Initial reports suggest we should expect a sharp rise in levels of depression, anxiety and loneliness. The pandemic could have implications for those already suffering from addiction, OCD, and eating disorders. Concerns have prompted a number of initiatives supporting mental well-being. These include guidance from the World Health Organisation (WHO) and Public Health England (PHE), resources from the devolved administrations, and formation of the Help Hub, a service set up by volunteer therapists.
On 4 May, the Office for National Statistics reported that well-being levels are at their worst since data collection began in 2011. In April, a representative survey of 2,010 people in Great Britain found that four in five people were worried about the effect of COVID-19 on their lives. Almost half reported that it was affecting their well-being.
Mental health can be compromised by fear of the virus itself, and indirectly through non-pharmaceutical interventions (NPIs), such as social distancing, school closures and home isolation or quarantine. NPI measures are required to combat the spread of the virus, but they can introduce further strain. This can include sudden changes in routine, financial hardship and physical separation from loved ones.
NPI measures can make it harder to maintain activities that benefit mental well-being. For example, it may be harder harder to exercise outdoors, particularly in dense urban areas. People may also find it hard to return to ‘normal’ social relationships after social distancing.
Current restrictions also make it harder to access mental health services. These include support groups, counselling and medication. There were long delays to accessing support before the COVID-19 outbreak. Mental health charities are concerned that services will be further impacted due to the loss of fundraising streams.
Early research suggests that social distancing is having significant impacts on mental health and well-being during the COVID-19 outbreak.
Current evidence has been produced in rapid response to an ongoing situation and is often not peer-reviewed. The timeframe of the pandemic means that evidence so far captures short-term emotional responses, which would be expected in the face of a threat. Initial responses are not necessarily reflective of long-term mental illness.
Past pandemics reveal potential for long-standing effects, although studies tend to focus on the impact of measures that are not currently being used in the UK, such as mandatory quarantine. For example, a rapid review of evidence from SARS, Ebolavirus disease and influenza pandemics revealed that quarantine measures were linked to increased risk of psychological distress, often manifesting as post-traumatic stress disorder (PTSD).
The review indicates that negative psychological effects are linked to longer quarantine duration, so mental health may be impacted by specific approaches taken to social distancing over the longer term.
Below is a summary of potential mental health risks based on evidence from the current COVID-19 outbreak, as well as past pandemics.
People have had to adjust to a new routine with restrictions on personal liberties. This can contribute to frustration, boredom and low mood, and could lead to depression. Sudden changes in a person’s life situation and feeling lonely can also cause anxiety.
University College London has been conducting weekly surveys with over 80,000 members of the UK public since 21 March. Reported levels of depression and anxiety are significantly higher than usual. Levels had been declining slowly since social distancing measures were introduced. However, since 24 April reported depression levels have been rising again.
The study found that self-reported depression and anxiety levels were higher in younger adults, those living alone, those with lower household income, and those with an existing mental health diagnosis. They have also been higher in women than men, in those living in urban areas, and in people living with children compared to those living just with adults.
Additional studies from Swansea University and University of Manchester, and University of Sheffield and Ulster Univerity also suggest that social distancing measures have led to heightened feelings of anxiety and depression amongst the general public.
Loneliness occurs when there is a gap between our actual and desired social relationships. Social distancing can make people more prone to loneliness, through enforced reduced physical contact with family and friends.
At the beginning of April, the Mental Health Foundation conducted a representative survey of 2,221 UK adults, and found that one in four people had experienced feelings of loneliness in the past 2 weeks. Young people were three times more likely to have experience loneliness, with 44% feeling this way.
Loneliness has increased during previous pandemics. For example, a study of 1,932 people quarantined during the 2003 SARS outbreak in Canada found that 39% reported feeling lonely.
Loneliness is linked to poor health and has been estimated to be as damaging as smoking 15 cigarettes a day. It often co-occurs alongside other lifestyle factors (such as smoking), therefore these health risks might not necessarily apply to loneliness as a result of short-term measures. However, they may be potential risks for extended periods of social distancing.
Expert opinion and commentary suggest that the COVID-19 outbreak may also have consequences for addiction, obsessive compulsive disorders (OCD) and eating disorders. However, research evidence that is specific to the outbreak is not available yet.
People may be more at risk of forming addictions or relapsing from recovery. The current strain on health services may mean that those facing addiction are reluctant to seek help, and reduced social contact means that friends and family are less likely to notice.
