Anxiety and Depression in COVID-19 Times

1. Introduction

Much is said about the epidemic of mental problems due to the pandemic caused by COVID19, particularly anxiety and depression. People have difficulties in dealing with confinement and more than that, facing excessive information - usually causing fear and panic. The scenario completes the fact that a very large number of families lost family members and acquaintances as a result of the complications of COVID19 [1, 2, 3, 4, 5, 6].

But beyond all that, the world population, in particular the western one, has experienced a radical change in living conditions, life expectancy, mobility and access to information without precedent. For those who did not make this reflection, in the year 1900 - that is 121 years ago - there were no radio broadcasts, the telephone was a novelty and rare people had access. The automobile was being invented and there was no aviation. More than 90% of the western population knew nothing more than 10 km from their place of birth. And the vast majority were illiterate, unable to read simple texts or understand the context in which they were inserted.

Over these 121 years, the exchange of information has become increasingly accelerated and people have come to consider formal education an essential need and today it is mandatory in most of the western world. But this is not linear and even in developed countries there are many people who have difficulty interpreting texts and information, dealing with divergent information and knowing how to separate it by assessing what is relevant is even more complex. All of this is already a powerful stressor, generating feelings of inadequacy and difficulties in adapting.

With the emergence of the pandemic, the first movement was one of denial - both by governments and the population. But the bill came heavy, Italy, Spain, France, Belgium and England had an explosion of cases in the beginning of 2020, with many deaths and an inability of the health sector to offer an adequate response - not to mention the mortality of health professionals, generating more care deficit.

This, plus the action of the media, which dedicated a huge portion of its programming to address the issue, generating stories that scare and misinform more than anything else. First, doctors and scientists had no appropriate answers to offer, and speculation only served to increase anxiety. Secondly, the lack of consensus on the best attitudes to be taken and what response should be given has generated a complex and certainly inconclusive debate, as there was no experience and scientific knowledge to support the decisions [7].

2. Anxiety

By definition, anxiety is the suffering caused by the anticipation that something will happen and people suffer from it, losing sleep, being afraid to perform tasks or being exposed to situations that would be part of their lives.

DSM-5 [8] defines it according to the following criteria:

1. “Excessive and inappropriate fear or anxiety for the individual’s level of development in relation to his separation from those to whom he feels attached, evidenced by at least three of the following circumstances:

   1. Excessive and recurring discomfort when a separation from home or the closest figures is anticipated or experienced.

   2. Excessive and persistent preoccupation with the possible loss of the most attached figures or who may suffer possible damage, such as illness, injury, calamity or death.

   3. Persistent and excessive concern about the possibility that an adverse event (for example, getting lost, being abducted, having an accident, getting sick) will cause the separation of a highly attached figure.

   4. Persistent resistance or refusal to leave the house, go to school, work or elsewhere for fear of separation.

   5. Excessive and persistent fear or resistance to being alone or without the most attached figures at home or elsewhere.

   6. Persistent resistance or refusal to sleep outside the house or sleep without being close to a figure of great attachment.

   7. Repeated nightmares on the subject of separation.

   8. Repeated complaints of physical symptoms (eg, headache, stomach pain, nausea, vomiting) when separation from the most attached figures occurs or is expected.

2. Fear, anxiety or avoidance are persistent, lasting at least four weeks; in children and adolescents it is usually six.

3. The disorder causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning.

4. The disorder is not best explained by another mental disorder, such as refusing to leave the house due to excessive resistance to change in an autism spectrum disorder; delusions or hallucinations related to separation in psychotic disorders; refusing to go out without someone you trust in agoraphobia; concern about health problems or other harm that may happen to close people or other significant people in generalized anxiety disorder; or worrying about having a disease in the anxiety and illness disorder”.

At a time when there was persistent talk about the death of many people, the possibility of contagion and the need for social isolation, it is easy to imagine that anxiety symptoms become common, and people who are prone to develop pathological symptoms related to this feeling.

