BRIEFING - Covid-19 and the nation's mental health

 
BRIEFING - Covid-19 and the nation's mental health
BRIEFING

Covid-19 and the nation’s mental health
Forecasting needs and risks in the UK: July 2020
Curtis Sinclair, Nick O’Shea, Louis Allwood and Dr Graham Durcan

 Summary
Levels of psychological distress and mental ill health      access to mental health support and increased
are rising internationally in the wake of Covid-19. It is   isolation. This is likely to have a significant mental
not yet known how far and how soon they will fall back      health impact for prisoners subject to long periods of
to levels that existed prior to the pandemic.               being confined to cells.
Research has identified specific groups of people           Youth unemployment has both short- and long-term
facing higher risks to their mental health at this time,    impacts on mental health, as well as on lifetime
including the families of people treated in intensive       earnings. There is a risk that young people will be
care, people with existing mental or physical health        especially badly affected by the recession, whose
conditions, and pregnant women. There is also               biggest impacts are likely to be in industries that
evidence that people with existing mental health            employ large numbers of younger workers.
difficulties have been experiencing a worsening of their    The economic impact of Covid-19 is likely to exacerbate
mental health during the pandemic.                          and entrench social inequalities. This is because its
The impact of the pandemic on children and young            impact is felt disproportionately due to age, existing
people’s mental health is greater in areas and              poverty and deprivation, mass unemployment and less
communities hardest hit by the virus and by lockdowns.      work, and accelerated economic change.
Children from low income families, from Black, Asian        The only solution for the economy will be to cure
and minority ethnic communities and young carers            Covid-19. Reducing the duration of the pandemic will
are all more likely to experience poor mental health        be crucial to reduce its economic impacts.
as a result of the pandemic. Children’s mental health
has been affected by disruptions to their education,        A combination of further waves of Covid-19, a potential
compounded by reduced access to support for their           winter flu epidemic, the likely absence of the furlough
mental health.                                              scheme and a possible no-deal Brexit at the end of
                                                            2020 could have a significant impact on all parts of the
In prisons, actions taken to reduce the risk of Covid-19    UK economy and a consequent effect on the nation’s
to prisoners have also reduced levels of violence and       mental health.
use of drugs, but at the same time they have limited
BRIEFING - Covid-19 and the nation's mental health
Centre for Mental Health BRIEFING Covid-19 and the nation's mental health: July 2020
 Introduction
The global Covid-19 pandemic has brought             research, much of it from China. It looks at
about profound changes to societies worldwide,       emerging evidence from surveys about the
including in the UK. It has also had a significant   mental health of the general population and
impact on people’s mental health. This is Centre     from studies focusing on the risks faced by
for Mental Health’s second forecast of the           specific groups of people, including the families
implications of the virus for the mental health of   of people treated in intensive care, people with
the UK population, in both the short- and long-      existing mental or physical health conditions,
term.                                                and pregnant women.
In our first forecast, we projected that the         This briefing provides a further assessment of
pandemic would increase the number of                the economic impacts of the pandemic and their
people experiencing a mental health difficulty       implications for public mental health. It also
by approximately half a million in the UK. This      reviews evidence relating to the criminal justice
paper updates our forecast, using research           system and to young adults and the potential
and other evidence published since our first         longer term psychological impacts of rising
briefing. It reviews evidence from sources           youth unemployment.
including a growing body of international

 The prevalence of mental health problems in the general population
There is growing evidence of worsening mental        in England, which was 16.9% in 2017 (Public
health in both adult and youth populations           Health England, 2019), these figures point to
attributable to the various social restrictions      a possible rise in demand for psychological
in response to Covid-19. Presently, research         services. Analysis of Understanding Society
on the mental health of a population has come        Covid-19 survey data indicated that self-report
primarily from Asia and, more specifically,          scores on General Health Questionnaire-12
China. However, findings from other parts of         (GHQ-12) had deteriorated by 8.1% per cent
the world are emerging and suggest a similar         since the beginning of the pandemic (Banks and
pattern in terms of mental health deterioration.     Xu, 2020).
Large scale surveys of the general population        What is less clear is the likely number of those
help to capture the likely prevalence of             who are currently experiencing distress who
individuals experiencing symptoms related to         will then go on to develop a common mental
common mental health conditions. In Spain,           health condition as the pandemic continues. A
depressive, anxiety and post-traumatic stress        longitudinal study from China would suggest
symptoms exceeded cut-off points in 18.7%,           that, certainly in the early stages of the
21.6% and 15.8% of the sample respectively;          pandemic, a reduction in these numbers is
meaning that these scores were indicative of         unlikely, at least at 4-week follow-up (Wang
a possible disorder (González-Sanguino et            et al., 2020). Understanding Society study
al., 2020). Similarly, in Italy, 18.6% reported      data may provide further insights, as we move
moderate-to-severe likelihood of psychological       through the various stages of the pandemic, as
distress (Moccia et al., 2020). Compared with        to how quickly, after restrictions are eased, the
the estimated prevalence of common mental            mental health of the nation might return to pre-
disorders (e.g., depression, phobia, PTSD, OCD)      pandemic levels.

