As of early November 2020, the number of confirmed coronavirus 2019 (COVID-19) cases in the United States is approaching 10 million, with more than 230,000 total deaths.1 We must acknowledge the social determinants of health and how our populations of vulnerable patients are at higher risk for morbidity and mortality from COVID-19. Although there is mounting evidence that people infected with COVID-19 may be asymptomatic,2 we must be mindful that they may not be truly asymptomatic from a mental health perspective. Many are developing a growing sense of anxiety, often influenced by their perception of the news, their current state of health, and the change within their social, familial, and environmental interactions. In the fight against COVID-19, we must apply what we have learned from how past pandemics and natural disasters affected mental health. At the same time, we must remain vigilant about how mental health trends may unfold for years to come because of the current pandemic. Mental health professionals will have an essential role in identifying, evaluating, and treating special populations that are vulnerable within the pandemic, including the elderly, racial and ethnic minorities, children and adolescents, and those with chronic medical illness.
COVID-19 and the Older Adult Population
Older adults are at risk of acquiring COVID-19 due to low immunity and multiple medical comorbidities. The risk and severity of COVID-19 illness increases with age.3 According to the Centers for Disease Control and Prevention (CDC), 8 of 10 deaths related to COVID-19 have been in adults age 65 years and older, with the greatest risk of severe illness in patients age 85 years and older.3 The risk of hospitalization and use of medical resources is 5 times higher in patients age 65 to 74 years as compared to a control group of patients age 18 to 29 years.3 This risk is further increased to 13 times more in the patients age 85 years and older.3 The statistics also show a 90 times higher mortality risk in patients age 65 to 74 years as compared to patients age 18 to 29 years. This risk further leaps to 630 times for those age 85 years and older.3 Cognitive impairment can also be a significant barrier in following the guidelines for infection prevention, such as social distancing, wearing face coverings, and hand hygiene.4
Pandemics have significant impact on mental health and can result in anxiety, panic, adjustment disorder, posttraumatic stress disorder, and insomnia.4 Altered mental status can be the only clinical presentation of COVID-19 and can present with confusion and agitation in older adults.5 The implementation of “lock-down” orders in many states has resulted in increased isolation, loneliness, and disruption of daily routine and activities, resulting in worsening of psychiatric symptoms.5 Retrospective studies of the severe acute respiratory syndrome coronavirus in 2003 showed a spike in the in suicide rate among older adults during the pandemic.6 Social distancing can affect the dynamics between older adults, their caregivers, and their medical providers.6 It can result in an increased risk of anxiety, depression, and suicide, especially in nursing homes or assisted-care facilities.4
Those with mental health disorders are more vulnerable to acute exacerbation during this crisis.4 In a survey that evaluated 1,556 older adults for their mental health impact during the COVID-19 pandemic on the elderly population, 37.1% of the respondents (predominantly women) reported experiencing depression and anxiety.7 Effective strategies to mitigate the mental health effects of COVID-19 in older adults need to be implemented. Experience from previous pandemics has shown that regular counselling sessions via telephone, relevant and updated dissemination of information about the pandemic, providing effective care for general medical conditions, and enhancing online peer-support activities are all key components in providing support for mental health.7
COVID-19 and Ethnic and Racial Minorities
Due to systemic health and social inequalities, racial and ethnic minorities, including Latinx, African American, Asian, and Native American populations, have had significantly higher rates of infection and death caused by COVID-19. The CDC reports that the number of cases of COVID-19 in racial and ethnic minorities is 2.8 times higher than in White or non-Latinx people. Hospitalization rates are 5.3 times higher than in White or non-Latinx people, and the death rate is 2.1 times higher than in White or non-Latinx people.8 In fact, 21.8% of COVID-19 cases in the United States are African Americans and 33.8% are Latinx, even though these groups make up only 13% and 18% of the US population, respectively.9
The higher rates of infections in these minority populations are due to multiple factors, including reduced access to health care and health insurance. People with lower incomes may also receive poorer quality of care than people with higher incomes.10 Being insured is also less pervasive, as only 78% of Native Americans, 81% of Latinx, and 88% of African Americans are insured, compared to 92% of White people.10 Due to these factors, racial and ethnic minorities are less likely to visit a clinic or hospital if they have symptoms of COVID-19, and may not have access to affordable or free testing. Historical events, such as the Tuskegee study (conducted from 1932–1972, in which Black men with syphilis were told by the US Government that they were receiving free treatment for the disease but in reality were given no medication so US scientists could observe the natural history of untreated syphilis) have also caused African American citizens to be suspicious and skeptical of the American health system.11 Communication can furthermore be adversely affected by implicit bias among clinicians and other health care workers, which can potentially affect the outcomes of care.9
