Patricio V. Marquez and Toluwalola Kasali

As if foreseeing the impacts of the COVID-19 pandemic – arising from the spread of a novel coronavirus, which was first identified at the end of 2019, Ministers and high-level representatives from countries and international organizations convened in Amsterdam on October 7-8, 2019, to attend the International Conference on Mental Health and Psychosocial Support in Crisis Situations, hosted by the Dutch Minister for Foreign Trade and Development Cooperation. The Conference Declaration, "Mind the Mind,"  was clear in stressing the need to scale up mental health and psychosocial support services during and after emergencies to support individuals, families, and communities across a continuum of care.  

Nowhere is this truer, or more revelatory and applicable, than amidst the COVID-19 pandemic.  While the pandemic is unfolding as the largest public health crisis in our lifetime, with a toll, as of mid-April 2021, of more than 140 million confirmed cases and 3 million deaths, the necessary quarantines and social distancing practices adopted by countries to contain the pandemic put the world in a "Great Lockdown." Data and information from across the world provide ample evidence that this crisis and the consequent lockdown has negatively affected many people's mental health and hindered access to services for people already suffering from mental illness and substance use disorders.  The loss of loved ones, stress about contracting the COVID-19 disease, or having a family member get sick from the disease, coupled with job and income losses, school closures, and loss of childcare, are some of the ways in which the pandemic has impacted the mental well-being of people across age-groups. 

Here, we revisit and present a snapshot of how this reality has manifested in some regions and countries around the world. We will also discuss why in order to achieve the goal to "build back better" in the post-COVID-19 period, the common practice of relegating "mental health" to the margins of the health and development agendas has to end.

The impact on youth in Africa and South America

The impact of the pandemic has been severe on children and adolescents worldwide, upending their daily routine and isolating them from their social structures.  For example, it disrupted education for 1.6 billion children across countries over 2020-2021.  In more than 90 countries, students are being instructed through multiple modalities, with some schools open, others closed, and many offering hybrid learning options.  According to World Bank Group specialists, COVID-19 related school closures are likely to increase learning poverty (the proportion of 10-year-olds unable to read a short, age-appropriate text) to as much as 63% (it was 53% in low- and middle-income countries prior to COVID-19, compared to only 9% for high-income countries). 

In Africa, the varying degree of restrictions imposed by governments to curb the spread of the virus, reduce the risk of COVID-19 disease severity and death, including school and university closures, limits on social gatherings, and closure of non-essential services, have led to increased levels of stress, anxiety, and depression. The restrictions are likely to have had a greater effect on young people, who make up about 60 percent of Africa's population. This is because it exacerbates pressures in a region where young people are already struggling with disruptions in completing their education, unemployment in highly competitive labour markets, and uncertainty in the informal sector where the majority of African youth earn their living.

As a result, the demand for mental health services by young people across Africa is on the rise,  and mental health advocates like the Mentally Aware Initiative in Nigeria,  Waves for Change in South Africa, and StrongMinds in Uganda are using innovative solutions to offer counselling and support.  "We saw a 70 percent increase in the number of people reaching out for help at the start of the pandemic.", said Jolade Phillips, communications lead at Mentally Aware Nigeria.  In South Africa, where one of the world's strictest nationwide lockdowns was imposed due to the high number of COVID-19 cases, a report by the Southern Africa Labour and Development Research unit showed a prevalence of depressive symptoms of 72% among the young participants aged between 18 and 35.

In terms of substance use, evidence from the World Drug Report 2020 shows that non-medical use of synthetic opioids like tramadol (a narcotic-like pain reliever) fuels public health crises in West, Central, and North Africa. A report indicates that the ease of access to cheap opioids has increased its use among African youths due to prevailing socio-economic situations that COVID-19 has aggravated.

As lockdown rules are being relaxed across Africa and with low vaccination roll-out, some young people are experiencing moral fatigue. Explaining this term, Kareem, a 24-year-old consultant in Nigeria, said, "Some friends suffered from moral fatigue arising from socially distancing and staying away from groups of people in order to protect their loved ones even after the lockdown was lifted due to individual or family vulnerabilities." Moral fatigue is harder because it requires subjective decisions, especially while other friends can enjoy themselves without that burden, he said.

