'Flattening the curve may shorten your life'

A Q&A with Dalhousie University psychologist, Dr. Simon Sherry

“By policy, we have required Nova Scotians to engage in avoidance, isolation, and vigilance, and this is, in effect, a province-wide prescription conducive to developing mental illness.” [Dr. Simon Sherry, Psychologist, Dalhousie University]

After the pandemic was declared nearly two years ago, followed by the lockdown to “flatten the curve,” one concern that struck me early on was what the unintended fallout might be. By that point in my life, looking at the world through a full-cost accounting lens had become second nature for me. I had spent ten years as a senior researcher for a non-profit organization based in Nova Scotia that tried to measure the hidden costs associated with public policy. While my work focused mainly on forests, I also did indicator research on education, work hours, living standards, and greenhouse gas emissions. I co-wrote a policy manual for Nova Scotia’s civil servants, to help them incorporate this kind of thinking into their decision-making. No matter what subject I was working on, the key message was always the same: every policy decision comes with hidden costs—things that end up being bad for society, but are often not counted or even considered, but should be.  

Public health measures are no exception.

Dr. Simon Sherry, psychologist and professor, Dalhousie University, Halifax. Photo contributed.

Dr. Simon Sherry is a psychologist and professor in the department of psychology and neuroscience at Dalhousie University in Halifax. Sherry is also director of the university’s Personality Research Team, which has made advances in our understanding of the link between personality and mental health. Sherry’s clinical practice specializes in treating eating disorders, perfectionism, alcohol problems, depression, anxiety, and personality disorders.

According to his Web site, Sherry “regularly works with the media as part of his goal to educate the public about mental health problems in a scientific, non-sensationalized way.”

I reached out to Sherry for his insights on how the pandemic and the government’s reaction to it has affected Nova Scotians as we approach the two-year mark, and what we can learn from it.

[This interview was initially conducted over the phone, and then continued over email. It has been edited for length and clarity]

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Linda Pannozzo [LP]: What has concerned you the most in terms of the mental health of Nova Scotians over the last two years?

Simon Sherry [SS]: I would say what concerns me most is that poor mental health has now become statistically normal. Poor mental health is now common, frequently observed. There has been in our country and in our province, a population level shift in the direction of poor mental health and that's concerning.

Let me unpack this some more. We've learned a lot in the last two years, and one consistent research finding is that people with a pre-existing vulnerability—people with a pre-existing mental health problem—have had a particularly difficult time in the pandemic. So, if for example, you had a history of depression or current depressive episode prior to March 2020, prior to the onset of all this mess, during the pandemic you've had a particularly difficult time. If you're already prone to panic or anxiety, the pandemic has made it worse.

Something that's especially concerning is evidence of what we call new onset cases or new onset problems. This is someone who did not have a mental health problem prior to the pandemic, but because of pandemic related factors, developed a mental health problem. This would be a new case of depression or a new case of alcoholism and once you inaugurate something like a new case of depression— once that problem gets initiated—it tends to be a longer-term problem. You don't necessarily just have one episode of depression. It can take nine months on average to recover from a depressive episode and when a person has one depressive episode across their life, they're likely to have several, with four being a typical number.

Another big problem when it comes to mental health and the pandemic would be the issue of relapse. In this scenario, we've got someone who's maybe been doing well for years. Maybe they haven't had a drink in years if alcohol used to be a problem, or had a history of depression, but they had learned to manage that through medication or change in behaviour, and the conditions around the pandemic triggered a relapse in them. In other words, their old problem comes out under the stress and adjustment of the pandemic.

One more thing that relates to the fact that poor mental health is now statistically normal is that by policy we have required Nova Scotians to go home and behave as if they are mentally ill. What do I mean by that? By policy, we have required people to engage in avoidance, isolation and vigilance, and this is, in effect, a province-wide prescription conducive to developing mental illness. Now, we could argue that these were necessary to mitigate the spread of COVID-19, but isolation, avoidance, and vigilance are also patterns of thinking and patterns of behaviour that are known to produce mental illness.

LP: What do you mean when you say poor mental health is now ‘statistically normal’?

SS: I would say that more than half of the population now has poor mental health.

I will also point out that Statistics Canada had Nova Scotia approaching that number pre-pandemic. But that means if we were to sample the average person across a number of indices—depression, anxiety, stress, well-being—they would now tell us that they have poor mental health.[i]

LP: Have you noticed a change in the kinds of difficulties that people are having since the start of the pandemic or a shift in the people experiencing them? You have touched on some of that, but I'm just wondering if you have any more detail you’d like to share.

