Cases of depression and anxiety continue to skyrocket, as it is becoming clear that the global pandemic will leave a legacy of poor mental health. Each of us has been affected by this shared trauma on some level; the most effective solutions will be collective ones, focused on healing our ties with each other.
As the world moves toward a post-pandemic future, there is little sign of a return to ‘normal’, in large part due to the psychological burden we have all carried. Commentators refer to the experience of the past two years as a collective trauma so frequently that it has essentially become a truism.
Whether it is on the scale of a global pandemic or more localised disasters—earthquakes, wildfires or wars—a collective impact is inevitable. Trauma symptoms, intrusive thoughts, flashbacks, excessive vigilance and, at the sharp end, post-traumatic stress disorder (PTSD) are the consequences of events affecting the mind. In a recent article on the BBC website, UK psychologist David Trickey, a representative of the UK Trauma Council, described trauma as a “rupture in ‘meaning making’” that comes from the way an event changes how individuals see themselves, the world and others.
In the case of the covid-19 pandemic, the two years of illness, death and intermittent lockdown have affected individuals and communities, raised demand for mental health services and showcased the lack of capacity in mental health systems, according to Steve Appleton from the International Initiative for Mental Health Leadership (IIMHL), a global network supporting groups around the world focused on mental health leadership, including population-based mental health.
“It is fair to say there has been a traumatic impact, but it has been varied in its reach and effect,” he says. “The pandemic has shone an increasingly bright light on mental health issues and how they arise and how they are responded to. The other impact it has had is to demonstrate to a wider audience what those of us working in the field already knew, which is that the social determinants of health are critical.”
While experts debate whether entire populations are experiencing PTSD or something more nuanced, there is clear evidence that rates of depression and anxiety have skyrocketed, and mental health is climbing up the health policy agenda.
“It is a really important form of global collective trauma because [the impact of] covid is ambiguous, and we don’t know how bad it is going to get,” says E. Alison Holman, a professor in the department of psychological science at the Sue and Bill Gross School of Nursing at the University of California, Irvine, and an expert in collective trauma. “We had zero clue [about the pandemic] at the beginning, which created immense uncertainty and threw people’s sense of wellbeing and sense of their future into complete disarray.”
“With traditional media, editors are reviewing the content before it gets shared; with social media, there is no filtering”
For Holman, who has studied reactions to traumatic events in the US ranging from the September 11 attacks to the Boston Marathon bombings and California wildfires, the reverberations from the covid-19 pandemic share many of the same characteristics, yet its scale and unrelenting persistence are likely to have more long-term consequences, she says.
The pandemic has highlighted the connections between mental and physical health, as well as the broader flaws in health systems around the globe, especially the vulnerability of the most disadvantaged and socially isolated populations. Policymakers in many countries have recognised that there is work to be done. But it remains to be seen how ambitious they will be as we reimagine health delivery after the pandemic.
Impact on the global psyche
During the pandemic, extreme trauma has been documented in intensive care staff, other emergency service workers and those grieving lost loved ones everywhere from the US and the UK to Brazil and China. Data from the International Council of Nurses found that the proportion of nurses reporting mental health distress had risen from 60% to 80% since the first wave of the pandemic.
Yet even those not as directly affected have experienced disorientation of time and other stressors linked to the uncertainty and extended nature of the pandemic. “Covid has created a circumstance of loss that is like a sneak attack,” Holman says.
“When you undermine someone’s sense of the future, you completely mess with their mental health. Human beings count on having some sense of where they are going with their lives, and when they lack that all bets are off and you are coping with that sense of trauma.”
Social media and 24-hour news coverage feed the apparently inescapable sense of doom emanating from the pandemic and parallel events, including racial tensions and divisive politics in the US, economic downturns globally and, more recently, the war in Ukraine. This cycle, and an inability to find respite, can be traumatising in its own right. “With traditional media, editors are reviewing the content before it gets shared; with social media, there is no filtering” Holman adds.
A final factor that is likely to distinguish the legacy of the pandemic from that of other traumatic events is the experience of repeated mass lockdowns and the isolation they engender. Reaching out to others and repairing community ties are key to building resilience and recovery from collective trauma. Yet, in some parts of the world, societies are still emerging from a deep sense of caution, and, in many cases, individuals are expressing their own trauma by continuing to isolate themselves from others, even when their risk of infection is fairly low.
The evidence that isolation increases stress and trauma symptoms has been documented repeatedly in research over the past two years. A study of Chinese young people in lockdown during the first month of the covid-19 outbreak found that 13% had symptoms consistent with PTSD, while an online survey of 3,500 people in Spain found symptoms of PTSD in nearly 16%, and depression and anxiety in more than 40% of respondents.
