The COVID-19 pandemic is one of the most influential global events of the 21^st century and its mental health impact is a prominent area of concern for researchers and policy makers.

Past epidemics, such as the SARS-Cov outbreak in 2003, were significantly linked with an increased prevalence of psychiatric disorders, such as PTSD, for the survivors of the disease (Mak, Chu, Pan, Yiu, & Chan, 2009). Moreover, amongst a group of people who adhered to quarantine measures aimed at the containment of the spread of the virus, a relationship between length of quarantine and PTSD symptoms was identified (Hawryluck, 2004).

Studies investigating the mental health impact of the COVID-19 pandemic appeared shortly after its onset. Nevertheless, most of the studies so far have been limited by small sample sizes or no pre-COVID-19 measures to compare the population’s responses to.

Pierce at al. (2020) conducted the first study attempting to address these limitations by performing a secondary analysis of a large sample of longitudinal UK data, to investigate whether the psychological distress experienced by the UK population was greater in response to COVID-19 compared to previously observed levels.

Methods

The authors analysed annual interview-collected data from 53,351 participants in waves 6-9 of the UK Household Longitudinal Study. Participants (N=42,330) in waves 8-9 were also invited to complete a COVID-19 web survey in April 2020, with 17,452 of those completing it.

The authors used the General Health Questionnaire – 12 (GHQ-12) to measure non-specific mental distress. Data collected also included various demographics. For the web survey two further variables were examined: key-worker status and receiving a National Health Service shielding letter.

The authors firstly described the levels of distress across different covariates in the web survey. Secondly, they performed multiple cross-sectional analyses to compare pre-COVID-19 mean distress scores to the mean GHQ-12 web survey scores. Lastly, they performed fixed-effects regressions to examine the effect COVID-19 had on mental distress scores after adjusting for the variables that significantly affected GHQ outcomes in unadjusted regressions. Finally, a sensitivity analysis was conducted to identify whether seasonality had an effect on the data.

Results

The mean GHQ-12 score in the COVID-19 web survey was 12.6 and the percentage of participants scoring above the threshold score indicating a clinical level of mental distress was 27.3%.

The GHQ-12 scores were higher for women (13.6), younger age groups (16-24: 14.7), Asian participants (13.7), people in London (13.3) and urban-based areas (12.8), lowest economic quantile (13.9), unemployed (15.0) or economically inactive (15.3), not living with partner (13.8), living with children (0-5 years: 13.7; 6-15 years: 13.4) and receiving a shielding letter (13.7).

Comparison between pre- and post- COVID-19

The repeated cross-sectional analyses showed that:

• Participants had higher average GHQ-12 scores in April 2020 (12.6; 95% CI: 12.5 to 12.8) compared to previous years (2018-2019: 11.5; 95% CI: 11.3 to 11.6), with this change being significant across both gender groups. The most notable increase was in men aged 16-24 and women aged 16-44.
• In line with expected annual trends, there was an increase in the proportion of participants scoring higher than the clinically relevant threshold GHQ-12 score in April 2020 (27.3% compared to 18.9% in 2018-2019). The increase was steeper than expected, with the highest increase witnessed in young age groups and women.

Comparisons adjusted for individual covariate effect

The fixed-effects regression analyses suggested that when adjusting for age, gender, income, employment status, living with partner, age of youngest child, and presence of underlying health condition, the participants’ GHQ-12 scores were 0.48 points greater than what they would have been according to expected trends, with the highest point increases noted in:

• Younger participants aged 18-24 (2.69) and aged 25-34 (1.57)
• Women (0.92) and no observed effect for men
• Participants living with children younger than 5 (1.45)
• Being employed (0.63) or in retirement (0.73)

No trend was observed for household income and the remaining variables were not independent predictors of effect differences.

Seasonality

The analysis (N=9,294) examining the effect of seasonality, suggested that COVID-19-associated increase in GHQ-12 scores was 1.13 points when previous data was limited to spring/summer months (April – August).

Conclusions

• The authors concluded there was an increase in the overall levels of mental distress amongst people aged 16 and older in the UK in April 2020, which was higher than the expected annual trends.
• This increase was not shared amongst all subgroups of the population and it is suggested that the differences will widen further as the pandemic continues, mainly due to the economic effects of the pandemic disproportionately affecting those with established health inequalities.
• The need for increased efforts to inform the public about the above findings as part of a mitigatory and management response is stressed.

Strengths and limitations

The study provided insight into the immediate effects of the pandemic on the levels of mental distress in the British population, by examining a large sample, while also controlling for temporal effects and established-in-evidence covariates affecting mental health outcomes. The rapid-rate at which the study was published also allows policy-makers to inform their actions by firstly reviewing the findings.

