After approximately two and a half years and three vaccinations Covid has finally stopped by my house.
My wife and carer started showing symptoms of it last night when visiting my daughter and her family, we thought it may be hay fever as my wife does suffer from that when pollen is high. That wasn’t the case
This morning she tested positive which has meant she has had to cancel a few things. I was also tested this morning but that came back negative but still have to cancel something for tonight at least because we’re both living in same house.
We have been told that we should keep our distance as much as possible and open windows for fresh air.
One of the events she has had to cancel is an evening invite to a wedding, something she was looking forward to.
My wife now housebound for 5 days and we both have to test every day until my wife is negative. Let’s just hope and pray I don’t get it because of my health issues!
One of the most significant public health measures implemented during the COVID-19 pandemic has been extended periods of ‘lockdown’ where whole populations have been advised to remain in their households other than to collect necessary supplies, to care for others, or to exercise.
There are increasing calls to understand the impacts of this lockdown, and of subsequent school closures, on the mental health and wellbeing of children and young people during the COVID-19 pandemic1-5. As lockdown measures begin to ease, we require an understanding of what children and young people have been experiencing during the lockdown period1 as well as how children and young people can be best supported to resume to normal life, or the ‘new normal’, over the coming months and years. This understanding can inform responses to recovery implemented at the policy level and by those working directly with children and young people. Such responses are beginning to be formalised in other countries. For example, the New Zealand Government have published a national psychosocial and wellbeing recovery framework with a focus on prevention and early intervention upheld through the principles of collectivity, empowerment, community solutions, assets-focus, and support for community and specialist services.
In this evidence overview, we consider empirical studies of the impacts of lockdown of both COVID-19, and of similar previous health-related disasters, to identify important considerations about the mental health and wellbeing impacts of lockdown, both positive and negative, on children and young people. By similar health-related disasters in the past, we refer to previous pandemics, epidemics, and other health disasters. Given that much of the literature in this space is not focused specifically on the mental health and wellbeing of children and young people1 , we consider the empirical evidence of impacts across three areas:
1. The individual: Direct impacts on children and young people’s mental health and wellbeing
2. The interpersonal/family: Impacts within the family context
3. The school: Impacts within the context of education
Based on our findings, we consider policy and practice recommendations that can help to inform solutions and responses to the challenges facing children and young people, their families, and those who work with these groups. As a result, this overview is focussed predominantly on the problem. This is an emerging situation evidence of effective interventions are limited. As such, we hope that by broadly contextualising some of the mental health impacts and challenges for children and young people, that decision-makers have more informed scope to develop effective programmes and interventions to support children and young people going forward.
Approach to reviewing literature
This evidence overview used the following structured approach to identify key pieces of empirical literature to include. The focus was on empirical research and therefore we include both primary research articles and articles analysing secondary data or conducting systematic/ rapid reviews of empirical literature.
To begin with we focussed on a wide set of events which could be considered similar to COVID-19. Initially, this included pandemics, epidemics, health disasters, natural disasters, and conflict zones. The hits on this wide search were large, so we decided to focus on health-related disasters more narrowly. Indicative search terms relating to health-related disasters include: pandemic OR endemic OR covid OR coronavirus OR SARS OR MERS OR H1N1 OR ebola OR health NEAR/2 [N1] disaster OR outbreak OR isolate* OR quarantine OR social distanc* OR home confin*. Searches were then refined to focus on mental health and wellbeing impacts and children and young people. This overview includes only articles printed in English. Searches were undertaken in the Web of Science and PsychInfo databases. Thereafter, the reference lists of relevant articles were reviewed to identify additional relevant articles. In the overview of evidence, we also consulted available findings from several large-scale surveys of the mental health impacts of COVID-19 that relate to the potential impacts of lockdown. The surveys include but are not limited to: Mental Health in the Pandemici , Lockdown Lowdownii, Co-SPACEiii & Co-SPYCE studies, Office for National Statistics routine survey of 16+iv, and the Carers Trust Survey of Young carersv.
The individual: direct impacts on children and young people’s mental health and wellbeing
The direct impact of lockdown on the mental health and wellbeing of children and young people yields mixed findings. Findings center on the mental health and wellbeing impacts of lockdown and the factors affecting mental health and wellbeing.
Mental health and wellbeing impacts of lockdown for children and young people
In some cases, where quarantine was not at the population level, e.g. only required for those with contact with infected persons, one study on the impacts in the context of the H1N1 influenza found no immediate negative psychological effect of quarantine for undergraduate students7 . However, in the case of the SARS epidemic, stress scores for Post-Traumatic Stress Disorder (PTSD) were reported by parents to be 4 times higher in children quarantined than those not quarantined8,9: in this case, criteria for PTSD was met by 30% of quarantined children. A study from India, during the COVID-19 pandemic, yields similar results10 and further studies conducted in China find that young people report increased depressive symptoms and anxiety symptoms11 and can experience negative psychological consequences as a result of the COVID-19 pandemic12.
Qualitative evidence indicates a number of reasons for these findings including the perceived threat of the virus, confusion, disruption, and isolation imposed by this type of health-related crisis8. Other studies have found that levels of distress were higher in young adults as a potential consequence of increased consumption of social media for example13,14. Emerging evidence from the COVID-19 pandemic in the UK suggests similar trends that young people, in particular teenagers, in the UK are feeling more anxious than they did before the outbreak, a trend which is up to 10% higher for black and mixed race participants15. Further evidence of the mental health and wellbeing impacts of this kind of quarantine related to both the fear of stigma and the stigma experienced by those young people who had been quarantined and returned to college16 which this study identifies as a risk factor for maintaining social support mechanisms with friends, classmates, or roommates post-quarantine.