SS: Yes, I'd say it's wave-dependent. In wave one, we saw a lot of fear, a lot of obsessionality, a lot of anxiety about health. But several waves and two years later you start to see people having a different set of concerns, like feeling defeated and demoralized and fatigued and worn out by the ceaseless change that this pandemic brings. Mental health problems would be common across waves, but they seem to be different over time.

This pandemic and its restrictions are a lot like a cheese grater that's worn our population down substantially.

LP: So, for two years, we've been told by public health to social distance, wear masks, limit our contacts, be vigilant. And I'm just thinking of little children now, who are just developing cognitively, socially, emotionally, who are being forced to wear masks, and limit their interaction with friends. I’ve heard you talk in the past about how the pandemic may result in a “permanent recalibration” of certain aspects of our society. Can you say a little bit more about that, with particular attention to the effects of the restrictions on young children?

SS: Yes, absolutely, and it's part of an overall problem. We've made this a pandemic about what is easily countable: positive tests, new cases, hospitalizations, ICU admissions, and deaths. These are not only easily countable, but they're widely reported, and I think what we've actually failed to do is to count what is more important.

What's being missed, which is enormously important, is the impact that this pandemic is having on the psycho-social development of our children and adolescents. We are raising kids who are socially and emotionally starved. We're raising kids who are disconnected from recreation and socialization and sports and experiences that are fundamentally important to them, and there's a very real risk that with all of the closures and restrictions that we're starting to push children down a completely different trajectory in their lives because as these experiences accumulate, it's harder to bounce back from them.

Take a child who's six. They've had two years of this now. That's going to fundamentally change their development and their trajectory unless they have significant supportive factors that buffer against all this stress and changes.

Another thing we've learned in the pandemic is that the misery associated with COVID-19 is not randomly or equitably distributed. It's concentrated disproportionately on certain groups, such as those who are disadvantaged and don't have the resources to buffer the stress that we're all being subjected to.

LP: Could you talk more about that? That’s a really important point.

SS: It is. So, we know that socioeconomic disadvantage is a real risk factor for mental illness in the pandemic. What's happening is that people who don't have advantages in terms of, say, the supports and resources that can be purchased or provided, are more susceptible to developing problems. Home schooling would be one example and I’m very pleased to see our government have the conviction to send our kids back to school.

But there's this mythology that's been circulating during the pandemic: that home is safe, that in order to be safe in this pandemic, the best thing you could do is go home, isolate and avoid and hide away. But home is not always a safe place, and cancelling school—these kids are socially and emotionally deprived and the learning loss they experience is real and accumulating and can have lifelong consequences.[ii] If you come from a household where there are fewer resources, there's greater vulnerability to a wide range of outcomes. In terms of how this is affecting some groups more than others, something like homeschooling or school cancelation lands disproportionately on mothers.

LP: Right. So, an additional burden is being placed on them as well.  

SS: Yes, absolutely. A huge burden.

LP: As you’ve just said, disadvantaged groups suffered disproportionately from the lockdowns and public health restrictions, but didn't they also suffer disproportionately from COVID-19, the disease, since they have a higher incidence of chronic disease or co-morbidities and weren’t paid to work from home like the professional classes were?[iii] 

SS: Social inequalities are too often ignored as risk factors for COVID-19. But ample evidence suggests socio-economic disadvantage leaves people vulnerable to COVID-19 itself. Poverty appears to raise the risk for COVID-19 through hardships such as increased exposure to COVID-19 in workplaces, the stress of poverty undermining immunity, barriers to healthcare utilization, such as language barriers, and poverty-linked co-morbidities, such as obesity or diabetes.

LP: Statistics Canada data now show that during the first year of the pandemic, from the end of March 2020 to the beginning of April 2021, 73% of the excess deaths among those under the age of 65 was not a result of dying from COVID 19, but a result of drug and alcohol use, a side effect of the lockdowns and the restrictions. Do you have any thoughts that you'd be willing to share on whether policy decisions about the pandemic reaction should have taken a wider range of possible public health ramifications into account, not just the infection from the virus?

SS: That’s a great question. So, a legitimate question is why is COVID-19 being put above all other diseases and problems? Smoking, alcoholism and suicide, to give just three examples, all kill more Nova Scotians on an annual basis than COVID-19. And one real problem with the COVID-19 pandemic is that it's resulted in a diminution of other problems like obesity or smoking. Even each of those problems are quantifiably and obviously worse than COVID-19.

To give you one example—you touched on drugs and alcohol—every year in Nova Scotia,  1,700 people die from smoking related illness and about another 200 die from second-hand smoke. You can find that data in a quick Google search from the Nova Scotia government website. So, despite this extensive public health effort, you could still smoke throughout the pandemic. This is part of an irrationality where we've lost track of proportionality, where the risks are. And I think what's happened is we have habituated to death by alcohol, smoking, cancer, heart disease and stroke. We've normalized death by those same problems, but we haven't yet normalized or habituated to death by COVID-19. So, we're going all out to stop COVID-19 and neglecting a wider perspective.

