How Policymakers Responded to Mental Health Issues During the COVID-19 Pandemic
By Professor Sir Geoff Mulgan, Engagement Lead and Co-Investigator of IPPO and Professor Muiris MacCarthaigh, Policy Engagement Lead for Northern Ireland, with contributions from the wider IPPO team.
This paper accompanies a systematic evidence review carried out during 2022 by the EPPI centre for the International Public Policy Observatory (IPPO) on the nature and extent of mental health issues arising during the pandemic and the evidence on the effectiveness of mental health interventions delivered at-scale.
This work has been supported by an advisory group chaired by the Mental Health Champion for Northern Ireland, Professor Siobhan O’Neill, and provides a brief overview of the policy context across the UK and internationally.
Why population mental health has risen up the agenda
IPPO started this systematic review by asking how a society can improve its collective mental health and what are the options available to a government, a city, a foundation, an employer or a charity addressing the many challenges of population mental health.
Such questions have reached unprecedented prominence in the context of COVID-19.
The United Nations estimates that over a billion people worldwide now suffer with some sort of mental health issue. As social acceptance and awareness about the challenges of mental health have grown, governments have become more concerned about wellbeing and investing in population mental health measures, although as recently as September 2022 the World Health Organisation suggested responses globally are insufficient and inadequate. In the US there is evidence of a significant upwards trend of those suffering acute mental distress, especially less educated whites.
The Office for National Statistics (ONS) started systematically measuring wellbeing in the UK in 2010. Large-scale programmes providing access to CBT began in the previous decade and then cointinued to scale up, benefiting from significant investment in evaluations that showed their potential impact. Other countries created ministers for happiness and the UK for a time even had a minister for loneliness.
The pandemic pushed these concerns to the fore as never before. It soon became clear that lockdowns would have a big impact on many, fuelling anxiety and depression in particular, and especially amongst teenagers.
In 2021, responding to the interests of governments across the UK, IPPO started to address these issues in relation to both young people and the elderly in care homes, whose chances to socialise had been severely restricted. We published a range of overviews, blogs and held events linking researchers, policy-makers and civil society that addressed different dimensions of population mental health, including a roundtable with IPPO Cities on Mental Health in the City.
This work and feedback prompted us to launch a full systematic review in collaboration with the EPPI Centre at University College London (UCL). The key question we wanted to answer was how to improve mental health not just of the 1-2% of the population requiring the most acute help, but also of much larger proportions of the population in need of various forms of support. We were also interested in the issue of mental health intervention scalability, an issue that has also received increased global attention. These took us to a series of challenging questions.
How could governments help to provide direct, face-to-face therapy of different kinds, including the kind of CBT provision that had dominated policy in the last fifteen years? Usually, the key challenge here is the lack of trained people – so attention soon turns to how to both grow and speed up training while retaining quality.
In the era of digital connectivity, there is also now great interest in the role of digital tools in mental health service delivery. What works, why and for who? Use of digital tools has been steadily growing through the 2010s, with more than 10,000 apps now on the Apple and Google Play stores claiming to treat psychological difficulties. This growth accelerated fast during the pandemic with the advantage that digital tools, such as TogetherAll, ReachOut, 7 Cups, Stand, are easy to access and there is no stigma in using them. But their disadvantage is that there is still only thin evidence on whether they work or to be more precise who they work for and when.
We were also interested in improving peer to peer support; what works best in encouraging people to help each other? What should be the role for schools in spotting needs, supporting young people or referring them? What role for others like care homes? And how could we make the workplace more supportive: are mental health first aiders the answer or an exercise in kickboxing, for example?
These are questions being addressed all over the world, partly in response to public demand but also as the wider consequences and costs of not addressing them are realised. For example, the International Labour Organisation and World Health Organisation have jointly called for greater attention to be given to the mental health concerns of the working population. A global poll earlier this year showed a big shift towards recognising mental health as just as important as physical health. The UK came top with 76% saying that mental health is an illness like any other.
