No 'Tidal Wave' of New Mental Illness; Pandemic Exacerbates Preexisting Conditions

Liam Davenport

July 21, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

The COVID-19 pandemic and resulting lockdown are associated with increased depression and lower levels of life satisfaction ― but primarily in specific demographic and socioeconomic groups, new research shows.

A survey of more than 72,000 individuals in the United Kingdom shows that young adults, those in lower income groups, and those who had been diagnosed with a mental illness were most affected. Interestingly, anxiety increased during the lead-up to the lockdown for the overall group but decreased during the lockdown itself.

A second survey showed that the pandemic triggered poorer mental health among more than 1400 patients with mental illness or their caregivers. However, individuals found ways of coping despite the increased stress.

Commenting on the findings, David Spiegel, MD, professor and associate chair of psychiatry and behavioral sciences and director of the Center on Stress and Health at Stanford University, Palo Alto, California, noted that expectations of a "tidal wave" of mental health problems during the pandemic may have been wide of the mark.

Instead, the pandemic seems to have caused "an exacerbation" of preexisting mental health conditions, Spiegel told Medscape Medical News.

The studies were presented during a dedicated session at the European Psychiatric Association (EPA) 2020 Congress, which was held online this year because of the COVID-19 pandemic.

Underrepresented Groups

The first presentation was given by Daisy Fancourt, PhD, associate professor of psychobiology and epidemiology, University College London, United Kingdom. She described the COVID-19 Social Study, which included more than 72,000 individuals.

Participants were recruited via research databases, media communications, and "more targeted sampling at underrepresented groups, including people from low educational backgrounds and low-income households," Fancourt noted.

The respondents took part in the study once a week. This resulted in more than 500,000 completed surveys at a rate of between 3000 and 6000 responses per day. Sixteen weeks of data have been gathered so far.

The samples were weighted so they "aligned with population proportions in the UK for demographic factors such as age, ethnicity, gender, geographical location, and educational attainment," said Fancourt.

Results showed that mental health decreased in the lead-up to lockdown, with decreases in happiness and increases in fear, stress, and sadness.

At the start of lockdown, approximately 60% of people reported that they were stressed about COVID-19 itself, whether catching it or becoming seriously ill.

During lockdown, there was little change in levels of depression, but anxiety decreased and life satisfaction increased during this period.

"We're Not All in This Together"

The lower stress level wasn't surprising, "because people were at home much more. But what is particularly surprising is that it's continued to drop even though lockdown easing has now been taking place for a number of weeks," Fancourt said.

"A big question is, Has mental health been equally affected across this period? And our data seem to suggest that's very much not the case," she added.

After assessing different demographic and socioeconomic groups, the investigators found that participants aged 18 to 29 years had much higher levels of anxiety, depression, and thoughts of death or self-harm and much lower levels of life satisfaction than older participants.

A similar pattern was found for lower-income groups in comparison with those earning more and for individuals in Black, Asian, and minority ethnic groups compared with White individuals.

For patients who had been diagnosed with a mental illness, levels of depression, anxiety, and thoughts of death or self-harm, as well as life satisfaction, generally ran parallel to those of the general population, although at a far worse level.

Overall, the results suggest that "we've not all been 'in this together,' as we heard in some of the media," Fancourt said. "In fact, it's been a very different experience, depending on people's demographic and socioeconomic characteristics."

Increased Loneliness, Economic Worry

Further analysis into loneliness showed that twice as many respondents described themselves as lonely during the COVID-19 pandemic in comparison with beforehand (18.3% vs 8.5%).

There was very little improvement in loneliness across the study period, "so whilst it might be higher than normal, we've not really seen any reduction, even when there's been easing of lockdown," Fancourt said.

A possible reason could be that some of the most lonely respondents were not able to come out of lockdown because of being in a higher-risk group, she noted.

As with the main findings, loneliness during the pandemic was worse for younger adults as well as for those of low income, those who lived alone, and those who had a mental illness.

