It wasn't much — just a tickle in her throat — that made Clare Carr wonder if she was getting sick in mid-April. "My roommate and I were sort of joking around, like, 'rona, is that you?," she recalls.
It was, in fact, 'rona (short for coronavirus). The otherwise healthy 32-year-old yoga instructor and nanny felt fatigued at the beginning, and wasn't very worried about how COVID-19 would affect her. She would quarantine for two weeks and get on with her life.
A few days after her diagnosis, though, her condition took a frightening turn: Several complete blackouts. Blue toes. Chest pains evolved into four cardiac arrests. She felt like she was dying from a disease that had changed from being a tepid intruder to a ferocious attacker.
And now, many months later, she faces enduring mental health issues as her physical health slowly rebounds. She is working with a therapist, Elizabeth Duval, Ph.D., assistant professor of psychiatry at Michigan Medicine, to address her mental health concerns.
"I thought it would come back," says Carr, who lives in Ferndale, Michigan. "I was afraid to go to sleep at night because I didn't think I would wake up."
It isn't just COVID-19 survivors who are experiencing intense mental health issues. Providers at Michigan Medicine also are treating many patients who have not had the disease, but who are struggling nonetheless with the psychological fallout of the pandemic's upheaval of everyday life.
"We're also seeing many people in the clinic who are being impacted by these things who haven't had the infection," Duval says. "There's a lot of anxiety about contracting COVID-19, uncertainty about transmission risk, and fear and grief associated with losing a loved one to COVID. It's impacting a lot of people in profound ways in terms of our ability to function."
Michelle Riba, M.D., clinical professor of psychiatry, associate director of the U-M Depression Center, and director of the PsychOncology Program at the U-M Rogel Cancer Center, voices similar concerns. "I'm worried about post-traumatic stress. People are tired and not sleeping well, and we're seeing PTSD-like symptoms. We're seeing a lot of people self-disclosing that they're anxious, depressed, maybe not attending to their medical issues, so we're seeing people coming to get medical attention with more serious illness, including psychiatric problems."
Here, we tell the stories of three patients who have found ways to survive, and sometimes thrive, in the new normal.
Joe's story: The power of distractions and gratitude
When retiree Joe Ebbitt started feeling sick at the beginning of the pandemic, he was worried. He had gone to the doctor's office a week prior, before there were stay-at-home orders and before mask use was common. He thought he might have contracted COVID-19. "My mind played all sorts of tricks on me," he says. He had a couple video visits with his doctor, who thought Ebbitt's symptoms were likely due to allergies.
After a couple of weeks, Ebbitt recovered physically from his breathing issues and was never diagnosed as having the coronavirus. But he was still experiencing effects of COVID-19 — mental health effects. "I was pretty paranoid [about getting COVID-19]," he recalls, noting that he has health concerns that put him in the high-risk category. "My wife and I decided we were going to stay home." And that's where they've remained, for the most part, since the spring. "I'm afraid of it, and so is my wife," he says. They gave up their annual Fourth of July gathering with family. They haven't gone to restaurants or to the gym, and they didn't set foot in a grocery store for the first several months. "It's changed our life."
But the real kicker came in April. Ebbitt's son, who got married last year and had a baby in January, was having headaches and throwing up. Ebbitt took him to the emergency room, and he was eventually diagnosed with a malignant brain tumor. That news, on top of the pandemic, sent Ebbitt into a depression. "It can't help but affect your mental health. Your life changed," he says. "It's just upsetting, the whole thing."
That's when Ebbitt decided to get professional help. He began virtual appointments with Riba. With her help, Ebbitt has focused largely on self-care as a way to manage his anxiety and depression. "What's worked for me is creating distractions. … If I'm sitting there starting to get anxious, I'll get up and try to do something." He works in the yard, does home improvement projects, rides his bike, and walks. "Exercise changes my mood," he says. "If I go on a long bike ride, I come back feeling better. I'm not just obsessed with one thought." For Ebbitt, these strategies have helped him not to dwell on pandemic concerns and his son's health. "Dr. Riba has helped me realize I've got to take care of myself. That's the best way to help my son and get through this in general.
