Expert tips on learning new coping skills to help with pandemic-induced anxiety and substance use

With more than 5 million confirmed cases of COVID-19 in the U.S. and more than 167,000 deaths from the virus, the uncertainty of how long we'll need to maintain this new way of life continues. And with that sustained uncertainty comes sustained anxiety, depression and substance use for an increasing number of people.

Researchers and mental health professionals have been watching and working to gather data on behavioral health both before and since the pandemic began, with more than 30 percent of American adults reporting experiencing symptoms that line up with anxiety and/or depression, according to the Kaiser Family Foundation.

Although it's still too early to declare any data about the effects of the pandemic as definitive, early reports about an increase in alcohol sales, results of urine drug tests and a climb in suspected drug overdoses have brought up more conversations about healthy ways to cope with COVID-related stress.

Carla Marienfeld is a clinical professor of psychiatry at UC San Diego, medical director of the UC San Diego Addiction Recovery and Treatment Program, and program director of the UC San Diego Addiction Psychiatry Fellowship. She took some time to talk about the kinds of trauma that can be experienced during a pandemic, how mental health and use of substances may be affected, and some of the differences between coping with distress versus coping with a disorder during the pandemic. (This interview has been edited for length and clarity.)

Q: According to the Household Pulse Survey from the National Center for Health Statistics and the U.S. Census Bureau, the rate of people reporting symptoms of anxiety and depression has tripled from April to June of this year, compared to a year ago. We've obviously been navigating COVID-19 during this time, with an increased concern regarding behavioral health and substance use. What kind of trauma do people experience during situations/disasters like this one?

A: The types of trauma that people experience with coronavirus really depends on many factors, including your mental health status prior to the pandemic. It can also depend on what your circumstances were prior to the pandemic, like difficulties with financial stresses or not having support networks. So, all of those things that were existing pre-pandemic, have often worsened during the pandemic; and yet, we also see many people who were doing okay before, and who are now struggling with symptoms they hadn't been struggling with before. We see it across the mental health spectrum, so we can see things like worsening episodes of psychosis because of a loss of contact with services and support. We certainly see worsening anxiety and mood symptoms because of isolation from family and support networks, shifts in financial status and security. We see a lot of anxiety just based on this sense of uncertainty.

I think we've also seen people become creative with managing anxiety and depression. People are using group and individual therapy, formally and online, more now than they were in the past. This allows them to connect with other people who are struggling, and having a good peer group can be really helpful for positive changes. In addition, there is more acceptance that this is a hard time for people making therapy more normalized and less stigmatized. We are starting to see people reach out a little bit more. People who might have been nervous to go to something like an AA (Alcoholics Anonymous) meeting might be willing to do so in a virtual format, or find support or recovery groups online that aren't limited by location.

Q: What was your organization's initial response to how the pandemic may affect substance use and mental health?

A: Early on, we were really trying to support patients who were losing contact with the support that were helping them in the past. We saw a significant decrease in people who were coming to our clinic, but that has since changed and now we're getting a lot more referrals than we had pre-pandemic. I think it's because a lot of people are changing their behaviors. I've heard patients who've said the pandemic has helped them because they're not going out as much and being triggered by environments that would get them to use. But for most people, the anxiety and uncertainty, the financial and other stressors, have led to increased substance use and the risks associated with this like overdose. People typically have more time at home, more time alone, and now they're using substances in a way that might be less social and for more concerning reasons like trying to escape uncomfortable feelings. Or, they're drinking or using drugs alone or in more isolated ways, which is concerning for medical risks and overdoses. For some, they're seeing their changing patterns of use and use of increased amounts, and recognizing that there might be a problem. The pandemic has really served to highlight what may have been going on at a lower level before, but that's now causing them problems. For some people, this is leading to them seeking help.

Q: What examples do we have from history (i.e. the Spanish flu pandemic, the Great Depression and the Great Recession) about how people chose to cope with similar circumstances in the past? And what seemed to work to help people find and utilize healthy coping strategies?

A: That's an interesting question. The coping strategies that people develop are not really complicated or that different from what we recommend to address many stressors; they may just look different because of the pandemic. The same principles apply where people try to find behaviors, make choices that give them a sense of purpose, or find relaxation in what they do, but how that looks during the pandemic might be slightly different. If, beforehand, socializing with friends and family was a source of enjoyment, now we have to potentially work harder to maintain those circles given that we might be physically distanced from people. The friend networks that help to manage anxiety and depression and other circumstances are still a good thing to do. Exercise is still something that's very beneficial for mood or anxiety, but where it might have taken place in a gym before, that's not the safest place now. Now, it might take place outdoors and that might be a better way to do it. I don't think (the coping strategies are) that different; it's about how we adapt those behaviors to do it in a safe way.

Q: What's the difference between coping with distress versus coping with a disorder? And why does this distinction matter?

A: Any time we make a diagnosis in psychiatry, we think about the symptoms that somebody is presenting with, where they fall on the normal continuum of emotions and experiences, and whether or not they're causing functional impairment in how someone is able to get along in their lives. When we think about distress, we think about somebody who probably does not have a disorder, but has difficulty managing things because of a particular situation. When somebody has a disorder, the symptoms are typically more numerous, frequent, and severe and it impacts their functioning — their ability to do the things they need to do in their lives. They're less able to bounce back or tolerate the distress that's coming from a particular situation, so if somebody had a disorder, medications can sometimes be helpful and sometimes they need more support and therapy to help identify ways to manage the symptoms. Coping skills are useful for anybody and everybody. If somebody's coping with a disorder, coping skills may help, but may not be sufficient. Other therapies may be more helpful. Many therapies involve coping skills, but that may be just one aspect of the treatment that may be more helpful.

Q: What would be an example of a wellness plan that could be helpful in elevating a person's mental health right now and curbing the propensity for using substances to cope?

A: I think that when we think about the term of "wellness" in general, the idea of wellness is useful for everyone. "Wellness" is a goal for all of us, but it might be more difficult to achieve if you have symptoms or situations that make it harder for some. There is no magic one-size fits all plan that works for everyone to have a sense of wellness. I think that it's really helpful to think about what works well for the particular person. So, we can consider all of the good things that one might do: connecting with friends and family, exercising and yoga, doing relaxation, setting healthy boundaries in relationships and at work; all of these things are good things that people can do. When you think about a wellness plan, it's helpful to think about what are your strengths that you can affirm and support the things you do well, and want to maintain. And then look at the areas where you're struggling, and look at what you can do to improve those areas. Look at where you're doing well in life and where you're struggling, and think about how you can target and change one or two things in a reasonable and realistic way, so that you set yourself up to succeed. People can come up with the most amazing plan ever, but if it's not something they're likely to do, it's not going to make a change in their life. The more success somebody has in their goals, the more likely they are to continue to keep making positive choices.

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