The researchers assessed lower socioeconomic position (SEP), which was defined by several indicators:

  • Annual household income less than £30,000 (about $38,000)

  • High school or lower education

  • Being unemployed

  • Renting instead of owning one's own home

  • Living in overcrowded accommodations

During the COVID-19 epidemic, having a lower SEP was associated with a 1.5-fold to twofold increased risk of losing work in comparison with having a higher SEP. There was also a fourfold increased risk of being unable to pay bills and a sevenfold to ninefold increased risk of not being able to access essentials, such as medication or sufficient food.

Interestingly, worrying about potential adversities during the pandemic had a similar impact on anxiety and depression.

"In other words, worrying about what might be about to happen seems to be as bad for mental health as those things actually happening," Fancourt said.

The majority of participants did not feel in control of their future plans and felt more out of control of their employment and mental health than they did their physical health.

Individuals aged 18 to 29 felt least in control over finances, relationships, future plans, and mental health. Those aged 60 years or older were the most likely to report feeling in control on all measures.

Puzzling Results

Spiegel described the results as "a little puzzling in some ways." He noted that the easing of discomfort that participants felt during lockdown suggests that the idea of a lockdown being a terrible thing "is not necessarily the case."

"People realize that their lives and lifestyles are being threatened, and it can be actually comforting to be doing something, even if what you're doing is rather uncomfortable and disruptive of life," said Spiegel, who was not involved with the research.

The lockdown may have led people "to think a little more deeply about what matters to them in life," he added.

A big message from the study is that "the most anxious and depressed were young people in their late teens to late twenties," Spiegel noted.

That's when individuals are most sociable, when they form their own social networks, and when they look for partners, he added.

"What's a little scarier is they also had higher levels of thoughts of death and self-harm and less life satisfaction. So I think the consequences of social disruption were most profound in this study for people for whom social life is the most important," said Spiegel.

However, Roxane Cohen Silver, PhD, professor of psychological science, medicine, and public health, University of California, Irvine, noted that despite the large number of participants, the study's methodology left many questions unanswered.

Commenting for Medscape Medical News, she explained that to make sound public policy recommendations, "one needs to pay a great deal of attention to the methods that are used in collecting those data."

From the available information, the degree to which the sample is representative and the participation rate are unclear, which leaves the study open to selection bias, despite the weighting the researchers performed to generate the results, she said.

"The methodological soundness of the studies on the mental health effect of COVID are just as important, I believe, as they are when we're trying to understand the effect of treatment or a drug," Cohen Silver said.

Relief During the Pandemic?

The second presentation was given by Sara Simblett, PhD, Department of Psychology, King's College London, United Kingdom, who described the Coronavirus Outbreak Psychological Experiences (COPE) Study.

This was a two-part investigation in which 31 semistructured interviews with users of mental health services and carers formed the basis of a qualitative survey. It examined the impact of the pandemic on thoughts, emotions, behaviors, and life situations.

The survey was advertised via social media and mental health charities, yielding a total of 1402 responses. These included responses from 968 individuals who had experience of a mental health condition. Of these, 266 were currently using mental health services, and 189 were informal carers.

Of those, 46.8% met the case threshold for anxiety, 40.3% met the threshold for depression, and 45.3% were determined to have "low resilience."

The COVID-19 pandemic triggered poorer mental health in the majority of respondents, at 60.8% among those with a preexisting mental health condition and 64.1% among informal carers.

This was reflected in 95.3% of respondents saying that things were uncertain, 81.3% saying they felt restricted by the pandemic, and 71.9% saying that their day was less structured.

However, the survey also revealed that 79.8% felt relieved during the pandemic, 82.1% said that their memory was "much better," and 62.9% found it easier to concentrate and make plans.

In addition, many people turned to coping mechanisms; 74.7% looked to religion and spirituality as a source of support, and 64.2% used health and wellness apps.

The COVID-19 Social Study is funded by the Wellcome Trust and the Nuffield Foundation. The COPE study is a collaboration with the McPin Foundation. The investigators and commentators have reported no relevant financial relationships.

European Psychiatric Association (EPA) 2020 Congress: Session 1847, presented July 6, 2020.

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