Introduction
COVID-19 has been the most seismic public health event in living memory with reverberations globally across all strata of society necessitating unprecedented governmental interventions which have altered daily living. In the early aftermath of the WHO declaring a global pandemic in March 2020, there was an awareness that the impact of the pandemic and the measures necessary to curtail it, would inevitably result in psychological morbidity (Holmes et al. Reference Holmes, OConnor, Perry, Tracey, Wessely and Arseneault2020; Hotopf et al. Reference Hotopf, Bullmore, OConnor and Holmes2020). While the focus at the outset of the pandemic was understandably sharply focused on physical illness, the likely mental health implications were also highlighted at a very early stage with calls for appropriate measures to offset this risk (OConnor et al. Reference OConnor, Wrigley, Jennings, Hill and Niazi2021). Data from previous major emergencies and pandemics pointed to a likely peak in mental health problems which was predicted to occur later than the initial peak in physical illness, and also to endure for longer (NATO Joint Medical Committee 2008; Shultz et al. Reference Shultz, Neria, Allen, Espinel and Bobrowsky2013; Health Service Executive, 2014). Similarly at a very early stage in the pandemic, based on evidence from previous epidemics such as the severe acute respiratory syndrome (SARS) virus, it was postulated that particular groups were likely to face higher rates of negative mental health outcomes for a variety of reasons (Cheung et al. Reference Cheung, Chau and Yip2008; Cheung et al. Reference Cheung, Chau and Law2010; Mak et al. Reference Mak, Chu, Pan, Yiu and Chan2009; Lee et al. Reference Lee, Kang, Cho, Kim and Park2018; Gao et al. Reference Gao, Zheng, Jia, Chen, Mao and Chen2020; Rogers et al. Reference Rogers, Chesney, Oliver, Pollak, McGuire and Fusar-Poli2020). These included healthcare workers, those with pre-existing mental illness, the youth population and individuals experiencing socio-economic adversity. It was also anticipated that pre-pandemic inequalities and associated mental health risk would be increased by the pandemic and its aftermath (OConnor et al. Reference OConnor, Wetherall, Cleare, McClelland, Melson, Niedzwiedz, O'Carroll, OConnor, Platt, Scowcroft, Watson, Zortea, Ferguson and Robb2020).
Approaching 2 years into this pandemic efforts continue to clarify how this unique event has impacted the global population. Research into the evolving societal impact and mental health consequences remain at an early stage as the global population continues to cycle through various stages of psychological response and adaptation. As such the pandemic remains a dynamic global psychosocial stressor. The evidence in relation to neuropsychiatric impact also continues to evolve as COVID-19 inflammatory responses, neurotropism and iatrogenic effects can change at different points of illness and recovery. The potential for distinct neuropsychiatric consequences with emerging variants remains uncertain. Furthermore, the impact of long COVID on psychological well-being and rates of mental illness needs further consideration (Berenguera et al. Reference Berenguera, Jacques-Avi, Medina-Perucha and Puente2021). Without doubt, it is injudicious to draw definitive conclusions on a process which is ongoing. Notwithstanding the fact that much remains to be learned, it seems timely to reflect on what is now known about the impact of the pandemic on population mental health and how this is likely to shape prevalence of mental illness and service needs in the short and long term. Moreover, the pandemic provides a useful prism through which to consider contemporary views of mental illness and service provision.