3. Depression

It is a defense mechanism of the brain that, losing the perspectives of an organized and structured life, descends to the depths of its interior, leading individuals to close themselves in their inner worlds, not always with pleasant memories and experiences. This can lead to isolation and feelings of worthlessness, with ideation of death. But the process is usually self-limiting, tending to spontaneous recovery in a period of 6 to 12 months.

DSM-5 [8] defines it according to the following criteria:

1. “Five (or more) of the following symptoms were present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is (1) depressed mood or (2) loss of interest or pleasure.

   Note: Do not include symptoms that can be clearly attributed to another medical condition.

   1. Depressed mood most of the day, almost every day, depending on whether you get subjective information (eg, you feel sad, empty, hopeless) or other people’s observation (eg., it is observed weeping). (Note: in children and adolescents, the mood can be irritable.)

   2. Significant decrease in interest or pleasure in all or almost all activities most of the day, almost every day (as can be seen from subjective information or observation).

   3. Significant weight loss without diet or weight gain (for example, more than 5% change in body weight in one month) or decreased or increased appetite almost every day. (Note: in children, consider failure for expected weight gain.)

   4. Insomnia or hypersomnia almost every day.

   5. Psychomotor agitation or retardation almost every day (observable by others; not just the subjective feeling of restlessness or slowing down).

   6. Fatigue or loss of energy almost every day.

   7. Feeling of worthlessness or excessive or inadequate guilt. Self-reproach (which can be delusional) almost every day (not just self-censorship or guilt for being sick).

   8. Decreased ability to think or concentrate, or to make decisions, almost every day (from subjective information or observation by others).

   9. Recurring thoughts of death (not just fear of death), recurring suicidal ideas without a specific plan, attempted suicide or a specific plan to carry it out.

2. Symptoms cause clinically significant distress or impairment of social, occupational, or other important areas of functioning.

3. The episode cannot be attributed to the physiological effects of a substance or other medical condition”.

   Note: criteria A - C constitute an episode of major depression.

   Note: Responses to significant loss (eg, grief, financial ruin, losses due to a natural disaster, serious illness or disability) can include feelings of intense sadness, rumination about loss, insomnia, loss of appetite and weight loss listed in Criterion A, and can simulate a depressive episode. Although these symptoms may be understandable or considered appropriate for the loss, the presence of a major depressive episode, in addition to the normal response to significant loss, should also be considered carefully. This decision inevitably requires clinical judgment based on the individual’s history and cultural norms for the expression of distress in the context of loss.

4. The episode of major depression is not best explained by a schizoaffective disorder, schizophrenia, a schizophreniform disorder, delusional disorder or other specified or unspecified schizophrenia spectrum disorder and other psychotic disorders.

5. There was never a manic or hypomanic episode.

   Note: This exclusion does not apply if all episodes of the manic or hypomanic type are substance-induced or can be attributed to the physiological effects of another medical condition.”

The feelings triggered by the orientation to isolate oneself, to move away from loved ones and especially the loss of love and acquaintances to COVID19 can lead to feelings very close to the situation described as depression. Not to mention the modern language, which calls all sadness a depressive episode or depressed mood.

4. Reflecting on the functioning of our brain

The human brain is apparently redundant, as it has one side focused on logic and the control of volitional functions, but the other side of the brain works by understanding contexts and is based on feelings and emotions - which the logical side usually cannot explain. This concept, developed by Watzlawick [9], helps to understand people’s difficulties in controlling their feelings and why complex contexts, such as the one experienced during the COVID pandemic19, generate responses of suffering and anguish, sometimes leading to the emergence of pathologies.

The rapid changes in the way of living, which have occurred over these years, alone have already caused adaptive disturbances. This led to changes in family structures, with greater absences from adults - necessitating the development of work activities to support families. This led the elderly or institutions to take care of the education and training of children and adolescents - without them having a parental presence. Add to that the revolution caused by the mass media and more recently by access to the internet.

Social models were diluted and behaviors became more related to external models, living and acting in different contexts. This creates a complex stress context that is difficult to interpret by people and families, and the systemic context approach [10] is central to understanding adaptation difficulties.

