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COVID and mental health challenges: mental health services are not the only answer!
There are numerous references in the international press and professional journals to the “pandemic of mental health disorders” that is developing as a result of COVID-1 . Evidence is emerging of an increase in demand on mental health services from people with no previous history of mental health problems. Surveys of the general public report increased stress, anxiety and depression related to disruptions related to COVID-19 (fear, isolation, uncertainty, loss of income leading to financial difficulties which threaten housing, childcare, social life….); people quarantined are more likely to be socially isolated and experience increased stress related to boredom, lack of social support, increased online gambling with potentially negative consequences, fear related to exposure to media reports […] (Li et al., 2020; Fullana et al., 2020). People who have had COVID-19 may have experienced serious physical symptoms (such as neurological problems and post viral depressive symptoms) which themselves are linked to mental health problems, they may have symptoms of post-traumatic stress disorder or post intensive care syndrome as a result of spending long periods in intensive care.
Clearly some of these people might benefit from specialised mental health support (and as Moreno et al suggest (Moreno et al., 2020) the global nature of the challenge brings opportunities for international expertise to work together to “build back better”). However, the vast majority of these problems are understandable and expected emotional responses to distressing disruptions in life rather than symptoms of mental “illness” that require specialist interventions. As Lucy Johnstone comments , “We are not facing a pandemic of mental health disorders. We’re all facing a truly terrifying situation that challenges our whole way of life […] The more we label our understandable human reactions as disorder, the greater the temptation to disconnect them from their source and focus on new individual ‘treatments’ instead”.
In the case of COVID-19, the “source” that Johnstone refers to is not just emotional – fear and uncertainty – it is the very real experience of material hardships resulting from the disease. It is no surprise that COVID-19 has disproportionately impacted the most socially disadvantaged (especially those from BAME communities) who already experienced poor housing, unstable or lack of employment, financial insecurity, inadequate welfare benefits, daily experience of exclusion, discrimination (Public Health England, 2020). And the broader effects of COVID-19 on this group will intensify and extend as the social and economic consequences of the pandemic play out over time (Rose et al., 2020).
The challenge then is not merely wholesale improvement and rectification of long-term underfunding of community mental health services, but urgent rebuilding of social and economic supports to prevent the social factors underpinning distress leading to long-term and serious mental illness (Rose et al., 2020). Marmot has long argued for greater recognition of the social determinants of health including mental health (Marmot, 2005). Poor and disadvantaged populations are most affected by mental disorders and cumulative stress and physical health serve as mechanisms through which the impacts of social determinants multiply across the lifespan and effect the mental health of multiple generations. Fisher and Baum (2010) propose mechanisms by which low socioeconomic status impacts mental health for those who are socially disadvantaged, including stress from navigating everyday circumstances, anxiety about insecure and unpredictable living conditions and perceived lack of control.
Employment provides a useful example of the link between social factors and mental health and is particularly pertinent due to the impact of COVID-19 on employment/increasing levels of unemployment and precariousness of employment both directly through lockdown and restrictions on social contact and indirectly through the consequent economic recession. Unemployment is clearly linked to increased mental health problems resulting from: reduced standards of living resulting from loss of income (Björklund, 1985); anxiety about duration of income loss and potential drop in standard of living, threat to housing, etc. (Darity and Goldsmith, 1996); self stigmatisation due to a sense of failure, and drop in status among family, friends and community leading to reduced self-esteem (Björklund, 1985); and loss of social contacts and work and reduced social networks. That loss of engagement and “social capital” leading to a decline in personal well-being (Helliwell and Putnam, 2004). Johnstone makes the salient point that “Not a single new research study is needed to confirm that being jobless, isolated, ill and bereaved makes people unhappy, or to work out the appropriate remedies” (Johnstone, 2020).
Such social realities as unemployment do not respond to therapy or treatment but as with many other social factors, long-term stress can lead to serious and long-term mental health problems. The challenge is to prevent unemployment and provide support to find new meaningful work, not to provide mental health care. The same can be said for problems with housing and homelessness, poverty, isolation and exclusion: none in themselves require mental health services.
So what can be done?
As Rose et al.(2020) state, “we need to create the social and material environments that not only address the causes of mental ill-health but also enhance the capabilities of all citizens to create lives of meaning and purpose for themselves”. They urge the development of innovative new social, legal and economic policies informed by social, political and economic sciences and critically, drawing on the expertise of lived experience.
