This paper aims to examine recent papers on the effects of the COVID-19 pandemic on mental health, including implications for some of the groups of people already less included in society.
A search was carried out for recent papers on mental health and the COVID-19 pandemic.
Two papers describe surveys of adults in the UK and Irish Republic in the first days of lockdown. Low income and loss of income were associated with anxiety and depression. These surveys could not examine distress in Black and minority ethnicities, who have higher death rates from COVID-19. Two surveys of children and young people report distress and what can help. One paper summarises a host of ways in which the pandemic may affect mental well-being in different groups, and what might help. Another calls for research to understand how to protect mental well-being in various groups.
These five papers give a sense of the early days of the pandemic, especially in the UK. They also highlight the needs of some specific groups of people, or the need to find out more about how these groups experience the pandemic. They suggest some ways of trying to ensure that everyone has the best chance to thrive in the aftermath of the pandemic.
Holttum, S. (2020), "Research watch: Coronavirus (COVID-19), mental health and social inclusion in the UK and Ireland", Mental Health and Social Inclusion, Vol. ahead-of-print No. ahead-of-print. https://doi.org/10.1108/MHSI-05-2020-0032Download as .RIS
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Copyright © 2020, Emerald Publishing Limited
In light of the pandemic the UK, like other countries, went into “lockdown” in March 2020 – the severe restriction of movement, gatherings and normal work other than what was considered essential or could be done at home. However necessary for curbing the spread of infection, lockdown and social distancing have unintended consequences, as some new research has begun to show. Two surveys examined mental wellbeing in the UK (Shevlin et al., 2020) and the Republic of Ireland (Hyland et al., 2020) in the first few days of lockdown. A summary of calls to Childline has appeared (NSPCCLearning, 2020a, 2020b), and another survey was conducted on young people with existing mental health difficulties (YoungMinds, 2020). One paper has attempted to bring together the ways in which lockdown and social distancing may affect different groups of people (Douglas et al., 2020). Another has called for research on ways of supporting people’s mental well-being (Holmes et al., 2020). These papers to some extent help us understand how people who are already less included in society may experience the pandemic, and what can help.
Mental well-being early in lockdown in the UK and Republic of Ireland
Shevlin et al. (2020) surveyed 2,025 UK adults (18 and over) about their experiences of anxiety, depression and traumatic stress during the first week of lockdown. Hyland et al. (2020) surveyed 1,041 adults in the Irish Republic about anxiety and depression in the first week of the Irish lockdown. Both surveys used the nine-item Patient Health Questionnaire (PHQ-9, Kroenke et al., 2001) and the seven-item Generalized Anxiety Disorder (GAD-7) questionnaire (Spitzer et al., 2006). The UK study (Shevlin et al., 2020) also included the six-item International Trauma Questionnaire (ITQ, Cloitre et al., 2018). For the trauma questionnaire, the pandemic was assumed to be a traumatic event in the sense of feeling directly life-threatening for all participants. Shevlin et al. (2020) acknowledge that this may be problematic because different participants may or may not have experienced it in this way.
Different levels of distress in different groups
In both surveys, more younger than older adults reported anxiety or depression, as did more people who had lost income. Infection with COVID-19, and feeling at risk of infection were also linked with anxiety and depression. Hyland et al. (2020), however, reported some differences between Ireland and the UK. Anxiety or depression was reported more in the UK by people with children, those on lower incomes before any losses, and by those with underlying health conditions or close to someone with such a condition. Hyland et al. (2020) think these differences might be explained by Ireland’s higher income levels and better welfare supports, as well as higher COVID-related death rates in the UK.
Older people in early lockdown
In both surveys, anxiety specifically about COVID-19 was higher in older people, which may, suggest Hyland et al. (2020), be due to their higher risk from it. Hyland et al. (2020) suggest that older people might benefit from extra support, including for linking up with others online. They point to a reported increase in older people in Hong Kong taking their own lives during the SARS outbreak of 2003 (Yip et al., 2010). However, Hyland et al. (2020) do not discuss the effect of health service mobilisation for COVID-19 on access to routine operations and other treatment for non-COVID-19 health conditions. Many delayed operations are those needed by older people. Access to cancer treatment is also affected (Jones et al., 2020). Addressing these problems swiftly may benefit the whole of society in the longer term, and not just those in direct need.
