COVID-19 pandemic, mental health care, and the UK

Abstract

The unprecedented SARS-2 COVID-19 pandemic has had a profound impact on individuals, families, and societies worldwide. The impact of the illness does not only directly relate to poor health on infection but also social and political determinants of health. As such, the secondary effects of the pandemic have been profound. Mental health and well-being have been one such area of concern, with the causal links thought to occur in three ways. First: the impact on general population, particularly vulnerable groups such as BAME individuals; Second: the impact on people with pre-existing psychiatric disorders; Third: mental health of COVID patients and those who have recovered and their careers. There are lessons to be learnt from previous pandemics and the impact on mental health. There are high levels of anxiety, depression, substance use (particularly alcohol), posttraumatic stress symptoms, and survivor guilt. Within this context, there is a need to consider the differential impact on underprivileged populations. Vulnerable groups include women, children, elderly, minority racial and ethnic groups, LGBT + individuals and the poor. It is noted that these classifications are met with challenges related to definition, and there is significant heterogeneity within the groups and the focus on race, gender, and poverty must be seen through an intersectional lens.

The COVID pandemic has shaken the globe in more ways than one. It has brought into focus inequalities between the global north and global south, across minorities and between the rich and the poor. Although in the recent decades, there have been epidemics of SARS, Middle East respiratory syndrome, Ebola among others the impact of SARS-2 (COVID-19) is likely to last long. The challenges related to the consequences of the pandemic, especially related to the mental health cannot be underestimated. Not since World War Two has there been such a massive risk to communities worldwide. Although an infectious disease, it affects individuals, families, and communities in a number of ways where loss, bereavement, survival guilt, displacement, and other consequences are likely. The scale of trauma remains difficult to judge, and individual countries are responding often in individual ideological ways rather than a global effort. This not only indicates weakness of the international organizations such as the World Health Organization but tragically highlights self-centered approaches by many high-income countries. Such massive trauma is likely to have long-lasting and long-term impact on individuals, their families but also politics and economy as a whole.

Others have noted the societal response to the pandemic and context related to this fear, with impacts resulting from lockdown, gradual opening of public places, restrictions to schooling and education, and leisure activities (such as cinemas, stadiums, and others). Lockdown has resulted in a specific set of stressors. These related to self-isolation (due to having the illness), isolation (due to societal and governmental policy to prevent spread), and working from home (for some in cramped and unsuitable conditions). Often the lack of structure, difficulties with distraction and limited social contact lead to loneliness and symptoms of mental health distress.

In this article, we present some of the findings and observations from the UK which has a central National Health Service. Ironically, it was the protection of the service rather than health of the individuals which was given prominence in the government messaging.

DIFFERENCES

As far as mental health of populations is concerned, especially in the time of the pandemic, three key issues are important to bear in mind. First, it is the impact of the pandemic on general population including ethnic minorities. Second, its impact on people with already diagnosed psychiatric disorders and lastly mental health of COVID patients and those recovered. In response to the pandemic, Ventriglio et al.[1] suggested potential five stages of the pandemic where public responses and emotions may change: Fear, anxiety and panic, anger, depression, and finally acceptance.

Many governments globally have acted in unusual ways, we do not propose to discuss this political scenarios here. However, suffice it to say that leadership and the way in which messages are conveyed matter. For example, using the term social distancing in many countries was problematic. Just when you expect people to be socially close to each other but physically distant creates a sense of confusion. Another problem was the data collection and sharing of the data across nations. The interpretation of research too has been problematic. The publication data suggest that over half a million research papers related to COVID-19 have already been published (not just related to mental health)[2] and the number continues to grow on a daily basis. With regard to mental health, online surveys with varying degrees of research robustness have shown possibly an over-diagnosis of anxiety, depression, and other common mental health disorders.[3] As such, caution should be exercised when interpreting these findings seeking to implement policy solely based upon them because a large proportion of studies and findings on the prevalence of psychiatric disorders have been related to online surveys. Thus, it is very difficult to ascertain the genuine representative nature of these findings. The studies discussed in this article highlight other challenges and we are focusing on underprivileged populations. These underprivileged groups include women, children, elderly, minority ethnic groups and LGBTQ + among others. By virtue of being underprivileged often socially, they are deprived and poor. It must be emphasized that even within such groups, there can exist a large degree of heterogeneity which must be remembered. Very often ethnic minority groups were working on the frontline and already had preexisting higher rates of diabetes mellitus, hypertension, obesity, and other physical illnesses such as osteoarthritis, chronic obstructive pulmonary disease, etc., All these chronic conditions affect mental health. These individuals were more likely to be working in transport and frontline of health and social care and anecdotally had major problems in accessing personal protective equipment.