Mental health and societal impacts of COVID-19
Measuring the impact of COVID-19 on population mental health poses significant challenges (Patten et al. Reference Patten, Kutcher, Streiner, Gratzer, Kurdyak and Yatham2021). While numerous studies have reported increase in psychiatric morbidity since onset of COVID-19, in particular for population levels of depression and anxiety (COVID-19 Mental Disorders Collaborators, 2021; Thorisdottir et al. Reference Thorisdottir, Asgeirsdottir, Kristjansson, Valdimarsdottir, Jonsdottir Tolgyes, Sigfusson, Allegrante, Sigfusdottir and Halldorsdottir2021; Santabrbara et al. Reference Santabrbara, Lasheras, Lipnicki, Bueno-Notivol, Prez-Moreno, Lpez-Antn, De la Cmara, Lobo and Gracia-Garca2021; Fancourt et al. Reference Fancourt, Steptoe and Bu2021; Pierce et al. Reference Pierce, Hope, Ford, Hatch, Hotopf, John, Kontopantelis, Webb, Wessely, McManus and Abel2020; Samji et al. Reference Samji, Wu, Ladak, Vossen, Stewart, Dove, Long and Snell2021), some studies have also suggested the possibility that the overall effect on population mental health was moderate (Hafstad et al. Reference Hafstad, Stren, Wentzel-Larsen and Augusti2021; Sharp et al. Reference Sharp, Serfioti, Jones, Burdett, Pernet, Hull, Murphy, Wessely and Fear2021; Knudsen et al. Reference Knudsen, Stene-Larsen, Gustavson, Hotopf, Kessler, Krokstad, Skogen, verland and Reneflot2021; Nichter et al. Reference Nichter, Hill, Na, Kline, Norman, Krystal, Southwick and Pietrzak2021; John et al. Reference John, Eyles, Webb, Okolie, Schmidt, Arensman, Hawton, OConnor, Kapur, Moran, O'Neill, McGuiness, Olorisade, Dekel, Macleod-Hall, Cheng, Higgins and Gunnell2020). Several of these studies suggest greater mental health issues among those diagnosed with COVID-19 and perhaps among certain population cohorts such as the youth population. However, interpretation of the findings is complicated by the possibility of variation in population mental distress at different phases of the pandemic and in particular with respect to the lockdown restrictions imposed at different phases.
The impact of the pandemic on referrals and presentations has also varied across pandemic phases, with some empirical research suggesting a delayed surge in psychiatric referrals to both adult (McIntyre et al. Reference McIntyre, Tong, McMahon and Doherty2021) and paediatric emergency departments (McDonnell et al. Reference McDonnell, Barrett, McNicholas, Barrett, Conlon, Cummins, Hensey, McAuliffe and Nicholson2021). Studies have suggested that tertiary mental health services have experienced a delayed but significant increase in both routine and urgent referrals to Child and Adolescent Mental Health Services, with one study demonstrating substantial increases from September 2020 post-COVID-19 when compared with pre-pandemic years (McNicholas et al. Reference McNicholas, Kelleher, Hedderman, Lynch, Healy, Thornton, Barry, Kelly, McDonald, Holmes and Kavanagh2021).
The pandemic management strategies, such as lockdown restrictions, employed by many governments globally have required myriad shifts in population behaviours, which may have negatively impacted certain vulnerable populations more than others. Numerous examples of negative consequences exist, such as dramatically increased rates of domestic violence, the deleterious impact of school closures for vulnerable children (Kofman & Garfin, Reference Kofman and Garfin2020), and concerns about the impact of punitive restriction regimens on the elderly, especially by way of increased social isolation and loneliness (Van Tilburg et al. Reference Van Tilburg, Steinmetz, Stolte, van der Roest and de Vries2021). Debates have ensued as to the rationale and evidence base for the restrictions imposed and the unintended, unforeseen consequences of these restrictions (Boettke & Powell, Reference Boettke and Powell2021). While the need for a nuanced approach for certain populations in society is evident, the feasibility of enacting in real-time, a population level pandemic response catering to the particular needs of multiple different vulnerable groups, is a uniquely challenging task for all governments.
Delivering healthcare for severe and enduring mental illness
One consequence of the enforced changes to peoples daily lives is that arguably there has never been more societal and media focus on mental health. However, in keeping with the trajectory of this discourse pre-pandemic it appears reasonable to assert that this increased awareness of mental health is not translating as effectively into increased awareness of severe mental illness, and by extension the serious implications of the pandemic for those with severe mental illness. Against this backdrop, caution was urged early in the pandemic as to the danger of an over-focus in epidemiological research on the psychological needs of milder psychological distress, instead of concentrating more efforts on vulnerable groups at higher risk of severe and enduring psychological morbidity (Danese & Smith, Reference Danese and Smith2020). An emphasis on delivering resources for severe and enduring mental illness is crucial in the post-pandemic period as this population will continue to endure mental health difficulties in the longer term.
