Paul Rosenfield, MD
The coronavirus 2019 pandemic has impacted people of color disproportionately. SARS-CoV-2 infection case rates, hospitalizations, and death rates among black, Latinx, and Native American populations in the United States are 2 to 5 times higher than among white populations.1 While this disproportionate physical health toll has been well documented, we have limited data on the mental health toll of the pandemic.
On one hand, SARS-CoV-2 has been seen by many as an equal opportunity pathogen, ravaging communities, taking lives, and causing financial and emotional distress for people of all backgrounds across the world. However, in the United States, due to legal, social, and economic inequities across society, as well as disparities in physical health and access to good medical care, black communities have been disproportionately impacted by both economic losses and deaths from COVID-19 directly.2 The intergenerational trauma and systemic racism that black Americans have faced within the past 400 years have fomented conditions that lead to vulnerability within this historically resilient community. The pandemic impact is consistent with the old saying, “When white folks catch a cold, black folks get pneumonia.”
The economic downturn and staggering job losses due to the pandemic have resulted in lost health insurance, financial instability, food insecurity, and loss of housing among those lacking the safety net of savings and family resources. The median net worth of white families (more than $170,000) is nearly 10 times higher than black families (less than $20,000), and black households have been hit harder by downturns, whether in 2008 or currently.3 These stresses and losses increase the risks of depression, anxiety, substance use, and suicide, as well as poor physical health. Black individuals with preexisting mental illness are among the most vulnerable for a myriad of reasons, including greater chances that they are living in poverty and population-dense conditions, or are homeless or incarcerated. Not only do they experience stigma and marginalization related to their mental illness, but also bias and discrimination related to race and class. Further compounding the pandemic stressors are the well-publicized and distressing police brutality incidents that have sparked emotionally charged national protests and a collective outcry against racism and inequality.
Distress is also increased by fears of getting infected, particularly as black Americans and their families are highly represented among essential workers and have suffered more deaths of family and community members.4 They continue to face the highest risk of exposure whether through their work in health care and other essential services, their greater use of public transportation to get to work, or in their homes. In recent surveys, blacks are 3 times as likely to know someone who has died from COVID-19 than whites.5 The personal impact of deaths, whether in family or community networks, have left many to face unexpected loss. The loss of community members, compounded by the relative isolation based on stay-at-home orders and social distancing measures, act as a stressor by limiting access to support systems. These communities typically have strong networks through local organizations, houses of worship, and schools. While many organizations transitioned to remote communication strategies, black individuals with limited resources have less access to smartphones and broadband internet, which impacts their ability to access support and care systems. This undermines a key resilience factor.
Psychological distress for many black Americans often goes untreated and this is another area of disproportionate impact compared to white individuals that existed before the pandemic.6 For instance, 69% of black adults with mental illness and 42% of black adults with serious mental illness received no treatment in 2018. Similarly, 88% of black adults with substance use disorders reported receiving no treatment in 2018.7 Substance use has increased during the pandemic and preexisting trends such as increased drug-induced deaths among Native Americans, blacks, Latinxs, and older adults may only get worse.8
Prior to the pandemic, individuals with mental illness faced many obstacles in obtaining adequate physical and mental health care. While stigma and minimization of symptoms are often identified as significant obstacles for mental health care, studies have shown that cost is cited as the biggest barrier; thus, this impacts poor and historically oppressed communities most.9 Pandemic-related public health measures at times left those most vulnerable without services or on the margins. For many, the period of lockdown was marked by the sudden loss of familiar routes of access to their treatment providers. Clinics and private practitioners switched to remote care only, and outreach teams and case managers/care coordinators stopped making in-person visits, which made it more difficult to monitor and support these patients, leading to greater risk of relapse. Individuals who sought care for the first time or attempted to re-establish care found clinics closed to new referrals due to limited resources. Furthermore, structural barriers to accessing medical care already existed in that black Americans were more likely to be uninsured, not have a primary care doctor, and to live in an underserved area.10,11 Many individuals delayed seeking care, including at times urgent care, for fear of exposure to the virus in hospitals and medical offices.
For those with psychotic disorders, the social distancing may be less distressing, but if they are living in congregate dwellings, they are at higher risk of exposure. Black Americans, including those with mental illness, are also disproportionately represented in prisons, a congregate dwelling where it is difficult to control outbreaks, leaving blacks at disproportionate risk of infection and death. Among homeless individuals or those with unstable housing, who are grossly disproportionately black, there are high rates of mental and medical illness, as well as substance use disorders. They are at even greater risk of contracting COVID-19 and facing challenges in accessing care.12 During the pandemic, homeless individuals in New York were relocated to shelter hotels, which helped decrease crowding in shelters, but for some, created a stress of dislocation.