During the initial “lock-down” for COVID-19, 30% of Whites had the luxury of being able to work from home, whereas only 20% of African Americans were able to do so.12 This is because a disproportionate percentage of workers in essential industries such as public transportation and food services are from racial and ethnic minority communities. People from these communities are also more likely to use crowded public transportation to get to and from work, resulting in a higher risk of being exposed to the virus. Because racial and ethnic minorities are mostly employed as frontline workers, they were also the most to be affected by the failing labor market during the COVID-19 pandemic. Unemployment rates skyrocketed to 14.7% only 2 months after local governments enforced quarantine and social distancing. After the COVID-19 lockdown, the unemployment rate jumped from 7% to 16.1% for African Americans and from 5.1% to 16.7% for Latinx people, while increasing from 3.7% to only 12.4% for Whites.12
Living conditions as well as common comorbidities can also predispose people to COVID-19 infection. Members of Latinx and African American communities tend to live in multi-generational homes, which increases the risk of exposure to older adult members from other family members who are often frontline workers in transportation, grocery stores, food service, package delivery, or other service industries and/or cannot work remotely. Studies have also shown that hypertension, diabetes, and cardiovascular disease are common comorbidities associated with COVID-19 hospitalization, and these occur at a higher prevalence in minorities compared to Whites.13 People with these preexisting conditions are at an increased risk of contracting the virus as well.13
There is concern that the lack of health care access can also lead to reduced treatment for either preexisting mental health conditions or newly developed ones. Even where there is access, patients may be subject to either conscious or subconscious bias from their providers, which may further limit their recovery.14
According to a CDC survey conducted from June 24 to June 30, 2020, Latinx respondents reported a higher prevalence of anxiety and depressive symptoms, substance use, and suicidal ideation than non-Latinx Whites or non-Latinx Asians.15 African Americans respondents also had increased rates of substance use and serious consideration of suicide compared to Whites and Asians.15
COVID-19 and Children and Adolescents
At the onset of the COVID-19 pandemic, there was an assumption that children and adolescents may be less susceptible to the virus.16 A review of cases from December 2019 to February 2020 found only 1% of teenagers and children younger than age 10 years in China were affected.17 The first pediatric COVID-19 case was reported in the United States by the CDC on March 2, 2020.18
An increasing number of young people have been diagnosed as the pandemic has progressed and because of the development of rapid COVID-19 testing techniques. Now, we know that young people can be seriously affected by COVID-19, although some infected youth are completely symptom-free or have less severe symptoms.16
The lifestyle disruption caused by this pandemic has been disproportionately burdensome on youth. The unexpected early ending to the school year in the spring of 2020 (due to COVID-19 precautions), with loss of face-to-face interaction, rampant uncertainty, and upset routines, left many children experiencing anger, anxiety, and an acute sense of loss. Education shifted rapidly from in-class to distance learning, education by television or laptop, or no structured schooling at all. The loss of traditional in-person education severed a connection to a safe place that provided not only learning opportunities, but also food, exercise, creative outlets, structured routines, extracurricular activities, and encouragement from friends and adults.
Isolation has provided the opportunity for enhanced contact between parents and children but has also exposed them to varied types of abuses. The lack of supervision of internet access increases children's vulnerability to online offenders, attempted fraud, and access to sexually inappropriate content. Worsening school performance, increased agitation, and regression may become more pronounced.19
The period of early adolescence is critical for psychosocial development, during which children and adolescents require special care to promote their mental health.20 Finding and reaching distressed youth during a time of increased isolation and dislocation is challenging. Successful strategies will require new techniques that use media, mobile devices, and social media applications to connect with affected communities to provide psychological counseling to youth as well as their families.