The pandemic as a traumatic life event
Shevlin et al. (2020) say that traumatic stress was reported by 17% of people in their UK sample, which they say is unusually high. More men than women reported it. Although it is possible that these results are inaccurate (because the modified questionnaire assumes everyone experienced the pandemic as directly traumatic), Shevlin et al. (2020) suggest that men might be more affected by the knowledge of higher death rates in men from COVID-19, or by the loss of their normal working lives during lockdown. Perhaps the questionnaire might be used as originally intended in further surveys so that participants can record actual events or circumstances that they experience as traumatic during the pandemic.
People belonging to Black and Minority Ethnic groups
Neither Shevlin et al. (2020) nor Hyland et al. (2020) report on mental well-being in those identifying as BAME. Perhaps their numbers of responses were too small for statistical analysis. However, given the reports of higher death rates among BAME groups (Meer et al., 2020), it might be expected that distress would be higher in these groups. Meer et al. (2020) call for more attention to the likely social causes of higher susceptibility to COVID-19 in BAME groups due to existing health inequalities. Many people belonging to these groups are in low-paid or insecure employment, they point out, as does Marmot (2020). The Marmot reviews (Marmot, 2010; Marmot, 2020) have described the well-established links between disadvantage and poor mental and physical health. Recently, the increase in life expectancy in the UK stalled compared to the rest of Europe, and this may be linked to austerity and increased inequality (Marmot, 2020). Marmot (2020) provides actionable policy suggestions for enhancing equality and inclusion.
Children and young people’s well-being in lockdown
NSPCCLearning (2020a) has used anonymous call data collected by the UK counselling charity Childline to summarise what children call about. They searched through the counsellor-recorded notes for references to the virus and found this in 2,200 calls from 21st January to 8th April 2020. Children and young people have felt more anxious and depressed since the virus appeared, the NSPCCLearning (2020a) report says. Many of their worries have been about catching or spreading it. Children were missing both their school friends and seeing other friends and family, and there were more arguments in the home.
Being trapped in the home
NSPCCLearning (2020a) reports some children and young people feeling distressed seeing their parents arguing about money, or parents who had begun to separate being stuck together. Visiting a supportive relative was now impossible, especially if it was a grandparent, who might be in danger from the virus. Children were suffering when there was no quiet space for their school studies, or when they felt over-organised by parents, says the NSPCCLearning (2020a) report. They missed classroom support, and worried about their future. NSPCCLearning (2020a) also reports some calls from children experiencing abuse and neglect. NSPCCLearning (2020b) provides guidance for social work during lockdown and social distancing, and notes additional government provisions, such as additional funding for care placements.
Before schools closed as part of lockdown, says the NSPCCLearning (2020a) report, some children experienced bullying, especially in relation to assumed Chinese ethnicity, and they did not always find it easy to tell a teacher or parent. Calls about bullying reduced when schools closed, but this may be a concern when they reopen, so it will be important that strategies are in place to tackle it.
How are children with pre-existing mental health difficulties coping?
Another survey (YoungMinds, 2020) entailed an online questionnaire completed by 2,111 young people who answered yes to a question about whether they had ever sought help for their mental health. All lived in the UK and were between 13 and 25 years. The timing was during the five days after UK schools were closed due to the pandemic.
About one-third of young people in the YoungMinds (2020) survey said their mental health was much worse due to the pandemic, and another 51% said it was a bit worse. Only 1% said it was better. Similar to the NSPCCLearning (2020a) report, children and young people in the YoungMinds (2020) survey reported anxiety, panic and difficulty sleeping. Urges to self-harm increased in those who had self-harmed before. Some of the anxiety, as in NSPCCLearning (2020a), was about spreading to family, and for young people in essential work, spreading it there. Some experienced a worsening of obsessive and compulsive thoughts and behaviour such as hand-washing.
