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A quintessential neuropsychiatric disorder might be one that reflects the variety of ways that the brain and mind can be adversely affected. Neuropsychiatry would consist both of the direct neurological impact of some pathogen on the brain, which is what we used to call “organic,” as well as the psychological reactions to the impact, or what we used to call the “functional.”

At various times, there have been failed attempts to connect neurology and psychiatry into 1 specialty. Certification testing has always overlapped the fields to some degree. Some given examples of neuropsychiatric disorders are traumatic head injury, migraine headaches, menopause, and medication side effects.

Although the major pathology of COVID-19 is respiratory damage, over time it has become clearer that there also are neuropsychiatric ones. I apparently had an acute respiratory episode, but did not notice any neuropsychiatric aspects—that is, until recently, when I experienced more anxiety and uncertainly about how much risk to take outside of the home. I reluctantly decided that coming to the 2022 APA annual meeting next week was too risky.

Around this same time, I ran across a new COVID-19 study out of England.

 The results indicated that new and increased rates of anxiety disorder, dementia, psychosis, and bipolar disorder were occurring. It is unclear how much is the result of the viral pathogen, the psychological response, or both. Some also seem to be associated with long COVID including unexplained mood changes, brain fog, and language difficulties. When the illness is more severe or a loved one dies, posttraumatic stress disorders and prolonged grief disorders are likely to increase. Then there is the conscious and unconscious defense mechanism of denial of the risk we have encountered over the last 2 years.

All of this complexity and uncertainly suggests that COVID-19 would benefit from being studied at academic neuropsychiatric centers, if only more of them existed. In the meanwhile, I would suggest leaning to the safe side for now as the infections, and now even hospitalizations, are increasing.

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues relate to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

1. Clift AK, Ranger TA, Patone M, et al. 

Neuropsychiatric ramifications of severe COVID-19 and other server acute respiratory infections.

What are the neuropsychiatric effects of COVID-19, and how can we study them further? 

Is COVID-19 the Quintessential Neuropsychiatric Disorder?

Although we have all been challenged by the COVID-19 pandemic, those with underlying mental health and neurodevelopmental diagnoses have faced particular hardship. Individuals with attention-deficit/hyperactivity disorder (ADHD) especially seem to have struggled to effectively adapt to the pandemic, showing more vulnerability to its many challenges.

Individuals with ADHD have showed a higher level of mental health concerns, difficulty adhering to preventive measures, and less economic success during the pandemic, as well as negative impacts on behavioral, emotional, and perceptual skills.

 Other challenges reported by adults with ADHD and caregivers of children with ADHD during the pandemic included social isolation, motivation difficulties, managing boredom, and difficulty engaging with online learning. Individuals with ADHD also reported increased symptom severity with higher risk factors for both major depression and school dropout.

 As the pandemic eases, these individuals are likely to require a high level of support, including therapy, psychiatry, and school and workplace accommodations to attain optimal functioning.

The COVID-19 pandemic forced most students to engage in virtual learning. During that time, caregivers of children with ADHD reported significant changes in the children’s behaviors, suggesting a higher level of underlying emotional dysregulation.

 After returning to school, many children with ADHD have found it harder to adapt. They have required a higher level of support in reacclimating to a set schedule and have needed to rely on executive functioning skills that they may not have had support for during the period of virtual learning.

Due to the combination of online learning, increased access to devices, and, for many, increased hours spent on digital media, it is not surprising to see struggles increase among children with ADHD. It has been suggested that ADHD symptoms, behavioral concerns, executive functioning difficulties, and family struggles all increased as digital media use increased during the pandemic.

 For many, the combination of these challenges and the challenges faced by exhausted parents has caused ongoing conflict even as the pandemic has begun to calm. Families continue to require mental health support for children and coaching for parents to manage these concerns.

The routine changes caused by the COVID-19 pandemic also presented a particular challenge for adults with ADHD. These individuals tend to require a higher level of structure than neurotypical peers and colleagues and are more likely to struggle when changes to routine occur. Creating a new schedule requires the ability to plan, organize, and initiate independently, which can be particularly challenging for those with ADHD, many of whom reported experiencing decreases in motivation and increases in distractions during the pandemic.

