxiety about getting infected or touching surfaces that might carry the virus; intrusive thoughts and nightmares about COVID-19 that affect a person’s ability to function; compulsively checking social media; and panic buying and stockpiling. Xenophobia is also a key characteristic.

So far, Dr. Taylor estimates about 50 per cent of people have relatively moderate symptoms of distress. “They aren’t happy. But they are coping, more or less.” Another quarter fall into the pandemic-is-overblown group, which carries its own particular risk, since studies of previous pandemics show they’re most likely to spread the virus.

But Dr. Taylor says roughly 25 per cent of the respondents are experiencing high rates of anxiety and depression – for them, the isolation and uncertainty are potentially devastating.

Some of the more acute symptoms will wane once we adjust to the new post-pandemic normal. But as Dr. Taylor notes, even if only 10 per cent of Canadians suffer serious, long-term mental-health consequences, that’s 3.7 million people who will need help from a mental health care system that was already overwhelmed before anyone had even heard of COVID-19.

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Stock up on masks.

Fix the internet.

Brace yourself.

The first time that researchers closely examined the short-and long-term mental-health effects of a pandemic was during, and after, the SARS outbreak in 2003. In one study of Torontonians quarantined during SARS, 29 per cent had symptoms of post-traumatic stress disorder, and 31 per cent had symptoms of depression. Among health care workers – many of whom had to follow strict quarantine rules while the rest of the country carried on like normal – the stress and anxiety could be long-lasting: After SARS, a follow-up study in China found that 10 per cent of health care workers still struggled with high levels of PTSD..

“You weren’t meant to interact with family members. You had your groceries left at the door. That was for weeks and weeks,” says Dr. Taylor, who interviewed front-line staff who worked during SARS. “It was very stressful.” Those who worked in SARS wards, or had friends or relatives who contracted the virus, were up to three times more likely to have acute PTSD symptoms.

Damir Huremovic, a New York psychiatrist who closely reviewed the SARS research for a new book, says that even three years later, those difficult experiences resulted in higher use of alcohol. Nurses were found to have higher rates of PTSD than doctors, and the risk was higher still among workers who were dispatched into unfamiliar jobs.

Similar reports of mental distress are already emerging from hospitals around the world hardest hit by COVID-19. Meanwhile, research suggests that many front-line workers were struggling before the virus landed. A Canadian study had already documented high rates of burnout and suicidal thoughts among emergency department physicians – a specialty now bearing the brunt of care.

The trauma was also felt by SARS patients themselves. In one study, they reported feeling alone, dehumanized and anxious about dying. That research has raised concerns about possible PTSD among patients who survive serious cases of COVID-19. And grief counsellors caution the same will happen to families who lose loved ones, especially if they couldn’t see the person before they died or it was an unexpected death they couldn’t ritualize with a funeral. Dr. Taylor also wonders if there will be a rise in people obsessively fearful of germs or a trend toward isolating in the safe bubble of our homes, spending more time than is healthy on social media.

The fact that COVID-19 has also pulverized the economy will add significantly to the long-term mental-health effects of the pandemic. Anxiety and depression go up during any recession, and economic misfortune is associated with higher suicide rates. A September, 2019 analysis had already found an uptick in suicides among Albertans as the provincial economy stumbled – and that was before the pandemic threw millions more Canadians out of work. According to Alberta data, published by the University of Calgary’s School of Public Policy, a one-percentage-point rise in the unemployment rate increases suicide by a “statistically significant” 2.8 per cent.

Young people are also at risk. Millennials, who came of age during the 2008 recession, are already struggling with student debt, high housing costs and limited job prospects; now they’re facing a second downturn just as they’re buying homes and having children. Over the past decade, the number of children and youth visiting emergency departments for self-harm and suicidal behaviour nearly doubled in 2017-18, to 80,000 visits, according to the Canadian Institute for Health Information.

