Coronavirus (COVID-19): Press Conference with Karestan Koenen, 04/16/20

You’re listening to a press conference from the Harvard T.H. Chan School of Public Health with Karestan Koenen, professor of psychiatric epidemiology. This call was recoded at 11:30 AM Eastern Time on Thursday, April 16.

Previous press conferences are linked at the bottom of this transcript.


KARESTAN KOENEN: Hi, everyone. This is Karestan. Thanks for taking the time today to talk about mental health.

So just a little background on me. My research for the past about 20 years has focused on studying traumatic events, particularly post-traumatic stress disorder, depression and other mental health problems after traumatic events. And so, I’ll be talking a bit from that perspective. I’m a clinical psychologist and licensed, as well as an epidemiologist at the School of Public Health. So, I speak from a clinical and a population perspective.

And so, some of the things – I just wanted to start with a few comments and then would like to answer questions. One of the things that might be obvious to everyone on joining this call is that the COVID pandemic has all the hallmarks of a traumatic event. It’s unusual in that it’s global and usually when we think of typical disasters, such as hurricane Katrina or even the terrorist attacks – I lived in New York City at that time – they have a really profound local impact. But it’s unusual for a disaster to affect so many places at once.

And the COVID pandemic, some of the things about it that are really challenging for mental health are its level of unpredictability, uncontrollability. I’m sure you’ve all experienced personally how the news sort of changes every day. We don’t know when things will open. We don’t know when our kids’ schools will open. We people don’t know if they’ll have jobs tomorrow, etc. And that makes it incredibly stressful.

And then on top of that, on top of people worrying about getting sick and the disease itself, people are facing job loss and foreclosures, which we know have adverse effects on mental health. People are losing loved ones. And on top of that, what’s particularly challenging about this is that normally in a disaster, one of the biggest protective factors after a trauma – and especially a large-scale trauma like a disaster – the biggest protective factor is social support and social connection. And while we most need social connection, we’re being told to physically distance ourselves and stay at home. So, this adds extra challenges to mental health.

So, I guess I wanted to say it’s really normal for people to being feeling anxious, depressed have trouble sleeping right now. People may find themselves – you drink alcohol, you’re drinking, more people talk about how much they’re eating, etc. That’s normal. When I think about it, what I want to think about is how do we prevent this sort of normal reaction to a very stressful situation from becoming a real mental health problem. So, I’m happy to talk about that.

Another couple of topics I just wanted to hit on. One is disparities. We’ve heard a lot about how, at least in the Boston area, we hear a lot about how the burden of COVID is falling disproportionately on African American and minority communities. And we would expect that also some of these mental health consequences might fall disproportionately on these communities as they suffer the burden of the disease, but also suffer the burden of job loss and the economic consequences disproportionately.

And then a last piece that I’ll mention and then happy to answer questions is, we’ve also seen a transformation in mental health care incredibly rapidly related to the pandemic. So, previously with most insurance companies, it was actually very challenging to get them to cover telehealth, either phone therapy or video therapy. And within really weeks, mental health services have converted to telehealth and I think that is something that will have an impact on mental health services for the time to come because once that’s happened and people have converted to telehealth, people can see their therapist on their video or with their phone and they can get reimbursed for that, it’s going to be hard to go back, go back to the office. This has made – for some people, it has made mental health more accessible.

So, with that, I will stop talking and answer questions.

MODERATOR: Thank you, Dr. Koenen. Alright, it looks like we have a couple of questions already. First question.

Q: Hi, Professor Koenen. Has there been any statistical evidence – you know, the idea that this would have a significant impact on people is clear and makes a lot of sense. But do we see rising numbers of suicides or depression and, you know, do we have any statistics about the mental health impact that might parallel what we’re seeing on the physical health side?

KARESTAN KOENEN: So yes, thank you for that question. So, we do have already some initial data on that. So, in the US, there was a Kaiser Family survey and, in their survey, they asked people if this was affecting their mental health and how severely. And I think it was something like 19% said that it was having a significant a very significant impact on their mental health. So, we have that that sort of very, very rapid data, they’ve been able to get out.

