This article will deal with the impact of the COVID-19 pandemic on mental health. It is important at the outset to briefly review how the pandemic was realised, appreciate the depth and breath of the impact on health services in general – then drill down into what happened with mental health. I will focus on what economic stress may mean for the future. This post is a foundation for the follow up post: Health debt – the post-pandemic trauma.

A repeating theme in this article is the move to ‘telehealth’. The concept includes remote consultations and assessment, by whatever means.

Table of Contents

• Preamble
• Scale of impact
• General mechanisms of impact
• Mental health services
• Mental health 
  • Overall psychological toll
• More specific mental health impacts
  • The most vulnerable: learning disabled
• Suicide
• Discriminatory impact
• The outlook
• Economic and financial stress in focus
• Concluding remarks

Preamble

The first cases of a mysterious pneumonia-like illness, later identified as COVID-19, were reported in Wuhan, Hubei Province, China, in December 2019. Chinese officials reported the outbreak to the World Health Organisation (WHO) on December 31, 2019.

After a rapid rise in cases, both within China and in other countries, the WHO declared the COVID-19 outbreak a Public Health Emergency of International Concern on January 30, 2020. This is a designation used for extraordinary events that constitute a public health risk to other countries through international spread and require a coordinated international response.

Then, as the disease continued to spread globally, the WHO officially declared COVID-19 a pandemic on March 11, 2020. A pandemic is declared when a new disease for which people do not have immunity spreads around the world beyond expectations. This was the first time that the WHO declared a pandemic caused by a coronavirus.

The pandemic caused a global shock to financial systems and health systems. To avoid catastrophic meltdown many countries on both sides of the Atlantic embarked on unprecedented levels of quantitative easing (money printing in lay language). Financial analysts predicted that this would lead to hyperinflation and long-term economic pain. Such predictions appear to be materialising as we witness in the last quarter of 2022 and the first half of 2023 the initial stages of bank failures, soaring inflation figures, increased levels of debt, and wide-spread job layoffs in the face of high employment figures. Health services’ employment figures in the UK are the exception. In the face of such escalating problems, it is important to evaluate what the future may hold for health services, and mental health services in particular. People suffered.

Scale of impact

Hard data on the impact on health services is emerging every day (at time of publishing this article) Data is always looking back in hindsight by about 6 to 12 months. In other words, it was difficult to find real time data that was meaningful or reliable.

The impact of the COVID-19 pandemic on health service delivery had been widespread, affecting many different patient groups. However, several groups were particularly impacted:

1. Patients with chronic conditions: Individuals with chronic conditions like diabetes, heart disease, and chronic obstructive pulmonary disease (COPD) often require regular check-ups and management. Disruptions in regular care, difficulty accessing medication, and fear of attending healthcare settings due to risk of COVID-19 infection worsened their health outcomes.
2. Patients needing elective surgeries: Many non-emergency procedures were postponed or cancelled to free up resources for COVID-19 care. This included elective surgeries like hip replacements or cataract surgery, resulting in prolonged discomfort and reduced quality of life for these patients.
3. Cancer patients: Some cancer treatments and screenings were delayed or cancelled, potentially leading to later-stage diagnoses and poorer prognoses. Fear of infection also caused some patients to delay seeking care for potential symptoms.
4. Mental health patients: Individuals requiring mental health support faced significant challenges due to changes in the provision of services, such as transitioning to telehealth. The increased demand for these services during the pandemic stretched resources, leading to delays in access to care.
5. Older adults: Older individuals who had more complex health needs found it more difficult to access care during the pandemic. Many struggled with the transition to telehealth due to unfamiliarity with technology.
6. Children and adolescents: Paediatric healthcare services, including immunisations and developmental screenings, were disrupted. Additionally, the closure of schools impacted school-based health and mental health services, affecting children’s and adolescents’ access to care.
7. Individuals with disabilities: Many people with disabilities relied on regular healthcare services and support, experienced the impact of disruptions. They faced additional barriers to accessing telehealth due to lack of technological means or skill.
8. Socioeconomically disadvantaged groups: These groups already faced numerous health disparities and barriers to healthcare access. Financial hardship, housing instability, lack of access to technology, and other challenges made it harder for these individuals to access care during the pandemic.
9. Non-COVID infectious disease patients: Patients with other infectious diseases, such as HIV or tuberculosis, faced disruptions in their care, impacting disease management and control efforts.