Young carers are one group whose mental health has been negatively impacted by the lockdown restrictions. A survey of nearly 1000 young carers in the UK found that over half of young carers have felt overwhelmed and stressed and have, as a result, suffered worsened mental health during the a. The individual: direct impacts on children and young people’s mental health and wellbeing 7 lockdown period17. Around a third of those surveyed said they struggled to get emotional support with some respondents saying they had increased their alcohol intake as a result of the stresses they were feeling, and were struggling to take care of themselves. The survey identified that young carers require more practical support in coping with day to day life, but also more access to peer support, either online or in-person.
Factors affecting the mental health and wellbeing of children and young people
Loneliness is considered as a key risk factor of lockdown for the mental health and wellbeing of children and young people. A rapid review of the links between loneliness and mental health highlights the potential for increases in children and young people experiencing loneliness to link to mental health problems in children and young people18. However, it is important to note that experiences of loneliness involve some form of social comparison, and in the UK case, the shared experience of lockdown might mitigate the negative impacts of loneliness to some extent18. Yet, emerging evidence of the impact of the COVID-19 pandemic suggests that, despite the shared experience of lockdown, children and young people are experiencing loneliness. Emerging evidence suggests that, amongst the general population in the UK, the proportion of adults experiencing loneliness is highest amongst young adults aged 18-2419, with another survey identifying that 50% of 16-24 year-olds have experienced ‘lockdown loneliness’20. This could, as the literature suggests, be a consequence of the loss of peer group support during this important developmental stages where peer interaction is important for brain development, self-concept construction, and ultimately mental health and wellbeing18,21. #
Worries about school and the future
Emerging evidence from the COVID-19 pandemic also suggests several other factors influencing the mental health and wellbeing of children and young people including: worries and concerns around their education (all ages), missing school (all ages), transitions and being away from school (primary school age), academic pressures (secondary school age), their career (young adults), and uncertainties about the future more generally (young adults)19,22,23. Similarly, in the case of children and young people currently in contact with youth justice systems, it has similarly been reported that lack of contact with others, boredom, not being able to attend school, financial worries and general uncertainty about the future are key factors impacting mental health and wellbeing24.
Supporting mental health and wellbeing
One study has found that a majority of participating parents report that their children are keeping in regular contact with family and friends via video-chat and are getting regular physical exercise25, factors that can support the mental health and wellbeing of children and young people21. However, this was not the case with pre-school age children in one survey, where parents had concerns about their children’s lack of communication with others outside the household26.
The interpersonal/family: impacts within the family context/on parents and carers
An important consideration about the impact of quarantine is the impact on both the relational family contexts in which children and young people are isolating, and the impacts on the mental health and wellbeing of parents/ caregivers more generally. This is particularly important to consider given the wide range of literature evidencing the long-term health and wellbeing impacts of traumatic events that occur during childhood27. Such traumatic events include but are not limited to the experience of or witnessing violence, abuse, and neglect in the household, substance abuse, mental health problems, and parental separation and, overall, a lack of sense of safety, stability and bonding within the household28.
Mental health and wellbeing impacts of lockdown on parents/carers
For a variety of reasons, quarantine can be traumatising for some parents8. In a study on post-traumatic stress disorder in health-related disasters, criteria for PTSD was met in 25% of isolated or quarantined parents8. The same study found links between PTSD criteria in adults and their children having PTSD symptoms8. Duration of quarantine and consequent lack of social and physical contact with friends/family and the outside world has been shown to be associated with increased PTSD symptoms29. Similarly, it has been shown that social isolation and associated loneliness have a negative impact on mental health outcomes for adults30. Other factors that have been shown to have an impact on stressors and wellbeing9 include the duration of quarantine, fear of infection, frustration and boredom, inadequate supplies and information (guidelines, rationale for actions, and level of risk), loss of work or working more than usual31, or COVID-19 related stressful life events e.g. bereavement/having an acquaintance infected14,31,32. The links between experience of COVID-19 related stressful life events and increased stress were shown to be the case in one study regardless of previous mental illness or childhood trauma31.
Impacts on key workers
The psychological impacts are particularly important to consider in cases where parents are front-line workers4 with much evidence showing that those working in health care in particular, experience negative psychological consequences during health emergencies33,34. Moreover, in the case of healthcare workers, quarantine has been associated with distress, exhaustion, detachment, anxiety, and PTSD symptoms over time9, all of which will impact upon the home environment. Worryingly, the same study identified that alcohol abuse and dependency, and avoidance behaviours were positively associated with workers having been quarantined9 , all of which have been shown to have negative effects on the mental health and wellbeing of children in such households28. One UK-based study has found that children (aged 13-24) of key workers have experienced greater levels of COVID-19 anxiety and trauma and also report more somatic symptoms15.
Factors affecting mental health and wellbeing in the context of the family
Groups disproportionately affected by lockdown
There is mixed evidence of the factors associated with pre-quarantine predictors of impact on mental health and wellbeing. Some factors associated with negative effects on the mental health and wellbeing of adults include those that are younger9,13,31,35, female9,13,14,31,32,33,35,36, with a history of psychiatric illness or chronic illness/ poor health (diagnosed or selfreported) 14,31,32,33,35,36, and single parent adolescents1 . There is mixed evidence on the impact of education level as a predictor of impact of lockdown on mental health9,13,36. Post-quarantine stressors can include: finances9,37 and stigma for healthcare workers9 . At a broader level, Harkins has identified that there are several groups who have experienced, and are still experiencing, disproportionate vulnerability to the ‘lockdown’ public health measures32. These groups include: disadvantaged communities, people with disabilities, BAME groups, people experiencing homelessness, those affected by violence, older people, and frontline health and care staff32. Particular note should also be given to the increases in both calls and referrals to domestic abuse charities38,39, with the mental health impacts this has for the victim, and to the children and young people witnessing or experiencing such abuse, being of primary concern as we emerge from lockdown.
