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COVID-19 and Mental Health: Clinical and Public Health Reflections Ronny Bruffaerts and Rozemarijn Jeannin

METAFORUM

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COVID-19 and Mental Health: Clinical and Public Health Reflections

Without question, we tend to assume that the pandemic has had a considerable impact on the mental health of each of us, whoever we are and wherever we live or reside. We share the common conviction that the curtailment of human freedom of the past two years should be associated with a more negative psychological health than before the pandemic. The first scientific reports on the impact of the pandemic on mental health were frankly frightening: the entire world population was expected to be affected and burdened by such a long-term stressful context, which would invariably lead to another long-term pandemic, one of persistent mental illness. Almost two years after the start of the pandemic, we know that these early publications were largely of poor quality and often did not meet rigorous scientific standards. Nonetheless, they were a leitmotif in our endeavour to understand society and its underlying processes. This brings us to the question of whether, and if so to what extent, the COVID-19 pandemic ‘led’ and may still be leading to a dramatic increase in mental disorders at the population level or in specific segments thereof, and whether the COVID-19 pandemic has effectively led to an increased demand for care and the use of services. A data-driven approach is most appropriate for reflecting upon such questions. We therefore used a descriptive epidemiological framework to study 3 target groups to answer the afore -mentioned research questions: the mental health of KU Leuven students (N~21,700 students) and Belgian healthcare providers (N~8,800 healthcare providers), and patients referred to

the emergency room of the University Hospitals Leuven because of an emergent psychiatric crisis (N~7,300 referrals).

COLLEGE STUDENTS Independent of the pandemic, the college years are a developmentally crucial period in which students make the transition from late adolescence to emerging adulthood. International epidemiological studies suggest that 12-50% of college students meet criteria for one or more common mental disorders (Auerbach et al., 2016). Mental disorders in early adulthood are associated with long-term adverse outcomes in later adulthood, including persistent emotional and physical health problems, relationship dysfunction, and labour market marginalization. These long-term adverse outcomes may be mediated by mental health problems that exist during the college years, as the years in question constitute a peak period for the first onset of a broad range of mental disorders. Against this background, studying alternations in student wellbeing and mental health is of crucial importance. This is especially the case in the pandemic, because of the simple fact that normal student life and academic courses on campus were largely suspended and replaced by either self-study or online teaching. The lack of social cohesion and campus life may have impacted mental health.

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We report on cross-sectional and longitudinal data from the Leuven College Surveys (LCS), as a part of WHO’s World Mental Health International College Student (WMH-ICS) Initiative1. The LCS consists of approximately 21,700 mental health assessments of KU Leuven students since 2012, statistically weighted in order to be representative for the entire student body. In the academic year 2020-2021 (N=3,801), approximately 1/3 students screened positive on any of the mental disorder instruments included in the assessment: depression and generalized anxiety were most common (around 19% and 17%, respectively), but disordered eating problems (such as binge eating and purging) were also quite prevalent among college students (with estimates of 11% and 3%, respectively). Non-suicidal self-injury (NSSI) was estimated at 6% of the respondents. Around 37% of the students with positive screens reported a strong to severe impact of the stated mental health problems. Evolutions between 2012 and 2021 demonstrated that, on average, the proportion of students with mental health problems remained quite stable: around 4/10. The question whether, and if so to what extent, the pandemic can be associated with an increase in emotional problems or mental disorders remains important. Of the 1,791 college students assessed in the first COVID-19 wave, most students reported an increase in stress, anxiety, and sadness.

More fine-grained analyses show that students experienced the pandemic in very different ways. 1/4 reported having experienced no emotional impact at all. Most students – around 55% – reported increased stress, anxiety, and sadness, albeit not most days; 20% reported high impact. Students with financial difficulties at home and those with anxiety problems in the past are clearly overrepresented in the group that reported high impact. The incidence of mental disorders remains low and comparable to previous academic years. The longitudinal data clearly show that the levels of stress and suicidal thoughts and behaviours (STB, which includes suicidal ideation, plans or attempts) in the period March-April 2019 and March-April 2020 were comparable and not statistically different from each other. This finding strongly suggests that self-reported impact of COVID-19 on the experience of stress reflects primarily students’ causal attributions: in the first COVID-19 wave, stress is likely to be attributed to the pandemic, whereas in the pre-pandemic era it was more likely attributed to other factors. The assessments performed in the second COVID-19 wave (i.e. December 2020, N=3,638) showed that around 1/5 experienced low mental health, 36% reported good-to-excellent mental health, and 44% reported moderate mental health. The proportion of students who reported both low mental health and high impact of the pandemic was 10%.