The disparities in the impact of the pandemic highlight the need for a health equity approach in the COVID-19 response and recovery, as well as in the broader healthcare system. This includes addressing socioeconomic and structural determinants of health, improving access to care, and prioritizing the needs of the most vulnerable.

General mechanisms of impact

1. Cancellation and delay of non-emergency services: In order to manage the influx of COVID-19 patients, many non-emergency procedures and services were delayed or cancelled. This included some cancer treatments, elective surgeries, and routine screenings, creating a significant backlog of patients needing care.
2. Shift to telemedicine: To reduce the risk of transmission, many healthcare services moved to telemedicine platforms where possible. This allowed patients to consult with healthcare providers via video or phone calls. While this has expanded access for some, it highlighted digital inequality issues and some consultations were less effective when not done in person.
3. Primary care: Primary care services saw a significant shift in their operation, with many appointments moving online and an emphasis on triage to determine the most urgent cases.
4. Mental Health Services: As with other health services, many mental health services transitioned to telehealth platforms. The pandemic increased demand for these services, but the shift made it difficult for some patients to access care.
5. Staff shortages and burnout: The intense pressure of responding to the pandemic led to staff shortages and burnout among healthcare workers. That impacted on the quality and sustainability of healthcare services.
6. Changes in emergency services: Emergency departments had to change their protocols to manage the risk of COVID-19 transmission, including segregating COVID and non-COVID patients and introducing additional infection control measures. This contributed to delays and changes in the way care is delivered.
7. Vaccination program: The rollout of the COVID-19 vaccine was a major focus of the healthcare system. This required significant resources and was a priority over some other health services.
8. Health inequalities: The pandemic highlighted and exacerbated health inequalities in the UK. Some groups, including racial and ethnic minorities, people with lower incomes, and people living in deprived areas, were disproportionately affected by COVID-19 and faced greater barriers to accessing care during the pandemic

Mental health services

The COVID-19 pandemic has significantly impacted mental health services, prompting both challenges and innovations.

1. Increased demand: The pandemic resulted in a surge in people needing mental health services, due to heightened stress, anxiety, depression, and other mental health issues. This increased demand put additional strain on an already strained mental health system.
2. Disruption to services: Many in-person mental health services were disrupted, especially during lockdowns. Some clinics and hospitals had to divert resources to deal with COVID-19, leading to a reduction in available mental health services.
3. Transition to telehealth: A significant adaptation was the rapid shift to telehealth. Therapists and other mental health professionals provided more services remotely via video conferencing, phone calls, or messaging. While that expanded access for some, it challenged those without reliable internet access, digital literacy, or a private space to talk. Some people were left out.
4. Digital mental health interventions: There has been a rise in digital mental health resources, including mental health apps, online support groups, and AI-based cognitive behavioural therapy programs. These can help supplement traditional therapy, particularly in areas with limited access to mental health services.
5. Access inequalities: The pandemic has highlighted and exacerbated existing inequalities in mental health care. Those with lower incomes or who are part of marginalised communities may face increased barriers to accessing care, particularly as the economic impact of the pandemic continues to unfold.
6. Workforce mental health: The mental health of healthcare workers has been a critical issue. Hospitals and clinics have instituted support programs, including counselling and peer support, to help healthcare workers cope with the high stress and trauma of their work during the pandemic.
7. Policy and funding: The pandemic has led to policy changes at various levels to support mental health. This includes increased funding for mental health services, temporary changes in regulations to facilitate telehealth, and efforts to integrate mental health into broader pandemic response plans.

There is a need for long-term investment in mental health care, recognising its integral role in overall health and wellbeing. The widespread impact of the pandemic on mental health also underscores the need for a public health approach to mental health, prioritizing prevention and community-based support.

