PTSD and Mental Health during the Coronavirus Pandemic: A Conversation with Dr. Karestan Koenen

interview by kiran ebrahimi

Creator: Charlie Samuels | Copyright: ©2012 Charlie Samuels

HHPR Associate Editor Kiran Ebrahimi interviewed Dr. Karestan Koenen, a psychologist and epidemiologist at the Harvard T.H. Chan School, whose research focuses on the physical and mental effects of trauma and PTSD. Dr. Koenen received her B.A. in Economics from Wellesley College, M.A. in developmental psychology from Columbia University, and Ph.D. in clinical psychology from Boston University. She is a strong advocate of better support for victims of sexual assault and PTSD. This interview has been edited for brevity and clarity.

Kiran Ebrahimi (KE): Thank you for meeting with me today. Could you tell me a little bit about your research career and your motivation for studying PTSD and mental health?

Dr. Karestan Koenen (KK): I am a professor of psychiatric epidemiology at the Chan School. But my Ph.D. is actually in clinical psychology. This year, I am on sabbatical and spending the year in the psychology department and William James Hall at Harvard, which I am enjoying a lot. I came to the work of PTSD through personal experience. When I was in college, I majored in economics, and I was going to do economic development work. I was particularly interested in Africa and empowering women during a time when there was a big focus on women and development. Then in my early 20s, while volunteering in the Peace Corps, I was raped and developed PTSD, in part because of what I experienced, but also in part because the institutions and the medical care I dealt with afterwards were incredibly poor. They did everything wrong. So I had a horrible experience, post-sexual assault, and I developed PTSD. I actually started getting interested in PTSD through my own recovery, trying to understand what was happening to me. I started reading books and doing my own research, and that led me to be interested in changing my career and pursuing a career in psychology. I thought I would be a private practice clinician where I would treat women, especially sexual assault cases, and go into clinical practice. And then when I was in grad school, I fell in love with research. So I ended up pursuing a research career, but my interest in the broad field is really through my personal experience. I also think a clinical background can be really informative for research. When I was a grad student, I did a practicum at the Boston VA hospital in the Women's Health Sciences Division, which treats women veterans, and I noticed that the women who came in because they had military sexual trauma and PTSD, also had all these physical health problems: diabetes, hypertension, and autoimmune problems. And at the time, I remember wondering — did their PTSD cause the physical health problems or vice versa? One of my main areas of research for the past 10 or 15 years is on the intersection of mental and physical health and how trauma, PTSD, and depression affects physical health over the life course and accelerated aging. A lot of the things that I pursued for the longest time have come out of things that interest me through experience. Even though I haven’t done one on one treatment in quite a long time, I still feel like my clinical background shapes the questions I focus on in my own research.

KE: Since the start of the pandemic, health professionals have become more aware of mental health issues like PTSD and health care worker burnout. Would you like to share your thoughts on that?

KK: The issues around stress for health care workers, med students, and all kinds of hospital staff have been known for a long time. Before the pandemic, there were a lot of articles about the number of hours residents work and negative outcomes. The pandemic aggravated a problem that already existed and hadn't been addressed. I think the same thing can be said more broadly for mental health. For example, we know, for youth, that rates of anxiety and depression at the population level have been increasing, since about 2010-2012. The pandemic didn’t make it happen. It created some problems but in terms of mental health, a lot of the problems already existed and were exacerbated by the pandemic. That suggests to me that there were factors that were bad for health care workers’ health and well-being and for young people in the population at large that existed before the pandemic. There’s ideas about what those are, but no one has answered them for sure. We have a misplaced focus on mental health and well-being as a completely individual-level factor. If you're stressed and you work in the hospital, society says that you need to do better self-care, you should go for walks and take a bath and yoga or meditate, which all are great things. But it puts all this pressure on the individual to change their behavior. I think that's the wrong way to think about it. I think the shift we need to make is to look at the structural factors and institutional factors that are adversely affecting people's mental health and well-being. At the same time, we need to think of policies at an institutional level or a lab that can make it easier for people to do the things that would support their well-being. Some examples are places that have longer or more flexible parental leave policies that tend to reduce stress on their workers. I'm someone who studies genetics, but in the pandemic, I became more interested in the structural factors that improve people's mental health. What are the policies and what are the modifiable ones that could really improve and buffer mental health and well being? For example, there's some evidence that economic policies that protect people from losing their homes or jobs are better for mental health and reduce distress. Those kinds of policies can help reduce all kinds of stress and also obviously improve physical health and be a buffer for mental health. I think we need to pay more attention and think about what those policies could be that would improve mental health.

