When Dr. Amy Barnhorst treats patients for mental illness in county jails, emergency rooms, and psychiatric hospitals, she sees more than the person standing before her. She takes in their life circumstances, too. That can include childhood trauma, food insecurity, neighborhood violence, unemployment, and personal and institutional racism.
These experiences, among others, influence a person’s emotional and psychological well-being. Yet mental health is typically cast as a biological condition shaped by genes and character traits. While that’s true, ending the story there is misleading, says Barnhorst, vice chair of community mental health in the department of psychiatry at the University of California, Davis.
Nothing could’ve proven that more than the COVID-19 pandemic. The threat of death, along with the economic and social costs of lockdown, brought a heightened sense of anxiety and fear into most people’s lives. Suddenly, they were thrust into shared trauma and grief. They laid awake at night, waiting for dawn to come. Few endured what came next without some form of suffering.
COVID-19 demonstrated in painful ways how personal mental health is a reflection of what’s happening in the world. This doesn’t mean one should give up on emotional and psychological wellness, but that awareness can put into perspective why healing may feel out of reach. The pandemic holds numerous such lessons, but three defining experiences from the past year uniquely illuminate the connection between one’s circumstances and their mental health: racism, financial strain, and weight stigma.
Research shows that such external factors, which exist well beyond a person’s body and mind, can play an important role in worsening mental health. While personal behavior is critical for positive well-being, a person can only adopt so many new habits to counter powerful forces over which they have little say.
Barnhorst argues that treating mental health should involve addressing and reducing inequality.
“When someone loses their ability to pay rent or buy food for their family because of our government’s failure to manage a pandemic, psychiatric care will have a minimal impact,” Barnhorst recently wrote in Slate. “Suggesting an antidepressant for them is like offering someone aspirin for their headache while repeatedly hitting them in the head.”
For critics, identifying and describing outside factors that contribute to poorer mental health is akin to complaining or surrendering instead of rising up to change one’s circumstances. Barnhorst looks at it differently.
“Sometimes I think it’s helpful to have the perspective that you weren’t dealt the same hand as everyone else,” says Barnhorst, “You are doing the best with what you have.”
“You are doing the best with what you have.”
Though prior research had already established associations between one’s circumstances and poorer well-being, the pandemic made the stakes frighteningly high.
People of color have been disproportionately infected and killed by coronavirus as a result of structural racism and inequality. While the wealthy became richer during the financial crisis, middle-class and low-income families, many of them Black, brown, and Indigenous, struggled to put food on the table and lived under the threat of eviction. Body weight became an obsession as experts identified obesity and extra weight as a risk factor for hospitalization and death in COVID-19 infections. As people gained weight during the pandemic, some used it as an opportunity to shame them into compliance. Now imagine moving through the world as someone who experiences all three of these inequalities, or more.
While there’s no immediate remedy for inequality, people may benefit from understanding that poor mental health isn’t just about their choices or biology. That knowledge can reduce the stigma associated with talking about well-being. It also points to solutions within a person’s control, like practicing self-compassion, developing skills to regulate their emotions, and making feasible changes to their life circumstances. While the long-term answer is fundamental societal change that reduces inequality, certain strategies can offer self-empowerment in the meantime.
Can’t sleep? It might be racism.
Months into the pandemic, the most sought-after commodities looked something like this: dry beans, toilet paper, hand sanitizer, flour, and sleep. Restful sleep became as elusive as once-common grocery store goods.
Between the anxiety of a deadly pandemic; the pressure of working while simultaneously providing childcare; working in hospitals, agricultural fields, slaughterhouses, and supermarkets; and, coping with job loss and economic uncertainty, people stopped sleeping well. That matters significantly for mental health and well-being. Researchers who surveyed 1,103 adults in the first weeks of lockdown found that insomnia had troubling implications for people’s mental health. In their analysis, severe insomnia predicted suicidal thinking.