Given the anticipated challenges and concerns through the pandemic, researchers and organizations have sought to better understand the scale of mental health challenge. Furthermore, concerns have also been raised related to the framing of measures and disease during the pandemic. For example, as mentioned earlier, the term social distancing is a misnomer and should instead be labelled as personal distancing as social closeness is to be encouraged rather that discouraged. The terminology used, and related precision matters as otherwise they can lead to disjointed thinking, confusion, and varied practice both at policy and clinical levels. Similar concerns have been raised with the identification of COVID-19 strains to particular regions, and only more recently have they been coded with Greek alpha going on to delta variant.

Office for National Statistics survey[4] published in October 2020 reported that Asians and British Asians were 1.5 times more likely to be infected by COVID-19 and Black Africans were 2.7 times more likely when compared with white British. Public Health England Second Generation Surveillance[5] reported that rates were 2.0 times higher for the Bangladeshi group.

Rogers et al.[6] showed that mortality due to COVID-19 was much higher in non-hispanic black individuals. They attributed this to the observations that this population was more likely to be doing essential jobs, for example, transportation, frontline health care, food preparation, serving, cleaning, maintenance, etc., Minority communities sample expressed deep dismay, anger, loss, and fear in the communities. Many had lost colleagues, friends and family members and were experiencing significant social, physical, and mental health impacts and complications.

Public Health England[5] in their surveillance report with 4000 individuals interviewed over 17 sessions while collecting qualitative data, noted that minority communities showed an increased risk of exposure to and acquisition of COVID-19 and had a clearly increased risk of complications and death from COVID-19 partly attributed to higher rates of long-term conditions, mental ill-health, poorer uptake of prevention services, and importance of risk factors such as diabetes, obesity, and COVID-19. The authors observed that economic disadvantage leading to poorer health outcomes was also associated with smoking, obesity, hypertension, and their cardio-metabolic complications. Various social factors linked with increased risks of infection and racism and discrimination needed to be addressed urgently. In addition clear and targeted public health messages for specific communities were needed. Interestingly, they recognized the lack of trust these communities had in the government and recommended that this needed to be addressed urgently. Similar findings of distrust have emerged in the context of vaccine hesitancy.

Sze et al.[7] in a meta-analysis of 18,728,893 individuals in 50 studies mostly the USA, including 8 from the UK reported that black and Asian ethnicities had higher rates of COVID infections with pooled adjusted relative riskfor Blacks was 2.02 and 1.50 for Asians. Thus, there appear to be several challenges to the mental health of the UK ethnic minority populations.

As mentioned earlier, a great number of front-line staff in the NHS, care sector, police forces, and elsewhere are from minority ethnic groups and were likely to be exposed not only to the virus but also to prolonged anxiety from several sources. Persistence worries about their own health and that of their families and fear of passing the virus on is likely to contribute to anxiety and panic. Seeing members of their family, peers and friends becoming ill and unwell and in some tragic cases die, at a much higher rate than in the general population[8] is likely to cause fear and anxiety. In addition being exposed to unprecedented rates of death and illness is likely to lead to burnout and emotional, physical and mental exhaustion. The sheer volume of tragedy experienced is truly unprecedented except perhaps in times of natural disasters. Such an exposure is likely to create cumulative impact leading to significantly increased rates of mental health problems such as posttraumatic stress disorder, anxiety, and depression.[9]

INEQUALITIES

Physical or social distancing is reported to have further negative consequences for the population as a whole.[10] Despite the political rhetoric that COVID affects us all equally, it is clear that it does not and has a very differential effect on well-being of individuals and families. Not having access to open space, good quality WIFI, access to nutritious food, ability to isolate among other factors can contribute to isolation and higher rates. Several large groups in society are suffering disproportionately. Many women may be trapped in abusive situations and rates of interpersonal violence have risen in many countries.[11] Women are not often considered when making national or global decision-making on the response to the pandemic. Ebola virus showed that quarantines significantly reduced the women's economic and livelihood activities, increased the rate of poverty and worsens food security. In Liberia, where roughly 85% of daily market traders are women, the Ebola prevention measures (which included travel restrictions) had detrimental impact on the women's livelihoods and economic security. During the Zika outbreak in Latin America, women had limited access to reproductive health care and financial resources. Whilst men's economic activity returned to precrisis levels shortly after preventative measures diminished, the impact on women's economic security and livelihoods lasted much longer.

