This is our final research summary of 2020. Every month, we publish these articles to inform our network about the latest research on how the COVID-19 pandemic has influenced the mental health and wellbeing of populations across the world.
We finish the year by focusing on five important areas of research: whether the pandemic has or will lead to higher suicide rates; the range of findings on how young people and students are coping with this difficult time; the extent to which people with pre-existing mental health conditions have been worse affected than others; whether digital mental health services can fill a gap during the pandemic; and how our behaviour and habits have changed in the last year.
1. How has the pandemic affected national suicide rates?
As the pandemic took hold across the world this year and countries launched national lockdowns, it was predicted that national suicide rates would increase. Unemployment, social isolation, and declining mental health were all considered key factors. However, findings have been mixed.
Our October summary showed how the relationship between the pandemic and suicide rates in different places was ambiguous, especially as evidence was limited and emergency hospital visits for suicidal attempts decreased in countries like France and the USA. This has continued to be true across many countries. However, researchers have been careful to note that this could be the result of patients not seeking care during national lockdowns and not a reflection of the mental health state of the population nor the actual number of suicide attempts.
Only recently are studies beginning to suggest that COVID-19 might lead to increases in global suicide rates. Perhaps the most striking change has been in Japan. The country had a lower average suicide rate at the beginning of the pandemic, but this soon rose above the average of the three previous years. Females were particularly affected, with a 70% rise in October. Another study analysed data from Japan from 2010 to 2020 and concluded that excess suicide deaths occurred among women in July, August and September, which had not been observed since 2016. Regarding suicide among males, researchers estimate that loss of employment due to the pandemic is a key factor. They propose that a one-percentage point decrease in the employment rate has led to an additional 86-270 males suicides per month. As many countries have not yet felt the full impact of unemployment due to furlough schemes, there may be changes in suicide rates across 2021 as and when economic buffers for companies and job retention schemes are reduced or withdrawn altogether.
However, overall evidence is limited or conflicting. For example, in contrast, an Australian study found no differences in the Queensland suicide rate compared to 2015-2019. However, this only applied to the first 7 months of the pandemic. We unfortunately may still be in the early stage of the pandemic’s effects and, as argued here, preventive efforts should be prioritised and implemented immediately, especially among particular groups. Evidence shows that suicidal ideation among young people increased during the lockdown. Racial inequalities have also emerged. For example, in Connecticut in the United States, the suicide rate among racial minority groups increased during the peak of quarantine earlier this year, even though the overall average was lower. More data is therefore required before we can make confident statements on how the pandemic will have affected suicide rates.
2. Mental health among students
Certain groups have been hit hardest by the COVID-19 pandemic. Women and those from vulnerable socioeconomic backgrounds, for example, have been psychologically impacted more than others. In addition, age has been a powerful determining factor—students in particular have really struggled with the effects of the pandemic. For example, in China a study of 164,000 students showed that while acute stress decreased, depression and anxiety rose between the onset of the pandemic and its remission.
This pattern has been particularly clear amongst medical students and nursing students, many of whom have taken on frontline work during the pandemic. Longitudinal and cross-sectional studies from around the world indicate this. In India, undergraduate medical students had higher levels of anxiety and stress. Depression was also high among nursing and midwifery students in Albania. Researchers in Saudi Arabia have found that the pandemic has resulted in higher levels of stress among undergraduate medical students. Nursing students who were incorporated into Spain’s national health system predominantly reported negative feelings, including anxiety, fear, and uneasiness.
However, some longitudinal studies are yielding unexpected results. For example, a sample of students in China experienced stable or improved mental health, which the authors attribute to increased “novelty” seeking or exploring new activities during the lockdown. A study in the Netherlands, which followed university students for three months, found no change in their mental health. In Canada, students who were more likely to face worsening mental health proved to be, counterintuitively, those without pre-existing mental health challenges and not those who had experienced such difficulties.
