What the Great Resignation can tell us about mental health in the US

All of a sudden the US is a nation of quitters. From exhausted healthcare workers to CEOs deciding to spend more time with their families, American workers have been resigning at record rates. In 2021, an estimated 47 million of them left their jobs—many to change careers, some just to take breaks.

Neither innovative employee benefits—carrot—nor the horizon of health insurance loss—stick—have done much to curb the exodus. Workers have given various reasons for their decisions to quit, such as low pay, lack of respect in the workplace, issues with child care, and work overload.

Workplace experts have branded this the Great Resignation, and have been looking for ways to tackle it as a talent retention crisis. But what if it isn’t? What if mass quitting is a symptom, and a warning to heed, not so much about the workplace, but about the state of American mental health? Millions have had the opportunity to quit their jobs, but many have not and are just as exhausted, running on fast-depleting psychological resources. The pandemic has heightened, and made more visible, a crisis in wellbeing that may well last for years to come, with potentially dramatic consequences.

We can’t predict the future, but we can look at patterns of human behavior in the face of trauma. To grasp the impact of covid-19 on mental health it may be helpful to look at the last time humanity faced a similar situation: The influenza pandemic of 1918-1920.

Until 1920, the US didn’t have a standardized taxonomy of diseases for monitoring purposes, nor did it collect mental health data. It did, however, record deaths by suicide, which can be taken as a proxy for mental wellbeing—or lack of thereof. A look at the data from the Centers for Disease Control and Prevention (CDC) shows an increase in suicides just after that pandemic.

Rates declined between 1918 and 1920, going from 14.7 per 100,000 deaths in 2017 to 11.3 in 2020, only to shoot back up to 13.9 in 1921.

What data we have so far about the covid-19 pandemic are similar. Suicide rates declined during the first year, going from 13.9 (47,511 deaths) in 2019 to 13.5 (45,855 deaths) in 2020. Estimates put the US suicide rate in 2021 at 15.1. This is consistent with literature about mental health effects following large-scale crises—such as the Fukushima disaster, or 9/11. The worst impact is usually felt about a year after the disaster, says Aki Nikolaidis, a scientist at the Child Mind Institute, who has been researching the effects of covid-19 stressors on mental health.

Of course, there are differences between the two pandemics. Influenza, for one, infected half a billion people, and killed 50 million—many more than covid-19 so far.

Further, people lived the influenza epidemic as a personal tragedy, without being aware of a global narrative akin to the one that has accompanied covid-19 since its beginning. At the time, a larger percentage of the population was rural, and most people weren’t receiving news about influenza outbreaks that didn’t affect them directly. This was especially true in Europe, where people often dealt with waves of influenza without realizing it was a pandemic, says John Eicher, a professor of modern European history who is conducting research on a body of about 1,000 letters written by survivors of the 1918-1920 pandemic.

Perhaps most importantly, the pandemic hit at the end of World War I, which had already killed 20 million people worldwide and wounded as many. Unlike the pandemic, the war had been lived as a collective tragedy, says Eicher, and the trauma was still showing its impact. Although past studies have shown a connection between the flu pandemic and the increase of suicides in the US, independently from the war’s long tail, the war’s influence still makes it somewhat difficult to compare the US situation post covid-19 to that of the US post influenza pandemic.

Unless we look at Norway. The Scandinavian country, which excelled in data collection even in the early 20th century, offers important insight when it comes to the effects of the pandemic on mental health—because it didn’t fight in World War I.

Norway’s data on suicides follows a pattern similar to the US. But the Norwegians’ mental health in the 1920s is unlikely to have been so significantly affected by the war.

The country remained a so-called “neutral ally”—external pressures made it a British sympathizer, but the kingdom stopped short of active military involvement. Although about 400 ships were sunk by German submarines, with a loss of around 1,000 lives, the direct impact of the war on the population was minimal compared to the rest of Europe.

The country suffered much larger losses due to the influenza pandemic, which killed between 13,000 and 15,000 people out of a population of 2.65 million, mostly in the first wave in 1918. Following it, Norway, too, experienced an increase in suicides.

“The data is fairly stagnant between 1910 and all the way through 1913, with suicides averaging around 150 per year. But then in 1914, the suicide rates went well above 200, and a year after 240 or so. Then it continues, and by the time it was 1920, it was over 400,” says Carla Hughes, a researcher at the OsloMet Centre for Research on Pandemics and Society. This translates to a suicide rate of about 15 deaths per 100,000 people, higher than the US at the time.

The magnitude of the mental health crisis in Norway, as indicated by the suicide numbers, might be even bigger than reported, says Hughes. Much of the data on deaths at the time was retrieved by parishes and churches, who might not have maintained accurate records of suicides, which were stigmatized and considered sins.

Suicides aren’t the only indicator. Svenn-Erik Mamelund, a professor of demographics and the president of the Norwegian Demographic Society, collected data on asylum hospitalizations in the years following the pandemic, finding that first-time asylum hospitalizations went up by 7.2 times on average (pdf) for the six years following the pandemic.

“Spanish influenza survivors were reported to have problems with sleeping, depressions, mental distractions, low blood pressure, dizziness and to cope at work and with everyday life for weeks, months or even years after 1918-19,” writes Mamelund. These numbers, too, are likely lower than the actual values, because, he writes, “it is likely people affected by milder or temporary post influenza melancholia did not see a psychiatrist.”

