Public health responses to the pandemic have focused on preventing the spread of the virus, limiting the number of deaths and easing the burden on healthcare systems. But there’s also potentially another, less visible epidemic we should be focusing on: mental illness.

Our found that people’s mental health worsened following the onset of the pandemic. We discovered this by analysing data provided by 17,452 UK adults, who were surveyed in April 2020 as part of the . This is a large ongoing study of people who contribute data every year, some from as far back as 1992.

Not everyone, we discovered, was affected equally. Young people, women, and those with small children saw their mental health worsen significantly more than other groups.

How we measured distress

The survey measured mental health using 12 questions, which covered people’s difficulties with sleep, concentration and decision making as well as their emotional state, such as whether they were feeling strained or overwhelmed.

People’s answers were then assigned a value between zero and four, with higher scores indicating worse mental health. These scores were added together to give each person a total of between zero and 36, which offered an overall measure of their mental health. We also applied a separate scoring system to people’s answers to estimate whether they were showing clinically significant levels of psychological distress – that is, if their distress was high enough to potentially need medical assistance.

We found that many common and well-known mental health inequalities persisted in the middle of lockdown. For instance, women showed substantially worse mental health than men (with a mean score of 13.6 compared with 11.5), and one-third of women had clinically significant levels of distress compared with one-fifth of men.

Mental health also tended to get worse further down the income scale. The lowest fifth of earners had an average score of 13.9, with 32% showing clinically significant levels of distress. This compared with an average score of 12.0 in the highest fifth of earners, of whom 26% showed high distress levels.

It was important to try to separate out the effect of the pandemic from the general decline in mental health, particularly among young people.

Yet while this told us where the mental health need was, it didn’t tell us what the pandemic’s effects had been. We got a better sense of this by comparing this year’s scores with prior measurements – and indeed, mental health was, on average, worse this year. Average scores have risen from 11.5 in the 2018/19 financial year to 12.6 in the recording made in April 2020. We also saw a significant overall increase in the proportion of people showing clinical levels of distress: 19% in 2018/19 versus 27% in April 2020.

However, because the pandemic arose against a background of worsening mental health in the UK, we expected some deterioration. We took account of this by looking at each individual’s pre-pandemic answers, stretching back to 2014. These helped us predict what the scores were likely to have been in April 2020 had the pandemic not happened.

Overall, we found that scores were 0.5 points worse this year than we would have expected, suggesting that the pandemic – specifically – has had an effect on mental health.

Not everyone is affected equally

This worsening of mental health differed considerably for different groups. Compared to what we would have predicted to see, men’s scores got only marginally worse (+0.06), while the change for women was far greater (+0.92). Young people, aged 18-24, were most affected, seeing a relative increase of 2.7 over what we would have expected if the pandemic had not happened.

We had also predicted that fear of the virus would be a driver of poorer mental health, and that this would disproportionately affect key workers or people with underlying health conditions. But this was not the case.

The factors driving the decline in some people’s mental health are not yet clear. But some clues are revealed when we consider who was most affected. The deterioration in women and those with young children points to the difficulty of managing the domestic load during lockdown. Having young children is challenging at any point, and we know that reliable support from family members, paid childcare and friends lessen its impact. The government’s social restrictions and lockdown abruptly cut off most of these supports.

The effects on young people are especially troubling to see. These have happened against a background, in the past decade, of significant and of young people’s mental health services .

Some young people are vulnerable to social isolation and are affected badly by being withdrawn from school. They may lose oversight of their wellbeing by teachers and other responsible adults, as well as access to regular meals and peer support from friends.

Could there be long-term effects?

As lockdown measures ease, we may see improvements in people’s mental health. It remains to be seen whether there will be any long-term effects, such as pre-existing mental health inequalities becoming more entrenched.

The pandemic has brought people’s differing life circumstances into stark contrast. , , , , , , and are all relevant to mental health. It’s likely these differences will become more important during the anticipated economic recession, and these may have different effects on mental health compared with the government lockdown.

What these changes will do to people’s overall health, wellbeing and family is not known. But to mitigate and manage any additional mental health needs requires them to be closely monitored. People also need to receive high-quality information about mental health in public health messaging and be provided with adequately resourced services. We would do well to remember that our mental health is as important as our physical health, and this should not be lost in our future planning.

