Original Article Written By Stephanie Innes
According to a World Health Organization scientific brief released in March 2022, the global prevalence of anxiety and depression increased by 25% during the first year of the pandemic. A meta-analysis from Canadian researchers published on March 8 of this year in the BMJ Journal suggests the mental health effects of the pandemic were minimal and "not statistically significant," though that conclusion has garnered some public criticism.
Arizona shows several indicators of distress and rising mental health needs, including higher numbers of people seeking free grief support in groups offered by the state's largest hospice organization; consistently high call volumes from Arizonans to the national 988 suicide hotline and a statewide crisis line; and state data that shows suicides in Arizona reached a 12-year high in 2022.
Evidence indicates that substance use disorder, which is often exacerbated by loneliness, untreated mental illness and unresolved trauma, rose during the pandemic.
Deaths from opioid overdoses in Arizona increased by 55% between 2019 and 2021. In 2021, 2,015 opioid overdose deaths were reported statewide, or an average of five per day.
Citing an "alarming rise" in mental health problems, combined with a shortage of mental health providers, the University of Arizona College of Medicine Tucson on March 11 hosted a conference titled "Psychiatry for Non-Psychiatrists."
"Given the increase in clinically significant depression, anxiety, addiction, suicidal ideation and behavior, and trauma associated with the pandemic, training primary care doctors in evidence-based psychiatric care is needed more than ever," said Dr. Jordan Karp, chair of the UA College of Medicine Tucson's Department of Psychiatry.
Karp noted that the national nonprofit organization Mental Health America in its most recent rankings placed Arizona among the worst states in the country for mental health because of its high prevalence of mental illness and low levels of access to care. The report was based on 2019 and 2020 data from the federal Substance Abuse and Mental Health Services Administration.
The 2023 State of Mental Health in America report, released in October, ranks Arizona 49th out of 50 states and the District of Columbia in a ranking from best to worst for mental health. Oregon was 50th and Kansas was 51st. Wisconsin ranked No. 1.
The indicators in the report where Arizona fared worst were its percentage of adults with serious thoughts of suicide, its ratio of mental-health workforce availability and a high percentage of adults with any mental illness who reported that they were not able to receive the treatment they needed.
In the U.S., there are 350 individuals for every one mental health provider, the Mental Health America report says. In Arizona, the ratio is 660 to every one mental health provider, the report found.
Data from Tempe-based Solari Crisis & Human Services shows combined calls to a statewide crisis line and to the national 988 Suicide and Crisis line topped 40,000 in January, which was the highest level in four months. The most common reasons for calling are related to self-harm and suicide.
A crisis line solely for Maricopa County managed by Solari went from dispatching a mobile mental health crisis team an average of 1,650 times per month in 2020 to an average of 1,948 per month in 2021 and then to an average of 2,270 per month during the first nine months of 2022.
People who experienced serious COVID-19 illness may be more vulnerable to mental health problems. Researchers from Iceland published a study of people in six countries in the journal The Lancet in 2022 that found those who were bedridden with severe COVID-19 had an increased risk of depression and anxiety.
Gauging mental health needs is not an exact science, because there are people who need help and never seek it out. And the level of need depends on who you ask.
Mental health crisis 'its own separate pandemic'
A Pew Research Center analysis released in December found that 41% of U.S. adults experienced high levels of psychological distress at least once since the early stages of the COVID-19 pandemic.
The American Psychological Association in November released a national practitioner survey that found demand for mental health treatment grew to such a degree during the pandemic that many practitioners reported no longer having the capacity to see new patients.
Nearly eight in 10 psychologists said that they had seen an increase in the number of patients with anxiety disorders since the beginning of the pandemic, and 66% saw an increase in demand for treatment for depression, according to the report, which analyzed responses from 2,295 psychologists.
Children have been particularly hard hit with mental health issues, and several national studies have shown that emergency department visit rates by children for mental health reasons increased during the COVID-19 pandemic − a trend that providers at Phoenix Children's Hospital observed as well, particularly among young people with eating disorders.