The constant access to media and electronics created a difficult distraction for many. The stimuli of “in-person” work was lost, and the ability to “body double”—that is, to work beside another person while completing a nonpreferred task to support engagement and accountability—was diminished. Individuals with ADHD are easily distracted and prone to missing social and environmental cues. The impact of both masking guidelines and frequent changes to these guidelines and other rules have likely increased these challenges and related stress, as well. It is important to support individuals with ADHD as they continue to adapt to changing guidelines, including changes to masking requirements.

Accurate diagnosis of ADHD has also become more challenging because of the COVID-19 pandemic. Now more than ever, it is imperative to explore neurodevelopmental history to determine early signs and traits of ADHD. Even neurotypical individuals have found themselves more distracted and distressed during the COVID-19 pandemic, including those who have not struggled with attention, executive functioning, or related emotional or behavioral dysregulation in the past. As a result, more people sought care for potential ADHD as evidenced by increased inquires to CHADD.

 In some cases, caregivers began noticing their children’s attentional concerns for the first time while virtual learning was in effect. In other cases, caregivers found their child’s ADHD easier to manage without the restrictions of the pandemic. With increasing calls for diagnosis, practitioners have had to take great care to avoid misdiagnosis. It has been imperative to recognize that children may display ADHD symptoms when preferred distractions are nearby, when anxiety is high, when social opportunities are limited, when children are sitting on a screen and exercising infrequently, and when children are internalizing their caregivers’ anxiety.

A final concern related to ADHD during the COVID-19 pandemic has been the response to infection itself. Research shows that individuals with ADHD are at increased risk of acquiring COVID-19, experiencing greater severity of COVID-19 symptoms, and being hospitalized for COVID-19. The same study noted the need for more research on whether individuals with ADHD are at higher risk for long COVID or for neuropsychiatric symptoms resulting from COVID infection.

 Long COVID is an emerging challenge that is in need of additional study. For some, long COVID symptoms include cognitive impairment and memory loss, as well as disturbed sleep and increased anxiety.

 These symptoms mirror those of ADHD and will require accurate diagnosis and treatment.

is a licensed psychologist with Washington Behavioral Medicine Associates, LLC, and director/co-founder of The SOAR Program for Psychotherapy and Testing at WBMA.

is a psychiatrist and the director of Washington Behavioral Medicine Associates, LLC, and the co-founder of The SOAR Program.

Symptoms of ADHD predict lower adaptation to the COVID-19 outbreak: financial decline, low adherence to preventive measures, psychological distress, and illness-related negative perceptions

Top problems of adolescents and young adults with ADHD during the COVID-19 pandemic

Acute stress, behavioural symptoms and mood states among school-age children with attention-deficit/hyperactive disorder during the COVID-19 outbreak

Helping adults and children with ADHD in a pandemic world

Influences of digital media use on children and adolescents with ADHD during COVID-19 pandemic

6. Merzon E, Weiss MD, Cortese S, et al. 

The association between ADHD and the severity of COVID-19 infection

7. Raveendran AV, Jayadevan R, Sashidharan S. 

What are the unique challenges for individuals with ADHD?

ADHD and the COVID-19 Pandemic

COVID-19 rewrote—and continues to rewrite—the rules as to how medicine can be delivered. Like many of you, I spent the first 14 or so months of the pandemic exclusively engaged in 

, working out of my home. However, as soon as our clinic reopened to in-person patient appointments with rigorous safeguards in place, I returned to that setting. In fact, I was—and frankly remain—befuddled as to how few clinicians, both at our clinic and across the country, have returned to providing in-person treatment when the option to practice virtually continues to exist for them.

Fortunately, many of my patients returned to in-person visits right away, and when we meet in the waiting room for the first time since the pandemic started, it is a welcome reunion. In my experience, so much more clinical information is accessible and treatment planning is more easily negotiated. Loose ends from the telemedicine days can be quickly tied up.

Still, some patients prefer telemedicine. Each of the 20 or so patients I am scheduled to see a day are given the option to meet in person, on the doxy.me virtual platform, or by voice only over the telephone. It has been fairly consistent over the past 10 months: About a third attend in person, a third I meet with on doxy.me, and a third I meet over the telephone. I have read studies that consistently conclude patients and clinicians are equally or more satisfied with their virtual treatment option than meeting in person. There are likely many reasons for this: no need to travel to the appointment; the ability to wait at home if the clinician is running late rather than waiting in a busy/noisy waiting room; lower no-show rates, which greatly improve clinician productivity; the clinicians’ ability to work from home, eliminating the stress of commuting to work; no need to rent office space; greater ease ending an appointment than in person, and more.