LP: And ignoring the public health impact that the restrictions themselves are having.

SS: Yes, we have a narrow focus and a disproportionate fear of COVID-19. We've lost track of numerous other factors that compromise the health of Nova Scotians and that shorten lives such as [being] sedentary, smoking, drinking, obesity and mental illness.

LP: Some people will argue that if it wasn’t for the lockdowns and the restrictions, especially prior to the availability of vaccines, the death toll would have been much higher. So even though the sweeping measures have created a whole other set of mental as well as physical health problems, they were necessary to minimize the damage. What would your response be to that?

SS: Wave 1's restrictions were harsh but mostly necessary. At that time, COVID-19 was novel and misunderstood. An invisible, hard-to-contain virus is a formidable foe. Vaccines are also a very useful addition to our COVID-19 mitigation toolbox, especially in terms of reducing severe COVID-19 symptoms.

But I want to focus on the death tolls you mentioned. Death is obviously an important outcome. It's also unambiguous. Grandpa is either dead or he isn't. But death tolls tell partial, incomplete, and sometimes misleading stories. What happens if we shift perspectives from a focus on death tolls to years of life lost or death that is premature? This can be estimated or predicted. We can predict how many years of life are lost when we remove children from schools and sports and recreation, workers from jobs, family from each other, and so on.

And these predictions of years of life lost are ugly. Studies suggest millions of years of life are projected to be lost due to school closures.[iv] Research also indicates lockdowns shorten lives, resulting in millions of years of life lost, especially among people who enter into lockdowns with pre-existing mental illnesses. Lockdown-induced marital problems, domestic violence, mental illness, addiction, and social isolation may very well shorten lives. Years of life lost are also concentrated, disproportionately, on people who are ill or poor or otherwise vulnerable. 

Studies on years of life lost are not without controversy or detractors, but looking at pandemic restrictions through the lens of years of life lost warrants close consideration. People may be less supportive of lockdowns and restrictions if they knew it was trimming years of life off their existence or that of their children.

In other words, flattening the curve may shorten your life.

LP: As a result of the restrictions, people have died alone. We've not been allowed to gather properly for funerals, and now there appears to be a large segment of the population that seems OK with the vilification of another segment of the population, namely the unvaccinated. I would argue that’s a misdirection of justified anger about the pandemic and how it's been handled. My question is, are we losing some of our humanity?

SS: Yes, and it's sad. I think there is an anger and a cynicism that has set in, and I think there's an emotional exhaustion that's conducive to a basic incivility to one another. I think Nova Scotians are tired, for good reason, and sometimes that's resulting in us being horrible to each other. As a counterbalance, I would also say that I've seen some impressive displays of humanity and kindness in this pandemic. I have seen people pull together and step up in the middle of all this mess, too. So, there's still a bit of goodness that shines through among Nova Scotians, despite our very understandable emotional exhaustion in this whole mess.

LP: In the last few days we’ve been hearing from the leadership of the Nova Scotia Teachers Union as well as some parents that the schools are not safe enough for kids to return. And yet experts in children's health have repeatedly said the schools are the best place for children to be. You have touched on this, but I just wonder if you could expand on your thoughts about this.

SS: Sure. So, there's much more to life than avoiding disease, and we cannot have a myopic focus on just case-containment. There's no sense in having kids who are COVID-safe but mentally ill. And we're being prescribed avoidance and isolation and vigilance, but at this point, what our kids and our brains really need would be fun, novelty, and connection. So, these complaints, these fears involve Nova Scotians showing an unreasonably low level of risk tolerance for COVID-19. The fear of COVID-19 in our community is disproportionate, and we need to stop pretending that zero is the only tolerable level of risk. Not all risks should be avoided in this current fourth wave, and its variant represents a risk that is tolerable for most.

LP: I wanted to ask you about fear. Early on in the pandemic, when we knew very little about the virus, people were made to feel fearful by both the public health messaging, but also as a result of a relentless diet of click-bait stories in the media. And now the situation is quite different. I mean, nearly two years have passed. We now know who's most vulnerable for serious outcomes from the virus. Nearly everyone is vaccinated, at least in Canada. Many of the most vulnerable have gotten three shots, and OMICRON appears to be less pathogenic. Nevertheless, the fear seems to be ramping up rather than abating, and I think it would be fair to say that public health policies now have more to do with public opinion than they have to do with science. Do you have any thoughts about how we get ourselves out of this culture of fear?