It is likely that the COVID-19 global recession will result in prolonged dip in women's incomes and unpaid care work, with additional impacts for women living in poverty. For those who have escaped from extreme poverty, they are likely to fall back into poverty.

At the same time older adults from minority groups may be living in multi-generational households and exposed to a severe lockdown leading to prolonged and debilitating loneliness for many. Among those with preexisting psychiatric disorders almost 80% of people have reported a worsening of their condition and at the same time many are feeling less supported because of changes in service delivery.[12] People with psychiatric disorders are not only more likely to experience physical illnesses but are also likely to be more reluctant to seek help which has become an additional problem in the pandemic. Individuals are delaying help-seeking making their conditions more chronic. As mentioned earlier in many countries, ethnic minorities are disproportionately affected by COVID, both in health-care settings[13] and in the general population.[14] A lack of contact due to restricted contacts and visits and no possibilities of attending funerals and saying goodbyes to the loved ones has added another layer of isolation and helplessness.

Not surprisingly, the lockdown and inevitable ongoing physical distancing measures have had a significant effect on global economy and regrettable affecting underprivileged populations disproportionately. It is well recognized as in previous recessions, most recently in the financial crisis of 2008, that economic factors affect health and well-being with increases in suicide rates.[15] Austerity imposed or otherwise is likely to influence mental health and wellbeing of individuals who are most vulnerable anyway thus creating a vicious cycle of poverty and poor mental health.

Mental health services nationally have already suffered under austerity[16] and demands on health care has increased and the system has not been able to cope with increased pressures. This is particularly true in mental health care.[17] Increased rates of mental health problems amongst the workforce due to burnout, stress, depression, and anxiety have added yet another dimension along with preexisting shortages among staff.

THE WAY FORWARD

There are some positive signs emerging through the darkness of the pandemic. Mental health services and primary care services in many countries have taken to tele-health and e-mental health in assessments and management of people with psychiatric disorders, thereby making services more easily accessible. Furthermore, certainly, in many countries, levels of altruism have increased. Communities are beginning to look after and support their neighbors, friends, and families are undoubtedly checking in on and supporting each other more both practically and psychologically. The use of video-links to communicate has increased dramatically. There have been clear shifts in certain attitudes in some countries at least for example, a resetting of the values attached to roles such as caring, neighborhood links, doing shopping for vulnerable individuals, getting essentials to them, etc., Hopefully such shifts will enable a degree of community cohesion and partnerships through supporting and helping others which will contribute to altruism and a sense of purpose and community belonging.

It has been apparent for many years that mental health services in many settings have needed to change as it has become increasingly apparent that they are unable to meet the steadily increasing demand for them in a human and person-centered way rather than a mechanistic one. Perhaps coming out of the pandemic is a good opportunity to do exactly that. If as a society, we do continue to volunteer in large numbers as we are now and use that human and social capital wisely by valuing those who help others more there is every likelihood that we can meet the looming challenge of supporting each other through this mass trauma and its consequences for decades to come. Most individuals who have mental illnesses do not necessarily need to see specialists but will nevertheless need to feel supported and heard. The healthcare system can use this opportunity to train vast pool of people who are supporting and listening to others especially vulnerable and isolated individuals facing loneliness in lockdown conditions. A small proportion will need mental health services. Innovations in developing services and delivering these can lead to better targeted use of technology to reach out to those who need it quickly, individually, and humanely.

CONCLUSIONS

There is no doubt that COVID-19 infection and mortality rates are associated with income inequality, ethnicity, and other vulnerable groups. These associations and causal links need further exploration, and a greater appreciation and targeted action on social determinants of health. In addition, it is clear that pre-COVID-19 structural and systemic challenges – such as related to structural racism– have increased vulnerable and been exposed during the course of the pandemic. Cross country comparisons offer some help in helping to better appreciate the causal link and seek to address this inequity in care and outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.