We would like to thank Dr Dan Chisholm, Regional Adviser for mental health in WHO Regional Office for Europe, for his helpful comments on an earlier draft of this blog
Much of the focus of measuring the toll of COVID-19 has been on tabulating cases and deaths, but what do we know about the dire consequences of the pandemic on mental health?
The World Health Organization defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” An exclusive focus on physical well-being—although relatively easier to track—will mask the full extent of the excess burden of COVID-19. In this blog, we highlight the effects of COVID-19 on mental health and provide some thoughts on what needs to happen to better understand the nature, scale, and scope of the global mental health crisis.
What did we know before the pandemic?
Mental health is an important cause of ill-health globally
In the 2017 global burden of disease study published last year, mental health (defined here as the burden of mental, neurological, substance use disorders, self-harm, and domestic violence) globally accounted for 9 percent of 56 million deaths, and a whopping 27 percent of the 850 million years lived with disability (YLDs). These numbers mask variation in the burden (measured in terms of disability-adjusted life-years) across country groupings—with mental health in high-income countries representing a larger proportion of the global burden—but across all countries, mental health accounts for a significant and increasing proportion of overall burden.
An exclusive focus on physical well-being will mask the full extent of the excess burden of COVID-19
Mental health services are underfunded and understaffed
Interventions to address mental health represent excellent value-for-money, as the Disease Control Priorities project has shown. But unfortunately, mental health continues to be a relatively underfunded area of global public health. A clear consequence of this underfunding is the chronic shortage of psychiatrists and psychologists in most low- and middle-income countries (LMICs). This lack of resources already translated into unmet need prior to the pandemic, which has only exacerbated and amplified the need for mental health services.
Previous quarantines triggered an upsurge in mental health conditions
A rapid review published in The Lancet in late February during the city-wide quarantines in China in response to the COVID-19 outbreak examined the psychological impact of previous quarantines. The authors reported negative psychological effects including post-traumatic stress symptoms, confusion, and anger. Stressors included longer quarantines, infection fears, frustration, boredom, inadequate supplies, inadequate information, stigma, and financial loss. These predicted consequences have been borne out by many recent studies showing the psychological impact of self-isolation, quarantine, and lockdowns. A recent example from the UK shows that depression has nearly doubled during the pandemic, with almost 20 percent of adults experiencing depression.
There are long-term deadly consequences
We also know that the effects of poverty and despair can have long-ranging effects, resulting in increases in related deaths over many years. In a book published earlier this year, economists Anne Case and Angus Deaton described how, in the past two decades in the US, deaths of despair from suicide, drug overdose, and alcoholism have risen dramatically. Recent research from Brazil assessed the association between economic recession and adult mortality, and ascertained whether health and social welfare program in the country had a protective effect against the negative impact of this recession. The bad news is that the Brazilian recession contributed to increases in mortality. However, the good news is that health and social protection expenditure seemed to mitigate detrimental health effects, especially among vulnerable populations. But whist this is good news for the likes of Brazil, with a relatively robust tax-funded public health system, the impact of the crisis in less resilient and chronically underfunded systems across sub-Saharan Africa and South Asia will be harder to counter.
What do we now know?
Fast forward six months from that February Lancet article, and most of the world—with few exceptions—introduced required stay-at-home measures (see figure below).
Evidence of the impact of the COVID-19 pandemic on mental health is now growing, and we see six distinct dimensions of this impact:
COVID-19-related stigma. Some patients and health care workers face stigma and discrimination based on fear of the virus. They have experienced, and are experiencing, discrimination such as the refusal of housing, verbal abuse or gossip, and social devaluation. Also, their family members or friends are experiencing “secondary” or “associative” stigma.
The aftereffects of COVID-19 infection. We don’t know how many patients recovering from COVID-19 will experience neurological or psychological after-effects of their infections; but some predict as many as one in three.
The inherent fear of getting infected by COVID-19, and the contagion of this fear.
Distress due to measures to control the spread of COVID-19, such as lockdowns and school closures. See for example:
Wang and colleagues investigated the psychological impact of the pandemic, including anxiety and depression during the initial stage of the outbreak in China. They found that 16.5 percent and 28.8 percent of respondents reported moderate to severe depressive symptoms and anxiety, respectively.
A study from the UK found that population prevalence of clinically significant levels of mental distress rose from 18.9 percent in 2018–19 to 27.3 percent in April 2020, one month into UK lockdown.
In the US a study found that in April 2020, 13.6 percent of adults reported symptoms of serious psychological distress, relative to 3.9 percent in 2018.
A recent survey conducted by the South African Depression and Anxiety Group found that nearly half of respondents felt that financial stress and pressure were one of the main challenges during the lockdown. Over half of respondents also cited anxiety and panic as a major challenge.
Reports of child abuse and domestic violence have increased across the globe, from Addis Ababa to Zagreb.
The longer-term mental health effects of unemployment, indebtedness, and poverty. For example, a recent report estimated how many deaths of despair (due to drug, alcohol, and suicide) there might be due to COVID-19 in the US over the course of this decade. Given the uncertainty in such an effort, additional deaths of despair range from around 28,000 (quick recovery, smallest impact of unemployment on deaths of despair) to around 154,000 (slow recovery, greatest impact of unemployment on deaths of despair).
The disruption to existing mental health services. For example a Times of India article reported that mental health services are facing disruptions due to COVID-19. One of the country’s largest psychiatric hospitals would typically see between 1,200-1,300 outpatients daily before the pandemic; a few weeks after India went into lockdown on March 24, they were seeing zero patients.
What do we still not know?
Let’s be clear: there is still a lot we don’t know about how COVID-19 is affecting people’s mental health. And it will be years before we have a more complete understanding of the true toll of this pandemic on mental health.
The pandemic presents a historic opportunity to reimagine mental health care
As the saying goes, “What gets measured gets managed.” A corollary of this saying might be “What gets funded gets measured.” Unfortunately, mental health, particularly in LMICs, has historically been underfunded. Efforts to assess the collateral damage of COVID-19 have gravitated toward less-stigmatized, better-funded, and hence better-measured areas, such as cancer care, maternal and child health, and malaria treatment and prevention. It is undoubtedly true that there is depressingly little to disrupt in many LMICs when it comes to mental health services. But paradoxically, perhaps this offers a unique opportunity to “build back better.” And in the case of low-income countries in particular, they can choose to avoid some of the worst aspects of mental health care in high-income countries, such as an overreliance on institutions and a biomedical approach. Options for LMICs to explore include e- or tele-mental health services and other digital solutions.
We don’t know if the excess mental health burden reported so far is transient or persistent; it will most likely be both—transient for some, long-lasting for others. Nor do we know if/how this excess distress translates into actual mental disorders. The initial increases in mental distress after lockdown—and all three studies from China, the UK, and US mentioned above do not measure mental health beyond the early stages of the lockdowns in each country—might represent a so-called spike in emotional response that stabilizes or falls as people adjust. However, as the authors of the UK study wrote:
“as the economic consequences of lockdown develop, when furloughs turn to redundancies, mortgage holidays expire, and recession takes effect, we believe it is reasonable to expect not only sustained distress and clinically significant deterioration in mental health for some people, but emergence of well described long-term effects of economic recession on mental health including increasing suicide rates and hospital admissions for mental illness.”
It remains to be seen how the United Nations, its partners, and national governments will respond to this unprecedented surge in need. The pandemic presents a historic opportunity to reimagine mental health care. Will governments and funders rise to the challenge?