, Professor of Psychological Medicine, and , Research Fellow in Psychology and Mental Health,

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Reflection has taken place in isolation during lockdown but coming together is vital to deal with what we have lost. EPA/Facundo Arrizabalaga 

At the end of July, the charity Marie Curie UK launched a campaign for a national day to the thousands of people who have died during the COVID-19 pandemic. The charity pointed out the incongruity between the scale of bereavement since March 23 and the absence of familiar mourning rituals.

Indeed, the absence of public mourning during the pandemic is striking – particularly in Britain, where the closest equivalent to a patriotic national day is Remembrance Day.

While Remembrance Day lacks the celebratory parades and fireworks of national days in other countries, it carries the same effect: mourning the dead binds people together through shared memories, rituals and values. Mourning, in short, creates a sense of solidarity, and even shared identity, amid a shared loss. That solidarity is neither arbitrary nor apolitical. Remembrance Day, for example, gives prominent roles to royals and politicians and invokes courage, heroism and sacrifice.

Since mourning serves so many important purposes for individuals and nations alike, this raises the question of what happens in its absence. The alternative to mourning is melancholia: the denial that a loss is real, the inability to make sense of it or learn from it and, ultimately, the inability to move on.

Like mourning, melancholia may apply to individuals and groups alike. At the national level, without formally acknowledging loss, governments may find it easier to suppress difficult memories – such as of state racism, empire or genocide. In each case, there is a fear that acknowledging the horror of the past will threaten the identity of the nation in the present. Officially recognising Britain’s colonial atrocities, for example, would undermine the myth that Britain is fundamentally more liberal and tolerant than its European neighbours.

Mourning and melancholia

The same is true of the COVID-19 crisis: the way we remember Britain’s experience of the pandemic will shape the way we understand Britain at large. Grappling with difficult memories enables us to critique leaders, policies and even identities. But whether a national day of mourning would achieve this very much depends on how it is framed.

The UK government has stopped holding daily press briefings on COVID-19. Over the summer, the rainbows in front windows have begun to fade and weekly claps for the NHS have ended. The public discussion of COVID-19 has shifted away from the death toll and towards the politics of the lockdown. We talk about the reopening of pubs and restaurants, wearing masks and the logistics of taking holidays. These stories are far removed from the jarring images of military convoys transporting bodies in , or of mass graves in , that circulated in the early months of the pandemic.

If we understand the absence of mourning as melancholia, then this gives us insight into why death is so absent from representations of the pandemic in Britain. Prime Minister Boris Johnson touted the declining daily death toll as a but the UK’s death toll is the in the world. The Office for National Statistics that England had the highest excess mortality rate in Europe during the first six months of 2020. Within this context, acknowledging the scale of death would betray the idea of Britain as resilient, sovereign and a world leader in public health. It would throw into question the government’s claim to legitimacy. Many people would feel that Britain had lost its sense of self.

The high stakes of mourning and melancholia provide some insight into what pandemic bereavement might look like in the future. The Marie Curie initiative is likely to gain the government’s endorsement, in large part because it appeals to solidarity and national character. Its slogan, #UniteInMemory, makes it clear that the charity’s goal is to shore up solidarity rather than challenge the government’s handling of the pandemic.

Within the initiative’s remit is every death that has occurred in Britain since March 23. These are linked by the survivors’ inability to because of lockdown rules. The lockdown is framed as a shared experience of sacrifice that reveals national character.

Focusing on individual deaths, however, also limits what mourning can achieve. An alternative to this approach would acknowledge, and grieve, the government’s failure to control the pandemic and Britain’s disproportionately high coronavirus death toll. By extension, it would mourn the myth of British exceptionalism – and of a particular idea of Britain itself. It is highly unlikely that such an approach would receive the endorsement of Johnson’s government. Until this narrative takes hold, however, any state-sanctioned national day of mourning will bear a closer resemblance to melancholia.

, Presidential Fellow in Ethnicity and Inequalities,

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While the pace of research on the novel coronavirus has been impressively rapid, there remains a lot we still don’t know about the wily pathogen. One of those unknowns is the potential long-term health implications for people who have had the disease.

There has been an avalanche of research on the virus, but the immediate priority has been to report on epidemiology, diagnosis, treatment, vaccines and antibody tests. However, there is already growing evidence that COVID-19 is not a simple lung infection. Why, for example, is asthma when it is a major risk factor for influenza?

There may well be long-term health consequences for a variety of organ systems that extend beyond the respiratory system, including the , and . And there may be implications for health disciplines that are seemingly unrelated to COVID-19. For example, there are reports of headaches, blood clots, digestive problems and the .