During the pandemic, some young people also took to social media and the streets in countries like Nigeria, Namibia, South Africa, Côte d'Ivoire, and Uganda to protest police brutality and human rights abuses, violence against women, child labor, and human trafficking, amongst others. The psychological impact and feelings of helplessness could be traumatic for people already dealing with pandemic-related anxiety. 

While issues persist around cultural beliefs, stigma, acceptability, access, and the cost of seeking help, some young people in Africa are now more open to discussing their mental health and the positive impact of therapy on their lives. Compared with other regions, there is inadequate information and resources regarding mental health disorders and their impact on young people. The region has 1·4 mental health workers per 100 000 people, compared with a global average of 9·0 per 100 000. Broader coverage of mental health support and resources are needed across rural and urban areas to reach more young people. This is critical at a time when the pandemic is causing increased anxiety and depression in order to avoid the longer-term adverse effects on young people.

The situation in Africa is also observed in South America.  For example, preliminary results of a study carried out by Miguel Uribe and the team at the Pontificia Universidad Javeriana, which focused on mental health and resilience in young adults in Bogota, Colombia, during the COVID-19 lockdown, provides evidence of the high mental health toll that social distancing measures are having on young adults aged 18-24 years.  While 59% of males and 70% of females presented depressive symptoms, 47% of males and 56% of females had anxiety symptoms.

In terms of substance use and addiction, it is observed that this can have long-term effects on young people because it can affect their brain development and contribute to the development of adult health problems, such as heart disease, high blood pressure, and sleep disorders.

Children, young adults, and adults have also been negatively impacted in rich countries

The COVID-19 pandemic has had a significant toll on school-age children.  A year of school shutdowns and family trauma leads to social isolation, stress, and mental health issues.  Harvard University researchers who have been following 224 children, ages 7 to 15, found that about two-thirds (67%) had clinically significant symptoms of anxiety and depression. The same number had behavioral problems such as hyperactivity and inattention between November 2020 and January 2021. This represents a significant increase from the 30% with anxiety and depression symptoms and the 20% with behavioral problems before the pandemic. Symptoms were more common in children who had experienced events such as having a family member hospitalized or dying from the COVID-19 disease or having a parent lose a job.

Young people in high-income countries have not fared better than their peers in low-and-lower-middle income countries.  In the case of the United Kingdom (UK), one in four young people has felt unable to cope with life since the start of the pandemic due to increased loneliness and anxiety arising from school closures, isolation from friends, job losses, exam cancellations, and uncertainty about the future.  The Prince's Trust Youth Index report, which surveyed 2180, 16 to 25-year-olds, showed that young people experienced self-loathing feelings, insomnia, panic attacks, suicidal thoughts, and self-harm. In each of these cases, young people who were not in education, employment, or training suffered more with their emotional health.

The Royal College of Paediatrics and Child Health, specialists working across England, Scotland, and Wales, have also seen a three to four-fold increase in referrals for eating disorders in children and young people and believe that the pandemic is a major reason behind the rise.  There is an increasing call for parents to be alert and watch for signs of eating disorders in young people. Reasons given by young people about their eating disorder mostly began with "at the start of the lockdown or when GCSEs were cancelled.", said Dr. Karen Street, a consultant pediatrician.

Many young people feel anxious and frustrated that the teacher-assessed grades, which replaced their A-level and GCSE exams due to the pandemic, might not correctly recognize their potentials and affect their ability to get into first-choice universities and their future.  Uncertainty about future employment prospects also continues to play on young people's minds. Laura, a 23-year-old worker, was furloughed for three months in the first lockdown but did pretty okay. It was not until the end of 2020 that her mental health began to dip a bit. "As we entered into the third lockdown in January, I felt a sense of dread that it would never be over.", said Laura.

Since the start of the pandemic, many young people have turned to virtual and digital support. Locked up at home with their families, some young people shared concerns about a lack of privacy when talking on the phone with counsellors.  Many of them also spoke about the challenges of losing access to informal support, particularly from trusted friends and teachers. A participant in the YoungMinds survey said, "I got a lot of support from a few teachers at my school and trusted them with what I was telling them. Now I can no longer speak to them and have been isolating myself from speaking to anyone else."

