WHO Mental Health and COVID-19 PDF

Mental Health and COVID-19: Scientific brief Mental Health and COVID-19: Early evidence of the pandemic’s impact Scientific brief 2 March 2022 Introduction The COVID-19 pandemic has had a severe impact on the ment...

Mental Health and COVID-19: Scientific brief Mental Health and COVID-19: Early evidence of the pandemic’s impact Scientific brief 2 March 2022 Introduction The COVID-19 pandemic has had a severe impact on the mental health and wellbeing of people around the world (1). While many individuals have adapted (2), others have experienced mental health problems, in some cases a consequence of COVID-19 infection (3–5). The pandemic also continues to impede access to mental health services and has raised concerns about increases in suicidal behaviour (6). The aim of this scientific brief is to present current evidence regarding the mental health aspects of the pandemic and inform prevention, response and recovery efforts worldwide. The target audience includes health care providers, researchers, policy- makers and any other stakeholders interested in the evidence on COVID-19 and mental health. Key questions This scientific brief provides a comprehensive overview of the current evidence about: 1. the impact of the COVID-19 pandemic on the prevalence of mental health symptoms and mental disorders 2. the impact of the COVID-19 pandemic on prevalence of suicidal thoughts and behaviours 3. the risk of infection, severe illness and death from COVID-19 for people living with mental disorders 4. the impact of the COVID-19 pandemic on mental health services 5. the effectiveness of psychological interventions adapted to the COVID-19 pandemic to prevent or reduce mental health problems and/or maintain access to mental health services. Each question is addressed in a dedicated section of the brief. Key findings are highlighted at the end of each section to summarize the data described therein. Process and methodology Because WHO Global Health Estimates for frequency of mental disorders are aligned with Global Burden Disease study estimates, the brief summarizes recent estimates of the Global Burden of Disease 2020 study (7). This brief is also based on evidence from research commissioned by WHO, including an umbrella review of systematic reviews and meta-analyses (published up to October 2021) (8) and an update to a living systematic review (updated to September 2021) (9), and other relevant WHO publications (10-12). Literature searches in commissioned reviews were not restricted by language. Research evidence Prevalence of mental health problems: GBD 2020 The GBD 2020 (7) estimated that the COVID-19 pandemic has led to a 27.6% increase (95% uncertainty interval (UI): 25.1–30.3) in cases of major depressive disorder (MDD) and a 25.6% increase (95% UI: 23.2–28.0) in cases of anxiety disorders (AD) worldwide in 2020. Overall, the pandemic was estimated to have caused 137.1 (95% UI: 92.5–190.6) additional disability- adjusted life years (DALYs) per 100 000 population for MDD and 116.1 per 100 000 population (95% UI: 79.3–163.80) for AD. The greatest increases in MDD and AD were found in places highly affected by COVID-19, as indicated by decreased human mobility and daily COVID-19 infection rates. Females were more affected than males, and younger people, especially those aged 20–24 years, were more affected than older adults. Many low- and middle-income countries (LMICs) were also majorly affected. Limitations GBD 2020 prevalence rates are based on statistical modelling from survey data. The variable quality and availability of these data can lead to over- or under-estimates and uncertainties. Additionally, the GBD study identified few studies from LMICs. Therefore, estimates are based largely on data from high-income countries and may generalize less to these settings. Further, the large uncertainties around estimates may also be related to the limited high-quality data from many LMICs (13). Finally, GBD 2020 also has yet to publish data on disorders beyond MDD and AD and concern only the first year of the pandemic. Prevalence of mental health problems: umbrella review From an initial 46 284 records, the umbrella review identified 577 systematic reviews with or without meta-analyses. These were full-text screened for eligibility. Eligible papers were quality assessed according to AMSTAR-2 (14). In total, 480 reviews were excluded for key question one assessing the impact of the COVID-19 pandemic on mental health, retaining 97 systematic reviews of primary studies with longitudinal, cross-sectional or time-series designs. From these, only meta-analyses published in 2021 were selected, to examine the most up to date evidence. In total, 21 meta-analyses were eligible for assessing the impact of the -1-  Mental Health and COVID-19: Scientific brief COVID-19 pandemic on mental health in the general population, 32 in healthcare workers and 26 in other specific populations. Only three meta-analyses gave pooled effect estimates comparing prevalence of mental health problems before to during the pandemic or during implementation of public health and social measures (PHSMs) (15-17). Table 1 provides selected outcomes. In the general population, Robinson et al (15) reported a small but statistically significant overall increase in mental health symptoms during March-April 2020 compared with pre-pandemic measures (standardized mean change (SMC): 0.10). This declined over time and became non-significant by May-July 2020 (SMC: 0.07). Increases in symptoms of depression and mood disorders remained significant over time (March–April SMC: 0.23 and May–July SMC: 0.20); but those for anxiety did not (March–April SMC: 0.14 and May–July SMC:0.05) (15). Kunzler et al. (17) also found a moderate symptom increase in the general population for depression (standardized mean difference (SMD): 0.67) and a small but significant increase in symptoms of anxiety (SMD: 0.40). Prati & Mancini (16) found that early implementation of PHSMs in 2020 also led to small but significant increases in symptoms of anxiety and depression in the general population (Hedges’ g: 0.17 and 0.15, respectively). An additional 19 meta-analyses examined mental health in the general population through cross-sectional studies; however, their interpretability is limited by their lack of baseline comparison data. For health care workers, only cross-sectional studies were carried out. One meta-analysis compared cross-sectional data on prevalence of symptoms of anxiety and depression in health care workers during the pandemic with prevalence rates from matched pre-pandemic studies and found no increase (SMD: -0.08 and -0.16, respectively) (17). An additional 31 meta-analyses examined cross-sectional studies of health care workers, but, interpretability of these studies is limited by their methodology. For other specific populations, only 2 out of 26 eligible meta-analyses reported changes in mental health symptoms based on either longitudinal data or a comparison of pandemic with pre-pandemic cross-sectional prevalence rates from matched studies. The first (15) found no increase in mental health symptoms for people with pre-existing mental disorders (SMC: -0.02); non-significant increases for university students and children and adolescents (SMC: 0.13 and 0.11, respectively); and a significant increase for people with pre-existing physical health conditions (SMC: 0.25). The second (17) also found small but non-significant increases in symptoms of anxiety and depression in populations of patients with COVID-19 (SMD: 0.31 & 0.48, respectively). However, pre- pandemic data was from only four studies while pandemic data was from a mixed population that included both people with COVID- 19 and those with physical and mental health conditions. In all other meta-analyses on specific populations, the pooled prevalence rates ranged widely and were difficult to interpret. Two meta-analyses in children and adolescents (18,19) reported relatively similar pooled prevalence rates of elevated levels of depression (1 in 4) and anxiety (1 in 5) and showed that symptoms, particularly depression, were higher in older children and adolescents, among girls, and greater over time. For specific populations experiencing post-COVID-19 condition, no eligible reviews were identified during the umbrella review. However, after completion, a potentially eligible systematic review and meta-analysis (20) was published that reported pooled prevalence rates of persistent mental health symptoms, such as anxiety and post-traumatic stress symptoms, in COVID-19 patients after an average follow-up duration of 77 days post recovery. Two studies in the review compared control groups to COVID-19 patients and indicated that mental health symptoms were elevated among COVID-19 patients. Across all studies in the review, there was no difference in mental health symptom prevalence among COVID-19 patients based on hospitalization status, infection severity or follow-up duration. To date, many challenges exist in the literature regarding mental health aspects of post-COVID-19 condition, such as limited studies with active control groups to attribute symptoms to COVID-19, inconsistent definitions of post- COVID-19 condition and varying participant selection criteria. Table 1. Pooled effect sizes of meta-analyses including a change or comparison with pre-pandemic prevalence Variables Population Studies Comparisons Pooled Pooled 95% CI (n) (n) sample size effect* change Mental health problems Before vs. during pandemic (15) Mixed 61 165 55 015 0.11 0.04 to 0.17 Before vs. during pandemic (15) General 