COVID-19 and Patients with Chronic Medical Illness
Patients with multiple chronic medical conditions such as cancer, chronic kidney, lung, or cardiovascular diseases, immunocompromised state, obesity, sickle cell disease, and diabetes, are at increased risk of acquiring COVID-19.21 Early reports from China found that cardiovascular disease and its risk factors, such as hypertension and diabetes, were common preexisting conditions in patients with COVID-19. The prevalence of any comorbidity was 32% and the most common underlying diseases were diabetes (20%), hypertension (15%), and other cardiovascular diseases (15%).22 Importantly, the prevalence of these preexisting conditions was higher in patients who were critically ill, such as those admitted to the intensive care unit (ICU) and those who died. In a single-center cohort study of 138 patients hospitalized with COVID-19 in Wuhan, China, 46% of patients had at least one comorbidity (72% of patients in the ICU), 31% of patients had hypertension (58% of patients in the ICU), 15% of patients had other cardiovascular diseases (25% of patients in the ICU), and 10% of patients had diabetes (22% of patients in the ICU).22
People with obesity and COVID-19 have increased odds of being hospitalized. The prevalence of obesity in hospitalized patients was much higher than that in non-hospitalized patients diagnosed with COVID-19.23 A study including 5,700 patients with obesity in New York City showed that 41.7% of patients hospitalized with COVID-19 were obese,24 whereas the average prevalence of people with obesity in New York City was 22%.24 Diabetes can increase the risk of morbidity and mortality due to suppressed immune functions, as studies report diabetes to be associated with 58% of patients with COVID-19.25
The underlying chronic illness can increase the susceptibility to COVID-19–related anxiety and depression. The worsening psychiatric symptoms could also affect a person's ability for self-care as well as the manifestation of pain, further lowered immunity, and somatization. The prevalence of depressive and anxiety symptoms in patients with diabetes may be a 2 to 4 times higher compared to the general population.25 The psychological stress imposed by social distancing is expected to further increase symptoms of depression and anxiety. A study in Brazil found that about 1 month after the social-distancing recommendation, almost one-half of participants with diabetes had positive screening for psychological distress, such as anxiety and depression; whereas the presence of diabetes-related emotional distress was present in only 29.2%.26 Those suffering from depression and diabetes may then have poorer outcomes related to missed appointments, reduced medication compliance, and effect on diet.27 Providers must be aware of how this may lead to a perpetual cycle of decompensation for these x patients who are at risk.
Caring for patients with COVID-19 or those who have risk factors for developing the disease requires careful and thoughtful treatment plans to evaluate and treat for comorbid psychiatric symptoms. It is our obligation to recognize these vulnerable populations and to provide the necessary education and outreach to help prevent or at least mitigate a parallel mental health pandemic for years to come.
- US Centers for Disease Control and Prevention. COVID data tracker. Accessed October 30, 2020. https://covid.cdc.gov/covid-data-tracker/#cases_casesinlast7days
- Zhao H, Lu X, Deng Y, Tang Y, Lu J. COVID-19: asymptomatic carrier transmission is an underestimated problem. Epidemiol Infect. 2020;148:e116. doi:10.1017/S0950268820001235 [CrossRef] PMID:32525469
- US Centers for Disease Control and Prevention. Coronavirus disease: older adults. Accessed October 30, 2020. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older-adults.html.
- Banerjee D. The impact of COVID-19 pandemic on elderly mental health. Int J Geriatr Psychiatry. 2020;1–2:gps.5320. doi:10.1002/gps.5320 [CrossRef] PMID:32364283
- Vahia IV. COVID-19, aging, and mental health: lessons from the first six months. Am J Geriatr Psychiatry. 2020;28(7):691–694. doi:10.1016/j.jagp.2020.05.029 [CrossRef] PMID:32532653
- Vahia IV, Blazer DG, Smith GS, et al. COVID-19, mental health and aging: a need for new knowledge to bridge science and service. Am J Geriatr Psychiatry. 2020;28(7):695–697. doi:10.1016/j.jagp.2020.03.007 [CrossRef] PMID:32278745