It is well known that viruses such as . And coronaviruses can cause peripheral neuropathy, damage to the nerves that . It is possible, in theory, that COVID-19 could cause auditory neuropathy, a hearing disorder where the cochlea is functioning but transmission along the auditory nerve to the brain is impaired. People with auditory neuropathy have difficulty hearing when there is background noise, such as in a pub.

Anatomy of the ear, showing the cochlear and the auditory nerve that carries the sound signal to the brain.

Auditory neuropathy has been linked with Guillain-Barré syndrome, an acute immune disease that affects central and peripheral nerves. Importantly, COVID-19 is also .

Low-quality evidence, but we need to be ready

There are unsubstantiated and anecdotal cases of COVID-19 and hearing loss reported in . But my colleagues and I wanted to know if there was any more robust evidence this, so we conducted a systematic review of the available evidence. Our review, , found reports of hearing loss and tinnitus, but there were only a small number of studies and the quality of evidence was low.

It is important not to diagnose hearing loss where it does not exist, or where it is coincidental given the high rates of COVID-19 in the population. On the other hand, the findings of our review might simply reflect the start of our understanding of this emergent health condition. We need to be prepared to act.

A physician friend of mine working in 91Ö±²¥ told me they have surveyed COVID-19 patients after discharge from hospital and, so far, three out of 25 have reported problems with their hearing. Until the data have been published in a peer-reviewed journal we need to treat it cautiously, but it does provide a possible early indication of what might be to come.

Because of the need to provide timely evidence for decision-makers on this urgent and emergent health issue, we are planning to repeat our review of COVID-19 and hearing loss at regular intervals over the coming year. It is likely that other health disciplines will follow suit. Health conditions may emerge over time that have clear clinical relevance. Following up with COVID-19 patients will probably teach us a lot about the long-term consequences of this destructive disease.

, Ewing Professor of Audiology,

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The use of face masks by the public is a controversial topic and . Evidence suggests that while face coverings and surgical masks can prevent large particles spreading from an infected person wearing a mask to someone else, they don’t trap .

A mask may also increase a person’s risk of contracting COVID-19 by encouraging them to touch their face as they fit and adjust it. Exhaled air can irritate the eyes, which might also tempt the wearer to wipe them.

On the other hand, wearing a mask may stop people with coronavirus spreading it to others (although the evidence for this is currently weak). As governments search for a surefooted transition to whatever the new norm will be, there is a danger that a policy of encouraging the public to wear face masks may precede the evidence.

Unintended consequences

It’s important to consider some of the unintended consequences. Wearing a face mask may impair the ability for some people to communicate with ease because it prevents lip reading and it can reduce the level of speech transmitted from the mouth.

At the very least, removing visual cues can make communication more taxing because of the mental exertion required to listen, especially when there is background noise. As a result, even if a person can follow what is said, they have fewer mental resources left to think about and recall what they heard.

Research has shown there are beneficial effects of wearing surgical masks made from a transparent material that , but these aren’t widely available. And there have , rather than masks, which may offer a solution. But the public has yet to adopt this solution.

The increased effort needed to listen and communicate is exacerbated in people who have a hearing loss. According to the WHO, there are .

Hearing loss leads to communication difficulties between family members, colleagues and friends. It is associated with such as poor social interactions, isolation, depression and anxiety, increased risk of dementia and reduced quality of life. In fact, there are probably many people with hearing loss who were able to manage but would struggle with the widespread use of masks.

Mask misery

An unintended consequence of wearing a face mask might be that social distancing is replaced with social isolation and poor mental wellbeing in older adults with hearing loss. A huge section of society could be subjected to mask misery.

It is also not clear whether wearing a face mask provides a false reassurance about risk reduction (encouraging people to relax behaviours that are known to interrupt transmission, such as keeping at least two metres apart), or if it acts as a reminder to steer clear of people.

Coronavirus tends to take a , many of whom are likely to suffer from hearing loss. This means that those admitted to a hospital are especially vulnerable.

The N95 and FFP3 respirator masks for frontline health and care workers , but they are much more likely to distort and reduce the level of speech. This makes communication particularly difficult at a time of heightened anxiety and when the content of conversations is novel and unpredictable. Imagine the apprehension of being greeted by someone in full PPE wearing a fitted mask and muffled speech competing with the hiss of oxygen from a breathing mask or nasal cannula.

Practical advice for the hard of hearing

So what can you do to improve communication if you have a hearing loss and are confronted by someone wearing a face mask?