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COVID-19 and Mental Health: Clinical and Public Health Reflections

1 See https://www.hcp.med.harvard.edu/wmh/college_student_survey.php

Figure 1. Self-reported impact of mental health on academic functioning and personal life in the past year The assessments in the second wave also showed a further increase in the proportion of students with disordered eating behaviours. With 14% and 3% reporting binging and purging eating behaviours, this estimate is far higher than estimated in 2012-2014 (i.e. 7% and 1%, respectively – see Serra et al., 2020). This is in line with estimates from the general population in Belgium, based on the results of the Health Interview Survey (Sciensano, 2021). In March 2021, Sciensano included an eating disorders screen in their COVID-19-Health Interviews and found an increase in eating disorder symptoms compared with the results in 2013 and 2018. The same counts for suicidal thoughts and behaviours. With an increase in STB in the second wave (and not in the first wave), this condition warrants both clinical attention and attention from policy makers, in terms of detecting, treating, and preventing STB in students.

These findings also show the importance of preventing emotional problems in general and developing resilience among college students – during and probably beyond the current COVID-19 pandemic. In conclusion, available data demonstrate that the net extent of emotional problems among college students did not change dramatically during the pandemic, except for anxiety problems, suicidal thoughts and behaviours, and disordered eating problems. Attention should thus be given to detection and referral to appropriate intervention on both the policy level and the level of organizing student healthcare services. It should be underlined, however, that with 2/3 of the students reporting no emotional problems, equal attention should be given to sustainable efforts to support students’ psychological resilience.

HEALTHCARE PROFESSIONALS On March 13th 2020, the WHO considered Europe as the new epicentre of the COVID-19 pandemic. With only limited testing capacity in place, the cumulative number of confirmed cases in Belgium was >3,100 when it went into lockdown on March 18th. At that point, 650 COVID-19 patients had been admitted to hospital, the very beginning of a wave that would occupy almost 6,000 hospital beds from April through June 2020. Studies in the context of COVID-19 (Pappa et al., 2020) shed light on the potentially vast impact of the pandemic on healthcare professionals.

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Moderate-to-excellent mental health

82,9%

Low mental health with moderate

impact

Low mental health with severe

impact

6,8%10,2%

100%

80%

60%

40%

20%

0%

Specifically, frontline healthcare workers may be at highest risk of emotional impact because of the combination of the experienced impact of the pandemic, social isolation due to social distancing, in addition to their ongoing job requirements. Pappa et al. (2020) performed a meta-analysis including 13 studies with more than 30,000 professionals, reporting high proportions of depressive and anxiety symptoms, and sleeping problems. It is imperative to monitor emotional health of healthcare providers, especially in regions with less experience of such outbreaks. In the Recovering Emotionally from COVID-19 (RECOVID) study (Bruffaerts et al., 2021; Voorspoels et al., 2021), we examined population-representative data from Belgian healthcare providers (N~8,800). The RECOVID study focuses on cross-sectional and longitudinal measurement of two central constructs, mental disorders/suicidal thoughts and behaviours on the one hand and psychological resilience on the other. As the study is still ongoing, we will report baseline data here (obtained during the first wave of COVID-19 in Belgium). Longitudinal data is currently being collected. Historical issues were common, with 19% indicating having had at least one emotional problem in the past. Turning to the current timeframe, 30% reported emotional problems in the past month and 4% STB (mostly death wish). Almost one in five healthcare workers had experienced panic attacks, followed by positive screens for depression (9%) and generalized anxiety disorder (8%). Among respondents without any prior mental health problems, one in four screened positive for current problems.

Further analyses of the longitudinal data demonstrates that the 6-month incidence (i.e. new cases in the first follow-up six months after the baseline assessment) of suicide ideation is estimated at 0.7% whereas the incidence of mental disorders is estimated at 3.7%, lower than we might expect from population-based studies. In any event, observed rates of the prevalence of emotional problems and STB are higher than those found in the general population, healthcare professionals in the pre-pandemic era, and even along deployed army personnel. This brings us to the hypothesis that healthcare professionals may have increased odds for developing emotional problems such as anxiety and depression and STB. The risk factor analyses showed three very important factors that are independently associated with emotional problems among healthcare providers: emotional problems in the past (associated with a threefold to fourfold increase in current emotional problems), problematic working conditions such as problematic work-life balance, shortage of professional resources, or co-worker conflicts (associated with a twofold increase in STB and emotional problems), and social support (associated with a 20% decrease in odds of emotional problems and STB). Counterfactual analyses showed that social support may be the most important protective factor against emotional problems and STB, with population attributable risk proportions (PARP) in the 27%-44% range. This means that 27%-44% of the existing emotional problems and STB among Belgian healthcare providers could be prevented in the presence of sufficient social support.

