In October last year in Amsterdam, the Netherlands Ministry of Foreign Affairs hosted a high-level international conference that discussed the mental health and psychosocial support needs of people affected by emergency situations and protracted crises.
The conference declaration, endorsed by 25 countries, stressed that “armed conflicts, natural disasters and other emergencies take an immense toll on people’s mental health and psychosocial wellbeing.” Best estimates, the declaration noted, suggest that “these experiences more than double the prevalence of depression, anxiety, and other mental health conditions that impair daily functioning.”
The world was failing to respond to this problem. Delegates at the conference expressed concern that:
“The vast majority of people in need of adequate mental health and psychosocial support affected by humanitarian crises do not have access to evidence-based, quality and human rights-based services … Mental health and psychosocial needs have thus far had low priority on humanitarian agendas at national and international levels.”
Now, six months later, we are all in a protracted crisis, whose impacts on mental health are only just beginning to be felt. Many of us are grieving lost friends and relatives, others live in fear of infection or unemployment, and all of us are having to adjust to lockdowns or other measures that have upended the lives we were used to. Before the spread of the coronavirus, almost 600 million people worldwide were estimated to be suffering from anxiety or depression. Suicide took the lives of 800,000 people a year, and was the second leading cause of death among those aged 15–29.
These figures are now likely to rise. During the severe acute respiratory syndrome (SARS) epidemic in 2003, the number of suicides in hard-hit areas among people aged 65 or older increased by 30%. Almost one third of health workers suffered emotional distress. Of people who recovered from SARS, half experienced anxiety in its wake, while post-traumatic stress disorder and depression were common among those who survived life-threatening bouts of the disease.
“A 2016 study showed that even a week-long lockdown can have deleterious effects on depression and mood among young people.”
SARS infected only 8,000 people and killed fewer than 800. At the time of writing on 27 April, COVID-19 has infected 3 million and taken the lives of 200,000 – and that’s only those we know about.
The toll on our mental health is likely to be severe. Countries such as Italy are now approaching their third month of lockdown, but a 2016 study showed that even a week-long lockdown can have deleterious effects on depression and mood among young people. A survey of 3,000 people with experience of or an interest in mental health problems in the UK in late March found widespread concern about COVID-19’s impacts.
Respondents were already experiencing increased anxiety and were worried about the impacts of isolation for themselves and their relatives (Britain had only just begun its lockdown). They also feared being unable to access mental health support services during the pandemic.
It is not only our minds that will suffer. Before the coronavirus, poor mental health was estimated to cost the world economy $2.5 trillion every year as a result of increased healthcare costs and lost productivity at work. This toll was projected to double by 2030, even in the absence of the pandemic.
Mental health problems may also make it harder for governments to stem the spread of the virus. As people grow more distressed and find it harder to stay indoors, for example, adherence to containment measures and compliance with public health advice could weaken.
Governments around the world dedicate an average of just 2% of their health budgets to mental health. This proportion ranges from an average of 20% in Europe to 0.1% in South-East Asia and sub-Saharan Africa. Such investment has clearly been insufficient even in a pre-coronavirus world, and increasing expenditure can have large positive impacts on individuals, economies, and societies.
“Governments around the world dedicate an average of just 2% of their health budgets to mental health […] Such investment has clearly been insufficient even in a pre-coronavirus world”
A 2016 study found that scaling up effective treatment for depression and anxiety would cost the world approximately $147 billion over 15 years (an annual sum less than 0.5% of the annual cost of mental health disorders to the world economy). Even if these measures improve the ability to work and productivity at work by just 5%, the benefit to cost ratio will be between 3.3 to 1 and 5.7 to 1.
It is likely that new treatments will be needed to help people cope with a novel crisis such as the coronavirus, but we don’t yet know what works. A position paper in The Lancet has highlighted the “urgent need for research to address how mental health consequences for vulnerable groups can be mitigated under pandemic conditions, and on the impact of repeated media consumption and health messaging around COVID-19.” The immediate research priorities, it argues, are to “monitor and report rates of anxiety, depression, self-harm, suicide, and other mental health issues both to understand mechanisms and crucially to inform interventions.”
While we wait for definitive evidence, a number of organisations have been producing guidance – for policy-makers, healthcare workers, employers, and ordinary people – on how to mitigate the virus’s mental health impacts. I’ve collated a few of them here.