Florence et al.(2020) offer suggestions for learning from those with lived experience of mental health problems. They suggest that the experience of managing everyday struggles posed by their mental health conditions gives them skills and wisdom that might be transferable to all of us fearing the threat of COVID and its ramifications. In particular, they suggest that a recovery informed approach could be capable of addressing people’s fears about the future, “[…] to recover is not to restore or reclaim a former state of normality, but to forge new pathways and create ones’ life within and beyond the constraints and limitations, in this case imposed by reality itself”. Certainly people with lived experience of mental health problems are often accustomed to living and coping with experiences of a different reality, and many have expertise in ways of managing daily struggles, anxiety, fear and isolation. Byrne and Wykes (2020) explain “Lived experience roles provide a common first hand understanding and approach to surviving and thriving with mental health challenges. It is therefore difficult to imagine a reasonable argument for not including lived experience as one of the multiple perspectives guiding research”. The same can clearly be said for their contribution to the development of policies, services and practice.
Perhaps the greatest lessons learnt throughout the development of this pandemic has been, not the contribution of politicians, statutory services or research, but the power of communities to support, sustain, adapt and offer a way in which all us of can have a meaningful role even if we are quarantined, unemployed or furloughed, isolated or immobile. Stories of creativity, generosity and real commitment to local communities abound. The most disadvantaged communities have developed neighbourhood support schemes, shopkeepers have found ways of keeping communication going and ensuring that people get vital supplies. Teachers have gone way beyond the call of duty to support their pupils, not just educationally but with meals. Voluntary sector organisations have rapidly responded to needs, finding ways of enabling people unfamiliar with It to both access and use virtual communication. Within days of the NHS volunteer scheme being announced, over 750,000 people had signed up. The COVID-19 Mutual Aid movement has mobilised 2.5 million people across the UK who worked with community groups to deliver emergency food parcels.
However, the community is not and should never be a replacement for the local or national state and this idea must be continually challenged. The question now is how to sustain this movement, how to grow it, how to invest in it to continue to shore up the backbone of the country and reduce the disruption that COVID-19 continues to wreak on all of our lives – but most of all on those who are most vulnerable and disadvantaged. As McInroy and Goodwin from the national organisation for local economies state, “Communities must be empowered to take the economy on as we rescue, recover and reform in the wake of COVID-19” .
Björklund, A. (1985), “Unemployment and mental health: some evidence from panel data”, Journal of Human Resources, Vol. 20 No. 4, pp. 469-483.
Byrne, L. and Wykes, T. (2020), “A role for lived experience mental health leadership in the ag of Covid-19”, Journal of Mental Health, Vol. 29 No. 3, pp. 243-246.
Darity, W., Jr. and Goldsmith, A.H. (1996), “Social psychology, unemployment and macroeconomics”, Journal of Economic Perspectives, Vol. 10 No. 1, pp. 121-140.
Fisher, M. and Baum, F. (2010), “The social determinants of mental health: implications for research and health promotion”, Australian & New Zealand Journal of Psychiatry, Vol. 44 No. 12, pp. 1057-1063.
Florence, A.C., Miller, R. and Bernard, et al. (2020), “When reality breaks from us: lived experience wisdom in the COVID-19 era”, Psychosis, doi: 10.1080/17522439.2020.1817138/217667.
Fullana, M.A., Hidalgo, D., Vieta, E. and Radua, J. (2020), “Coping behaviours associated with decreased anxiety and depressive symptoms during COVID-19 pandemic and lockdown”, Journal of Affective Disorders, Vol. 275, pp. 80-81.
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Johnstone, L. (2020), “Does coronavirus pose a challenge to the diagnose of anxiety and depression? A psychologist’s view”, BJPsych Bulletin, pp. 1-10, doi: 10.1192/bjp.2020.10.
Li, J., Qi, H., et al. (2020), “Anxiety and depression among general population in China at the peak of the COVID-19 epidemic”, World Psychiatry, Vol. 19 No. 2, pp. 249-250.
Marmot, M. (2005), “Social determinants of health inequalities”, The Lancet, Vol. 365 No. 9464, pp. 1099-1104.
Moreno, C., Wykes, T., Galderisi, S., et al. (2020), “How mental healthcare should change as a consequence of the CVID-19 pandemic”, The Lancet Psychiatry, Vol. 7 No. 9, pp. 813-824.
Public Health England (2020), Disparities in the Risks and Outcomes of COVID-19, London PHE Publications.
Rose, N., Manning, N., Bentall, R., et al. (2020), “The social underpinnings of mental distress in the time of COVID-19 – time for urgent action”, Wellcome Open Research, Vol. 5, p. 166.
About the authors
Julie Repper is based at the Nottingham Recovery Centre, Nottingham, UK.
Rachel Perkins is an Independent Consultant and Trainer, London, UK.