Maybe I am just old fashioned. I enjoy and learn a lot clinically when I walk out to the waiting room to meet my next patient. In that moment of eye contact and recognition, I usually have a good sense as to how they are doing. I observe their energy level, posture, body tension, unusual movements, hygiene, smell, and overall presence as I walk behind them to my office. And, after practicing virtually for 14 months, it has been refreshing to be face to face in the same room to explore my patient’s challenges, stressors, achievements, progress, and fears, and genuinely be present in a way that is not possible through telemedicine.

Let me be clear: I am delighted over the impressive and exponential advancements that have developed in telemedicine over the past 2 years. I support and appreciate the growth in the telemedicine arena, which has greatly improved access for patients who had significant treatment roadblocks due to geographic distance and isolation, institutional deficits in necessary clinicians, transportation issues, health conditions that prevented or required avoidance of hospitals and clinics, and many other barriers. Through virtual platforms, expert consultants are now available to assist hospitals and clinics that lack the resources to hire the wide range of specialists who are commonplace at major medical centers. Innovators are broadening options to enhance access for populations in need of virtual access. During the pandemic, many of my patients were perfectly happy having our scheduled appointments by voice only over the telephone. Remarkably, no-shows and canceled appointments dropped to close to zero.

Yet it was not ideal. I remember the many times when my patients’ inadequate cellular or internet connection interfered with our ability to meet satisfactorily. I had to recommend parking near a Starbucks or Panera to use their wireless network to some of my patients for our next virtual appointment.

In addition, some patients whispered to me that they could not really talk openly, as their partner, roommate, or child was in the room or within hearing distance. I rarely received results from the lab orders I mailed to the patient after the virtual appointment. I had “appointments” with patients at checkout lines in stores, taking a walk with a friend, or while they were in waiting rooms for some other appointment. I lost the intuitive sense that had developed after 8 years of medical school and residency and 30 years of in-person clinical practice that would often provide significant insight into my assessment and treatment planning.

After all, sitting in my office with a patient allows for much communication, especially through our mutual eye contact. Sometimes sitting in silence and gazing into each other’s eyes creates a powerful therapeutic moment. The eyes are a special sensory door for us humans and can facilitate quite a range of emotions, including fear, paranoia, acceptance, joy, and relief.

That is why I am now concerned that telemedicine is, unfortunately, metastasizing into clinics and settings where the option to meet in person is readily available. This is a dangerous evolution away from in-person treatment. Our brains are wired to engage in a 4-dimensional environment using all of our sense modalities. I cannot imagine a parent raising their child virtually or spending the majority of time in a relationship with a loved one or friend virtually. I am not interested in virtual vacations. Scuba diving or hiking on a digital screen or over a telephone, for that matter, does not sound appealing.

Medicine is a healing profession. Qualities like empathy, compassion, acceptance, “sitting” with our patient’s pain and suffering, listening to a traumatic life story, discussing treatment options, being present and attentive to our patients in a way that they feel it, and breathing the same air in the same room and in the same moment while looking at their soul through the windows of their eyes are qualities that are greatly diluted and often absent through a virtual platform. 

is medical director, Brain Health, Exeter, New Hampshire; Editor in Chief, 

; staff psychiatrist, Seacoast Mental Health Center, Exeter; Consulting Psychiatrist, Exeter Hospital, Exeter; consulting psychiatrist, Insight Meditation Society, Barre, Massachusetts.

There have been many exciting advances in telemedicine in recent years. But does telemedicine really allow us to be genuinely present for our patients?

A Dangerous Evolution?

Most physicians will probably recall Dr Birx from her role as coronavirus response coordinator within President Trump’s White House. Recently, her book 

, was published to present her side of the story. At its basis, it is a story of medical ethics choices.

Although I have not yet read the book, I did read the 

 book review by David Quammen: “Deborah Birx’s Excruciating Story of Donald Trump’s Covid Response.”

Perhaps the ethical decision most well-known occurred early on, just about 2 years ago during a televised White House briefing. In discussing disinfection chemicals that could kill SARS-CoV-2 on a tabletop, President Trump wondered if it could be used as a treatment. Dr Birx froze and looked down. Then he turned to her for a comment, and she replied: “Not as a treatment.” From then on, she was marginalized from the team, but stayed on, going around the country educating on her own until the end of that administration.

