PORTLAND, Maine —
Buffy Johnson hasn't strayed far from home for more than two months.
She plays with her dog in her yard but doesn’t visit stores unless it’s absolutely necessary.
“If I have to, I instantly start having chest pain and anxiety,” she said. “I’m walking through the grocery store and I have to keep telling myself I’m OK like 500 times,” Johnson said. “Every step I take, in my brain it’s like, ‘I’m OK, I’m OK.’”
“The anxiety of the unknown – ‘Am I going to get this? Am I going to die from this?’ – that’s also been a really scary piece for myself and others,” she said.
Adjusting to an uncertain, ever-changing world is triggering nearly every emotion imaginable: Horror at the national death toll, panic about catching the coronavirus, frustration about getting groceries and other essentials, and grief and sadness for the world that was.
As public health officials wage war against the COVID-19 virus, though, mental health experts are warning of a second, impending health crisis as pent-up Mainers begin to emerge from their homes and the emotional effects of the pandemic – and its isolation, worry, and grief – become visible.
On May 11, the National Alliance on Mental Illness (NAMI) urged advocates to contact Congress to urge action prior to “a mental health crisis that the U.S. is not prepared for” including anxiety, depression, trauma, and substance abuse are all on the rise, and “huge increases in unemployment increase the risk of suicide.”
A tracking poll by the Kaiser Family Foundation in late March found nearly half of the people polled in the United States said COVID-19 was harming their mental health, the Washington Post reported, and a federal substance abuse and mental health hotline showed an increase of more than 1000 percent in April compared with 2019.
In a state that already sees one person die by suicide every 36 hours, the coronavirus is poised to strike Mainers' mental health with equal vengeance, targeting a variety of high-risk groups with potentially deadly consequences.
“We are very concerned about really the effects of this pandemic to peoples’ psychiatric well-being for decades to come,” Dr. Robyn Ostrander, interim chief of psychiatry at Maine Medical Center, said.
"People don’t have that same structure. There’s not the same certainty," said Jenna Menhert, executive director of NAMI Maine. "Knowing what’s coming is really helpful for people’s mental health. So all of that is a challenge for everybody’s mental health. Social connection, things you’re looking forward to ... all of those things have been completely thrown to the wind."
In the months since the COVID-19 pandemic reached the state, Mainers have been visibly struggling, experts say.
Calls to the Intentional Warm Line have increased an estimated 57 percent since the beginning of the pandemic, and people spend 71 percent more time on the calls, according to Sweetser spokeswoman Susan Pierter.
Maine DHHS Commissioner Jeanne Lambrew said at a press briefing last week that more people have called the 211 line regarding mental health concerns, and the state had seen a small increase in the number of deaths by suicide and a decrease in in-person mental health visits.
The Augusta Police Department has seen dramatic increases in calls for domestic violence and mental health compared to this time last year.
Calls for domestic violence during March and April were up 19 percent and mental health crisis calls were up 31 percent, Sgt. Jesse Brann said. Calls for overdoses were up 61 percent.
Psychiatric evaluations were "extremely low" through the month of April at the 18 emergency rooms Acadia Hospital Consult Service conducts assessments in, but then "increased substantially" in early May when Gov. Janet Mills' executive order stretched into another month.
"That was a game-changer for everyone," said Jamilyn Murphy-Hughes, a licensed clinical social worker and clinical director of Acadia Hospital Consult Service.
The Opportunity Alliance, which contracts with the state of Maine to provide mental health and other services, has continued to enroll "dozens" of people each week into substance abuse programs and children's services, according to President and CEO Joe Everett, as well as administer a rental assistance program, help people find food and diapers and potentially find track phones to allow access to telehealth.
"People are so confused and scared and anxious and depressed," Everett said. "And increased suicidal ideation -- not that they have the intent, but they're so overwhelmed because they already have a complicated life ... the people we support live with such struggles anyway ... the playing field is so unfair."
