We know people’s mental health levels have deteriorated during COVID-19. Now we must find out which responses work at scale

Governments are committing more resources towards mental health – yet do we even know which interventions could be scaled up in the face of widespread experiences of anxiety and depression? The simple answer is no

Eleanor Williams

It has been a very tough two years for mental health and resilience in the face of the global pandemic. People have wrestled with changes and disruptions to their lives, routines and plans that could hardly have been anticipated before COVID-19 struck. Individuals have been isolated and distanced, children have been in and out of schools, workers have experienced too much or not enough work, and there has been an overarching sense of not having individual or collective control of the situation.

For almost everyone, there is a sense that the COVID-19 experience has led to compounding challenges. And facing multiple challenges and stressors predictably leads to increased mental health burdens.

I’ve heard it said that everyone has been living in their own circus this year. For some, it has been job loss and the associated financial worries, isolation and loneliness, the inability to support other family members who are also struggling. For others, it has been managing existing health issues and the daily risk of infection, and the limitations that this places on your ability to shop, work and visit friends. And for families of school-age children, it has been the pressure of balancing work, remote learning, and the high-stakes debate around vaccines for this age group.

In more normal times, these mounting stressors can be balanced by protective factors such as community and family – but these supports have, of course, also been interrupted and challenged throughout the pandemic experience.

Given this context it is unsurprising that, in the UK, average levels of depression and anxiety have been much higher than usual – particularly for women and young people, and for those in an at-risk group for COVID-19. A similar pattern has been observed in Victoria, Australia (where I am based), despite the vastly different policy responses in the UK and Australia. And these mental health trends have played out internationally with very few countries spared.

The scale of the increase

There have been some attempts to quantify the scale of the increase in mental health issues across countries during the pandemic (a task that is even harder than it sounds). This exercise unsurprisingly found that countries that were hit hardest by the pandemic in 2020, as measured by decreased mobility (related to lockdown measures) and daily infection rates, had the biggest increases in the experience of major depressive and anxiety disorders.

This is a pretty significant finding for the UK which, as of November 2021, has had the fourth-highest recorded case numbers of COVID-19 of all countries internationally – with the very real threat of new strains entering the country. But it also matters for places such as Victoria in Australia, where case numbers have stayed relatively low but we have spent more time locked down than anywhere else in the world (262 days in total).

I spent much of 2020 working in the Victorian Department of Health, in a role that contributed to introducing and easing COVID-related restrictions including lockdowns, mask requirements, and a ‘ring of steel’ initiative that prevented travel between metropolitan and regional areas to reduce transmission. My team was acutely aware of the trade-offs between the policy objective of reducing viral transmission and the wellbeing impacts of separating families, restricting employment, and isolating people across the community including children and the elderly. Judgment calls had to be made about the balance between the policy objectives of (i) containing the virus to support population health, and (ii) reducing restrictions to support people’s wellbeing.

Inadequacy of existing systems

As with many policy areas, the pandemic shone a light on the inadequacy of the existing systems for mental health in most countries. Australia was not alone in being badly equipped to meet demand for mental health support even during ‘business-as-usual’ periods – and we definitely don’t have the ability to scale-up support quickly in a crisis.

The World Health Organization (WHO) has been outspoken about the fact that COVID-19 has demonstrated the chronic underfunding of mental health all over the world. Put simply, spending 2% of national health budgets on mental health is not enough. The WHO has provided guidance to countries on how to maintain their mental health services during the pandemic, as a component of their response and recovery plans – but finds that only 17% of countries have committed the level of resources that are needed.

This is not to say that nothing has been done. The UK has announced a £500m mental health recovery plan to support hundreds of thousands of people facing mental health issues. This funding will expand existing therapies through the Improving Access to Psychological Therapies programme, train more mental health practitioners, and increase the number of community-based mental health services. I am now working in mental health reform in Victoria, and there have been similar investments by both the Victorian and Australian Governments.

The UK’s National Institute for Health and Care Excellence (NICE) has also issued draft guidance on treatment options for people suffering from depression. This guidance aims to summarise the menu of evidence-based options (psychological and pharmacological treatments, and group and individual therapies) to respond to a range of depressive disorders in multiple contexts. This advice helps practitioners support people at the individual level but it cannot provide answers to how to support population-level mental health issues.

We don’t know what is likely to work at scale

However, the important question that still needs to be considered is: even with governments committing more resources to mental health, do we even know which mental health interventions could be scaled up in the face of widespread experiences of anxiety and depression? The simple answer is no. It would take substantial new work both to bring existing evidence together, and to generate new evidence about emerging treatments such as digital options, to answer this question.

We are experiencing mental health issues at an unprecedented scale in most countries, yet the research in relation to ‘what works’ to support positive mental health at scale is patchy. We have good evidence to answer more discrete and contained policy questions, such as what are the most effective treatment options for schizophrenia, or what treatment pathways are effective for eating disorders? But we do not have the consolidated information about what options are most likely to be effective in addressing the widespread increase of conditions such as anxiety and depression.

What is needed to prevent mental ill-health from escalating, and how do we respond when it does? We don’t know what is likely to work at scale, and we haven’t worked through what we can deliver with the current workforce in mental health – with its mix of disciplines, training and approaches.

The International Public Policy Observatory (IPPO), working with UCL’s Evidence for Policy and Practice Information and Co-ordinating (EPPI) Centre, has spotted this evidence gap. To get the conversation started, IPPO is bringing policy-makers and experts from throughout the UK (and beyond) together in a virtual roundtable event on Tuesday 14 December (9-10am GMT).

Attendees will consider key questions for mental health systems across the UK. We will be trying to work through what evidence would be most helpful and informative as governments navigate this new and emerging challenge. This session will aim to get us started on the important journey of building the evidence base to support the emerging population-level issues that COVID-19 has raised in mental health.

Eleanor Williams is Executive Director at the Victorian Department of Health