We also have data from China, where they have done surveys, or empirical surveys of mental health among healthcare workers and nonhealthcare workers, general population. And those have come out in The Lancet in the last couple of months and they find high rates of depression, anxiety, I think, close to 40%.

And then we also know the third piece of evidence is from prior disasters and epidemics. So, there is a literature on epidemics themselves on Ebola and SARS. And for example, in SARS, they found the increased suicide rate in Hong Kong among the elderly, partly attributed to social isolation. And after the Ebola epidemic, even a year later in the population there they found elevated rates of anxiety and depression.

So, I think we have these different pieces of evidence that we can pull it from to say likely that – we’re seeing some emergence of that locally in the US or Boston, but that we’re likely to see it globally as well.

And I guess a final thing I’ll say my own anecdotal evidence is that we have these mental health forums at Harvard on Wednesdays at 11 am. And they started off as just a little phone call among people and we’ve had our one on bereavement had over 700 people. And I’ve had those same reports from people around the country doing similar things, that people are kind of really reaching out for information about mental health, which suggests to me that this is something that’s important to people.

Q: Is there one particular impact that you are most concerned about, whether it’s depression or suicide or?

KARESTAN KOENEN: That’s a good question. Well, these mental health consequences don’t occur in isolation. So, I think that it’s hard to say there’d be one. I think I would be most concerned about sort of the range of depression and anxiety, given the scope of the consequences, including the financial consequences, when we know that job loss and foreclosure, etc. are associated with increased rates of depression and anxiety, and then also, we know that depression occurs after bereavement. So, I think that around that kind of scope would be the things I’m most worried about

Q: Thank you.

MODERATOR: Okay, next question.

Q: Hello, Professor Koenen, thank you for this interview. I’d like to ask you about the emerging issue, which is the stigma of go with – how are we going to – how we react to that the people who have been diagnosed with COVID and also the rest of the society too with the people who have been diagnosed as positive. There is an emerging stigma around them and what are the strategies of dealing with it?

KARESTAN KOENEN: That’s an excellent question and we know stigmas toxic to mental health and it’s toxic to health broadly. So, you mentioned stigma of people who had COVID and perhaps have been quarantined and then coming out, and then also we see increased stigma in the US against Asian Americans and other groups that are being – that, you know, people blame for infection.

So, think there’s a number of things we can do to battle the stigma. One is we need leadership at the national and local level that provides good information and that does not increase stigma. So, when leaders blame specific groups, then that that adds to the risk of stigma. But when they provide good information and we really get good information out there, that fights against the stigma.

The second thing is that really fighting stigma is everyone’s responsibility. So, if any of us, any of us on this call, but in our communities, are in a situation where we see someone being wrongly stigmatized, then we all need to be allies and we all need to stand up.

It’s similar to – I don’t know if any of you have kids – my son is 13 but they do anti-bullying prevention in school and they talk a lot about stigma and things in school. And one of the basic things they teach kids is that if you see someone being bullied, it’s everyone’s responsibility to stand up for that person. And I think that’s true, that fighting stigma as a community response.

And then the third thing is that, and this is where I do believe science will help us, as we have treatments, which hopefully, you know, these interventions are coming in the next few months, we’ll see, that will also help. When there’s something we can do about it that’ll fight that stigma that’s more specific, I think, to people emerging from COVID.

And then finally, I think that really good information about, you know, the ways this actually is spread the way it’s not, how people can protect themselves by wearing masks, can help. If people, can do something to protect themselves, they’ll feel less likely to lash out and blame people who are suffering.

So, I hope that’s helpful, but it is a big concern.

Q: Certainly. Thank you very much.

MODERATOR: If anybody has a question, go ahead.

Q: Sure. I wonder if you could address specifically loneliness, since where we’re all in, you know, we talked about physical distancing these days.

 KARESTAN KOENEN: Sure. So, loneliness is a big concern, particularly for groups of people who are already isolated, such as, you know, older adults tend to be more isolated, people with significant mental health problems already before this happened. And we know that loneliness is also really toxic to health, not just mental health but physical health.

So, and now the typical things, right, we would tell people to do, we’re unable to do – go visit people. I’m thinking about people who’ve lost loved ones that are unable to get together for services or stop by people’s houses. So, it is a big issue.

