A hidden pandemic? An umbrella review of global evidence on mental health in the time of COVID-19
Background: The mental health impacts of the COVID-19 pandemic remain a public health concern. High quality synthesis of extensive global literature is needed to quantify this impact and identify factors associated with adverse outcomes.
Methods: We conducted a rigorous umbrella review with meta-review and present (a) pooled prevalence of probable depression, anxiety, stress, psychological distress, and post-traumatic stress, (b) standardised mean difference in probable depression and anxiety pre-versus-during the pandemic period, and (c) comprehensive narrative synthesis of factors associated with poorer outcomes. Databases searched included Scopus, Embase, PsycINFO, and MEDLINE dated to March 2022. Eligibility criteria included systematic reviews and/or meta-analyses, published post-November 2019, reporting data in English on mental health outcomes during the COVID-19 pandemic.
Findings: Three hundred and thirty-eight systematic reviews were included, 158 of which incorporated meta-analyses. Meta-review prevalence of anxiety symptoms ranged from 24.4% (95%CI: 18–31%, I2: 99.98%) for general populations to 41.1% (95%CI: 23–61%, I2: 99.65%) in vulnerable populations. Prevalence of depressive symptoms ranged from 22.9% (95%CI: 17–30%, I2: 99.99%) for general populations to 32.5% (95%CI: 17–52%, I2: 99.35) in vulnerable populations. Prevalence of stress, psychological distress and PTSD/PTSS symptoms were 39.1% (95%CI: 34–44%; I2: 99.91%), 44.2% (95%CI: 32–58%; I2: 99.95%), and 18.8% (95%CI: 15–23%; I2: 99.87%), respectively. Meta-review comparing pre-COVID-19 to during COVID-19 prevalence of probable depression and probable anxiety revealed standard mean differences of 0.20 (95%CI = 0.07–0.33) and 0.29 (95%CI = 0.12–0.45), respectively.
Conclusion: This is the first meta-review to synthesise the longitudinal mental health impacts of the pandemic. Findings show that probable depression and anxiety were significantly higher than pre-COVID-19, and provide some evidence that that adolescents, pregnant and postpartum people, and those hospitalised with COVID-19 experienced heightened adverse mental health. Policymakers can modify future pandemic responses accordingly to mitigate the impact of such measures on public mental health.
COVID-19 and Australia’s Mental Health:
An overview of academic literature, policy documents, lived experience accounts and community reports
Over the past 20 months, the COVID-19 pandemic has been a profound disruption to Australians’ daily lives. Many of our daily activities and schedules have changed beyond recognition, including the way we work, go to school, see friends and family, play sport, travel, exercise and engage in hobbies. Economic insecurity and increased job loss have propelled many Australians into financial stress. With the recent Australian outbreak of the Delta Variant, there is widespread uncertainty about what the future will look like.
Compiled by Australia’s Mental Health Think Tank, this is the first Australian report to tie together multiple streams of knowledge to present an overview of the mental health impacts of COVID-19 and resultant policy measures. Using the best available knowledge, it aims to understand:
What are the main ways COVID-19 has impacted on Australia’s mental health?
Who has been the most impacted, and why?
What are the lessons from the COVID-19 pandemic that can inform a plan to protect
Australia’s future mental health?
The evidence collated in this synthesis contains important depth and insights, but it is not exhaustive. It draws on a wide-ranging knowledge base including Australian and international published literature, government plans, budgets, policy reports, inquiries, grey literature and public commentary about the mental health and wellbeing impacts of the COVID-19 pandemic, and voices from those who have generously shared their experiences around COVID-19 and mental health.
At the time of writing (August/September 2021), NSW, VIC and the ACT are amid another extended lockdown and SA, WA, the NT and QLD have been in-and-out of snap lockdowns, and with a slower than hoped vaccine rollout, there may be more lockdowns and border closures to come. Much around the pandemic, including pathways to an Australia beyond the pandemic, remain uncertain.
Unfortunately, there are gaps in the evidence and data. Much of the existing Australian published research relates to the March to May 2020 period when national lockdown and restrictions first occurred. While this provides meaningful learnings about the mental health effects of early-stage COVID-19, more research is needed to track the longer-term mental health impacts of COVID-19 in Australia.
Based on the evidence presented the Think Tank identified several key insights, including:
- Australians are experiencing deteriorating mental health as a result of the COVID-19 pandemic. While the pandemic experience across communities in Australia has varied, there has been a population-level deterioration in mental health which echoes experiences overseas in countries with much higher COVID-19 infection and mortality rates. For example, there is evidence that Australians are experiencing more anxiety and depression, and are engaging with suicide prevention and other mental health support helplines, more often than prior to the pandemic.
- The impact of the pandemic on mental health appears to have disproportionately burdened certain members of Australian society, including but not limited to young people; females; people living with a disability or existing mental health issue; culturally and linguistically diverse people; Aboriginal and Torres Strait Islander peoples; people on low incomes, people experiencing job loss or people living in poor quality housing conditions.