Worries about financial security, homelife, and the future
Emerging evidence from the COVID-19 pandemic suggests that in general, many adults are feeling anxious or worried about the future. In particular, adults who are unemployed have reported not coping as well19 with a quarter of this group feeling hopeless with primary concerns around financial security19. Parents who are working have also reported difficulties in balancing the needs of their child with the demands of working23. Moreover, parents with children with special educational needs/ neurodevelopmental disorders have reported that they were experiencing higher levels of stress and require more support to cope with changes in their children’s behaviour23. One study has reported that difficulties in relationships and conflict within the family home are problematic for children and young people, particularly those with experience of the youth justice system24.
The school: Impacts within the context of education
Lockdown related school closures has been one of the most significant public health measures across the world. For children and young people in the UK , this has been the first extended closure of schools in recent history and as such, its impact on their mental health and wellbeing is important to consider, particularly given the already contentious nature of the effectiveness of school closures on disease containment1,40 and the fact that school is often the first place that children and young people can and do seek support for their mental health and wellbeing4.
Worries about education
An extended period of school closures will no doubt impact curriculum delivery over the coming years and as such, school is an emerging source of distress and worry for children and young people17,19,41. In particular, young adults are experiencing concerns about their education being interrupted and their future career opportunities19. Young carers have also reported concerns about their education, with half of those surveyed in one study reporting that their education has suffered as a result of increased caring responsibilities and associated stresses17. With respect to returning to school, children and young people have reported having worries over losing the enjoyable aspects of school and the impact of social distancing on friendships. In particular, one surveyreports that primary aged children worry about being away from home and transitioning between schools, whereas secondary aged children worry about increased academic pressures as well as catching COVID-1942. Moreover, a case study of a group of quarantined students during the SARS outbreak found that the students experienced stigma upon returning to their studies due to their contact with infection16, a factor which is important to consider should we experience more localised lockdown measures during future outbreaks of COVID-19.
Factors affecting the delivery of education
Disadvantage and engagement with curriculum
In terms of the delivery of education during lockdown, there has been concern over the exclusion of children without digital access, physical space, and other resources to support their learning43. Emerging evidence from England suggests that there has been a substantial deficit in curriculum coverage across schools, that just over half of parents are engaged with their children’s home learning, and that less than half of pupils had returned their last piece of work at the time the survey was undertaken43. In this particular survey, teachers expressed concern over the engagement of the most disadvantaged pupils with the analysis finding that the level of disadvantage of the school being influential on pupil engagement43. Variability in engagement with the curriculum will potentially have differing effects on both the development and mental health of pupils returning to school43. Moreover, those receiving free school meals may have experienced increasing food insecurity, although recent policy changes reflect governments’ commitment to continuing such funding over the summer break this year44.
In previous outbreaks, there has been variability in school responses to public health measures. In one study, despite highly consistent evidence of duty of care, schools varied in extent to which information was shared openly and transparently; in how responsive school decision-makers were to the changing situation45. In this study, schools had reservations about the need for closures/quarantine, including a lack of understanding about the rationale for this action45. The study concludes that there needs to be high levels of trust between schools, public officials, and governments. School closures worked where there were high levels of trust between key players. The findings here highlight the importance of schools as agents of public health and the significance of their role in response to such crises45. This variability in response may have implications for parents and children. For example, there may be parental concerns about going back to school23, particularly worries around the child being upset and not understanding social distancing measures and so increasing their chances of catching/transmitting COVID-19. In this survey, these findings were particularly relevant in cases where children has special educational needs/ neurodevelopmental disorders, or for parents with lower incomes23.
Policy and practice implications for suppor ting children and young people
The overview of evidence presented here highlights some of the needs children and young people may have going forward, as lockdown measures begin to ease, and children return to school. Echoing earlier calls1, there seem to be several areas where attention is required, highlighting the need for a multi-disciplinary and multi-sectoral responses going forward3. Given the emerging nature of the COVID-19 pandemic, evidence for effective support mechanisms for children and young people is lacking. Nevertheless, we use the findings presented here, on the evidence of the problem, to highlight several areas for consideration for those developing programmes, interventions, and support for children and young people going forward.
a. Supporting the mental health and wellbeing of children and young people
Many children and young people have likely experienced loneliness during lockdown and in particular, been affected by lack of physical contact with their friends, families and peers, and the boredom and frustration associated with a loss of all the activities they have been used to taking part in. Moreover, many children and young people have experienced worries and distress about their education and returning to school. It therefore seems important to facilitate support for children and young people that allows them to talk through some of these shared experiences and in turn, validating their experience of lockdown, whilst simultaneously informing them of what is being done to ensure their return to school and education is impacted as little as possible. For example, in one post-quarantine study of young students, students benefited from sense of connection developed with group and validating their experiences with peers, and through gaining reliable information to ease early anxieties16. Success factors associated with this particular case of group work included a combination of psychoeducational, interpersonal, and effective elements introduced in a phased, structured approach over 5 weeks16.
