After I confirmed with Falcone that he had no intent to harm himself, I recommended that he seek medical help. But given the unprecedented circumstances we’re all in, I’m not sure whether I under- or overreacted—or even what “help” should look like, exactly. The pandemic is a moment of historic loss: unemployment, isolation, stasis, financial devastation, medical suffering, and hundreds of thousands of deaths globally. Suddenly droves of people are being thrown into a state like Falcone’s, feeling lost, hopeless—in his words, “depressed.”
Over the past month, Jennifer Leiferman, a researcher at the Colorado School of Public Health, has documented a tidal wave of depressive symptoms in the U.S. “The rates we’re seeing are just so much higher than normal,” she says. Leiferman’s team recently found that people in Colorado have, during the pandemic, been nine times more likely to report poor mental health than usual. About 23 percent of Coloradans have symptoms of clinical depression.
As a rough average, during pre-pandemic life, 5 to 7 percent of people met the criteria for a diagnosis of depression. Now, depending how you define the condition, orders of magnitude more people do. Robert Klitzman, a professor of psychiatry at Columbia University, extrapolates from a recent Lancet
Feelings of numbness, powerlessness, and hopelessness are now so common as to verge on being considered normal. But what we are seeing is far less likely an actual increase in a disease of the brain than a series of circumstances that is drawing out a similar neurochemical mix. This poses a diagnostic conundrum. Millions of people exhibiting signs of depression now have to discern ennui from temporary grieving from a medical condition. Those at home Googling symptoms need to know when to seek medical care, and when it’s safe to simply try baking more bread. Clinicians, meanwhile, need to decide how best to treat people with new or worsening symptoms: to diagnose millions of people with depression, or to more aggressively treat the social circumstances at the core of so much suffering.
Clearly articulating the meaning of medical depression is an existential challenge for the mental-health profession, and for a country that does not ensure its people health care. If we fail, the second wave of death from this pandemic will not be directly caused by the virus. It will take the people who suffered mentally from its reverberations.
Like COVID-19, depression takes erratic courses. Some predictable patterns exist, but no two cases are exactly alike. Depression can percolate for long periods then quickly become severe. Some people will barely notice it, and others will be tested in the extreme.
Andrew Solomon, the author of The Noonday Demon: An Atlas of Depression , groups people based on four basic ways they’re responding to the current crisis. Two are straightforward. In the first are people who are drawing on huge stockpiles of resilience and truly doing okay. When you ask how they feel and they say “eh, fine,” they actually mean it. In the second, at the opposite end of things, are people who already have a clinical diagnosis of major depressive disorder or a persistent version known as dysthymia . Right now, their symptoms are at high risk of escalating. “They develop what some clinicians call ‘double depression,’ in which the underlying disorder coexists with a new layer of fear and sorrow,” Solomon says. Such people may need higher levels of medical care than usual, and may even need to be hospitalized.
The remaining two groups constitute more of a gray area. One group consists of the millions of people now experiencing depressive symptoms in a real way, but who nonetheless will return to their baseline eventually, as long as their symptoms are addressed. People in this group are in urgent need of basic interventions that help create routine and structure. Those might involve regularizing sleep and food, minimizing alcohol and other substances, exercising, avoiding obsessions with the news, and cutting back on other aimless habits that might be easier to moderate in normal times.
The fourth group encompasses people who are starting to develop clinical depression. More than simply a wellness regimen or a Zoom with friends, they need some type of formal medical intervention. They may have seemed fine and had adequate resilience in normal times, to deal with normal difficulties, but they’ve always had a propensity to develop overt depression. Solomon describes this group as “hanging on the precipice of what could be considered pathologic.” It can be especially precarious because people in this state—what some researchers refer to as “subclinical depression”—have not dealt with depression before, and may not have the capacity or resources to proactively seek treatment.
The earlier specific types of depression can be identified, the better people can be directed toward proper treatment. The mental-health system has always had barriers to identifying and helping people early—issues like access to care and stigma around seeking it out. In the midst of this pandemic, not only is the current population of psychiatrists insufficient to suddenly treat several times as many people as usual, but their basic capacities of diagnosis are also hindered by distance, volume, and confounding variables. “It takes considerable wisdom to delineate who has a clinical condition and needs medication and therapy, and who is just stressed out within the bounds of good mental health,” Solomon says. Clinicians train for years to understand that line, and placing people on one side or the other typically requires long interviews in which every element of a person’s affect is noted.
Even for people who manage to connect with clinicians, subtleties are difficult to read over video calls, says Meghan Jarvis, a trauma therapist who has been seeing a spectrum of reactions to the pandemic, including depression. Normally, Jarvis sends maybe one patient a year to the hospital for a pathologic response to trauma. Since March, she has already had to hospitalize four people. Typically, she explains, symptoms of depression are considered problematic if they last six weeks after a traumatic event. The precise length is arbitrary, but is meant to generally help distinguish depression from periods of grieving, such as after the death of a loved one. That distinction is largely useless in the pandemic. “I mean, we’re all going to have that,” Jarvis says, “because we’ve been in this mode for more than six weeks.”