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Factors affecting mental health                     from a sample in China that indicates an

                                                                                                         Centre for Mental Health BRIEFING Covid-19 and the nation's mental health: July 2020
                                                    increase in hazardous and harmful alcohol use
Across the range of international studies,          (Ahmed et al., 2020). Furthermore, the issue
several characteristics were found to               was found to be more prominent in younger
be associated with an increased risk of             people (i.e. 18-40 years old). Concerns have
experiencing greater levels of psychological        been raised about the possibility of a surge
distress (such as anxiety or depression). For       in serious alcohol use cases because of the
instance, being female, younger (i.e., under        stress caused by the pandemic (e.g. Clay &
35), having no psychological support, higher        Parker, 2020). Moreover, warnings have also
education level, patients with Covid-19             highlighted the increase in alcohol sales during
and their families, individuals with existing       the beginning of lockdown and how this might
physical or mental health problems, greater         greatly affect both those who are already
exposure to social media and loneliness have        alcohol dependent – who already struggle to
all been indicated as possible risk factors for a   access support – and those on the brink (Finlay
deterioration in mental wellbeing.                  and Gilmore, 2020).
Longitudinal data showed that women’s
scores on a measure (the General Health             Pre-existing health conditions
Questionnaire) of self-reported mental
                                                    Two studies highlight a possible issue around
health worsened by a greater degree (27.4%
                                                    the availability of medication and access to
pre-pandemic vs 44.5% in April 2020) in
                                                    health services for people with existing mental
comparison to men (18.8% vs 28.6%) (IFS,
                                                    and physical health problems. A study from
2020). Moreover, young women saw the
                                                    China found that some people with a mental
largest decline (18.2%) in their mental health
                                                    illness had reduced or completely stopped
alongside an increase in the proportion
                                                    their psychiatric medication because access
reporting at least one severe problem (17.6%
                                                    to prescriptions had been severely impacted
pre-pandemic vs 35.2% in April 2020), which
                                                    (Zhou, Liu, Xue, Yang & Tang, 2020). Moreover,
was higher than that seen for the entire adult
                                                    nearly a quarter of patients in this study
sample (10.6% vs 23.7%). Certain factors
                                                    reported that routine appointments had been
were reported to greatly impact upon women
                                                    suspended since the start of the pandemic.
more than men, such as having symptoms of
                                                    Similarly, Mind (2020) recently found that
Covid-19 at the time of the survey, very young
                                                    around a quarter of people surveyed who had
children, and working in shutdown sectors.
                                                    attempted to access mental health support in
Several other studies, from Asia and Europe,
                                                    the previous fortnight were unsuccessful in
support the finding that women’s mental health
                                                    getting support. Reasons included cancelled
is being more adversely affected than men (e.g.
                                                    appointments, difficulty getting through to
González-Sanguino et al., 2020).
                                                    GP or community mental health team, being
                                                    turned away by crisis services and issues
Alcohol and substance use                           accessing digital alternatives. The sample were
Government advice to remain indoors and             predominantly those who had direct experience
avoid social contact will have affected each        of mental health problems.
person differently. Indeed, findings suggest        A study from Iran, focused on the experiences
that it is not the direct impact of being placed    of people with Parkinson’s disease, reported
in lockdown that predicted mental health            higher levels of anxiety around having access to
deterioration in China, but rather the impact on    medication. Undoubtedly, health care provision
daily life (Zhu et al., 2020).                      and access to medication are substantially
Moreover, some groups will be at greater risk       different in the UK, but this highlights the risks
of engaging in high-risk or unhealthy means of      associated with a perception that medical
coping, such as increasing alcohol use or other     care might be restricted (Salari et al., 2020).
substances. Whilst there is scant research on       Furthermore, some people with a pre-existing
this issue, it is worth highlighting the finding    mental illness may be at increased risk of

                                                                                                                                      3
relapse or new episodes of illness (Yao et al.,     (48.4%), sharing in decision making (47.8%),

                                                                                                          Centre for Mental Health BRIEFING Covid-19 and the nation's mental health: July 2020
2020). Certainly, initial evidence would indicate   whose relative died after end-of-life decisions
that many people are experiencing a worsening       (60%), and who shared in end-of-life decisions
of symptoms (e.g. Vindegaard and Benros, in         (81.8%) (Azoulay et al., 2005). Family members’
press).                                             post-traumatic stress symptoms were found to
                                                    vary in severity during the first year after the
Impact on families of people treated for            relative’s admission to ICU (Alfheim et al., 2019).
Covid-19
                                                    Pregnant women
There is an inherent risk of developing
post-traumatic stress disorder (PTSD) after         Pregnant women assessed during the pandemic
experiencing intensive care treatment for           reported more distress and psychiatric
Covid-19, as we noted in our first forecast.        symptoms than pregnant women assessed
Family members are not exempt from                  before the pandemic. One study found that
developing PTSD, especially given that many         two thirds of women reported anxiety higher
would have been denied contact with their           than normal (Saccone et al., 2020). It has
loved one whilst in ICU.                            been suggested that, because of the harmful
                                                    consequences of prenatal distress on mothers
In general, when family members of ICU              and babies, extra measures should be put in
patients were surveyed, a third of respondents      place to carefully monitor the physical and
reported post-traumatic stress symptoms             mental health of mother and child during
consistent with a moderate to major risk of         the pandemic, such as asking about specific
PTSD. People who experienced higher rates           distress or symptoms during prenatal care
of post-traumatic stress included those who         (Berthelot et al., 2020).
reported receiving incomplete information