Continued communication about COVID-19
It is important that there is continued provision of clear information about COVID-1946, the rationale and guidelines for both public health measures and for supporting mental health and wellbeing for children and young people, in terms which are accessible for these groups. It is recommended that such communication continues for the foreseeable, beyond the easing of lockdown measures and return to school. Young Scot for example have provided access to a ‘jargon buster’ webpage on their website which communicates information about coronavirus in accessible ways: https://young.scot/ get-informed/national/coronavirusjargonbuster and provides information on the ways in which coronavirus is directly impacting children and young people.
b. Identifying and supporting vulnerable groups of children and young people
This overview has also identified that those children and young people living in families where the experience of lockdown may have been particularly difficult and challenging may require additional support to deal with the mental health and wellbeing impacts of lockdown. For example, the findings from several of the studies presented suggest that families that are young, have parents with a long-term physical or mental health conditions, have low household incomes/unemployment, or those that have experienced a COVID-19 related stressful life experience may have had particularly difficult experiences of lockdown. These are groups that may require additional support in making sense of and coping with their experiences of lockdown, particularly within the context of family support.
One study included in this overview highlights that those working with vulnerable groups should adopt a traumainformed approach to understanding the impacts of lockdown on such groups during health-related crises8 in order to understand the different biopsychosocial reactions to the pandemic. The authors here suggest utilising a traumatic stress framework to organising response to provide appropriate evidence-informed care to vulnerable groups. From a policy perspective it will be important to continue to support vulnerable groups as we move out of lockdown. For example, informing policy through a trauma-informed perspective will be an important part of adequately supporting vulnerable families to begin shifting out of lockdown, especially in cases where the experience of lockdown has been particularly difficult. Similarly, some have highlighted the value of community responses to recovery32 whereby policy should: incorporate the views and insights of community members, particularly the most vulnerable; policy should work with communities to identify and develop responses that are innovative and flexible to local circumstances and to build social cohesion; and should endorse community-based support to enhance mental health and wellbeing.
c. Returning to school
Clear communication about returning to school
This overview has identified evidence that both parents and children and young people are experiencing worry and distress about the return to school, both in terms of the process of returning to school safely and the impact on their educational experience, curriculum delivery and future prospects. Therefore, providing clear information and communication to both parents and children about the return to school will be important. This will include ensuring clarity over processes for returning to school safely, what the school-day will look like, and curriculum delivery. Evidence from experiences during the H1N1 pandemic suggest that clear communication and support from government (national and local) in facilitating the safe re-opening of schools is important. The study highlights that trust between schools and government officials will be central to enabling a safe re-opening of schools in a consistent way for all children and young people45. Young people have also expressed worries about how lockdown will affect their educational and career prospects. It is therefore also important to ensure that schools are providing support and reassurance to children and young people on how schools will support them to continue to sit exams and apply for further education/higher education/jobs.
Supporting those who have struggled to engage with the curriculum during lockdown
Additional guidance and support at the policy level will help schools support those children and young people for whom lockdown has been particularly challenging in terms of engagement with virtual learning, including those with no access to digital technologies and physical space to do school work, or those children and young people with special educational needs.
There are many studies emerging of the impact of COVID-19 on the mental health and wellbeing of the population. We can also learn from similar events in the past, but evidence in such cases should be interpreted with caution given the differences between events and subsequent localised policy response. Based on the findings of this study, there is a need to understand the mental health and wellbeing impacts for children and young people, and particularly those in vulnerable groups and for whom lockdown has been particularly challenging.
The long-term effects for these groups will also require attention. In the case of education, research should continue to track the impacts of this extended period of lockdown on the delivery of the curriculum and of the process of returning to school. This learning is important for future outbreaks, but also in terms of coping with subsequent periods of lockdown should they be required in the case of a second wave of COVID-19. Moreover, as support is developed for children and young people and their families, careful attention should be paid to the evaluation of the effectiveness of such support, particularly for those groups mentioned above, for whom experiences of lockdown may have been particularly difficult.
There are several limitations of this overview of evidence:
Whilst a structured approach to searching the literature was adopted, this was not a systematic search and as such, some relevant literature may have been omitted. Nevertheless, by searching the reference lists of identified studies, we hope that this overview provides a good coverage of empirical literature.
In terms of articles included in this review, there was no assessment of the quality of empirical studies. Moreover, the findings of different studies cannot be compared due to differences in methodology and measurement tools. This means that findings presented should be interpreted with caution.
The use of survey data is useful to contextualise academic research. However, it should be noted that included survey data are from a number of surveys, using different methodologies, and sampling strategies which are not necessarily representative of whole populations.
The findings and recommendations of this overview should be interpreted given differences of past pandemics and differences in international policy responses. Direct comparisons between events and policy responses is therefore not possible. For example, findings from the SARS epidemic should be interpreted considering a particularly high mortality rate when infected with SARS. Moreover, in past events the definition of ‘quarantine’47 may refer to individualised instances of isolation, rather than the population level lockdown experienced in the UK during the COVID-19 pandemic.
As this is an emerging phenomenon, and even though research on the impacts of COVID-19 is developing at great pace, there is still much to learn about this phenomenon, particularly its long-term impacts. These longerterm impacts should be the primary focus of researchers going forward.
This overview sought to provide an overview of evidence on the mental health and wellbeing impacts of lockdown for children and young people during both the COVID-19 pandemic and during similar events in the past.
Whilst studies yielded mixed findings, the findings presented here reflect not only evidence on the direct impacts to the mental health and wellbeing of children and young people but also Impacts of lockdown on the mental health and wellbeing of children and young people 16 how the challenges in the context of families and education can influence their mental health and wellbeing. As a result, it is recommended that policymakers and those working with children and young people develop and support multidisciplinary and multisectoral responses that ease the anxieties and worries of this group more broadly, but also identify and support those for whom lockdown will have been most challenging.
Spread of Indian COVID variant ‘made worse by test and trace failure’ that kept councils in the dark for weeks
The spread of the Indian coronavirus variant was made worse by a failure in the test and trace system which meant eight councils didn’t know about more than 700 positive test results, according to a report.
The BBC reported the eight English councils did not have access to full coronavirus infection data between 21 April and 11 May.
