Over the past two years, the COVID-19 pandemic has brought concerns about mental health to the forefront of discussions around societal wellbeing. Many discussions in the media would seem to suggest that the pandemic has led to the widespread worsening of mental health across the whole population. However, although the pandemic has led to an increase in social isolation and stress for many, a closer look at the most rigorous psychological research on mental health during the pandemic shows that the picture is more nuanced. While it’s certainly true that many people have faced challenging mental health problems over the course of the pandemic, there are many people whose mental health has remained unchanged or even improved during this time.
Learning from this complexity is key. If we can better understand who is at greatest risk and learn from those who remained resilient to the stress of the pandemic, we can be better informed on how to handle stress - both at global level and in our daily lives. In this blog, we discuss why mental health might have changed during the pandemic, and review the evidence assessing whether mental health has changed during the pandemic. We also discuss why the question of “whose mental health has worsened during the pandemic” is essential to improve our understanding of the needs of those at greatest risk.
Why might mental health have changed during the pandemic?
The dramatic changes to our daily lives brought about by the pandemic have the potential for broad psychological implications. Social isolation caused by lockdowns and social distancing measures has increased experiences of loneliness for many, particularly those living alone, or those cut off from friends or family. In addition, the unpredictable and unfamiliar threat of contracting COVID-19, disruptions to daily routines, changing workloads, and reduced access to health and social care have undoubtedly contributed to heightened levels of stress for many. Both loneliness and stress are known predictors of poor mental health, including increased risk for depression and anxiety1,2.
Has mental health worsened during the pandemic?
Although this question may seem simple, there are lots of different ways to answer it, from opinion polls to questionnaires assessing symptoms and even health records for psychological support services. While each of these sources provides valuable information, results from different studies vary. Estimates range anywhere between 6% and 54% of individuals reporting elevated symptoms of anxiety, depression, and post-traumatic stress disorder from before to during the pandemic (see systematic review3. The most reliable data comes from studies that: a) compare mental health during the pandemic to mental health prior to the pandemic, and b) study a sample of the general population that reflects the diversity in age, gender, ethnicity, and socio-economic background present in our society.
A recent review article identified only two such studies4. Of these, a UK-based study showed a worsening in ‘general mental health outcomes’ from pre-COVID to April 2020, but this effect was no longer present by September 20205,6. However, a similar study conducted in the Netherlands did not show any evidence of worsening mental health from pre-COVID to April 2020, or a later time point, in November 2020 (see this preprint7). Overall, this work suggests while there may have been a brief worsening of mental health in the UK during the early months of the pandemic, there is no strong evidence that mental health in the general population has consistently worsened since the beginning of the COVID-19 pandemic8.
Whose mental health has worsened during the pandemic?
However, just as it would be incorrect to conclude that the COVID-19 pandemic has had a disastrous effect on everybody’s mental health, it would be equally wrong to conclude that there have been no changes in anybody’s mental health during the pandemic. There are, of course, many people who have experienced a worsening in their mental health during this time. But there are also people whose mental health has remained stable, and some whose mental health has substantially improved.
Looking first at those at greater risk, it’s clear that the pandemic has exacerbated existing mental health disparities. People who were at the greatest risk of poor mental health before the pandemic are also most likely to have experienced worsening mental health during the pandemic. Groups at elevated risk are younger people, females, those with pre-existing mental health problems, and individuals in unstable employment or lower socio-economic groups5,9. For example, one study of the UK general population found that those who had pre-existing mental or physical health problems lived in deprived neighbourhoods, or had Asian, Black, or mixed ethnicity were more likely than other groups to have experienced worsening general mental health from pre-COVID to October 202010.
Fewer studies have examined groups of individuals whose mental health remained stable or improved during the pandemic. One study showed that ‘resilient’ individuals – those who had sustained good mental health between March and July 2020 – were more likely to report less loneliness, fewer worries about death, and a greater ability to tolerate uncertainty11. Other work has shown that those with greater resilience were more likely to have higher levels of social and family support and higher levels of physical activity (see discussion12). Understanding more about the thought patterns and behaviours of those who have not experienced worsening mental health during the pandemic will be key to developing strategies to promote resilience in the future.
What do we do next?
