An increase in the already substantial burden of disease related to mental health will put a strain on healthcare systems at risk of collapsing under the pressure of the Covid-19 outbreak.
As the world grapples with the Covid-19 outbreak, rushing to “flatten the curve” and mitigate the risks of collapsing health systems, it is imperative we turn our attention to the mental health implications of this pandemic. Many proactive measures put in place around the world have underestimated the importance of incorporating MHPSS (mental health and psychosocial support) as an essential component of any emergency response. In a recently released report, the Inter-Agency Standing Committee (IASC) for Mental Health and Psychosocial Support in Emergency Settings advise that Mental Health and Psychosocial Support (MHPSS) “should be a core component of any public health response.” The fear of being infected can not only lead to severe anxiety, but also cause individuals to avoid seeking healthcare to prevent being exposed to the virus – or, paradoxically – to present too readily at emergency centres without medical cause. As noted in an article recently published in the British Medical journal,
“Surges of such low risk patients are often precipitated by high levels of anxiety, leading patients to identify, catastrophise, and seek help for symptoms that might otherwise have prompted little concern, and leading clinicians to refer patients to hospital at the first sign of a mild symptom developing.”
Considering the mental health impact is essential:
The baseline prevalence rates of mental health disorders – before the outbreak – already constitute a significant portion of the global burden of disease.
Under the current climate of fear, enforced social isolation, and economic devastation, mental health difficulties may be expected to increase sharply.
This burden will have a substantial impact on already over-stretched health systems.
Baseline prevalence: the substantial global burden of mental health diseases
The Institute for Health Metrics and Evaluation and reported in their flagship Global Burden of Disease study estimates that 970 million people lived with a mental health or substance abuse disorder in 2017. This represents a staggering 1 in 7 people (15%) globally. The ‘disease burden‘ – measured in Disability-Adjusted Life Years (DALYs) — considers not only the mortality associated with a disorder —, but also years lived with disability or health burden. Of this, mental health disorders accounted for around 5% of the global disease burden when measured in 2017 (up to 10% in several countries). We may consider these to be conservative estimates. Many difficulties go under-reported and undetected, particularly in the developing world where there is typically less awareness and more stigma around mental health issues, and fewer resources at hand to identify and treat those in need.
Mental health from a socio-ecological perspective
Mental health disorders are complex. They take many forms. Difficulties may range from depression, anxiety, PTSD, and schizophrenia — through to substance abuse disorders. They are not only located at the level of the individual. They are increasingly understood as unfolding within the context of systems of relationships which constitute our socio-cultural environment. They are exacerbated by harsh living conditions, the erosion of mutual social support mechanisms, limited access to basic needs and services and lack of opportunities for maintaining livelihoods and education. In recent years, there has indeed been a burgeoning of theoretical models for understanding mental health disorders that situates individuals’ mental health sequelae and recovery within interpersonal, political, and social context. This ecological perspective similarly incorporates a “resource perspective”, which assumes that human communities evolve adaptively. We are deeply embedded in complex and dynamic social contexts. Equally, symptom severity is not static but fluid and changes according to a continuum of pathological reactions.
Simply put, the social and economic environment has a fundamental role to play in mental health. We need to pay attention to the various, context-dependent, long-term, and complex social, political, and economic measures affecting the mental health of populations. Given the importance of the socio-cultural and economic environment on mental health, the anxiety, economic impact, and social isolation brought about by the Covid-19 pandemic can only exacerbate the burden.
The mental health impact of Covid-19
Some of the key factors related to the Covid-19 outbreak and its influence on mental health include:
Boredom linked to quarantine: risks exacerbating most mental health difficulties, including substance use disorders, anxiety, and depression.
Frustration, anger, and powerlessness linked to quarantine: risks exacerbating domestic violence, sexual abuse and violence and childhood abuse – further linked to the increased risk of substance use disorders as a maladaptive coping mechanism. In China and Italy, cases of domestic violence have increased. Several organisations preventing violence against women and feminist collectives are sounding the alarm.
Social isolation and loneliness: risks exacerbating most mental health conditions, notably depression, anxiety, and substance use.