Everywhere there are signs of a generational shift. Globally a quarter (25%) of 16-34-year-olds think about their mental health very often – the most of any age group, and more than twice the rate of the elderly.
Policy makers are running to catch up. The state of Victoria in Australia ran a Royal Commission just before the pandemic, which made 65 recommendations about, amongst other issues, the governance and delivery of population mental health measures. Around the world many places are experimenting with new approaches. Trieste in Italy, for example, has experimented with an interesting model moving away from the coercive models of locked in-patient wards to more support in the community, including emergency overnight beds, and trying to link support to things like employment.
There is growing interest in measurement (some led by the OECD that pioneered the earlier wave of wellbeing measurements in the 2000s), and there is also increased interest in collective mental health, and the role played by companies.
The professional bodies have increasingly worked to synthesise evidence. For example, the Royal College of Psychiatrists and the Public Mental Health Implementation Centre produced a summary of evidence on public mental health interventions in June 2022 which found positive evidence on interventions for children, prevention programmes, that both poor quality employment and unemployment have serious negative effects, that exercise is good, and that simple signposting services are effective to reduce social isolation and loneliness in older people.
Many other issues are also in play in relation to scaling up action on mental health: the role of community peers, the use of psychedelics, particularly psilocybin, and the design of cities and buildings. The WHO suggests a framework for policy-makers to transform their mental health services based on better appreciation of the issue and associated public investment; reshaping our physical, social and economic environments to better facilitate mental health issues; and strengthening mental health care in general.
That is easier said than done, and for now there is much thinner evidence on mental health than there is on physical health interventions.
However, the IPPO Systematic Review shows that there are clear lessons in relation to the provision of CBT for different purposes and in different contexts, such as schools; in relation to online services; and in the community. These findings are summarised in this policy briefing [LINK] and set out in more detail in the full report [LINK].
Our hope is that this work will contribute to what is a much longer-term shift to growing a mental health care system that is as developed, rich in evidence and sophisticated as the system we depend on for our physical health.
COVID-19 and policies across the UK
When governments acted decisively to contain the spread of the COVID-19 virus there was relatively little focus on population mental health, understandably given the speed and danger of the pandemic. But it soon became clear that significant numbers were suffering from depression, anxiety and loneliness and that these would become significant costs of the pandemic. Since then, many studies have confirmed that the prevalence of mental health problems grew during the pandemic.
However, it was less clear what governments should do, or how they should weigh up the potential impacts of lockdowns on mental health. While they had access to good data on infections, hospital admissions and mortality, and could use sophisticated models to attempt predictions, there was little equivalent for mental health.
Governments at different levels in principle have many different options for action, which include:
Providing CBT, therapists etc and accelerating training for providers. For example, the Improving Access to Psychological Therapies (IAPT) in England has made use of CBT approaches over the last decade, strongly based on evidence. These reach up to 1m each year, i.e. some 2% of the adult population.
- Scaling up online tools for self-diagnosis and self-help.
- Backing peer support networks.
- Community based solutions to help understand what we know about environmental policies i.e. reducing noise and fear.
- Mobilising employers including Mental Health First Aiders.
- School based therapists. This also includes acknowledging what works best for school-age populations – training teachers, therapists/counsellors on school premises and other kinds of referral.
These various approaches can be directed to different parts of the population. The challenges facing the frail elderly who may suffer from serious cognitive impairments are very different from those for children, for example. Here our main focus has been on children and young people and in the following sections we summarise some of the policy contexts across the UK.
On Wednesday 18th March 2020, Prime Minister Boris Johnson announced that from 23rd March schools across England would close, except for the children of key workers and vulnerable pupils. Schools then reopened in the autumn term, closed again in a second wave and then reopened again in the spring of 2021.
This brought a host of challenges from disruption to learning, to issues of digital inequality, and many measures were introduced to mitigate the harms including in May 2020 a £750m package of support to the Voluntary, Community and Faith Sector (VCFS) with £4.2 million earmarked to support mental health charities including Young Minds and Place 2 Be. Additionally £5m was allocated to community projects supporting people with their mental health, administered by MIND as part of the Mental Health Consortia.