Increased alcohol consumption can lead to addiction. A representative UK survey of over 2,000 people commissioned by Alcohol Change UK found that one in five have been drinking more often during lockdown, and one in five daily drinkers have increased the amount they drink. This carries health risks for the individual and others in the household. Alcohol misuse has been shown to increase the risk of domestic violence and one in 14 respondents felt that alcohol has worsened tensions during lockdown.
Cancelled sports events could lead to gamblers turning to online casinos (which carry higher rates of addiction). Clean Up Gambling commissioned a survey of over 1,000 people. They found that 39% of regular gamblers were gambling more since the start of the COVID-19 outbreak, and 41% had signed up to new gambling accounts. At the end of April, the Betting and Gaming Council (a UK industry standards body) announced a six-week removal of all their members’ advertising from broadcast in order to safeguard those at risk.
Those with OCD can have a wide range of obsessions and compulsions. Uncertainty from a crisis can trigger compulsive behaviours used to feel more in control. The threat of unknowingly spreading COVID-19 can cause distress, as those with OCD often feel an intense responsibility towards others. A news article suggests that advice to wash hands ritualistically to ‘keep people safe’ can be stressful for those who have trained themselves out of compulsive handwashing routines.
Mental health practitioners have warned that this time can be particularly difficult for those who have a history of disordered eating. UK charity Beat has reported a 35% increase in people contacting its services and an 80% increase in people reaching out via social media since social distancing measures were announced. Anxiety and the need for control can trigger harmful relationships with food, which may be exacerbated by food availability and disruptions to mealtime routines.
Anybody can be affected by a mental health condition or decreased well-being. Approximately 1 in 4 people in the UK will experience a mental health problem each year. However, there are some groups that may be particularly susceptible during the current measures. These include:
People who are at higher risk or clinically extremely vulnerable from COVID-19 might experience greater social isolation. This can contribute to loneliness and depression. They may also experience heightened levels of anxiety due to increased health risks from contracting COVID-19.
The lack of structure and routine from school closures could negatively affect children and adolescents. UK charity Childline has reported a ‘huge spike’ in the number of counselling sessions relating to coronavirus after school closures were announced. Young children have lost the opportunity for face-to-face contact with friends, which is fundamental to well-being and development. Older children may be stressed about disrupted exams and separation from their peers. Children with special educational needs are particularly sensitive to disrupted routines and may not be able to access their usual support.
Those with communication or learning difficulties may have greater difficulty understanding the situation, accessing healthcare information and coping with lack of social contact. According to UK charity Mencap, people with learning disabilities were seven times more likely to be socially isolated before the pandemic, indicating that their support networks may already be compromised.
Research from previous pandemics indicates that healthcare workers may experience greater psychological distress. A poll commissioned by the Institute for Public Policy Research (a UK think tank) found that 50% of 996 healthcare workers reported that their mental health had deteriorated since the COVID-19 pandemic began. In April, the NHS launched a mental health hotline to provide psychological support for staff tackling COVID-19.
Existing societal inequalities may exacerbate mental health issues during this time. Disrupted food availability and uncertain job markets can increase mental strain on low-income families. Restrictions on leaving the house may be more challenging for those in poor or unstable housing conditions. The UK Government has acknowledged the potential impact on people experiencing domestic abuse and has pledged £76 million to support them.
The World Health Organization (WHO) published guidance on supporting well-being during this time, including specific guidance for healthcare workers, children, older adults and those with underlying health conditions. Advice includes:
In the UK, there have been several initiatives set up by government bodies or the third sector to support mental health and well-being. Public Health England, the Scottish Association for Mental Health and Northern Ireland’s nidirect website have published guidance on looking after personal well-being, alongside advice for parents and carers on children’s mental health. Public Health Wales is conducting a weekly survey to monitor public well-being during this time.
The UK Government has also published COVID-19 specific guidelines for providers of services for people who use drugs or alcohol, and announced that mental health charities will be given £5 million to expand their support services. The Welsh Government has established a National Mental Health Collaborating Centre (NMHCC) to provide a central point of guidance for mental health service providers during the COVID-19 outbreak.
Volunteer therapists have set up The Help Hub, which offers free 20 minute counselling sessions online. The service aims to support those who are isolating and more vulnerable, such as the elderly. Many support groups, such as those held by Alcoholics Anonymous and Narcotics Anonymous, are operating online.
Many other organisations have dedicated hubs to provide mental health and well-being advice and information during COVID-19. These include:
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