- Government interventions during the pandemic have had mixed impacts on Australians’ wellbeing. Financial support and adaptations to the Medicare Benefits Scheme appear to have played an important role in protecting against the increased mental ill-health risks, including suicide risks. However, lack of systemic change to our already-stretched service system has meant that increased demand has further intensified barriers to high quality mental healthcare.
- The impact of social connection and disconnection on Australians’ mental health is becoming increasingly clear, as more research into the impact of the pandemic is being undertaken. The difficulties that some Australians have faced in maintaining their social connections during the pandemic appears to have led to significant mental health challenges.
Directions for reform
Over the coming weeks and months, Australia’s Mental Health Think Tank will release research and recommendations for reform in response to each of the key lessons outlined above. As the Think Tank prepares those recommendations, the team warmly welcomes contributions from the broader community.
Supporting long-term community resilience and recovery has never been so important. With the full and lasting impact of this global pandemic still to be realised, we must create and invest in innovative solutions now and into the future. Pandemics and other crises can be catalysts to rebuild in new, more effective, systems but this requires vision and interconnectivity at Local and National levels.
Evidence review – what we found
Following is a summary of the key findings within the three components of this report.
Part A. Overview of Evidence: COVID-19 and Mental Health in Australia
- 1. Acute and long-term impacts of COVID-19 infection
- Emerging global research suggests that contracting COVID-19 may be linked to acute and long-term mental health outcomes, particularly connected to ‘Long-COVID’. As case numbers in Australia have been heavily geographically-focused to certain States and, within these States, to people experiencing socioeconomic disadvantage, the mental health outcomes of COVID-19 infection are likely to be disproportionately experienced by these members of Australian society.
2. Physical restriction measures such as hotel quarantine and lockdown
At a Federal / State / Territory level, lockdowns have been instituted at different times and in different areas, significantly varying the pandemic experience for Australians. The lockdowns implemented in Australia were some of the longest in the world. There is evidence that periods of lockdown are associated with deteriorated mental health.
Undergoing hotel quarantine could have negative mental health consequences. There is limited research, but one study showed mental health was the most common presentation category amongst people referred by Sydney hotel quarantine to hospital emergency departments.
3. Economic impacts
The Australian Government’s economic support package introduced in 2020 (including JobKeeper and the ‘Coronavirus Supplement’ to welfare benefits) buffered the negative impacts of COVID-19 on mental health to some extent. Research showed financial stress was a primary driver/risk factor for poorer mental health outcomes during the pandemic. Receiving the ‘Coronavirus Supplement’ income support was found to be associated with reports of improved living standards and lower anxiety. Many lost work due to lockdowns – either temporarily or for an ongoing period – and those who did experienced worse mental health outcomes. Younger people, particularly younger women, were likely disproportionately affected by the mental health impacts of employment loss.
4. General population-level mental health impacts
There were population-level mental health impacts, with increases in psychological distress coinciding with increases in case numbers and resultant lockdowns. No significant differences were found in mental health outcomes between States and Territories, even during the 2020 elongated Victorian lockdown, suggesting that COVID-19 outbreaks and restrictions appear to have a universal effect on Australians’ mental health, irrespective of location. There was also some evidence that COVID-19 lockdown and restrictions may have led to an increase in alcohol consumption and drinking behaviours, particularly amongst those who had worse mental health, had higher income, or were middle-aged. Fortunately, despite an increase in psychological distress during 2020, National and State suicide monitoring data showed no evidence of a rise in deaths by suicide in the same period.
5. Mental health impacts on specific populations
5.a Unfortunately, the pre-existing mental health inequalities between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians continued, with Aboriginal and Torres Strait Islander peoples experiencing higher anxiety and stress than non-Indigenous Australians during the pandemic.
A world-leading Aboriginal and Torres Strait Islander community response to COVID-19 meant there were no deaths from COVID-19 in Aboriginal or Torres Strait Islander people prior to August, 2021. However, delayed rollout of the COVID-19 vaccine has seen a disproportionate impact of the Delta variant on Aboriginal and Torres Strait Islander communities.
5.b Some evidence suggests that COVID-19 was associated with a worsening of symptoms amongst Australians with existing mental health disorders, including those with eating disorders, bipolar disorder, anxiety and depression. Fortunately, there was evidence that these elevated symptoms reduced over time. Very little Australian research exists exploring the impact of COVID-19 on people with co-occurring mental health and substance use disorders, however international research suggests that the pandemic is likely to have a negative psychological impact on this group. Research also suggests that people with pre-existing mental health disorders may be at increased risk of contracting COVID-19.