As the threat from the pandemic increased, NAMI Maine and other agencies have raced to increase the resources available to those struggling with mental health. It's not an insignificant number: According to the Substance Abuse and Mental Health Services Administration, 63.8 million adults in the U.S. had either a substance use disorder or a mental illness in the past year, and about 12 percent, or 7.9 million people, experiencing both.
Mehnert said NAMI Maine is focusing its efforts on several high-risk groups.
Adolescents and children
Perhaps no one has seen as much disruption in their lives as children and adolescents. With school canceled for months, students are adjusting to completing assignments at home, but many have lost not only the social activity, but the structure, sources of food, physical and mental health care, supports such as speech and behavioral services, and in some cases the only day-to-day check-in with an adult outside their home.
"That adolescent brain we know is not fully mature until 25 and the last part of the brain that develops is the executive function, so the ability to say, 'This will end, this too shall pass' is not actually fully developed," Mehnert said. "So when a 16-year-old feels like it’s the end of the world, they’re not just being a drama king or queen. Their brain doesn’t actually have the capacity to process past that."
Because adults have never experienced anything like this pandemic, many are ill-equipped to offer perspective or comfort.
Ostrander said quarantine can result in multiple mental and physical health issues for children and adolescents.
“Children being put in quarantine has significant mental health effects that linger as well,” Ostrander said. “As you can imagine, children’s lives have been completely upended and it’s harder for them to put in context. Your world is completely shut down. You’re being separated from all of your normal life experiences. You’re not seeing your friends, you’re not in sports, you’re not in clubs … You’re also at the same time potentially in financial distress. Children who are in less-safe homes are stuck there with families who are multiply stressed ... childhood abuse and neglect goes up in times of incredible stress on parents."
“Now that we have people that are so isolated at home, there’s been some preliminary evidence suggesting that we’re having much more difficulty with domestic violence and with child abuse,” said Dr. Ed Pontius of the Maine Medical Center Department of Psychiatry and the Maine Association of Psychiatric Physicians.
Greg Marley, clinical director and director of suicide prevention at NAMI Maine, said school staff continues to provide support just as they continue to teach.
"I was talking to a social worker last weekend and she said, 'Our goal in this school is to reach every kid every week,'" Marley said. "It might be through email or text, following up with a Zoom meeting or face to face, we want to reach every kid, every week."
NAMI Maine has established a Teen Text support line in response to the crisis.
Ostrander suggested parents or caregivers create with children a time capsule of the COVID-19 era in a shoebox, to give context to the shut-down and instill the idea that it will end.
"And [someday] we'll say, 'Oh my gosh, remember that summer,'" she said. "It creates this idea that this is a moment in time. It might be a long moment, but it's not forever."
"Not knowing what’s going to come next ... certainly, we don’t either, but we have a better idea," she said. "At least we can manufacture for ourselves some even fake sense of control over our destiny. Children can’t."
ACES (Adverse Childhood Experiences)
Also at risk are Mainers -- including children -- affected by childhood trauma, or "adverse childhood experiences." Maine has a higher-than-average national rate of childhood trauma, which studies show has a direct correlation to adult health.
Isolation, lack of support, and more time alone with their thoughts can trigger flashbacks and nightmares if someone has not processed a past experience, Mehnert said.
“Being alone with your thoughts can be really overpowering, especially if you’ve kind of hidden something away in there and haven’t processed it and worked through it,” Mehnert said. “Because when we have this kind of time, anything that’s hidden away inside is going to come to the surface -- whether we’re talking about kids or adults, but definitely for kids who’ve had traumatic events because we always think, ‘Oh they’re fine’ because they just keep going. But right now, they’re not.”
Substance use and mental illness
People struggling with substance abuse and mental illness are at risk, in part because their hard-won coping strategies may now be insufficient.
Nicole Foster is director of peer services for NAMI Maine and oversees the Waterville Peer Recovery Center for people battling major mental illnesses.
Many peer centers have transitioned from in-person support meetings to Zoom or video meetings, which work for some, she said. But for those whose homes are not safe, or whose trauma took place at home, being “stuck” for an extended period of time is akin to torture. Some members are dropping out as the pandemic continues.
