The Covid-Minds Network tracks research related to the impact of COVID-19 on mental health across the world. Every month, we list five key findings from recent research.
So far, we have learnt that in the early months of the pandemic, mental health and wellbeing significantly worsened as the pandemic escalated. However, there were signs of improvement over the course of national lockdowns and as restrictions eased. Certain groups have been more affected than others, especially young adults, females, and individuals from black, Asian and ethnic minority groups. Working parents and those with financial problems have been at risk of worsening mental health. Individuals can potentially improve their mental health by absorbing less media content related to COVID-19 and adopting certain behaviours and attitudes that have shown to make a positive difference. For example, having gratitude, performing altruistic actions, following daily routines, and spending time outdoors have helped reduce emotional distress. For more information, see our August and September blog posts.
This month, we’ve investigated what the impact of COVID-19 has been on the prevalence of loneliness and the rate of suicide. We’ve also outlined evidence for the psychological effects of COVID-19 infection, as well as the role physical activity can play in buffering against poor mental health. Finally, we examined COVID-19-related mental health inequalities among black, Asian, and minority ethnic groups.
1. Loneliness has worsened among particular groups, but more research is needed to establish its relationship with the pandemic and its effect on mental health.
Loneliness is already recognised as a major health problem across the world. Studies have demonstrated the health consequences of loneliness, which include impaired immune responses, greater risk of depression and neurological diseases, and earlier death. The potential of the pandemic to worsen the prevalence of loneliness and exacerbate its negative psychological effects was highlighted early in the pandemic.
Loneliness levels have been high but not all studies show clear increases due to COVID-19 and the onset of national lockdowns. For example, cross-sectional studies have shown that more than half of Canadians have felt lonely or isolated during its national lockdown, that the UK has witnessed a loneliness rate of 27% and that loneliness was linked to a decline in self-rated health among people with chronic illnesses in Israel.
A longitudinal study of elderly adults in the San Francisco Bay Area reports that older adults were more lonely due to COVID-19 but that this decreased over time. An Austrian study compared pre-pandemic and pandemic levels of loneliness among older adults and found that loneliness had increased from 2019 to 2020, was highest during lockdown, and decreased during re-opening. Symptoms of loneliness were highest shortly after lockdown in Germany, as shown by a longitudinal nationally representative study, but also decreased over time. The UK Household Longitudinal Study showed that loneliness remained stable before and during the lockdown, but increased among young people. Other researchers have reported no significant changes in loneliness between late January and late April 2020.
Loneliness affects particular groups more than others. For example, while overall loneliness in the United States did not increase between 2019 and 2020, analyses of the American Family Survey showed that loneliness increased among people without partners but not among married individuals. Furthermore, the gap in loneliness between those with two or more children and those with one or no child also increased. In the UK, the COVID-19 Social Study has shown that loneliness seems to be most prevalent among young adults, women, people with low income, little education, mental health conditions and those living alone. In addition, people who were most lonely at the start of the UK lockdown became more lonely, while the opposite was true among least lonely people. Those who have experienced symptoms related to COVID-19 have been lonelier, with women and young people at higher risk.
Loneliness during COVID-19 has had some consequences for mental health. During the United States’ third week of national lockdown in April, a nationally representative cross-sectional survey showed that lonely individuals were significantly more depressed than the non-lonely. A UK longitudinal analysis of depression and anxiety among people over 50 showed that loneliness was a risk factor for worsening mental health from previous years to mid-2020. However, not all increases in loneliness from before to during the pandemic have been associated with worsening mental health.
2. COVID-19 could lead to higher rates of suicide but evidence is limited.
The pandemic has exacerbated risk factors for suicide, such as stigma, loss of employment, domestic violence, alcohol consumption, mental health problems, and extreme trauma among certain groups such as frontline workers. Again, loneliness could play a role in suicide, especially as isolation or feeling lonely is associated with suicidal ideation and behaviour. In addition, lockdowns can prevent people from accessing community support and mental health treatment—a combination of events described as a “perfect storm” for suicide mortality. The 1918 Spanish Flu and the 2003 SARS outbreaks also suggest that increased suicide could occur with the COVID-19 pandemic.
Thoughts of suicide have still been occurring during the pandemic. The COVID-19 Social Study found that of 44,775 people across the UK who had reported abuse, self-harm or thoughts of suicide during the pandemic, 7984 (18%) reported thoughts of suicide or self-harm in the first month of lockdown. Results from a survey in June in the United States showed that about 11% of adults had seriously considered suicide in the 30 days prior. Responses in both countries were higher among 18- to 24-year-olds, minority racial and ethnic groups, black respondents and unpaid caregivers and essential workers.
Actual suicide rates during country lockdowns vary, and their relationship with the pandemic are ambiguous. In Nepal, the suicide rate increased by 15 more deaths per month than the previous year. However, in Japan the overall suicide rate declined, thought to be the result of the government’s generous efforts to protect the public from consequences of the lockdown. Interestingly, some studies have shown that the number of suicide attempts during the pandemic have decreased, but that this is due to a reduction in psychiatric emergency visits and hospital admissions, including to paediatric emergency departments.
Analyses of the causes of suicides reveal the social and psychological consequences of the pandemic. Many causes of suicide have related to the economic impact on individuals, as illustrated by analyses of suicides in Bangladesh and Pakistan. Stigma and misinformation have also played a role. Individuals who died by suicide in villages in India faced prejudice from others and feared that they had caught COVID-19, although many were not actually infected with the virus.
