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By Steven J. Karageanes, DO, FAOASM
April 2020

In the midst of the COVID-19 pandemic, we can expect many things about daily life to change once we get through this. One aspect of the pandemic that is sliding under the radar is mental health. Up until this time, the topic of mental health was getting significant attention in the medical field, directed at several populations: physicians, collegiate athletes, teens, and so on. Performing arts organizations such as Athletes and the Arts, PAMA, and IADMS have been dedicating time and research towards awareness and developing resources to treat this.

Unfortunately, COVID-19 came along and blindsided the world, becoming a viral contagion that crossed species and adapted well to human hosts (as opposed to SARS and MERS), making it easily contagious. The respiratory damage COVID-19 causes is well known now, but numerous reports show COVID-19 presenting first with gastrointestinal symptoms, musculoskeletal aches, and even cardiac symptoms. Indeed, this pandemic will require the strength of our healthcare system to fight it.

What has not been noticed as much are the mental health effects of COVID-19. Not the virus itself, but the effects of the isolation, quarantine, and disruption of work and daily life. The effects are profound:

1. Anxiety in healthcare professionals: On March 23, JAMA Network Open published results of a survey of more than 1200 healthcare workers in China, where about 50% reported at least mild depression; 14% of physicians and nearly 16% of nurses reported moderate or severe depressive symptoms and about 34% reported insomnia. Those at greatest risk included women, those with intermediate seniority roles (compared with those with junior roles), and those at the center of the epidemic in Wuhan. Symptoms were assessed using the Chinese versions of the 9-item Patient Health Questionnaire, the 7-item Generalized Anxiety Disorder scale, the 7-item Insomnia Severity Index, and the 22-item Impact of Event Scale.

2. Anxiety in the public: A survey of 1004 adults by the American Psychological Association showed that 62% of respondents are anxious about the possibility of family and loved ones falling ill, 59% said COVID-19 having a serious impact on their daily life, and 36% said COVID-19 is seriously affecting their mental health. According to the APA president Bruce J. Schwartz, this is within normative levels, but “rates of mental distress in the country could surge if the pandemic continues for much longer…we have learned from other disasters that chronic stress has an effect on people’s physical health and mental health.”

3. Child abuse: With most state governments issuing “shelter-in-place” orders, parents used to going to work and children used to going to school are now at home together. In some cases, the time together can seem like a blessing—a reprieve from our prior on-the-go lifestyles.

But these sudden changes has increased stress dramatically in the home. Parents may struggle with loss of income, work, and child care, leading to increased substance abuse. Many children are more likely to be left unsupervised with other children or unsafe adults due to school closures. But because everyone is now (hopefully) following social distancing and quarantine restrictions, the signs of child, domestic, and sexual abuse are harder to see. Melissa Merrick PhD, CEO of Prevent Child Abuse America, states that “the risk of to our children for experiencing child abuse and neglect in times of extreme stress and uncertainty…is actually quite high.”

This is reflected sharp decreases in calls to child abuse hotlines in regions such as Oregon, Minnesota and Indiana. This is largely because most children no longer have daily interaction with teachers and school personnel who are required by law to report concerns of abuse and neglect, and therefore many cases are going unrecognized. When social distancing mandates are also factored in, it is even less likely that children have much if any interaction with adults outside of their home who might be able to identify and report signs of abuse.

Worse, according to Sarah Burns, chief marketing officer for Dallas Children’s Advocacy Center, “We’re going to have an influx of cases that haven’t been reported that will be (reported). Once kids are seeing teachers again, or seeing coaches, they’ll be hearing about things that have been going on in kids’ homes during the COVID crisis.”

4. Domestic/sexual abuse: Almost 85% of abuse victims experience abuse at the hands of someone they know and often live with. Now, the states have mandated that everyone stay at home. Numerous crisis hotlines and shelters across the country have seen a surge in the number of domestic abuse calls, such as Washington, D.C., where one nonprofit, DC Safe, receiving more than 1,500 calls since March 8, and Connecticut, where domestic violence shelters have seen an increase in calls from survivors concerned about being stuck inside with their abusive partners.

