COVID and the true cost of mental health crises

Famously, one of our prime ministers, Jim Callaghan, returned from holiday once to an economic crisis and announced on the steps of the plane: “Crisis? What crisis?”

I've often said the same about mental health because, throughout my career, we've always thought we were in a mental health crisis. Things were always thought to be getting worse. Things were harder for us than for the previous generation, with rates going up.

However, in my work as an epidemiologist, I know that the rates for nearly all of our mental disorders have been very stable since the Second World War. These disorders are schizophrenia, bipolar disorder, obsessive compulsive disorder and major depression. None of this has changed.

On the other hand, people are talking about mental health much more. That's a good thing. People are presenting to services much more often than they used to, which is also a good thing, providing the services can cope. But the true rates of disorders have not changed until recently.

When I talk about shifting trends in mental illness, I’m not just talking about COVID. Over the last five years, we've seen rates of anxiety and depression in younger people, and in particular in young women aged 16 to 24, steadily increasing. They now account for around 18% to 25% of the population. That may not seem like very much, but in population terms, it's a lot of people.

It may surprise you to learn that the people most likely to die from COVID have not been those with diabetes, hypertension or heart disease. Serious though these conditions are, and vulnerable though those people may be, the people most at risk have been those suffering from schizophrenia.

That's partly because people with schizophrenia already have worse health than the rest of us, due to smoking, alcohol, drugs, poor physical health care, not going for health care screening and many other factors. All of these have been made worse because of the absence of community services during the pandemic. When people with severe mental illnesses lose their normal sources of social support, they are more likely to come off their medication and relapse.

When we talk about the mental health effects of COVID, we tend to fall back on the more easily understandable things such as the fear of the virus and the changes in the way that we live now. This has affected people’s mental health, but it hasn’t affected everyone equally. That is the principal truth of pandemics. They have always been exploiters of social division, discrimination and exclusion.

This is nothing new. Take, for example, the Black Death. In 1356, the chronicler Simon de Couvin wrote that the plague spares the judges, the knights, the bishops and the princes. In other words, the better off you are, the better you do. In most of our societies, those with severe mental illness are very much at the bottom of our social scales, as are those discriminated against for other reasons.

Since young people have been the ones most affected by the increase in mental disorders over the last decade, it’s no surprise that they’ve also been more affected by COVID. I say no surprise, but actually it is a little surprising because we all know that the younger you are the less likely you are to suffer from, or indeed die of, COVID. The older you are, the greater that risk, particularly if you're very infirm and elderly.

If young people have little to fear from COVID, why do they have the highest rates of mental disorders? There are various reasons. First, it's interesting that this time last year I was doing a lot of media talking about the non-crisis or the small crisis in mental health and was always being told that the obvious cause in the young must be social media. This was usually said by people my age, i.e. people for whom social media has been a bit of a surprise and who aren’t very comfortable with it.

I've always thought this reflects my generation's lack of understanding of social media. We seem to instinctively believe that it’s a kind of social ill that causes great problems in the young. If you ask the young, they don’t always say that. In fact, the evidence shows that social media has been a real godsend during the pandemic, particularly to teenagers in our secondary schools who would have coped far worse without it.

So why have younger people been hit so hard by the pandemic? I suspect some of it is to do with loneliness, which has increased most in that group. Then there’s the tremendous, appalling things that have been happening in their education. Finally, there’s the fact that COVID is affecting their life chances. If young people are able to go to university at all, they’re having a pretty dreadful time there. People like me had a great time at university, and we didn’t even have to pay for it.

It may seem obvious why COVID has worsened mental health. Like all pandemics, it's a frightening thing. There is a new threat of death. There is a new concern about our health. It affects us all. Our prospects have changed. All of that is true but, of course, it's been true of a lot of other adversities in the past as well. I've studied war, terrorism, floods and natural disasters. None of them have had the effects of COVID. Why?

What COVID has done – its essential wickedness – is to affect the very thing that gets us through adversity, which is sharing the experience with our friends, family or colleagues, the people we knew before, during or after a particular serious event. Because it is the best way to manage the pandemic, we have had no choice but to destroy those social connections that keep us mentally healthy and resilient for most of the time, without any intervention from people like me.

We must remove social distancing limits as soon as possible. I’ve heard people talking about a new world in which we will have to be socially distanced for years and maybe generations to come. I hate this talk. We need to go back to the old ways when it comes to socialising, being with each other, getting comfort, support and resilience from each other. The old ways worked very well and will work very well again. The quicker we remove the bans on social distancing the better our mental health will be.

Speaking as someone trained in epidemiology, it's important to differentiate two things. On the one hand, we're talking about the true rates of disorder in a population, be it mental illness, cancer, diabetes or heart disease. Those true rates tend not to change very much. In mental health, they've changed very little until very recently.

On the other hand, rates of help and treatment seeking have changed dramatically, particularly for mental health issues. People are seeking help for problems of depression and anxiety in far greater numbers now than they did even five years ago, let alone 30 or 40 years ago. That is why it appears that the numbers are going up: it’s because the waiting lists are getting longer. But the actual disorders themselves have not changed much.

Does that matter? Actually, it does because some people are probably receiving treatment that they don't need. They would probably have recovered anyway using their own resources, their own networks and their own resilience. Adding in a professional like me, who’s expensive and has long waiting lists, may actually perpetuate someone’s mental health issues.

That’s the problem of medicalisation. It may change something from a transient disturbance that doesn’t require professional help into something more prolonged. This is not unique to psychiatry and mental health, but it can sometimes be more pronounced in the world that I live in than the world of some of my colleagues.