The enforced seclusion and inability to plan ahead made working full-time as an administrative assistant at WakeMed and getting her daughter ready for kindergarten more difficult. When Kimray confided that she was feeling stressed and overwhelmed, her doctor recommended she talk to a behavioral health associate through a virtual hookup in the office.

That first meeting led to two more. Kimray says the person is calming and receptive to her anxieties and helped her steady herself through simple things such as exercise, reaching out to friends and drinking more water.

But one of the big benefits of their meetings, Kimray said, was “just figuring out that I’m really not alone and that everyone is struggling in their own way.”

More than 6.6 million Americans, about 2% of the population, have tested positive for coronavirus, and more than 195,000 have died of COVID-19. But the mental health effects of the pandemic and the economic fallout touch a far larger number of people.

More than a third of Americans reported having symptoms of anxiety or depression in July, according to an online survey done by the U.S. Census Bureau and the National Center for Health Statistics. That compares to about 11% in the first half of 2019, the center reported.

Meanwhile, a survey of more than 5,400 adults in late June found 41% said they had struggled with a mental or behavioral health problem since April, including anxiety, depression and increased use of drugs or alcohol to deal with emotional issues. Both surveys found symptoms were most prevalent in young adults and decreased with age.

The stress caused by the pandemic can affect different people in different ways, says Dr. Samantha Meltzer-Brody, chair of the psychiatry department at the UNC School of Medicine. How it plays out depends on factors such as a person’s coping skills, genetics, social support and financial situation, Meltzer-Brody said.

Demand for behavioral health appointments is up by a third at UNC, Meltzer-Brody said, for people with symptoms such as trouble sleeping, irritability, lack of energy or motivation and feelings of anxiety or hopelessness. Some people report losing their appetite, she said, while others are over-eating.

“We’re not talking about one bad afternoon,” she said. “We’re talking about something that has become persistent.”

Sometimes these emotions can have serious consequences, as when stress and irritability lead to domestic violence or hopelessness causes thoughts of suicide. Binge drinking and drug overdoses have increased. As of July, the number of people visiting an emergency room for an overdose of opioids or other addictive drugs in North Carolina was up about 20% compared to the same period last year, according to NCDETECT, a statewide surveillance system.

The state Department of Health and Human Services has responded by beefing up its mental health hotline, the Hope4NC Helpline (1-855-587-3463), and developing a crisis counseling program tailored for COVID-19. The state also established a similar helpline, Hope4Healers (919-226-2002), for first responders, teachers, child care providers and anyone who works in health care.

“The behavioral health challenges brought on by this pandemic are great,” Victor Armstrong, director of the Division of Mental Health, said during a press conference. “As a state, we must be prepared to address the long-lasting stressors presented by this pandemic.”

For his patients who have a history of anxiety or depression, the coronavirus pandemic has only made things worse, says Dr. John Holly, a primary care doctor and medical director for six WakeMed primary care practices. Not only has life become more stressful, but often the routines and social connections and interactions that help patients deal with their emotions have been curtailed, he said.

But Holly says other patients are also volunteering that they’re worried or having trouble sleeping.

“Everybody seems to be more stressed,” he said.

Holly can arrange for someone to speak to a behavioral health specialist via computer, through a new program WakeMed began putting together before the pandemic. For those who don’t need that level of care, he’ll recommend simple steps, such as unplugging from social media or the nightly news and taking a walk.

Ernestine Briggs-King, a psychologist at Duke University School of Medicine and director of research at the Center for Child and Family Health in Durham, says she recommends the basics: eating healthy food, getting exercise, trying to sleep eight to 10 hours each night. On top of that, she suggests people work on coping skills, such as deep breathing and other mindfulness exercises.

Briggs-King also tells people to go easy on themselves.

“What I tell my families is give yourself some grace,” she said. “We’re all trying to figure this stuff out.”

Mental health professionals say it’s also important to try to maintain contact with friends and family, by phone, text or email if not in person.

“We are social creatures that require social support And we don’t have opportunities for social connection right now,” said Jessica Tomasula, a pediatric psychologist and manager of behavioral health services at WakeMed Children’s Hospital. “Working out in your garage to a video is not the same.”

As North Carolina’s stay-at-home order took hold and businesses, schools and other institutions shut down, calls to the HopeLine, a crisis intervention and suicide prevention hotline based in Wake County, spiked in April, said executive director Lauren Foster. The 960 calls and texts that month were a record, exceeding the normal range of 500 to 700, Foster said.

Though Hopeline helps people in crisis, only a small fraction of callers are actually contemplating suicide. Of the 2,500 calls the agency received from April through August, 239 were from people who said they were thinking about suicide, Foster said. Most callers just want someone to talk to.

“So we just listen,” Foster said. “And we provide that encouragement and support and that validation that what they’re going through is really hard or scary and give them a safe space to process what they’re feeling.”

The volunteers who answer the phones at the Hopeline record the reasons people call. About 500 of the 2,500 callers mentioned COVID-19, and 80 were people who said they had tested positive for coronavrius and wanted to talk about how they felt about it.