How to assess her medical ethical responses? Since she was not directly responding as a clinician seeing patients, the AMA’s Principles of Medical Ethics did not fit. But once upon a time, due to the takeover of psychiatry systems by for-profit managed care, I was asked by the American Association of Psychiatrist Administrators to put together a corresponding set of ethical principle for psychiatrist administrators.

The administrative role, of course, brings in the responsibility to the organization in addition to the patient and to the physician’s own well-being. Besides managed care and business versus health care ethics, the multiple ethical responsibilities can occur in such systems as prison and military health care. In her case, it involved political policies.

In the Preamble to the administrative ethical principles, the key statement is:

“When conflict exists between the needs of the organization or society and the needs of patients, the psychiatric administrator must be guided by an ongoing commitment to the needs of patients. If and when the psychiatric administrator can no longer follow these principles, resignation would be an ethical option.”

Dr Birx did not take the ethical option of resignation, but quietly did follow one way of staying committed to the COVID needs of patients and would-be patients that fit her personal well-being well enough. May other physicians learn from her for the future.

1. Quammen D. Deborah Birx’s excruciating story of Donald Trump’s Covid response. 

https://www.nytimes.com/2022/04/21/books/review/deborah-birx-silent-invasion-trump-covid.html

2. Moffic HS, Saeed SA, Silver S, Koh S. 

Ethical challenges in psychiatric administration and leadership.

This is a story of medical ethics and choices. 

Deborah Birx, MD, and Her Excruciating COVID Ethical Dilemmas

, we worked with experts from multiple areas in psychiatry to bring you thoughtful articles about a wide variety of psychiatric issues, from managing depression in older adults and differences in trauma response to the effects of the COVID-19 pandemic on youth and the growing US mental health crisis. Here are some highlights.

Psychiatric Care in the US: Are We Facing a Crisis?

By the end of 2021, many American adults found themselves inthe worst mental state in years. According to the US Census Bureau’s Household Pulse Survey, 47% of adults reported symptoms of anxiety,

 and 1 in 5 adults disclosed suffering from a mental illness.

 Despite this, it is estimated that less than half of Americans with a mental disorder get adequate treatment.

“It has been just over a year now since the COVID-19 pandemic struck the United States full force. A year of hunkering down and Zooming in, teleworking and telepsychiatry, economic and social upheaval, and steady scientific progress. Looking back to last March, we knew this would be difficult. But we didn’t know how difficult. And we certainly didn’t know that the challenge of COVID-19 would last this long,” said Joshua A. Gordon, MD, PhD, director of the National Institute of Mental Health, in a 2021 director’s message.

Why Men and Women May Respond Differently to Psychological Trauma

Posttraumatic stress disorder (PTSD) is a mental health disorder that arises after experiencing a traumatic event in about 10% of exposed individuals. A hallmark symptom is the reexperiencing of the traumatic event in the form of nightmares or flashbacks or reliving the event upon certain triggers. 

These unwanted memories cannot be controlled, and the event may feel like it is happening again. Individuals with PTSD will try to avoid these memories by not talking about them or by staying away from situations where potential triggers might be present (eg, the store where the robbery took place or watching the news about current combat events or natural disasters).

Several cognitive and mood alterations—such as memory problems, negative thoughts or feelings, and high arousal levels—may manifest themselves in several ways. These include being easily startled and having angry outbursts, sleeping problems, or difficulty concentrating on everyday tasks. 

The Management of Depression Among Older Adults

Depression is not an uncommon condition among older adults, and it is often underdiagnosed in this population. Depression also results in greater rates of morbidity and mortality among older adults. 

The neurobiology of depression includes a complex interaction among various biological, psychological, and social factors. The identification of depression among older adults requires a thorough history, a focused physical examination, appropriate laboratory studies, and the use of neuropsychological testing when necessary.

Current available treatments for older adults with depression include psychotherapy, pharmacotherapy, electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), and collaborative care approaches.

 In addition, some evidence indicates that aerobic and supervised group exercise regimens may improve depressive symptoms among older adults.

 In this review, we assess the evidence for using psychotherapy, pharmacotherapy, ECT, TMS, and collaborative care approaches for the treatment of depression among older adults. 

Here’s How the COVID-19 Pandemic is Shaping the Next Generation

The full picture of teenagers’ experience of COVID-19 is just beginning to emerge. The school closures, canceled proms, and separation from friends seemed a small price to pay to save the lives of thousands—but in exchange, the adolescents who represent the younger side of Generation Z were robbed of the capstone of their formative years. It created an atmosphere of uncertainty and anxiety among some teens, about both the future and their place in it.