SS: You know, we’re always looking for a glimmer of hope amid this adversity. So, here's a potential glimmer of hope. We need to rely on observational learning. People need to examine the data, the information available in their immediate social circle. They need to take a look at their friends, their co-workers, their families and others and see that COVID-19, when vaccinated, is readily survivable, and I'm hoping that these observational learning opportunities correct the irrational and disproportionate fears that have emerged. I think we have a real shot to overcome some of this fear through examining others.

I'd also say this: you don't overcome fear by shrinking from it. You don't overcome fear by hiding, running, sheltering or cowering. You overcome fear by being brave and moving forward and that braveness can come out in various ways. If you are anxious, fearful and avoidant about a trip to the grocery store, then you need to go and you need to go repeatedly until you can overcome that barrier. If you are anxious, fearful and avoidant about dropping your kid off at school, then you need to go, and you need to go repeatedly until you overcome that fear.

But a lot of our messaging has been, go home, stay home, shelter in place and hide. And people have internalized that messaging, and part of the problem is they're reflexively reacting to wave four, as if it is wave one. So, we need to download some updates, get some new information and most importantly, stop running and start approaching your COVID-related fears.

LP: In your opinion, should public health be trying to allay the public’s fears at this point? Or do you think they are just reacting to a now fearful public who are demanding to be kept safe?

SS: Yes. The problem with providing safety is that it breeds more fear, especially when the safety is unnecessary. If you're providing a false and unnecessary safety, then all that does is convey the message that there's a large danger out there that you require protection from. And so, if you're providing safety that's out of proportion to the actual danger, it conveys alarm to brains and to populations, and that alarm is out of proportion to the actual danger.

So, I think a much better messaging track would be: be brave and move forward.

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[i] After our formal telephone interview, Sherry shared some studies with me to support his contention that poor mental health has become “statistically normal.”  This study, from the Mental Health Commission of Canada, indicates that prior to the pandemic, by the age of 40, nearly 50% of the population will have had a mental illness. Also, if people reach 90 years of age or older, about 65% of men and almost 70% women will have experienced mental illness in their lifetime. Also, as reported by Canada’s Health Info Database, prior to the pandemic, it was estimated that 1 in 3 Canadians will have severe mental illness in their lifetime. Sherry says the study focuses narrowly on severe mental illness, such as bipolar disorder and schizophrenia, and does not include common impairing mental illnesses like social phobia, panic disorder, or personality disorder. If it did, the incidence would be higher, he says. Also, an epidemiological estimate from 2005 indicates the lifetime, pre-pandemic, rate of mental illness is 48.6%. According to Sherry, “When we consider the pandemic exacerbated rates of mental illness, sadly, the prevalence of mental illness in North America, Canada, and Nova Scotia almost assuredly sits above 50%.” Sherry points to the two studies provided below (on years of life lost) as further evidence that the incidence of mental illness has increased during the pandemic.

[ii] In the first week of January, Premier Tim Houston said as much at the weekly COVID-briefing. As was reported here, Houston said, “[Children are] the safest at school, it’s sad but it’s true. The reality for many children in the province, particularly as we move to the depths of winter, school is the place where they are most warm.” Schools are also where some students need to be to access food. “It’s heartbreaking and it’s a terrible reflection on our society but we can’t ignore it.” But child poverty is not a fact of life. It’s an outcome of globalization/ neoliberalism/ industrial capitalism. Governments make policy decisions that impact children and their families all the time. Houston could try to do something to address this in a meaningful way, if he wanted to. Instead, he managed to acknowledge the problem, but wash his hands of it at the same time.

[iii] Dennis Raphael is a professor at the School of Health Policy and Management at York University in Toronto. He is also Canada’s leading expert in the field of social determinants of health, and how poverty and inequality influence health outcomes. He has authored or co-authored at least 10 books on the subject. As previously reported in 2020, Raphael pointed to evidence coming from studies in the US and the UK, that people of colour, immigrants, and people working in lower paying jobs were more likely to contract COVID-19 and then die from it.

[iv] If you’re interested, Sherry pointed to two studies about years of life lost: “Estimation of US Children’s Educational Attainment and Years of Life Lost Associated with Primary School Closures During the Coronavirus Disease 2019 Pandemic, in the Journal of the American Medical Association (JAMA), and “Years of Life Lost due to the Psychosocial Consequences of COVID-19 Mitigation Strategies Based on Swiss Data,” in the journal European Psychiatry. In the latter study, the authors state: “Strict social mitigation strategies to reduce the morbidity and mortality from acute infections…carry a significant risk for mental health, which can lead to increased short-term and long-term mortality and is currently not included in modelling the impact of the pandemic.”