Loneliness has always been a big reason people call the Hopeline, Foster said, but since April many have spoken about a related emotion: isolation. About 20% of callers said they felt isolated from family, friends, co-workers and their old lives.

Calls to the Hopeline fell off this summer, but Foster said she expects an uptick again now that schools have reopened and unemployment and other economic assistance has begun to run out.

Unlike the HopeLine, the student counseling center at N.C. State University wasn’t particularly busy last spring. Executive director Monica Osburn says she thinks students were focused on the logistics of moving home and adjusting to online learning after the university shut down.

But the calls for help began to pick up in June and remained steady through the summer, Osburn said. Depression and anxiety have always been the big reasons students reach out for help, but now they’re aggravated by the pandemic, the economy, racial tensions and political divisions in the country, Osburn said.

At the base of these problems is a sense of grief and loss, Osburn said. Loss of routine, loss of contact with other people, loss of control and loss of the milestones and activities that bring joy or a sense of accomplishment.

“Students who are experiencing loss over many of these rights of passage — it’s real loss to them,” Osburn said. “It may be the loss of someone’s sports season when their identity is very connected to being an athlete. The loss of attending your first football game, having your first residence hall meeting, joining your first club or being able to be in a lab and really learn your craft, all of those things are losses.”

As with other adults, the depression some students experience often comes from a sense of isolation at a time when they’re expected to make new friends and connections, Osburn said. And many of these young people haven’t learned yet how to manage stress on their own.

“With all of the things happening in the world, that armor of invincibility is feeling chipped, and they have to make choices of where they have to prioritize their energy,” Osburn said. “Because if they’re not, they’re just going to be exhausted and overwhelmed and stressed.”

Osburn said counselors primarily work with students on ways to tolerate and cope with stress, including meditation, focusing on one task at a time and knowing the difference between what they can control and what they can’t.

Other groups who may be particularly susceptible to COVID-19 related depression and anxiety are Blacks and Hispanics.

For starters, both groups are more vulnerable to the disease itself. According to NCDHHS, Hispanics account for 35% of coronavirus cases in North Carolina, even though they make up only 10% of the population. And Blacks, who are about 22% of the state’s residents, account for 31% of COVID-19 deaths.

Those numbers reflect pre-existing disparities in income, insurance, access to health care, housing and other resources that along with discrimination and racism are themselves sources of stress, said Duke’s Briggs-King. A federal survey in 2017 found that Black adults in the U.S. were nearly 70% more likely than white adults to report persistent symptoms of emotional distress such as sadness and feeling like everything is an effort.

“What COVID has done for people of color is it has exacerbated many of the stressors that were already there,” Briggs-King said.

The economy and the need to keep working jobs that put Blacks and Hispanics in close contact with other people during the pandemic can also be a source of stress, Briggs-King said.

“People of color may be less likely to have a job that allows them to work from home and puts them on the front line a little more,” she said. “They may be working in a position where if they get sick they may not have the coverage they need.”

At the same time, Blacks and other people of color may be less likely to seek help with emotional problems such as depression and anxiety, surveys and other research shows. The stigma that many people feel about revealing a mental health problem is particularly acute in the African American community, said Sharon Dickey, a mental health counselor in Wilmington.

“We tend to keep our personal things private,” Dickey said. “It’s a culture. It’s pretty much how we’re raised. We think that we have to keep things inside of our home. It’s seen as a sign of weakness if you feel like you need a therapist.”

Dickey is helping organize a series of activities at Warner Temple AME Zion Church in Wilmington this fall to raise awareness of mental health issues. Pastor Clifford Barnett Sr. says the church has always focused on mental health each October, but this year the need is particularly acute.

“Because of where we are now, not only the pandemic but the election, George Floyd, all that’s happening around us, it’s like we’re in a pressure cooker, and they’re turning up the heat,” Barnett said. “And we’ve got do what we can to ease some of that pressure.”

Barnett said it’s been important that he and other church leaders stay in touch with members and their families during the pandemic. Like the volunteers on the Hopeline, he strives to provide a listening ear to people’s concerns and stresses.

“We do that by asking questions,” he said. “How are you? How are folks in your family? Is there anything you need? Is there anything you need to talk about?”

Clergy of all kinds play an important role in helping people deal with the emotional strains of events like the pandemic, says Jessica Stokes, an ordained Baptist minister who leads mental health advocacy for the N.C. Council of Churches.

“When someone is experiencing an issue, whether it be an emotional concern or a mental health concern or something around addiction, if they are part of a faith community they tend to ask their pastors or faith leader for guidance or encouragement first,” Stokes said.

People who would never consider talking to a therapist or other mental health professional will confide in a member of the clergy, Stokes said.

“A lot of people, particularly older people and men, they trust their pastors,” she said. “The only reason they opened up is because it was their pastor.”

Sometimes that’s all people need, is the reassurance and advice from a priest or rabbi or imam. But clergy must know when someone’s anxiety or depression would better be treated by a mental health professional, Stokes said. She works with pastors and congregations to destigmatize the idea of mental health therapy and to encourage clergy to make referrals when necessary.

“There is a time when clergy need to hand the baton off,” she said.