Researchers are calling for specific “tailored” suicide prevention programmes for particular groups, such as the elderly, as well as broader public messages through innovative projects such as Cov’Art launched by the French National Centre for Resources and Resilience.
3. Survivors of COVID-19 experience poor mental health but more research is needed on the psychological and neurological effects of SARS-CoV-2 infection.
While there is much agreement that the COVID-19 pandemic will take its toll on global mental health, there is limited evidence for the psychological outcomes of individuals infected with the virus. It is thought that long-term neuropsychiatric conditions are likely, including depression, PTSD, panic disorder, and chronic fatigue syndrome. Especially among those who require acute care and are mentally ill, there may be an “aftershock” of psychiatric issues ranging from adjustment disorder to psychosis.
Literature regarding previous outbreaks and lung disease supports this. For example, studies of SARS survivors and people with acute respiratory distress syndrome indicate that poor mental health is a common long-term outcome. A Canadian study showed that of 117 SARS patients, 33% were still reporting reduced mental health a year after hospitalisation.
So far, research has shown that COVID-19 survivors suffer considerable anxiety and depression. An Italian study showed that of 402 adult survivors surveyed one month after hospital treatment, 28% had PTSD, 31% depression, 42% anxiety, 20% obsessive-compulsive symptoms, and 40% insomnia. Neurological conditions of the central and peripheral nervous systems were reported early in the pandemic among patients with severe COVID-19. Another study in the UK found that catching COVID-19 was associated with increases in depression. In the United States, a survey of 292 outpatients found that 2-3 weeks after testing positive, 38 reported anxiety disorder, 21 depression, 2 PTSD, 2 paranoia, 1 OCD, and 1 schizophrenia. Regarding any direct relationship with mental illness and SARS-CoV-2 infection, a nationwide cohort study in South Korea indicated that those with severe mental illness had a slightly higher risk of severe clinical outcomes.
It seems that mental health issues related to COVID-19 are being incorporated under the variety of symptoms of so-called “Long Covid,” which is becoming accepted as the term for the lasting effects of the disease. In addition to physical symptoms such as low-grade fever, fatigue and headaches, sufferers also report mental health challenges including depression and neurocognitive difficulties. In addition, there is growing evidence for the neurological and neuropsychiatric impact of COVID-19, described as its “long neurological tail.” Researchers warn that the virus’s effects on the brain, manifesting as loss of smell and taste, confusion, delirium, and psychosis, requires further research to determine consequences for brain behaviour, function and cognition.
Doctors and patients are calling for greater recognition and action regarding Long Covid and its physical and mental burden, which some say should not be downplayed by health professionals as anxiety. Patient groups are organising support groups and setting up research initiatives to study its effects, including the long-term mental health effects of COVID-19.
4. Reductions in physical activity may be a risk factor for declines in mental health and wellbeing during the pandemic.
Cross-sectional studies have indicated the benefits of exercise on mental health during national lockdowns. In Austria more physical activity was related to better mental health among individuals during the lockdown. A UK sample also showed negative associations between physical activity and poor mental health, including moderate-to-severe depression, anxiety and mental wellbeing. Similar results have been found in Canada. In the US, those forced to be less active than normal during quarantine had higher depressive and anxiety symptoms, as shown by cross-sectional data from 3,052 adults. There are similar findings across the UK, Ireland, New Zealand, and Australia. Participants who reported a negative change in exercise habits early during national lockdown restrictions had poorer mental health and wellbeing.
Longitudinal studies have also shown the negative effects of less physical activity on mental health, as well as the buffering effects of exercise on mental health. Among students at the University of Pittsburgh disruptions to physical activity were found to be the largest risk factor for depression during the pandemic. Researchers in Australia have compared nationally representative pre-COVID data from the Longitudinal Study of Australian Children with baseline data from the pandemic. They found that lower levels of exercise were associated with poorer mental health. Similar findings have emerged from a German longitudinal population-based survey, in which less physical activity was related to greater symptoms of anxiety, depression and loneliness. The PROTECT longitudinal study in the UK also showed that decreased physical activity during the pandemic was associated with a 20% increase in scores for depression and anxiety. Those who maintained their physical activity experienced much less worsening of mental health and increases in time spent exercising have been associated with decreases in depressive symptoms during the UK lockdown. Daily physical activity can be a strategy for improving mental health, as demonstrated by a longitudinal study of 66 Chinese college students.
5. Individuals of minority ethnic groups within populations of largely white ethnicities face more mental health problems in comparison.
The disproportionate effect of COVID-19 on ethnic minorities became apparent in the early months of national lockdowns. In the UK, COVID-19 death rates were higher among BAME communities and BAME health workers. Hospitalisation rates in March in the USA showed that black populations were over-represented among patients. Public Health England released a report on the issue, acknowledging that those of Black African or Black Caribbean ethnic backgrounds are more likely to test positive for COVID-19 and had a higher excess mortality than those identifying as white British.
In addition, research is emerging that suggests that BAME groups also are facing inequalities in mental health due to COVID-19. Through the UK Household Longitudinal Study, researchers in the UK have confirmed that mental health has deteriorated among BAME groups during the pandemic, particularly among men. Reports from the COVID-19 Social Study show how half of BAME adults have reported worse mental health as a result of the pandemic. Individuals from BAME communities have higher levels of anxiety, depression, and loneliness compared to people from white backgrounds. It is clear that financial stress and fear of unemployment are also significant contributors to poor mental health.
While many have predicted the effects of COVID-19 on those already suffering social inequalities, more research is needed to understand the long-term mental health implications of the pandemic on BAME communities, in addition to investigations into disparities between subgroups of ethnic minority groups.