An analysis of 8 million mental health helpline calls from 19 countries early in the pandemic reveals a 35% jump in calls related to fear and loneliness rather than to problems with relationships, finances, domestic violence, and suicidal thoughts that dominated before COVID-19 emerged.
The study, published yesterday in Nature, suggests that concerns related directly to the pandemic replaced, rather than aggravated, common underlying anxieties, the researchers said.
The study team, led by researchers from the University of Lausanne in Switzerland, said they used helpline call data because they provide a real-time picture of the state of public mental health, unaffected by the design and framing of a study.
The researchers evaluated data from 23 helplines in 14 European countries, the United States, China, Hong Kong, Israel, and Lebanon from 2019 to early 2021, taking into account differences in the timing of local COVID-19 waves and pandemic-related policy measures.
Fear, loneliness amid lockdowns
Of calls to the 21 helplines for which daily data were available, volume rose 13.5% above prepandemic levels. After peaking at week 6 at 35% above pre–COVID-19 levels, call volumes began to decline, reaching 6.2% above prepandemic levels in week 11.
When the investigators defined the beginning of the pandemic as the time when stay-at-home orders were first issued, call volumes rose to 11.2% above prepandemic levels by week 2, climbed to 27% by week 3 until week 8, and then declined. The authors attributed the differences in time profiles to variations in implementation of stay-at-home orders, which typically occurred 2 or 3 weeks after local outbreaks.
Call volumes could have been limited owing to helpline capacity; at first, some helplines were unable to answer all calls and then gradually increased capacity to meet demand, the researchers said. As a result, total call numbers in the study should be interpreted as a low estimate of the true increase in calls.
"However, unanswered calls are not pre-screened, and call answering is thus a random process unrelated to the motives of the caller," the authors wrote. "Thus our data provide representative information on the reasons for calling even if some calls were left unanswered because of capacity constraints."
Prepandemic, most helpline callers wanted to discuss relationship problems (37%), loneliness (20%), and fears and anxieties (13%). At that time, women placed 61% of total calls, and people 30 to 60 years old made 63% of the calls. Both before and after the emergence of COVID-19, 49% to 81% of calls were made by first-time or sporadic callers.
After the pandemic began and up to the end of June 2020, call topics changed substantially, with a 2.4-percentage-point rise in calls made because of fear, including fear of SARS-CoV-2 infection, and a 1.5-percentage-point increase for loneliness amid lockdowns.
Over the same period, other call topics decreased, with overall drops in relationships (-2.5 percentage points), financial concerns (-0.6), violence (-0.3), and addiction (-0.3).
But there was no significant decline in calls for suicidal ideation (-0.1 percentage points) other than for men younger than 30 (-1.6 percentage points). In contrast, women 30 and younger made more calls for violence (0.9 percentage points), which the authors said was particularly important in light of the possible increased difficulty in making those calls during lockdown.
When changes in topics of calls made after the pandemic began were broken down by sex and age-group, the rise in fear-related calls was attributed entirely to callers 30 years and older of both sexes (2.1 to 3.1 percentage points). The increase, according to the authors, likely reflects age-related vulnerability to COVID-19.
Analysis of calls made to two large helplines in Germany and France, which had data up to Mar 31, 2021, showed that call volumes rose again in the second half of 2020, likely reflecting COVID-19 case surges and stricter public health mandates. In Germany, calls increased continuously until early 2021, but calls in France declined again after December 2020.
Fewer suicide calls during surges
Examination of suicide-related calls made to the Lifeline hotline in the United States showed that a 10% increase in SARS-CoV-2 infections was tied to a 0.1% decrease in calls. "One interpretation of this result is that the pandemic itself attenuates suicidal anxieties, perhaps by shifting people's focus towards the distress of others, or to their own fear of the pandemic," the researchers said.
A pattern of a decrease in suicide-related calls amid more generous income support policies was observed in the United States, Germany, and France. "Our findings suggest that public compensation payments for pandemic-induced losses not only reduce economic hardship but also have broader benefits," including fewer calls due to fear (-0.042 percentage points), loneliness (-0.024), physical health concerns (-0.026), and economic anxiety (-0.016).
"This is a first-order issue for policymakers, as interventions designed to contain infections might also affect mental health by exacerbating unemployment, financial stress, loneliness, relationship problems and pre-existing mental vulnerabilities," the authors wrote. "These are, in turn, well-recognized risk factors for suicide."
In a commentary in the same journal, Cindy Liu, PhD, of Brigham and Women's Hospital, and Alexander Tsai, MD, PhD, of Harvard Medical School, said that helpline call data could allow policymakers, mental health providers, and the public to identify the best ways to address mental health issues and other problems.
"Understanding how policies specifically influence mental health on the basis of location (for example, country) and caller demographic (including age, gender and race) could enable policies to be tailored and optimized," they wrote.