A number of authors have noted the bidirectional link between COVID-19 and mental illness; COVID-19 elevates risk of mental illness and mental illness elevates the risks of COVID-19 (Taquet et al. Reference Taquet, Luciano, Geddes and Harrison2021; Wang et al. Reference Wang, Xu and Volkow2021). A recent meta-analysis has robustly demonstrated that pre-existing mood disorders are associated with higher rates of hospitalisation and death from COVID-19 infection (Ceban et al. Reference Ceban, Nogo and Carvalho2021). Additionally, individuals with mental illness requiring inpatient or residential care, by virtue of congregated living and difficulty in adherence to risk mitigation strategies can be at increased risk of exposure and transmission of COVID-19 (Kozloff et al. Reference Kozloff, Mulsant, Stergiopoulos and Voineskos2020). The authors argue that mental health disorders should be recognised as a high-risk condition similar to other pre-existing conditions such as obesity; however, this has not been adequately recognised in delivering COVID-19 risk categorisation and vaccine access for those with mental illness. The inclusion of mental illnesses in the algorithms employed to characterise COVID-19 risk levels is fundamentally important to a society which aims to provide parity of health services for those with physical or mental illness and by extension parity of resourcing and safety in the workplace for healthcare workers in the physical and mental healthcare domain.
Impact of COVID-19 on healthcare workers
Concerns were also voiced from the outset of the pandemic as to the likely impact of the pandemic on the psychological well-being of healthcare workers (Greenberg et al. Reference Greenberg, Docherty, Gnanapragasam and Wessely2020). This was based on the noted increase in psychological morbidity associated with healthcare workers in previous epidemics, most notably SARS (Maunder, Reference Maunder and Maunder2004, Reference Maunder, Leszcz, Savage, Adam, Peladeau, Romano, Rose and Schulman2008; Preti et al., Reference Preti, Di Mattei and Perego2020). While much of the research on the psychological fallout emanating from the pandemic has focused on frontline acute hospital settings, emerging data suggests that many of the psychological stressors, such as fears of illness, staff shortages, lack of personal protective equipment were also present across other non-frontline healthcare settings (Billings et al. Reference Billings, Biggs, Ching, Gkofa, Singleton, Bloomfield and Greene2021). Furthermore, while research has indicatedelevated levels of psychological morbidity in frontline hospital workers (De Kock et al. Reference De Kock, Latham, Leslie, Grindle, Munoz, Ellis, Polson and OMalley2021), it is also evident that morbidity has been significant among other healthcare workers.
The additional stress of introducing urgent systems change across the healthcare system cannot go unrecognised. For example, many community-based healthcare workers were required to introduce very significant changes in models of care provision such as providing interventions virtually. It has been hypothesised that pandemic preparedness, a known protective factor relating to post-pandemic psychological morbidity, may have been better in acute hospital settings leading to greater resilience among staff in these settings (Li et al. Reference Li, Jingwu, Meiling, Jianping, Mei and Riyue2020). Another area of growing concern is that a possible over-focus on individual rather than systemic factors relating to psychological morbidity in healthcare workers may inappropriately result in resourcing of interventions focused on enhancing individual resilience as opposed to resourcing a system which reduces burnout by optimising effective working.
Mental health service resourcing for the post-pandemic period
In anticipation of continued increased demand on specialist mental health services, increased resourcing is essential if meaningful progress is to be achieved in providing adequate psychiatric services in line with post-pandemic need (COVID-19 Mental Disorders Collaborators, 2021). Undoubtedly this pandemic has provided an opportunity for increased awareness of mental illness and has highlighted the need for delivering appropriate resources. The arbitrary distribution of mental health funding without an evidence-based approach remains a concern in many jurisdictions.
However, despite these well-founded concerns, cause for optimism should remain. Utilisation of post-disaster recovery approaches such as developed by the UN in Build Back Better can enhance societal resilience by utilising multi-layered actions in the short and longer term to optimise outcomes (United Nations General Assembly, 2016). The paradigm of Build Back Better has resonance for mental health services with calls for policymakers to seize the opportunities presented by the pandemic (Hoagwood & Kelleher, Reference Hoagwood and Kelleher2020). Given the groundswell of grassroots support for increased funding for mental health services together with the evident desire across all sectors for improved service provision, the time has arrived to ensure the unique opportunities presented by this pandemic can translate advocacy to resourcing, ensuring actionable outputs are delivered for better mental health services (Latoo et al. Reference Latoo, Haddad, Mistry, Wadoo, Islam, Jan, Iqbal, Howseman, Riley and Alabdulla2021).
Financial support
This article received no specific grant from any funding agency, commercial or not-for-profit sectors.
Conflict of interest
BG has no conflicts of interest to disclose. JL has no conflicts of interest to disclose. FMcN has no conflicts of interest to disclose.
Ethical standards
The author asserts that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008.