Yet, people of color faced unique challenges, says Dr. Dayna Johnson, an assistant professor at Emory University’s Rollins School of Public Health, and an epidemiologist who studies sleep health disparities
Last summer, Johnson co-authored a letter to the editor of the Journal of Clinical Sleep Medicine outlining these disparities. She wrote that people who are part of a racial minority sleep for shorter periods, have lower-quality sleep, and experience more severe sleep apnea, which Johnson’s research suggests is largely the result of stress, discrimination, air pollution, and household crowding. In general, experiencing or witnessing racism is associated with poorer sleep, according to past research.
If people of color began the pandemic with a sleep deficit, it may have worsened in the months that followed. Those who continued to work in person, many of whom were low-wage essential workers of color, couldn’t escape the anxiety of the front line because they lacked the “flexibility or privilege” to take days off, Johnson wrote. Then George Floyd’s murder exposed Black Americans to fresh racial trauma, which also affects sleep. Johnson and her co-author called on their peers to recognize and address the factors that drive sleep disparities.
“Ignoring sleep disparities essentially ignores the people who need the attention most,” she wrote in an email to Mashable.
“Being exposed to all of these things, by no fault of your own, it’s setting you up for worse sleep.”
Dr. Michael Grandner, director of the Sleep and Health Research Program at the University of Arizona, says that experiencing discrimination and racism in multiple forms may lead to hypervigilance around physical and social safety. Yet he believes the toll on sleep extends beyond hearing bigoted remarks or the horror of seeing another Black person killed by a police officer. It’s also the compounding effects of institutional racism that, for example, drives Black people out of their neighborhoods and forces them to commute for longer distances, which means waking up earlier, or disproportionately exposes them to pollution, which may cause sleep apnea.
“It becomes a cycle whereby being exposed to all of these things, by no fault of your own, it’s setting you up for worse sleep,” says Grandner, whose own research found an association between perceived racism and poor sleep for Black Americans.
Grandner believes that addressing inequality will reduce sleep health disparities. He also urges people to seek help for insomnia and other conditions. When poor sleep interferes with the ability to function, Grandner recommends working with a specialist, if possible. He likens sleep conditions to depression: They’re highly treatable with professional expertise. Even without that resource, he says it’s helpful to develop a pre-bedtime routine and wake up at the same time every day. That consistency creates important cues for the mind and body. If someone wakes and can’t fall back asleep, he recommends getting out of bed to do something boring. Though it seems counter-intuitive, it prevents an association between anxiety and the bed.
“I can’t fix your neighborhood. I can’t fix your job. I can’t fix the people who you’re around,” he says. “I can fight for it, and it eventually might happen…but what I could do is take this one corner of your life, no matter what else is going on in the background, and it’s probably still movable. Sleep is almost always at least modifiable, if not fixable. Whatever little good that can do for you, great.”
The link between financial strain and suicide
In 2020, Jeff Bezos’ net worth grew by $75 billion. He wasn’t the only billionaire who became richer, either. The richest people on the planet saw their wealth grow by $3.9 trillion during the pandemic. Meanwhile, the World Bank predicted that the crisis would push, at minimum, an additional 88 million people around the world into extreme poverty. In the U.S., 8 million people became impoverished as stimulus payments temporarily stopped last year. When the government issued new rounds of checks, in December 2020 and March 2021, it significantly reduced financial instability as well as symptoms of anxiety and depression for recipients, according to an analysis of federal data conducted by researchers at the University of Michigan.
While it’s possible that other factors, like the availability of vaccines and a resurgent economy, helped improve mental health symptoms, some recipients say the cash aid made the difference.
“I really got down and depressed,” Chenetta Ray, a mother who lost a third of her work hours during the pandemic, told The New York Times. Ray, who makes $13 an hour, fell behind on rent, car insurance, and utilities.
“Part of the benefit of the stimulus to me was God saying, ‘I got you.’ Spiritual and emotional reassurance. It took a lot of stress off me.”
Free access to mental healthcare is critical, but therapy isn’t a solution for worker exploitation and subhuman conditions.