 Children’s mental health
There is emerging evidence that lockdown itself     much higher proportion of single parents has
is taking its toll on young people. A YoungMinds    experienced anxiety, loneliness, hopelessness
survey of children and young people who have        and ‘not coping well’ (Mental Health
experienced mental health problems, carried         Foundation, 2020a). These experiences may in
out in the first week of lockdown at the end        turn impact on children in those households.
of March, found that 83% reported that the          There is also a trend in adult surveys that young
pandemic had made their mental health worse.        adults are more likely to experience increasing
A survey of 11-25 year olds in Scotland carried     anxiety and lower wellbeing (Kwong et al.,
out in April found that 39% of respondents          2020; Fancourt et al., 2020; Mental Health
were moderately or extremely concerned about        Foundation, 2020a). This may relate to the
their own mental wellbeing and 61% were             employment status and financial instability of
moderately or extremely concerned about the         young adults rather than age itself.
impact of coronavirus on their future (YouthLink
                                                    There is limited international evidence of the
Scotland, 2020).
                                                    longer term impact of lockdown on children’s
Of the numerous surveys tracking changes in         mental health. A study from the Chinese Hubei
mental health in the UK during the pandemic,        province, carried out in early March (fewer than
few are gathering the views of children. Some       two months since restrictions on movement
surveys suggest that depression, anxiety,           were first implemented), measured signs of
loneliness and lower levels of life satisfaction    depression and anxiety in primary school age
have been more common amongst adults                children. It found that children in Wuhan, where
living with children (Fancourt et al. 2020), and    the number of Covid-19 cases and mortality
that, compared to the general population, a         rates were much higher, had a much greater

                                                                                                                                    4
prevalence of depressive symptoms than               around two in five young carers were thought to

                                                                                                           Centre for Mental Health BRIEFING Covid-19 and the nation's mental health: July 2020
children in Huangshi, where cases of the virus       experience a mental health problem (Alexander,
were much lower. The children least likely to        2014). While a much smaller number of
experience symptoms of depression or anxiety         young people with caring roles are officially
were those who were least worried about              recognised, the estimated total number of
Covid-19 and the most optimistic about the           young carers in the UK is around 800,000. In a
future of the epidemic (Tuo et al., 2020).           survey of over 250 young carers, 70% reported
                                                     that lockdown has made their mental health
This suggests that children in areas where
                                                     worse (Channel 4 News, 2020). A qualitative
the Covid-19 virus is more prominent locally
                                                     study identified key themes driving this change.
experience a more significant impact on their
                                                     These include an increasing complexity of the
mental health. This resonates with earlier
                                                     carer role; the added vulnerability of the looked-
research on post-traumatic stress amongst
                                                     after person; new responsibilities to look after
parents and children following health-related
                                                     siblings not in school; loss of support and
disasters. One study found that post-traumatic
                                                     regular contact from local services, especially
stress scores were four times higher in children
                                                     where these have been pared back by local
who had been quarantined compared to those
                                                     authorities; uncertainty over assessments;
who were not quarantined (Sprang and Silma,
                                                     difficulty home learning; and not having
2013). This is an important consideration for
                                                     space to process stress or break from caring
targeting mental health resources alongside any
                                                     responsibilities (Blake-Holmes, 2020).
‘local lockdowns’ implemented in future – and
for responding to the disproportionate presence      The economic impact of Covid-19 creates both
of Covid-19 cases in some communities and            immediate and long-term concerns for children
in areas with high levels of socio-economic          living in or at risk of poverty. The Trussell Trust
deprivation.                                         has reported an 89% increase in demand
                                                     for food in April 2020 compared to the same
Inequalities                                         month last year, with the number of families
                                                     with children relying on parcels doubling (The
We know that experiences of the pandemic             Trussell Trust, 2020). Food poverty exacerbates
have been far from equal across the population       health inequalities and is associated with a
(Allwood and Bell, 2020). This is no less true for   range or poor outcomes, including behavioural
children and young people. The digital support       and emotional difficulties (Gitterman et al.,
service Kooth, for example, has (based on            2015). Poverty itself is a determinant of poor
requests for help from 51,321 young people)          mental health – children from the poorest 20%
reported a steep increase during March, April        of households are four times as likely to have
and May in the number of Black, Asian and            serious mental health difficulties by age 11
minority ethnic young people under 18 seeking        than those from the wealthiest 20% (Morrison
help for:                                            Gutman et al., 2015).
•   Anxiety or stress, rising by 11.4% compared
                                                     During the pandemic, families have lost
    to 3% among white children of the same age
                                                     access to schemes like breakfast clubs and
•   Suicidal thoughts, rising by 26.6%               school resources which can alleviate some of
    compared to 18.1% among white children           the impact of poverty. At the same time, the
•   Self-harm, rising by 29.5% compared to           cost of living has increased, with less time
    24.9% among white children                       to source affordable food and longer periods
                                                     spent at home incurring higher household bills
•   Depression, which rose by 9.2% among
                                                     (Mental Health Foundation, 2020b). Children
    BAME under-18s and fell by 16.2% among
                                                     in families already living in poverty, and those
    white children (XenZone, 2020).
                                                     whose guardians are facing financial insecurity,
Children with caring responsibilities face           have been exposed to a significant threat to
additional mental health challenges as a             their mental health, the effects of which may
result of the pandemic. Before the pandemic,         manifest over several years.

