David Rosmarin.

David H. Rosmarin, associate professor of psychology at Harvard Medical School and a clinical psychologist at McLean Hospital.

Kris Snibbe/Harvard Staff Photographer


How the already anxious avoided global spike in COVID anxiety

Psychological tools learned by those in treatment proved protective in high-stress event, study finds

8 min read

As the COVID-19 pandemic was raising anxiety levels around the world, psychologist David H. Rosmarin noticed something surprising: Patients being treated for anxiety weren’t reporting the worsening symptoms he expected.

Rosmarin, associate professor of psychology at Harvard Medical School and a clinical psychologist at McLean Hospital, decided to take a closer look. Now in work published this month in the journal PLOS One, Rosmarin and colleague Steven Pirutinsky of Touro University, showed that the two main therapies used, cognitive behavioral therapy and dialectical behavior therapy, appear to have been protective against pandemic-related anxiety in the cohort of 764 individuals being treated during the pandemic.

Rosmarin spoke with the Gazette to highlight an encouraging take-home message for those with the condition. The interview was edited for length and clarity.

How did this study get started? Did you see the chance for a natural experiment on anxiety when COVID struck?

It started with clinical observation. At the start of the pandemic, we had 500 active patients in our cognitive/dialectical behavior-therapy outpatient center, and I was expecting their mental health to plummet.

I actually felt anxious myself, thinking that it was going to be a total disaster. But disaster did not happen.

Our patients seemed to be fine. Many of my colleagues reported the same. We weren’t getting emergency phone calls from patients who were in treatment before March 2020. We didn’t need to hospitalize a single one of those patients since they were not threatening suicide or decompensating.  

About 18 months ago, I wondered if these clinical observations might map onto our data, because you don’t know unless you take a look at the numbers. Working with my long-time colleague Dr. Steven Pirutinsky from Touro University we sorted our patients, based on when they commenced treatment, into four groups mapping onto recommendations from Yale University: prepandemic, pandemic onset, during the pandemic, and post-pandemic.

“When people get the skills and the tools that they need — specifically CBT and DBT skills — they can be protected against surges in anxiety even in the context of wild uncertainty.”

We then compared their treatment trajectories, from intake to discharge and at all points in between. This allowed us to compare not only whether they had the same levels of anxiety at the beginning and at the end of treatment, but whether the slopes of treatment change were the same.

We found that patients who initiated treatment before the pandemic — prior to Dec. 31, 2019, or in the first months of 2020 — did not have any bump in anxiety in mid-March through May, when the whole world was anxious.

In addition, the trajectories of patients in different groups were no different from each other, demonstrating that therapy was equally effective, even when patients initiated treatment during the pandemic. I believe this is a pretty cool finding, since it shows that CBT and DBT are powerful to protect against once-in-a-century levels of distress.

So the data came retrospectively, from questionnaires routinely filled out at each visit?

Yes, we administered the GAD-7 at intake and every subsequent visit. The measure contains seven questions to measure generalized anxiety disorder, and it’s the American Psychiatric Association’s gold standard self-report measure.

What is the message that you get out of the apparent stability of anxious people during undoubtedly anxious times?

When people get the skills and the tools that they need — specifically CBT and DBT skills — they can be protected against surges in anxiety even in the context of wild uncertainty. We have known for many years that these are effective treatments, but to see it in the context of the pandemic is, I think, quite unique and striking.

The second message is that having anxiety can be a good thing and help us to thrive. When anxiety leads us to get the help we need, it can inoculate us against future distress. If you compare the trajectories of prepandemic patients from our sample — all of whom had pre-existing anxiety disorders — to the general public, you find that the patients did better.

An analogy might be someone who’s overweight, and they finally say, “I can’t do this anymore.” They diet, exercise, and even get a nutritionist and a trainer. They do what they have to do to lose weight and because of that, in the end, they may have a better trajectory in terms of metabolic syndrome and heart disease compared to others who were never overweight.

You see a similar trend in relationships. When couples hit a rough patch, and they say, “We have to work on our dynamics,” and they go and get the help they need, the resulting connection is often much stronger for many more years, as opposed to those who trudge through since it never got so bad that they needed help. There are plenty of other examples of this in behavioral health, but it’s the same concept.

Had any of these people completed therapy and were using tools learned in therapy on their own?

That’s a good question. The length of therapy depends on a number of different factors. One is how severe symptoms are at intake. Two is how much people are implementing these skills between sessions on their own. Sometimes people take to them quickly; sometimes people need to hear it several times before they are ready. So everybody’s treatment trajectory was unique, but the mean average was just over seven sessions, which is not a high dose.

Outside of your cohort, how much did mental health issues rise among the general public during the pandemic?

In the first year of the COVID pandemic, anxiety and depression increased 25 percent among adults, according to the World Health Organization.

“I should clarify something: Uncertainty does not cause anxiety. It is intolerance of uncertainty that causes anxiety.”

Does this belie a general perception of people with anxiety, whether they’re in therapy or not, that they are very fragile or frail?

Yes, this is the core of the issue: This is the perception, but it’s not true. In fact, it was my assumption going into the pandemic that my patients wouldn’t make it. But they were actually much more resilient because they had been taught what to do.

One of the things we teach our patients in CBT is to do things that make them anxious and learn that the feelings will subside. This is called exposure therapy, and it directly makes people more resilient to face uncertain situations, which tend to make us anxious.

You can have a lot of uncertainty in your life, but if you’re able to tolerate that uncertainty, you’re able to weather it. If you understand what to do, then you’re not seeking to eliminate uncertainty all the time, you understand that’s par for the course. You’re not judging yourself or catastrophizing about it. And when you have a higher tolerance for uncertainty, then it doesn’t need to lead you in the direction of worsening anxiety.

And that’s healthier simply because uncertainty is just part of life?         

Definitely, and during the pandemic it was a part of everyone’s life. But I should clarify something: Uncertainty does not cause anxiety. It is intolerance of uncertainty that causes anxiety.

Would it be accurate to say that one of the core principles of cognitive behavioral therapy is to expose yourself in different ways to your fears and your anxieties?

Yes, this is a key strategy. It is fair to say that a core tenet of CBT is facing one’s anxieties head-on.

And what about DBT?

DBT is similar, but it balances change and acceptance: “Yes, I want to change. I want to face my fears, but I need to accept that I’m not quite ready to do that. I’m a little bit further away from where I really want to be.”

In DBT, we are more attentive to this and gradually help patients to move in the direction they want, while accepting that we’re not always going to get there. That’s as opposed to CBT, which is like, “You have OCD? OK, we’re sticking your hands in the toilet today. We’re doing this!”

Do patients start with DBT and then move to CBT?

Well, when it comes to anxiety disorders, often it’s the reverse. We first try to get patients to move forward, and if it’s not working, then we’ll have to balance with acceptance. We move back, pause, stay where we are, or coast in neutral for a while.

Is there a take-home message for people who have anxiety?

Yes, use the opportunity of your anxiety to build your resilience and get the skills that you need, because you never know when you’re going to need them. And they can make a massive difference when a crisis hits.