You need to get paid. Guaranteed living wages, healthcare, material stability and safety – these are key conditions for mental & general public health. ⬇️ https://t.co/kP5U0BVYYN
— Alexandria Ocasio-Cortez (@AOC) June 2, 2021
Past research has found that increasing the minimum wage by a dollar may reduce the suicide rate among those with a high school education or less. Researchers have also seen links between increased , , and . In a study published last fall in the American Journal of Epidemiology, a team of researchers found that people who’d dealt with all four different types of financial strain — financial debt and crisis, unemployment, past homelessness, and lower income — were 20 times more likely to attempt suicide compared to those who’d never had such experiences. Other risk factors included depression, substance use, past suicidal thinking and behavior, and being younger and female.
Dr. Jack Tsai, co-author of the study and campus dean of the UTHealth School of Public Health in San Antonio, says financial strain creates psychological stress while also affecting other critical aspects of one’s life, like housing and doing work that’s meaningful. Though Tsai and his co-authors didn’t look specifically at the role of substance use, one theory that might explain why financial strain predicts suicide attempts is the idea that people undergoing intense stress may self-medicate, which can increase their impulsivity and impair their judgment. They may also feel helpless, worthless, and hopeless, emotions that increase suicide risk in tandem with other factors.
“It’s often this kind of cumulative, low-grade, long-term stress that affects and deteriorates mental health.”
“It’s often this kind of cumulative, low-grade, long-term stress that affects and deteriorates mental health,” Tsai says, describing the emotional cost of financial strain. Even high-income earners can experience it when they’re unable to manage their finances.
Tsai believes there’s a case for policy solutions that support employment opportunities, financial education, and some minimum level of income, which would reduce anxiety and uncertainty related to paying for housing, food, and other basic needs, as well as improve the nation’s general welfare. He and his co-authors argue that asking about financial strain should be part of suicide prevention. Many of the screening tools meant to determine someone’s suicide risk don’t include questions about economic instability and crises.
Tsai, who is also research director of the Department of Veterans Affairs National Center on Homelessness Among Veterans, is an advocate for financial education and literacy, which he believes could improve people’s financial decision-making. Using an app or software program to track income, expenses, and debt may improve someone’s sense of control and their ability to plan. Yet, Tsai understands that the act of budgeting won’t change reality for people who don’t earn enough to pay for their basic needs, or the fact that Americans, in particular, live in a culture that loves consumption. That social pressure, along with the widespread availability of credit, is a potent combination that influences people’s financial choices.
“Sometimes folks that are depressed, it helps a lot to know the source, because otherwise it feels overwhelming,” he says. “And being able to identify, well, financial stress is one of them…knowing the source, and even normalizing it a little bit, could help somebody cope with the depression and possibly reduce their risk of suicide.”
Weight stigma takes a real toll on mental health
A once-in-a-lifetime pandemic focuses attention on the human body in profound ways. Scientists first scrambled to understand how the novel coronavirus invaded the body’s cells and evaded the immune system. Then risk factors for severe illness began surfacing, including older age, diabetes, cancer, smoking, and pregnancy. When it became clear that being overweight or obese dramatically increased the risk of hospitalization, the long-standing bias against heavier bodies suddenly emerged as a new source of pandemic pain. As surveys showed that many people reported gaining weight during the crisis, it prompted shaming commentary about their dietary choices.
Such treatment is familiar to those who’ve lived with weight stigma for years or decades. Friends and family remark on their size or diet. Classmates bully them in school. Healthcare professionals treat them poorly, and they may rarely seek care as a result. Judgments of heavier people often hinge on their supposed lack of willpower, laziness, or discipline. Public health messages sometimes convey a similar sentiment under the guise of improving people’s well-being: A fat body is not an acceptable body. During the pandemic, social media posts argued that people who exercised and cared for their immune system were protected from COVID-19, claims that were untrue yet played into discriminatory ideas about who’s susceptible to infection, and why.
In general, the science is far from conclusive on the health risks of extra weight. While studies have shown an association between obesity and conditions like diabetes and cardiovascular disease, other research suggests it’s possible to be “fat but fit.”