Mental health

Overall psychological toll

The COVID-19 pandemic has had a substantial impact on mental health worldwide. The psychological toll is vast and varied, affecting different populations in different ways. Below are several key areas of impact:

1. Increased stress & anxiety: The pandemic has generated a surge in stress and anxiety levels among the general population. The uncertainty of the situation, fear of infection, and worries about financial implications have all contributed to this increase.
2. Depression: Economic uncertainties, job losses, and financial hardship associated with the pandemic have contributed to a rise in depressive symptoms. Isolation due to lockdowns and social distancing measures has also led to increased feelings of loneliness and despair.
3. Post-Traumatic Stress Disorder (PTSD): Exposure to traumatic experiences, such as losing a loved one to the virus or being severely ill oneself, can lead to PTSD. Frontline healthcare workers are also at high risk due to constant exposure to trauma and high-stress environments.
4. Substance use & abuse: The stress and anxiety triggered by the pandemic have resulted in increased substance use and abuse. Isolation and lack of support networks have exacerbated this problem.
5. Effects on existing mental health conditions: For those already suffering from mental health issues, the pandemic has often exacerbated symptoms due to increased stress, changes in available support and treatment, and the general disruption of routine and stability.
6. Children & adolescents: School closures, social isolation, and heightened stress in the family environment have led to mental health issues in children and adolescents, including depression, anxiety, and problematic behaviour.
7. Healthcare workers: Healthcare providers and first responders have been under significant stress due to the burden of treating COVID-19 patients, fear of contracting the virus, and witnessing high rates of morbidity and mortality. This can lead to burnout, depression, anxiety, and PTSD.
8. Older adults: Older adults, especially those in nursing homes or who are isolated from family, may experience increased feelings of loneliness, anxiety, and depression. They may also experience heightened fear due to their vulnerability to the virus.
9. Grief & bereavement: With the high death toll of the pandemic, many individuals have lost loved ones, often without the ability to say goodbye in person or hold traditional funeral rites. This experience can result in complicated grief and mental health issues.
10. Domestic violence & abuse: Lockdown measures have led to an increase in reports of domestic violence and abuse, causing further mental health implications for victims.

In response to these impacts, there is a growing demand for mental health services, prompting a shift toward telehealth and digital mental health services. The long-term mental health impacts of the pandemic are yet to be fully understood and will likely be a focus of study in the years to come.

More specific mental health impacts

The most vulnerable: learning disabled

People affected by disorders of intellectual development are mostly unable to assert themselves. The vast majority are unable to ask for help, seek advocacy services, complain or sue for negligence or breach of their human rights.

Whilst the impact of the pandemic varied from individual to individual some general trends emerged:

1. Increased health risks: Some individuals with learning disabilities had comorbid health conditions that increased their risk of severe outcomes from COVID-19. Additionally, some individuals struggled to understand public health guidelines or to follow preventative measures such as mask-wearing and hand hygiene due to their disability.
2. Disruption of services: Many individuals with learning disabilities relied on a range of support services, such as educational services, occupational therapy, and other interventions. These services were disrupted or modified during the pandemic, leading to a decline in support and progress.
3. Social isolation: Social distancing measures and lockdowns led to increased isolation for people with learning disabilities, who often relied heavily on social routines and interaction for their well-being. They were unable to participate in regular community activities, attend school, or see friends and family.
4. Mental health impact: The fear and uncertainty associated with the pandemic, along with social isolation and disruption of routines, increased stress and anxiety for individuals with learning disabilities. Some individuals also struggled to understand the situation, which escalated their fear and anxiety.
5. Educational impact: For children with learning disabilities, school closures and the shift to online learning proved particularly challenging. They struggled with the lack of structure, the difficulties of online learning, and the lack of in-person support from teachers and other professionals.
6. Challenges for caregivers: The pandemic also had an impact on caregivers of people with learning disabilities. They faced increased stress due to the need to provide additional support, concern for the health of their loved one, and the challenges of navigating changes in services.

It was important for policymakers, educators, healthcare providers, and communities to consider the needs of people with learning disabilities in their pandemic response and recovery plans. However, hard evidence of positive action was hard to find.

