Restricting the spread of SARS-CoV-2 or safeguarding mental health: a false dichotomy?

Governments have implemented policies to curb the spread of SARS-CoV-2 at various points of the pandemic. Such measures have often been perceived as beneficial for public health but detrimental to mental health¹ and evidence indicates that lockdowns have had an adverse effect on mental health.² However, minimising the spread of SARS-CoV-2 might also have positive impacts on mental health by reducing anxiety about contracting the virus and decreasing death rates. Additionally, contracting COVID-19 has been associated with an increased risk of psychiatric disorders.³

In The Lancet Public Health, Lara Aknin and colleagues report the results of a large scale study that investigated the association between COVID-19 policy stringency, psychological distress, and life satisfaction in 15 countries.⁴ The study leveraged two unique datasets: the Oxford COVID-19 Government Response Tracker, which provided a timeline of the stringency of COVID-19 public health policies in different countries, and the Imperial College London-YouGov COVID-19 Behaviour Tracker Global Survey, which provided a timeline of psychological distress and life evaluations in these countries. Using these data, the authors were able to compare countries and in particular, countries with different strategies to contain the spread of SARS-CoV-2.

The study found that higher policy stringency (comprising eight items such as stay at home requirements, school closures, and the cancellation of public events) was associated with worse psychological distress and life satisfaction (standardised coefficients β=0·014 [95% CI 0·005 to 0·023] for psychological distress; β=–0·010 [–0·015 to –0·004] for life evaluation). The association was subtle: increasing the stringency index by 76 points (corresponding to the transition from the lowest to the highest stringency level observed in the period of analysis) was associated with an increase in psychological distress of 0·11 point on a scale from 1 to 4. The authors also found that not all countries used the same level of stringency to curb the spread of COVID-19: countries that pursued an elimination strategy (eg, Australia) managed to decrease COVID-19 deaths more than countries that pursued a mitigation strategy (eg, the UK), while implementing fewer stringent measures (ie, by implementing earlier contact tracing while relying less heavily on the cancellation of public events). As a result, eliminator countries seemingly managed to find a balance between restricting the spread of SARS-CoV-2 and safeguarding mental health.

Should policy makers and public health agencies of mitigator countries switch to an elimination strategy on the basis of this study? We believe that at present, the data are insufficient to drive change in public health policies. Since this study was observational, the results do not indicate whether lower death rates with less stringency were achieved in countries that pursued an elimination strategy because of their COVID-19 policies or whether this resulted from factors not measured in this study (eg, health-care provision, health behaviours, general population health). Since a randomised controlled trial to answer this question is not feasible, observational studies and natural experiments can help to provide necessary evidence to guide policies aimed at containing the spread of the infection, while safeguarding mental health.⁵ For example, Serrano-Alarcón and colleagues compared the mental health in England and Scotland before and after the COVID-19 policies started to diverge between these two countries, indicating that stringent policies had a negative effect on mental health.⁶ Many such transition points in COVID-19 policies across countries have been observed during the pandemic and each provides an opportunity to investigate the impact of a subset of policies on mental health.

The dichotomy between restricting the spread of SARS-CoV-2 and safeguarding mental health might not be needed: the choice of policies used to contain the spread of the virus are likely to have differential effects on mental health. Establishing an inventory of the mental health impact of public health policies will help inform strategies to respond to potential future waves of COVID-19 and to other future pandemics. Well-designed and adequately powered studies that can provide data for such an inventory should be incentivised.

We declare no competing interests.