A widening of disparities in mental health during the stress of the pandemic is of particular concern when planning for how to best support those in need. If vulnerable groups already had reduced access to mental healthcare before the pandemic, then solutions that aim to provide ‘replacement’ remote or online care run the risk of leaving these groups behind. When designing digital mental healthcare interventions there must be a focus on prioritising inclusivity and access to high-quality, evidence-based mental healthcare for all who need it. Learning from resilient groups is also essential to inform the development of interventions and public health strategies to reduce the risk of worsening mental health during times of stress.
At SilverCloud we have been developing more targeted interventions for vulnerable groups. One example of this is the recent and ongoing development of our Children and Young People’s (CYP) programmes for anxiety and depression. This suite of programmes, developed over the course of 2019-2021, was co-designed with young people, parents, and healthcare professionals with the goal of providing high-quality interventions for young people, many of whom may be experiencing worsening anxiety or depression since the onset of the COVID-19 pandemic. In the second blog in this series, we will discuss how healthcare systems have adapted to the remote provision of mental health services and the challenges remaining in getting help to those with the greatest need.
References
1. Beutel, M. E., Klein, E. M., Brähler, E., Reiner, I., Jünger, C., Michal, M., ... & Tibubos, A. N. (2017). Loneliness in the general population: prevalence, determinants, and relations to mental health. BMC psychiatry, 17(1), 1-7.
2. Conway, C. C., Raposa, E. B., Hammen, C., & Brennan, P. A. (2018). Transdiagnostic pathways from early social stress to psychopathology: a 20‐year prospective study. Journal of Child Psychology and Psychiatry, 59(8), 855-862.
3. Xiong, J., Lipsitz, O., Nasri, F., Lui, L. M., Gill, H., Phan, L., ... & McIntyre, R. S. (2020). Impact of COVID-19 pandemic on mental health in the general population: A systematic review. Journal of affective disorders, 277, 55-64.
4. Sun, Y., Wu, Y., Bonardi, O., Krishnan, A., He, C., Boruff, J. T., ... & Thombs, B. D. (2021). Comparison of mental health symptoms prior to and during COVID-19: evidence from a living systematic review and meta-analysis. MedRxiv.
5. Pierce, M., Hope, H., Ford, T., Hatch, S., Hotopf, M., John, A., ... & Abel, K. M. (2020). Mental health before and during the COVID-19 pandemic: a longitudinal probability sample survey of the UK population. The Lancet Psychiatry, 7(10), 883-892.
6. Daly, M., & Robinson, E. (2021). Longitudinal changes in psychological distress in the UK from 2019 to September 2020 during the COVID-19 pandemic: Evidence from a large nationally representative study. Psychiatry research, 300, 113920.
7. van der Velden, P. G., Marchand, M., Das, M., Muffels, R., & Bosmans, M. (2021). The prevalence, incidence, and risk factors of mental health problems and mental health services use before and 9 months after the COVID-19 outbreak among the general Dutch population. A 3-wave prospective study. MedRxiv.
8. Robinson, E., Sutin, A. R., Daly, M., & Jones, A. (2022). A systematic review and meta-analysis of longitudinal cohort studies comparing mental health before versus during the COVID-19 pandemic in 2020. Journal of affective disorders, 296, 567-576.
9. Kwong, A. S., Pearson, R. M., Adams, M. J., Northstone, K., Tilling, K., Smith, D., ... & Timpson, N. J. (2021). Mental health before and during the COVID-19 pandemic in two longitudinal UK population cohorts. The British Journal of Psychiatry, 218(6), 334-343.
10. Pierce, M., McManus, S., Hope, H., Hotopf, M., Ford, T., Hatch, S. L., ... & Abel, K. M. (2021). Mental health responses to the COVID-19 pandemic: a latent class trajectory analysis using longitudinal UK data. The Lancet Psychiatry, 8(7), 610-619.
11. Shevlin, M., Butter, S., McBride, O., Murphy, J., Gibson-Miller, J., Hartman, T. K., ... & Bentall, R. P. (2021). Refuting the myth of a ‘tsunami of mental ill-health in populations affected by COVID-19: Evidence that response to the pandemic is heterogeneous, not homogeneous. Psychological medicine, 1-9.
12. Manchia, M., Gathier, A. W., Yapici-Eser, H., Schmidt, M. V., de Quervain, D., van Amelsvoort, T., ... & Vinkers, C. H. (2022). The impact of the prolonged COVID-19 pandemic on stress resilience and mental health: A critical review across waves. European Neuropsychopharmacology, 55, 22-83.
