Ronald W. Pies, MD

As a psychiatrist, I do not need much convincing that millions of people are suffering emotionally as a consequence of the coronavirus disease 2019 (COVID-19) pandemic. (Most of us have our “war stories” to tell.) For example, a recently released survey from the Centers for Disease Control found that from June 24-30, 2020, adults in the United States reported “considerably elevated adverse mental health conditions associated with COVID-19.”

 Using validated screening instruments, the CDC survey found that, 40.9% of 5470 respondents reported an adverse mental or behavioral health condition, including symptoms of anxiety disorder or depressive disorder, trauma-related symptoms, new or increased substance use, or thoughts of suicide (

). The prevalence of anxiety and depression symptoms were substantially higher than reported in 2019, and people with preexisting (clinically diagnosed) psychiatric disorders reported an even higher prevalence of symptoms, compared with those without an established diagnosis.

 So, yes, many folks are indeed suffering.

All this has led many news outlets and even some psychiatrists to 

a “mental health pandemic” or “secondary pandemic” amidst the already devastating COVID-19 pandemic.

 I found about 145,000 results, searching the term mental health pandemic on Google. Indeed, several respected mental health professionals have taken to using this linguistically awkward term. (Ironically, mental health pandemic understood in epidemiological terms would mean something like “a worldwide outbreak of mental health.”) While well-intentioned, the casual and colloquial use of the term pandemic is not warranted in this context.

Of course, I understand that the intention underlying the term is to highlight a worldwide upsurge in mental health issues and symptoms, which is a valid concern. But problems often arise when we co-opt terms and apply them to psychiatry. For example, the same casual misuse of epidemiological terms has been commonly used in the popular press for years when referring to various “epidemics” of psychiatric illness in the United States—even though no credible evidence ever supported that bogus claim.

 And this is more than a semantic quibble. The use or misuse of language can have powerful effects on the public’s beliefs and perceptions—witness the baneful effects of the “schizophrenogenic mother”

Let us back up a bit and explore the definitions of these terms. An epidemic refers to an increase, often sudden, in the number of cases of a disease above what is normally expected in that population in that area. A pandemic refers to a disease epidemic that has spread over several countries or continents, usually affecting a large number of people.7 The critical term here is disease, and the critical point is that self-reported symptoms obtained from a screening survey do not establish the presence of a psychiatric disease, illness, or disorder. Many people can experience a new onset of—or an increase in—one or more symptoms of anxiety or depression, but not meet clinical criteria for a psychiatric disorder.

Upon careful, clinical evaluation, such self-reported symptoms may or may not turn out to be a clinically significant disease or mental illness. The CDC report itself notes this limitation of its survey, stating “a diagnostic evaluation for anxiety disorder or depressive disorder was not conducted.”

Consider the diagnosis of generalized anxiety disorder (GAD). According to the DSM-5, symptoms must be present for at least 6 months—so no one who responded to the CDC survey in June 2020 would have met that criterion if their anxiety symptoms began, say, in March 2020. Furthermore, DSM-5 criteria for nearly all the major disorders require that the person demonstrates “clinically significant distress or impairment in social, occupational, or other important areas of functioning.”

Experiencing an uptick in some symptoms of anxiety or depression does not necessarily mean that you have reached that distress-impairment threshold—much less, that you have a mental disorder. The difference between symptoms and disorder is not merely semantic. A formal, clinical diagnosis of a mental disorder has wholly different implications—medical, legal, and psychological—than those associated with, say, a normal or adaptive response to the stress and strain of the COVID-19 pandemic.

The nebulous term depression may be misleading when considering many emotional reactions to the pandemic. I suspect—although I cannot prove—that many of the respondents were reporting symptoms reflecting understandable demoralization andgrief—and these are not mental disorders. On the contrary, as psychologist John F. Schumaker9 has elegantly put it, demoralization is “an overarching psycho-spiritual crisis in which victims feel generally disoriented and unable to locate meaning, purpose, or sources of need fulfilment.” And grief, of course, is a normal, adaptive reaction to life’s “slings and arrows” and its manifold, painful losses.

In my experience, only a careful clinical evaluation could distinguish profound demoralization and grief from major depressive illness among the CDC survey respondents.Screening instruments like the 4-item Patient Health Questionnaire (PHQ-4)—used in the CDC survey—simply cannot do the job.