Later in August 2020, £8 million was announced for an expert training programme, ‘Wellbeing in Education Return’ ahead of the full return to education in September. The aim of the training was to support pupils in their wellbeing on their return to education with the Department of Education subsequently reporting that ‘97% of local authorities had taken up training offered by the government’ including investment in additional staff and providing training to schools.
Marking World Mental Health Day in October 2020, the Department of Education published its annual State of the Nation Report with its findings painting a ‘surprisingly positive picture’ of the wellbeing of children and young people aged five to 24 who ‘…generally responded with resilience to changes in their lives’ with respect to the ‘wider support structures helping them to navigate a difficult time’. However, the report acknowledged the limitations of such a statement ‘given the lack of data that can be compared to a period prior to the pandemic’ and that ‘developing impacts on wellbeing and mental health were not yet observable in validated scales and other harmonised measures.’
However, this narrative was challenged in the Fourth Annual Report on the state of the children’s mental health services in England published in January 2021. In this report, Anne Longfield, the Children’s Commissioner for England from 2015-2021 stated that the ‘damage to children’s mental health caused by COVID-19 crisis could last for years without a large-scale increase for children’s mental health services’. While acknowledging the work over the last five years (2016-2021) including integrated mental health care across schools and the NHS, the report stated that greater ambition is needed by the U.K government, and highlighted the need to include quicker access to children’s mental health services, long-term and sustainable funding locally as well as nationally to help to end the postcode lottery regarding the provision of mental health and wellbeing services.
In February of 2021, Dr Alex George was appointed as the Youth Mental Health Ambassador, to sit on the newly formed Mental Health in Education Action Group. This group chaired by Children’s Minister Vicky Ford and Universities Minister Michelle Donelan was to look at how to support young people with their wellbeing as they return to school and university since the start of the pandemic. In March 2021 a new £700 million package to support the return to school for all pupils was announced. This included a new one-off Recovery Premium for state primary, secondary and special schools to support disadvantaged students including interventions to support mental health and wellbeing. Additionally, a £79m COVID-19 Mental Health and Wellbeing Recovery Action Plan was announced to improve access to CYP Mental Health support, accelerating the commitment to expand services as a part of the NHS Long Term plan.
Interventions this fund was to support included:
- Nearly 3 million children in England to be supported by mental health support teams in schools.
- Around 22,500 more Children and young people (CYP) to access community mental health services, including enabling children to text their local mental health support team, with a health professional responding within an hour during the school day offering them advice, or providing families with tips on how to spot that the CYP are struggling with their mental health.
- 2,000 more CYP people to access eating disorder services.
Further funding was announced in May 2021 with £17m allocated to improve mental health and wellbeing support in schools and colleges, building on previous packages of support for young people in educational settings including training for senior mental health leads. An additional £7 million was also allocated to build on the Department of Education’s Wellbeing for Education Return programme. From May 2021 onwards as the U.K. emerged from the pandemic, educational catch-up schemes as well as wellbeing programmes were tied to wider COVID-19 recovery plans. This included addressing the factors that shape mental health and wellbeing outcomes, the expansion of specialised mental health and wellbeing services as well as placing prevention of poor physical and mental health at the heart of government and more widely across local and national governments.
Prior to the pandemic, research identified that Northern Ireland had particularly high levels of mental illness amongst its population, with estimates suggesting that 1 in 5 adults experience a mental health problem at any given time, and the highest suicide rates in the UK and Ireland. In large part, this is a legacy of the 1968-98 conflict, but ongoing deprivation levels remain a major contributor. Since 2021, and in response to these research findings, Northern Ireland has had a dedicated ‘Office of the Mental Health Champion’, headed by Professor Siobhan O’Neill. The role of the office is to help implement the NI Mental Health Strategy for 2021-31, which has an associated funding plan.
The strategy is founded upon three themes:
- Promoting mental wellbeing, resilience and good mental health across society
- Providing the right support at the right time
- New ways of working
The latest Delivery Plan, for 2022/23, that was published in July 2022 can be found here.