As lockdown measures are being gradually eased across the UK (since March 2021) and the vaccination program progresses, some young people might begin coping better as they receive more help.

In the United States, the situation is not different.  Data from the CDC shows that young adults in the country are among the groups disproportionately affected by the mental health impacts of the COVID-19 pandemic, struggling with issues such as anxiety/depression (31%), trauma/stressor-related disorders (26%), starting or increasing substance use (13%), and seriously considering suicide (11%).  A more recent analysis from the March 2021 Kaiser Family Foundation (KFF) COVID-19 Vaccine Monitor found that those hardest hit by the mental health impacts of the coronavirus pandemic have been younger people and women, including mothers with children under 18 years old in their households.  These groups were among the most likely to report that stress and worry related to coronavirus have had a negative impact on their mental health. More than half of women overall (55%) report a negative impact on their mental health related to the coronavirus pandemic, compared to about four in ten men (38%) who report the same.  Smaller shares of adults ages 65 and older and men (including fathers with children in the home) say they have experienced mental health impact from the coronavirus.

The KFF assessment also shows that access to providers and affordability appears to be the biggest barriers for those who felt they needed mental health care in the United States because of the pandemic but did not receive them. The main reason was that they could not find a provider (24%) or could not afford the cost (23%). An additional one in five (18%) say they were too busy or could not get the time off work to receive treatment. One in ten say they had problems with the insurance covering their treatment, while 5% said they were afraid or embarrassed to seek treatment.

Have substance use disorders increased during the COVID-19 pandemic?

Alcohol misuse is already a public health concern in many countries, and it has the potential to further complicate the COVID-19 pandemic in multiple ways.  Excessive alcohol consumption can influence COVID-19 susceptibility and severity, as it both activates the immune system, causing inflammation, and interferes with the body's immune response to viral and bacterial infections.  In a vicious cycle, the broad effects of the pandemic are also likely to lead to excessive alcohol consumption. As documented in a previous post, people are more likely to drink more as a coping mechanism "during times of uncertainty and duress," particularly in the face of rising unemployment and loss of income.  The COVID-19 crisis is not an exception. For example, with bars and restaurants closed in the United States, sales of alcohol in the United States have spiked since the start of the pandemic, with consumers gravitating to larger pack sizes. As stay-at-home orders began in some US states as a mitigation strategy for COVID-19 transmission, Nielsen reported a 54% increase in national sales of alcohol for the week ending March 21, 2020, compared with 1 year before; online sales increased 262% from 2019.

Also, stress due to lockdown and isolation may have contributed to increasing the risk of developing Alcohol Use Disorder (AUD) and relapses among people struggling to overcome this disorder.  Both prolonged drinking and alcohol withdrawal is associated with an increased incidence of anxiety, creating a cycle. People with general anxiety and panic disorders often self-medicate their condition with alcohol, and people with anxiety who self-medicate with alcohol often develop AUD. 

For example, an American Psychological Association (APA) survey of US adults, conducted in late February 2021 by The Harris Poll, provides evidence that the widespread fear, frustration, and social isolation surrounding the pandemic and other civil and political upheavals,  caused stress levels to increase significantly.  The results show that one in four adults reported drinking more this past year to manage their stress. That rate more than doubled among those who had children between the ages of 5 and 7, particularly among women.  A survey done by PAHO/WHO in 2020, also showed that as the rates of anxiety, fear, depression, boredom, and uncertainty became more commonly reported during the pandemic in Latin American and Caribbean countries, alcohol consumption increased as well, despite the closure of licensed premises—indeed, those who experienced a greater number of emotional symptoms/feelings had a higher prevalence of drinking and heavy episodic drinking.

