The divergence of mental health experiences during the pandemic

Overall, the levels of distress are receding, and most people are feeling able to cope. As of the third week of June, 49% of the population had felt anxious or worried in the past two weeks due to the pandemic, down from 62% in mid-March. But there are still millions of people across the UK who are struggling with the stress of the pandemic. Therefore, it is important to look at the effects over time and watch for groups that might need more help as their social circumstances change during each phase of the recovery.

Differences in people’s response to the pandemic are not randomly distributed across the UK – they arise from people’s social and economic position in society. Groups affected by socioeconomic inequalities have been more likely to experience anxiety, panic, hopelessness, loneliness, and to report not coping well with the stress of the pandemic. Most worryingly, as of the end of June, one in ten people in the UK reported having had suicidal thoughts or feelings in the past two weeks, and in certain disadvantaged groups there are even higher proportions of people with suicidal thoughts and feelings. These inequalities in impact have important implications for planning public services and support.

The divergence in the mental health effects of COVID-19 is of serious concern. It points to the need for a response and recovery plan that is multifaceted and addresses not just provision of mental health services, but also the social determinants of mental health and a reduction in socioeconomic inequalities, in order to minimise the extent of mental health problems during and after the crisis.

This briefing reports findings from the Coronavirus: Mental Health in the Pandemic study as of the fifth wave of data collection carried out between 18th and 22nd June. 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. Read more 'About the 'Coronavirus: Mental Health in the Pandemic study'.

Much of the difference in mental health effects depends on the level of resources each of us has to weather the storm: depending on the size of our boat and the navigation equipment at hand, we will be able to cope better or worse with the waves of the pandemic. For example, it may be easier to cope with some consequences of the virus, such as changes in working conditions, income, or access to education, or even not being able to be physically close to friends and family, if one lives in a comfortable house, with a good internet connection and some savings, in an area with good access to parkland.

Some of the difference in capacity to cope reflects differences in age, gender, and other demographic factors, as well as other pre-COVID19 life experiences, including, crucially, having pre-existing mental health problems, having lived through adverse childhood experiences, being a victim of racism and discrimination, or suffering from loneliness and isolation. It is important, therefore, to pay particular attention to social groups who are likely to have been affected worse by lockdown measures, the coronavirus and the economic consequences.

Differences in impact of COVID-19

In this report we highlight the divergent experiences of the pandemic that are surfacing in the Coronavirus: Mental Health in the Pandemic Study.

Evidence is increasing that the COVID-19 pandemic has affected the mental health of sections of the population differently, depending on their circumstances. The pandemic seems to have widened mental health inequalities, with the groups that had the poorest mental health pre-crisis also having had the largest deterioration in mental health during lockdown.¹ The economic effects are also variable. There are some signs of increasing economic inequality, with more people on lower personal incomes reporting reduced income in the household because of the coronavirus as lockdown has continued, working fewer hours, and being less able to save for the future, while fewer people with higher incomes have been impacted financially.² Already, estimates are that half a million people are likely to experience mental health problems as a result of the economic impact of the pandemic.³

Members of our study’s Citizens Jury agreed that the pandemic and related measures affect everyone, but some more than others.

One member of the Jury commented:

I see almost a kind of big matrix, where you have, sort of the effects on the population as a whole. And then kind of additional effects at different times, for different groups. And then you begin to build up the picture of how it affects the population as a whole. (Citizens’ Jury member)

The Jurors identified issues around communication, information sharing and transparency across the UK and devolved nations in relation to lockdown and especially in relation to the lifting of the lockdown. The Westminster Government and the devolved Governments have different approaches and messaging. This generates confusion, stress and anxiety about who to believe and about who to follow.

As one member of the Jury noted:

It's worth noting devolution. So, in Wales, we’re a few weeks behind what you're doing in England. Scotland, again, slightly different. And I think it's difficult for people to know where they should get their information from, sometimes, in order to know exactly what the situation is for them, where they're based. (Citizens’ Jury member)

These feelings are also reflected when it comes to returning to work and more anxiety related to financial security, once financial support (such as the furlough scheme and grants) will cease (especially in light of ongoing issues with Universal Credit, self-employment, zero hours contracts, the job market drying up, and more). Further concerns were expressed in relation to Health & Safety at work, public transport when travelling to work and being in the workplace when working in proximity to each other.