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COVID-19 and Mental Health: Clinical and Public Health Reflections

Further counterfactual analyses showed a similar, albeit lower preventive impact of prior emotional problems (with an estimate of 4%-14% less current emotional problems/STB), and problematic working conditions (with an estimate of 12% less current emotional problems). We also assessed levels of psychological resilience among healthcare providers and found that the average scores were in line with those obtained from the general population, and far above resilience measured in other segments of the general population, such as college students, inpatients, and outpatients.

More detailed analyses on the baseline RECOVID data (N=6,409) shows that low resilience is associated with work loss (such as absenteeism and presenteeism), but beyond its association with mental disorders. This leads us to hypothesize that psychological resilience may be a stronger driver of absenteeism and presenteeism among healthcare professionals than the mere impact of mental disorders.

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Table 1. Risk and protective factors associated with emotional problems in healthcare providers

RISK/PROTECTIVE FACTOR CURRENT MENTAL DISORDERS STB SUMMARY

Prior mental disorders OR=3.8 OR=2.7 3-4 times higher odds PARP=4% PARP=14% societal gain 4-14%

Current mental disorders NA OR=3.0 3 times higher odds PARP=24% societal gain 24%

Exposure to COVID OR=1.2 OR=11.5 1-12 times higher odds PARP=0% PARP=3% societal gain 0-3%

Contextual working conditions OR=1.7 ns 2 times higher odds PARP=12% societal gain 12%

Social support OR=0.8 OR=0.7 20% lower odds PARP=44% PARP=27% societal gain 27-44%

Note. STB = suicidal thoughts and behaviours; OR = odds ratio; PARP = population attributable risk proportions (similar to ‘societal gain’); NA = not applicable, ns = not significant.

We thus found a high prevalence of emotional problems among Belgian healthcare providers, mostly among those who reported emotional problems in the past. The 6-month incidence of mental disorders was low, which suggests that the pandemic was not associated with higher odds concerning the onset of emotional problems. Similar to what we found among college students, the average levels of psychological resilience of healthcare providers was high, indicating psychological strength against potential emerging emotional problems. Figure 2. Resilience and work loss n <pc25 n pc25-pc75 n >pc75

Note. Pc = percentile; <pc25 = low resilience, pc25-pc75 = average resilience, >pc75 = high resilience.

PATIENTS REFERRED TO THE EMERGENCY ROOM BECAUSE OF EMOTIONAL REASONS Following decades of deinstitutionalization, the primary purpose of hospital emergency rooms has been defined as rapid referral of patients, triaging those who need urgent care from those who do not, especially when it pertains to emotional problems. However, a merely triage-based conceptualization of the psychiatric patient in the emergency room (ER) does not take into account the ever increasing number of patients, the low accessibility of specialized services, the elevated need for early recognition of emotional problems, and the necessity of a more continuous provision of care. At the present time, ERs serve as a central entry point for a broad range of patients in psychological/psychiatric crises (Bruffaerts et al., 2008). In this context, an epidemiological study of patients presenting at the ER during the pandemic is an excellent proxy to study any pandemic-related impact on the patterns of crisis-related emotional problems and help-seeking behaviours of patients with mental disorders and suicidal thoughts and behaviours. With a total amount of psychiatric patients around 4,000 a year in 2016-2020, the ER of the University Hospitals Leuven remains an excellent location to study patterns of service use. In order to do so, we describe symptoms at referral, severity of the presented sympto -matology, and dispositions post-referral of 7,295 psychiatric referrals between 2016 and 2020.

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COVID-19 and Mental Health: Clinical and Public Health Reflections

Any work loss

4,6

Absenteeism

Resilience

Presenteeism

1,3

4,5

3,8

1,2

3,5

7,4

1,9

6,5

Days

of w

ork

loss

and

pre

sent

eeis

m

8

7

6

5

4

3

2

1

0

Socio-demographic characteristics of patients referred to the ER for psychiatric reasons are quite similar during the pandemic (2020) compared to the pre-pandemic years (2016-2019). From 2016-2020, around half are female patients, with a mean age of 41 years; 95% have the Belgian nationality, 4/10 live alone, and 7/10 do not have a formal paid job. During the pandemic, fewer patients were referred to the ER. Compared to 2019, there were 13% fewer referrals for adult and elderly patients, whereas the proportion of referrals younger than 18 remained fairly stable. If we compare the proportion of referrals because of STB (which in this dataset includes suicidal ideation, plans and attempts, as well as NSSI) in the years 2016-2020, we see that the proportion of STB is similar between years.

