Longstanding reasons to prioritise mental health

The high global burden of mental and substance use disorders highlights the need to make mental health a higher public health priority. Approximately a quarter of adults experience a mental disorder each year.^{Reference Wittchen and Jacobi4} The Global Burden of Disease Study calculated burden of disease using several metrics, including disability-adjusted life years (DALYs) and years lived with disability (YLDs). Worldwide in 2010, mental and substance use disorders accounted for 7.4% of total disease burden (DALYs) and 22.9% of the non-fatal burden (YLDs).^{Reference Whiteford, Degenhardt, Rehm, Baxter, Ferrari and Erskine5} Mental and substance use disorders were ranked the fourth leading cause of DALYs and the leading cause of YLDs respectively worldwide. The biggest psychiatric contributors in terms of DALYs, in descending order, were depressive disorders, anxiety disorders, drug use disorders, alcohol disorders and schizophrenia. These data underestimate the demand on mental health services as they exclude personality disorders and dementia and other neuropsychiatric disorders. Population ageing means that the number of people with dementia will increase dramatically over the next decade. Worldwide, nearly three million people die owing to harmful use of alcohol each year and there are 800 000 deaths by suicide.³ Mental disorders result in an enormous economic cost to society, primarily though indirect costs (i.e. lost income and productivity) rather than direct costs (i.e. healthcare costs).^{Reference Trautmann, Rehm and Wittchen6}

The individual suffering and economic costs associated with mental disorders could be reduced, as effective and low-financial-cost treatments exist for many psychiatric disorders. These include cognitive–behavioural therapy (CBT) and antidepressants for anxiety and depressive disorders, medication and psychological therapies to treat substance use disorders, and antipsychotic medication for psychotic disorders. However, inadequate funding, lack of trained healthcare professionals, stigma and inefficient use of existing services often prevent effective treatment. A study in low-, middle- and high-income countries showed that, in each of the 17 countries involved, most people with a mental health disorder within the last 12 months had received no treatment.^{Reference Wang, Aguilar-Gaxiola, Alonso, Angermeyer, Borges and Bromet7} A related problem, also seen worldwide, is delay in seeking treatment. Data from 15 countries, including low-, middle- and high-income nations, showed that the median delay before seeking treatment ranged from 3 to 30 years for anxiety disorders, 1 to 14 years for mood disorders, and 6 to 18 years for substance use disorders.^{Reference Wang, Angermeyer, Borges, Bruffaerts, Chiu and De Girolamo8} Delays tended to be greater in developing countries, men, older cohorts and people with earlier age of onset.

A major contributor to delayed help-seeking is mental health stigma. Stigma can be conceptualised as being made up of problems with knowledge (ignorance), attitudes (prejudice) and behaviour (discrimination).^{Reference Thornicroft, Rose, Kassam and Sartorius9} Stigma causes great personal distress, with many people describing its consequences as worse than the psychiatric disorder itself. Human Rights Watch recently highlighted that people with mental illness are still shackled in over 60 countries.¹⁰

At least 20% of general practice visits in Western countries are related to mental health problems.^{Reference Fleury, Imboua, Aubé, Farand and Lambert11} Well-designed primary healthcare services can diagnose and manage most psychiatric disorders, provided there is access to specialist services to manage more complex disorders. However, primary care services are poorly developed in many low- and middle-income countries. Their ability to provide psychiatric care is often further compromised by a lack of mental health training for staff, whether they be doctors, nurses, other healthcare professionals or lay health workers.^{Reference Rathod, Pinninti, Irfan, Gorczynski, Rathod and Gega12} About 30% of general hospital in-patients in the UK have a comorbid psychiatric disorder, and this is associated with poorer clinical outcomes and increased financial costs. Consultation-liaison psychiatry services can reduce in-patient stays and be cost-effective.^{Reference Wood and Wand13}

Most countries spend less than 2% of their health budgets on mental health.³ This is despite the high burden of mental health disorders and estimates that every US$1 invested in mental health will lead to saving US$5 in improved health and productivity.³ Increasing investment in mental health was the theme of World Mental Health Day 2020.³ Problems of underfunding are often compounded by poor integration and use of services.^{Reference Thornicroft14} In particular, some low- and middle-income countries divert a large proportion of their mental health budget to specialist psychiatric hospitals which only cater for a minority of those with mental disorders at a population level. In some high-income countries, a high proportion of those with relatively minor mental health disorders, which could be treated effectively at a primary healthcare level, are treated by specialist services.

The COVID-19 pandemic and its aftermath

Research on the mental health consequences of the pandemic is at an early stage. Many existing studies are cross-sectional, employ convenience samples and report the prevalence of self-reported psychiatric symptoms (i.e. psychological distress) rather than psychiatric disorders (i.e. psychiatric syndromes). Nevertheless, subsyndromal symptoms can cause distress, impair functioning and warrant intervention, though usually at a primary care level. The pandemic's impact in terms of rates of infection, mortality and social disruption has varied geographically and over time. Consequently, long-term longitudinal studies, specific to regions/countries, will be necessary to build up an accurate picture of the psychiatric consequences. Although we focus on its detrimental psychiatric effects, the pandemic will provide an opportunity for psychological growth for some people.