None of this is to minimize the mental health challenges posed by the COVID-19 pandemic. Individuals with established psychiatric diagnoses (eg, posttraumatic stress disorder, schizophrenia, or bipolar disorder) may be experiencing serious, pandemic-related exacerbation of their illness, and they may require immediate treatment or refinement of their current treatment. There is also strong, emerging evidence that COVID-19 may lead to serious and enduring neurological complications.

 Care and treatment of these seriously affected individuals should be our priority. We must also carefully monitor the long-term psychological effects the pandemic may have on children and adolescents.

 Finally, we must remain vigilant regarding the enormous physical and emotional toll the pandemic is taking on our physicians, nurses, and other frontline health care workers.

And, let me clarify: the mere fact that someone may not meet full DSM-5 criteria for a mental disorder does not mean that the person is unworthy of professional attention, or undeserving of insurance coverage for, say, telemedicine counseling. We know, for example, that subclinical depression—ie, falling just short of full DSM criteria for major depression—can nevertheless be a disabling condition that needs treatment, and may respond to psychotherapy.

So, no—the term, mental health pandemic is not really helpful or accurate. But that observation does not negate the distress and loneliness of so many who are enduring the COVID-19 pandemic, nor should it diminish our efforts at comforting and supporting them.

is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University; clinical professor of psychiatry, Tufts University School of Medicine; and editor in chief emeritus of

 — I wish to thank Awais Aftab, MD, for his helpful comments on an earlier draft of this piece; and Ms Grace Huckins for prompting my consideration of this issue.

Pies RW. Care of the Soul in the Time of COVID-19. 

 May 13, 2020. Accessed August 21, 2020. 

https://www.psychiatrictimes.com/view/care-soul-time-COVID-19

1. Czeisler MÉ , Lane RI, Petrosky E, et al. Mental health, substance use, and suicidal ideation during the COVID-19 pandemic — United States, June 24–30, 2020. 

2. Gold J. Covid-19 might lead to a ‘Mental Health Pandemic.’ 

. August 6, 2020. Accessed August 21, 2020. 

https://www.forbes.com/sites/jessicagold/2020/08/06/COVID-19-might-lead-to-a-mental-health-pandemic/#333f0013706f

3. Pies RW. The bogus “Epidemic” of mental illness in the US.

June 18, 2015. Accessed August 21, 2020. 

https://www.psychiatrictimes.com/view/bogus-epidemic-mental-illness-us

4. Pies RW. The astonishing non-epidemic continues. 

. October 5, 2017. Accessed August 21, 2020. 

https://pro.psychcentral.com/the-astonishing-non-epidemic-continues/

5. Johnston J. The ghost of the schizophrenogenic mother. 

6. Pies RW. Debunking the two chemical imbalance myths, again. 

August 2, 2019. Accessed August 21, 2020. 

https://www.psychiatrictimes.com/view/debunking-two-chemical-imbalance-myths-again

7. Center for Disease Control. Lesson 1: Introduction to Epidemiology. In: Principles of Epidemiology in Public Health Practice. October 2006; updated May 2012. Accessed August 21, 2020. 

https://www.cdc.gov/csels/dsepd/ss1978/lesson1/section11.html

Diagnostic & Statistical Manual of Mental Disorders, 5th ed. 

American Psychiatric Publishing, Inc; 2013.

April 1, 2016. Accessed August 21, 2020. 

https://newint.org/columns/essays/2016/04/01/psycho-spiritual-crisis

10. Pies RW, Geppert CMA. Clinical depression or “life sorrows”? Distinguishing between grief and depression in pastoral care. 

https://www.ministrymagazine.org/archive/2015/05/depression

11. Heidt A. Dozens more cases of neurological problems in COVID-19 reported. 

. July 8, 2020. Accessed August 21, 2020. 

https://www.the-scientist.com/news-opinion/dozens-more-cases-reported-of-neurological-problems-in-COVID-19-67717

12. Harris NB. Children will pay long-term stress-related costs of Covid-19 unless we follow the science. 

 August 4, 2020. Accessed August 21, 2020. 

https://www.statnews.com/2020/08/04/children-long-term-stress-related-costs-COVID-19

13. Kelly M. The pandemic’s psychological toll: An emergency physician’s suicide. 

 2020;76(3):A21-A24. [Epub ahead of print]

14. Cuijpers P, Koole SL, van Dijke A, et al. Psychotherapy for subclinical depression: meta-analysis. 

This article was originally posted on August 23, 2020, under the title "

Are We Really Witnessing a 'Mental Health Pandemic?'