1. Ask them to reduce the background noise as much as possible or move to a quieter location.

2. Ask them to talk slowly and not shout.

3. If you have a hearing aid, make sure to wear it.

4. Some hospitals provide portable hearing amplifiers to help with communication if you have lost your hearing aid or it has stopped working.

5. If you don’t have a hearing aid but need one, you can always download a hearing aid app to your mobile phone that can provide amplification to improve speech understanding. Or you can find an app that translates speech into text in real-time.

, Ewing Professor of Audiology,

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Having better access to mental health support could be one reason for lower self-harm rates among Danish teens.

Concern has been growing over in teenagers. In the UK and Ireland, increases began around the time of the and . One study of the UK found rates among teenage girls between 2011 and 2014.

But some surprising new findings suggest that stress caused by recession and financial uncertainty does not necessarily lead to rises in suicidal behaviour. My colleagues and I examined rates of in Denmark. Contrary to expectations, we found that rates of self-harm in Danish teenagers actually fell between 2008 and 2016. Although Denmark experienced an economic recession, why didn’t rates of self-harm among teenagers see a similar spike as in other countries?

analysed , which contain data on individuals treated in hospitals and outpatient departments in Denmark. Such population-level registers are unique to Scandinavian countries. The registers allowed us to look at the numbers of young people attending hospital or outpatient clinics after having self-harmed and compare them against all teenagers of the same age in Denmark.

We found that the rates of self-harm in young people living in Denmark aged between ten and 19 decreased each year between 2008 and 2016. The rate decreased by more than 40% from the beginning to the end of the study period. This pattern was seen in younger and older teenagers and in both girls and boys.

It has long been accepted that economic recession is associated with . Suicidal behaviour is undoubtedly a highly personal experience, but the way that society can influence it has been recognised as early as . Following the most recent global recession in 2008, increased rates of suicide and self-harm were seen .

In Ireland, rates of self-harm among teenagers between 2007 and 2016. In the UK, the government’s response to the recession was to impose austerity measures. This resulted in cuts to government spending on healthcare, unemployment benefits and social services, all of which have a proven .

But free universal healthcare, widespread and increased welfare spending during recession . In line with , we found that the highest rates of self-harm were among teenagers from the poorest households. But our research found that, even for these teenagers, rates fell between 2008 and 2016. While we can only speculate about the causes of the fall in rates, Denmark appears to have protected its most vulnerable young people from rises experienced by other countries.

Of course, adolescents will be affected by economic recession – but, being less directly affected by the job market, they’re unlikely to experience it in the same way as adults. However, there are a number of other factors that are , such as pressure at school, difficulties at home, or mental health issues such as depression or anxiety – but certain measures can also protect teenagers’ mental health, which may be especially important during economic upheaval when populations are more vulnerable.

Social media pressures

While social media pressure may be particularly intense for teenagers, frequently voiced concerns that it might cause harm to mental health and well-being . that most social media content concerning self-harm was positive. The study found that social media was mostly used as a platform to process difficult emotions creatively and share stories of recovery – rather than to promote self-harming behaviours. Social media also has the potential to increase awareness about seeking help for mental health problems – but this would only reduce self-harm rates if mental health support was available and accessible for young people.

Social media might actually provide much-needed support for teens.

More availability and better access to mental health support might be one reason for lower rates of self-harm in Denmark. Since 2007, suicide prevention clinics have been across Denmark for people at risk of suicide. The program was introduced gradually from 1992 and expanded to cover the whole country. These clinics have been found to have positive effects on reducing self-harm and suicide.

Yet, in many parts of the world, . Evidence from the UK shows that teenagers from the most deprived neighbourhoods are yet are less likely to receive mental health treatment.

Denmark has also taken steps to to under-18s. In many parts of the world, , there’s been a sharp rise in the number of young adults who have overdosed on painkillers and antidepressants. Tougher regulations of these common painkillers might help to delay access – and research has shown that can be enough to halt the act.

Having access to health and welfare services, alongside good social connections within societies, can help reduce the prevalence of self-harm – especially during difficult economic times. Places that young people spend time in – such as schools, colleges, universities and health services – can also offer opportunities for social connection.

Social media that encourages social connections could also help young people build more resilience and better manage uncertainties such as a poor job market and financial insecurity. Better funding for mental health services may also be able to help protect younger populations from the harmful effects of economic turmoil and other stresses.

, Presidential Research Fellow,

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