At time of writing, the NI Assembly has not sat since May 2022, and decisions on new policy actions and funding allocations cannot be made. The Department of Health continues to implement the delivery plan within existing budgetary parameters but cannot initiate many proposed new policy interventions in the absence of Ministerial and Assembly approval. The Delivery Plan does identify ongoing work in the following areas:
- Creation of a Regional Mental Health Crisis Service that is fully integrated in mental health services and which will provide help and support for persons in mental health or suicidal crisis. A plan for delivering this during 2021-31 is here.
- Continued rollout of specialist perinatal mental health services.
- Enhanced provision of personality disorder services regionally through the formation of a Personality Disorder Managed Care Network.
- Enhanced regional eating disorder service.
- Develop a regional mental health service, operating across the five Health and Social Care Trusts, with regional professional leadership that is responsible for consistency in service delivery and development.
- Develop a regional Outcomes Framework in collaboration with service users and professionals, to underpin and drive service development and delivery.
Other actions awaiting the return of the Assembly and therefore political and funding approval include:
- The expansion of therapy hubs
- A new dedicated resource for student mental health at third level
- Integration of unpaid carers, families and others in supports for people with mental ill health and also in the development of mental health policy and wider decision-making
- Increase funding for Children and Adolescent Mental Health Services (CAMHS)
- Develop proposals for transitions between CAMHS and adult mental health services
- Creation of a peer support and advocacy model
- Integration of community and voluntary sector in mental health service delivery
- Digital delivery of mental health services
- Create a centre of excellence for mental health research
Before the pandemic, the mental health priorities and policies for the Scottish Government were set forth in the Mental Health Strategy 2017-2027. In October 2020 the Scottish Government published a Mental Health Transition and Recovery Plan, which took into account the key areas of mental health that have arisen as a result of Covid-19 and lockdown. This Recovery Plan is currently in effect and folds in some of the areas of work of the previous strategy that were paused when the crisis began.
The Scottish Government is currently consulting on a new Mental Health Strategy (as of September 2022). This new strategy will be refreshed to focus on four key issues: addressing the underlying reasons behind poor mental health; helping to create the conditions for people to thrive; challenging the stigma around mental health; and providing specialist help and support for mental illness. An important framing in Scottish policy is a distinction between mental health and mental wellbeing, which runs throughout policy documents. This overarching strategy is supplemented by specific work in areas such as suicide prevention (a new strategy will be published in autumn 2022), perinatal and infant mental health and children and young people’s mental health.
For children and young people specifically, the Scottish Government and COSLA have convened the Children and Young People’s Mental Health and Wellbeing Joint Delivery Board since December 2020. This Board’s work focuses on prevention and early support as well as promotion of good mental health and the services children, young people and their families’ access. The voices and experiences of children, young people and their families will remain central to decision making and service design. The Board’s deliverables include:
enhance community-based support for emotional wellbeing/mental distress through ongoing investment and support for local partnerships
- ensure crisis support is available 24/7 to children and young people
- support mental health pathways and services for vulnerable children and young people, aligned to the work of the Promise, the plan driving change in the care system initiated by the Independent Care Review in 2016
- develop a support programme to enable the implementation of the CAMHS service specifications
- agree and support the implementation of a neurodevelopmental service specification/principles and standards of care
- develop a programme of education and training to increase the skills and knowledge required by all staff to support children and young people’s mental health
In February 2021 the Scottish Government announced £120 million for a Mental Health Recovery and Renewal Fund. The aim of the Fund is to ‘ensure the delivery of the Mental Health Transition & Recovery Plan. It will prioritise our ongoing work to improve specialist Children and Adolescent Mental Health Services (CAMHS) services, address long waiting times, and clear waiting list backlogs.’ The Recovery and Renewal Fund also allocated nearly £10 million to clearing backlogs in Psychological Therapies waiting lists for adults. The announcement of this fund was the largest single investment in mental health in the history of devolution. Additional areas of focus for the Scottish Government include providing additional support for mental health in primary care settings and early intervention, which includes more investment in community-based support (Mental Health Strategy Third Annual Progress Report, March 2021).