                                                                                                                                        5
Disrupted education

                                                                                                           Centre for Mental Health BRIEFING Covid-19 and the nation's mental health: July 2020
                                                       issues and put protective measures in place
                                                       have been missed. Teachers and other school
Most schools have stayed open during the               staff play a key role in raising concerns and
pandemic, but with minimal staff and for a very        referring to services. Early reports from local
small fraction of school-age children. Children        authorities suggested sharp falls in referrals to
across the country have experienced a major            social services over child protection concerns
disruption, losing the social interaction and          (The Guardian, 2020).
stability that school brings to their lives. A large
national survey in which over 10,000 parents
                                                       Accessing mental health support
participated found that those with children
aged 4-10 years old reported significant               Children and young people’s mental health
increases in emotional, behavioural and                services have remained open during the
attention difficulties. Adolescents and children       pandemic, but referrals have fallen sharply in
with special educational needs do not appear           some areas. Estimates by NHS England and
to have been affected in the same way – some           Improvement are that referrals for children and
have even reported improvements in emotional           young people have dropped by 30-40% overall
difficulties (Pearcey et al., 2020). A rapid review    (Health and Social Care Committee, 2020). It
also suggests that the risk of social isolation        is too early to access published data on recent
is less likely to occur among older children, for      and current referral rates, but a comparison
whom activities and contact with their peers is        with data from April-June 2018, which shows a
more likely to continue (Brooks et al., 2020b).        total of 144,224 referrals to children and young
                                                       people’s mental health services in England
Some children will emerge from lockdown
                                                       (NHS Digital, 2019), suggests that somewhere
having endured traumatic experiences at home
                                                       between 40,000 and 60,000 children and
without the respite or relief that school or
                                                       young people who might have been referred to
informal services can offer. Sources point to a
                                                       mental health services in the same period in
rise in experiences of abuse at home. Domestic
                                                       2020 have not been. This drop has likely been
abuse charity Refuge recently reported a tenfold
                                                       affected by the closure of schools, meaning
increase in visits to its website during lockdown
                                                       a loss of contact with school nurses – a key
(BBC News, 2020a). Calls to NSPCC’s Childline
                                                       referral route to services – and difficulties in
increased by 20% in the first four weeks of
                                                       making appointments with GPs.
lockdown (BBC News, 2020b).
                                                       Children with mental health problems and
Other children normally in receipt of enhanced
                                                       their families have faced difficulties getting
provision at school may have missed out. The
                                                       help long before any new challenges posed
latest data (11 June) from the Department for
                                                       by the pandemic. Research suggests that, in
Education suggests that the number of children
                                                       recent years, less than one third of children
attending school has risen over the course of
                                                       who have a diagnosable mental health problem
the pandemic, but that only 18% of children
                                                       received any access to NHS care and treatment
in years 1-6 who are classified as ‘children in
                                                       (NAO, 2018). Many who do get referred to
need’ or who have an Education, Health and
                                                       NHS mental health services are rejected, often
Care Plan in place attended school in the last
                                                       without being signposted to less formal support
week (Department for Education, 2020). This
                                                       (Crenna-Jennings and Hutchinson, 2020). It is
means that at least 419,000 children did not
                                                       not uncommon to experience a decade of delay
attend school, despite places being available
                                                       in receiving any mental health support from first
for them to meet their wider needs, safeguard
                                                       becoming unwell (Khan, 2016). These delays
their wellbeing or support their development.
                                                       have stark consequences for mental health
Some of these children could, however, be
                                                       during childhood and long into adulthood –
in the cohort within which improvements in
                                                       most parents report that their children’s mental
wellbeing have been reported.
                                                       health deteriorates while waiting for support,
Significant reductions in school attendance            and the longer the wait, the worse the impact
means that opportunities to identify emerging          (YoungMinds, 2018).

                                                                                                                                        6
With children’s mental health services already

                                                                                                         Centre for Mental Health BRIEFING Covid-19 and the nation's mental health: July 2020
                                                    by voluntary sector organisations, schools,
stretched in many areas, the consequence            youth services, online providers, community
of the current drop in referrals could lead to      groups and in other less formal settings. 26%
a backlog of cases, creating longer waiting         of participants in YoungMinds’ survey (2020)
lists, higher thresholds and worse outcomes         reported that they were no longer able to
for children. A financial outlook which             access any kind of mental health support during
compromises the ability of the wider children’s     lockdown. Longer term, the economic situation
sector to promote good mental wellbeing is          presents a further threat to access to non-
concerning given the evidence that children are     statutory services, with frontline organisations
experiencing rising anxiety and distress.           across the third sector so far reporting steep
                                                    falls in income, cashflow and reserves (ACEVO,
Many children receive support for their mental
                                                    2020).
health outside of NHS services, delivered