This meant 734 positive tests were not registered, according to the report, meaning their contacts were not traced locally and told to self-isolate.
Among those councils was reportedly Blackburn with Darwen, which has among the highest number of cases of the B.1.617.2 variant in England.
According to the report, the other council areas affected were Blackpool, York, Bath and North East Somerset, Bristol, North Somerset, Southend-on-Sea and Thurrock.
Officials at one of the councils reportedly said the spread of the variant was “exacerbated by the sporadic failure of the national test and trace system”.
Cases involving the variant have accelerated across England in the past week, with 2,967 reported on Wednesday. This was up 1,654 from 1,313 on Thursday last week (13 May).
Downing Street labelled the issue a “short delay” on Thursday and said problems with informing eight councils about the positive cases were “quickly resolved”.
Boris Johnson’s official spokesman told reporters: “In this specific instance, all positive cases were contacted and told to self-isolate for 10 days.
“As you know, there was a short delay when asking some of those positive cases to provide details of individuals they had contacted since contracting COVID.
“This issue was across a small number of local authority areas and was quickly resolved.”
Asked whether the government accepted the failure contributed to the spread of the variant, the spokesman said: “The spread of the variant will be down to a number of factors. This was an issue that occurred across a small number of local authority areas, so I don’t think it is possible to draw that conclusion from this.”
Labour shadow health secretary Jonathan Ashworth said: “It beggars belief that yet again local health experts on ground have been left in the dark for two weeks [sic] when we know acting with speed is vital to containing an outbreak.
“Ministers need to explain what’s gone wrong and provide local health directors with all the resources they need to push infections down.”
At least up until last October that’s what I called it
What is this side effect as I call it and please drop a note in the comments if anyone with epilepsy or othr type of seizures suffer from it? Well every so often mainly after a Focal seizure and after the occasional absence seizure I would have to run to nearest toilet because It triggered of not diohrea but a ” loose bowel movement”
When I suffered from it, it could happen at the most inconvenient times, such as when out in public.
It had me at a point where if I entered a public building the first thing I would look for was the toilet just incase I had one of these seizures
Having said that we in the UK have been under lockdown restrictions since late last year. I because of the guidelines have not been able to do any of the things I did before Covid – 19 therefore I haven’t been under any stress that I would normally wouldbe under if Covid – 19 did not happen.
Personally I am hoping and praying that the dreaded and incovenient side effect does not come back.
The ongoing Covid-19 outbreak is in many ways unprecedented, in both the scale of this challenge, the scale of public health response, and the historical context in which all this is unfolding. Covid-19 is the first global pandemic of the social media age, the first of the “alternative facts” era, and is occurring at a moment when politics and society seem to be in a state of accelerated flux.
Yet for all that is new about Covid-19, the disease still behaves like any number of prior epidemics. It is, for example, similar to the 2003 severe acute respiratory syndrome (SARS) outbreak, an event which created a number of lessons for our present moment. SARS was, in many ways, the best-case scenario for responding to a global infectious threat. The spread of SARS was contained fairly quickly by public health efforts, chiefly through the widespread use of quarantine. But even this relative success still had consequences for health. In 2004, I worked with colleagues on a study of SARS control and the psychological effects of quarantine in Toronto, Canada. We found among quarantined persons a high prevalence of psychological distress, including symptoms of depression and posttraumatic stress disorder (PTSD). A key takeaway: Even if we can halt the physical spread of a disease through the expeditious use of quarantine and social distancing, we will still have to contend with its mental health effects in the long-term.
This is a message that is frequently forgotten. The mental health effects of Covid-19 can shape health for many years, long past the events that precipitated them. We have been focusing, correctly, on saving lives and mitigating the short-term consequences of Covid-19, but the long-term consequences may be equally, if not more, important. While it can be difficult to take the long view when the events of the moment are so compelling, it is necessary, if we are to ensure the steps we take now are in the best interest of public health once this pandemic passes and our task moves from one of response to one of recovery.
To envision how this long-term future may unfold, it helps to look to the past, and not just to past epidemics. Protests, riots, mass uprisings, and natural disasters can also teach us much about how large-scale, disruptive events can shape mental health. What do we know about the consequences of such events?
In a study published earlier this year, I worked with colleagues to investigate the mental health effects of protests, riots, and revolutions. Our work looked at the immediate effects of these events, as well as their long-term consequences. We found that the prevalence of depression and PTSD among populations after collective actions like protests and riots is comparable to levels experienced after natural disasters and terrorist attacks. This was the case for populations directly and indirectly affected by such events, suggesting a “spillover effect,” as anxiety over a disruptive event ripples through communities. We see similar effects after natural disasters, where mental health consequences can include depression, PTSD, and substance use disorders.
Then there are the economic effects of such events. In the case of Covid-19, we have already seen traces of these effects in the falling stock market, but the fortunes of Wall Street do not reflect what may be the true cost of this pandemic. With so many eyes focused on the stock market, it is possible to miss that the economic brunt of Covid-19 will likely be borne by low-wage, hourly workers, who can ill-afford the time away from work that containing the disease may necessitate. This will have consequences for health. Income is closely linked to health—physical and mental. There is, for example, a 10 to 15 year difference in life expectancy between Americans at the very bottom of the economic ladder and those at the very top, and income inequality has been linked with depression risk. Covid-19 could deepen this inequality over the long-term, even as, in the short-term, it undermines the peace of mind necessary for robust mental health, and compounds the challenges of people already prone to mental health struggles.
For those of you who don’t know where I live, I live in Scotland a part of the UK that is splt into four parliments, Westminster, Irish, Welsh and Scottish. I am obviously in the later!