“You’re just in a box with no escape,” said Anika Virgin, director of York County’s Victim-Witness Assistance program. “It makes things feel even more hopeless.”

Meanwhile, other programs are fearful that abuse is happening but not being reported.

Many domestic abuse shelters, such as Dallas Children’s Advocacy Center, First Step in Wayne County, MI and KIDS Center in Oregon, have only skeleton crews of workers left as loss of crucial funding has made keeping the lights on difficult, let alone take in new victims. Virtual visits with professionals can help victims, but not those who are afraid to call when the abuser is in the other room.

But to further complicate the issue, COVID-19 has made victims afraid of staying in a communal facility like a domestic abuse shelter. Maureen Curtis, vice president of criminal justice and court programs at Safe Horizon, a nonprofit organization in New York City, points out, “A woman who is in a violent relationship and is thinking about going into the shelter will say, ’You know what? I don’t want to go into a shelter right now because I’m afraid of my children getting infected, living in a place where it’s a shared living space.”

These issues touch everyone in our society right now. However, when you see these problems through the lens of a performing artist, the problems become more acute.

1. They rarely have guaranteed salaries. The vast majority make money by performing. If nobody is putting on performances, nobody can earn money performing.

2. Prevalence of mental health disorders such as depression and anxiety are higher among performing artists.

3. Performing artists are a community used to consistent and close interaction. Losing that support system and being isolated can have a stronger impact than someone who is used to video chat meetings or having family at home.

4. Substance abuse is a problem in performing artists, particularly smoking and alcohol use. These are commonly used as aids in times of anxiety and depression in the normal population. In the performing arts population, this can become higher.

Paul Saintilan, director of the Australian College of the Arts, published a research paper in 2019 (“Musicians & Substance Abuse”) which outlined five pressures musicians that influence the vulnerability of musicians to alcohol and drug dependence:

1. Pressure to be creative

2. Pressure generated by performance anxiety

3. Managing emotional turbulence (doubt, fears)

4. Social, cultural and workplace pressures

5. Identity issues

Based on these areas, one can extrapolate the difficulty performers can have in a pandemic such as this. Identity issues are similar to those in athletes—who am I if I am not performing for others? This helps explain the vast number of performers utilizing video social media such as
Instagram, Facebook Live, Tik Tok, Zoom, and others to put on performances in their house. They may be doing this not for the American population as a whole, but for themselves, to maintain their identity and be creative.

Keep all of this in mind when you start doing virtual visits with your patients. You may want to reach out to some of your performers and schedule a check-in, just to make sure they are enduring the quarantine well.

The CDC has a resource page on stress and coping with COVID-19 here.

References
1. https://www.medscape.com/viewarticle/927581
2. https://www.medscape.com/viewarticle/927711
3. https://keyt.com/news/2020/03/30/covid-19-shelter-in-place-has-contributed-to-anincrease-in-sexual-abuse-ca-rape-crisis-center-is-here-to-help/
4. https://ktvz.com/news/coronavirus/2020/03/31/kids-center-covid-19-concern-abuse-risksoars-in-times-of-high-stress
5. https://www.nbcdfw.com/news/coronavirus/dallas-nonprofit-fights-child-abuse-financialstress-due-to-of-covid-19/2341062/
6. https://wydaily.com/local-news/2020/03/30/no-escape-domestic-violence-casesexpected-to-rise-during-coronavirus-pandemic/
7. https://www.cnbc.com/2020/03/31/new-york-coronavirus-domestic-violence-programssee-decline-as-disease-spreads.html
8. https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/managing-stressanxiety.html
9. Saintilan, Paul. (2019). Musicians and Substance Abuse.

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