On average (2016-2020; N=3,949), 29% of referrals to the ER related primarily to suicidal thoughts and NSSI (20.2%) or a suicide attempt (9.1%). In 2020 (N=1,132), this was 28% (19.0% in relation to suicidal thoughts and NSSI, and 9.1% for a suicide attempt). Also in 2020, 27% of referrals related primarily to problematic substance abuse, followed by depressive symptoms (11%), psychotic symptoms (11%), and anxiety (7%). These figures are in line with what is generally expected (Bruffaerts et al., 2004). We were unable to discern a pandemic-related change in symptom profile at referral. In addition, the level of psychological/psychiatric crisis (as measured with the Crisis Triage Rating Scale – Bengelsdorf et al., 1984) of referred patients remained stable over the years.

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Figure 3. Primary symptomatology at referral between 2016 and 2020

Note. NSSI = non-suicidal self-injury; other = aggression, decision-making ability/legal capacity, eating problems, agitation, medically unexplained symptoms, sleep problems, other problems (not specified).

35,0%

30,0%

25,0%

20,0%

15,0%

10,0%

5,0%

0,0%

2016 (n = 992)

– suicidal thoughts and NSSI – psychotic symptoms

– suicide attempt – anxiety

– substance abuse – other

– depressive symptoms

2017 (n = 763) 2018 (n = 909) 2019 (n = 149) 2020 (n = 1,132) All (n = 3,949)

22,6%

18,3%

15,8%

9,9%

8,7%6,7%

22,8%

20,6%

11,5%10,1%

9,0%5,4%

21,3%

17,4%

13,2%

11,1%

8,6%

6,9%

30,9%

14,8%14,1%13,4%11,4%8,1%

7,4%

26,5%

19,0%

16,3%

11,4%

11,1%9,1%

6,6%

23,1%

20,2%

17,6%

10,5%

13,0%

9,1%

6,5%

Although the symptoms at referral remained quite stable in 2020 compared to previous years, we did find differences in patient aftercare. Remarkably, the proportion of patients who were discharged without any prescribed aftercare increased during the pandemic from 1%-2% in the pre-pandemic era to 7% in 2020. This seemed to be mainly at the expense of outpatient aftercare: the proportion of patients referred to outpatient care was estimated at 48% of the referrals in 2020, whereas in previous years this was around 56%. This could be due to the fact that both the locus as well as the organization of outpatient treatment dramatically changed during the pandemic. Figure 4. Patient aftercare between 2016 and 2020

The main conclusion from the epidemiology of psychiatric referrals to the emergency room is that the pandemic did not seem to change the general symptomatic profile or symptom severity of referrals. The pandemic did seem to affect the organization of outpatient aftercare. It is unclear whether this relates to patient characteristics not explored in this study, or to the impact of COVID-19 on the organization of outpatient mental healthcare in general. To conclude, when we combine the results of the three studies, the COVID-19 pandemic does not seem to affect every person to the same extent. Some are more vulnerable, such as persons who experienced mental health issues in the past, people with a higher socio-economic burden, and professionals who deal with the impact of COVID-19 first-hand. At the same time, our results also point to elevated resilience in a large group, and the importance of supporting this resilience, and strengthening it in those with higher mental health risk.

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COVID-19 and Mental Health: Clinical and Public Health Reflections

100%

80%

60%

40%

20%

0%

40,9%

57,3%

42,0%

56,1%

40,1%

58,6%

47,9%

51,9%

7,4%

44,6%

48,0%

42,8%

54,2%

2016 (n = 1,154)

2017 (n = 866)

2018 (n = 1,132)

2019 (n = 651)

2020 (n = 1,420)