The high-risk population groups

Based on quantitative evidence from our repeated representative surveys, and qualitative evidence from our citizens’ panel, we are highlighting the following groups as being at particularly increased risk of mental health problems or of not benefitting from recovery equally, unless action is taken. We acknowledge that our list is unlikely to be exhaustive.

Young adults have been especially badly hit during the pandemic with a triple whammy of curtailed education, diminished job prospects and reduced social contact with peers. The period between ages 18 and 24 is already a time of especially high risk for experiencing a mental health problem. Three-quarters of mental health problems arise before the mid-twenties. Post-traumatic stress disorder (PTSD) usually peaks in young adulthood (16 to 24).⁴ The Adult Psychiatric Morbidity Survey for England and Wales carried out in 2014 found that 17.3% of adults aged 16 to 24 (26% of young women and 9.1% of young men) had symptoms of a common mental disorder such as anxiety or depression.⁵ The gender dimension of mental health among young people is important: the trend in mental health problems between 2000 and 2014 was of an increase among young women, while young men’s mental health had remained relatively stable. However, the latest suicide statistics (2018) showed that rates among young men aged 20 to 24 increased by 30%.⁶

A young Jury member confirmed these feelings of anxiety, and described the impact that the pandemic is having for the current generation of young people:

...And I feel like this pandemic, as we are all aware, is exacerbating existing inequalities, and existing forms of oppression. And I feel like, I can probably understand why young people feel anxious, when it feels like their whole, like, their whole generation is being wasted.

I feel like we don't have enough guidance in regards to what’s happening, and how quick the economy is shifting, in our lifetime, and how quickly and flexible we have to be with digital skills. (Citizens’ Jury member)

There is an urgent need to put in place special measures to support the mental health and well-being of young people aged 18 to 24 with a particular view to addressing uncertainty around employment opportunities and education provision.

Members of the Citizens' Jury discussed how young people are experiencing the threat of unemployment, and loss of other opportunities, which in turn will have a negative knock-on effect for future career and development opportunities. Moreover, the younger generation may be more prone to counteract this threat of unemployment, through the unrealistic expectation of ‘vlogging’ or ‘youtube fame’. This is also coupled with the adverse impact of comparison on social media, for example body image issues from the pressure to look a certain way and comparing one’s body to idealistic ‘perfect’ bodies on social media. This may be a particular threat at the moment as presumably more people are likely to be spending time on social media as they are at home much more.

And I feel like there has always been a, like, a false conception in my generation that, you know, like you do something and all of a sudden you become a celebrity, and you have this whole influencer kind of persona that’s hanging over your head. And it's just unrealistic. (Citizens’ Jury member)

However, specific issues exist around older people (over 60) and loneliness which were already there before lockdown and are now exacerbated with lockdown and shielding.

Members of the Citizens’ Jury emphasised the types of strain felt by people in later life due to lockdown measures. While the restrictions have brought separation from family, friends and a range of other social supports, lifting the restrictions may cause new worries for older people who will no longer have the same level of protection as during full lockdown.

Specific issues were raised around older people (over 60) and loneliness which were already there before lockdown and are now exacerbated with lockdown and shielding. Furthermore, some Jurors identified a fear of death in older people, and being alone much more so than younger people. Some had a perception that the end of the lockdown was pushed by the demands of those of working age, who do not have the same health risks as the older population.

There's two million people that have been shielded, or just over two million that have been shielded. Of those, the vast majority are over 60. Those people are not satisfied, a lot of those people are not satisfied with the public health measures which have been put into place to entice them out of their homes. […]

Their support is going to be cut off, in terms of free food parcels, that will rely on local charities. And statutory sick pay, if they are working, is going to be cut off, and a lot of over 60s have to work. And all these people are extremely concerned about life and death, and that is, you know, a very big issue. (Citizens’ Jury member)

These feelings were shared by our Jurors, as for example one member stated:

Quite clearly, people with pre-existing mental health conditions, there are fairly serious impacts in lots of ways in terms of lockdown, in terms of coming out of lockdown (Citizens’ Jury member)

People with long-term, disabling physical health conditions

Some people with long-term, disabling physical health conditions have been more likely to experience poor mental health and/or well-being during the pandemic.⁶