Learnings from traumatic events
The mental health consequences of trauma can persist long past the event. For example, where a natural disaster has caused widespread property damage, just the prolonged experience of dealing with insurance claims can be a continued stressor. In the longer term, anger, substance abuse and domestic violence can increase, especially for those who are more isolated.
Like many places around the world, Christchurch, New Zealand, has some experience with collective trauma. The largest city on the country’s South Island, with a population of around 500,000, Christchurch experienced a deadly earthquake in 2011 that killed 184 people. In 2019, it became the site of a terrorist attack in which 51 people were killed in two of the city’s mosques.
“We were the trauma city, but it prepared us," says Dr Peri Renison. "We were better prepared to respond to the mosque shooting because of the [earth]quake response and what we learned from that. By the time of covid, the rest of the country was seeing increased demand for mental health services, and we weren’t. It was resilience and the community pulling together.”
The lessons learned from dealing with both tragedies have equipped Christchurch and its population to respond better to subsequent stressful events, including the pandemic, according to Dr Peri Renison, until recently the chief of psychiatry for the Canterbury District Health Board and director of area mental health services for Canterbury, the region encompassing the city.
“We were the trauma city, but it prepared us," says Dr Peri Renison. "We were better prepared to respond to the mosque shooting because of the [earth]quake response and what we learned from that. By the time of covid, the rest of the country was seeing increased demand for mental health services, and we weren’t. It was resilience and the community pulling together.”
The region heavily invested in its mental health response, especially in youth and child support, Renison says. After the earthquake, the public health sector launched an online poster messaging system, ‘All Right?’, that asked people when they had last caught up with their neighbour and what they had done to look after themselves today, and advised that it was okay to feel worried. The campaign was so effective that it was adopted in other parts of the country.
In 2019, the New Zealand government announced a NZ$1.9 billion (US$1.3 billion) wellbeing investment on top of the usual funding for mental health. It included investment in more than 200 sites delivering integrated primary mental health and addiction services across New Zealand and 134,000 sessions delivered by newly added primary mental health and addiction services.
While the earthquake and terrorist attack helped increase awareness of mental health in Christchurch, the pandemic still posed significant challenges—even though New Zealand has been less seriously affected. “With covid, no one has been exempted from it, so there has definitely been a heightened awareness, in a way destigmatising mental health, because so many people are experiencing what it is like to be really anxious,” Renison says.
Looking ahead, she says the post-pandemic period is likely to provide a unique opportunity to study the impact of severe isolation and further inform the city’s approach to traumatic events. “Normally, with disasters, people come together in support groups and have contact that they haven’t had before,” Renison says. In the case of the pandemic, “people have withdrawn”.
Investing in sustainable mental health
Despite the sharp rise in global mental distress over the past two years, there have been some upsides to the dislocation experienced. The global nature of the pandemic has made it more acceptable for people to admit to feeling stress. There are clear efforts to improve access to services in many countries.
The pandemic has also highlighted the underinvestment in mental health services in many parts of the world, including the heavy reliance on institutional care, and the funding and labour crisis. The quick switch to telehealth has also revealed digital inequalities, Appleton observes.
Some of the problems brought to the fore by the pandemic are already being addressed in several countries. Notably, these include care delivery gaps, such as the lack of integrated mental and physical healthcare, insufficient funding, and the heightened need for preventative care and community support for those with milder mental health illnesses.
Yet longer-term problems, such as the impact of economic inequalities and workforce challenges—in particular, a worldwide shortage of trained therapists—will be more difficult to remedy. And it remains to be seen whether the priority focus on mental health and the commitment to more investment in support will continue.
Like the pandemic itself, mental health is not a quick fix. “I think it is going to depend on a lot of factors, including how we reconnect socially,” Professor Holman says. “There will be more requirement for an outlay of resources. Is it going to be protracted and long-term? It depends.”
In the US, President Joe Biden’s budget plan for the 2023 fiscal year proposes requiring both private insurers and Medicare, the public health insurance programme for senior citizens, to cover three ‘behavioural health visits’ annually with no cost-sharing by patients.
The plan would also end the current lifetime limit of 190 days of inpatient psychiatric treatment for Medicare. The limit does not apply to inpatient hospital care for any other health conditions. It also includes nearly US$700 million funding to create a telephone hotline for mental health care.
At the same time, says Renison, new investment in mental health at the primary care and NGO level, while welcome, cannot be a substitute for funding specialist services.
More broadly, mental health care must not remain isolated from other determinants of health. This will also require global populations that have become introverted and isolated to reconnect.
“Covid has caused a withdrawal into homes and an inward focus on ourselves, our country and our town,” Appleton says. “We need to start looking outwardly again.”
Holman agrees, explaining that a shared focus on mental health can help ease the impact of our collective trauma. “People need to realise they are healthier mentally and physically when they live in a community where others are healthy mentally and physically,” she says. “People are profoundly resilient, but what is in my best interest is to help you.”