Due to "soaring rates" of depression, anxiety, trauma, loneliness, and suicidality, the Academy of Child and Adolescent Psychiatry, the American Academy of Pediatrics, and the Children’s Hospital Association joined together in October 2021 to declare a national children's mental health state of emergency.
"It's a crisis. It's its own separate pandemic. ... We have more referrals than we can handle sometimes," said Suma Hodge, who is the regional clinical director of Phoenix-based MiKid, which stands for Mentally Ill Kids in Distress. "A lot of it has been behavioral − kids are re-adjusting to being back to school, learning in a setting where you have to sit down."
One big challenge for many individuals who were affected by a COVID-19 death is that the world appears to be moving on, "almost as if the pandemic didn't happen," Pyles said.
The national COVID-19 public health emergency isn't technically scheduled to end until May 11, but COVID-19 mitigation measures have all but disappeared. Even major hospital systems are dropping face mask requirements.
What needs to happen now is a wider public acknowledgment of the lives lost to COVID-19, said Kristin Urquiza, co-founder and co-executive director of Marked By COVID, a national organization created after Urquiza's father, Mark Anthony Urquiza, 65, died of COVID-19 in June 2020.
"It's really important that grief is witnessed and that mourning is collective," Kristin Urquiza said.
Marked By COVID is supporting a proposed congressional resolution to make the first Monday in March "COVID-19 Victims and Survivors Memorial Day" to memorialize those lost to the COVID-19 virus and also to recognize the suffering of those who were infected and still have side effects. The resolution was reintroduced by Rep. Greg Stanton, D-Ariz., on March 6, and companion legislation was introduced by Sen. Elizabeth Warren, D-Mass.
"Commemoration we see as an essential part of recovery," Urquiza said. "If we don't acknowledge how bad it was, how are we ever going to step up to the plate to recover in a way that brings resilience to our public health system, to our emergency response systems, to our data tracking systems and so on?"
Bereavement expert: 'The country is in a funk'
Whether we acknowledge or recognize it, we've all been affected by COVID-19, even if we didn't lose a loved one to the virus, according to longtime bereavement researcher Dr. Toni Miles, a physician, professor emeritus at the University of Georgia and visiting scholar at the Rosalynn Carter Institute for Caregivers.
"The country is in a funk," Miles said. "I'm encouraging physicians to ask about bereavement when a patient comes to see them. It will help put behavior in a larger context. It opens the door for conversation."
A COVID-19 memorial quilt is on display during an event at the Arizona Heritage Center on March 6, 2023.
To Miles, bereavement is a public health problem so prevalent that if everyone who lost someone they cared about during the past 24 months were to suddenly turn purple, purple people would be everywhere.
She notes a distinction between bereavement, which is the fact of losing someone you know, versus grief, which is the emotional response to death. What her research has found is that even if people aren't having an emotional response to a death, it still may be adversely affecting their health.
"What I've learned over the years is that the volume of deaths in a community has an effect on community health," said Miles, who began researching bereavement when she was a medical resident during the AIDS crisis in the 1980s. "We're still counting the bodies with COVID. There are people who died of the disease and then there are people who died because of their connection to the person who died."
What Miles means is that whether it's deaths due to COVID-19 or to AIDS, often other, associated, deaths occur. She gave as an example a teenager she remembers whose father died of AIDS. The teenager had asthma that she controlled, but when her dad died, she stopped taking care of herself, had an asthma attack and died.
"His death killed her," she said.
In 2019, before the pandemic, Miles was part of a team of researchers that conducted a statewide survey of bereavement in Georgia that found 45% of adults over the age of 18 were newly bereaved.
Like the teenage girl who neglected to take care of her asthma after her father died, bereaved people are at risk for behaviors that can lead to poor health outcomes, Miles said. Her research in Georgia found that bereaved young men were more likely to engage in binge drinking, for example.
Miles and other health experts explain the needs of those who are grieving are on a continuum. Some people might respond to visits or calls from friends, some might need a support group, while others may need a higher level of care such as counseling and psychiatric medication.