While the ONS has also found that, as of 9th-18th June, a majority (60%) of people in the official category of ‘shielding’ had not experienced a worsening in their mental health since being given shielding guidance, 29% said that their mental health had become slightly worse, and 7% said it had become much worse.⁷

The UN Office of the Commissioner for Human Rights has also drawn attention to the exacerbation of disability inequality during the pandemic due to attitudinal, environmental and institutional barriers.⁸ People with disabling long-term health conditions may find themselves even more isolated and cut off from essential support. If living in residential care settings, they may find themselves at high risk of getting the virus while at the same time having less access to information and health services. Ironically, the normal barriers people with disabilities face in trying to gain access to health services will have increased at a time when they are at even greater risk of disease. So too, their unequal position in the labour market may be exacerbated at a time when employment becomes more uncertain in general.

Disabled people who are trying to seek work, they are already disadvantaged in the labour market, they're going to be even more so, you know, when you’ve got increased competition for work. And you’ve got employers who think that disabled people are, you know, they're going to be a higher risk to take on in the workplace. (Citizens’ Jury member)

Single parents

The Gingerbread charity for single parent families has highlighted the worries of single parents at this time. They have seen a large spike in the number of single parents seeking support through their helpline and their online forum.⁹ Many single parents are reliant on insecure jobs which have been disproportionately cut during the pandemic. Financial strain combined with greater isolation and loss of social support has put single parent families under duress. Home schooling will have been much more difficult for single parent families than for those where the ability to share such duties exists.

Single parents of infants and toddlers are of special concern due to the formative impact of the early years on later mental health. The pandemic has heightened the mental health risks associated with being socially isolated with a baby or very young child, at a time when parents are known already to experience sleep deprivation, which itself can affect their mood and their ability to cope with stress. There is thus potentially a higher risk of postnatal depression and other perinatal mental health problems, with far fewer opportunities for these to be identified by people close to them or by primary care services, to enable support to be offered at an early stage. This is not only a concern for mothers themselves, but, because of the negative effects of postnatal depression, on babies’ own emotional health, and their social and cognitive development.

Transgender people

While it was not possible to gather information on the LGBT+ community in our UK-wide surveys and most surveys conducted so far in the pandemic comprise convenience samples, the Citizens' Jury has expressed clear concern about transgender people’s mental health during the pandemic.

Our Jurors presented issues that the lockdown has posed to trans people, for example living with non-supportive families:

I think some of the difficulties people are experiencing, for example, I think trans people are, have been reported to be having to increasingly, you know, stay at home with parents who might not be supportive of their gender identity, and their pronouns. (Citizens’ Jury member)

As reported in our special briefing, The COVID-19 pandemic, financial inequality and mental health, 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.¹⁰ The 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.

Members of the Citizens’ Jury highlighted frustration and uncertainty about benefits claims, with difficulties reported in filing claims for Universal Credit. They highlighted financial insecurity, which is particularly pronounced for students and the unemployed, but also for those in employment who cannot make ends meet, such as in the gig economy, arts industry, zero-hours contracts, working multiple jobs, and for those who have been furloughed or are at risk of redundancy. This increase in financial insecurity will widen the gap between people with wealth or employment and people without these things, particularly as those in secure jobs and secure households have mentioned one of the positives of lockdown is that they were able to save more money. Therefore, this has led to huge feelings of unfairness among people, as well as feelings of powerlessness, hopelessness and feeling loss of identity. We know that being in secure employment is protective for mental health and often tied in some part to self-esteem, self-confidence and how one perceives oneself.

And yeah, I mean, it's that sense of powerlessness, isn't it, to know that things have shifted so much, and you can say, well what are my opportunities, what can I go to? (Citizens’ Jury member)

And I'm a first-generation migrant, so since my family has arrived in this country I've been trying my best to work up the socio-economic ladder. And I feel like this pandemic, as we are all aware, is exacerbating existing inequalities, and existing forms of oppression (Citizens’ Jury member)

Black, Asian and Minority Ethnic (BAME) communities

The mental health of BAME communities is important to review because people from these communities often face individual and societal challenges that can affect access to healthcare and overall mental and physical health. This is perhaps even more critical during the pandemic due to pre-existing influences on mental health problems – such as racism and discrimination and social and economic inequalities – exacerbated by the spread of the infection, lockdown measures and economic downturn.