Due to a fresh spike of Covid-19 in the UK Westminster put London and all of the Southeast England in lockdown as from boxing day. The leader of the Scottish parliament has also put the whole of Scotland in lockdown for three weeks.
The new spike forced the parliament in Wales to go to lockdown before Christmas.
Hospitals in Ireland are that over run they are having to use ambulances for make shift treatment.
We all can experience mental health problems, whatever our background or walk of life. But the risk of experiencing mental ill-health is not equally distributed across our society. Those who face the greatest disadvantages in life also face the greatest risk to their mental health.
The distribution of infections and deaths during the COVID-19 pandemic, the lockdown and associated measures, and the longer-term socioeconomic impact are likely to reproduce and intensify the financial inequalities that contribute towards the increased prevalence and unequal distribution of mental ill-health.
This briefing discusses the mental health effects of these financial inequalities in the context of the COVID-19 pandemic. It draws evidence from the “Coronavirus: Mental Health in the Pandemic” research – a UK-wide, long-term study of how the pandemic is affecting people’s mental health. The study is led by the Mental Health Foundation, in collaboration with the University of Cambridge, Swansea University, the University of Strathclyde and Queen’s University Belfast.
Since mid-March 2020, the project has undertaken regular, repeated surveys of more than 4,000 adults who are representative of people aged 18+ and living in the UK. The surveys are conducted online by YouGov. They shed light on people’s emotional responses to the pandemic, the key social drivers of distress, coping mechanisms and suicidal thoughts. A diverse Citizens’ Jury is contributing qualitative information, personal insights and comments on the data generated by the study. Ethical approval has been obtained from the Cambridge Psychology Research Ethics Committee.
To contextualise our findings, first we review existing knowledge on the links between financial inequality, employment and mental health; then we review what official figures are telling us about the financial consequences of the COVID-19 pandemic. This review provides the backdrop to our own survey data and Citizen’s Jury findings. We conclude with recommendations to UK central and national governments.
Financial Inequality, Employment and Mental Health: what did we already know?
The link between poverty and mental health has been recognised for many years and is well evidenced. In general, people living in financial hardship are at increased risk of mental health problems and lower mental wellbeing.(1) It is well established that people in the lowest socioeconomic groups have worse mental health than those in the middle groups, who in turn have worse mental health than those in the highest. This ‘social gradient’ means that mental health problems are more common further down the social ladder.(2)
The evidence of this social gradient in the UK is clear and has been established repeatedly. For example, the Health Survey for England has consistently found that people in the lowest socioeconomic class have the highest risk of having a mental health problem.(3) As another example, a 2017 survey commissioned by the Mental Health Foundation with participants from across the UK found that 73% of people living in the lowest household income bracket (less than £1,200 per month) reported having experienced a mental health problem during their lifetime, compared to 59% in the highest household income bracket (more than £3,701 per month).(4)
The mental health risk of economic hardship starts early in life. Socioeconomically disadvantaged children and adolescents are two to three times more likely to develop mental health problems.(5) The World Health Organization (WHO) has concluded that material disadvantage “trumps” emotional and cognitive advantages.(6) In other words, people from poorer economic circumstances are still more likely to have worse mental health, even if they have been supported to develop good personal coping and cognitive skills. People with an existing psychiatric diagnosis are also at greater risk of financial inequality and less likely to be in employment, fuelling their experience of multiple disadvantage.
Furthermore debt itself is an issue: people in debt are more likely to have a common mental health problem,(7) and the more debt people have, the greater is the likelihood of this.(8) One in four people experiencing a mental health problem is in problem debt, and people with mental health problems are three times more likely to be in financial difficulty.(9)
Employment is one of the most strongly evidenced determinants of mental health.(10) Lack of access to either employment or good quality employment can decrease quality of life, social status, self-esteem and achievement of life goals.(11) In the Mental Health Foundation’s survey across the UK in 2017, 28% of people who identified as unemployed reported current experience of negative mental health, compared to 13% of people in paid employment, 20% of people in full-time education and only 9% of people who had retired.(4)
Studies have found that unemployment has a range of negative effects, including relative poverty or a drop in standards of living for those who lose a job, stresses associated with financial insecurity, the shame of being unemployed and in receipt of social welfare and loss of vital social networks.(12) The Organisation for Economic Co-operation and Development (OECD) has described how job loss has a traumatic and immediate negative impact on mental health and noted that there is further damage where unemployment continues into the long term.(13) A meta-analysis has shown that unemployment is associated with varieties of distress including mixed symptoms of distress, depression, anxiety, psychosomatic symptoms and drops in subjective wellbeing and self-esteem. The same study found that 34% of unemployed people experienced mental distress, compared to 16% of those in employment. Importantly, the analysis showed that unemployment causes this distress.(14) Research also consistently shows that unemployment has been associated with lower wellbeing.(15) Furthermore, job insecurity and restructuring also have negative impacts on employee wellbeing over time.(16)
It is not only having a job that can benefit mental health; the OECD has recognised that the quality of employment also matters for supporting mental wellbeing.(13) In its 2008 Employment Outlook report, the OECD found that work-related mental health problems occur more often for employees with detrimental working conditions (e.g. toxic stress, discrimination, and bullying).(13) The conclusion that good quality work is important for fostering good mental health has been affirmed by successive UK policy reports and was emphasised by Farmer and Stevenson in their 2017 review of mental health and employment.(17) In their report, they incorporated good working conditions (e.g. fair pay, job security, education and training, and staff consultation and representation) as one of their proposed mental health core standards.(17) Some groups of self-employed workers are also vulnerable to lower mental well-being. One quarter of self-employed workers in Europe are in situations characterised by economic dependence (i.e. dependent on a single employer for their source of income), low levels of autonomy and financial vulnerability, and people in this category have reported lower levels of mental well-being than self-employed workers with more stable work.(18)
The Financial Inequalities of the COVID-19 Pandemic and Mental Health
The Institute for Fiscal Studies (IFS) has stated that the economic downturn resulting from the COVID-19 pandemic “will have significant consequences for people’s health outcomes in the short and longer term.”(19) There is no health without mental health and the negative effects of economic recessions on people’s mental health are already well-evidenced.(20)
In April of this year, the IFS pointed out that: “Groups that are vulnerable to poor health are likely to be hit hardest even if the crisis hit all individuals equally, but evidence is already emerging that the economic repercussions of the crisis are falling disproportionately on young workers, low-income families and women (Joyce and Xu, 2020).”(19) The Breugel agency has also noted that among workers across Europe, the self-employed are being hit hardest by the work-related effects of social distancing measures.(21)
In terms of the scale of potential need, the IFS cites Janke, et al. (2020) in stating that if the economic downturn were similar to that after the 2008 financial crisis, then the number of people of working age suffering from poor mental health would rise by half a million. Research in England on the 2008-10 recession showed that each 10% increase in the number of unemployed men was significantly associated with a 1.4% (0.5% to 2.3%) increase in male suicides.(22) We know that the mental health impacts of job loss and economic or employment uncertainty, compounded by financial worries about housing, heating and food, can be serious. They can also contribute to feelings of hopelessness. This may be what lies behind the high rate of suicidal thoughts and feelings among unemployed people. We don’t know yet whether the COVID-19 pandemic will affect suicide rates but we do know that suicide is potentially preventable, if we take action to mitigate those effects early rather than waiting for the number of suicides to rise.
