In 1918, as the world collapsed under the weight of a different pandemic, a simultaneous mental health toll rose from underneath. While the influenza pandemic of that era infected 500 million people — taking the lives of 50 million globally and 675,000 in the United States – many survivors suffered a "post-influenzal depression." Historians noted how their lives became "unbearable, even after the infection had passed." Today, we are seeing similar trends among COVID survivors.

When pandemic flu took hold, a novel clinical entity called "encephalitis lethargica" also surged. Despite unclear evidence, doctors connected it to influenza. The syndrome’s constellation of vague neuropsychiatric symptoms sounds eerily similar to long COVID.

Psychiatrists, then, also linked new episodes of psychosis to influenza infection, as we have seen with COVID. One oft-cited study indicates that suicide rates in the U.S. increased during the 1918 influenza epidemic. So far, data from 2020 shows that overall suicide rates declined by three percent compared to 2019, but increased among racially minoritized men.

While the clinical history of the COVID-19 pandemic is constantly being rewritten, these echoes of a pandemic past are haunting. But what remains largely absent from influenza’s historical record is what I see every day as a doctor training in psychiatry: a mental healthcare system constantly fraying at re-stitched seams.

We were warned.

Though the incessant exposure to never-ending death and fear from influenza are well-documented today, accounts of how this stress impacted community mental health at the time were scarce. The early 20^th century was notorious for more severe mental illness stigmatization than now, so the lack of coverage on the optics of a psychiatric crisis is unsurprising.

These days, however, the signs are everywhere. For me, the biggest red flag was when a young woman who came to the emergency room scribbled "PAY ATTENTION TO US" in black Sharpie on the glass wall separating us. She was waiting several days on a gurney for an elusive psychiatric bed. There are thousands more in the country just like her.

Symptoms of anxiety and depression have skyrocketed since the first cases of COVID appeared in the U.S., disproportionately affecting racial minorities and low-income populations. Despite overall statistics reporting a decline in suicides, COVID’s first wave saw more patients come into the emergency room after suicide attempts and overdoses than in the year prior, and emergency psychiatric care overall increased after COVID surges. Amid cycles of school closures and virtual learning, the mental health of children and adolescents has been uniquely impacted, with pediatric emergency rooms overwhelmed with psychiatric crises. As the country’s mental health worsened and more patients required hospitalized treatment, the media was consumed by stories of excessive wait times for an inpatient psychiatric bed.

On shifts when I work in the psychiatric emergency room, each morning begins walking past a row of patients resting in stretchers against the wall adjacent to the staff entrance. Many of them wait in a metaphorical line for admission to an inpatient unit for further care. Before COVID, that line moved forward gradually as admitted patients were discharged. When COVID hit, that linear process was upended – moving less in an efficient, Tetris-like fashion, and more like a game of Pacman with an everchanging maze and triple the ghosts chasing you. Except the ghosts are COVID.

Much of the bottleneck in inpatient mental healthcare during COVID revolves around the social nature of treatment. Despite popular but inaccurate depictions of psychiatric units, a core piece of healing is engaging in activities with other patients and healthcare providers. The infectious nature of COVID paralyzes this crucial part of recovery. Infected patients are moved from psychiatric wards and onto a medical floor, where they do not receive the much-needed social supports built into the unit they left. Affected psychiatric wards then undergo a quarantine period that suspends them from admissions, further straining emergency departments.

While comparisons of the mental health toll of pandemic flu to that of pandemic COVID can only be traced so far, the writing is on the wall. And given the untenable psychiatric crisis we are facing today, it appears leaders are taking notice.

In his State of the Union address in March, President Biden pledged support for stronger mental health investments. His strategy includes financial commitments to build a more robust mental health workforce, broader access to treatment, and the launch of a federal crisis line. While the President’s plan is commendable, his overall blueprint must also address the chronic shortage of psychiatric beds plaguing this country for decades, which has directly led to the backlog in mental healthcare witnessed over the last two years. His strategy should also consider the much needed expansion of supportive housing programs critical to discharging patients safely from the psychiatric ward, and protecting them from returning to the emergency room.

Federal policy formulations serve as a necessary first step to turn the tide against our nation’s psychiatric emergency. Adopting them into the appropriate actions will determine the difference between being prepared for the next spiral in this mental health crisis, or ignoring the lessons from the far and recent past.

If you or a loved one is experiencing a mental health crisis, call Connecticut’s crisis line at 211 or go to your nearest emergency room. The National Suicide Prevention Lifeline is also available at 1-800-273-8255. You can also text with a crisis counselor by texting "CT" or "TALK" to 741741. Additional resources are available online at the American Foundation for Suicide Prevention in the U.S., or the International Association for Suicide Prevention outside the U.S.

Sandhira Wijayaratne is a psychiatry resident at the Yale School of Medicine.

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