Covid-19 hasn't been the only catastrophe sweeping the country this year.
Health experts say Americans are experiencing symptoms of anxiety and depression made worse by pandemic-related stressors, including job loss, evictions, remote learning, travel restrictions and limits on gathering.
The contentious presidential election, increased racial tensions and natural disasters, in addition to Covid-19, added to Americans' stressors, said Dr. Joshua Gordon, director of the National Institute of Mental Health.
An NBC News analysis of a Census Bureau survey conducted Oct. 28 to Nov. 9 found that symptoms of depression and anxiety have been seen in all 50 states, with people in major metropolitan areas, such as San Francisco and Philadelphia, hit harder by mental health challenges.
More than 1 in 4 in the U.S. reported having felt anxious more than half of the previous seven days. For feelings of depression, the number was close to 1 in 5, a figure that has inched up since near the start of the pandemic. The numbers of calls and texts to prominent help lines have soared compared to previous years' numbers, driven by Covid-19-related concerns.
Nancy Liu, an assistant clinical psychology professor at the University of California, Berkeley, said California residents found ways to take care of themselves with outdoor activities, such as walking and other exercise, before wildfires intensified this summer.
Anxiety in metropolitan San Francisco is among the highest of any region in the country. One of 3 people in the Census Bureau survey reported having felt nervous or anxious more than half of the previous week.
It wasn't just the wildfires that added to residents' stress burden — it was also the air quality, which forced people indoors, Liu said.
"These doors were being shut.It was like a wave after wave that just kept crashing," she said. "It added this additional heaviness. I think a lot of people were feeling really stuck."
In Washington, D.C., close to 2 of 5 people said they felt anxious at least four days of the previous week in the census survey. While people in metropolitan Washington felt less anxiety on average than the country as a whole, people in the city itself experienced higher rates of anxiety than those in any other metro area or state.
Ekwenzi Gray, a clinical psychologist at Howard University Hospital in Washington, said that among the clients he sees, many talk about feeling isolated and targeted because of racial tensions as citywide protests took place over the deaths of George Floyd and Breonna Taylor.
"We had parents and grandparents coming in asking for advice, like 'What does this mean for my child? What do I tell them?'" Gray said. "The impact is significant."
Despite barriers to in-person contact, there has been increased access to treatment options through online therapy and telehealth measures.
Yasha Duggal, a graduate student in the chemistry department at Pennsylvania State University, went from working full time in a lab to being alone at home. Duggal started online therapy in March because of stress of making the transition and says starting online therapy was tricky.
"It wasn't an overnight switch," Duggal said. "Talking to my computer was very difficult to adjust to at first, but over time I got used to it."
Crisis hotline operators are experiencing heavier, more intense workloads, sometimes to their own distress.
Rebecca Zeitlin, assistant director of Didi Hirsch Mental Health Services in Los Angeles County, said working parents are frequent callers to the Disaster Distress Helpline, a national round-the-clock hotline for which she is an operator.
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Christian Burgess, director of the Disaster Distress Helpline, said the crisis hotline has received about 50,000 calls so far this year, more than during the last four years combined.
Similarly, those seeking help through texts engaged in more than 1.2 million conversations with the 24-hour Crisis Text Line this year, compared to 1 million for the same period last year, said Bob Filbin, the service's chief data scientist.
Zeitlin, who is also a new mother, said helping others from home while juggling the demands of being a new mom has been a challenge.
"We're all part of the same community experiencing the same feelings," she said.
This is a different disaster, because everyone is affected by it.
Christian Burgess, director of the Disaster Distress Helpline
Burgess said the record use of the hotline this year points to the contrast in types of concerns from last year.
"This is a different disaster, because everyone is affected by it," he said.
As the colder months roll around and the impact of staying indoors may challenge the mental health of many, experts say there is still reason to be optimistic.
"The pandemic is an opportunity to build resilience," said Dr. Gordon of the National Institute of Mental Health. "People can endure quite a lot if they know there is a light at the end of the tunnel."