Suicide

The data on suicide rates is still emerging and is always looking back. The longer term impacts on people and services could mean that overall suicide risk is increasing. But we also need to factor in how well services may adapt positively, to reduce the risk.

Preliminary studies from a few countries showed varied outcomes – some regions did report an increase, while others reported a decrease or no change in suicide rates during the early phase of the pandemic. There are a few reasons why this might be the case:

1. Economic stress: Previous economic crises have been linked to increases in suicide rates, and it is plausible that the economic impact of the pandemic could have a similar effect.
2. Isolation & loneliness: Social isolation and loneliness, which have increased due to social distancing measures, are known risk factors for suicide.
3. Barriers to mental health services: Disruptions to mental health services could potentially make it more difficult for people at risk of suicide to get the help they need.

On the other hand, some factors could potentially mitigate the impact of the pandemic on suicide rates:

1. Community solidarity: Some experts have speculated that the shared experience of the pandemic could create a sense of community solidarity, which might reduce feelings of isolation and therefore potentially reduce suicide rates.
2. Increased attention to mental health: The pandemic has increased attention to mental health issues, which could lead to improved support for individuals struggling with mental health issues.
3. Changes in routine: While changes in routine can be stressful, they can also disrupt patterns of suicidal behaviour. For example, less commuting might reduce the incidence of suicides on train tracks.

Regardless of the overall trends, it is clear that the pandemic has heightened many risk factors for suicide, and suicide prevention should be a key part of the mental health response to COVID-19.

Discriminatory impact

Racism has had a significant impact on mental health during the COVID-19 pandemic. This has been observed in several ways:

1. Direct racial and ethnic harassment and discrimination: With the COVID-19 virus first identified in Wuhan, China, there has been a global increase in racism, xenophobia, and discrimination towards people of Asian descent. This harassment and discrimination, both in person and online, have caused increased levels of stress, anxiety, and depression among these populations. Similar discriminatory experiences have been reported among other racial and ethnic groups as well, exacerbating their mental health risks.
2. Disproportionate impact of COVID-19 on racial and ethnic minorities: Racial and ethnic minority groups, particularly Black, Latino, and Indigenous communities, have been disproportionately affected by COVID-19 in terms of infection rates, hospitalisations, and deaths. These disparities reflect longstanding social, economic, and health inequities, and witnessing these inequities and experiencing or fearing serious illness and death can have a significant impact on mental health.
3. Socioeconomic stressors: Racial and ethnic minorities are disproportionately represented in low-wage jobs, many of which are at higher risk for COVID-19 exposure and may not provide paid sick leave. They are also more likely to face economic hardships due to the pandemic, including job loss and housing instability. These stressors can contribute to mental health problems.
4. Racial trauma: The pandemic period has also been a time of heightened attention to racial injustice, including the killing of George Floyd and the subsequent protests. These events can cause racial trauma – mental and emotional injury caused by encounters with racial bias and ethnic discrimination, racism, and hate crimes – among people of colour.
5. Barriers to mental health care: Racial and ethnic minorities often face greater barriers to accessing mental health care, including systemic biases in healthcare, lack of culturally appropriate care, and lack of insurance coverage. These barriers mean that many individuals do not receive the help they need for their mental health problems.

It is important to note that these impacts are interrelated, creating a complex set of challenges for mental health among racial and ethnic minorities. Addressing these challenges requires a comprehensive approach that includes addressing systemic racism, improving access to and quality of mental health care for racial and ethnic minorities, and providing support for communities disproportionately affected by COVID-19.

