Hello everyone, thank you very much for inviting me to give a talk at this Kenya Psychiatric Association meeting on the Impact of COVID-19 on mental health.
First, I would like to introduce myself to you. My name is Graham Thornicroft and I am a professor of community psychiatry at King’s College London.
In the plan of this meeting, I would like to tackle three issues. Firstly, briefly, the global context of mental health, secondly, the mental health impacts direct and indirect of covid-19 pandemic and thirdly, some of our required actions.
First of all, the wider context. And I’m going to talk about two particular gaps or treatment gaps, first in relation to the quantity of treatment and care provided. Here we can see data from the world mental health surveys, looking at how far people with three particular conditions; depression, anxiety, and substance disorder actually receive treatment. In the dark blue columns, you can see high-income countries, and in the light blue columns, low and middle-income countries. And the overall picture is clear, between 10 and 20 percent of people with these conditions in the rich countries of the world, do get treatment. And perhaps, one-two-three or four percent of people with these conditions get treatment in low-income countries. So the bigger picture is that we manage not to treat the large majority of people with mental illness in every country in the world, but also we need to think about the quality of care that is provided where and when it is provided. This is an example from one country in my own region in Europe, and this is the sort of exercise area of a large psychiatric hospital. And we can see, I think that none of us and I think perhaps none of our family members we would want to have treated in these prison-like conditions. So we have two huge challenges; the quantity and the quality of care being provided for people with mental illness. So it’s in this context I’d like us to think about the impacts during this year, in 2020 of the COVID-19 pandemic. I’m going to revert to sources from a couple of recent papers I’ve done with colleagues. This first one is about the impact upon communities and this the impact more specifically on people in low and middle-income countries written with my colleagues Daniel Vigo from Canada and Oye Gurejey from Nigeria.
And I’ll cover the impacts under these four main headings.
First, on the general population. Second, people with pre-existing mental illness. Third, first responders and health care and staff directly providing services, and fourth, the impacts on people who are or who have been infected by COVID-19. So let’s think first about the general population, well certainly in many countries in my region in Europe and I think elsewhere in the world. We’ve seen manifestations of what’s sometimes called health anxiety stockpiling, sometimes it’s pasta or rice or dry goods or milk powder. Sometimes it’s toilet vapors on but also increase over time as the mortality rate rises, the mental health consequences of grief, loss, sometimes multiple griefs. Many people also find that the uncertainty caused by the pandemic for example, in terms of a lockdown or reduced social and economic opportunities causes symptoms, that we would perhaps recognize as those of common mental disorders. So, more anxiety, more depression, more insomnia, more irritability in the general population. And now we’re beginning to see papers showing increasing rates of common mental disorders overtime during this year, also in some certainly in European countries it’s been found that there are increasing rates of alcohol use among those who already were using alcohol pre-pandemic. But it seems to me that the bigger story, is actually the impacts of economic recession and austerity over time indirectly, which may come to be seen as dwarfing the direct mental health implications. Now it’s interesting that the pattern of spread has been really quite different in different types of countries. We can see here for example, that the uptick of the cases surged certainly in my country. But then began much more slowly for example, in India but then rapidly accelerated later on. So it’s very difficult to generalize across countries and I’m not familiar with the situation in Kenya so I won’t attempt to overgeneralize. From my own experience, what we do know however from data from different countries published by the United Nations, is that although there are some variations, there are some big picture findings. For example, on rates of distress within the whole population, here between one and two-thirds of the whole population, different countries showing distress measured in the first three to four months of the pandemic by the UN.
Secondly, response with respect to young people also important changes in their experience and these again from different countries like Italy and Spain. Some of the earliest countries to have severe effects, looking at the impact on children and remarkably three-quarters reported difficulty in concentrating. Remembering that these schools were by then closed and so this is perhaps an implication both of the generalized anxiety of uncertainty, but also the conditions of being away from school. So I mentioned that we’re seeing data beginning to emerge now, of rates increasing over time during the last six to eight months. This is one example published just a few weeks ago in BMJ Open, I’m looking at data from the UK where they found increasing rates of common mental disorders, especially in young people; women, and people positive for COVID-19. Interestingly in this study, a population-based study, they didn’t find increasing rates of continental disorders in older adults, and this is the I think my main concern at the moment.
