The intersection of COVID-19 and mental health.

On Oct 6, 2020, WHO published the results of a survey of the impact of COVID-19 on mental, neurological, and substance use (MNS) services in 130 WHO Member States, ahead of World Mental Health Day on Oct 10. The survey revealed that most countries are experiencing some disruption to MNS services, with the greatest impact on community-based and prevention and promotion services. Reasons for disruption included an insufficient number or redeployment of health workers to the COVID-19 response (in 30% of countries), use of mental health facilities as COVID-19 quarantine or treatment facilities (in 19% of countries), and insufficient supply of personal protective equipment (in 28% of countries). Although 116 (89%) countries reported that mental health and psychological support was part of their national COVID-19 response plans, only 17% said they had committed additional funding for this. This report comes on the back of mounting evidence that the COVID-19 pandemic is having monumental effects on the mental health and wellbeing of populations worldwide. With seemingly low capacity to respond, it is unclear how the world will deal with this looming mental health crisis.

Historical examples show the detrimental impact events such as a pandemic can have on the mental health of affected populations. For example, research from communities affected by outbreaks of Ebola virus disease (EVD) revealed widespread panic and anxiety, depression resulting from the sudden deaths of friends, relatives, and colleagues, and stigmatisation and social exclusion of survivors. A meta-analysis found that depressed mood, anxiety, impaired memory, and insomnia were present in 33–42% of patients admitted to hospital for severe acute respiratory syndrome or Middle East respiratory syndrome, and that in some cases these effects continued beyond recovery.

In the case of COVID-19, non-pharmaceutical interventions (NPIs), although essential to halt transmission of the virus, have led to physical isolation, closure of schools (with untold effects on the development and wellbeing of children), and widespread job losses. Misuse of substances, particularly alcohol, is rising. Emerging evidence suggests that COVID-19 could even have direct neurological consequences. And as with many other features of this pandemic, not all people have been affected equally. Disruptions to MNS services, as reported by WHO, are disproportionately affecting people with pre-existing mental health conditions by limiting access to essential treatment and support services. People with salaried jobs are far less likely to be affected than those with informal, daily wage jobs, which include a substantial proportion of the workforce in lower-income countries. Frontline workers are experiencing increased workload and trauma, making them susceptible to stress, burnout, depression, and post-traumatic stress disorder (PTSD).

Even under normal circumstances, good mental health is crucial to the functioning of society. During a pandemic, however, it can affect how we respond and recover. Health-care workers are essential to the COVID-19 response but may have to leave the workforce if their mental health is not protected. Mental ill health may also affect uptake of a vaccine and adherence to NPIs, with some evidence suggesting that poor mental health could increase susceptibility to infection and transmission of the virus. For example, a study in Sierra Leone found that EVD risk behaviours were associated with intensity of depression symptoms, PTSD symptoms, and war exposure. People with dementia might be at high risk of exposure to COVID-19 because of difficulty in remembering instructions for, and importance of, physical distancing and hand hygiene. Confinement of people with and without mental illness in institutions can increase their risk of infection, as witnessed in long-term care facilities and prisons.

Even before COVID-19, mental health conditions were prevalent, accounting for about 13% of the global burden of disease. Yet, the world was woefully unprepared to deal with the mental health impact of this pandemic. Years of underinvestment in mental health, especially in low-income and middle-income countries, have left us vulnerable. It is well known that our ability to respond to, and recover from, the COVID-19 pandemic will require development of effective vaccines and treatments and strict adherence to NPIs. Less well known is that to minimise the impact of the pandemic, we must also address the substantial unmet mental health needs of whole societies, with a focus on the most vulnerable.

For WHO's survey on MNS services see https://www.who.int/publications/i/item/978924012455

For more on World Mental Health Day 2020 see https://wfmh.global/world-mental-health-day-2020

For more on vulnerable groups see https://www.bond.org.uk/resources/covid-19-and-mental-health-immediate-and-long-term-impacts

For Ebola virus disease risk behaviours see PLoS Med 2016; 13: e1002073