 Prisons and Covid-19
Prisons are notorious ‘hot houses’ for spreading    2020). The prison population across England
communicable diseases and can be a source           and Wales reduced by 3.6% between April
for a contagion further spreading into the          and June 2020 (women by 9.3% and men by
community, through prisoner release and staff       3.1%), probably due to normal releases and a
living in the community. The predictions for the    reduction in new arrivals due to court closures
UK’s prisons during the pandemic were dire,         (Ministry of Justice, 2020c).
with media reporting the worse-case scenario
                                                    The impact that these actions have had appears
estimates of 800 predicted Covid-19 related
                                                    to be dramatic. At the time of writing there are a
deaths. The prison authorities and NHS partners
                                                    small number of deaths attributed to Covid-19
in the UK responded rapidly to this threat.
                                                    (23, according to Gye, 2020), and certainly a
For example, in England and Wales, any new
                                                    much smaller number than predicted. Although
arrival had a period of 14 days’ isolation. HM
                                                    there is limited data we also believe that
Prison and Probation Service also attempted
                                                    infection rates have been lower than predicted,
to achieve single cell occupancy for as many
                                                    though there have been several hundred
prisoners as possible by creating several
                                                    confirmed infections among prisoners and
hundred temporary single occupancy cells
                                                    prison staff.
and recommissioned at least one mothballed
establishment (Ministry of Justice, 2020a).         In addition, for at least part of the lockdown
                                                    there have been significantly reduced transfers
Prisons were shielded to some degree in
                                                    from prison to mental health facilities, and a
that, for several weeks, courts effectively
                                                    reduction in reported self-harm and in ACCTs
shut down and the flow of people coming to
                                                    (the system used in English and Welsh prisons
prison significantly slowed down. In addition,
                                                    to manage vulnerable prisoners at risk of self-
prison visits were curtailed (alternate virtual
                                                    harm). There was also a reduction in referrals
means of maintaining contacts with family
                                                    to prison mental health care teams. Perhaps
were introduced) and prisoners were locked in
                                                    unsurprisingly, given prisons have had no or
cells for most of the day with no or only limited
                                                    only limited chances for association, violence
periods of association with other prisoners
                                                    had reduced, as had incidences of bullying.
(Ministry of Justice, 2020b).
                                                    The actions by prison authorities appear to
Plans for early release for low risk offenders
                                                    have reduced the use of mental health services
were put in place, though it is not clear how
                                                    and perhaps mental health need initially. This
much this has been used. Up to 4,000 early
                                                    may have come about through a reduction in
releases had been proposed but as few as 175
                                                    bullying, violence and substance misuse (all of
prisoners were actually released early (Gye,

                                                                                                                                      7
Centre for Mental Health BRIEFING Covid-19 and the nation's mental health: July 2020
which affect mental wellbeing) amongst other        was especially so in the justice sector and
things, as a consequence of a regime of virtual     prisons. The cuts to front line prison staff and
solitary confinement. However, we do not know       especially those with the most experience have
what the longer-term impact will be of such         been associated with record levels of suicide,
a restrictive regime (now being relaxed) and        reported self-harm and violence, including
we understand that referrals to prison mental       violence on staff. It is anticipated that prisons
health care services have or are now returning      will take several years to recover from the impact
to ‘normal’ levels, as may levels of self-harm      of austerity cuts despite of a programme of staff
and admission to hospital.                          recruitment to prisons. It is vital that we learn
                                                    from our response to this previous crisis and
As is detailed elsewhere in this report, the UK
                                                    that the Government does not respond in similar
economy is and will continue to be, perhaps
                                                    fashion. Instead, where the evidence supports
for years to come, severely impacted by the
                                                    it, there should be greater utilisation of effective
pandemic and the necessary responses to it.
                                                    community sentencing (e.g. see Mews et al.,
With greater unemployment we might expect
                                                    2015) for non-violent offending. The decision to
a rise in offending (non-violent offending
                                                    build four new prisons and add 10,000 places
in particular – see Jawadi et al., 2019) and
                                                    to our current prison capacity suggest the
therefore greater pressure on the justice system
                                                    Government is looking to economies of scale
and prisons.
                                                    (if built on the HMP Berwyn model) for savings,
A key response to the most recent recession was     rather than effective sentencing and robust
huge cuts in public sector spending, and there      community offender management for non-
may be a strong temptation for the Government       violent offenders. This is a missed opportunity
to revisit such measures in combatting the          to achieve longer term and sustained savings
current crisis. These previous cuts were            through effective rehabilitation.
arguably disastrous for all sectors, and this