Again similar to NSPCCLearning (2020a), young people responding to the YoungMinds survey missed their school friends (or university for over-16s). There was again concern about grades and the future. The support and structure of school was missed, and home did not feel safe for some young people. Important routine ways of coping, such as dance and other activities, were lost.
Difficulty getting the same level of support as before
Some young people pointed out that their efforts to cope in “healthy” ways via contact with friends and family (YoungMinds, 2020, p. 5) were now less feasible, and they were being pushed back into the kind of isolation that made their difficulties worse. In relation to a sub-sample of 1,294 children and young people who had received support for mental health in the past three months, most could still get it but it was less than before. Home situations meant that some young people felt less able to use telephone or online support. Lack of privacy was an important issue, and some counsellors encouraged young people to speak on the phone while on their daily walk (YoungMinds, 2020).
Similar to NSPCCLearning (2020a), some children and young people in the YoungMinds (2020) survey worried about their family’s or their own financial security. In fact, getting food and other supplies was one of the “top three concerns” the YoungMinds survey elicited (p. 6). The other two were isolation and coping with mental health difficulties.
What children found helpful
Those few reporting improved mental health had left school bullies behind, or friends contacted them saying they valued them, or they felt that being anxious was more normal because everyone was anxious. The top three helpful things (for 72, 72 and 60% of participants) were speaking to friends online, “watching TV/films” and “exercise”. Attending to daily news was felt to be unhelpful by 66% of participants. With high value placed on continuing face-to-face counselling and therapy, the YoungMinds (2020) report suggests that this needs to be available wherever possible. Listening and understanding were highly valued. For some, still having a weekly online counselling session could be a lifeline. Many children and young people valued help to stay calm. News media could be more helpful if they included more positive news.
YoungMinds (2020) survey authors recognised that they did not reach children and young people without access to technology, some of whom are those most in need of support. The authors call for clear information about support, and for more support for families and others who provide care.
Why lockdown and social distancing can harm mental health and what can help
Douglas et al. (2020) have examined relevant research and created a detailed diagram of how the pandemic might affect mental health. They discuss the effects of the infection itself, self-isolation, the shutting down of “non-essential” work, reduced public transport and school and university closure. They also discuss the complex routes and interactions between these things, and how specific groups of people might be adversely affected. Finally, they suggest some ways of reducing the negative effects.
Likely worst effects on those already disadvantaged
Douglas et al. (2020) point out that many of those who are already low-paid are least likely to be in jobs they can do from home or are most likely to find their work-place has shut down or they are redundant. With schools closing, parents may be unable to work while caring for their children. Many provisions have been made, but some people may fall through the net. Some, Douglas et al. (2020) point out, may lose their homes. They highlight the established links between wealth and health, with low income reducing people’s ability to pay for things that preserve health and wellbeing, and contributing to increased stress, echoing Marmot (2020).
In the longer term, suggest Douglas et al. (2020), there could be major effects on mental and physical health of people who lose their employment, with “a 76% increase in all-cause mortality”, based on a review of evidence by Roelfs et al. (2011). Recession, Douglas et al. (2020) point out, is associated with a rise in people ending their own lives and in murder (Stuckler et al., 2009).
What might help?
A major review, Douglas et al. (2020) remind us, suggests how policies can reduce these harms (McCartney et al., 2019), and how people can be protected from exploitation, and inequality can be reduced. McCartney et al. (2019) reviewed 58 other reviews covering numerous individual research studies, and reported evidence that population health and well-being is better in countries that have higher welfare support, spend more on public services and are more equal societies.