In May this year, the Office of National Statistics (ONS) published statistics on COVID-19 deaths broken down by local area and socioeconomic deprivation. These revealed that the age-standardised mortality rate of deaths involving COVID-19 in the most deprived areas of England was 55.1 deaths per 100,000 population, compared with 25.3 deaths per 100,000 population in the least deprived areas (see ons.gov.uk/releases/spatialanalysisondeathsregisteredinvolvingcovid19), showing that people living in deprivation are bearing the brunt of the pandemic in the UK.
The report further showed that for most socio-economic groups, the number of COVID-19 deaths broadly maps the existing social gradient of health, with the proportion of COVID-19 deaths much worse in the three most deprived deciles when compared with overall deaths. In mental health terms, this further suggests that the burden of excess bereavement and trauma will fall most heavily on those who are already most disadvantaged.
Our Survey Data
The impact of financial inequalities on mental health during the pandemic is becoming evident in our longitudinal research.
Worries about employment:
One in five people surveyed (20.55%) – and more than one third (34.01%) in full-time work – are concerned about losing their job.
One fifth (19.70%) of people surveyed who identified as unemployed have had suicidal thoughts and feelings in the last two weeks – this is compared to 8.64% of people in employment.
People most worried about financial concerns are people in middle age.
Twice as many unemployed people (25.85%) surveyed say they are not coping well with the stress of the pandemic compared to people in employment (12.25%).
Over one in 10 (10.93%) unemployed people surveyed say nothing has helped them cope with the stress of the pandemic.
Worries about finances, debt and having enough:
Whilst the overall picture for many is improving, one third (32.66%) of UK adults say they are worrying about their finances, such as bill payments and debt.
Using a broad categorisation, people in lower socioeconomic groups (c2de) (35.11%) are more likely to have financial concerns than people in higher groups (abc1 – 30.81%).
Almost half of people surveyed who are unemployed (44.7%) say they were worried about having enough food to meet their basic needs in the past two weeks, compared to 29.32% of people in employment). Since early April, unemployed people are the only group for whom worry about this issue has not reduced.
The Verdict of Our Citizens’ Jury
Our Citizens’ Jury stressed that although the coronavirus pandemic is felt across most of the world, and the UK lockdown measures apply across the country, not everyone experiences its consequences in the same way. The Jury expresses the need to view health and financial security as equally important.
While there will be generic worries about the future across the population, the detailed picture is far more nuanced. People are affected in different ways depending on their age, demographic background, employment sector, type of job and contract, geographical area, membership of at-risk groups and more. Self-employed, small businesses, people with disabilities, people from Black, Asian and Minority Ethnic background, domestic abuse survivors and informal carers were considered high risk groups in this context.
“I think, to some extent, it depends where people start. Because, you know, many people were in insecure jobs, gig economies, part-time jobs, etc, to begin with. And, you know, this has had a massive impact on them. I think the other different impact is people who thought they were in secure positions, so they were in full-time jobs, you know, and generally had enough money to survive, however that was defined, and suddenly find themselves in a very different position. Or, I know some people, to give another example, who are currently furloughed on 80 per cent, or 100 per cent wages, and therefore, in the short term, are okay, but worry whether they will ever have a job to go back to […] So there are so many nuances to this for so many different people.” (Citizens’ Jury member)
They also felt that financial security and related worries and mental health problems are also an evolving situation (dynamic not static). In other words, someone might be fine now but perhaps not in three or six months’ time. They expressed worries that these shifts have been happening since the start of the pandemic and other factors – such as Brexit – might further exacerbate financial insecurity and inequality in the UK.
“We’ve got Brexit that’s still in the background, and how is that going to affect the price of food, the availability of food? Personally, I need fresh green, it’s very helpful for my condition, where is the guarantee that the prices of simple foodstuff isn’t going to go through the roof?” (Citizens’ Jury member)
The voluntary sector is crucial in the coronavirus response, because it supports and safeguards large parts of the population (including those who may be digitally excluded), and the level of financial and other support from the government should reflect that. Any government support should be equitably distributed and should safeguard the diversity of the sector.