 Youth unemployment and mental health
The impact of the pandemic and lockdown on          earning and job satisfaction may be lower than
the economy is going to be severe, of that there    with employed peers (Bell & Blancheflower,
can be no doubt. But we will not all be affected    2011) which may also impact on mental
equally. Parts of our economy have been more        wellbeing. The evidence suggests that,
dramatically affected and the travel, hospitality   regardless of the economic climate, youth
and leisure industries have experienced the         unemployment can have these long-term
biggest harm. Any ongoing social distancing         negative impacts on mental health (Virtanen
requirements will likely continue to negatively     et al. 2016), with depression being cited as a
impact these industries and there have already      prominent problem. This means that during a
been some large-scale redundancies. These           recession, the number of young people affected
sectors employ predominantly young people           by this ‘scarring’ is greater. Huegaerts and
and therefore it makes sense to review the likely   colleagues’ (2017) study of the impact of the
impact on younger workers.                          2008 financial crisis on youth unemployment
                                                    in Belgium found marked differences in mental
The research evidence is quite consistent that
                                                    wellbeing between unemployed and employed
youth unemployment has long-term ‘scarring’
                                                    young people. They found 14% higher levels of
effects (e.g. Bell & Blancheflower, 2011), and
                                                    reported distress and 12% greater likelihood of
part of this is on future mental health. The
                                                    suffering from a diagnosable mental disorder
impact of unemployment in a person’s late
                                                    among the unemployed young people.
teens and early 20s can be seen in their 30s
and 40s (Strandh et al., 2014). Prolonged           Such concerns beg for employment programmes
unemployment and repeated episodes when             that focus on young people and help them to
young also makes it more likely there may           find sustained employment.
be further periods of unemployment. Future
                                                                                                                                       8
Centre for Mental Health BRIEFING Covid-19 and the nation's mental health: July 2020
 Economic forecast
Prescient economic forecasts are rare. During       possible to reverse much of the damage
the recession of 2008, the Queen asked a            caused and the only negative will be a large
team of top economists, ‘Why didn’t you see         National Debt. A ‘boom’ will ensue, where
it coming?’. Everyone looked at the floor. This     pent-up demand is released instantaneously,
year’s World Economic Forum, Davos 2020, did        restaurants and pubs are overflowing and more
not include ‘pandemic’ in its Top Five Global       people take holidays. This is the ‘V’ shaped
Risks by either ‘impact’ or ‘likelihood’ rankings   recovery referred to in the previous Centre
(World Economic Forum, 2020).                       forecast (sharp recession, sharp recovery).
Consequently, economists often rely on the          If that does not happen and we are subjected
traditional cycle of boom and bust to inform        to further waves of Covid-19, it is difficult to
forecasts. Typically, every ten to twelve years,    see how the following months will be positive.
a crisis emerges and the economy shrinks.           The OECD (2020) already forecasts that the UK
Two or more quarters of decline is a recession.     will see the biggest economic deterioration of
Most recessions are caused by an economic           any ‘developed’ nation, -11.5%. And that is in
shock: sub-prime loans (2008), Exchange             a ‘single hit’ Covid-19 scenario. Recovery from
Rate Mechanisms (1990), share-price collapse        multiple waves is harder – with hope of a ‘W’
(1929).                                             shaped recovery (repeated downturns), but
                                                    potentially an ‘L’ (a recession followed by little
But this one is different: Covid-19 is a
                                                    or no growth).
health problem, not an economic one. So,
while the financial symptoms are the same           Four inauspicious factors are particularly
– unemployment, receding economies,                 relevant for the next six months, suggesting a
ballooning debt – the cause does not stem from      difficult winter:
faulty economic levers. Nor does its solution.
                                                    1. Furlough will come to an end. 9.4 million
The only cure for the economy is an actual cure
                                                       people have been furloughed since April.
for Covid-19.
                                                       That means that business owners judged
This shifts the status of economic forecasting         the production value of 9.4 million workers
from ‘unpredictable’ to ‘unknown’. The future          to be less than 80% of their salary. This
of the economy is dependent on scientific              scheme is expensive (£60bn, according to
endeavour and ingenuity.                               Financial Times, 2020) and ends in October,
                                                       when companies will have to decide
For forecasting purposes, there is one crucial
                                                       whether to effectively re-employ people
vector to consider: time. How long does the
                                                       or make them redundant. Even if 80% of
pandemic last?
                                                       people are retained, that is still nearly two
                                                       million people made newly unemployed.
Duration of the pandemic
                                                    2. National Debt is greater than the value of
The longer the duration of the pandemic, the           the UK Economy for the first time since
greater the economic damage and the greater            1963, at 100.9% of GDP (Office of National
its lasting impact. A trivial but illustrative         Statistics, 2020). While this will not cause
example is spilling red wine on a white carpet.        a further economic shock immediately, it is
There is a short window of opportunity where           the breaching of a key psychological barrier.
the damage can be reversed. But leave it too           Second waves of the fiscal generosity
long and the stain becomes indelible. We               to metabolise the major impacts of the
are within that window now. We have slid               pandemic will be less attractive to debt
all our fiscal ‘chips’ onto a date in October          markets – particularly if there is no end in
when furloughing and related compensatory              sight. It also makes us highly vulnerable
measures end. If there is a vaccine, medication        to increases in interest rates, where small
or other medical breakthrough, it will be

                                                                                                                                      9
rises would result in much larger debt         4. Each winter, influenza kills between

                                                                                                     Centre for Mental Health BRIEFING Covid-19 and the nation's mental health: July 2020
   servicing costs. The ability of the Bank of       11,000 and 28,000 people in England
   England to purchase much of this debt             (PHE, 2019b). Unhelpfully, it has similar
   (as it has been) will also recede over time,      symptoms to Covid-19 which make it
   increasing exposure to international debt         difficult for the sufferer to know which they
   markets.                                          have contracted. The NHS would be strained
                                                     by either, but both are likely to hit at the
3. Brexit is set for 31 December, but with
                                                     same time creating dual epidemics. This
   no-deal. The economic impact will be akin
                                                     increases the potential need for further
   to throwing another (slightly smaller)
                                                     lockdowns and the accompanying economic
   glass of red wine onto that white carpet.
                                                     damage.
   An important factor is that while Covid-19
   has hit the hospitality, leisure and travel    Overall, the economic impact of Covid-19
   sectors, Brexit’s biggest impact will be       is increasingly negative. The pertinent
   in manufacturing, science and financial        consideration is how this will create, reinforce
   services. The combination of the two           and entrench economic inequality.
   laminates most of our economy:

    Pandemic impacted No-deal Brexit
    industries        impacted industries
    Travel                Science
    Leisure and           Financial Services
    entertainment
    Hospitality           Manufacturing