Which is if we will see in the next few years, increasing rates of suicide, because of the economic impacts of this pandemic. We can see here data from my own country, which shows that it’s men much more likely to commit suicide or die by suicide than women. And i know from working with your colleague Mary Britta from Kenya recently, that also there’s a very great concern about male suicide rates in Kenya at the moment. So it seems to be that it’s people who become unemployed, also those in insecure employment and those who fear who they may use lose their jobs or their livelihoods. This seem to be one of the risk groups of developing death by suicide during a period of economic difficulty, and indeed the suicide expert Stukler and Basu said ‘’recessions can hurt, but austerity kills’’.
And the second main heading is the impact of covid on people with pre-existing mental illness i.e before the start of the pandemic, and here we can see a number of issues. Firstly, because of the increased rates of physical comorbidities among people with severe mental illness. It, therefore, follows that such people are themselves at higher risk of having a severe infection and poor or worse outcomes if they do become infected. They’re also at risk of being neglected whether through neglect or social isolation or lack of support, and we have evidence now accumulating from many countries that mental health services are decommissioned or asset stripped as healthcare is moved rapidly into the covid response. So we may see fewer for example; hospital beds, outpatient clinics, or staff working in mental health care facilities added to which may be interruptions or even great interruptions to the supply the logistical supply chains for medication for people needing ongoing psychoactive medications. What about the carers? about staffs? Thinking not just of healthcare staff, but also those providing social care and support and other essential supplies such as people in grocery shops or drivers supplying food and other essential supplies well. We also see data emerging in many countries that there is a high rate of burnout and common mental disorders in these groups including, post-traumatic stress disorder:- where they have been working in very difficult conditions for long periods often without much break, or without holidays.
There’s also this concept called moral-hazard, which means the discomfort and the mental stress of having to make decisions for which, one is unprepared or untrained. For example, which groups to prioritize to get access to oxygen, or intensive care, or ventilators, or other scarce resources. And because of the relative lack of these specialist facilities to aim to prove prolonged life in people most severely affected by covid. Some of these stresses may be all the greater in low and middle-income countries.
What then about the effects on the mental health of people who are infected or who have been infected? What we’re just beginning to see how to develop this concept of long or long-term covid including months and perhaps longer of fatigue disorientation, mild symptoms of distress and delirium in some cases, and more generally it’s true that there seem to be higher rates of anxiety and depression and OCD, including people who’ve been ventilated or temporarily put into induced comas. Who then have disorientation as they may come around and recover.
There’s also because of the polymorphous nature of the virus, other system implications, for example, renal damage, hepatic damage, brain damage, and cardiac damage which can have impacts upon mental health. Where there are people in isolation or in quarantine or deaths in the family, then people may also have reduced networks for social support just at the time when these are most needed. And we’re seeing as well examples from around the world of stigmatization, social exclusion, shunning of people either with the infection, or who have had the infection, or people who are suspected of having any contact with the virus including healthcare staff.
This is an example from Spain the woman is holding up a sign. She’s being treated in a socially excluding way by people in Spain because she’s Chinese and she’s holding up a sign saying “I do not have coronavirus”. We can see here a literal stamp or stigma of a person in India who has been his home-quarantined, so it’s quite clear if they should be outside the house or not. And we’ve also seen claims that covid has been described as the China virus and so on. Grossly stigmatizing against specific ethnic groups.
So in the last part of this talk, I want to say a little bit about what we might want to do positively to reduce the mental health impacts. And we’ve seen in some countries including my own, opinion leaders influence whatever we might say taking a strong view about supporting people, who have mental health problems sometimes called, the Invisible Epidemic because the physical problems are much more clearly recognized. And I think we’ve seen a helpful intervention as well from the United Nations including, The World Health Organization and here is Antonio Guterres, who is the Secretary-General of the United Nations a new report. Now, one has to be rather cautious here because some of the measures designed to reduce the impact including, reduce the mental health impact of the pandemic may be difficult or even much more difficult in low and middle-income countries. So, for example, if one is living in an informal settlement or a slum then the idea of maintaining a meter or two-meter social distancing may be simply impossible. But also the idea that you might take a week or two in isolation or quarantine away from work, again is essentially impossible in a subsistence economy where people may need to work day by day to be able to survive. So one’s got to adapt these general rules very specifically to the particular context.