As if the pandemic was not enough, teens watched as police violence and racial tensions reached breaking points. They saw angry mobs take over cities and storm the Capitol. Then Mother Nature swept in with deadly wildfires and other natural disasters that underscored the threat of climate change. 

. And be sure to stay up-to-date by subscribing to the 

Do you have a comment on any of these or other articles? Have a good idea for an article and want to write? Interested in sharing your perspectives? Write to us at 

The experts weighed in on a wide variety of psychiatric issues for the April 2022 issue of Psychiatric Times.

From the Pages of Psychiatric Times: April 2022

H. Steven Moffic, MD, shares his thoughts on the lifted mask mandate and the increasing death toll of COVID-19.

The mask mandate has been lifted in the wake of the million death milestone for COVID-19.

Passing the Million Lives Milestone in Our Age of Uncertainty

A study found that exercising and playing online games were the most common means of addressing mental health issues during the COVID-19 pandemic.

The international study, conducted by digital board game publisher Marmalade Game Studio, highlighted the mental health issues individuals have experienced during the pandemic and the steps these individuals have taken to address the issues. The study included adults from across France, Germany, Hong Kong, Singapore, and the United States. Nearly 6 out of 10 (57%) of all participating individuals reported experiencing mental health issues, with individuals in Singapore (65%) and Hong Kong (64%) the most affected, followed by France (57%), Germany (56%), and the United States (52%). The most commonly cited mental health issues were stress (38%), anxiety (30%), and depression (22%), with 4% of individuals reporting that they have had suicidal thoughts.

In order to address these issues, 38% of individuals reported exercising more, and 30% reported playing online games, with 29% visiting with friends and family more often, 27% seeking help from a doctor, 26% speaking to their loved ones, and 25% seeking help from mental health professionals. The study also found that 42% of gamers from the European Union said playing multiplayer games during lockdown made them happier, while 16% said that playing games online and connecting with others—particularly family—helped them during lockdown.

“The pandemic has had a huge effect on mental health globally, and millions have at points suffered from a range of conditions caused by worries about their own and others physical health as well as financial worries,” said Cristina Mereuta, Marmalade Game Studio co-CEO, in a press release. “Many people are clearly taking action, with increased exercise and online gaming appearing to be the most popular ways of relieving stress and anxiety. It is important, however, that people seek professional help where appropriate.”

Exercise and online gaming are helping beat mental health issues.

 News release. The Worldliness. April 6, 2022. Accessed April 21, 2022.

The most common issues during the COVID-19 pandemic included stress, anxiety.

Individuals Cite Exercise, Gaming as Top Ways to Address Mental Health Issues

It is January 17, 2020: The first case of COVID-19 in the United States is reported by the Centers for Disease Control and Prevention (CDC). Although it would take until March of that year for states and municipalities to deploy mandatory lockdowns and quarantines, our country was fully enveloped in what we know today as a worldwide pandemic, unlike anything we have seen for many generations. We also know there have been many victims over the past 2 years, and this has not stopped at the loss of life—it also includes the loss of our collective sense of safety, community, and emotional stability.

To say the past 2 years have made an impact is an understatement.

Personally, COVID-19 has impacted my family on a physical and psychological level. In a strange twist of fate, in addition to being a child and adult psychiatrist, my graduate schoolwork entailed infectious disease and global health policy. I sat at a unique place to both understand what was coming and why we reacted the way we did to shortages and hoarding. Professionally, my child and adolescent practice went from an office to a virtual setting overnight. All the behavioral practitioners know exactly what I am talking about: We saw patients dealing with everything from social and academic issues at school to homebound stressors of isolation and amotivation, as well as existential fears that were beyond the realm of comprehension for adults, let alone for children. Treating others in need while trying to maintain our own mental health and wellness, and that of our friends and family, is an enormous task.

In April 2020, almost 1 month to the day after Denver declared its lockdown, I took on the role of chief medical officer at SonderMind, a company dedicated to redesigning mental and behavioral health through improved access and outcomes, building a community of practitioners, and enabling clients to use insurance to access quality care. I continued my independent practice while taking on the tremendously rewarding, yet daunting, role of helping other providers transition their practices from in-person to virtual while supporting them through a virtual professional community with education and development.