75 0.12 0.04 to 0.19 Before vs. March–April 2020 (15) Mixed 98 0.10 0.03 to 0.19 Before vs. May–July 2020 (15) Mixed 67 0.07 -0.02 to 0.16 Before vs. during pandemic (15) Pre-existing physical 14 0.25 0.07 to 0.43 Before vs. during pandemic (15) Pre-existing mental 25 -0.02 -0.21 to 0.18 Before vs. during pandemic (15) University students 40 0.13 -0.01 to 0.27 Before vs. during pandemic (15) Children/adolescents 38 0.11 -0.03 to 0.26 PSHM vs. no PHSM (16) General (adult) 20 72 004 0.17 0.07 to 0.26 Anxiety Before vs. March–April 2020 (15) Mixed 29 0.14 -0.02 to 0.30 Before vs. May–July 2020 (15) Mixed 23 0.05 -0.04 to 0.14 PHSM vs. no PHSM (16) General (adult) 10 0.17 0.07 to 0.27 Before vs. during pandemic (17) General 23 49 746 (p) 0.40 0.15 to 0.65 132 145 (c) Before vs. during pandemic (17) Health care workers 13 5 508 (p) -0.08 -0.66 to 0.49 22 204 (c) Before vs. during pandemic (17) COVID-19 patients 6 1 845 (p) 0.31 -0.07 to 0.69 12 458 (c) -2-  Mental Health and COVID-19: Scientific brief Depression Before vs. March–April 2020 (15) Mixed 32 0.23 0.11 to 0.34 Before vs. May–July 2020 (15) Mixed 26 0.20 0.10 to 0.30 PHSM vs. no PHSM (16) General (adult) 9 0.15 0.01 to 0.30 Before vs. during pandemic (17) General 25 60 213 (p) 0.67 0.07 to 1.27 183 747 (c) Before vs. during pandemic (17) Health care workers 14 2 226 (p) -0.16 -0.59 to 0.26 4 605 (c) Before vs. during pandemic (17) COVID-19 patients 7 1 461 (p) 0.48 -0.08 to 1.04 21 934 (c) * Pooled effect = SMC (15), Hedges’ g (16) or SMD (17); (p) = pandemic participant; (c) = control participants. Bold represents significant effects. PHSM = Public health and social measure. Limitations There is a lack of studies with longitudinal designs. Most of the eligible meta-analyses were rated as low quality, with a high risk of bias. Prevalence rates were also often based on diverse screening tools that were not always validated and use different cut-off scores to reflect mild, moderate or severe symptoms, which makes rates across studies difficult to interpret. Importantly, meta- regression analyses also revealed that studies with high risk of bias often yielded higher prevalence rates. Also, few studies examined mental health problems among people with post-COVID-19 condition and none of the eligible systematic reviews or meta-analyses examined mental health problems among certain groups of interest, such as people living in psychiatric institutions or refugees and other migrants. Key findings There was a significant increase in mental health problems in the general population in the first year of the pandemic. Though data are mixed, younger age, female gender and pre-existing health conditions were often reported risk factors. Further research on mental health and COVID-19 among specific at-risk populations and in LMICs is needed. Suicide Suicide mortality The update to an ongoing living systematic review of the impact of the COVID-19 pandemic on self-harm and suicidal behaviour (9,21) identified 51 time-series studies or reports comparing national or subnational suicide rates before and during the COVID-19 pandemic to answer key question two of this brief. The most comprehensive assessment carried out an interrupted time series analysis of monthly trends in 21 countries (22). None of these countries reported evidence of an increase in suicide rates in the first four months of the pandemic (April–July 2020); and there was evidence of a fall in rates in 12 countries. By the end of October 2020, areas in another three countries showed a drop in suicide rates (Mexico City, Mexico; Thames Valley, United Kingdom of Great Britain and Northern Ireland; and Victoria, Australia) while there was evidence of suicide rate increases (5– 31%) in Vienna, Austria, Japan and Puerto Rico. Other studies reported a drop in suicide mortality in Guangdong Province, China (23), New Delhi, India (24), and the United States of America (25); no change in rates was reported in Victoria Australia (26); and a rise in rates was reported in West Bengal, India (27). There are few studies from LMICs (9,22). Following the update to the living systematic review discussed here, a systematic review of studies from LMICs was published (28) and found only 22 studies, the majority of which were low-quality, with no data from Africa. Time series analyses from seven countries provided the most robust evidence and indicated no change or decreases in suicide deaths. However, of note, two studies published after the update reported national suicide mortality data from two LMICs, Nepal up to June 2021 (29) and India up to December 2020 (30), and demonstrated increases in suicide mortality in those settings. Studies on sex and age differences showed mixed results. In Japan, the rise in suicide rates after July 2020 was greatest in young women (aged