Considering the model proposed by Grassano [11] it is from adults that one learns to be a person, to survive in the world, it is from this primary coexistence that the individual develops and he learns to relate to his surroundings and to have stable social relationships and balanced. The loss of this benchmark generates insecurities that are profound and are often not easily understood by people.

The lack of understanding of feelings and emotions - explored by Watzlawick [9] - makes personal, family and peer conflicts difficult and is often not even properly perceived. And this without the presence of the pandemic.

With the advent of it, the situation of anguish with the illness and death of acquaintances, friends and relatives, people seek internal support to deal with the pressures. But what if these are not solid? How to face loneliness and isolation, especially if you do not know how to deal with your own emotions? What strategy to develop to deal with the fear of falling ill, of losing loved ones, the fear of losing your job or business?

Abruptly, the pandemic created the need to look within oneself, to reflect on the choices and possibilities. For many, this rethinking in life is healthy and opens up horizons to seek more suitable paths to dreams and perspectives, but for people who cannot be just with themselves, this is frightening.

For them, living depends on third parties, and the absence - either by distance or by illness or death - is traumatic. It causes suffering and insecurity that can lead to the development of mental illness.

In a very digital world, like the current one, relationships and experiences are often fictitious - people play games to get in touch, post their presence in places they do not know and talk to strangers about their own or third party fantasies. This world turns out to be a house of cards, and the pandemic makes isolation and fear bring the castle down.

5. Dealing with information overload

The first step, which is fundamental to controlling feelings of insecurity, anxiety and depression, is to reduce the consumption of information. As much as possible using the most reliable and the minimum necessary to orient yourself.

The massacre of the media when talking all the time about the spread of the pandemic, about the numbers of serious cases and deaths, only increases the panic. It does not guide or allow the stabilization of people in the search for suitable alternatives to move on with their lives.

The pandemic is complex due to its high transmissibility, although the rates of serious cases and deaths are not very high - as it has a very high volume of people, it ends up generating frightening numbers. This causes overload of health services and restriction of care. To increase the complexity, many health professionals fell ill and several died from the disease.

Today, more than a year after the onset of the condition in Wuhan - China (12/2019), there is still no adequate response and studies on different therapeutic approaches still do not indicate an appropriate treatment.

Even mass vaccination, a response proposed by the World Health Organization [12], generates insecurities - typical of the rush to develop immunizers quickly and without the necessary studies. This also generates the refusal of many to become immunized.

It is this conflict of information that the media exploits - often even with political overtones, supporting or discrediting government officials. The more people read this type of information, the more insecure they become and this makes the environment prone to suffering and anxiety. For this to evolve into mental suffering is a step.

The selection of less sensational sources is a necessary path, and the need to seek confirmation of data, avoiding the magnification that ends up occurring within social networks. And the people who take refuge in these networks, for not being able to deal with their moments of isolation, are victims of this unbridled exchange of dubious and alarming information.

Social networks deserve a separate paragraph. The quick access to the networks made the relations progressively more virtual, reaching absurdities of people in the same room exchanging messages over the networks instead of talking. This cooling of interpersonal relationships, generates the need to be accepted and supported by virtual friends - often unknown and in no way significant in real life. But these virtual contacts end up being artificial life and the cause of many to despair.

It is essential to search for real contacts, even if virtual - with real people who have meaning in people’s lives. And this first strategy is necessary to maintain balance and mental health in a time of collective stress. Listening to people and dealing with real consolation when people close to them eventually fall ill or perish is essential for the emotional maintenance of the population.

People’s credibility must be valued, and if there are people who are very anxious or who propagate dubious information, it is essential that this is worked on to keep the group of relatives and acquaintances stable and healthy. Seeking balanced and well-informed references helps to keep this under control.

Studies about how does emotions had been built show the complexity of paths, and that an answer flashes when it had been provoked, but when it starts, it is out of control [13].