As I write this, COVID-19 continues, but is thankfully trending toward an endemic phase. However, there is no relief from a world of existential threats to freedom and humanity, whether in Europe or on our own shores. I will continue to treat my patients while ensuring other practitioners can treat theirs. There are no easy solutions, but if we lead through compassion and understanding, we can do so much good for so many. It starts with us helping 1 life at a time.

is a child and adolescent psychiatrist and chief medical officer at 

Reflections from a child and adolescent psychiatrist in the wake of the COVID-19 pandemic.   

One Life at a Time

As we rather quietly approach the landmark of one million pandemic deaths in the United States with no clear end in sight, we may be psychiatrically boosted by an official new diagnosis. Last month, the update of the American Psychiatric Association’s DSM included a timely new disorder: prolonged grief disorder.

 article, “How Long Should It Take to Grieve? Psychiatry Has Come Up With an Answer,” this development was not without controversy.

 Would it pathologize and stigmatize normal grieving? Or would it be a welcome addition for those who still seem preoccupied with loss and do not seem to be getting over it enough by the 1 year mark, which preliminary research puts at 4%? If that percentage does not seem high, consider that it seems that about 10 people are profoundly affected by pandemic losses. In a way, it updates Freud’s discussion of mourning and melancholia, with the melancholia representing the continuing conscious and unconscious preoccupation with—and longing for—the loved one. Moreover, the social isolation of the pandemic has hindered the use of normal community and religious mourning processes.

The other important grieving number is how many grieving individuals are generally left behind from COVID-19 deaths. Research estimates at least 9.

 So, if this preliminary research and my math is right, if 1,000,000 will have died, then on average 9,000,000 loved ones will be at risk for prolonged grief. Using 4%, that projects out to be 360,000 with prolonged grief disorder and coming at a time of limited resources and an epidemic rate of burnout in clinicians.

The good psychiatric news among all the bad news of the pandemic, as well as the Ukraine invasion and all our usually ambivalent losses, is that there are promising new treatments that may help. There is a 16-session program called prolonged grief disorder therapy, which has some similarities to exposure therapy for the trauma underlying PTSD. Another perspective is that prolonged grief is like an addiction, and hence the trials of whether a medication like naltrexone would provide some relief. Interestingly enough, antidepressants do not seem to be beneficial for this condition. The message to us and primary care physicians is: do not prescribe them for prolonged grief.

There is an implied preventive aspect to this disorder. That means trying to reduce unnecessary deaths, such as with the pandemic, and resolving ambivalent relationships with loved ones before they die. When that cannot be done, transforming the suffering into psychological strengthening, or is sometimes called posttraumatic growth, becomes the goal.

Responding to these challenges will be quite a test of psychiatry in terms of being an appropriate resource to society. Time will help tell us whether this new diagnosis, coming at a time of great societal psychological need, will have enough beneficial consequences to justify its inclusion in our diagnostic manual. I am predicting that it will.

1. Barry E. How long should it take to grieve? Psychiatry has come up with an answer. 

March 18, 2022. Accessed April 12, 2022. 

https://www.nytimes.com/2022/03/18/health/prolonged-grief-disorder.html

2. Verdery AM, Smith-Greenaway E, Margolis R, Daw J. 

Tracking the reach of COVID-19 kin loss with a bereavement multiplier applied to the United States.

The newest DSM official disorder, prolonged grief disorder, comes at just the right time. 

Approaching 1,000,000 Pandemic Deaths and 360,000 Prolonged Grief Disorders

As if the pandemic was not enough, teens watched as police violence and racial tensions reached breaking points. They saw angry mobs take over cities and storm the Capitol. Then Mother Nature swept in with deadly wildfires and other natural disasters that underscored the threat of climate change.

Throughout COVID-19, the physical health needs of the most vulnerable often took priority over the mental health needs of others. But as the pandemic dragged on, health care providers expressed concern over its long-term mental effects on youth and teens. Against expectations, suicide rates for all ages dropped by 5.6% in 2020 compared with 2019.

 This is not entirely unusual. In what is known as the “pulling together” effect, suicide rates tend to dip during shared experiences of catastrophe. Nonetheless, despite this decline, there are indications that the pandemic has triggered a ripple of mental health concerns across all age groups.

When the shelter-in-place measures went into effect in late March 2020, trips to the emergency department (ED) for anything other than COVID-19 plummeted by 42% across all ages.

 Yet while these non–COVID-19 trips declined, the proportion of ED trips for psychosocial issues actually increased by 69%.

