Londoners’ mental health and wellbeing: direct impacts of COVID-19

Introduction and context

COVID-19 has had a significant impact on the mental health and wellbeing of the population in London. Even now with a largely positive outlook for controlling the virus, more than 2 years since the outbreak of the pandemic, current evidence continues to suggest there is still a direct mental health impact of COVID-19.

Throughout the pandemic, a number of forecasting models indicated that the prevalence of poor mental health was expected to increase and that this could impact on demand for mental health services over the years to come. This is commonly seen in the non-linear, nuanced, and lengthy process of disaster recovery^[1]. Research from the King’s Fund^[2] published in 2021 suggested that up to 75% of the population has already experienced or will experience normal distress that should resolve with the right support but could escalate if left unaddressed. The research goes on to suggest that 15-20% of the population will experience mild to moderate disorder, and 3-4% severe disorder. Furthermore, research from the Strategy Unit^[3] conducted in late 2020 suggested that there would be around a 33% increase in demand for mental health services over the next three years across the UK, which equates to an extra £1 billion a year or around 8% of annual NHS expenditure on mental health services.

This briefing examines the direct mental health impact of life with COVID-19, the vaccination programme, long-COVID, bereavement, and the collective trauma associated with the pandemic.

^[1] WHO (2022) Mental Health in emergencies: https://www.who.int/news-room/fact-sheets/detail/mental-health-in-emergencies

^[2] The King’s Fund (2021) Covid-19 recovery and resilience: what can health and care learn from other disasters? https://features.kingsfund.org.uk/2021/02/covid-19-recovery-resilience-health-care/

^[3] The Strategy Unit (2021) Estimating the impacts of COVID-19 on mental health services in England https://www.strategyunitwm.nhs.uk/sites/default/files/2020-11/Modelling%20covid-19%20%20MH%20services%20in%20England_20201109_v2.pdf

Living with COVID-19 and the vaccination programme

COVID-19 continues to demonstrate that we face an uncertain future, where the future path and severity of the virus is unknown, acknowledging that it may take several years before the virus becomes more predictable. Over the winter months and coming years it is likely resurgences will occur, it is possible more severe variants will emerge and there will be more hospitalisations and deaths. This is both a psychosocial stressor for many individuals and a barrier to community resilience.

However, the rollout of the vaccine programme has enabled the gradual and safe removal of restrictions on everyday life over the past year and continues to remain central to the Government’s approach to living with COVID-19 in the future. The Government and the NHS, with the help of volunteers, has delivered one of the largest vaccination programmes in history, with around 93.6% of people in the U.K aged 12 and over having received at least one dose of the vaccine^[1]. In London, more than 17,000,000 vaccines have been administered with more than 6,000,000 people having received the second dose of the vaccine and 4,436,617 having received a booster or third dose^[2].

There are a number of complexities which exist in relation to the vaccine programme. Ethnicity, deprivation and age continue to be important and complex factors influencing whether Londoners are vaccinated or not.

Insights gathered from community research activities with Toynbee Hall^[3] during the peak of the pandemic identified how experiences of structural racism and inequality compounded mistrust, suspicion, and fear within marginalised communities. As a consequence, these factors may lead to confusion, misinformation, and reduced uptake of the vaccine by ethnic minority groups.

Given the clear disparities for COVID-19 which exist for racially marginalised groups, culturally competent and tailored communications are required as part of the continued rollout of the COVID-19 vaccine programme along with flexible models of delivery to promote high uptake in marginalised and discriminated groups; as well as groups who may experience inequalities in access to, or engagement with, healthcare services. In particular, it is important to address the issue of trust for Black communities in London, who may have low trust in healthcare organisations and research findings due to historical issues of unethical healthcare research.

Whilst it is necessary to continue addressing issues which present as a barrier to vaccine uptake, it is important not to medicalise or put blame on human behaviours and Londoners’ responses and comprehension of complex advice and information whilst dealing with the ongoing impact of COVID-19 and other challenging circumstances.

^[1] ONS (2022) Coronavirus (COVID-19) latest insights: Vaccines https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/articles/coronaviruscovid19latestinsights/vaccines Last updated 07 October

^[2] ONS (2022) Vaccines in London https://coronavirus.data.gov.uk/details/vaccinations?areaType=region&areaName=London Last updated 06 October

^[3] Thrive LDN (2020) Thrive Together: A summary of recent experiences and ideas to support the wellbeing and resilience of all Londoners: https://thriveldn.co.uk/wp-content/uploads/2020/11/Thrive-Together-report.pdf

Long Covid

The health and wellbeing trajectory for those recovering from COVID-19 is not uniform and can have serious implications for both physical and mental health on a longer-term basis. Long COVID has been defined as not recovering for several weeks or months following the start of symptoms that were suggestive of COVID-19, whether you were tested or not. Long-term complaints of people recovering from acute COVID-19 include extreme fatigue, muscle weakness, low grade fever, inability to concentrate, memory lapses, changes in mood, and sleep difficulties.

An estimated 3.5% of the population are reported to be experiencing self-reported long COVID. Using a simple proportionate approach, this translates to approximately 315,000 Londoners living with long COVID. Of those, almost half reported experiencing long COVID symptoms at least one year after first having (suspected) COVID-19.

