During a mid-week night recently, restaurants in the Dupont Circle area of Washington, D.C., were packed with young professionals. One would never have guessed from this lively, jovial crowd that America was experiencing a major economic crisis, perhaps the most seismic since the Great Depression.

But it was.

And still is.

And it's taking its toll not just on the pocketbooks of a number of Americans, but also on their mental health as well, psychiatrists in various areas of the United States report. In brief, not all Americans are as lighthearted as the young professionals observed that day in the nation's capital.

Probably the most common emotion that many Americans feel these days is anxiety, Hunter McQuistion, M.D., reported in an interview. McQuistion is director of outpatient and community psychiatry at St. Luke's and Roosevelt Hospitals in New York City and president of the American Association of Community Psychiatrists. And "with everybody sitting on the edge of their seats, it is [often] being manifested clinically," he said.

For example, one of his patients works in the financial industry and is going from week to week waiting for a pink slip. Another patient works as a paralegal for a law firm. The firm has already laid off dozens of lawyers, so he dreads that he will be next. McQuistion suspects that his patient's apprehension may be behind the abdominal discomfort he's been experiencing.

Rosalind Griffin, M.D., a Farmington Hills, Mich., psychiatrist, has observed something interesting in her practice in recent months, she said—an upswing in people seeking mental status evaluations for plastic surgery. This upswing mirrors people's fear of losing their jobs and their hope that a little "nip and tuck" will help them look younger and keep their jobs, she believes.

"The most stressed individuals from the economic downturn in my practice have been small-business owners," observed Charles Berlin, M.D., a private practitioner in Pittsburgh. "These individuals have been extremely worried about the survival of their businesses. At stake for them has been the very real issue of their economic livelihood, as well as much worry about their employees and their employees' families who depend on their business's health."

"Yes, absolutely, people are worried," Barbara Fitzgerald, M.D., an associate professor emeritus of psychiatry at the University of Louisville and past president of the Kentucky Psychiatric Medical Association, said. "They wonder, 'Am I going to have a job?' Or, if they are on disability, which many of our patients are, they wonder, 'Are the [government's] resources going to continue to be available to support me?' Especially in their health care, I would say."

There is also widespread trepidation about shrinking investments, especially among people who are retired or near retirement, Berlin noted." I started hearing frequently about these concerns [from my patients] several months ago. Most individuals expressed distress, but felt that there was little they could do about it, so they mostly put it out of their mind. A number stopped opening investment statements."

Young Americans are skittish too, as Leigh White, M.D., who works in a student psychiatry service at Michigan State University and is president-elect of the Michigan Psychiatric Society, pointed out. "You probably know that the car industry in Michigan is in big trouble, and that the unemployment rate in Michigan is very high, quite a bit higher than the national average.... A lot of the students I am seeing now [are extremely stressed] because their parents are losing their jobs.... There are questions about whether they can continue in college."

The number of students visiting her service has also increased by a third or so since last year, White said. "This is very similar to what is happening nationally. Part of that may be good news in that some of the stigma about seeking mental health care is lifting. There are certainly a lot of public-service campaigns going on now, including APA's, which are trying to get college students to seek mental health care. But part of the increase in visits to our service may be due to students' anxieties about their particular economic situation."

Yet the angst that many Americans are experiencing because of the economic crisis may pale in comparison to the psychological devastation that many others are experiencing when they lose their jobs because of it.

Michael Engel, D.O., a psychiatrist in private practice in Traverse City, Mich., has a number of patients who have been especially hard hit by the economic crisis because of the near collapse of the automobile industry in his state. Some of those who have been laid off and have been unable to find other work are terrified that they are going to lose their homes to foreclosure or that they will have to declare bankruptcy, he said. Others have psychologically deteriorated to the point that they qualify for Social Security disability payments. "In some of these patients, a kind of hopelessness—you know, 'Is the sky falling?' or 'Will there be a tomorrow?'—weaves into their world," he observed. "In psychiatry, hopelessness is a very malignant symptom."

Indeed, depression and hopelessness stemming from loss of job, home, or income may play a part or be the trigger behind cases of suicide reported prominently in the news, Daniel Dahl, M.D., said. In addition to being an associate professor of psychiatry and psychiatry residency training director at the University of Alabama, he is president of the Alabama chapter of the American Foundation for Suicide Prevention.

Ironically, the economic crisis that has wrought such havoc with people's psyches is also jeopardizing their access to care (see Chronic Illness More Often Going Untreated).

"There are more people struggling to keep their psychiatric appointments because of cost," said Howard Weeks, M.D., medical director of youth services at the University of Utah Neuropsychiatric Institute." They are having more trouble filling prescriptions because of costs."

Dahl described a similar scenario: "Some patients are not coming in for visits because they cannot afford the copay. Others are not buying their medications for the same reason."

As many Americans have lost their jobs, they have also lost their health insurance, and as they have lost their health insurance, a number have turned to the public sector for help, Michele Reid, M.D., said. Reid is medical director of Michigan's largest community mental health program—the Detroit-Wayne County Community Mental Health Agency—and the representative of the Committee of Black Psychiatrists to the APA Board of Trustees. "Normally in times of economic downturn, more people qualify for Medicaid," she explained, "but an ongoing concern is that as we have more and more Medicaid beneficiaries choosing our services, we may be less able to serve people who are totally uninsured...."

That concern is not limited to Michigan. "I was just in California doing a consultation with the medical directors of the county mental health programs," David Pollack, M.D., a professor of public policy at Oregon Health and Science University, told Psychiatric News. "They were describing how fairly stark the cuts in services for their patients have been. I'm sure that the same is true, maybe to a lesser degree, for many other states. For example, in some counties, all the case management and counseling services for patients with severe mental illness have been cut, so that they are receiving only psychotropic medications. In at least one county it is the other way around—they are getting case management but no psychotropic medications.... And in many places, services for people who are totally uninsured are being slashed or eliminated altogether."

Still other Americans who have lost their jobs and thus their health insurance are not even trying to seek refuge in the public safety net. And those who do may still have to cope with unintended, sometimes tragic, consequences. Take, for example, 57-year-old "Jim." After he lost his construction job, he could no longer afford health insurance, and once he could no longer afford health insurance, he could no longer afford to visit a psychiatrist or buy his psychotropic medications. He became severely depressed and suicidal and ended up in a hospital as an unfunded patient. His psychiatrist lamented, "And the worst for him is yet to come—the bill that he is going to receive for his hospitalization."

No one knows when the financial gloom will lift. No one knows how many more people will be mentally ailing due to the ailing economy (see Psychiatrists Are Helping Their Patients Get Care).

"It is my understanding that all of these recessions have a cyclical nature to them," Engel said. "If the economy is better and if job security is better, then obviously you would see patients do a little better in that regard."

"I am fairly optimistic that our economy will start to recover in a year," Weeks opined. "But I think that the average American worker will still be significantly stressed. The downsizing, the layoffs, they are going to have a huge ripple effect on mental health."

"If the economy continues to get worse before it gets better, and if more and more people are out of work, I suspect that we are going to see much more family discord and depression in addition to anxiety and maybe even an increase in the suicide rate over the next couple of years," McQuistion ventured. "We may see an uptick in acute exacerbations of chronic mental illnesses and more utilization of emergency rooms and inpatient services if the social safety net does not remain sufficiently intact. Despite the Obama administration's social commitments and the [recent federal financial] stimulus package, it is important to remember that the American mental health care budget is primarily determined state by state." ▪