So there remains much to be understood about why some students are being particularly adversely affected and how factors such as living alone, spending substantial time in isolation, and virtual learning are moderating experiences.
3. How have people with pre-existing mental health conditions fared?
People who experienced mental health challenges prior to the pandemic have also been considered a particularly vulnerable group. For example, the COVID-19 Social Study of UK adults has shown that such individuals were more likely to have higher levels of anxiety and depression during the lockdown. Similarly, studies of students have shown that those with pre-existing psychological distress had elevated risk for mental health concerns. The Australian COLLATE project found that individuals with bipolar or depressive disorder had heightened psychological distress compared to those with no disorder.
However, other studies indicate that people with pre-existing mental health conditions have also shown surprising resilience. For example, in the early months of the pandemic, people with severe mental illnesses did not have worse symptoms, according to a survey in the United States. Three Dutch case-control cohorts examined both people who had had previous experiences of depressive, anxiety or obsessive-compulsive disorders and those who had not. The former group did not report a greater increase in symptoms during the pandemic. An Argentinian longitudinal study of health workers also found that pre-existing mental health vulnerabilities did not play a significant role in anxiety outcomes.
Further research could investigate the variability in response among people who have experienced mental health conditions. One study of UK adults found that those who felt isolated or had disrupted mental health services, or faced cancelled plans, changed routines and who lacked control or were affected by media coverage, experienced deteriorating mental health. However, those who had had previous experiences of adversity, who enjoyed feeling less accountable to others, engaged in hobbies and activities, stayed connected with others, and believed they had social support were able to maintain positive wellbeing.
4. Considering tele-mental health and its effectiveness during the pandemic
Tele-mental health (TMH), also called telemedicine, telehealth, or tele-psychiatric services, has been proposed as an effective way to ensure continuity of care for patients with mental health challenges during the pandemic and lockdowns. For example, cognitive processing therapy has shown to still be effective when delivered digitally, as has treatment for substance use disorders. Not much evidence exists for the longitudinal effects of tele-mental health during the pandemic. However, a longitudinal study of changes in treatment numbers at the US Veterans Health Administration, where patients have received tele-mental health services, has shown that TMH kept stable the number of patients receiving care for suicide attempts. Telehealth programmes for children with autism have also shown promise during the COVID-19 pandemic.
On the other hand, some studies have found that telemedicine has not proven to be an effective alternative to in-person mental health services. Patients have felt less supported and less able to convey their emotions, while clinicians found it difficult to provide appropriate emotional support, build relationships virtually, and identify crucial signs of health deterioration in patients.
5. How has COVID-19 affected our behaviour and habits?
Social isolation has changed how we spend our day, our levels of physical activity, and eating and drinking habits. Studies are indicating that such issues have affected people of all ages from countries all around the world. Examples of studies are listed below:
Among adults, longitudinal evidence from the UK indicates that high-risk drinking increased by 5% among adults.
Almost half of participants in a Lithuanian study reported eating more than usual. Those who were already overweight were more likely to gain weight.
Similarly, another UK study found that 56% of participants reported snacking more and struggling to manage their weight. Again, people with obesity or high BMIs were disproportionately affected.
The COVID-19 Social Study also found that during the UK lockdown, 17% of adults reported eating more than usual, 40% gained weight, 17% drank more, 33% smoked more, and 11% gambled more than usual.
Younger age groups have also experienced changes to their daily habits. A longitudinal study in Spain found that children were less physically active and spent more time on screens compared to pre-pandemic times.
Another study suggests that our food intake is related to our psychological state. Among Italian college students, researchers found that those with poorer moods during the pandemic were more likely to have unhealthy dietary habits. In contrast, exercise led to healthier nutritional choices.
As health behaviours are linked to mental health and wellbeing, this research highlights that changes in factors such as smoking, drinking and diet should be closely monitored. Support and advice is needed to help individuals lead healthy lifestyles during the pandemic.