In recognition of the ongoing mental health crisis, the Scottish Government announced further investment in the most recent budget (2022-2023), released in December 2021. In the 2022-2023 budget the Scottish Government pledged to make a ‘direct investment of £290 million in mental health, including £120 million in the new Mental Health Recovery and Renewal Fund’.
Although Wales has law-making powers under the Government of Wales Act 2006, these are limited. The Coronavirus Act 2020 granted Welsh ministers additional powers to deal with the pandemic. Its response was largely more cautious than that of the UK government, with longer and more universal lockdowns, more stringent mask-wearing rules, and tighter restrictions on the number of people who could meet in which types of settings. However, after the first wave, a number of exceptions were made to enable support ‘bubbles’ to provide informal care for those with particular needs, such as those living alone or with young children. School closures were also minimised and making sure vulnerable pupils were ‘safe, seen and heard’ was prioritised.
In Wales, health services are devolved (i.e. under the responsibility of Welsh Government ministers). It is, however, worth noting the similarities between the Welsh and English landscape including the way mental health services are accessed through GPs, midwives and health visitors.
Together for Mental Health, the Welsh Government’s 10-year cross government strategy to improve mental health and wellbeing was published in October 2012. The strategy and accompanying delivery plan took a human rights approach to improving the mental health and wellbeing outcomes of all people in Wales to better support them during mental illness. The strategy and delivery plan was split into three phases covering both short and longer term outcomes. Phase 1 covered the period between 2012-2015, phase 2 covered 2016-2019 and phase 3 covered 2019-2022. Cutting across all phases is a focus on prevention, integration, costs and savings and mechanisms for delivery. Sitting in phase 3, the Welsh Government acknowledged the impact of COVID-19 and related public health measures on mental health and wellbeing outcomes and adjusted their approach and subsequent delivery plan. As Wales nears the end of its 10-year cross government strategy it is expected that a review via a monitoring, learning and evaluation of the strategy will be completed to understand the progress made and the scale of the challenge in the next 10 years.
In 2020, the Welsh Government published a review of the Together for Mental Health delivery plan in light of Covid-19. This review made a number of recommendations for health boards to evaluate delivery and changing needs in light of the pandemic. There has been an important shift towards wellbeing increasingly being seen as a wider societal responsibility, as reflected in the third sector playing an important role in the design and delivery of wellbeing interventions, for example in Welsh Government’s current consultation on social prescribing. This input is particularly valuable during the current mental health crisis, where NHS provision is unable to keep pace with demand, resulting in lengthy waits for care. During the pandemic, Welsh Government’s suite of financial support for the voluntary sector also enabled both prevention of and responses to emerging mental health needs.
Another important aspect of its approach is the piloting of mental health apps, such as SilverCloud and Minds active monitoring (both online CBT courses) and activate your life (self guided videos). The ability to self-refer for these interventions is seen as an important aspect
With respect to young people’s mental health, all local authorities (LA) in Wales must make counselling available from at least year 6. This is mostly provided through LA’s who recruit counsellors based in schools, but in some cases it can be a separate service.
During the pandemic, the Children’s Commissioner for Wales and the Welsh Government carried out a large-scale survey on children and young people’s experiences. Although its sampling methods meant that it was in no way representative, it highlighted issues such as digital exclusion, concerns about education provisions and lack of confidence in accessing some services.
In May 2021, Public Health Wales published a review of evidence on the impact of the pandemic (primarily control measures, such as school closures) on the mental wellbeing of children, babies and young people. Conclusions highlighted the negative impacts of school closures in terms of both disrupted learning and temporary lack of access to services associated with schools, such as free school meals and counselling services. It highlighted the increased exposure to adverse experiences for some children during lockdown and the impact of social distancing on social development, but comparisons with other areas of the UK were not made. Wales is investing in and advocating whole-school approaches and trauma-informed schools, alongside its counselling and CAMHS provisions for school-aged children and young people.