       Figure 1: Forecast for Winter 2020

       UK winter                    Covid-19                    Brexit

                                 No furlough                  Influenza

                                                                                                              10
Inequality                                         new families are forming and homes are being

                                                                                                        Centre for Mental Health BRIEFING Covid-19 and the nation's mental health: July 2020
                                                   bought – the ages of 25-35 – millennials face a
Covid-19 is likely to increase economic            second crunch point, probably worse than the
inequality because its impact is felt              first.
disproportionately due to age, existing poverty
and deprivation, mass unemployment and less        Poverty and deprivation
work, and accelerated economic change.
                                                   Covid-19 has been damaging for lower-income
Age                                                communities. In England, the age-standardised
                                                   mortality rate of deaths involving Covid-19 in
Undoubtedly, older people have been hit            the most deprived areas was 128.3 deaths per
hardest by Covid-19 in terms of health and         100,000 population. This was more than double
mortality. Economically however, over-65s          the mortality rate in the least deprived areas
hold 46% of all housing equity and 22% are         (58.8 deaths per 100,000) (ONS, 2020b).
millionaires (ONS, 2019). Currently, they
also benefit from a ‘triple-lock’ escalation for   Gateshead, South Tyneside, Sunderland and
pensions which maintains and increases its real    Middlesbrough currently have the highest
value.                                             rate of Covid-19 cases per head of population.
                                                   Regional unemployment is high and at least
Instead, it is millenials (people born between     20% of jobs are below the living wage. The
1981 and 1996) who will concede much of            North East economy was one of the worst hit
the economic pain. They have already faced         regions during the 2008 decade of austerity. It
a unique range of economic challenges. Their       is economically vulnerable and fragile. Parts of
initial careers were damaged by the 2008 Great     London and the South West of England are in a
Recession which coincided with their entry into    similar circumstance.
the labour force. Over the next ten years they:
                                                   There are some mitigating factors. The IFS
•   Worked in an economy where average real
                                                   predicts that poorer local authorities may
    wages in 2018 were lower than those of
                                                   manage to sustain more of their income than
    2008
                                                   affluent ones and notes that £3.2bn has already
•   Were the first to pay tuition fees and         been distributed to councils to cope with
    accumulate large-scale debt                    Covid-19 (Ogden and Phillips, 2020). However,
•   Rarely experienced a defined benefit           the ‘levelling-up’ agenda will require significant
    pension scheme                                 resource to be meaningful.
•   Entered a workforce where zero-hours
                                                   Mass unemployment and less work
    contracts, Sunday-working and limited/no
    overtime payments are the norm                 The previous forecast focused on the economy,
•   Were more likely to live at home with their    borrowing and fiscal stimuli. Jobs, employment
    parents than any other post-war generation,    and hours worked are now becoming the
    locked out of the housing market               measurements to watch because the impact
                                                   could be on millions of people. Whilst the
•   Only experienced government policy as
                                                   current unemployment rate (to end of April)
    adults in terms of austerity.
                                                   remains at 3.9% (ONS, 2020c), other measures
In 2020, following four years of Brexit            are less positive. The number of people
consuming all political minds, Covid-19 has        claiming out-of-work benefits increased to 2.8
resulted in the Chancellor predicting ‘the         million during May, a jump of 23%. The number
worst recession we have ever known’. Sectors       of job vacancies fell by 342,000 to 476,000
that employ large numbers of young people –        between March and May. Most concerning is
tourism, hospitality, leisure and fitness – have   that the number of people on company payrolls
been obliterated in just three months and may      fell by 612,000 over the same period (ONS,
never return in the way we have known them.        2020d), despite 9.4 million people being on
At the point where most careers are taking off,    furlough.

                                                                                                                   11
A significant change in the UK since 2010 has      now be sealed in weeks. The abilities to ‘pivot’,

                                                                                                        Centre for Mental Health BRIEFING Covid-19 and the nation's mental health: July 2020
been the emergence of the ‘gig’ economy,           to adapt, and to transform a business quickly,
characterised by zero-hours contracts, diluted     are crucial attributes. Those with business
labour rights and flexible working. This           models with debt, high rents and slow customer
pliability now means that many organisations       decline, who were waiting for sunnier economic
have simply cut hours, rather than sacking         times, will hit the buffers.
people. Similarly, those who are sole-traders
                                                   The key thing about accelerated change is
have seen their activity fall. For the quarter
                                                   that, much like an accelerating bus, it becomes
ending April 2020 (only half of which was in
                                                   increasingly difficult to steer. That increases
lockdown), hours worked collapsed by a record
                                                   the chances of change being felt differently and
fall of 94.2 million hours, or 9% (ONS, 2020c).
                                                   disproportionately. If you can adapt, you will
This statistic is bad. Someone may have a job
                                                   prosper. If you find yourself in possession of
but if they are working zero hours, it’s unclear
                                                   newly valued talents, you will thrive. But if your
how that is different to being unemployed.
                                                   options are limited and you only know one tune,
                                                   the economy is likely to deal a tough hand.
Accelerated economic change
The pandemic has induced rapid economic            The impact on mental health
change. Markets have been swept away
overnight, while brands that were unheard of in    The longer the pandemic lasts, the worse the
2019 (Zoom) are now common parlance. ‘Only         economic damage and the greater the impact
when the tide goes out do you discover who is      on our mental health.
swimming naked’ (Buffett, 2004). The tide has      The nature of the recession means we are not
indeed gone out.                                   ‘all in it together’ and so some will be worse off
Just as Covid-19 targets those with poor health    than others. Inequality will increase and that is
and underlying vulnerabilities, for the economy    bad for mental health.
it has proved an instantaneous exposition of       Unemployment will rise and will likely be the
financial weakness. The sudden visibility of       biggest financial impact of the pandemic. As
those weaknesses increases the velocity of         described in the previous forecast, long-term
change. Firms without the ability to adapt are     unemployment in particular impacts on mental
floundering. In retail, the collapse of the high   health.
street that was taking place in slow-motion will