Foster said many counted on the groups for not only therapy but for structure, a hug, and a connection.
“They were finally able to come to a space to be able to open up and connect with other people,” she said. “Then we have something like COVID happen. It’s really challenging for them,” she said.
Foster also struggles with major depressive order, generalized anxiety disorder, and post-traumatic stress syndrome, and has found the recent isolation difficult.
"I can go out. I can go for walks. I can hike, but ultimately if I'm in the house or I'm alone on a hike, the only thing I have with me is my head, which I can't turn off," she said. “That's really a struggle right now ... it's becoming too much sometimes.”
Maine Men at Risk
Men in the United States die by suicide 3.5 times more often than women, which Menhert said can be attributed in part to a culture, particularly among those between the ages of 40 and 60, in the traditional male role of “breadwinner."
"Middle-aged men die by suicide at a much higher rate than any other population," Mehnert said. "I'm talking about our fathers, husbands, brothers ..."
But as the unemployment rate increases, that role is jeopardized, as is a critical element of some mens’ identity.
Most at risk are men who work more physical jobs, such as fishermen, shipbuilders, loggers, construction workers, and farmers, Mehnert said.
NAMI is working with the Maine Coast Fishermen's Association on a mental health wellness blog for fishermen -- a project that was underway even before the losses of the pandemic as fishermen responded to the collapse of the seafood industry.
"It’s really taking a toll on a lot of us," Alex Todd, a commercial fisherman from Chebeague Island and MCFA board member said in a release. "I think even just letting people know that some fishermen are pretty anxious and depressed right now is important.”
Mehnert encouraged men struggling with effects of the pandemic to visit ManTherapy.org, a website developed by a graduate of Bowdoin College.
"We can't say to middle-aged men, 'Go to a therapist,' so we need to find a way to reach them," she said. "They developed a very campy, very funny website" aimed at helping that group.
Among those at greatest risk, both for contracting COVID-19 and suffering mental health effects, are those on the front lines of the battle against the coronavirus: emergency medical personnel, law enforcement, and healthcare workers.
Twenty percent of all cases of COVID-19 are in healthcare workers, according to Pontius.
"People we're working with, they're struggling," Dr. Tom Kivler, senior director of Behavioral Health at Mid Coast Hospital in Brunswick, said. "Providers who are [themselves] high-risk and have their own worries are still doing their jobs."
Dr. Eileen Barrett, an associate professor of medicine and academic hospitalist at the University of New Mexico who worked in Sierra Leone during the Ebola outbreak, told the Journal of the American Medical Association that healthcare workers are dealing with the same uncertainty and anxiety as everyone else, as well as the suffering of their patients and peers, guilt when a patient doesn't do well, and trauma of knowing they risk their own health and that of their family.
To address this, NAMI Maine and various hospitals are conducting "critical incident" debriefings for healthcare workers and other first responders.
Hannah Longley, director of community programs at NAMI Maine, conducts training on "critical stress," which affects the brain and body.
“We're experiencing it as a society,” she said.
"Critical stress," or stress for a prolonged period of time, forces the body into "flight, fight or freeze," she said. "Our bodies will overreact and people will feel a lot of physical symptoms. They may start feeling their chest tightening, their breathing picking up, blood rushing to their extremities, they may lose fine motor skills."
Barrett said frontline workers should do their best to get adequate sleep, eat well, exercise, and to “cultivate a sense of self-compassion so [they] aren’t too critical of [them]selves.”
Maine DHHS and the Maine CDC worked with Pontius and other organizations to create the Maine FrontLine WarmLine, which was launched in late April. More than 100 volunteers now work to cover three shifts every day, ready to provide mental health support for the state's 44,000 frontline workers.
"The calls that we have had have been from frontline people in really great distress," he said. "We're seeing clear signs of stress from their unique contact -- particularly that it continues with no certainty about anything approaching an end."