And I think what I’ve been impressed with is how people have been coming up with creative solutions to address loneliness. So, whether that’s all the sort of zoom Seders we saw or – I know there’s efforts in Boston, people I know are participating in to call elderly people in the community. On my own neighborhood email list, there is there’s a lot of efforts to figure out who might be isolated and alone and things that can be done for them without putting them at risk. So, I think that there’s a lot us as individuals and communities can do to address loneliness.

And then the other pieces, as you know, if people are feeling lonely, it’s now a situation where they need to kind of take it upon themselves to reach out and find out what resources are out there and connect with people. Which is really hard to do if you have loneliness but particularly when you’re feeling depressed, that is something we need to do.

And we also may need to reconceptualize social connection, like people are reimagining how to do memorial services, for example, having to do them online. What are some other ways we can connect with each other that don’t put us at physical risk. So, those are just some comments on loneliness.

Q: You have any possible resources that people either for loneliness, anxiety, depression, you know?

KARESTAN KOENEN: Yes, there are a lot of resources out there, if people – and I’ll name a few right now. We’ve actually pulled them together and I can send people – I think it’d be easier to do on email but some just sort of top -level resources is SAMHSA. If you go into the SAMHSA website, they actually have a helpline for people who are suffering from anxiety, depression, to link them with resources. And also, on the CDC website, there is a link, there is a section on mental health and COVID that has resources and will link you back to SAMHSA. So those are some sort of national resources.

We and other people have put together a lot of specific resources on stress, parenting, anxiety social connection, etc. So again, I’m happy to – anyone who wants it, I can send you guys the link.

MODERATOR: Next question.

Q: Hi, thanks so much for doing this. I was wondering about children, the effect on children. This is probably the most – well, certainly for adults it’s the most traumatic long-term situation we’ve been through. And it’s hard to protect children from a lot of what’s going on. What do you see long term, the effect on children and what can parents do to minimize that effect?

KARESTAN KOENEN: Thank you. Yes, and I think about it a lot because I mentioned I have a 13-year-old son, so – and he’s home, of course, with me. So, first, in terms of children, it’s important to think about – what you might do depends on the developmental stage of the child and the age of the child. And also, their reactions will depend on their age. So, we actually have done a session in our mental health forums on children and we have some stuff written, so also happy to send it to you.

But for example, I mean, I think a couple of the things is – one is what bothers kids isn’t necessarily going to be the same as what bothers adults. I think parents always know this, but it’s good to remind ourselves at this time. And the example I give is, you know, I have a million different things going through my head questions in my head, but my son’s first concern was when schools were closed, for example, his first worry was not ‘Am I going to get sick.’ It was ‘Is the homework that was supposed to be due Monday going to be due’ and then the texts between him and his friends were all about that and about then ‘when school starts, well, they said because the work is optional or, you know that it’s not going to be graded. What does that mean, are they secretly going to grade it.’ So that’s sort of a typical 13-year-old’s perspective.

Now he’s talked more about being worried what’s going to happen if I get sick, or his dad gets sick, or he gets sick, what’s going to happen, but really the first things were things that concerned them. And I think that for younger children I think it might be that, well, I mean, I’ve heard reports that some kids are happy because they get to be home with their parents. But why am I not seeing my teacher, etc.

So, I think one thing parents can do is really meet the kids where they’re at and not assume that the things that worry you are going to worry the kids. So that’s the first thing.

And I think it’s another general principle is, and this is really, at least I’m finding it challenging is keeping routines where you can and keeping connection where you can. So, some of the things people have done – I know some daycare centers or some schools have had videos of teachers reading to kids, etc. But as much as you can keep that. It’s very challenging. I’m a single mom, like I said, my kid’s home and I’m working, so, it’s challenging but trying to do that. We’re doing Sunday Zoom dinner with my family, which is pretty hit or miss on how that works.

And then the third thing is I would advise really controlling the media exposure for yourselves and your kids. And this is – I’m talking to the news people, so I don’t know how much you guys can preach this your own families, but kids can get overwhelmed with information and, depending on their developmental stage, things that seem okay to us can be overwhelming to them. And sometimes they take away things from it that we don’t realize.