                                                                                                                  12
Centre for Mental Health BRIEFING Covid-19 and the nation's mental health: July 2020
 Recommendations
The economy is markedly deteriorating and           by the virus – among them children from some
although a Covid-19 cure could be found, the        Black, Asian and minority ethnic backgrounds
most likely scenario is that the UK faces a tough   and children who experience socio-economic
winter. This is the moment to prepare ourselves     deprivation (Allwood and Bell, 2020). Children
to cope with the simultaneous impact of             whose access to schools and colleges, social
pandemic, epidemic, recession and Brexit.           services, mental health services and informal
                                                    support has been interrupted must be able to
An effective test-trace-and-isolate system is
                                                    find their way back to support that meets their
fundamental to limiting Covid-19 transmission
                                                    needs. This will require targeted funding for
and the number of infections in the absence of
                                                    services that are known to work effectively with
cure or vaccine to reduce the economic impact
                                                    the groups experiencing the biggest risk factors
of future lockdowns.
                                                    at this time.

1. Target mental health resources where
                                                    3. A psychologically informed return to
they are most needed
                                                    school
The NHS needs to prepare for winter by
                                                    Schools need to be prepared to respond
identifying those who are most vulnerable to a
                                                    to the psychological impact of Covid-19 on
pandemic in November which will be far harder
                                                    pupils attending school now and returning in
than one in a sunny April. We know well who
                                                    September. A safe return to education is about
is going to be disproportionately impacted
                                                    more than just ‘catching up’ on schoolwork
by the economics of Covid-19: the poor, the
                                                    and preparing for the next set of exams.
young and the most deprived geographical
                                                    There should be a national commitment to
areas. Ethnically diverse communities feature
                                                    encourage and enable all schools to adopt an
predominantly within all three categories.
                                                    effective ‘whole school approach’ to mental
Targeted interventions for mental health are
                                                    health (Public Health England/Children and
needed now.
                                                    Young People’s Mental Health Coalition, 2015).
We also need to adapt and change the offer,         Specifically, this involves:
providing mental health programmes that help
                                                    •   Adjusting behaviour policies for children
people to adjust to sudden and significant life
                                                        displaying conduct problems, recognising
changes. The chances of things returning to
                                                        they are a sign of distress
‘2019 normal’ recede daily and the population
is differentially prepared. The effect on mental    •   Preparing to respond to trauma, for example
health will be correspondingly disparate. And           where abuse has been experienced at
as many of the groups whose mental health               home (Wilton, 2020) and from bereavement
is at greater risk from the crisis have poorer          and loss (for example in families that have
access to effective mental health support, the          experienced deaths during the pandemic or
need is more pressing than ever to work with            losses of livelihood)
communities to co-produce services that meet
                                                    •   Taking steps to reduce anxiety, where some
their needs on their own terms.
                                                        children might fear school due to concerns
                                                        about the virus, or about returning to a
2. Proactively protect the mental health of
                                                        place where they have experienced bullying
children and young people                               or discrimination.
There is clear evidence that some groups of         Supporting the mental health of school staff will
children will experience the mental health          also be an important factor in providing the best
impacts of Covid-19 more than others. There         response to children. In professional surveys,
are children from communities identified in         teachers have reported increasing levels of
recent reports as disproportionately affected       stress (Education Support, 2020).

                                                                                                                  13
The £1bn package to support children to ‘catch-    5. Improve safety in the criminal justice

                                                                                                     Centre for Mental Health BRIEFING Covid-19 and the nation's mental health: July 2020
up’ academically is not enough. Children will      system
need access to support for learning; but they
will also need support to reflect on adverse       The Government should take action to reduce
experiences, manage anxieties and cope             the number of people going to prison, investing
psychologically with the fallout of the global     instead in community sentencing options.
crisis.                                            While the prison system has so far experienced
                                                   relatively few losses of life due to Covid-19,
4. Provide additional mental health                the measures taken to improve safety from
                                                   the virus may have longer term effects on
support for groups facing further risks
                                                   prisoners’ mental health. Instead of increasing
In the first forecast we recommended the NHS       prison places, the Government should focus
provides tailored and proactive mental health      on modernising the estate and reducing the
support to people who have received treatment      number of people who are detained.
in ICU for Covid-19 and those bereaved during
the lockdown. In addition, we would suggest        6. Support young people seeking
that support will also be required for the         employment
families of people treated in ICU. Extra support
should also be offered to pregnant women           The Government should prioritise employment
and those who have given birth during the          programmes that will support young people
pandemic – for example at the six-week GP          who are seeking work to reduce the long-
health check and in other routine appointments.    term psychological ‘scarring’ of protracted
Additional mental health support is also           unemployment. This should draw on the
needed for people with long-term physical and      principles of Individual Placement and Support,
neurological conditions whose mental health        which has been demonstrated to achieve higher
has worsened during the pandemic.                  success rates than traditional employment
                                                   programmes among many groups of people,
                                                   especially those living with mental health
                                                   difficulties.

                                                                                                            14
Centre for Mental Health BRIEFING Covid-19 and the nation's mental health: July 2020
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