5.c Several studies, mostly focusing on children and young people and their families, exposed the negative impact of the 2020 lockdowns and associated restrictions on the mental health of Australians with a disability or chronic illness, including compromised education and learning outcomes, and associated feelings of loneliness and isolation
5.d Few Australian studies specifically researched the mental health outcomes of migrants and culturally and linguistically diverse people, however one study found respondents born outside of Australia were more likely to report clinically significant levels of anxiety. In 2020, this group experienced unique COVID-19 related challenges, including a lack of eligibility for financial support from the Australian government, heightened racism and prejudice, and higher lockdown-related unemployment.
5.e Several Australian studies found that Australian children, adolescents and young adults have experienced heightened depression and anxiety during the pandemic, with research suggesting restrictions on social activities as a leading factor.
5.f There is some evidence that older Australians had better mental health during the pandemic than younger Australians. However, there was some indication that older Australians who were female, had lower educational attainment, received government pensions, had chronic health conditions, or were isolated had poorer mental health than those without these characteristics.
5.g Multiple Australian studies showed Australian females had significantly worse mental health during the April-May 2020 period of restrictions, including higher anxiety, depression, distress, self-harm and irritability, compared to males. In adolescents, identifying as non-binary or gender-diverse was associated with increased stress and anxiety relative to those identifying as male.
5.h Parents of children under the age of 18 were found to have worse mental health during the 2020 COVID-19 restrictions compared to pre-COVID levels, particularly those supporting remote learning. However, many parents also expressed positive experiences of meaningful connection and appreciation with their families during the restrictions. Studies highlighted that parental groups who appeared to be more susceptible to poor mental health during the pandemic, included parents of children with a disability, younger parents, mothers and employed parents.
5.i Very little research has examined the mental health of people in rural and remote communities during COVID-19. Commentary has highlighted the cumulative effect that COVID-19 may have above the psychological stress of the recent bushfires in regional and rural communities, however one study found that people in rural or remote communities may have been less susceptible to the poor mental health risks of COVID-19 than their urban counterparts.
5.j Australian research has found a general sense of anticipatory anxiety amongst health care workers. Nurses and midwives had worse mental health than doctors and allied health providers. Other non-healthcare ‘frontline’ workers, including emergency services, disability workers, and those working in logistics, transport, retail, or hospitality also experienced poor mental health.
5.k One study with data collected during and after COVID-19 lockdown and restrictions found individuals residing in unsuitable housing (poor-quality, noisy, dark, insecure, or unaffordable) were disproportionately affected by poor mental health.
5.l Evidence shows there has been a reduction in the number of Australians who reported gambling behaviours, in both online and venue-based formats, since the pandemic began.
5.m One study found that higher educational level was associated with lower psychological distress and loneliness, and higher quality of life and psychological wellbeing, compared to those with lower levels of education.
5.n While Australian research on the mental health impacts of COVID-19 on LGBTIQ+ communities remains critically scarce, Equality Australia’s 2020 COVID-19 Report highlighted that the pandemic has presented significant challenges for LGBTQI+ peoples, including greater barriers to accessing healthcare, increased levels of psychological distress, and reduced opportunities for social connection.
In a cross-sectional study among trans Australians (Zwickl et al., 2021), more than half (61.1%) experienced clinically significant symptoms of depression and almost half (49%) reported thoughts of self-harm and suicidal ideation during the first three months of the pandemic, underscoring the need for targeted mental health services and support amongst trans and LGBTQI+ communities during and beyond COVID-19.
Part B: Demands on the mental health service system
The Australian Government released several measures to support the mental health and wellbeing of Australians, including:
- Updates to the Medicare Benefits Schedule (MBS) to support the provision of mental health care via telehealth for GPs, psychiatrists, psychologists
- Updates to the MBS to provide access to 10 additional subsidised psychologist appointments, and
- Funding for charities to provide extra online and call centre counselling support associated with COVID-19.
The Think Tank has identified that, despite these government measures, the pandemic put further strain on Australia’s already over-burdened mental health system. Lived experience accounts from Australians surrounding their interactions with the mental health service system during the pandemic are presented in Section C.
Part C: What do Australians consider as the main issues in mental health since COVID-19?
As part of the Alone Together Study, 1037 adults across Australia shared their thoughts regarding the most important issues surrounding mental health between March and June 2021. We encourage you to read the rich insights provided by these Australians in the body of this report. Key themes that emerged in the analysis of their responses were:
- the pandemic led to an increase in job insecurity, financial hardship and precarity, causing stress and anxiety about paying for housing and resources,
- the pandemic shrunk and fragmented participants’ social worlds – leading to feelings of loneliness and isolation, and
- existing barriers to mental health treatment remained, or were exacerbated by, the pandemic, including access-related barriers (cost, waitlists, and lack of local service options), societal barriers (political and social stigma, social inequity), and holes in the mental health service system which meant people ‘fell through the gaps’ of available support and were not afforded the ‘right’ or appropriate care.
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