Dr Vince Gradillas, CEO and Medical Director at Claimont, shares some thoughts about how COVID-19 is impacting population resilience.
COVID-19 is proving to be the greatest global health, social and economic threat for decades. The pandemic has resulted in a series of severe preventative interventions including lockdowns, restriction of movement and imposition of new social norms aimed at reducing the spread and direct harm caused by the virus. It is difficult to determine what the total direct burden of COVID-19 will be but the effect of the global response to the pandemic in other areas of health (such as cancer detection, cardiac events, mental health), the economy, livelihoods, and wellbeing, are likely to dwarf these in magnitude and duration at a population and global level.
In relation to mental health, the psychological impact of adversity on an individual depends on their nature (genetic makeup) and nurture (environmental upbringing), as well as the context in which the index events take place. These factors underpin how someone appraises risk. Individuals with more ‘resilience’ at a given time – for example, greater social capital (family, friends, support networks), environmental stability (financial, residential), good physical and psychological health, enhanced problem-solving skills, realistic sense of control and capacity to make personal choices – will tend to adapt and cope better when presented with challenges. Individuals with less resilience, again either because of nature, nurture or context, have greater psychological vulnerability, and are more susceptible to stress-induced illnesses in response to adversity.
Global interventions have negatively affected the factors that make individuals more resilient to distress and increased their vulnerability. Over a sustained period, fear of direct viral infection, serious illness, and death, and anxiety related to an overall sense of elevated risk, uncertainty and social disruption, have inevitably stressed resilient factors. Whilst technology increases the opportunity for a greater quantity of social contact, for some vulnerable groups, the quality of virtual compared to face-to-face interactions is sub-optimal, when they already have lower social capital. Imposed restrictions have removed the ability to make personal choices, limiting one’s sense of control. There is uncertainty around jobs and economic stability. As the pandemic and restrictions draw out, the risk increases that individuals’ resilient factors ebb away.
Vulnerable groups are already less resilient, and have less margin to shoulder severe and enduring distress. The effects on mental health caused by the pandemic and the consequences of the global response were recently emphasized by the Office of National Statistics, which found that 1 in 5 people had experienced some form of depression during the pandemic in June 2020, compared to 1 in 10 the previous year before COVID-19 struck. This was particularly evident in 16-39 year old women, a group that had arrived to the pandemic in a state of growing psychological vulnerability. However, the pandemic has served to increase the burden on all vulnerable groups (the elderly, youth, isolated populations, those predisposed to stress conditions), highlighting and accelerating their vulnerability, as well as broadening health and other inequalities further.
In response to these events, it follows that building resilience will help people at greater risk of mental ill health, as well as maintain stability in resilient individuals. At a singular level for more resilient groups, there is no shortage of sensible approaches that help achieve this goal. Important features may include: establishing gainful routines in selected areas of importance, for example, that maintain some level of social, family, work, educational, physical and psychological functioning; setting specific goals in these areas; planning how to achieve them; and then following through with those plans. The challenge is still considerable but for self-starters, such plans will be more independently driven; others may need external motivators and structuring, and group activities may be more helpful.
The vulnerable and those already suffering mental ill health have less internal resources to cope with distress. They have a significantly greater need for external sources to help overcome their mental health problems and then to build their resilience, yet: professional services are already stretched and there is limited access; usual support networks are less accessible due to restrictions and social disruption; their overall motivation to seek support tends to be lower; and interventions are often less effective. The challenge for these groups is far greater and for many, unachievable without help.
Public health interventions to build resilience and help overcome mental health problems at a population level are far more challenging and ambiguous, in part because the problems and solutions are multifactorial, and harder to determine, implement and measure effectiveness. There is no equivalent in public mental health that comes close, for example, to the discovery of vaccines or that a surgeon washing their hands before surgery dramatically reduces death rates. In the current circumstances, interventions that could increase resilience (for example reinstating social norms), and reduce vulnerability, fear and anxiety (such as a more balanced presentation of data and narratives in the media that could start to normalise, add perspective, and dilute the impact of worldwide events), also risk worsening the direct impact of the pandemic on mortality and morbidity.
In the trade-off between acting to reduce the impact of the pandemic (infections, longer term consequences and death rates) versus the impact on other areas as a consequence of those actions (the sacrifices to personal freedoms, other areas of health, the economy and livelihoods) the balance is still very much tilted towards the former. There is, however, light at the end of the tunnel with the development of vaccines. Whilst there will be significant logistical and other challenges of vaccinating the world’s population, their mere availability will not only provide much needed direct defence against the virus, but a powerful shot in the arm against the current fears and anxieties. Without making light the very significant burden that the pandemic has and will continue to have on those personally afflicted by COVID-19, populations as a whole tend to be quite resilient to natural disasters and bounce back relatively quickly. We hope that the same will apply in these circumstances and that a significant majority will exit the pandemic and reinstate pre-pandemic levels of function over time.
Dr Vince Gradillas is Medical Director and CEO of Claimont, a leading independent healthcare service, providing care to clients with mental health problems at home and in their local communities.