Articles

There are epidemiological and clinical reasons why we should drop that term.

Is the Country Experiencing a Mental Health Pandemic?

The adage has it that the road to hell is paved with good intentions. It is evident from this revealing portrait of neurologist Walter Freeman-the originator of the infamous "ice pick" lobotomy-that good intentions without sober analysis can indeed have hellish consequences.

This film by Barak Goodman and John Maggio chronicles the rise and fall of one of medicine's most exalted and reviled figures. Using a series of interviews, film clips, and historical photographs, 

 reveals the history and motivation behind Freeman's ill-fated-and arguably, shameful--misadventure in neurosurgery. The film leaves no doubt that Freeman began with the noblest of ideals: to reduce the suffering of thousands of severely impaired patients, warehoused in unspeakably inhumane asylums across the United States. Indeed, to the film's credit, Freeman is not depicted as a monster or a madman; rather, he comes across as a deeply flawed human being, blinded by his overweening sense of ambition and destiny. The film also highlights the deep complicity of orthodox medicine in permitting Freeman (and, initially, neurosurgeon James Watts) to carry out his work without systematic oversight or substantial challenge. (Psychoanalysts protested, but Freeman argued with some justification that they had nothing to offer to the types of patients he treated; the AMA belatedly condemned the procedure as destructive, but by then, thousands had undergone lobotomy.)

The film does a good job depicting the historical context of Freeman's efforts. For example, the apparently successful neurosurgical technique developed by Dr Egaz Moniz (who won a Nobel Prize for his work) helped convince Freeman that a brain defect of some sort was at work in severe mental illness. Freeman had also observed that certain frontal lobe injuries, such as those sustained by soldiers in combat, could result in docility. He was certainly right in viewing frontal-subcortical circuits as critical in the mediation of aberrant or violent behavior. Indeed, some of Freeman's severely impaired patients seem to have improved modestly, after sectioning of nerve tracts connecting the thalamus to the frontal lobes. But far too many of Freeman's lobotomized patients (victims?) wound up worse off than before the procedure, often in near-vegetative states.

Freeman is described at one point in the film as a tragic figure. But this characterization misses the mark. Genuinely tragic figures-Hamlet or Macbeth, for example-are riven by conflict and self-doubt. The film suggests that Freeman suffered from few overt doubts, probably because he refused to see the catastrophic results of his own misguided efforts. As another speaker in the film suggests, Freeman was really a messianic crusader. And we have seen throughout history that crusades of all stripes usually lead to calamity.

The film could have used more commentary by neuropsychiatrists and neurosurgeons and a bit less from nonclinical writers, gripping though their accounts may be. Specifically, it would have been helpful to place Freeman's primitive procedure in the context of more recent and promising developments in neurosurgery, such as the use of bilateral anterior cingulotomy for refractory obsessive-compulsive disorder.

Nonetheless, the film does an excellent job of documenting one of the saddest chapters in the history of neuropsychiatry. Particularly moving is the testimony of Howard Dully, a 58-year-old bus driver who underwent Freeman's procedure. The film also presents us with many cautionary lessons for our own time, such as the need for genuinely informed consent (it hardly existed in Freeman's day) and scrupulous analysis of outcomes for any medical procedure. In short, despite its limitations, this film-which airs January 21st on PBS as part of its "American Experience" series-should be required viewing for every neurologist and psychiatrist.

 Jung HH, Kim CH, Chang JH, et al. Bilateral anterior cingulotomy for refractory obsessive-compulsive disorder: long-term follow-up results. 

The adage has it that the road to hell is paved with good intentions. It is evident from this revealing portrait of neurologist Walter Freeman--the originator of the infamous "ice pick" lobotomy--that good intentions without sober analysis can indeed have hellish consequences.

Ronald W. Pies, MD

Articles

Is the Country Experiencing a Mental Health Pandemic?

The Lobotomist