Shifts in patterns of mental health burden during the COVID-19 pandemic

Over 100 years ago the sociologist Emile Durkheim showed that during wartime, suicide rates fell. His explanation for this phenomenon was that during periods of collective adversity people pull together and resilience of the population increases.¹ On the other hand, during periods of social isolation, such as widowhood, suicide rates increased.² Do these observations have any relevance for mental health and mental distress during the recent COVID pandemic?

The dominant narrative since the pandemic is that personal and societal disruptions caused by the COVID-19 measures had an adverse impact for mental health. Lockdowns, social isolation, stress, etc, have reportedly increased the prevalence of mental health problems in COVID-affected populations.^3,4 Yet, in this issue of The Lancet Regional Health—Europe, Taxiarchi et al.⁵ raise some interesting challenges for this dominant narrative suggesting more population resilience than might have been predicted. The authors leveraged data from two parallel cohort studies, a population survey and primary care records, between January 2015 and December 2021 to investigate the effects of COVID-19 over the pandemic’s first 21 months. They used interrupted time series models to estimate changes in monthly prevalence of presentations and prescribed medications for anxiety and depression and self-reported psychological distress. The authors reported that primary care presentations dropped after the first 2 months of the pandemic and remained lower than expected. Self-reported distress was higher than expected for the first 6 months of the pandemic but then returned to expected levels. These findings propose that mental health may not have been harmed to the extent indicated by other studies looking at short term effects. Is it possible, therefore, that the effects of the pandemic should be seen more in terms of collective solidarity increasing resilience rather than individual isolation decreasing it?

The problem in determining whether the pandemic had negative or positive effects on mental health are largely methodological and these issues have been illustrated in the Taxiarchi et al. report. A strength of the paper is that it included two separate cohorts, one from the UK Household Longitudinal Survey, the other from primary care electronic health records, and then, in effect, triangulating the result. Yet both data sources used in this study suffer from known limitations.

First, the survey data which offered the clearest indication of mental health changes, is highly dependent on response rates and possible bias underlying these. To be included in the study respondents had to have completed at least one survey between 2015 and 2021. On the one hand mental distress may affect response rates but also did more of those single survey responses occur during the pandemic when respondents might have had time or inclination to answer the questions? The biases in response rates for those with mental distress and whether these changed over different periods of the pandemic is unknown.

The second cohort reported in the Taxiarchi et al. paper involved using electronic medical records to examine primary care consultation and medication rates over the pandemic period. The data here are known to be of high quality but they cannot reveal the relationship between mental distress and illness behaviour. The relationship between mental distress and illness behaviour (expressed in consultation patterns) is a complex one. It is unlikely to be linear—the more distress the greater the likelihood of visiting the doctor—and it may well not be stable over time. Most upper respiratory tract infections, for example, are known not to be taken to the doctor and those that are reflect more on the behaviour patterns of the patient than on any underlying pathological processes or severity.⁶ Did knowledge of strained health care provision during the pandemic affect decisions whether or not to visit the doctor?^7,8 In other words, lower health care use during the pandemic identified by Taxiarchi et al. might indicate changes in illness behaviour rather than changes in patterns of mental distress.

The key question is whether the adversity presented by the pandemic elicited a new social cohesion and resilience to mental distress—as Durkheim suggested occurred during wartime–or whether the response was primarily driven by individual isolation. Indeed, it is likely that both phenomena were operating but perhaps in different proportions and for different population subgroups during different times of the pandemic. At the very least, the accompanying Taxiarchi et al. paper in this journal begins to offer an alternative to the dominant narrative that perhaps the pandemic was not as harmful for mental health as is often presumed.

Contributors

Both authors contributed equally to the conceptualisation, writing of the manuscript, as well as reviewing and editing and the final draft. Both authors approved the manuscript for publication.

Declaration of interests

The authors declare the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.