 Children and teens experienced increases of about 24% and 31%, respectively.

 Further, there were troubling indications that suicide-related ED visits by girls were significantly higher than those of boys.

 In summer 2020, these visits for attempted suicide rose 26% among girls aged 12 to 17 years compared with 2019.

A September 2020 poll found that 59% of teenagers considered online school worse than in-person instruction, with 19% describing it as “much worse.”

 One survey found that half of US teenagers were experiencing anxiety, trouble concentrating, and social isolation/loneliness during remote learning.

 Also in the survey, 31% of parents reported that their child’s emotional health was worse than before the pandemic. About 53% worried that their children would contract COVID-19 if they went back to school the following fall. Another 36% worried that their mental health would suffer if they did not.

Interestingly, parents were more likely to notice new or worsening symptoms of depression and anxiety in teen girls.

 In July/August 2020, the number of girls admitted to the ED for suspected suicide attempts had increased 26.2% over a year prior.

 In February/March 2021, this rate was now 50.6% higher.

 Among boys, this rate had increased as well, but by 3.7%.

 These were troubling statistics, especially since suicide is the second-leading cause of death among youths aged 10 to 17 years.

 In 2019, almost 19% of high school students in the United States had seriously considered suicide, 15.7% made an attempt plan, and 8.9% reported attempting suicide at least once.

For many teens, COVID-19 took away coping strategies like after school clubs and visiting friends—activities that have always had a positive impact on depression, anxiety, and chronic health conditions.

 Ironically, remote learning did provide some protections for teens, namely against bullying, which is more commonly done in person. The results of one study indicated that online searches for “school bullying” and “cyberbullying” dropped by 30% to 40% in spring 2020 and maintained this level through the following winter.

 As students gradually returned to school, however, internet searches about bullying increased.

Alcohol and marijuana consumption among 12th-graders remained stable during 2020.

 This indicated that even though the pandemic created perceived barriers to access, teenagers could still acquire these substances.

 Nicotine vaping, however, declined from 24% before the pandemic compared with 17%.

A Centers for Disease Control and Prevention (CDC) report in October 2020 acknowledged that virtual education, compared with in-person education, presented more risks to the mental and emotional well-being of both parents and children.

 Children spent less time outside, less time with friends, and less time exercising because of it.

Children in Black, Latino, and multiracial families were particularly impacted, as they were more likely to receive virtual instruction compared with white children.

 Parents of remote-learning children were also more likely to report loss of work, job stability concerns, child care challenges, emotional distress, and difficulty sleeping.

Latino adults reported a higher prevalence of stress in relation to food, housing, and job insecurity.

 Racial tension, protests, and riots added another layer of stress within Black, Indigenous, and people of color communities, where more than half of teens worried about dealing with racial justice issues at school.

Asian Americans and Pacific Islanders were experiencing their own version of racism, as many others ignorantly held them responsible for the spread of COVID-19.

 No less than 81% of Asian Americans and Pacific Islanders felt that violence against them was increasing in 2020.

The pandemic has affected just about every teenager in some way. Cut off from their peers, there was little opportunity to socialize and commiserate in person. It is only natural that young people turned to social media to connect with others. In fact, 36% of teenagers found that social media helped them cope with the pandemic.

Prior to March 2020, 26% of students spent 4 to 8 hours a day on social media.

 That shot up to 39% during the lockdown periods of the pandemic.

 Aware that social media were among the few available ways to connect, many families relaxed their rules on screen time, with 81% saying it helped their children.

 Social media provided teens and younger children with comfort, inspiration, and something to do. Kids learned the latest TikTok dance, perfected making whipped coffee, and collectively laughed as school fun easily transitioned to online platforms.

A survey of teens taken between September and November 2020 revealed that 53% credited social media as “very important” to keeping them connected to friends and family.

 Among individuals aged 14 to 22 years, 43% said social media helped them feel better when they were depressed, stressed, or anxious—up from 27% in 2018.

 It was also where most of them got their news. A 2019 survey discovered that 54% of teens relied on social media and 50% on YouTube for information.

 When the murder of George Floyd and the killing of Breonna Taylor by police ignited racial unrest, teens turned to their phones to keep up-to-date.

But there was also a dark side to social media. A month after police Floyd’s death, the “George Floyd Challenge” encouraged some teens to recreate scenes of the crime and post them on social media. For youth who identified as Black or Indigenous or a person of color, it was a stark reminder of how powerful and hurtful social media can be. According to a survey, 69% of Black youth and 67% of Hispanic youths reported encountering racist content online.