Symptoms adversely affected the day-to-day activities of 72% of those with self-reported long COVID^[1]. Self-reported long COVID was more common in those aged 35 to 69 years, females, people living in more deprived areas, those working in social care, those aged 16 years and over who were not working and not looking for work, and those with another activity-limiting health condition or disability.  The adverse effects of medium to long term health conditions on mental health is generally well understood, with individuals with poor health over a longer period of time suffering from significantly lower life satisfaction and higher rates of mental health problems such as depression and anxiety.^[2]

^[1] ONS (2022) Coronavirus (COVID-19) latest insights: Infections https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/articles/coronaviruscovid19latestinsights/infections#long-covid

^[2] The King’s Fund (2012) Long term conditions and mental health – the cost of co-morbidities: https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/long-term-conditions-mental-health-cost-comorbidities-naylor-feb12.pdf

Bereavement

A bereavement from COVID-19 is likely to be a very sudden and challenging kind of bereavement for most people. The latest available data from the ONS shows there have been 24,229 deaths where COVID-19 was included in the death certificate in London since the start of the pandemic^[1]. COVID-19 has and will continue to have a major impact on the individual and societal experience of death, dying, and bereavement. In particular, the lack of usual support structures for grief and mourning and the changes implemented to services including end of life and palliative care during the peaks of the pandemic has led to collective and vicarious reactions which can persist over time and continue to be experienced by those directly and indirectly affected.

During the peak of the pandemic (March 2020 to March 2021) parts of London experienced record high mortality rates, replicating demographics for health inequalities and deprivation. Newham, Barking and Dagenham, Tower Hamlets, Redbridge, and Hackney^[2] all experienced disproportionately high rates of COVID-19 related deaths and continue to demonstrate how the poorest health outcomes are disproportionately experienced by those who already face multiple entrenched inequalities in society. Whilst it is not possible to measure the extent to which collective and vicarious grief and loss has impacted Londoners’ mental health and wellbeing, particularly those from racialised communities, the accumulation of stressors and trauma will continue to impact upon broader societal mental health for the months and years to come.

^[1] ONS (2022) Deaths with COVID-19 on the death certificate by area https://coronavirus.data.gov.uk/details/deaths?areaType=region&areaName=London

^[2] ONS (2021) Deaths due to COVID-19 by local area and deprivation: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/deathsduetocovid19bylocalareaanddeprivation

Collective trauma

It is clear from insights gathered from across London that communities are experiencing collective psychological reactions as a result of negative outcomes from the pandemic and the impact it has had upon their lives. The unfair outcomes experienced by certain groups disproportionately affected by COVID-19, such as care home residents, disabled people, front-line workers, and racialised and minoritised groups, continues to be felt and these communities will feel the collective memory of trauma. Collective memory can persist beyond the lives of the direct survivors of the events,^[1], compromising future generations’ opportunities for good mental health and wellbeing. Although trauma is a highly individual and personalised experience, manifestations of collective trauma are the same and are already being seen, for example in increased rates of depression and anxiety in the general population^[2], increased incidences of eating disorders^[3] and self-harm, and the highest number of alcohol related deaths in 20 years^[4].

The psychological toll of COVID-19 is already apparent in the general population; however, specific groups have been experiencing more critical mental health concerns, with the effects more likely to persist. Londoners with pre-existing mental health conditions, front-line workers and young people have reported increased symptoms of depression, anxiety, and stress related to COVID-19, as a result of psychosocial stressors such as isolation, life disruption, stress, or fear of negative economic effects.

Learnings from previous infectious disease epidemics have shown that exposure to disease can have direct links to psychological distress and trauma, particularly for those who experience and suffer from symptoms and traumatic treatment (for example, intubation and the use of ventilators for COVID-19 treatment), those who witness patients who suffer from, struggle against and die of the infectious disease, and those who experience fear of infection, social isolation, exclusion, and stigmatisation.

Concerns in terms of stress and burnout, depression, anxiety, and even post-traumatic stress disorder (PTSD) for frontline workers and the public sector workforce^[5] are now being realised against a backdrop of pre-existing problems, such as chronic underfunding, workforce issues and system fragmentation.

As London continues to live with COVID-19, additional challenges and crisis scenarios are manifesting with significant impacts on how individuals, communities and systems cope, adapt and survive through challenging circumstances. This is particularly relevant to the rising cost of living and global conflict as the collective trauma from the pandemic will leave Londoners with reduced resilience and inability to cope with future setbacks.

^[1] Hirschberger G. Collective Trauma and the Social Construction of Meaning. Front Psychol. 2018;9:1441. Published 2018 Aug 10. doi:10.3389/fpsyg.2018.01441

^[2] Office for National Statistics (2021) Coronavirus and depression in adults, Great Britain: July to August 2021: https://www.ons.gov.uk/peoplepopulationandcommunity/wellbeing/articles/coronavirusanddepressioninadultsgreatbritain/julytoaugust2021

^[3] The Lancet (2021) COVID-19 and eating disorders in young people: https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(21)00094-8/fulltext

^[4] Office for National Statistics (2021) Quarterly alcohol-specific deaths in England and Wales: 2001 to 2019 registrations and Quarter 1 (Jan to Mar) to Quarter 4 (Oct to Dec) 2020 provisional registrations: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/quarterlyalcoholspecificdeathsinenglandandwales/2001to2019registrationsandquarter1jantomartoquarter4octtodec2020provisionalregistrations

^[5] Bermingham, R. (2020), ‘Health and social care system and COVID-19: What are experts concerned about?’, POST Horizon Scanning, published 14 May 2020.