"The bottom line for me is, I started feeling better when I reached out and got some help from Dr. Riba. She taught me a little bit about how to concentrate on my own health … and let the doctors take care of my son." In addition to focusing on his own health, he helps his wife care for their grandchild a couple days a week. Ebbitt's son began treatment at Michigan Medicine in the spring and needed to be away from work for a while. He's back at work now, and his health care team is optimistic about his recovery.
"In the whole scheme of things, we're lucky," Ebbitt says. He feels grateful that he can spend time with his wife, and he was particularly relieved when many sports resumed. "When the Tigers started playing baseball, that was something I could do every night." He also enjoys watching football. "Although you've got to watch the Lions, so that's not great," he jokes.
Ebbitt recalls early predictions that the pandemic would keep people home for a couple of weeks before everything returned to normal. "It didn't take long to realize this thing just isn't going to go away," he says. "If there's anything that surprises me, it's my ability to accept the fact that this is changing our life for a significant time, and it's going to continue, and I'm learning how to deal with it."
Anna's story: Opening up space in one's mind
"At the very beginning, it was a matter of disbelief and shock … feeling like it was sort of an out-of-body experience," says Anna.* A Michigan Medicine patient who was diagnosed with breast cancer more than 10 years ago, Anna has also dealt with other cancers. Still, the pandemic was a challenge unlike any she had faced before. Her initial disbelief morphed into concerns about everyday needs: "How do I go grocery shopping? How will I see my doctors?" She compares it to a nuclear bunker: "We all would be hunkering down fearing that we might never be able to leave the safety of our home, never experiencing life as we knew it. It was and is a frightening vision, with so many unknowns."
Anna echoes fears that many people felt in the initial days of social distancing and stay-at-home orders. It's difficult to find a corner of life that hasn't been affected by the COVID-19 pandemic. Mental health concerns — for everyone from kids who can't socialize at school or with extended family members to elderly residents in nursing homes who are confined to their rooms — are nearly ubiquitous.
Anna was not alone in her fears, but she was more alone in her everyday life than she ever had been. Apart from the uncertainty she felt about the future and her fear of getting the virus, Anna was devastated to not be able to hug her young grandchildren and do the volunteer activities that gave her so much satisfaction. "Suddenly you're at home with your spouse 24/7, wondering how this seismic shift will play out, and for how long."
Anna is no stranger to depression and had, in the past, benefited from therapy sessions with Riba over the course of more than 10 years in and out of cancer treatments. In the spring, Anna had a virtual visit scheduled with Riba, which was initially a "tune-up, check-in" appointment, similar to others she had had. "At the end of the visit, Dr. Riba asked me if I felt like things were really going OK," says Anna. "I said, 'Well, I don't know.'"
That's when Riba and Anna began talking about how to manage the new pandemic way of life. "I realized that I was really seeing myself as a victim," Anna says. Her sessions with Riba have helped her create a new narrative. She's found many ways to stay active and fulfilled, walking outside, taking online courses, staying connected with friends and families via Zoom, pursuing her interest in painting, and doing lots of cooking.
Her marriage has been one of her biggest sources of comfort. Her husband recently retired, which meant spending a lot more time together. "I'm pleasantly surprised that after 45 years, my husband and I found renewed compatibility and enjoyment of shared interests," she says. The couple also has been in a "Marie Kondo phase" of cleaning out their home and deciding what to keep. "It's been a pleasant walk down memory lane," she says. "I think there's a lot of satisfaction that comes from opening up a physical space; you can then open up that space in your mind."
Anna has used some of that extra mind space to ponder some big questions. In the wake of increased racial tensions, she's contemplated "injustices and health disparities that are happening to people who are not privileged white people," and she's spent some time cultivating an interest in these topics and becoming more self-aware. "If there's a silver lining [of the pandemic], it's introspection and looking at myself not as a victim but as someone who can cope."
Clare's story: The COVID-19 journey continues
Carr, the 32-year-old yoga instructor and COVID survivor, anticipates that her mental and physical health challenges will continue for a while. She has experienced chest pains and panic attacks, as well as depression. She thinks often about the 11 days she was on a ventilator, the eight days she was on ECMO, the convalescent plasma — all of the medical tools that kept her alive. In all, she was in the hospital for a month. During that time, she could only see family members on FaceTime. Even after she was discharged, she continued to test positive, and she quarantined until her lingering cough went away.