Kivler said he's bracing for a post-pandemic surge in mental health crises like those experienced throughout history. Right now, people are still just “getting through,” he said, likening the experience to a soldier fighting during a battle.
"If you're quarantining, you don't have to get out of bed, you don't have to be as functional," he said. "A lot of people are home, they don't have great coping skills, they're not keeping on a schedule, they're not getting out of bed, maybe they're drinking more than usual. Then, once they have to go back to work, they're not functioning and it shows."
“Disaster-related stress can become more acute in the five to eight months after a disaster,” Dr. Jessica Pollard, director of the DHHS Office of Behavioral Health, told the Bangor Daily News.
DHHS declined to make Pollard available for comment despite four attempts by NEWS CENTER Maine.
"Broadly, we're concerned because one of the primary risk factors for suicide is social isolation," said Sheila Nelson of the Adolescent Health and Injury and Suicide Prevention Program at the Maine Center for Disease Control. "It's this contradictory thing. There's this public health response that has to happen to keep people healthy for sure, but we don't know what the consequences will be for peoples' well-being. It's still too early to tell."
But it's the skyrocketing unemployment rate that has others concerned.
Since March, Maine's unemployment rates have more than tripled, jumping from 3.2 percent to more than 10.6 percent.
The estimated number of nonfarm jobs decreased by 98,400 in April -- equivalent to one out of six jobs lost in Maine, according to the Bangor Daily News.
The job loss -- 98,400 nonfarm jobs -- was the largest on record for a one- or two-month period and translates to one out of six jobs lost in Maine.
And while research is unclear as to whether natural disasters trigger an increase in the suicide rate, the impact of a downturn in the economy is much plainer. The New York Times reported that while the rate has increased steadily by 35 percent since 2000, the rate of increase doubled following the 2008 economic decline.
In a letter published this month in The Lancet, Swiss researchers reported that data from 63 countries shows shows "the suicide risk was elevated by 20-30 percent when associated with unemployment during 2000-11 (including the 2008 economic crisis)."
Using that model, along with data from the World Bank, the journal said a decline of 5.3 to 24.7 million jobs as a result of the COVID-19 pandemic would likely increase the number of suicides by between 2,000 and nearly 10,000 per year.
Ostrander said the "really unprecedented, unbelievable" increase in unemployment is extremely concerning when considering the potential for increased deaths from suicide.
"For everyone in the family, there's just intense uncertainty about economics ... and that is very concerning to us," she said.
“The impact of social isolation is a here and now challenge,” Menhert said. “The long-term challenge is how do we bring back the economy as a suicide prevention strategy.”
SHIRTTAIL (suicide hotlines, etc.)
FrontLine WarmLine, phone support service for health care professionals, EMS personnel, law enforcement and other front line responders in the pandemic. 8 am-8 pm, 7 days a week, (207) 221-8196 or 866-367-4440
NAMI Maine Help Line 800-464-5767 (Press 1)
NAMI Maine Crisis Text Line Text HOME to 741741
Trevor Project LifeLine 866-488-7386
Trevor Project Text Line Text START to 678678
Intentional Peer Support Warmline to speak with staff who have lived experience with mental health conditions: 866-771-9276
24/7 Statewide Crisis Line 888-568-1112
24/7 Peer Support Warm line 866-771-9276
24/7 National Suicide Prevention Lifeline 800-273-TALK (800-273-8255) / suicidepreventionlifeline.org
SAHHSA Disaster Distress Helpline 800-985-5990 disasterdistress.samhsa.gov
SAMSHA National Helpline 800-662-HELP (24/7/365) samhsa.gov/find-help/
Teen Text Support Line 207-515-8398 (TEXT)
Disaster Distress Helpline: free, 24/7 support by calling 1-800-985-5990 or text "TalkWithUs" to 66746 | also as Disaster Distress Helpline information (PDF) 03/19/2020
Through These Doors domestic violence helpline 800-537-6066
How to Support Grieving Youth: https://www.maine.gov/suicide/parents/support.htm