KE: I read that you hosted a Mental Health Forum series at the Chan School. How has this conversation around mental health shifted during your career and during the pandemic?

KK: I've seen a huge shift during my career. I wanted to study trauma and PTSD. If I was going somewhere—let's say I was on a plane and someone asked me, what are you studying in school?—and I said, “PTSD,” they either looked at me not knowing what I was talking about or they would say, “Oh, you must work with Vietnam War veterans.” The huge shift I've seen now is, if I say I study PTSD, everyone has a story. And that has changed massively and it's changed even more during the pandemic. Before the pandemic there was interest in trauma-informed care. There was growing awareness around childhood adversity already, and that only increased during the pandemic. People who wouldn't even have been interested in the area at all are now really interested. So the pandemic brought it closer to home for more people. I think that has been a big shift.

Similarly, in terms of mental health, I've seen huge generational changes. My son is 16 and my niece is 17 and I see kids that age or young people and they are so much more open to talking about mental health. They have more language for it than I did at that age. So I hope that's positive and in the long-term, will translate into less stigma. I still think mental health is greatly stigmatized, but certainly, whether it's trauma or mental health more broadly, it seems like more people see it as something that touches them and not something that just happens to other people.

KE: You're involved in the Aurora study, a large NIH funded research initiative focused on improving our understanding of trauma and the recovery of individuals who have undergone traumatic experiences, and you conduct research on the relationship between genes and PTSD. What effect has your research had on your understanding of mental health?

KK: One area we already touched on is the intersection of mental and physical health and that's something I came to clinically. My research and the work of others has confirmed a bi-directional relationship between mental and physical health. Even though healthcare and the funding through NIH treat these as separate: We have a National Institute of Mental Health, and then we have NHLBI, which is the National Heart, Lung, and Blood Institute. Our brain exists in our body and our brain and our body are interconnected and affect each other, which seems really obvious, but it's just not how the healthcare system or even funding and research has been historically recognized. So my research has just convinced me of the importance of that interconnection and how by keeping them separate, we're probably missing a lot of modifiable factors that could help improve mental and physical health. Then I think my other work, which I've done a lot of work in genetics and putting the genetics of PTSD, we've made a lot of progress, but we're still in really early days there. When we started doing genetics of PTSD, there were some really early papers which suggested that you can predict PTSD with certain genes. People thought that would be the case, but what we've learned is how complicated it is. And it's not just PTSD and psychiatric disorders in general. It's been pretty sobering.

KE: There's a lot of misinformation and preconceptions surrounding PTSD and mental health. What should young people know about this important issue?

KK: A couple of things I think are really important. One is that it's normal to be upset or feel distressed if something bad happens, like a pandemic or the death of a loved one. Feeling distressed or upset or anxious does not, in itself, mean you have a mental disorder. I got this question a lot during the pandemic. Humans aren't robots. We have emotional reactions to things, and sometimes for example, someone in your life dies. It's really normal to feel sad about that for a while. And the question I always get is when do you know if being upset about something is a problem? Is it something you need to get help for? And the challenge is quite individual. The criteria you can use is the amount you’re upset and distressed whether it's feeling down for many days in a row or being really anxious or on guard. Is it interfering with you doing the things in your life? Is it interfering with you going to class, or is it interfering with how you're doing in school? If the answer is yes, that it is interfering with these different areas of your life, that's when the warning signs say okay, maybe I need to talk to someone about this. Each person has to learn that about themselves because the warning signs for me may be different for someone else.

The second thing for young people is to be careful of the information you find online. It’s great that there's so much information out there and it's so accessible, which wasn't the case when I was a kid. Try to find reputable sources, whether they are university-related or science-related like WebMD.

The third thing for young people is to try to identify someone who is older who you can talk to, even if it's not your parents. If a friend or somebody is very distressed or suicidal, don't handle that yourself. It's really hard if you're 17 and you have a friend who's ready to kill themselves. That’s too much for any of us. Get support.

The last thing I would say is peace of mind: your mental and physical health are interconnected. Eat well, get exercise, try to get enough sleep, etc. All those things will also be good for your mental health. When you find other things that help you like running or weightlifting or reading or things that you do in your life, try to start those habits at a young age because those habits will really serve you well through your adulthood. It's hard, but try to make time for those things that make you feel better. If you can do that when you're young, it will really make you more resilient later in life.

KE: Thank you for your time.