“I think it’s worth remembering that, like, within charities, we’re all humans, too, and a lot of the charities are paralysed because of the sheer number of demands upon them. So in terms of what Government and large charities can do, it’s actually supporting that specialist work, to make the community based stuff happen. Otherwise, yeah, a lot of really small specialist places are going to go, I think, unfortunately”. (Citizens’ Jury member)
Overall the Citizens’ Jury validated the view that protecting people’s mental health is of critical importance during this period. A fear was expressed that if the lockdown is very prolonged and/or repeated – the UK might lose more people to the social and economic consequences of the lockdown than to the virus itself.
“It really links in around trauma, and that a lot of people we support, they are dealing with ongoing, quite difficult mental health backgrounds, and different experiences. And I think it’s not so much that people are suddenly plunged into destitution, but that, I think our concern is around, if they start to struggle financially, that’ll be kind of the straw that broke the camel’s back. And that you might see more people in sort of mental health crisis, where it’s been really quite seen as medicalised, or as a disorder, when in fact, it’s really about their financial situation that they have been put in. […] And that I think it’ll be hard, but I think it’s quite important to stay quite focused on social causes of the crisis and difficulty at this time.” (Citizens’ Jury member)
Before the pandemic, it was already evident that higher national levels of financial inequality are linked to a higher prevalence of mental health problems, and that as countries become richer but remain unequal, the rates of mental health problems increase. This is an important risk for the UK government to take into account as the recovery from the pandemic begins. We can expect that the financial inequalities that lead to the increased prevalence and unequal distribution of mental ill-health will be intensified and the benefits of recovery will not be reaped equally by everyone. To address this, we need to see immediate and concerted policy action based on evidence. We recommend the following actions:
Economic security: As a first step, the Universal Credit advance payment should immediately be made a grant, removing the current requirement to repay it over the following 12 months. For the duration of the pandemic and the follow-on economic downturn this grant should be given to all applicants, regardless of their circumstances. In the medium term the Government should convene an expert Taskforce to consider the learning from the Covid-19 crisis and develop proposals for reducing economic insecurity on a long-term basis.
Tackling the debt crisis: Many households will face a financial cliff-edge unless urgent action is taken on debt. According to the Office of National Statistics, the average UK household credit card and personal loans debt in 2019 was £9,400. Importantly, the poorest households have the highest debt-to-income ratio. This means that households will not be in a position to borrow their way out of this crisis; substituting wages with loan debt will only make people’s finances worse given the medium to long-term economic uncertainty.
Government and all private sector providers should pause all debt collection, bailiff visits, interest accrual on debt and deductions from benefits during the pandemic. This will provide a degree of security for people who fall behind on their bills.
We are also calling on the UK’s energy suppliers to immediately halt their use of debt collectors to retrieve unpaid bills and uphold the agreement they have signed with Government to help households during the pandemic.
Finally, with the support from central government, local authorities should ensure that payment holidays on rent and council tax are being offered to those who need them.
Action on Child Poverty: The sharp increase in foodbank use, particularly among families with children, is a real cause for concern. Those who relied on community and school resources such as breakfast clubs, or grandparents to help with childcare, are suddenly having to cope on their own. More time spent at home means higher bills and fewer opportunities to shop around for affordable food. The Government should temporarily increase Child Benefit, the child element of Universal Credit and Child Tax Credit Payments to help low income families weather the storm.
We are also calling for the two-child cap and the benefit cap to be lifted to prevent households being pushed further into poverty.
In-work poverty: The immediate priority must be to guarantee economic security for all. However, research shows that more than half of people in poverty now live in a working family. Too many people are being trapped in poverty by low wages, zero-hour contracts and job insecurity. Key workers such as social care staff have been paid less than the Real Living Wage for too long. Governments across the UK must ensure that all key workers are paid the Real Living Wage. On a medium-term basis, governments across the UK must honour their commitments to tackle low pay across the board.
Prevent stress due to the risk of eviction: The Government should extend the current prohibition of evictions for at least another three months after the end of any lockdown period, and keep this under review with potential for further extension.
Ensure business changes are working for vulnerable customers: Government should monitor the measures being undertaken by businesses to support their vulnerable customers (including those with existing mental health problems) during the pandemic to ensure that these measures are effective.
Targeted outreach to people who are unemployed: The Department of Work and Pensions should make free psychological support available to all unemployed people and inform them of how they can access it.
Improve infrastructure for social connectedness: National governments should provide a designated funding stream for local authorities to support community development initiatives, including peer support, to promote public mental health. This should be available to all communities and include targeted initiatives for vulnerable communities.
A Whole-Government COVID-19 Mental Health Response and Recovery Plan: The UK Government and devolved governments should ensure a cross-governmental approach to mental health and reducing health inequalities during the COVID19-crisis and in the recovery phase by drafting a Whole-Government COVID-19 Mental Health Response Plan.
The COVID-19 pandemic is putting a huge strain on people’s mental wellbeing. Our longitudinal study on the mental health effects of the pandemic shows that the burden of mental distress is borne disproportionately by those with less economic security. In some cases, these are people facing considerable existing challenges, such as those with existing mental health problems surviving in a destructive cycle of poverty and mental distress, or those facing structural inequalities due to belonging to an ethnic minority group.
Unless action is taken to protect vulnerable people’s economic security and support them in dealing with the resulting stress, mental health inequalities are likely to be exacerbated as the pandemic and the ensuring economic downturn proceed.
There will be no vaccine for these population mental health impacts of the COVID-19 pandemic. Instead, we should urgently invest in meeting our fundamental and complex human needs, starting from addressing the key issue of financial inequality in our societies.