Nevertheless, an important variable that was not accounted for, was the sample’s history of mental health difficulties, which has been found to be a predictor of mental health response to disasters (Davidson, & McFarlane, 2006). The omission of this factor does not allow us to determine what extent of the increased mental distress is linked to an exacerbation of pre-existing symptoms. This could have also explained the increase in the level of people scoring above the clinical threshold score.

In addition to the above, the data collection occurred in late April with the study examining the immediate effect of the COVID-19 emergency. In past health-emergencies, an immediate stress response was observed which then subsequently subsided in the general population (North & Pfefferbaum, 2013). It is also worth noting that in April 2020 the UK saw its highest daily count of deaths from COVID-19 (Dong & Gardner, 2020). Potentially then, the effect observed in the study might not be indicative of the long-term mental health impact of the pandemic, but rather a normal response to a highly distressing and uncertain period. To address this, the authors could have collected further data at a later point in the pandemic to make further comparisons between the population’s levels of distress.

Implications for practice

Do the results suggest that COVID-19 will be both a physical and mental health emergency? The results from this study add to the growing evidence linking the pandemic to mental health problems, which have been systematically brought together in the Centre for Mental Health series on COVID-19 and the nation’s mental health.

In this study, younger participants had the steepest increase in their average mental distress score. This could be partly attributed to the groups’ more frequent social media use. Research has suggested an association between high frequency of social media engagement and increased prevalence of mental disorders during COVID-19, particularly amongst younger age groups (Gao et al, 2020). This implies that informing the public of the potential negative effects of prolonged social media use and benefits of monitoring this could act as a primary public health intervention for COVID-19-related-distress reduction.

Furthermore, the study provided insight on further research avenues. Namely, factors contributing to the increase in mental distress should be explored. This health emergency can cause anxiety around the potential health effects of the virus on the individual and their loved ones. Moreover, the public health response can result in limited social contact, increased levels of loneliness and uncertainty over future financial/employment circumstances. Deciphering which of the above are strongly associated with mental ill health can further direct decision-making in the domains of policy and influence.

The study is also valuable for mental health professionals in Improving Access to Psychological (IAPT) services, of which I am part of. Firstly, it acts as a reminder, particularly to us who work with diverse populations; this pandemic is not affecting everyone equally and we should consider wider social and cultural factors during assessment and treatment. Secondly, it indicates that we should increase efforts to inform the public of our services and equip them with evidence-based techniques to manage distress. Lastly, it suggests that we should adapt our available treatment options to address aspects of the pandemic such as the management of COVID-19 related stress.

Conflicts of interest

None.

King’s MSc in Mental Health Studies

This blog has been written by a student on the Mental Health Studies MSc at King’s College London. A full list of blogs by King’s MSc students from can be found here, and you can follow the Mental Health Studies MSc team on Twitter.

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Links

Primary paper

Pierce, M., Hope, H., Ford, T., Hatch, S., Hotopf, M., John, A., Kontopantelis, E., Webb, R., Wessely, S., McManus, S., & Abel, K. M. (2020). Mental health before and during the COVID-19 pandemic: a longitudinal probability sample survey of the UK population. The Lancet Psychiatry, 7 (10), 883-892.

Other references

Davidson, J. R., & McFarlane, A. C. (2006). The extent and impact of mental health problems after disaster. Journal of Clinical Psychiatry, 67(Suppl 2), 9-14. [PubMed abstract]

Dong E, D. H, & Gardner L. (2020). An interactive web-based dashboard to track COVID-19 in real time. Lancet Infectious Diseases, 20(5), 533-534.

Gao, J., Zheng, P., Jia, Y., Chen, H., Mao, Y., Chen, S., Wang, Y., Fu, H., & Dai, J. (2020). Mental health problems and social media exposure during COVID-19 outbreak. Plos one, 15(4), e0231924. [PubMed abstract]

Hawryluck, L., Gold, W. L., Robinson, S., Pogorski, S., Galea, S., & Styra, R. (2004). SARS control and psychological effects of quarantine, Toronto, Canada. Emerging infectious diseases, 10(7), 1206.

Mak, I. W. C., Chu, C. M., Pan, P. C., Yiu, M. G. C., & Chan, V. L. (2009). Long-term psychiatric morbidities among SARS survivors. General hospital psychiatry, 31(4), 318-326. [PubMed abstract]

North, C. S., & Pfefferbaum, B. (2013). Mental health response to community disasters: a systematic review. JAMA, 310(5), 507-518. [PubMed abstract]

Zhang, Y., & Ma, Z. F. (2020). Impact of the COVID-19 pandemic on mental health and quality of life among local residents in Liaoning Province, China: A cross-sectional study. International journal of environmental research and public health, 17(7), 2381. [PubMed abstract]

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