"Studies have shown that 25% to 27% of grievers will need and/or seek professional help," said Mara Goebel, manager of bereavement services at Hospice of the Valley Arizona, which is the state's largest hospice organization. "Others turn to friends, family, a church community and/or co-workers. Many will say their pets helped them immensely and some turn to acquiring a pet to help with their loneliness."
Goebel said that Hospice of the Valley transitioned its free grief support groups to virtual via Zoom during the pandemic and that participation in the groups soared, as did referrals for Hospice of the Valley bereavement counselors.
"We were swamped and remain so," Goebel said.
Early intervention is the best way to prevent poor outcomes from traumatic losses, experts agree. People who are bereaved want others to see them and to help them engage, Miles said. They may tell you to go away, but Miles advises circling back, even if it's just to bring them a cup of coffee or check in with a quick phone call.
The risks of unaddressed and unresolved grief include difficulty moving forward and in some cases difficulty finding hope and reasons for living, Goebel said.
"It often affects our ability to function from day to day and may include feelings of intense worthlessness, loneliness, internal questioning of personal beliefs, a strong yearning for the person who passed, and an inability to accept the passing," she said. "In some cases, suicidal thoughts can also present."
Another reaction to bereavement is anger, which Miles said could be exacerbating the often vicious divisiveness in American society.
"A lot of the anger that we're seeing in our public discourse is I think driven, not completely, but in part, by all the deaths. Not just by COVID-19. Remember, we've got an opioid crisis, too," Miles said. "They are angry because somebody died and what they get in response is not what they need."
'I didn't think he was going to die'
Kristin Urquiza grew up in the Maryvale community of Phoenix and that's where her parents were living when her dad got sick. The now-famous obituary Urquiza wrote for her father, which was published in The Arizona Republic, blamed his death on the "carelessness of the politicians who continue to jeopardize the health of brown bodies" by refusing to acknowledge the severity of the pandemic.
A COVID-19 Memorial Day would go a long way in shifting the focus of the pandemic to recovery and healing by recognizing the emotional pain that so many people continue to experience, Urquiza said. Her own organization is shifting its focus, too. Marked By COVID was created out of Urquiza's grief and anger over her father's death to demand that elected officials have a coordinated, data-informed response to the pandemic. Marked By COVID is now primarily about recovery and commemoration.
Urquiza was encouraged that Democratic Arizona Gov. Katie Hobbs accepted Marked By COVID's invitation to attend a March 6 vigil in Tempe, the same day Stanton reintroduced the COVID-19 Memorial Day resolution. At the vigil, Hobbs announced that Arizona as a state would be adopting the first Monday in March as a day for memorializing those lost to COVID-19.
"To have Gov. Hobbs step up and hold space with us is the type of acknowledgment that I think families across the state and across the country deserve," said Urquiza, who had invited former Arizona Gov. Doug Ducey, a Republican, to attend her father's funeral, though he did not take her up on the offer.
Urquiza's father died in a hospital intensive care unit with a nurse holding his hand, a common scenario that has often complicated the grief that survivors who lost loved ones to COVID-19 experienced.
After her 75-year-old father died of COVID-19 in August 2020, Phoenix resident Tara Krebbs says she began weekly therapy for what's known as complex Post Traumatic Stress Disorder, or c-PTSD.
"It's PTSD but it cycles, where you start to feel a little bit better and then you kind of revert. It's related not just to the loss of your loved one but to the events surrounding how it happened," Krebbs said. "I knew he was sick but I didn't think he was going to die. ... I didn't realize that part of grief wasn't just going to be sadness, it was also going to be being angry."
Krebbs will periodically think about the frantic early morning phone call from her mom, saying she'd called 911 because Krebbs' dad was having trouble breathing. She also can't forget saying goodbye to her father, Charles Henry Krebbs, over the phone while has was sedated in a hospital bed. Small moments still set her off. She remembers watching people cheering when mask recommendations were lifted, and feeling heartbroken.
