Challenges to and Recent Research on the Mental Health of Older Adults in China During the COVID-19 Pandemic.

Mental health services have played an important role in supporting people’s mental well-being during the COVID-19 pandemic and the associated periods of prolonged government-mandated restrictions such as lockdowns. China has the world’s largest population of older adults (people aged above 65 years), but its mental healthcare system is not well equipped to meet the growing needs of this population. Consequently, the pandemic has had a devastating impact on the mental health of older adults in China, especially given the rapid changes in traditions and family structures in recent decades. This special issue reviews the challenges to and recent research on the provision of mental health services to older adults in China during the pandemic.

Since the initial outbreak of COVID-19 in China in early 2020, strict public-health measures have been implemented throughout the country, such as periodic lockdowns, physical distancing requirements, and reductions in public services. These measures often have made it difficult for older adults with medical and psychiatric conditions to access healthcare services.[1] Widespread quarantine measures have also led to reductions in social support from family members and friends and outdoor activities for older adults. Thus, as most older adults have been required to remain indoors as much as possible, their opportunities for face-to-face social interactions have significantly decreased, further increasing their social isolation and loneliness.[2,3] In addition, only a relatively small proportion of Chinese older adults has access to the Internet and smartphones, which reduces the likelihood that they can use e-mail and social media to compensate for their lack of direct social interaction.[1]

Compared to community-dwelling older adults, institutionalized older adults, including psychiatric inpatients and nursing-home residents, usually experience more severe social isolation and loneliness because of strict restrictions on their ability to leave these institutions (eg, on day leave or home leave) and to receive regular visits from family.[4,5] In China, although over 80% of the population aged over 60 years has been vaccinated against SARS-CoV-2, the virus that causes COVID-19,[6] this population has experienced higher rates of hospitalization and death due to COVID-19 than people in other age groups. These high rates of morbidity and mortality may have increased this population’s frustrations and uncertainty about the future and exacerbated their existing mental health conditions.[7] Although small-scale pandemic outbreaks continue to occur in China due to imported cases,[8] China was the first nation to experience, fight, and achieve control over a COVID-19 outbreak. Therefore, the experiences and lessons learned in China can inform the planning and delivery of effective mental health services for older adults in other nations during the pandemic.

Numerous studies on the mental health of adolescents and younger adults during the pandemic have been published in China and elsewhere over the past few years.[9-11] In contrast, fewer studies have focused on the mental health of older adults during the pandemic.[12] There is thus a need for an overview of recent research on common mental health and psychosocial problems suffered by older adults in China during the pandemic, with a focus on research on depression, anxiety, loneliness, and suicidal behavior. This special issue of the Journal of Geriatric Psychiatry and Neurology comprises 8 articles that facilitate understanding of the mental health challenges faced by older adults in China during the pandemic.

This issue begins with a meta-analysis by Yan and colleagues of the prevalence of depressive and anxiety symptoms in older Chinese adults during the pandemic.[13] The wide variations in the prevalence of such symptoms in this population have led to debate on the impact of the pandemic on their mental health and hindered the development of mental health services for them. To address this problem, Yan and colleagues performed a meta-analysis to obtain reliable estimates of the prevalence of depressive and anxiety symptoms in Chinese older adults with COVID-19 or other major medical conditions, and in the general population of Chinese older adults.

Although the pandemic has led to an increased risk of mental health disorders, research on this relationship and its potential mediating factors has been limited. Li and colleagues applied network analysis to assess symptoms of depression, anxiety, insomnia, posttraumatic stress disorder, pain, and fatigue in a sample of clinically stable older adult psychiatric patients during the pandemic in China.[14] They found that depression was the most central psychiatric syndrome, and depression and anxiety were identified as the bridge syndromes in a network model of depression, anxiety, posttraumatic stress symptoms, insomnia, pain, and fatigue. These findings suggest that psychological interventions targeting depressive and anxiety symptoms may be important for improving the mental well-being of older psychiatric patients during the pandemic.

Unlike quantitative research, qualitative studies can provide deep insights into pandemic-induced psychosocial difficulties by examining the life situation, experiences, and views of older adults. Sit and colleagues used telephone interviews to qualitatively examine the psychosocial effects of the pandemic on fear and loneliness in a sample of Chinese older adults in Hong Kong.[15] Sit and colleagues concluded that participants’ uncertainty regarding the risk of SARS-CoV-2 infection and the effects of this uncertainty on their norms, values, and typical daily routines accounted for their fearful emotional state, while reductions in family and community support aggravated their loneliness.

In recent years, a sense of alienation has been recognized as a major psychosocial problem affecting Chinese older adults. As this sense is manifested as feelings of social isolation, powerlessness, and normlessness, it may have been exacerbated by mandated lockdowns and physical distancing measures. Chen and colleagues explored alienation and its associations with depressive symptoms and poor sleep quality in Chinese older adults who were subjected to lockdowns during the pandemic.[16] Over half of the participants expressed a sense of alienation, which was independently associated with depressive symptoms and poor sleep quality.

Insomnia is another major mental health concern that has affected older adults during the pandemic. However, the epidemiology of insomnia subtypes has rarely been reported during the COVID-19 pandemic. Xu and colleagues examined the prevalence of insomnia subtypes in Chinese older adults during the pandemic. They found that difficulty maintaining sleep was the most frequent subtype (17.1%), followed by difficulty initiating sleep (15.4%) and early morning awakening (11.2%).[17] In a subsequent classification tree analysis, worry about becoming infected with SARS-CoV-2, residence in the COVID-19 epicenter, and unemployment were identified as the correlates that primarily influence symptoms of insomnia in this population during the pandemic.

Clinically stable psychiatric patients have been particularly vulnerable to regression during the pandemic, as their ability to access psychiatric outpatient clinics for regular maintenance treatment has been decreased by mass quarantines and traffic restrictions. However, the negative effects of the pandemic on mental health-related parameters (e.g., sleep) in clinically stable psychiatric patients have been unknown. Xu and colleagues’ survey of the prevalence of sleep disturbances among clinically stable Chinese older adult psychiatric patients during pandemic reveals that the overall frequency of sleep disturbance was 57.1% and that this disorder was negatively associated with patients’ quality of life. This highlights the urgent need to screen for and treat sleep problems in vulnerable populations.[17]

Biological disasters and related social crises are often associated with an increased risk of suicide among older adults. However, there have been few data collected on the effect of the pandemic on the risk of suicide in this population. This research gap is addressed by 2 publications in this special issue that describe studies of the prevalence of suicidal behavior in clinically stable Chinese older adult psychiatric patients and in older adults in general during the pandemic.[18,19] In line with expectations, the results of both studies show that there was a high prevalence of suicidal behavior in their respective cohorts. Given the perception of an increased need for mental healthcare for older adults and their low level of access to mental health services,[19] these studies emphasize the need to recognize and remove barriers to this population’s timely treatment.

Overall, the studies included in this special issue clearly indicate that many Chinese older adults have experienced psychiatric illness during the pandemic and that their needs for mental health resources and services have not been met. We therefore hope that the information provided in this special issue will facilitate understanding of the mental health needs of Chinese older adults and those elsewhere in the world, and the importance of maintaining mental health services for these vulnerable populations during the pandemic.