Early in her recovery, Carr often would want to lie in bed all day. She recognized that her depression was deepening. "I knew that if I went hiking or bike riding, I would feel better. But I just didn't want to do it," Carr says. Working with Duval, her mental health is bolstered now with medication for depression and anxiety, in addition to talk therapy. For Carr and other COVID-19 survivors, the post-disease physical and mental health path is full of unknowns. "We're still in the early stages of understanding how COVID infections will impact people's mental health," Duval says. "What we're seeing is similar to the impacts of other serious medical issues, but because it's a pandemic, it comes with additional challenges."
Carr wishes that more people understood that COVID-19 can affect everyone differently, and that it can dramatically alter the life of even a young woman with no pre-existing conditions or health issues. She also wants people to know that recovery from COVID-19 goes well beyond one's discharge from the hospital.
"I'm learning strategies for how to cope with depression and anxiety, how to recognize it. I think it's hard for people to understand that COVID affects you long-term, physically and mentally," Carr says. "I'm taking it day by day."
You're feeling down, but so is everybody, right? Do you really need professional help?
Though Anna, Joe, and Clare have benefited from psychotherapy, not everyone feels their situation warrants professional help. Your mood during the pandemic "may not be a serious psychiatric problem," says Riba. "But it could be." For people who are feeling down and anxious, the U-M Depression Center Toolkit has self-screening questionnaires. The questionnaires aren't diagnostic, says Riba. "[A high score] just means that, on these measures, there's a likelihood that you have depression [or anxiety] and should be evaluated for that." If you do decide you could benefit from professional help, the Depression Center offers treatment services and other resources.
"The Zoom is OK, but you know, enough with the Zoom."
The Depression Center Toolkit can help you figure out if you need professional help. If you don't, what then? "Get back into some sort of routine that is healthy," says Riba. "That would be a good place for everybody to start thinking about." In addition to that, Riba says to think about what has helped in the past. Generally, she recommends that people focus on exercise, eating properly, and sleeping well. And she wants everyone to think outside the computer screen.
For example, pandemic baking is a thing. Riba was quoted in a March 24 article in the Washington Post on the shortage of flour and yeast that occurred as a result. "Right now, we're thinking about things that are very basic," she said back in the spring. "Bread-making is a pretty basic act over the centuries — it's a very earthy kind of thing." On the cusp of autumn, Riba was more inclined to recommend active hobbies: walking, golfing, biking. While she was playing tennis, Riba saw some people doing Zumba in a driveway. "We were playing tennis to the music."
For Riba, the important thing is to take a break from the screens: "The Zoom is OK, but you know, enough with the Zoom." Riba says she heard about someone who was playing Monopoly in a park while wearing a mask. "Families and groups are having fun with this, trying to be creative."
Riba also cautions against self-medicating. "Substance use, including use of alcohol, has been increasing during the pandemic. I want to make sure people are aware of this and keep this in check — especially with the holidays and winter weather approaching."
But what about the winter? **cue whining in anticipation of polar vortex**
As snow fell on daffodils in early spring, Michiganders followed stay-at-home orders. Then the "real" spring came, and many people explored nature as they never had before. The outdoors became a respite for many who had spent the tail end of winter cooped up at home. Now that winter looms before us again and the pandemic is no closer to ending, people are worried about how they will handle a lonely season of shortened days and, at least in the north, bitter cold.
"Medical management and prevention are probably better to focus on than a messiah with a vaccine," says Riba. "We don't know what the future is … [so] make the most of the present." Riba encourages getting outdoors in winter weather: "Cross-country skiing, snowshoeing, snowball fights." She mentions making soup and checking out books from the library.
"Maybe art or music are things you haven't thought about in a while. Maybe those are good hobbies to think about now," says Riba. Since the beginning of the pandemic, Anna has dipped back into her hobby of watercolor painting. "Dr. Riba has encouraged me to work on my art. … I sent her my pictures, and she is very encouraging."
