What’s the post-pandemic plan for mental health?
On May 11th, World Health Organization (WHO) officials stated that COVID is no longer a global health emergency, marking a symbolic end to the pandemic. WHO Director-General Tedros Adhanom Ghebreyesus said “That does not mean COVID-19 is over as a global health threat. COVID-19 has changed our world and it has changed us,” he said, warning that the risk of new variants remained.
But what about the fallout? writes Maya Bizri, MD, MPH, Disaster psychiatrist and founding director of psycho-oncology at the American University of Beirut Medical Center in Lebanon
Any global crisis, war zone, or disaster creates far-reaching mental health ramifications beyond the immediate crisis care – for emergency workers, those directly affected, and families and friends of victims and patients at least. Not just geographically, the trauma-induced effects cross all boundaries and have left a lasting crisis looming. Last December, the World Health Organization said one in five people in countries that have experienced conflict in the past decade will suffer from a mental health condition – so what is the post-pandemic plan for mental health?
When we see any ‘mass catastrophe’ which includes war, a public health emergency, or a natural disaster such as a hurricane or an earthquake, we see rates of mental illness such as anxiety, depression, and PTSD – whether a new-onset or the worsening of a pre-existing condition – increase.
As we have all moved forward with our lives post lockdowns and a seemingly ‘return to normal’ our collective mental health is still very much in disaster recovery.
The part that is seemingly missed and relevant to the post-pandemic era are the subsyndromal states – These are the reactions that are not necessarily pathological or disordered, but they’re extremely impairing. The term for the work my colleagues and I serve in these instances is ‘disaster psychiatry’, and for many patients, the stress may not be related to the disaster itself, but the post-disaster chaos that we are left with. Disaster stress behaviours have significant long-term outcomes – and these are the things that will affect us most going forward – from an increase in smoking habits, increased substance use, chronic irritability or even overwork used as a response mechanism. To this end, as a society, the effects of the pandemic on mental health will continue to be felt.
In regions made up of majority expatriate residents, disasters or occurrences in their home countries bring their challenges to those abroad – directly and indirectly, separate from witnessing suffering first-hand, the effects are still acutely felt.
During the pandemic itself, the global prevalence of depression increased by 25%. Documented levels of anxiety were up by 30%. In the U.S. four in 10 adults were reporting these symptoms. One reason for the increase in unprecedented stress was the major social isolation, the constraints on people’s ability to work, seek support from loved ones and engage in their communities. Other stressors were loneliness; fear of infection; fear of suffering; fear of death, whether that’s on you or your loved ones; grief after bereavement; but also, financial stress. Wouldn’t it be great if an official organisation could downgrade these ‘ailments’ too?
Frontline workers have their mental health challenges triggered by both trauma and exhaustion. Essential workers, healthcare workers and those directly affected by Covid-19 face a sense of moral injury. It’s a specific condition that is not just dealing with trauma, but also dealing with the dilemma of worrying about being a vector and carrying the infection back to your loved ones, and also providing adequate care and doing something that would not be aligned with your moral values or your ethical compass.
We must keep in mind how many people are still grappling with worsened mental health and well-being and still facing barriers in accessing mental health care and support. The most recent survey in 2023 among U.S. adults showed that 90% still believe that 3 years into the pandemic, there is very much a mental health and substance use crisis – and this is seen amongst the rest of the world also.
Other at-risk groups in society are women and young people. Self-harm behaviour among adolescents increased – more alarming when access to mental health services has become more difficult. Health care has been focused on treating those with direct Covid-19 infections and associated treatments, and functioning at full capacity and beyond. We found in our Beirut-specific study that adolescents were dealing with different pandemic-related consequences. They had the closure of universities, they had to switch to remote work, they had a loss of income or employment, and that of course, will contribute to poor mental health.
For children, we have seen an expansion of school-based mental health services in response to the growing mental health concerns. This is now part of the conversation globally as we understand the impact specifically on this demographic – so as a byproduct, we need to properly invest in these programmes, support and opportunities even further. We found more anxiety disorders in women, and we know that globally women have been hit harder than men with a loss of income and job security. With that comes the stressors of future employment amongst changes in economic conditions.
People who have chronic medical problems – including heart disease or asthma, were naturally worried more about being infected, and that health anxiety has often stayed, exacerbated by a lower access to healthcare provision over the past three years.
Alcohol-induced death rates also increased by 38% during the pandemic. Reliance on substances as an addiction doesn’t end with a WHO downgrade – it’s a legacy we have to address.
And we reach the wider issue – Long COVID. It’s not just the psychological responses to catastrophes and the pandemic, but COVID itself as an infection. Professionally, we still are not sure of the mechanism behind Long COVID. We know it exists, we know it persists for 3 months or returns after an infection with fatigue and shortness of breath, but also as a cognitive impairment that occurs in thinking and memory described as a ‘brain fog’. This impairs productivity and can overlap in people who have developed what we now call post-ICU syndrome. It can be extremely debilitating without you specifically having depression or anxiety.
With the major disruption in access to care for much of the pandemic, services for mental, neurological and substance use conditions were most affected. Many people have sought support online, and via ‘telemedicine’ and the growth here is positive. However, we also have unequal access to technology and services, so it also increases inequality globally in terms of access to care.
According to the WHO’s most recent survey, 90% of countries are working to provide mental health or psychosocial support not just to COVID-19 patients but also to responders. There is still a global shortage of mental health resources, as we saw before the pandemic, and it is even worse after. On average, governments spend just over 2% of their health budgets on mental health, and much less in lower- and middle-income countries.
One thing we have to learn from this pandemic is the sense of hypervigilance or hyper-alertness in terms of disaster preparedness. This was only a warning, there is bound to be another pandemic. For disaster preparedness, we have to make mental health more of an essential service, not just a secondary service or something that is an afterthought. It has highlighted the inequity in terms of accessing health care, whether it’s for younger people, minorities and those without financial means. We have to do a better job in providing access to health care, even before the next disaster strikes.