For policy makers:
- The Mental Health and Psychosocial Support Network (MHPSS) has published a comprehensive COVID-19 Toolkit that includes resources to support policies on quarantine, risk communication, community engagement, stigma, human rights, frontline healthcare responders, and support and protection for children and other vulnerable groups.
- UNICEF has developed operational guidance on MHPSS policies for children, adolescents, caregivers, and communities. The guidance emphasises the importance of designing policies in consultation with children and adolescents who are at risk of, or who have suffered from, mental health problems. It urges health policy makers to work with and share information with other sectors and organisations delivering services in areas such as education, gender-based violence, and child protection.
- United for Global Mental Health has a weekly webinar that provides policy makers with the latest evidence on the mental health impacts of COVID-19.
- Guidance produced by the Inter-Agency Standing Committee Reference Group on Mental Health and Psychosocial Support in Emergency Settings recommends that mental health should be a “core component of the public health response” to COVID-19.
Delivering effective mental health care, it argues, will not only help stop transmission of the virus but strengthen societies’ long-term resilience against such crises. Countries should not adopt one-size-fits-all approaches, but should make efforts to understand local contexts including pre-existing mental health issues in communities and the needs of specific groups including women, children, people with disabilities, older adults, and minority ethnic groups.
Where MHPSS services are thin on the ground, moreover, policy makers should work through and support local care providers such as families and community leaders. The briefing concludes with 14 globally-recommended activities for dealing with the virus.
- Given that COVID-19 presents us with a global humanitarian crisis, this toolkit developed by the Mental Health Innovation Network for integrating mental health into general healthcare in humanitarian settings is also of relevance. It contains tools for planning, building the capacity of general health workers to deal with mental health, strengthening referral pathways and follow-up mechanisms, and building partnerships and enlisting support from other sectors.
For healthcare workers, employers and ordinary people:
- ICRC guidance for health workers lists warning signs and steps for providing basic psychological support to colleagues and employees, and for looking after oneself, including when in quarantine or isolation.
- Guidelines for employers produced by UNICEF, the ILO, and UN Women underline the role firms can play in reducing stress by providing accurate information on the virus, supporting workers by providing counselling and access to psychosocial services, and allowing flexibility in working hours so that those working at home can better cope with family demands.
- Alzheimer’s Disease International has gathered a range of resources for people with dementia and their carers. The organisation’s website has webinars, news, case studies and advice from a number of countries and in several languages.
- The UK government has produced advice for parents who are at home with children (the most thorough of several similar efforts available online). The advice is broken down by age group (routines are particularly important, including sleep routines, both for parents and their kids) and includes children with existing mental and physical health issues and those who are themselves carers.
- This WHO briefing has advice for the general population, health workers, health facility managers, the elderly and their carers, carers of children, and people in isolation. Regular exercise, limiting intake of news, keeping to sleep routines, and supporting others in person or remotely are recommended for all groups.
“Countries should not adopt one-size-fits-all approaches, but should make efforts to understand local contexts including pre-existing mental health issues in communities”
Most world regions would benefit from devoting more resources to mental health in normal times – sub-Saharan Africa’s allocation of 0.1% of its healthcare budget to mental health, for example, comes in a context where the number of years lost to disability because of mental disorders almost matches the number of years lost because of infectious diseases.
During a crisis such as the coronavirus, mental health care becomes yet more urgent. There is an urgent need to ratchet up research into effective mental health interventions. Respondents to the UK survey in March reported that contact with relatives and friends, physical activity, managing news consumption, keeping busy, maintaining routines, and relaxation techniques including meditation, mindfulness and prayer were helping their mental health during the pandemic. Researchers and innovators should build on these insights and continue to consult those with experience of mental health problems as they develop high- and low-technology solutions.
They should also tailor interventions to different settings. Mental ill health is still a taboo subject in many countries, leading governments and communities to ignore it or even to punish those suffering from mental disorders.
Family and religion play a stronger role in providing psychological support in some countries than in others, and in these settings interventions that work through rather than parallel to these institutions may prove more effective. Where internet coverage remains low, digital interventions – to provide information, assess and monitor risks, connect people to services, and provide direct therapy – may need to be complemented by telephone-based solutions. And where the availability of pharmaceutical therapies is limited, an emphasis on counselling and community-based solutions will be more appropriate.
Given the urgency of responding to the mental health impacts of the coronavirus pandemic, asking people in different environments what they think will help them is a shortcut to developing successful interventions. Long-term monitoring of these interventions’ impacts and cost-effectiveness can assist policy makers to identify and scale up those that work.