Fear: risks exacerbating anxiety disorders, including Obsessive Compulsive Disorder and PTSD. Feeling overwhelmed by anxiety can make it difficult to cope with the new lifestyle changes that are required, or may lead to people using unhealthy ways of coping, such as substance use. Another risk related to fear is an increase in psychosomatic reactions, in other words, physical manifestations of psychological suffering (sometimes understood as conversion disorder). This again could result in an increased number of patients attending emergency centres.
Financial loss: risks exacerbating most mental health difficulties, including substance use disorders, anxiety, and depression.
We have little evidence on the mental health impact of quarantine on individuals. We have even less on the impact of a global enforced quarantine on entire communities. However, this rapid review recently published in the Lancet “suggests that the psychological impact of quarantine is wide-ranging, substantial, and can be long-lasting.” Most of the studies examined in this meta-review reported negative psychological effects including post-traumatic stress symptoms, confusion, and anger. Stressors highlighted across studies included longer quarantine duration, infection fears, frustration, boredom, inadequate supplies, inadequate information, financial loss, and stigma.
We need to be concerned for the individuals affected and for their families and communities. Importantly, we also need to be concerned for the healthcare systems at risk of collapse globally in the face of increased mental health difficulties.
The impact on frontline workers
A recent article published in the Lancet, exploring the lessons learnt on MHPSS in China, stated that:
“Under strict infection measures, non-essential personnel such as clinical psychiatrists, psychologists, and mental health social workers, are strongly discouraged from entering isolation wards for patients with COVID-19. Therefore, frontline health-care workers become the main personnel providing psychological interventions to patients in hospitals.”
This is a triple burden, with negatively reinforcing feedback mechanisms:
Healthcare workers “on the frontline” of the outbreak are particularly at risk of experiencing mental health difficulties themselves. The large body of literature on medical emergency workers in general attests to the high prevalence rates of mental health difficulties related to the stress of the job. This refers both to the nature and the amount of work, as well as the exposure to human tragedy, increasing the risk of secondary or vicarious trauma. A recently published article in Brain, Behaviour and Immunity confirms the significantly high levels of vicarious trauma among frontline workers facing the Covid-19 outbreak in China.
Healthcare workers are also asked to take on the double task of acting as both medical AND mental health care workers. Not necessarily within their scope of practice, they may not be equipped with the necessary tools and resources, both professional and psychological, to handle this extra load.
Healthcare workers may see an increase in the number of people presenting with mental health difficulties. There is a significant risk of the global burden of disease related to mental health difficulties increasing. This is not only necessary in relation to the virus itself (for example, anxieties and fears around contracting the illness), but more generally related to mental health conditions globally being exacerbated by current conditions.
Physical distancing, social solidarity: moving forward together
The crisis has catalysed countless creative examples of social solidarity, mutual aid, encouragement, and support. As global mental health experts have noted in a recent report:
“We need to encourage physical distancing along with social solidarity. And any MHPSS intervention during this time needs to include key psychosocial principles, including hope, safety, calm, social connectedness and self- and community efficacy.”
Healthcare workers need to be armed with adequate MHPSS strategy integrated into their response activities and the systems in which they work
Patients in quarantine should have access to mental healthcare
Mental health professionals should be resourced and equipped to offer support online/via tele-therapy – and paraprofessionals (such as community healthcare workers) should be trained and equipped to join them in picking up this load. Online mental health services have been successfully implemented in response to the outbreak in China, as confirmed in this report in the Lancet.
By mapping existing MHPSS service providers and institutions, efforts can be pooled to address the global burden of mental health disorders: a substantial burden projected only to increase.
About Gail Womersley and Outsight International
Gail Womersley is based at the University of Neuchâtel, where she lectures BA and MA students in sociocultural psychology. She has worked for over ten years as a clinical psychologist and researcher with displaced communities in the Central African Republic, the Democratic Republic of Congo, Greece, Iraq, Israel, the Philippines, South Africa, South Sudan, the Ukraine, and Zimbabwe. Her recent publications include the book: “Trauma Without Borders: Working with Adversity and Resilience Among Displaced Populations” (to be published by Springer in 2021).
Outsight International provides services to the humanitarian and development sector in an efficient and agile way. Outsight International builds on the range of expertise offered by a network of Associates in order to deliver quality results adapted to the specific tasks at hand. If you’d like to discuss working with Gail and the Outsight team, please get in touch or follow us on LinkedIn for regular updates.