Now Jarvis and others have to develop new thresholds. Just as, in the time of COVID-19, not everyone with a cough can go to the hospital, clinicians are working to identify and prioritize those who truly need in-person mental-health attention. Jennifer Rapke, the head of inpatient consultation at Upstate Golisano Children’s Hospital in New York, has seen a surge in teenagers reporting suicidal ideation and instances of self-harm, so she has been carefully turning away the less severe cases to make sure that inpatient facilities aren’t overwhelmed. “We’re only seeing people who absolutely need to be here,” she says. Meanwhile, those with milder, emerging cases are sometimes left in limbo. “The places we would normally send people, the things we would put in place to address the depression or the anxiety in early phases—they don’t exist or they’re unavailable,” Rapke says.
With less preventive and maintenance care accessible, people are more likely to come to hospitals in more severe states. During crises, extreme events like self-harm and suicide lag in time. At first, being anxious about the proximity of death, or sad about the loss of loved ones is logical; any other reaction would be bizarre. Our minds and bodies can’t endure that state for too long, though. The United States was slow to test for the coronavirus, and COVID-19 cases accumulated before we knew just how widespread it was. Rapke and others are now bracing for a similarly delayed wave of severe depression—and the difficult decisions they will have to make about treatments.
The elusive definition of depression has always been a source of academic tension with serious consequences. Among the many challenges the pandemic is posing, it is exposing the borders of medicine’s ability to distill human suffering into a billable diagnostic code. Some people with symptoms of depression will be told, “Everyone feels that way,” or advised to try breathing exercises when they need urgent medical attention. Others will be diagnosed with clinical depression, changing their life and self-conception indefinitely, when the problems were truly circumstantial. The system has never been flawless, but its limitations are now brought into stark relief.
For most of human history, depression was not treated in the same medical model as were diseases of the body. People with mental illnesses were written off as morally bankrupt or simply “insane.” Only in the latter half of the 20th century did the profession of psychiatry become a medical specialty and create systematic approaches to treatment. The process for diagnosing a condition in psychiatry and clinical psychology will never be as straightforward and objective as saying whether a bone is broken or not,
Today, depression—the clinical condition, otherwise known as major depressive disorder—is defined by the American Psychiatric Association in its Diagnostic and Statistical Manual * To receive the diagnosis, a person must have five or more symptoms such as the following, nearly every day during a two-week period: fatigue or loss of energy, feelings of worthlessness or inappropriate guilt, reduced physical movement, indecisiveness or impaired concentration, a decreased or increased appetite, and a greatly diminished interest or pleasure in regular activities.
Experts are trained to identify exactly how much “impaired concentration” or “loss of energy” is enough to qualify for a diagnosis, and the criteria are intentionally flexible enough to factor in patients’ individual circumstances. But as the pandemic has made clear, the DSM-5 and medical model as a whole don’t provide the richness of language to account for all the nuanced ways people might look or feel depressed, even when they don’t need medical intervention. Well-meaning attempts to standardize the diagnostic process have created a false binary wherein you are a person with depression, or you are not.
Outside of medicine, depression has been most cogently defined through metaphor. As Sylvia Plath wrote: “The silence depressed me. It wasn’t the silence of silence. It was my own silence.” David Foster Wallace described depression as feeling that “every single atom in every single cell in your body is sick.” Even some clinical models reach for alternative ways of articulating despair beyond the conventional medical model. James Hollis, a psychodynamic analyst and the author of Living Between Worlds: Finding Resilience in Changing Times , says that depression is sometimes the result of “intrapsychic tension,” a conflict between two areas of our psyche, or identity. The tension is created, Hollis observes, “when we’re forced to try to make acquaintances with ourselves in new ways.”
Many Americans do seem to be experiencing something like this tension during the pandemic. People who define themselves by their work can lose a basic sense of self if that work disappears. In such moments, Hollis says, many people regress. Many also try to escape—whether by organizing an already well-organized sock drawer, baking bread they don’t even want, or endlessly scrolling through Instagram. Jarvis, the trauma therapist, is seeing similar escapist tendencies: “For someone’s response to a huge global pandemic to be like, I’m going to work out really hard , is just as pathological and sort of dissociative as if you went to bed and didn’t get up for five days.”
For people whose response to the pandemic turns from acute anxiety into general malaise, Jarvis recommends facing the numbness head-on. It’s treatable, and not necessarily with medication. First, she says, create regimens of simple tasks that give structure to the day. The approach is working for Falcone, the acupuncturist. He starts every day with 30 minutes of stretching, no matter what. Then he walks his dog, makes coffee, and sits down to teach massage via Zoom. Deb Hawkins, the tech analyst, sent me a list of things she’s doing to help others and stay busy: She donated money to a couple of worthy causes, and made an appointment to give blood. She has created a small social bubble and signed up for an online ballet class. She says her sense of self is returning.
Small steps like these will not work for everyone, but they may help many in the subclinical realm to mitigate a dangerous slide. With the medical system already stretched thin, these could buy some time to build its capacity to care for the people who will emerge from the pandemic with severe and lasting symptoms. As important as preventive behaviors can be, human resilience has limits. Those will be tested for months to come.
The individual model of depression was never meant to address a significant percentage of a population. When the diagnosis seems to apply so widely, it’s not the people or the entire medical system that’s broken, but the social context. While many people will find ways to recalibrate their expectations and individual thresholds for joy in the pandemic,