- Meng H, Xu Y, Dai J, Zhang Y, Liu B, Yang H. Analyze the psychological impact of COVID-19 among the elderly population in China and make corresponding suggestions. Psychiatry Res. 2020;289:112983. doi:10.1016/j.psychres.2020.112983 [CrossRef] PMID:32388175
- US Centers for Disease Control and Prevention. COVID-19 hospitalization and death by race/ethnicity. Accessed October 30, 2020. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html
- Tai DBG, Shah A, Doubeni CA, Sia IG, Wieland ML. The disproportionate impact of COVID-19 on racial and ethnic minorities in the United States [published online ahead of print June 20, 2020]. Clin Infect Dis. doi:10.1093/cid/ciaa815 [CrossRef] PMID:32562416
- Artiga S, Orgera K, Pham O. Disparities in health and health care: five key questions and answers. Accessed October 30, 2020. https://www.kff.org/disparities-policy/issue-brief/disparities-in-health-and-health-care-five-key-questions-and-answers/
- Dyer O. COVID-19: Black people and other minorities are hardest hit in US. BMJ. 2020;369:m1483. doi:10.1136/bmj.m1483 [CrossRef] PMID:32291262
- Fairlie RW, Couch K, Xu H. The impacts of COVID-19 on minority unemployment: first evidence from April 2020 CPS microdata. Accessed October 30, 2020. https://www.nber.org/papers/w27246
- Abuelgasim E, Saw LJ, Shirke M, Zeinah M, Harky A. COVID-19: unique public health issues facing Black, Asian and minority ethnic communities. Curr Probl Cardiol. 2020;45(8):100621. doi:10.1016/j.cpcardiol.2020.100621 [CrossRef] PMID:32448759
- American Medical Association. COVID-19 FAQs: health equity in a pandemic. Accessed October 30, 2020. https://www.ama-assn.org/delivering-care/health-equity/covid-19-faqs-health-equity-pandemic?gclid=EAIaIQobChMI_MOFn7X16wIVh8DACh39hAe3EAMYASAAEgLGN_D_BwE
- Czeisler ME, Lane RI, Petrosky E, et al. Mental health, substance use, and suicidal ideation during the COVID-19 pandemic - United States, June 24-30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(32):1049–1057. doi:10.15585/mmwr.mm6932a1 [CrossRef] PMID:32790653
- Jeng MJ. Coronavirus disease 2019 in children: current status. J Chin Med Assoc. 2020;83(6):527–533. doi:10.1097/JCMA.0000000000000323 [CrossRef] PMID:32502117
- Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72,314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020;323(13):1239–1242. doi:10.1001/jama.2020.2648 [CrossRef] PMID:32091533
- CDC COVID-19 Response Team. Coronavirus disease 2019 in children — United States, February 12–April 2, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(14):422–426. doi:10.15585/mmwr.mm6914e4 [CrossRef] PMID:32271728.
- Liang L, Ren H, Cao R, et al. The Effect of COVID-19 on youth mental health. Psychiatr Q. 2020;91(3):841–852. doi:10.1007/s11126-020-09744-3 [CrossRef] PMID:32319041
- Marques de Miranda D, da Silva Athanasio B, Sena Oliveira AC, Simoes-E-Silva AC. How is COVID-19 pandemic impacting mental health of children and adolescents?Int J Disaster Risk Reduct. 2020;51:101845. doi:10.1016/j.ijdrr.2020.101845 [CrossRef] PMID:32929399
- US Centers for Disease Control and Prevention. People with certain medical conditions. Accessed October 30, 2020. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fneed-extra-precautions%2Fgroups-at-higher-risk.html
- Nishiga M, Wang DW, Han Y, Lewis DB, Wu JC. COVID-19 and cardiovascular disease: from basic mechanisms to clinical perspectives. Nat Rev Cardiol. 2020;17(9):543–558. doi:10.1038/s41569-020-0413-9 [CrossRef] PMID:32690910
- Popkin BM, Du S, Green WD, et al. Individuals with obesity and COVID-19: a global perspective on the epidemiology and biological relationships. Obes Rev. 2020;21(11):e13128. doi:10.1111/obr.13128 [CrossRef] PMID:32845580
- Richardson S, Hirsch JS, Narasimhan M, et al. the Northwell COVID-19 Research Consortium. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA. 2020;323(20):2052–2059. doi:10.1001/jama.2020.6775 [CrossRef] PMID:32320003
- Singh AK, Gupta R, Ghosh A, Misra A. Diabetes in COVID-19: prevalence, pathophysiology, prognosis and practical considerations. Diabetes Metab Syndr. 2020;14(4):303–310. doi:10.1016/j.dsx.2020.04.004 [CrossRef] PMID:32298981
- Alessi J, de Oliveira GB, Franco DW, et al. Mental health in the era of COVID-19: prevalence of psychiatric disorders in a cohort of patients with type 1 and type 2 diabetes during the social distancing. Diabetol Metab Syndr. 2020;12:76. doi:10.1186/s13098-020-00584-6 [CrossRef] PMID:32879637
- Gonzalez JS, Peyrot M, McCarl LA, et al. Depression and diabetes treatment nonadherence: a meta-analysis. Diabetes Care. 2008;31(12):2398–2403. doi:10.2337/dc08-1341 [CrossRef] PMID:19033420