Silver linings and gratitude
"I think I've forgotten how to put on makeup," Anna says. Although she's joking, she acknowledges the lack of primping as a silver lining of the pandemic. "I've learned that I don't have to always have on makeup and nice clothes. ... Talking to people and having your pajama bottoms on is also fine."
One of the major coping strategies Riba helps her patients put into practice is gratitude. For Anna, that's not just relegated to the realm of aesthetics. Like Ebbitt, Anna feels lucky in many ways: having a supportive spouse, having stable finances and internet access, living in a nice house that's close to all of her health care providers, and being connected to the health care providers themselves, whom she appreciates not only for their medical prowess but also for their emotional support. "They look out for me and involve me in decision making. They know me and my history, and they have really extended themselves to me."
Though health care professionals are seeing an increase in suicide, depression, substance use, and anxiety since the beginning of the pandemic, the global crisis has also been a period of personal growth for some people. "I have been quite impressed by the resilience of people," says Riba. "We're trying to help each other get through this in a collective way."
This story is part of a larger series on mental health and the pandemic. Explore these stories to learn more about mental health research and patient experiences at Michigan Medicine:
*Name has been changed
Virtual Mental Health Care
Telemedicine has made it easier for many people to access care during the pandemic, and insurance companies have made it easier for health care providers to be compensated for virtual visits. In addition to avoiding exposure to COVID-19, virtual visits allow patients to get health care from the comfort of their homes, without having to deal with transportation and parking. Riba has had success using virtual visits with many of her patients, and she hopes to continue virtual sessions for those who need them. However, Riba acknowledges gaps in virtual health care.
"When we talk about telehealth, it's great, but for some people it's very problematic," she says. She notes that some elderly people have had trouble accessing virtual care because of a lack of familiarity with the technology. She also says privacy is a big concern for some, such as single parents or those who live with abusers. Riba has one patient who does therapy sessions from her car and another "who's very scared of her husband. He's very controlling, and she actually is scared to have a visit with me, because she thinks he's listening through the walls."
Ultimately, virtual care is an important service, even if it isn't a perfect fit for every patient. "Insurance companies have been really good about paying for telehealth, but I'm not sure it's going to continue," says Riba. She hopes insurance companies will be able to see the value in virtual visits that have helped many of her patients.
Grieving in a Pandemic
COVID-19 has occasioned many losses. For some, it's the loss of a job or the loss of a chance to graduate alongside high school classmates. For others, it's the loss of a loved one. "It's horrifying to not be able to be at a loved one's funeral or wake or shiva," says Riba.
Katie Whitney (one of the writers of this article) experienced the loss of a loved one in July, when her father died of Alzheimer's disease. "In addition to the aching wrongness of not being able to see and hug all of my family members, I found it particularly heartbreaking to witness my mother's grief in isolation. Before my dad died, she had never lived alone." Whitney lives in a different state from her mother, and by the time they were able to see each other again in August, her mother hadn't touched another person in nearly six weeks. The family has decided to postpone a memorial service to a time when the virus has abated enough to allow a church service, in honor of Whitney's father's career as a minister. But whether a family decides to postpone a memorial service or finds a creative way to grieve together, there is a sense that this is one of the times when the pandemic is asking too much of us.
"Rituals around celebrating the life of a loved one (e.g., funeral, memorial service) are part of the healing process and should not be delayed," says Polly Gipson, Ph.D., associate professor of psychiatry and director of the Trauma and Grief Clinic, which is part of child and adolescent psychiatry services at Michigan Medicine. "Because these acts help facilitate grieving, I encourage families to explore options that may be carried out now, even if some aspects are non-traditional.
"For example, I recently participated in a virtual memorial service of a loved one. I am thankful that his immediate family thought of his wide-reaching impact, allowing me and so many others to participate in his homegoing celebration via livestream," Gipson says. "His immediate family was in the church pews and their wearing masks and physical distancing did not take away from the celebration of his life. Other options for families are to think creatively about how to celebrate their loved ones now in a way that is meaningful with a future plan to carry out traditional practices."
Michigan Medicine offers some online resources for dealing with grief.