The outlook

A very recent article from the Kaiser Family Foundation (KFF) in the USA, The Implications of COVID-19 for Mental Health and Substance Use (May 2023), explores where the USA is now and various scenarios:

Here are the key points:

1. The pandemic significantly affected public mental health and well-being due to factors like isolation, job loss, financial instability, and grief. About 90% of U.S. adults believe the country is facing a mental health crisis.
2. Symptoms of anxiety and depression increased during the pandemic, particularly among individuals experiencing household job loss, young adults, and women. Adolescent females also reported increased feelings of hopelessness and sadness compared to their male peers.
3. Deaths due to drug overdose increased sharply during the pandemic, more than doubling among adolescents. Drug overdose death rates were highest among American Indian and Alaska Native people and Black people.
4. Alcohol-induced death rates also increased substantially during the pandemic, with rates increasing the fastest among people of colour and people living in rural areas.
5. After a brief decrease, deaths from suicides were on the rise again as of 2021. Self-harm and suicidal ideation increased faster among adolescent females compared to their male peers.
6. Several changes have been implemented in the delivery of mental health and substance use services since the onset of the pandemic, including the utilisation of telehealth, steps to improve access to treatment for opioid use disorders, expansion of school-based mental health care, and the rollout of crisis helplines.
7. Despite these changes, challenges remained in accessing mental health and substance use services, including workforce shortages, outdated provider network directories, and high out-of-pocket costs for individuals with mental health needs.
8. The mental health impact of disasters tends to outlast the physical impact, suggesting that the increased need for mental health and substance use services may persist long term, even as new cases and deaths due to COVID-19 subside.

Economic and financial stress in focus

The power of economic stress is often under-realised. Economic stress resulting from the pandemic can increase suicide risk, as financial instability is a known risk factor for suicide. The following mechanisms are proposed:

1. Unemployment and job insecurity: Job loss is associated with an increased risk of mental health problems, including depression and anxiety, which are in turn risk factors for suicide. The fear of losing one’s job can also cause significant stress.
2. Financial hardship: Financial difficulties can lead to a sense of hopelessness and despair. The inability to pay bills, buy food, or meet other basic needs can create a significant emotional burden.
3. Business failure: For business owners, the failure of a business can be a significant crisis. This can be particularly acute for small business owners who may have invested significant personal resources into their business.
4. Housing insecurity and homelessness: Economic stress can lead to housing insecurity or even homelessness, both of which are associated with higher suicide risk.
5. Loss of insurance: In countries where health insurance is tied to employment, job loss can also mean loss of access to mental health services, making it more difficult for individuals to receive help if they are struggling.
6. Social isolation: Economic stress can lead to social isolation, as individuals may be unable to afford to participate in social activities. Social isolation is a risk factor for suicide.
7. Shame and stigma: Financial difficulties and job loss can lead to feelings of shame and stigma, which can exacerbate mental health problems and increase suicide risk.

Economic stress can also indirectly increase suicide risk by leading to increased substance use, which is another risk factor for suicide. I focus on economic issues later on (click here).

Given the above pictures of risk, it is critical that economic support measures during and after the pandemic are combined with mental health support. This can include measures such as integrating mental health services into employment support programs, providing free or low-cost mental health services for those experiencing financial hardship, and implementing suicide prevention strategies at a community and societal level.

Taking into consideration the KFF findings it is useful to consider financial instability and stress when projecting for the future. It is entirely understood that no one can predict the future. However, we know that people will more likely carry umbrellas and wear raincoats when the weather forecast is for higher probability of rain. Economic stress and financial instability are not easy for ordinary people to assess at a macro-level. Individuals feel the stress of reduced purchasing power, relative to inflation. Inflation is connected to cost of energy, demand-supply issues and political matters that have been baked into systems for over two years.

There is substantial evidence for the UK that health services have suffered chronic under-investment for the last decade. This has resulted in prolonged strikes among health workers; doctors and nurses in particular.

An article from The Health Foundation compares the UK’s health spending with other European Union (EU) countries over the past decade, before the pandemic. Here are the key points:

1. Average health spending in the UK between 2010 and 2019 was £3,005 per person, which is 18% below the EU14 average of £3,655. If UK spending per person had matched the EU14 average, the UK would have spent an average of £227bn a year on health during this period, which is £40bn higher than the actual average annual spending (£187bn).
2. The UK had a lower level of capital investment in health care compared with the EU14 countries for which data are available. Between 2010 and 2019, average health capital investment in the UK was £5.8bn a year. If the UK had matched other EU14 countries’ average investment in health capital (as a share of GDP), the UK would have invested £33bn more during that period, around 55% higher than actual investment.
3. The UK has fewer practising physicians per person and fewer hospital beds per person than the EU14 average. The UK also has fewer nurses than average per head of population.
4. In 2020, the UK had a larger increase in health spending in response to COVID-19 than any EU14 country. In the UK, spending increased by 14% compared with the EU14 average of just below 6%.
5. The article suggests that a decade of lower spending and fewer physical resources resulted in a health care system less resilient and one that needed to expand its capacity more rapidly when the pandemic hit.
6. If the UK had matched EU14 levels of spending per person on health, day-to-day running costs would have been £39bn higher each year, on average, over the past decade (£30.5bn of which would have been additional government spending). For capital spending, matching the cumulative EU14 average over the past decade would have resulted in the UK investing £33bn more in health-related buildings and equipment.

In conclusion, the UK has spent less on both day-to-day care and investment spending on health care compared with the average EU14 countries over the past decade. This has resulted in less capacity, fewer physical resources, and therefore greater vulnerability to sudden surges in demand.

Another article from The Health Foundation, What is the outlook for health funding (Jan 2023), focuses on funding in the context of the 2022 Autumn Statement. Here are the key points:

1. The 2022 Autumn Statement promised an extra £3.3bn for the NHS and £1.4bn for capital investment in 2023/24 and 2024/25. In cash terms, spending in 2024/25 will be almost £14bn higher than in 2022/23. However, much of this additional spending will be needed to meet inflation. After accounting for inflation, real-terms funding in 2024/25 will be £6bn higher than in 2022/23.
2. In real terms, core day-to-day spending on the NHS will rise by 2% a year by 2024/25, while capital spending will grow by just 0.2%. The Department of Health and Social Care’s funding settlement will increase by 1.2% a year in real terms over the next 2 years, which is higher than planned at the last Spending Review but far below the 3.6% long-term average growth rate.
3. The NHS continues to face rising cost pressures that will erode the spending power of this settlement, with pay being the most significant. Health service inflationary pressures may be higher than the government estimates through the central GDP deflator forecast.
4. The different methods used to estimate inflation for the whole economy show that the buying power of this settlement is uncertain. The unknown outcome of future pay negotiations and volatility in the cost of other key inputs add further uncertainty around the actual cost pressures the health care sector will face.
5. The 2022 Autumn Statement committed extra funding for day-to-day health care services that will help to mitigate the cost pressures facing the NHS. However, the true cost pressures in the health care sector might not be adequately captured by the official inflation estimates. Considerable uncertainty also remains in areas such as staff pay and the cost of energy in future years.

In conclusion, while the 2022 Autumn Statement has committed extra funding for the NHS, the true cost pressures in the health care sector might not be adequately captured by the official inflation estimates. There is also considerable uncertainty in areas such as staff pay and the cost of energy in future years. This could add to existing challenges around persistent workforce shortages and maintaining and improving NHS buildings and equipment. The funding outlook for the NHS remains very challenging for the rest of this parliament.

Concluding remarks

It is well known that there is a bias towards optimism. Reality often paints bleak pictures, which are then likely to be ignored.

UK public health services (the NHS) and mental health services nested in the NHS, in particular, suffered devastating blows when the pandemic struck. This occurred at a time when the NHS was already in crisis. On many occasions it was said that the NHS was on its knees or at breaking point – saved only by last minute cash injections. It is a common perception that mental health services were treated like ‘Cinderella’ over several decades, and there is some reality to that perception.

Chronic understaffing in the NHS has led to increasing levels of burnout, early retirement and sickness levels – during and after the pandemic.

The debt of under-investment in the NHS is of such a scale that it appears unlikely that it will be put right any time soon. Countries all over the world are competing for health care workers (doctors, nurses etc). It is the wrong time for the UK to be addressing longstanding issues of under-funding and under-staffing.

Interest rate increases intent on heading off hyper-inflation means that we can expect greater economic stress on ordinary people and NHS staff.

The future seems bleak, for objective reasons. There are few if any valid reasons to be optimistic. Mental health of the nation and mental health services are therefore likely to suffer in the longer term – over the next 5 years.