Recent CDC data also show that in the United States, drug overdose deaths have surged by 29% during the COVID-19 pandemic. More than 87,000 Americans died of drug overdoses during this period.  The drugs used include heroin, morphine and codeine, and semisynthetic opioids, such as oxycodone, hydrocodone, hydromorphone, oxymorphone; methadone; other drugs such as fentanyl and tramadol; cocaine; and psychostimulants with abuse potential, such as methamphetamine. The latest numbers observed during the pandemic surpass even the yearly tolls during the height of the opioid epidemic and mark a reversal of progress against addiction in recent years. The biggest jump in overdose deaths took place in April and May 2020, when fear and stress were rampant, job losses were multiplying, and the strictest lockdown measures were in effect. Many treatment programs closed during that time, at least temporarily, and “drop-in centers” that provide support, clean syringes, and naloxone, the lifesaving medication that reverses overdoses, cut back services. 

The impact of grief and social isolation

While the world is starting to see the “light at the end of the tunnel,” thanks to effective vaccines being deployed,  the still-growing death toll will leave behind millions of bereaved people, deeply affected by the loss of loved ones. This is ominous, particularly in countries where the COVID-19 disease deaths and excess deaths during this period reached historic levels. The short- and long-term impacts of bereavement are well studied and include trouble sleeping, higher blood pressure, depression, and anxiety. Studies have found that people who lose a spouse die earlier than their married peers. Children who experience the loss of a parent may suffer lasting consequences, including lower grades and failing in school, as well as increased experimentation with drugs and alcohol.

Although more subtle and complicated, another emerging challenge in a post-pandemic world would be how societies deal with the disproportionate psychological impact on the lives of aging individuals who avoided the disease itself by largely staying at home and isolating themselves, and their families.  This is important because social isolation and loneliness leave deep scars that need to be addressed. For some people, for example, social isolation during the COVID-19 period, as vividly described in an article in The Atlantic, resulted in the loss of “the last year your loved one was lucid”. In particular, memory-loss residents in nursing-homes or care facilities for the elderly, were not permitted to have visitors, socialize with other residents, or were denied access to day programs, as a preventive measure to contain the spread of the virus among an already highly vulnerable population group.  Amid social isolation, the condition of people suffering from Alzheimer’s and dementia rapidly deteriorated, even to the point that they were not able to take care of themselves in simple ways.  Sadly, as put in the article, “They’ve been robbed of both their health and some of their last clear memories with family members.”

Going forward, while new technologies can help, the routine part of medical care and social services should be assessing the roles and quality of social contacts and detecting the presence and degree of loneliness to build a social-contact remediation plan into overall treatment.

What to Do to "Build Back Better"?

The mental health toll of the pandemic is only beginning to show itself.  Although we cannot predict the scale of its impact, lessons from past crises and societal shortcomings in recent times can offer guidance on how to mitigate and address this challenge in the post-pandemic period. What should be clear is that the social cost of mental illness and substance use disorders – which compound the impact of poor physical health – are terribly high for individuals, families, communities, and the economy. Yet, the cost of effective treatments is surprisingly low.

As we start to move to a post-pandemic era, we need to be mindful to avoid the risk of "medicalizing" the response to mental health and substance use disorders amid the COVID-19 pandemic. They are part of a syndemic or multiple interrelated epidemics happening at the same time. Dealing effectively with this challenge requires attention to common social and biological underpinnings that are causing an increased public health burden on communities.

First, a fundamental rethinking is needed to overcome the false dichotomy between physical health and mental health in healthcare services.  Mental health parity must be placed at the core of human capital development, particularly to ensure that a healthy and more resilient cohort of young people emerges from the global health crisis.  This is required to protect hard-won advances made over the past decades in human capital, particularly among the poor and vulnerable, and to support human capital development in the future-the knowledge, skills, and health that people accumulate over their lives.

As we advocated before, numerous potential cross-sectoral platforms could serve as "entry points" to align funding, service provision, and population needs in the future:

1. Integrating mental and physical health services at primary health care and community levels and linking the provision of these services to social protection programs to assist people in need, both those already suffering from mental and substance use disorders pre-pandemic and those newly affected.   Also, provisions should be made to develop policy options and allocate resources to deal with grief and suffering in a post-pandemic period. 

2. Existing funding streams for maternal and child health, such as those under the Global Financing Facility (GFF) in support of Every Woman, Every Child, can be leveraged to deal with maternal depression, especially postnatal, and the associated stunting in children. Also, GFF operations could include support for strengthening the interface between disease surveillance, reporting, and intervention, particularly to track and address gender and domestic violence and child abuse during lockdowns.

