Mental health effects of COVID-19

It is assumed, based on extant data from previous pandemics, together with emerging data from this pandemic, that psychological morbidity will inevitability rise (Maunder et al. Reference Maunder, Leszcz, Savage, Adam, Peladeau, Romano, Rose and Schulman2008; The Academy of Medical Sciences, 2020). Furthermore, this morbidity may peak later and endure for longer than the physical health consequences of the pandemic (Gunnell et al. Reference Gunnell, Appleby, Arensman, Hawton, John, Kapur, Khan, O’Connor and Pirkis2020). This trend is seen in several perspective pieces in this edition where it is described that the early phases of the pandemic did not necessarily herald an increase in mental health presentations. It is clear, however, that adaptation to the new conditions imposed by COVID-19 has increased workloads on the frontline of mental health. Furthermore, the anticipated increase in mental illness, with potential also for increased suicidality, is deemed most likely in the mid- and post-pandemic phase, as economic contraction, constrained mental healthcare resources, individual vulnerabilities and the stark reality of dramatically altered lifestyles coalesce.

This Special Issue considers interwoven themes across several countries – the psychological impact on those who are carers and those who are cared for; the strain imposed on acute and long-stay settings; the spectrum of vulnerability and resilience to stress amongst the general population, healthcare providers and those with enduring mental health conditions. Efforts to adapt and provide excellent care at this unprecedented time are evident across multiple mental health disciplines.

A major concern now is that the mental health fallout will have a disproportionate impact on society’s most vulnerable and disadvantaged, such as those with pre-existing mental health conditions (Yao et al. Reference Yao, Chen and Xu2020). While empirical data are scant, it appears reasonable to assert that the widespread impact of a pandemic on mental healthcare systems had not been widely considered by psychiatrists prior to COVID-19. This has resulted in the rapid need to address a myriad of complex unanticipated scenarios, often with high-risk outcomes. This was epitomised by reports of children in residential settings being returned to their families without adequate safety planning or transitional supports in place (Goldman et al. Reference Goldman, Van Ljzendoorn and Sonuga-Barke2020). With these issues in mind, there have justifiably been calls for increased resourcing of mental health services, along with a collaborative international effort to address issues such as suicide prevention (Gunnell et al. Reference Gunnell, Appleby, Arensman, Hawton, John, Kapur, Khan, O’Connor and Pirkis2020).

Frontline workers

Frontline workers such as police and healthcare staff are another group who are potentially vulnerable to mental health effects during COVID-19 (Chen et al. Reference Chen, Liang, Li, Guo, Fei, Wang, He, Sheng, Cai, Li, Wang and Zhang2020). Several articles in this issue highlight the critical importance of self-care among these frontline workers in COVID-19. This has also been highlighted in a series of recommendations on COVID-19-related research priorities for mental health (Holmes et al. Reference Holmes, O’Connor, Perry, Tracey, Wessely and Arseneault2020).

Governments worldwide have appealed to the altruism of individuals to work collectively to implement stringent public health measures. Reassuringly, such altruism and sense of purpose, known to act as protective factors to mental ill health, may potentially offset some of the anticipated psychological morbidity (Post, Reference Post2005; Kingsbury et al. Reference Kingsbury, Clayborne, Colman and Kirkbride2019; Brooks et al. Reference Brooks, Webster, Smith, Woodland, Wessely, Greenberg and Rubin2020). However, there is unquestionably an urgent need to develop an understanding of how we can assist frontline workers and their families to utilise adaptive coping strategies both in the short-term and to enhance future pandemic preparedness (Duan & Zhu, Reference Duan and Zhu2020; Gavin et al. Reference Gavin, Hayden, Adamis and McNicholas2020). To develop such interventions in an empirical fashion, it has been recommended to investigate the causal and modifiable factors which can influence pandemic resilience. Such factors may include exercise, prosocial behaviours, conflict resolution and peer group-based interventions. When clear strategies have been identified, it will be crucial to adequately resource frontline staff supports to ensure continued work ethic and morale is maintained. Hopefully, this will come to pass if the pandemic provokes a paradigm shift in thinking as to the centrality of mental health in our global response to this crisis.

Distribution of finite resources

It is particularly important in this action-oriented phase of pandemic response that due care is given to ensuring that limited mental healthcare resources are utilised in an evidenced-based manner. There are dangers associated with rushing to implement novel psychological support innovations for pandemic-related stress if they are not robustly evaluated and economically viable in the longer term (The Lancet Psychiatry, 2020). In essence, this could potentially involve inappropriate redirection of our scant mental health resources. Against this backdrop, the pandemic should not be seen as merely a crisis to be endured, but also as a unique opportunity to progress targeted research and application of evidenced-based innovation. These sentiments are proposed in the collection of papers in this issue, with many examples and evaluations of service innovation as well as the progression of novel technologies such as providing remote consultation.

Future research

As the COVID-19 pandemic progresses, it is imperative that priority is given to evaluation of how mental health effects will evolve, and furthermore how to best address them. In particular, we need to determine how we can mitigate the mental health consequences for vulnerable groups. One proposal in this regard has been to use a multidimensional or syndemics approach which addresses the complexities of multiple interacting mental health determinants (Holmes et al. Reference Holmes, O’Connor, Perry, Tracey, Wessely and Arseneault2020). During service reform, it is also crucial to involve those with lived experience. Using an interdisciplinary approach within a coordinated national framework, we can ensure effective, efficient translational innovation.

The urgent need to learn more about the impact of public health measures on general population psychological wellbeing is further emphasised by ethical considerations proposed in relation to population ‘lockdowns’ (Upshur, Reference Upshur2003). The principle of reciprocity holds that if a society demands that individuals withdraw their liberties for the common good, then individuals must be provided with adequate psychological support to discharge that obligation. It is thus essential that policymakers strongly support research to help us understand the mental health reforms needed to deliver effective mental healthcare provision in this dramatically altered landscape.