So, what I do for myself is kind of limit when I have the radio on or the news. I use a lot of written stuff because then I can read it and I don’t really turn the television news on with my son. Now my son’s older so he can get the information himself, and I don’t have that much control over that, but.

And then the last thing is really listening and, I think answering your kids questions honestly. But I think kids take a lot of their lead from their parents. And that puts a lot of pressure on parents right now.

But if you think about it – there were studies done back in the day on, for example, the London Blitz and how kids who stayed in London responded. And a lot of – what I’ve noticed with my own son is a lot of how he – if I am sort of managing my own stress, he feels better. And he gets really stressed when I get stressed. So, that is just to tell parents that by taking care of yourself and trying to manage your stress and doing what you can to take care of yourself, you’re also actually really are taking care of your kids.

That’s not just a line that we say, but you are. Because if you are functioning better, that will be a sign to your kids that, you know, this is a manageable situation. So, those are some ideas. Again, we have a lot more detailed information in some of our handouts that I can give you. I hope that answered your question somewhat.

MODERATOR: Okay, it looks another question. Go ahead.

Q: Could you talk a little bit about mental health impacts and the duration here? Is this the kind of thing that will get worse if we are social distanced for, you know, four months or six months or is it – does it kind of bounce along at a, you know, as a similar level, you know, all the time?

KARESTAN KOENEN: That is a good question. One, we don’t. – we’ve never been in a situation like this. So, the one thing I’m going to say, I’m going to give the boring academic answer, which is, we don’t know.

I would – but based on other studies of epidemics and disasters, what I would expect is that we could expect worse mental health consequences based on the consequences of COVID.

So, what I mean by that are as the – social isolation itself or the physical distancing itself is one thing, and that is a stressor, but it’s all the other consequences that extended from that. So, as a mental health person, I am probably just as concerned about the resulting job losses and the effects on the economy. We know that economic downturn and a persistent recession/depression will have really significant effects on that mental health – anxiety, depression, potentially suicide rates, substance use. And so, I would say I’m as worried about that as I am about the social isolation. And I would expect is if those consequences get worse, that would have more long-term mental health effects.

Now the good news is there’s a lot we can do to promote longer term mental health effects. Actually, things like the stimulus bill and the supports coming through Congress, etc. Those actually can help they can support mental health by making sure people have money, get unemployment, can get food. Those things, reducing those kinds of stressors will also help improve people’s mental health, as well as providing good leadership and information to people. And direction and giving clear guidance will also help people feel less stress and anxiety.

So, I think the answer is we don’t know. It could have longer term mental health consequences. But I think there is a lot that we can do as individuals and policymakers to prevent those.

Q: Great, thank you.

MODERATOR: That looks like that was the last one. So, Karestan, do you have any final words before we end the call?

KARESTAN KOENEN: Well, I just wanted to thank everyone for having interest in mental health. I know it’s hard to – it’s probably hard to think about long term mental health consequences when we’re in the middle of still tackling the infectious disease part of the epidemic and then there’s really significant economic consequences, so I appreciate people taking the time to cover this.

The one other thing I did want to mention, which we didn’t get to is, is my colleagues in South Korea have warned me that another issue over time is really burnout. So as this goes on, I’ll raise this question –

As this goes on, there’s been a lot of sort of community organizing, and people stepping up and, in my own community, a lot of volunteering and things. And the challenge is keeping up that momentum over time while if this goes on months and months and then, you know, some of my colleagues saying until 2022. And so, again, I think that something we need to consider is how to keep people’s momentum going, and also to keep hope and optimism alive while long-term physical and social distancing measures are in effect.

This concludes the April 16 press conference.

Caroline Buckee, associate professor of epidemiology and associate director of the Center for Communicable Disease Dynamics (April 15, 2020)

Leonard Marcus, director of the Program for Health Care Negotiation and Conflict Resolution and co-director of the National Preparedness Leadership Initiative (April 10, 2020)

Paul Biddinger, vice chair for emergency preparedness in the Department of Emergency Medicine at Massachusetts General Hospital and medical director for emergency preparedness at the hospital and at Partners Healthcare (April 9, 2020)