If shaming is meant to motivate the people at whom it’s targeted, the strategy is a failure. Instead, weight stigma is associated with worse mental health, according to research. A meta-analysis on the link between weight stigma and emotional well-being, published in 2019 in Obesity Reviews, found that the greater perception of weight stigma, the more mental health worsened. After evaluating 105 studies that included more than 59,000 people, the researchers concluded that weight stigma is strongly associated with depression, disordered eating, anxiety, body image dissatisfaction, lower quality of life, and psychological distress. People were particularly affected by their own self-stigma, or negative feelings about their body and self-worth that they’ve internalized.
Though it’s typically used against people in larger bodies, weight stigma can also affect people who are worried about being judged by others and go to extreme lengths to achieve a body shape and size that fits society’s standards.
“A lot of times the perpetrators of stigma are actually your friends and family and people that you’re close to…so that could contribute to feeling like you’re a burden or that you don’t belong.”
The adverse effects go beyond everyday discrimination, says Christine Emmer, lead author of the meta-analysis and a Ph.D. candidate in health psychology at the University of Mannheim in Germany. For example, when people experience structural, weight-based stigma at school or in the workplace, it can lead to worse educational and occupational outcomes, which in turn influences their mental health and coping abilities, says Emmer.
Another study recently published by different researchers in Body Image explored the link between heightened suicide risk and weight stigma. They found an association between the two experiences among 156 undergraduate students. Those at higher risk were more likely to say they felt like a burden to others, a key factor for feeling suicidal in general.
“A lot of times the perpetrators of stigma are actually your friends and family and people that you’re close to…so that could contribute to feeling like you’re a burden or that you don’t belong,” says Dr. Valerie Douglas, the study’s lead author and a postdoctoral research scholar in the department of psychology at San Diego State University.
This field of research is relatively new and has largely focused on the experiences of white women while overlooking the effect of weight stigma on people of color and men. Yet Douglas says the overarching findings should change the way public health officials and experts talk about weight. Instead of trying to force people to lose a prescribed amount of weight, health professionals should prioritize overall health, help patients “dismantle diet culture,” and address the psychological effects of stigma. Douglas likens this to showing people, particularly those who are feeling suicidal and experience weight stigma, that there is an “exit option” — an alternative to the spiral of negative feelings that can lead to hopelessness.
Douglas also believes that some strategies can help people who experience such discrimination cope with its effects. These include compassionate self-care, emotional regulation skills, embracing or reclaiming one’s identity as a fat person, and engaging in enjoyable forms of movement (versus difficult exercise). Douglas says that advice, however, shouldn’t eclipse the real problem.
“Of course you want to teach people skills to regulate their emotions,” Douglas says. “However, the picture that popped into my head is someone kind of drowning in water in a pool and you throw them a life preserver — that’s the skills — [but] you could potentially pull the plug out of the pool and let all the water out, in terms of changing society to not put people in larger bodies in this position of negative stereotypes and being a burden.”
Where we go from here
The COVID-19 pandemic laid bare what’s broken in society. It also created an opportunity for people to see anew, or for the first time, what those fractures mean for their mental health and well-being.
The clarity is daunting, but it points to a radical path forward. We can talk about mental health as personal responsibility, detached from a person’s life circumstances and the culture in which they live, or we can be truthful. It often reflects, for better or worse, what a society values.
Improving people’s mental health means helping them understand how to cope with challenges, but more importantly it requires creating a society in which people can actually be psychologically well. They must be free from racism. They must earn enough to live. They must be able to move in their bodies without fear of judgment and discrimination.
These things — and many more — could ease widespread suffering. COVID-19 may have taken more than people could bear, but it’s also given people the courage to demand the fundamental change critical for improving our individual and collective mental health. If we create a post-pandemic world without seizing that opportunity, we’ll have lost more than we could imagine.
If you want to talk to someone or are experiencing suicidal thoughts, Crisis Text Line provides free, confidential support 24/7. Text CRISIS to 741741 to be connected to a crisis counselor. Contact the NAMI HelpLine at 1-800-950-NAMI, Monday through Friday from 10:00 a.m. – 8:00 p.m. ET, or email . You can also call the National Suicide Prevention Lifeline at 1-800-273-8255. Here is .