The most helpful document I think coming from the United Nations is one published in May called COVID-19 and the Need for Action on Mental Health. You can see here the three main headings, apply a whole of society approach. Secondly, ensure widespread availability of emergency mental health and psychosocial support and three support recovery. So I’ll say a little bit about each of these before we finish. First then a whole of society approach, means that the national covid response or recovery plan must include mental as well as physical health components. It needs to think about some of the implications of lockdown where that happens. For example, rates of domestic violence and mitigation and support in relation to that. But also ways to communicate clear understandable messages to the whole population that do not cause confusion or anxiety, and which are easily understandable as the population or segments are asked to take quite exceptional measures such as lockdowns. Number two, availability of emergency mental health and psychosocial support. We know from other emergencies, for example, the Tsunami, and Aceh, and so on that most of the population who have distress in a crisis whether it is man-made or not, will show resilience and recover within the year with normal social and community supports. So one shouldn’t rush in too quickly to do emergency debriefing and so on. On the other hand, those who have symptoms for example of PTSD you know a year after the event or the trauma certainly may need psychosocial support being delivered quite often by lay or perhaps non-governmental organizations, to provide the help required. Including a clear focus upon the human rights of people in this case, perhaps people with severe mental illness. Then also hard affected by the implications of the covid pandemic, and there’s a question of inclusion, not exclusion very much in line with the requirements of the sustainable development goals.
Let me come on to the longer-term looking forward, and the key concept here is that which has been developed by WHO and by the United Nations of Building Back Better. So what does it mean to Build Back Better? Well, it means thinking not just about the short-term response and what can one do in the crisis, but can one change the pattern or the shape of the service, learning from what’s happened during the crisis so that the service later is actually better than it was before the crisis. And one example here is the use of remote consulting. Now, in many countries low or medium or high-income countries, there’s been a remarkable rapid transfer from in-person consultations to remote types of video, or phone, or social media, or other, and chat lines, and so on. Text messaging consultations then make the locus, the place of the patient or the doctor, and so on, or the nurse largely immaterial. It’s much more a question of access if there’s a digital divide or people can’t get access to such support; Upon the availability of the help, upon the fee structure tariff rates and so on and whether help is actually given in a professional way. And for many purposes, remote consulting is appearing to be quite a good substitute for many clinical functions not all, not for crisis assessment, not for initial assessments of patients in many cases, but this opens up a huge opportunity for scaling up services for people especially in remote and rural areas which we weren’t using before the pandemic. So if you’d like to know more about these so-called systems or systemic implications, this is a paper that has just come out a few weeks ago published in the International Journal of Mental Health Systems, talking about involving a wider range of supports including not for profit, informal, social and community, and school groups and so on. Outside of the formal health sector to give the support necessary especially for vulnerable groups, those isolated, those bereaved, those lonely, and so on. And for more information about the bigger picture about a vision of the future of mental health care, in low and in middle and in high-income countries, then this lancet commission on global mental health, and sustainable development is one that you may find interesting and useful.
So to summarize, in this talk I want to say a little bit about the context of the qualitative and quantitative mental health gap that we all face, in every country in the world. Secondly, about some of the impacts in these four categories that we’ve gone through, the impacts of COVID-19 in relation to mental health, and then some of the required action especially highlighting this United Nations report. It’s been described as the hidden covert crisis because so far we haven’t heard nearly enough, about the mental health implications. About the mental health impacts of the pandemic, indeed some colleagues in China have published the idea that it’s a parallel epidemic running to have these huge mental health destructive impacts alongside at the same time, as the physical health impacts of the pandemic.
So on that note, I would like to finish the talk if you’d like more information about this or some of the papers I’ve mentioned, please do contact me and here is my email address. So I’d like to wish you all well for this difficult period and I hope your meeting goes very well, and I hope you and your families stay safe and we can get through this terrible pandemic period. Thank you and goodbye.