Among children and adolescents with psychiatric diagnoses or developmental disabilities, the school closures created challenges to accessing their clinical services and limited opportunities for ongoing academic and social development. Data prior to the pandemic, among United States adolescents of all races, show that only one-third receive mental health treatment for their illness. Black adolescents are significantly less likely to receive treatment, and when they do receive treatment, they have less frequent services compared to white adolescents.13 More recently, rates of suicide attempts and suicides have been rising more quickly among black youth for reasons not fully understood.14
Black children and adolescents are overrepresented among families with social disadvantage. The pandemic-related physical health, mental health, and economic and social consequences increased stress in black families. As previously mentioned, black Americans are more likely to know individuals who died from infection with SARS-CoV-2. This includes a disproportionate number of black youths who have experienced the loss of a loved one or member of the community, thus sharing in community grief. Furthermore, vulnerable youths may have adverse experiences in the home. There is a well-known impact of unemployment and increased financial strain on child neglect and domestic violence.15
Issues with pandemic-related access to care also impact socially disadvantaged children and adolescents with mental illness. They have limited access to technology for participating in telehealth and distance learning. An unintended consequence of distance learning is further exacerbation of the achievement gap between black students and other students due to a significant technological gap. For example, not having Wi-Fi access adversely affects distance learning and access to telehealth. According to the PEW Research Center Data, an estimated 35% of low-income households with school-aged children do not have high speed internet, whereas among middle class and affluent families an estimated 6% of households with school-aged children do not have high speed internet.16
Opportunities to intervene;Build trust and access. Discriminatory and exploitative behavior from the medical establishment toward black Americans throughout American history has led to understandable distrust among black communities. Efforts to deal with the pandemic within this historically oppressed group requires acknowledging the mistreatment the black community has faced, ensuring adequate access to care, and demonstrating that unethical experimentation will not be tolerated. As the world anticipates a vaccine for SARS-CoV-2, the expectation that such a vaccine would bring a sense of normalcy is a desire that many hold; however, a recent study reported that while “68% of Whites say they would ‘probably or definitely’ get a vaccine if one were available, only 40% of Blacks say they would.”17 Blacks and other non-whites should be recruited for vaccine trials to ensure the vaccine is effective in diverse populations and to build trust in its utility and safety.18 Addressing distrust about the medical and research systems can promote improved adherence to public health guidelines, thereby minimizing the challenge that the medical community faces in developing and implementing treatment modalities. Ultimately this can also lead to less emotional distress, depression, anxiety, and experiences of exclusion.
Communicate with Black communities and build social support. Political and medical leadership need to engage stakeholders and obtain critical input from schools (from elementary to undergraduate), fraternities/sororities, houses of worship, and community centers about identifying solutions to support the community. They can ensure that critical messages about science, health, safety, and resources are communicated through trusted community networks and sources. Community leaders can help spread vital information about health or vaccines.
Balance risk and benefits of public health policies. While social distancing has been an essential tool in preventing the spread of COVID-19, there is an adverse impact on the mental health and emotional wellbeing of both adults and children from the associated loss of in-person contact. These should be addressed by creating other opportunities for community connections online or in outdoor spaces and improving services and safe spaces for children to allow for learning, support, and social engagement, and to allow parents to return to work.
Ensure access to services. Early federal and state legislation allowed for revised regulations around telehealth and HIPAA to expand access to care by including telephonic contact and less secure communication technologies. This has helped provide access to care without in-person contact and has worked well to decrease the disparity in access to care due to limited technology access.19 However, patients with internet access can obtain virtual care and maintain treatment, but those without access are at a disadvantage. It is critical that we expand telehealth more extensively and permanently and maintain waivers for telehealth options. Also, we must provide secure broadband access to all individuals in light of limited access to shared Wi-Fi networks during the pandemic. Clinically, we should make accessible treatment modalities to promote resilience, such as the following: coping skills training, stress management, relaxation training, assertiveness training, and stress inoculation training. On a broader scale, we should advocate for universal access to insurance.
Improve existing mental health programs to assist vulnerable populations in various settings. Services for people with mental illness in prisons, homeless shelters, public clinics, and community outreach teams should be adequately funded and staffed to provide the high-quality care needed. For services in the community, clinical teams should be educated about personal protective equipment and have sufficient supply to allow more in-person visits at home or in outdoor spaces. Of even higher impact would be to reform the criminal justice system in order to reduce overall rates of incarceration and the criminalization of people with mental illnesses, and to provide more affordable and supportive housing to people with mental illnesses living in poverty.
Address policies and systems that maintain structural racism. There is an urgent need to address racism in society and the medical care system. A more diverse medical workforce, providers who are trained to be anti-racist, universal access to medical care, and efforts to reduce disparities will further this work. The Centers for Disease Control and Prevention and local health departments should include race in their data to study the impact of the pandemic on mental and physical health in order to better identify the disparities and areas for intervention.
In summary, the COVID-19 pandemic has affected the lives of all Americans, but some have been more adversely impacted. The social disruption and losses have generally impacted black Americans more severely than whites due to a host of primarily social factors that cause inequity in the United States. Longstanding effects of racism and racist policies must be addressed in order to improve the mental health of Black people in general and those with mental illness particularly. The pandemic has shed a clear light on these challenges and, with sustained efforts to fight racism, may help lead our society to increased empathy and action to reverse racial bias and dispari