"Everyone's grief timeline looks so different. I thought when I hit that one-year mark that the second year was going to be easier, and quite honestly, it was worse," Krebbs said. "The first year you are numb. I would wake up and think, 'OK, this isn't real.' Moving into that second year, the second round of holidays, it really hit me that my dad is gone."
Krebbs believes connecting with Marked By COVID is what prevented her from drowning in grief.
"You have a place to go to talk about your loved one where it isn't taboo to talk about COVID," Krebbs said. "Even now in 2023, it is kind of a controversial topic. You don't know how people are going to react."
'I think about some of the things she would have accomplished'
Vanielle Blackhorse said her sister Valentina, a mother of one who had won multiple Navajo Nation pageants, was competent and level-headed, someone her family had come to rely on. When Valentina died, Vanielle stepped in to handle her sister's funeral arrangements and knew she had be strong for her parents. When her dad died, she did the same. She was also working full time and raising two kids as a single mom.
"There are days when I miss her a lot. Especially now with her daughter being older. I try to picture how she would have been as a mom and how excited she would have been when her daughter started school," Vanielle said. "I think about some of the things she would have accomplished ... She wanted to run for council delegate and to one day be Navajo Nation president. I think about those things often."
Vanielle said some people told her to go to counseling, but she said she doesn't do well when she talks about her feelings. She also has very little spare time and chooses to deal with her loss in her own way, by praying to her sister and father every morning and holding her sister's black powwow regalia dress and a buffalo hide that belonged to her father close to her chest.
One thing that has helped is that members of the Navajo Nation still wear face masks, even though the tribe lifted its mask mandate, said Vanielle, who lives in Kayenta, which is on the reservation. She believes tribal members continue to wear the masks out of respect and reverence for those who died of COVID-19.
"We lost a lot of people to COVID," she said. "As a nation, they won't ever forget those who passed."
Todd Bailey, a special projects coordinator at the Arizona Heritage Center in Tempe, lost multiple family members during COVID-19, including his aunt, Kathy Sue Jones, who had multiple sclerosis and died from COVID-19 on July 6, 2020. His mother, Joyce Bailey, was hospitalized with COVID-19 while his aunt was sick. While Joyce recovered from COVID-19, she had a setback when she suffered a stroke after being released from the hospital. She still avoids talking about her sister's death.
"We're doing OK. My mother has a-fib (atrial fibrillation, an irregular heartbeat) from the COVID," Bailey said. "It shocks me at different times, mostly when I stop to think about how frightened my aunt was of COVID, sitting in front of the TV from March to July, knowing that she was compromised."
Bailey said his job has given him the privilege of connecting with other people who lost loved ones during the pandemic. The Arizona Heritage Center until recently had a national COVID-19 memorial quilt on display, with individual squares dedicated to people who died from the virus.
"It's hard to wrap your head around the immense loss and devastation that people have collectively," said Bailey, who is involved with Marked By COVID. "The quilt represents every different generation, class, occupation. There are prisoners, children, athletes."
Grief and trauma from COVID-19 did not occur in a vacuum. Other stressors were occurring simultaneously, including economic woes and outrage over police violence against Black people that manifested in Black Lives Matter demonstrations. Polarization continues, some of it involving COVID-19, including the origins of the pandemic, and the vaccines.
Political divisiveness has left many people feeling alone in their grief over losing a loved one to COVID-19, Urquiza said.
"I speak to dozens of people a day who have lost loved ones, and I've been doing that since I lost my own dad. There is so much grief, and the thing that breaks my heart even further is that so many people will share with me in confidence that they had no idea anyone cared," she said.
"If we don't tackle this head on, all that harm will manifest in other ways."
Socorro Gonzalez Pyles said her grief over losing her mom has been complicated because in 2019, her husband unexpectedly died at the age of 40.
When her husband died, Pyles went to therapy, kept a journal and did everything she could to work through her shock and sadness. It's been different with her mom.
She's often consumed by "what ifs" and guilt, including whether social isolation in the months before she got infected somehow exacerbated her extroverted mother's illness.
"I just don't think I've processed it yet," she said.