It is important to note that “BAME” is a term that covers a wide range of people with a very diverse range of needs. Different ethnic groups have different experiences of mental health problems that reflect their culture and context. Our repeated survey data reflect limitations related to small sample sizes, meaning our ability to look at mental health within a specific ethnic group is sometimes limited. Hence, since May, we have introduced additional data collection capturing the experience of BAME communities during the pandemic in relation to mental health. We will be reporting in detail on these data later in the year.

Other groups

Whilst there are some limitations in capturing more nuanced and in-depth details on the mental health of other population groups, in our qualitative work our Jurors identified other social groups as being at greater risk in relation to their mental health at this time and it is our view that these should be taken into account. These include:

• Children and teenagers missing out on schooling
• People with multi-morbidities
• LGBT+ people due to bullying and discrimination
• Parents facing additional pressures (e.g. home schooling)
• People in abusive relationships;
• People who live in areas of deprivation (and without access to green spaces)
• People living in houses of multiple occupation
• People with elderly relatives or with relatives who are shielding or in a high-risk group
• People in manual jobs and those who have to work in close proximity of each other and less flexibly
• People working in the Arts sector
• Non-native people in the UK with family abroad
• Healthcare workers.

Women make up the majority of frontline health and care workers, are more likely to do unpaid work, are overrepresented in low paid and insecure work, and are more likely to have pre-existing difficulties with debt and bills¹³. They are also more likely to shoulder a higher proportion of caring responsibilities. All of the women in these positions were at greater risk of developing a mental health problem before the pandemic and will be at increased risk as the economic ramifications of the pandemic are realised. It is also the case that women are much more likely to be affected by domestic violence and abuse, the risk of incidence of which have increased during lockdown.

A Jury member comments on the role that women have played in relation to caring responsibilities during the lockdown:

I run an entirely women’s organisation, and the majority of us have got school-aged children or other caring responsibilities. And all the kind of home schooling, furlough, or this, that, it's like a logistical absolute nightmare, and it really brings home to me that the people making the policies are not having to think about those kind of things. (Citizens’ Jury member)

The Women’s Mental Health Taskforce recommended that women be explicitly considered in all future mental health policy.

Implications for recovery planning

The findings of our Coronavirus: Mental Health in the Pandemic study point to the need for action to reduce social and economic inequalities when planning for both the recovery and forthcoming pandemic phases. Prevention of mental health problems is possible through effective societal, community and individual support, but it cannot happen within the health sector alone – action must be taken in the spaces where people are born, raised and live (in the home, in schools, their communities and workplaces). The UK and devolved governments must support improvements in people’s circumstances so that they have a better chance of weathering the storm and coming out of it well. While emergency income supports have helped many people, as these are wound down alternative, adequate supports must be put in place to prevent the financial strain that strongly risks poor mental health.

Policy would need to be trauma-informed, in the broadest sense, and have an understanding of what life experiences, and inequalities people might have experienced, that might have impacted on their well-being. And my ideal in a perfect world would be that, the majority of mental health support is actually sitting in a sort of social care type system, and that we’re looking at it from a social, and holistic view, rather than as a medical point of view. I really struggle with, you know, a lot of the holistic support around debt, and housing, and relationships, has been stripped out of mental health services. And I think that, actually, the bottom line is that those are the things that often cause the most problems for people. (Citizens’ Jury member)