6. Anxiety and depression in times of pandemic

The human being is gregarious, by definition, has difficulties in dealing with loneliness and needs to work on his self-knowledge to become more independent.

But the accelerating changes of the past 120 years have slowed down many processes. It is more and more frequent to see adolescences extending to 30, and sometimes more. People are unable to become autonomous, living with their parents and not assuming their role as adults. They find it easier to live with their mothers who pamper them with favorite foods and taking care of their rooms and clothes as if they were still children.

This makes establishing mature relationships with peers and loves become difficult and at any difficulty people escape to their comfort areas, without learning to deal with the difficulties that life presents, or even accepting that relationships with other people go through sharing feelings and difficulties and giving in is essential for harmony to be developed.

In the present situation, in which the pandemic generates many uncertainties, this adolescent attitude - in which the consequences of the actions taken are not foreseen, in which the comfort of protectors who welcome fears and insecurities is sought, it is very easy to develop symptoms.

Developing autonomy is fundamental and the approach to people who show symptoms must start by understanding the stage of personal development that the person presents, their surroundings - including family and personal contacts. According to Sluzki [14] realize how is the people’s social network, its functionality and balance helps to perceive the resistance to the aggressions that the environment offers. The work of strengthening connections and expanding networks helps to maintain health, and is essential to reinforce the emotional balance of people who have symptoms.

Encouraging conversation about signifiers - identifying weaknesses, such as virtual contacts with people who are physically unknown or very distant, favors the person to identify their needs and seek a more balanced network. Within the conditions caused by the pandemic, it is essential to recognize that very fragile networks will have difficulties to be expanded, but even so, the recognition of the weaknesses and the work for this to become a goal, makes life more concrete and reduces the risk of becoming ill.

Personal development failures, resulting from the absence of more significant people during childhood and the weaknesses in structuring concrete and healthy connections are one of the essential difficulties to be faced. But as the problem recognition block exists, being inherent to the emotional side, a conversation is essential in which these factors are explored.

Watzlawick [9] presents us with the difficulties to access deep areas of the emotional side and how people react, denying problems and difficulties. How to explore this is the key to care without the use of drug therapy, which can hinder a more adequate solution - making people dependent on drugs or feeling unable to face the problems that life presents.

Using a protocol developed by Schutz [15] and adapted by Doherty and Colangelo [16] for health interventions, it is possible to explore the forms of communication between people, how they perceive themselves within their different groups and how this defines the way of interacting.

Exploring how the person perceives his communication, how much he perceives himself heard and understood opens the door to the emotional side. By adding questions about how central (or not) the person perceives herself in her own life, it allows deep feelings to spring up. Within this context, the social network is being explored, and the reinforcement for understanding their own uncertainties and difficulties for true relationships. The flaws in the construction of personality, consequence of the lack of models, become apparent, making a more curative and constructive approach possible.

It is from these keys that it is possible to reduce the feelings of fear, anxiety and worthlessness, which are often characterized by the pathologies described as anxiety and depression.

Once the difficulties are identified, it is necessary to reframe the difficulties so that the potential and competences are perceived. Strengthening resilience and helping to improve symptoms.

7. Conclusion

Working in a time of extreme pressure, either due to the volume of cases and mortality associated with them, or due to pressure from the media and the population itself, frightened by the proportions of the situation, is not an easy task.

The search for viable alternatives to support the stress situations generated requires creativity and the ability to find collective and applicable solutions - as much as possible - via mass communication or in group activities. Seeking to guide the population on the different ways to better deal with social isolation, with care to avoid contamination of their own - and of third parties, in addition to stimulating the search for alternatives to obtain the most efficient and soonest possible immunization.

But when the need for individualized care arises - it is central to seek a holistic approach, using a systemic approach and deepening the study of the emotional side of patients - in order to give transparency to the deep reasons for fears.

The reframing of skills and ways of dealing with past problems will offer the possibility to find appropriate responses to the present situation. That will allow an ethical answer, respecting the history of the individual and strengthen their on capacity to face challenges.