About 74% of youth who identified as lesbian, gay, bisexual, transgender, and queer (LGBTQ) said they encountered homophobic content on social media. Gender and sexual identity were major topics of discussion in 2020, with almost a quarter of youths identifying themselves as some form of nonbinary gender.

 At 65%, LGBTQ youth were twice as likely to report symptoms of moderate to severe depression as non-LGBTQ youth.

 When 92% of them searched for health information online, the most common topics were COVID-19 and anxiety.

Girls continued to be exposed to the harsh side of social media. Body dissatisfaction and body shaming played out online, with 53% of girls exposed to at least 1 form of weight stigmatization.

 Eating disorders were also on the rise. The number of adolescents aged 12 to 18 years admitted to a hospital for an eating disorder increased by 25% from March 2020. This was mainly attributed to girls, who experienced a 30% increase, compared with boys at 4%.

By fall 2021, the prevalence of depression and anxiety in children and adolescents around the world had doubled from prepandemic levels to 25.2% and 20.5%, respectively.

 Symptoms were noted at higher levels later in the pandemic, especially in girls and older teens.

With COVID-19 infection rates constantly fluctuating, schools and communities debated, hesitated, and grappled with the decision to reopen schools for in-person learning. The city of San Francisco had to sue its own school district in March 2021 to force it to open its doors to students, citing a loss in learning and mental health concerns.

When students returned to school in fall 2021, only 31% felt emotionally prepared to socialize in person, 20% felt they would succeed in school, and 28% felt they would be able to focus on learning.

 Adding to the back-to-school jitters, 3 in 4 teens were worried about contracting COVID-19 during in-person school, according to a survey.

Anxiety and depression continue to be the most common mental health conditions among teens, with 1 in 3 adolescents meeting the criteria for anxiety by age 18 years.

 But there is growing discussion over whether the COVID-19 pandemic qualifies as a traumatic event. If so, this will affect how clinicians approach and treat patients.

Posttraumatic stress disorder (PTSD) can occur when people have experienced or witnessed a traumatic event in which lives and personal safety have been threatened. It involves 4 categories of symptoms (

Currently, the pandemic does not quite fit the criteria set within DSM-5. Qualifying traumatic events are generally direct events that happened in the past, and much of the trauma experienced during the pandemic has, instead, been the result of indirect reactions to what might happen in the future.

 For instance, there were teens who lost family members to COVID-19, an event that could meet the standards for PTSD. But what about waking up every day to news that thousands of people were dying from a ruthless virus and that you could be next?

The sheer number of COVID-19 deaths was 4 times higher than the number of American casualties killed in the Vietnam War.

 In the news constantly, COVID-19 dominated our lives and conversations. Teens and adults alike worried that they would either contract the disease or inadvertently infect someone else. Surely this fear—heightened and prolonged as it was—could qualify as a traumatic event.

PTSD’s symptoms of intrusive thoughts and heightened arousal were certainly present.

 One June 2020 survey by the CDC indicated that 26.3% of respondents had symptoms of trauma and stressor-related disorders related to the pandemic.

 Another study found that 13.2% of participants had PTSD symptoms even though their triggering events, such as being in lockdown, did not technically fit the description of trauma.

 Through it all, teens endured the fear, uncertainty, and suffering largely alone, isolated from friends. In fact, during the pandemic, 

 was the strongest predictor of symptoms of PTSD, depression, and anxiety.

In its simplest terms, trauma is what happens when an event challenges a person’s ability to cope. 

 serves as a buffer—a mental fortitude that allows people to bounce back from life’s challenges. It develops over time and is largely modeled and nurtured at a young age by parents and primary caregivers. Resilience involves a number of genetic components and can even be passed onto future generations, with an inheritance range of 33% to 53%.

 Research even suggests that maternal resilience can provide protective factors to children after birth.

During childhood, parents and caregivers can help build this resilience by reassuring kids that they are safe, establishing healthy routines, and regulating their own emotions so they can help their children do the same.

 This reflecting or leading by example was understandably difficult for many families during COVID-19. No one knew what to expect, and the shifting sands of the pandemic created feelings of panic that were hard to control.

Children and adolescents who experience stress early in life are particularly susceptible to psychiatric vulnerability.

How have the past 2 years affected our youth? The full picture is just beginning to emerge.

COVID-19