The Long-Term Implications of the Increase in Mental Health Disorders During the COVID-19 Pandemic

The COVID-19 pandemic has proved devastating to health globally and domestically. More than 6.5 million people have died from the pandemic worldwide, with about 630 million cumulative cases. In the United States, more than 1 million people have died, with nearly 100 million cases. The US has had substantially more deaths from COVID-19 than any other country. In addition to deaths directly attributable to COVID-19, the pandemic has been associated with an increase in a range of other physical conditions, both as a direct result of COVID-19 and as an indirect consequence of the limited attention to health and greater exposure to stressors during the pandemic. For example, there has been an increased risk in cardiovascular disease in the aftermath of even mild COVID-19 infection.¹  In addition, heart disease rose during the early days of COVID-19, reversing a trend of declining heart disease rates over the previous 5 years. The cumulative impact of COVID-19-related deaths and deaths due to other diseases during the pandemic have resulted in an unprecedented decrease in US life expectancy.  This sets national health achievement back many years, and the extent to which national health can recover post-COVID-19 depends, in no small part, on recovery from conditions that were worsened during COVID-19.

Perhaps central to the resolution of the health challenges that emerged during COVID-19 shall be the trajectory of mental health disorders that increased during the pandemic. COVID-19 was a traumatic event, one that caused psychological distress and threat to physical harm, positioning it as a cause of poor mental health. It is, therefore, not surprising that there is abundant evidence that mental health disorders across the spectrum of disorders increased during the pandemic.²  The earliest days of the pandemic, with its origins in Wuhan, China, were accompanied by an increase in depression³ among persons in the area. Subsequently, work in a range of countries, including the United States, showed that mood and anxiety disorders increased by a factor of two- to three-fold during the pandemic⁴, and stayed elevated during the first two years following the start of the pandemic.⁵  The World Health Organization estimated a 25% global increase in the prevalence of depression and anxiety. Consistent with this observation, a global systematic review⁶ documented more than 50 million more cases of depression and more than 75 million more cases of anxiety worldwide. It shall fall to future longitudinal research to document the trajectory of this burden of mental illness due to COVID-19, although prior research⁷ would suggest that these levels of poor mental health will remain elevated for many years to come.  This increase in mental health burden, and the anticipated persistence of at least some amount of this burden over many years, suggests important implications for the course of health overall in the years when the world is navigating past the COVID-19 pandemic. Four considerations rise to the forefront.

First, the burden of poor mental health itself is associated with morbidity and mortality that will continue to affect overall population health and well-being. We know, for example, that depression is linked to limitations in work and social function. Prior to COVID-19, it was estimated that the overall cost of major depressive disorders in the United States was more than $200 billion, and that depression in the United States cost more than 200 million lost workdays.  More than 10% of physician visits and more than 10% of emergency department visits are linked to depression. Persons with depression/anxiety die nearly eight years earlier than other persons, and about 3.5% of population deaths in national representative studies are attributable to depression/anxiety.⁸  It is unclear how much these costs may increase with persistent poor mental health in the post-COVID-19 period, but there is little question that we will continue to incur societal costs that well exceed those that would have occurred absent this increase in pandemic-related poor mental health.

Second, poor mental health is associated with the physical consequences of COVID-19 that are likely to linger and affect population health. For example, a systematic review found an association between mental health disorders and COVID-19-related mortality.⁹  It is also becoming clear that mental health disorders are important predictors of long-COVID symptoms¹⁰, and long-COVID is, in turn, likely to be responsible for substantial morbidity in the post-pandemic long run. Untreated mental illness is associated with an increased risk of cardiovascular disease. Other physical disorders with high morbidity and mortality rates, such as cancer and stroke, are worsened by poor mental health.¹¹  Importantly, the impact of increased mental health disorders can be felt over the lifecourse. For example, poor mental health among caregivers is associated with subsequent poor mental health among children that can then affect their health throughout their lives.¹²  This all points to a compounding effect of mental health disorders on other health conditions in the population that can extend for decades after the pandemic.

Third, the burden of mental health disorders linked to COVID-19—much as with all the other health consequences of the pandemic—was not experienced equally, with some groups experiencing a greater burden than others. Almost universally, persons with fewer socioeconomic resources bore, and continue to bear, a greater burden of mental health disorders than persons with greater resources.¹³  While the increase in mental health disorders during the pandemic have occasioned a greater appreciation of the importance of mental health in the public conversation, the disproportionate burden of mental health for groups that already experience socioeconomic disadvantage is far less well recognized.

Fourth, while much of our thinking about the mental health consequences of the pandemic focuses on increases in mental health disorders, it is equally important to recognize that the stressors of the pandemic are associated with an overall increase in symptoms, and a shift in the number of mental health symptoms that affects populations well beyond those who meet diagnostic criteria for disorders. This means, for example, that an increase in symptoms such as poor sleep or irritability may be experienced as challenges to social interactions or limitations to achieving role functioning like success in school and work.  These changes to social interaction have been experienced consistently in societies worldwide during the COVID-19 pandemic and threaten to continue as the world emerges slowly from the large-scale changes that were needed to contain the pandemics.

The rise in mental health disorders as a result of the COVID-19 pandemic should be renewed reason for redoubling our attention to providing mental health services and re-imagining the delivery of such services¹⁴—domestically and globally¹⁵— that have historically fallen far short of the need for them.  It also, however, suggests the need for a recentering of mental health in the population health conversation. When we recognize that the mental health consequences of COVID-19 include a direct increase in morbidity and mortality, an increase in the complications of other physical disorders, in an increased burden to groups that already face disproportionately poor health, and in an increase in sub-syndromal symptoms that affect a range of social functioning, it is not a stretch to note that these consequences may end up being among the most important long-term consequences of COVID-19. This also calls for renewed focus on understanding the mental health consequences of large-scale traumas like COVID-19, to the end of mitigating them.

References

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