Similar symptoms were reported elsewhere, too. “The flu left survivors with a variety of mental symptoms, many of them represented by physicians and the press in terms similar to those used to describe sufferers of shellshock coming out of the Great War,” writes Susan Kent, a professor of history at the University of Colorado, Boulder, and the author of The Global Influenza Pandemic of 1918-1920. In 1919, she writes, the medical journal The Lancet wrote that “the depression which follows influenza is so constant that it ought to be regarded as part of the disease.” Other scientific publications reported similar findings.

Some of the mental distress appeared to be caused by the illness itself, but some came from conditions of isolation, or seeing loved ones die. In one of the letters Eicher analyzed a woman went into a catatonic state after she witnessed the death of her sister and the rest of her family. Hughes, too, thinks some of the causes of distress could reside not in the direct exposure to the disease and death, but the experience of isolation and then socialization in bursts.

The mental health symptoms reported by influenza survivors appear similar to the issues that are pushing exhausted workers to quit their jobs. In fact, resigning from a job in the context of a pandemic can be seen as a coping mechanism to deal with loss of control, says George Kohlrieser, an organizational psychologist and a professor at the International Institute for Management Development in Lausanne, Switzerland. Making changes in our lives, he says, helps processing grief, and in this light the decision to leave a job could be an effective way to heal after the traumatic experience of covid-19.

But for every burned-out white-collar worker who decides to take a break from the rat race, there are many more hourly workers, low-wage employees, and single parents who can’t afford losing income or health insurance.

Research on the impact of the pandemic on Latinx essential workers outside of healthcare during the first months of covid-19 showed that their mental health was worse even than that of healthcare workers, who were at higher personal risk of being exposed to the disease, says Dana Garfin, public health professor at the University of California, Irvin’s School of Nursing. The reasons were often socioeconomic, and financial—such as loss of income, or lack of child care options.

Essential workers, too, were at higher risk of covid exposure. Transportation, logistics and facilities workers, followed by workers in agriculture and manufacturing experienced higher rates of death compared to workers in other, typically better paid, sectors, according to research by the University of California, San Francisco. The same study found that Latinx and Black workers in those sectors experienced the highest excess mortality per capita, which puts them at higher risk of experiencing trauma associated with the pandemic.

The research by Nikolaidis and his team found that those who are hit by the direct consequences of a collective trauma—for instance, seeing a loved one die—experience bigger threats to their mental wellbeing. Yet it’s not these workers who are quitting en masse: Data from the Bureau of Labor Statistics on people who left their jobs shows that people working in transportation and manufacturing quit at a lower rate than people working in professional and business services, and below the overall private industry average. Among industries with lower wages, hospitality did see a high level of resignation and job changes, though the industry typically has very high turnover (up to 70% to 80% yearly).

Hourly or low-wage workers by and large cannot afford to quit without a backup plan. “If you want to take even one shift off to take care of yourself, that’s a choice you have to make, whether to lose your income to take care of yourself,” says Sarah Qadri, a hospitality and event manager in Chicago.

Many continue running on empty without the opportunity to replenish, and that psychological distress only continues to accrue over time. “It’s palpable in the air, everyone is doing what they can but they are all exhausted,” says Kristina Oak, a manager at a small coffee shop in Saint Paul, Minnesota.

Nikolaidis’s research shows that some of the strongest determinants of lower mood after covid-19 were external social circumstances, including income or economic distress, as well as the person’s mental and socioeconomic conditions prior to the pandemic. People working in low-wage and hourly jobs have long expressed significant stress associated to their work, and their burnout epidemic arguably pre-dates covid-19.

If the issue of burnout isn’t so much individual as it is social, it can’t be solved by workplace changes alone. Adapting to more accommodating schedules, providing better benefits, and allowing more flexibility might do help some, typically more privileged, workers. But it will do nothing to address a simmering mental health crisis that was already emerging before the pandemic, with suicide rates going up by more than 35% between 1999 and 2018.

There are ways to address this as a society. Telehealth is making mental health support more easily accessible, and the reimbursement policies have changed during the pandemic so that insurance typically covers it.

Oak reports significant benefits from receiving direct financial support like the stimulus checks the US government sent to most Americans. “The financial policies that were put in place for the first year of the pandemic improved me and my partner’s financial situation so much that I was able to leave my second job,” says Oak, who thanks to these interventions was able to stop working two hospitality jobs during the second year of the pandemic. “I have been working in the service industry for 10 years and living paycheck to paycheck, as someone with $800 a month in student loans, and I was able to get a lot of things under control with the stimulus,” she says.

The US administration seems aware of the looming crisis, and has proposed a mental health strategy with an overall budget of about $1 billion for 2023, to provide mental health services, recruit a mental health workforce, provide support to frontline health workers, and strengthen the role of community behavioral health clinics.

Yet measures that would bring relief to many families, such as the child tax credit, paid parental and medical leave, child care support, easily accessible free testing and treatment for covid-19 to uninsured patients have been rolled back from emergency pandemic interventions, or are struggling to go through the legislative process.

Some of the more dramatic consequences of the past two years of isolation and trauma, such as the record overdose deaths, have already shown themselves. The number of adults who report suffering from mental health issues is now close to 60 million, and the projected suicide rate is on track to set a record for this century. History suggests it might be but the beginning.