The Silent Pandemic: Covid-19 and mental health

Health Anxiety & Mental Distress

What are the mental health effects of the pandemic for all of us, for the whole population? The early features of what is called ‘health anxiety’ were manifest from the first few days: panic buying, stockpiling and hoarding. Research in recent months has painted a picture of more prolonged and more generalised damage to public mental health. One study in the UK compared rates of mental distress in the general population between the spring of 2018 and spring 2020, which increased from 18.8% to 27.3%.

But these large increases did not occur equally across the population. Mental ill health grew more among young adults, women and people living with young children. A separate survey, also early during the pandemic, found that anxiety and depression were higher among young adults, women and people with risk factors for Covid-19.

A sobering discovery is that this increase in mental health problems during the pandemic may be a global phenomenon. Data from the United Nations have shown that in April 2020, levels of depressive symptoms were three times higher than the year before. A little later, in June, mental health and substance use problems were found in 40% of people in a survey in the USA, about twice the premorbid rates, at the same time as overall use of alcohol increased by 14%, with heavy drinking jumping by 41% for women.

The impact of an economic recession

But it is now looking possible that the worst mental health consequences of Covid-19 may be in the longer-term, and will not from the direct effects of the virus, but from the indirect effects of economic recession. There is now a huge array of evidence that economic downturns lead to increases in mental illness, risk of self-harm and suicide. Experience from previous periods of economic duress shows us that suicide risks are especially worse for men and young people. It is therefore especially important to mitigate the economic damage to individuals, families and communities because, as Stuckler and Basu have memorably put it, “recessions can hurt, but austerity kills”.

What are the impacts of Covid-19 for people with pre-existing mental health problems?  Again the research does not bring good news. For example, a survey by the Mental Health Foundation in the UK discovered that people with pre-pandemic mental health conditions are almost twice as likely to have panic attacks, and are three times more likely than the general population to have suicidal thoughts.

Chilling data have just emerged from a massive survey of over 63 million people in the USA. Compared with the whole population, people who had developed depression or schizophrenia just before the start of the SARS-CoV-2 pandemic were 7 times more likely to develop Covid-19, and infections were nearly four time higher from African American than for while people with mental illness. Compared with people who did not have a mental illness, those who did were admitted to hospital more often (27.4% vs. 18.6%) and had mortality rates almost twice as high ( 8.5% v. 4.7%).

Frontline Health and Social Care Staff

The third important impact of this coronavirus is the havoc it plays with the mental health of key workers and first responders. This category includes of course health and care staff, but also fire fighters, police, transport and delivery drivers, and all the other roles that are vital to maintain everyday life. Despite public acclaim for heroic contributions, such key workers also have greatly elevated levels of mental ill health.

The Covid Trauma Response Working Group study carried out in mid-summer this year among UK frontline health and social care staff,  reported that among over 1000 people surveyed 47% met the criteria for a diagnosis of anxiety, 47% for depression, 22% for post-traumatic stress disorder, and a majority (58%) had at least one of these disorders. Despite all the many efforts of the UK National Health Service and care sector to support staff, most workers in these settings have recently had clear-cut mental health problems.

A 'Parallel Epidemic'?

Have there been any adverse mental health effects for people who have developed Covid-19 symptoms? The answer here once again is salutary. In the phase of self-isolation or quarantine there is a rise in the symptoms of anxiety, depression and obsessive-compulsive disorder, and debilitating features of fatigue and problems akin to post-stroke depression are now being reported. We cannot assume that these will clear up quickly. The experience of the SARS and MERS epidemics shows us that stress related disorders can last for month or years.

How have public health agencies and governments reacted to what experts in China have called this ‘parallel epidemic’? Hardly at all. The challenge is best appreciated at the highest levels, with the Secretary General of the United Nations, Antonio Guterres, making it clear as early as May 2020 that mental health services are an essential part of all government responses COVID-19.

Yet the reality on the ground may be the exact opposite. A World Health Organisation report published a month ago assessed the impact of Covid-19 on mental health services in most countries across the world. The results from 130 countries showed not mental health services being rapidly scaled up to meet rising needs, but being diminished and downgraded. In 40% of countries community mental health services had been cut, in two thirds day care was reduced, and the overall picture was that in 93% of countries some components of the mental health service had been taken away since March of this year.

How should we respond?

What needs to be done is clear. First, to integrate mental health into the mainstream Covid-19 response across the whole of society, for example in terms of minimising health anxiety by clear and consistent public messaging.

Second, it is vital to provide emergency mental health, psychological and social support, for example to those who are most isolated or lonely. This will more often be possible with contributions from community and not-for-profit organisations than from health or social care services.

Third, mental health care and support must be an integral part of primary care and universal health coverage in those many countries where at the moment is it absent from these basic entitlements.

What this means in global terms is fully appreciating that what the United Nations calls the right to health applies precisely as much to mental health as to physical health.