Being born during a pandemic could also carry risks – a U.S. study that tracked babies born around the Spanish flu of 1918 found they achieved lower levels of education and income, and had higher rates of mental-health issues. Studies suggest recessions have similar long-term effects on kids and teenagers.

We won’t fully understand the larger effects of COVID-19 for a while – that will take the hindsight of historians. But past pandemics have always changed the course of societies one way or another, says Dr. Huremovic, who edited the 2019 book Psychiatry of Pandemics, a collection of expert essays, both historical and clinical. The Antonine Plague that ripped across Rome – and through much of its army – from 165 to 180 AD earned a supporting role in the decline of the Roman Empire. The Black Death wiped out so many workers that it forced innovations in agriculture and sowed the roots of a new middle class. The Spanish flu of 1918, which killed an estimated 50 million globally (including roughly 50,000 Canadians, many of them poor or isolated, as is the case with today’s pandemic) is credited with spurring the creation of national health services in Canada and Europe.

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It’s okay to be scared.

You’re stronger than you realize.

Remember the resiliency of your ancestors.

When the threat of COVID-19 finally passes, life will no doubt look different: At restaurants, the servers might be clad in masks and gloves, and the Plexiglas shields at banks and grocery stores could be here to stay.

But for most of us, the trauma will likely fade as we adjust to the new normal. It’s happened before.

The Spanish flu stole millions of lives in a few short months, and then returned months later for an even more vicious second wave. Unlike COVID-19, it was most virulent among those aged 20 to 40, which means children were orphaned en masse, and many families lost their primary caregivers. Teenagers were left to nurse their family members back to life – or bury them.

Yet, when it was over, the world moved on, and the Spanish flu came to be dubbed the Forgotten Epidemic. The families who suffered most never forgot, however. “There was a frequent sense of living your life surrounded by ghosts,” says Esyllt Jones, a historian at the University of Manitoba and co-editor of Epidemic Encounters: Influenza, Society, and Culture in Canada, 1918-20. Even as the public went on to celebrate victory in the First World War, with its narrative of nation building, the pandemic lingered in all kinds of ways. "There is a buried sense of social trauma that people rarely talked about,” says Dr. Jones.

In his book, Dr. Huremovic spends some time trying to unpack this human tendency, what Nietzsche referred to as “active forgetting” – letting go of the past for the sake of living in the future. Pandemics, he says, disrupt our sense of reality and order; amnesia is a coping skill.

Even among health care workers most effected during SARS, Dr. Huremovic says, the research shows that most of them exhibited incredible resilience and went on to live healthy lives. With COVID-19, if the economy pulls itself together and a vaccine is found, he expects most people will simply move on and adapt to whatever new conditions apply to regular life.

Indeed, that’s a notion Dr. Huremovic clings to now as he treats COVID-19 patients who crowd into the hospital where he works on the North Shore of Long Island, and counsels colleagues who are watching too many of them die.

He also knows that by the measure of past pandemics, the coronavirus is tiny – a perspective that is both disturbing, given the devastation that surrounds him, and reassuring. “Humankind managed to survive worse things, and moved on – even thrived.”

Dr. Huremovic has his own first-hand experience of getting past a collective trauma. As a medical student in his 20s, he was trapped in Sarajevo during the three-year siege on the city.

He remembers the period after the ceasefire, when people could finally walk in the street and not worry about getting hit by a sniper. “You simply decide one day to do it, and the first time it is strange. The second time, it is strange. And the third time, it is business as usual.”

If the pandemic ended on a Thursday, he predicts that by Sunday, people would “be outside having fun like nothing ever happened." The public can heal by moving on, he says. “Scientists cannot afford to forget.”

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Stop eating so much junk food.

Buy more snacks.

Keep calm, carry on, hug your dog.

On March 31, two weeks into the COVID-19 lockdown, calls and texts to Kids Help Phone surged. They’d already been rising steadily, with a 50-per-cent increase in calls about isolation and a 44-per-cent boost in ones related to anxiety compared to the previous year – and not just from children, either. But that Tuesday, the helpline recorded a distressing new record: Staff conducted 14 active rescues – sending police to find callers deemed at immediate risk of suicide.