Reducing harm to specific groups
Douglas et al. (2020) highlight the importance of older people being able to connect with support, especially given many are less confident online. Telephone support, they suggest, could be particularly important. The risk to children and mainly younger women from domestic abuse also needs attention, say Douglas et al. (2020), with consideration of new ways to support people. School closure, Douglas et al. (2020) suggest, may affect those on low income more than other families, because of lack of quiet space and computers in the home, echoing the NSPCCLearning (2020a) and YoungMinds (2020) reports. Douglas et al. (2020) suggest that these children may need more support on their return to school to safeguard their future. Also important, say Douglas et al. (2020), will be for government to avoid going back into austerity, because this would be likely to have the worst effects on those already struggling. They advise focusing on “inclusive and sustainable economic development” (p. 5). It will also be important to ensure essential services and “avoid stigmatising ill people or linking the pandemic to specific populations” (Douglas et al., 2020, p. 5). The quality of political, social and media discourse is clearly important here.
Making sure the right research is done
Understanding how mental health comes to be harmed
Many of the ways of mitigating the potential negative effects of both the virus and the lockdown have only been partly researched in terms of previous pandemics. Holmes et al. (2020) therefore call for research funding to prioritise specific areas. They drew partly on two large UK surveys of the general public and people receiving mental health services in March (Academy of Medical Sciences, 2020). Many of their priorities are consistent with the difficulties reported by the papers already discussed here. For example, Holmes et al. (2020) suggest a need for monitoring mental health and studying the helpfulness of online and other therapies and support. They suggest it is important to focus on why mental well-being is harmed because this can guide the ways to prevent or address it.
Doing research on what helps
Holmes et al. (2020) cover a vast array of issues, and I only touch on some of them here. They suggest studying ways to support people in coping with adversity, ways of ensuring they have the basic essentials for physical and mental health, how people can have good work and life conditions during on-going social distancing, and what will help people in the longer term, such as things that foster online and offline community and social resources. Holmes et al. (2020) also point to the needs of diverse groups who may be at particular risk, whether through domestic violence or from traumatisation while working in hospitals during the pandemic, and finding out how best to prevent further mental health difficulties.
It is important, say Holmes et al. (2020), to look at how reading and viewing news media affects mental well-being, and at what kind of reporting policies may be helpful, and also study helpful and unhelpful aspects and uses of social media. The effects of government health messages should also be studied, in terms of how people respond, and research should help prepare people for future pandemics. Finally, Holmes et al. (2020) suggest studying possible neuropsychological effects of the COVID-19 virus, as there are some indications that it may have effects on the brain and central nervous system for some people. If so, it will be important to work on finding out how to prevent and treat this.
The two surveys in the UK and Irish Republic highlight that low income and loss of income were associated with distress early in lockdown. However, these surveys were unable to consider BAME groups, who are over-represented in lower-paid and less secure employment, and have higher COVID-related death rates. Older people reported more COVID-related anxiety, but may also suffer more in the longer term from delay in, or reduced access to non-COVID-related health services, potentially affecting their quality of life and mental well-being.
Children and young people have also reported increased anxiety and depression. Their one-to-one online and telephone support often relies on private space at home, which tends to be less available in poorer households. However, being able to connect with friends and to do things they enjoyed were helpful for young people’s coping, and a weekly counselling call could be a lifeline for some.
The need to ensure that inequality does not continue to rise in the UK in the years after the pandemic may be one of the best ways to safeguard both physical and mental well-being across society. Good welfare provision can enable people to bounce back more quickly and thereby contribute more in line with their full potential. Some kinds of support are everyone’s responsibility, and that has been in evidence, with communities and neighbours helping each other. Research on the effects of policy is not the easiest to do, and as Holmes et al. (2020) suggest, it is important that it is high quality and focuses on understanding how specific kinds of support and higher level policies may have their effects.
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About the author
Sue Holttum is based at Salomons Institute for Applied Psychology, School of Psychology and Life Sciences, Canterbury Christ Church University, Royal Tunbridge Wells, UK. She works four days per week as a Senior Lecturer at the Salomons Institute for Applied Psychology, Canterbury Christ Church University, and one day per week as the research officer for the British Association of Art Therapists. Sue has experience of receiving mental health services and draws on this experience in her work.