3. School-based and youth interventions are critically important because 75 percent of mental and substance use disorders begin before age 25, and suicide is a leading cause of death among the youth.  Social and emotional learning programs and promotion of physical health, work and study support, and alcohol and other drug services positively impact healthy development, well-being, and academic performance. Integrating school and clinic-based services is an effective approach to improve human capital outcomes by investing in people earlier in life.

4. To achieve significant, measurable improvements in mental health – especially among young people – promising initiatives, such citiesRISE, need to be supported to scale up innovative and structured approach to cross-sector collaboration that brings creative and collaborative local leaders together under a common operating plan and goal framework to reach as many people as possible. By focusing on young people and youth leadership, often involving those with a lived experience of mental health disorders, these initiatives are helping create awareness of mental health from an earlier stage, mobilizing youth to be leaders, addressing large-scale stigma, and preventing mental health challenges before they become chronic or disabling. To engage with young people and youth leaders in settings they choose, activities take place in educational settings such as schools, through sports and arts, as well as technology-based channels. 

5. Similarly, integrating mental health into wellness programs in the workplace can mobilize private companies to invest in health promotion activities such as cognitive-behavioral therapies to reduce stress. These programs generate significant benefits for workers, their families, and employers, improving productivity and competitiveness, and tackling the stigma surrounding mental disorders.

6. Programs in fragile and conflict-affected settings can be leveraged, and the needs of displaced populations and refugees integrated into mainstream physical and mental health interventions alongside other social services. This requires community-based solutions in which displaced people and refugees are also empowered to build their resources and achieve self-reliance towards improving their overall well-being and reintegration into society.

7. Initiatives that focus on addressing the mental health needs of prisoners and bringing about their recovery are required to overcome the "punishment paradigm” often found in penal systems.  This requires a concerted effort to overcome the criminalization of mental illness and substance use disorders by offering comprehensive physical and mental health services during incarceration and supporting a transition to community life after prisoners are released.

8. Microcredit schemes to provide low-interest loans, small business loans, training, and mentorship to entrepreneurs with a history of mental health or addiction challenges (including former prisoners), facilitate reintegration into the community.

9. Pro-health taxes, such as those on tobacco, alcohol, and sugar-sweetened beverages, are effective but underused policies of disease prevention and health promotion, that could also help mobilize additional government revenue to fund investments and programs, such as the expansion of integrated services mental and substance use disorders.  Projections presented in a World Bank Group report for the G-20 meeting in Osaka, Japan in 2019  showed that the substantial UHC financing gap in low- and lower-middle-income countries (now exacerbated by COVID-19), can be attenuated by excise tax increases on tobacco, alcohol, and sugar-sweetened beverages. These calculations showed that a 50% increase in prices for these products could generate additional revenues of approximately $24.7 billion in 54 low- and middle-income countries by 2030.  Importantly, the revenue raised can additionally benefit poorer households when it is used progressively.  Additional revenue for expanding universal health coverage could come from other measures such as tax avoidance and evasion; tax exemptions, tax credits, preferential tax rates, and/or deferred tax liability to attract foreign investors; the elimination of wasteful subsidies for fuel products; and reduction of military expenditures.

10. Finally, as we have seen during the COVID-19 pandemic, leveraging the potential of technology such as cell phones, smartphones, and tablets can facilitate the provision of online mental health and peer-to-peer support services while helping to overcome stigma barriers to seeking help. This has been particularly beneficial for adolescents and young adults.  Monitoring and additional research are also needed to track and understand the long-term mental health impacts of the COVID-19 pandemic to guide action in the future based on evidence.

There is no time to lose!  A sustained focus on mental health can and will contribute to a more resilient recovery and develop more equitable and inclusive societies post-COVID-19.

 

Source of Images:  

First image: Royalty-free stock photo ID: 1688542201.  Indoors bed portrait of young desperate and depressed woman feeling scared and overwhelmed crying alone during COVID-19 virus home lockdown and quarantine.  By TheVisualsYouNeed

Second image: Picture taken by Patricio V Marquez in the Galapagos Islands, Ecuador, November 2019.  This pandemic shall also pass!