All years (n = 5,223)

n Outpatient care n Inpatient care n No referral

1,8% 1,8% 1,3% 0,2% 3,0%

LESSONS LEARNED The results of these studies invite us to think about what we can do to strengthen the population in non-pandemic times to cope with everyday stressors, in order to minimize the number of people who experience a high impact on their mental health in the context of a pandemic. How can we ensure that those who need professional help receive adequate support? First, a large segment of the population exhibits great resilience in times of stress, even stress caused by an unexpected and uncontrollable pandemic. Resilience should be nurtured in those who already exhibit it, and strengthened in those who still need to work on it. This is an ongoing endeavour, even in non-pandemic times, which includes, among other things, working on emotion regulation skills, social cohesion and work-life balance. In times of pandemic, resilience can be sustained with low-cost and low-threshold measures, including the promotion of self-help strategies through large-scale communication campaigns (WHO, 2021). Second, specific groups or segments of the population experience a serious impact and need extra care, during, and probably also after the pandemic. Offering additional mental health resources to these groups could be more effective than a ‘one-size-fits-all’ approach. When we look at the groups at risk, it is quite clear that existing (mental) health inequalities and low social economic status tend to be magnified during times of pandemic.

From a societal viewpoint, we need to think about how to provide care for these groups in times of pandemic, but also about how to improve support for groups at risk because of their socio-economic or mental health status in normal times and thereby reduce these health inequalities. Inequalities in (mental) health are not the only issues that become more apparent in times of high social stress. Existing struggles in – and barriers to – mental healthcare can also pose a greater threat to continuity of care and access to care. Working on several barriers to treatment – whether they relate to the availability of care or more intrapersonal issues – could also serve to protect our society against the lasting impact of a stressor like a pandemic in the future. These factors could guide governments and healthcare organizations to take responsibility for emotional issues and sustaining resilience in society as a whole, during, but also beyond the current COVID-19 pandemic.

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REFERENCES • Auerbach RP, Alonso J, Axinn WG, …,

Bruffaerts R. Mental disorders among college students in the World Health Organization World Mental Health Surveys. Psychol Med. 2016 Oct;46(14):2955-2970.

• Bengelsdorf H, Levy LE, Emerson RL, Barile FA. A crisis triage rating scale. Brief dispositional assessment of patients at risk for hospitalization. J Nerv Ment Dis. 1984 Jul; 172(7):424-30.

• Bruffaerts R, Sabbe M, Demyttenaere K. Attenders of a university hospital psychiatric emergency service in Belgium - general characteristics and gender differences. Soc Psychiatry Psychiatr Epidemiol. 2004 Feb; 39(2):146-53.

• Bruffaerts R, Sabbe M, Demyttenaere K. Emergency psychiatry in the 21st century: critical issues for the future. Eur J Emerg Med. 2008 Oct;15(5):276-8.

• Bruffaerts R, Voorspoels W, Jansen L, …, Alonso J. Suicidality among healthcare professionals during the first COVID19 wave. J Affect Disord. 2021 Mar 15;283:66-70.

• Pappa S, Ntella V, Giannakas T, …, Katsaounou P. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis. Brain Behav Immun. 2020 Aug;88:901-907.

• Sciensano. Zesde COVID-19-Gezondheids -enquête. Eerste resultaten. Brussel, België; Depot nummer/2021/14.440/29.

• Serra R, Kiekens G, Vanderlinden J, …, Bruffaerts R. Binge eating and purging in first-year college students: Prevalence, psychiatric comorbidity, and academic performance. Int J Eat Disord. 2020 Mar;53(3):339-348.

• Voorspoels W, Jansen L, Mortier P, …, Bruffaerts R. Positive screens for mental disorders among healthcare professionals during the first covid19 wave in Belgium. J Psychiatr Res. 2021 Aug;140:329-336.

• WHO. Action required to address the impacts of the COVID-19 pandemic on mental health and service delivery systems in the WHO European Region: recommendations from the European Technical Advisory Group on the Mental Health Impacts of COVID-19, 30 June 2021. Copenhagen: WHO Regional Office for Europe; 2021. Licence: CC BY-NC-SA 3.0 IGO.

Acknowledgements to Wouter Voorspoels (KU Leuven) and Glenn Kiekens (KU Leuven)

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COVID-19 and Mental Health: Clinical and Public Health Reflections

In 2021, six interdisciplinary short-term research projects on the COVID-19 pandemic, funded by the KU Leuven DOC Research Coordination Office, were initiated by Metaforum, KU Leuven’s interdisciplinary think-tank for societal debate. These research projects looked at the socioeconomic and psychological effects of the COVID-19 pandemic and the measures that were taken to contain it, and the systemic lessons that can be drawn from this crisis, especially with regard to policy making, governance, healthcare organisation and inclusion. More information can be found on:

www.kuleuven.be/metaforum/pandemic-preparedness

METAFORUM KU LEUVEN Hollands College

Damiaanplein 9 bus 5009 3000 LEUVEN, België

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