Mental Health Consequences of COVID-19 Pandemic
Introduction and specific aims:
The unfolding COVID-19 pandemic has led to an avalanche of information (often inaccurate and conflicting) about the risks posed by the disease, the numbers of people who have died and the expected exponential increase in the coming days. This has triggered almost daily changes in government policies at the national and local level which have a profound effect on the lives of entire populations. The fear associated with the most dire predictions and the uncertainty of what tomorrow might bring, is compounded by the effects of increasing isolation and being disconnected from the routine social connections and behaviours essential for the maintenance of good mental health. These highly stressful experiences are further exacerbated by the realignment of health care services to be focused on the expected surge of COVID-19 cases, making all other kinds of health care consultation feel of lesser importance or even irresponsible. Lastly, the devastating impact that COVID-19 is expected to have on the economy, resulting in massive layoffs and loss of income for millions of Americans, is expected to have detrimental impact on the mental health of those affected for years to come.
We hypothesize that this complex web of mechanisms has adverse impacts on a range of mental and behavioural health outcomes, especially for four specific high risk groups: students and young people (whose entire lives have been disrupted, who are the age group most sensitive to societal threats such as climate change, and who are the highest risk group to develop mental health problems); the elderly (in whom loneliness is recognized as a major risk factor for premature mortality, now compounded by social distancing and reduction of physical activity); people with pre-existing mental health problems (for whom, apart from heightened arousal and social isolation, reduced access to necessary care may pose enhanced risks); and people who have been infected by COVID-19 (who would have been quarantined and experienced the most intense fear and possible stigma due to the diagnosis). Our hypotheses are based on empirical evidence demonstrating the adverse mental health consequences of epidemics and associated control policies. Suicide rates in older Hong Kong residents showed a 31% increase during the peak of the SARS epidemic, fuelled by fear of contracting the disease and fears of disconnection(1). A recent review of the psychological impact of quarantine reported negative psychological effects including post-traumatic stress symptoms, confusion, and anger(2). Emerging data from the ongoing epidemic in China reported a very high prevalence of depression and anxiety(3). However, these data are among healthy people. We expect that these adverse outcomes will be considerably enhanced in high-risk groups–such as the four we will focus on. Our primary research questions and hypotheses are:
- Is the COVID-19 pandemic associated with increased mental health crisis consultations/admission and suicidal behaviors in the four high-risk groups? We hypothesize that exposures related to COVID-19 are associated with both adverse outcomes in these groups.
- What are the mechanisms through which risk is mediated and how might these be moderated? We hypothesize that lack of social support; exposure to online information on the threats of the pandemic; worsening of economic circumstances; living in a community with higher levels of COVID-19 infection; experience and duration of quarantine/lock-down; and the loss of continuing out-patient care for other ailments (including any current mental health problem) will be key mechanisms of poor outcomes.
Approach: We propose a mixed methods study, involving the following components:
- A longitudinal analysis of data from relevant sources (both national/state level as well as local/greater Boston-area) to assess the temporal patterns of mental health crisis consults/admissions and suicidal behaviors (the primary outcomes) in four high-risk groups (young people aged 14-24 years, including students enrolled in universities in the greater Boston area; older people aged 65+ years; people with a known diagnosis/under treatment for a mental health problem; and people with a confirmed diagnosis of COVID-19). We will map three exposures (temporally and for each state/neighborhood) related to the epidemic: the intensity and content of online information about the epidemic through social media and news coverage; the N of confirmed COVID-19 cases; and the incremental imposition of containment policies.
- The analyses will be conducted separately for each high-risk group. The analyses will test the hypotheses that these risk factors, individually and in combination, will lead to worsening of mental health outcomes by describing the temporal correlations, and the contextual variations, between the risk factors and outcomes. The analyses of the mental health outcomes in young and older high risk groups will be conducted using routine health information system databases, for e.g. the national suicide monitoring data maintained by the CDC, disaggregated by state. For the two clinical cohorts (individuals with mental health problems or COVID-19), we will access data from several different potential sources in the greater Boston area, each of which have been used in studies by our team: (a) Electronic Health Records from the Partners Healthcare system (N ~ 5 million); (b) Routine mental health surveys of Boston-area college and graduate students. We will utilize existing precision medicine platforms in the Partners Healthcare System using machine learning algorithms (we have expertise in these methods (4–8)) to prospectively identify high-risk groups and to assess for moderators of risk (individual socio-demographic and clinical variables, and neighborhood variables) and risk trajectories in these groups.
Funder: Massachusetts Consortium on Pathogen Readiness (MassCPR)
Project Period: May 1, 2020 – April 31, 2021
Vikram Patel, The Pershing Square Professor of Global Health, Harvard Medical School; and Professor, Harvard Chan School of Public Health
Karmel Choi, Clinical and Research Fellow, Massachusetts General Hospital
Jordan Smoller, MGH Trustees Endowed Chair in Psychiatric Neuroscience; Professor of Psychiatry, Massachusetts General Hospital and Harvard Medical School;Professor in the Department of Epidemiology, Harvard T.H. Chan School of Public Health
John Naslund, Instructor, Harvard Medical School
Juliana Restivo, Coordinator, Harvard Medical School
Allison Tu, Research Assistant, Harvard College
Hyunjoon Lee, Psychiatric & Neurodevelopmental Genetics Unit, Massachusetts General Hospital
Cindy Liu, Director, Developmental Risk and Cultural Disparities Program, Assistant Professor, Departments of Pediatric Newborn Medicine & Psychiatry, Brigham and Women’s Hospital
Paul Barreira, Henry K Oliver Professor of Hygiene, Emeritus, Associate Professor of Psychiatry, Harvard Medical School, Director, Graduate Student Mental Health Initiative