Two days earlier, Prime Minister Justin Trudeau had announced new funding for Kids Help Phone, recognizing the importance of access to free counselling and peer support. Millions of government dollars, both federal and provincial, are being earmarked for mental-health interventions.

Telepsychiatry and virtual care have been expanded, by both governments and organizations, to replace in-person appointments. These two fixes alone – public access to psychotherapy and expanding technology to improve access to limited specialists – have been long sought by experts trying to build a better mental-health system.

It’s happening at the grassroots level, too. At non-profits, volunteers are reaching out to lonely people with caring phone calls – a standard approach recommended by suicide-prevention experts. Kids Help Phone is expanding its 24-hour text service to include adults, who already account for about 15 per cent of their conversations. A call for volunteers to answer the increasing number of texts resulted in more than 6,000 people stepping forward.

In hospitals, doctors report an unprecedented spirit of collaboration across specialties, with psychiatrists providing treatment to both patients and colleagues. Compassionate palliative care is expanding beyond the hospice, forcing in-the-moment conversations about how we might better care for the aged and dying. Doctors are spending more time sitting with patients to hear their stories, filling in for family members who can no longer visit. A group of young people in Nova Scotia has organized a letter-writing campaign for seniors isolated in long-term care homes.

“We are seeing so much kindness right now,” says Anne Boyle, a palliative doctor at St. Joseph’s Hospital in Hamilton, Ont.

But can we sustain all of this, especially in the months and years to come? Will the pandemic lead to important changes to a fragmented mental-health system plagued by long wait lists and a lack of front-line support?

Early intervention will be essential, experts say. A recent article in the medical journal The Lancet noted that physical distancing alone carries mental-health risks – a potential increase in self-harm, alcohol and substance misuse, domestic and child abuse, and financial stress. “Tracking loneliness and intervening early are important priorities,” the authors concluded. With the right programs and supports, the rise of suicide "is not inevitable.”

Families dealing with grief will need access to counselling; teachers will need to be alert to the kids who are struggling. Suicide-prevention experts have long advocated for better standards of care in emergency departments; once people begin coming back to hospitals for mental-health issues, doctors will need places to send them. After the London bombing, the U.K. health care system implemented a screen-and-treat approach to identify those suffering from trauma, and direct them to the right level of care – a strategy Steven Taylor strongly endorses in his book.

Meanwhile, doctors speak in terms of hopes: They hope a new understanding of palliative care will improve the way we treat people with chronic and terminal conditions; that the openness to talking about well-being and mindfulness among health care workers will continue; that mental-health specialists will take up telepsychiatry to see more patients, especially those in remote or underserved areas; that the importance of community connections and compassionate contacts might become more embedded in the way we care for each other.

In the months and years that follow the pandemic, “we will need to think differently,” says Robbie Babins-Wagner, chief executive officer of the Calgary Counselling Centre. “The fact that we are all in this together is really important.”

Maybe, as history would suggest, this is all fleeting; perhaps institutions will prove inflexible, turf wars will resume, our generosity toward strangers will taper off. Maybe we’ll forget.

Until then, Prof. Blair says, the messages Canadians are sending to their past selves and the questions they’re sending ahead show a nation under stress – but one also wrestling to find meaning in their shared experience. People are writing about new hobbies or making the most of time with their families, says Prof. Blair.

In these uncertain times, her study suggests a society trying to stay positive. “The messages are overwhelmingly hopeful, encouraging and comforting.”

Appreciate what is important.

Take care of yourself.

You’ll get through this.

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If you are having thoughts of suicide, call Kids Help Phone at 1-800-668-6868 or text CONNECT to 686868, or contact Crisis Service Canada at 1-833-456-4566, or visit crisisservicescanada.ca.

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