Recommendations

1. A Whole-Government COVID-19 Mental Health Response and Recovery Plan – The Government and devolved national governments should ensure a cross-governmental approach to mental health during the COVID19-crisis and in the recovery phase by drafting a Whole-Government COVID-19 Mental Health Response and Recovery Plan.
2. The UK Government should formalise the importance of citizen well-being in all recovery plans by publishing a Well-being Economy Green Paper, drawing on international experience from New Zealand, and experience from elsewhere in the UK. Such a green paper would set out how societal progress could be measured by well-being indicators.
   In the UK, it should look to Scotland's National Performance Framework, which sets out a vision for national well-being across a range of economic, social and environmental factors, and to the Well-being of Future Generations Act 2015 in Wales, which provides not only the ambition and permission, but also the legal obligation, to improve social, cultural, environmental and economic well-being.
3. Trauma-informed public services: Relevant government departments and their arms-length bodies should ensure that standards of practice, guidance and training are made widely available to all public sector services during the recovery phase, ensuring that trauma-informed values and principles act as a framework for organising procedures and practice.
4. In order to increase the reach of mental health interventions, the NHS should accelerate its plans to roll out evidence-informed psychotherapeutic digital mental health interventions, ensuring that these interventions reach people in socioeconomically and/or culturally disadvantaged groups.
5. The government should provide additional resources and mechanisms to enable the health visiting function to continue to provide face-to-face and other support to parents and maintain safe early intervention with families, including those at risk, during the pandemic and in the recovery phase.
6. Local authorities should provide funding for development of safe places for social connection and interaction via community and peer support, utilising community assets such as libraries and other community spaces, green spaces, and also online provision/extension of these.
7. 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.
   Benefit sanctions, which often lead to unwanted stress and anxiety and a worsening of mental health problems, should be halted entirely; this will help both existing benefit claimants and people new to the system.
8. In-work poverty: Governments in the UK must ensure that all key workers are paid the Real Living Wage. On a medium-term basis, governments across the UK must work towards all workers benefiting from the Real Living Wage.
9. Action on Child Poverty: 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.
10. Targeted outreach to people who are unemployed: The Department of Work and Pensions should make free, accessible psychological support available to all unemployed people and inform them of how they can access it.
11. 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 mental health problems) during the pandemic to ensure that these measures are effective.
12. Tackling the debt crisis: 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.
13. 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.
    The mortgage holiday available to landlords should also be extended to provide landlords with equivalent support and to avoid undue pressure being placed on tenants. The government should offer clearer guidance on how landlords and tenants are “expected to work together to establish an affordable repayment plan, taking into account tenants’ individual circumstances.” Some tenants will have accrued significant debt to their property owner over this period and failure to come to an agreement could see a large number of evictions as soon as the prohibition on evictions ends.

Conclusion

While most people will exit the pandemic with good mental health, the findings of the Coronavirus: Mental Health in the Pandemic study clearly suggest that the benefits of exiting the lockdown measures will not be enjoyed equally by all.

Divergence of experience presents a big policy challenge as there are many different groups, areas, impacts and experiences to consider. This huge variety of individual and group identities is difficult to capture in research and it is challenging to produce nuanced policy recommendations that recognise all these different experiences and their effects. A recovery response needs to take a holistic approach that addresses social, systemic and structural inequalities rather than placing the onus on the individual.

The Coronavirus pandemic and related measures of lockdown and their effects on the economy are bringing about massive changes in our societies. While we are all facing this pandemic, there is clear divergence of experience across different ages, geographies and circumstances. We might all be sailing on the same rough sea, but we are not in the same boats and do not have the same equipment to navigate these waters. As a developed society, we have a duty to leave no one behind. In many ways, we were experiencing a mental health crisis before the pandemic. “Building back better” for mental health should start now by adopting a public health and prevention approach.

References

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2. Office for National Statistics (ONS) (2020) ‘Personal and economic well-being in Great Britain: June 2020’ available from https://www.ons.gov.uk/peoplepopulationandcommunity/wellbeing/bulletins…
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7. Office for National Statistics (2020) ‘Coronavirus and the social impacts on Great Britain: 19 June 2020'
8. ONS ‘Coronavirus and shielding of clinically extremely vulnerable people in England: 9 June to 18 June 2020’ available at https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/...
9. United Nations Office of the High Commissioner for Human Rights (29 April, 2020) ‘Covid-19 and the rights of persons with disabilities: guidance’
10. See https://www.gingerbread.org.uk/what-we-do/news/gingerbread-calls-on-gove...
11. OECD. Are All Jobs Good for Your Health? The Impact of Work Status and Working Conditions on Mental Health. In: OECD Employment Outlook 2008. OECD; 2008. p. 203–62.
12. Women’s Mental Health Taskforce (2018) Final Report. Department of Health and Social Care.
13. Women’s Mental Health Taskforce (2018) Final Report. Department of Health and Social Care.
14. Women’s Budget Group (2020) ‘Crises Collide: Women and COVID-19, available at https://wbg.org.uk/analysis/uk-policy-briefings/crises-collide-women-an…