Longitudinal studies in the UK,^{Reference Pierce, McManus, Hope, Hotopf, Ford and Hatch15} Europe^{Reference Varga, Bu, Dissing, Elsenburg, Herranz Bustamante and Matta16} and USA^{Reference Daly and Robinson17} showed a rise in the prevalence of psychiatric symptoms in the general adult population during the first wave of the pandemic compared with pre-pandemic levels. This was followed by an improvement indicating that the overall population response was one of adaptation. UK research using the 12-item General Health Questionnaire, administered monthly between April and September 2020, showed that within this overall pattern there were subgroups with different mental health trajectories.^{Reference Pierce, McManus, Hope, Hotopf, Ford and Hatch15} Most people were either resilient throughout the 6 month study period or showed a time-limited deterioration in their mental health. However, approximately 11% showed a sustained deterioration in their mental health throughout the study period. Risk factors for belonging to this group included female sex, a prior history of mental health problems, being single, living in a deprived area, experiencing financial difficulties and being of Asian or mixed ethnicity.^{Reference Pierce, McManus, Hope, Hotopf, Ford and Hatch15} It is of concern that the pandemic is exacerbating existing disparities in mental health. Children and adolescents, like adults, vary in their response to the pandemic, with the most common reactions including depressive and anxiety symptoms and female adolescents being at higher risk than male adolescents or children.^{Reference Meherali, Punjani, Louie-Poon, Rahim, Das and Salam18} The long-term effects of missed schooling and peer contact on future mental health are unknown.

The UK mental health charity Rethink Mental Illness reported a major increase in the number of people accessing its online guidance in the first year of the pandemic compared with the year before.¹⁹ High levels of psychiatric symptoms have been reported in front-line healthcare staff working during the pandemic.^{Reference De Kock, Latham, Leslie, Grindle, Munoz and Ellis20} Previous epidemics and pandemics indicate that the mental health impact on healthcare professionals can be long lasting, with post-traumatic stress disorder (PTSD) and depressive symptoms being reported 3 years after outbreaks of infection.^{Reference Preti, Di Mattei, Perego, Ferrari, Mazzetti and Taranto21}

A retrospective cohort study from the USA found that 34% of those who were diagnosed with COVID-19 received a neurological or psychiatric diagnosis in the following 6 months, with 13% receiving their first such diagnosis;^{Reference Taquet, Geddes, Husain, Luciano and Harrison22} 24% received a diagnosis of a mood disorder, anxiety disorder or psychotic disorder, with the rates for all three disorders being significantly higher than those seen after influenza or other respiratory tract infections (i.e. control disorders). An increased risk of psychiatric and neurological diagnoses was seen in those admitted to hospital with COVID-19 and in those treated in the community but was greater in the former group. The pathways by which COVID-19 could cause psychiatric disorders include psychosocial stress, inflammation, neurotropism and iatrogenic effects. Several studies have highlighted the bidirectional relationship between psychiatric disorders and COVID-19, i.e. not only does COVID-19 increase the risk of subsequent psychiatric disorder but those with existing mental health problems are at greater risk of infection with SARS-CoV-2.^{Reference Taquet, Luciano, Geddes and Harrison23,Reference Wang, Xu and Volkow24}

A report has predicted approximately 11% more referrals to mental health services in England each year for the next three years (2020 to 2023), with the costs of increased activity reaching £3 billion over this period.² Increased demand is expected to reflect a backlog of people who delayed seeking help for a mental health problem in previous lockdowns, people known to mental health services whose condition deteriorated owing to disrupted care in lockdowns and people who developed new mental disorders as a result of the pandemic.

The development of effective COVID-19 vaccines in under a year, with further vaccines in the pipeline, is an incredible scientific achievement. However, even with the support of the G7 countries, it will take until at least the end of 2022 to vaccinate the world's population. The duration of protection offered by vaccines is unclear, and new variants and vaccine hesitancy may undermine the effectiveness of the vaccination programme. As such, it is impossible to know when the pandemic will end.

Many experts predict that the COVID-19 pandemic will lead to a worldwide recession, which would be expected to increase rates of mental health problems.^{Reference McKee and Stuckler25} Previous economic recession have been associated with increased rates of mental disorders, with mediators being unemployment and financial hardship.^{Reference Frasquilho, Matos, Salonna, Guerreiro, Storti and Gaspar26} It has been suggested that the COVID-19 pandemic may lead to an increased suicide rate; however, this is not inevitable and there is a strong evidence base for suicide prevention.^{Reference Gunnell, Appleby, Arensman, Hawton, John and Kapur27}