Effect of nations' COVID restrictions on mental health varied by type, group

Stressed-out mom with daughter
Stressed-out mom with daughter

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Two studies published yesterday in The Lancet Public Health detail how COVID-19 restrictions moderately affected adults' mental health in 15 nations, with one finding that the type of lockdowns were linked to the level of distress and opinion of the government, and the other suggesting that mental health declined slightly but significantly under lockdown—especially among women.

COVID-zero countries had greater freedoms

An international team led by a Simon Fraser University researcher in Canada assessed the stringency of daily public health policies using the Oxford COVID-19 Government Response Tracker and psychological distress and life evaluations using the Imperial College London-YouGov COVID 19 Behaviour Tracker Global Survey.

Respondents from 15 countries were tracked from Apr 27, 2020, to Jun 28, 2021, when most participants weren't fully vaccinated. They completed the four-item Patient Health Questionnaire (PHQ-4) and the single-question Cantril Ladder every 2 weeks.

Included countries were Australia, Canada, Denmark, Finland, France, Germany, Italy, Japan, the Netherlands, Norway, Singapore, South Korea, Spain, Sweden, and the United Kingdom. The researchers also studied a subset of the Nordic countries, with Sweden following a mitigation strategy, and Denmark, Finland, and Norway adopting an elimination approach. Australia, Japan, Singapore, and South Korea pursued a COVID-elimination strategy, while the remainder took a mitigation approach.

Participants gave 432,642 valid responses, with 14,918 responses every 2 weeks, on average, on following physical distancing guidelines and their views of the government's pandemic response.

"Because early and targeted action resulted in lower levels of virus circulation, average policy stringency was lower in countries that pursued elimination strategies than countries that pursued mitigation strategies," in both the 15-country and Nordic samples, the researchers wrote.

After controlling for variables, stricter policies were tied to higher average psychological distress scores and lower life evaluations, as was pandemic intensity, defined by the number of deaths per 100,000 residents. But the effects were small, and the negative association between policy stringency and mental health was ameliorated by following physical distancing guidelines and positive views of the government's pandemic response.

In a Lancet news release, lead author Lara Aknin, PhD, of Simon Fraser University, noted that governmental responses to the pandemic have been widely debated. "At first sight, it may seem that eliminator countries implemented much harsher strategies than other countries because of their widely reported international travel bans," she said.

"But, in reality, people within these borders enjoyed more freedom and less restrictive domestic containment measures overall than citizens in mitigator countries."

Small effect on wellbeing

The public health measures of countries pursuing elimination were less strict, on average, than those taking a mitigation approach owing to faster and more widespread COVID-19 testing and contact tracing. They also reported fewer deaths.

"Psychological distress increased over time in countries that followed a mitigation strategy, and decreased over time in countries that followed an elimination strategy," the investigators wrote of the 15-country sample. "Similarly, life evaluations deteriorated over time in countries that followed a mitigation strategy, but this decrease was not significant among countries pursuing an elimination strategy."

In the Nordic sample, life evaluations were stable over time in elimination-strategy countries but fell significantly in those taking a mitigation approach.

"Changes in mental health measures during the first 15 months of the COVID-19 pandemic were small," the study authors wrote. "More stringent COVID-19 policies were associated with poorer mental health. Elimination strategies minimised transmission and deaths, while restricting mental health effects."

The researchers said governments could prioritize policies that slow virus transmission while imposing fewer restrictions. "Even in settings where governments were slow to respond and have consequently brought in restrictive policies such as stay-at-home orders, mental health has gradually declined only slightly, implying that policy makers should be largely reassured by people's aggregate capacity to cope," they concluded.

In a related commentary, Maxime Taquet, BCh, PhD, and Paul Harrison, BCh, DM, both of the University of Oxford, said that the study data are insufficient to drive a change in public health policy.

"Since this study was observational, the results do not indicate whether lower death rates with less stringency were achieved in countries that pursued an elimination strategy because of their COVID-19 policies or whether this resulted from factors not measured in this study (eg, health-care provision, health behaviours, general population health)," they wrote.

Taquet and Harrison also said that policymakers may not have to choose between slowing viral spread and protecting mental health.

"The choice of policies used to contain the spread of the virus are likely to have differential effects on mental health," they wrote. "Establishing an inventory of the mental health impact of public health policies will help inform strategies to respond to potential future waves of COVID-19 and to other future pandemics."

Women bore outsized burden

In the second study, a team led by an Australian National University researcher evaluated the mental health of Australians aged 15 years or older before (2011 to 2019) and amid (2020) the pandemic by mining data from 10 annual waves of the longitudinal Household, Income and Labour Dynamics in Australia (HILDA) Survey.

The investigators used difference-in-differences models to compare the changes in mental health of respondents in the state of Victoria who were in lockdown during 2020 (treatment group) and residents of other areas of Australia with few public health restrictions (control group). Participants completed a questionnaire that included the five-item Mental Health Inventory (MHI-5).

The sample was made up of 151,583 observations from 20,839 Australians. The treatment group consisted of 3,568 Australians contributing 37,578 observations (34,010 before COVID-19 and 3,568 in 2020), while the control group was composed of 17,271 participants with 114,05 observations (102,867 before COVID-19 and 11,138 in 2020).

In the pre-COVID period, average MHI-5 scores were similar in both groups (72.9 in the treatment group, 73.2 in controls). But that changed with the emergence of COVID-19, with lower average scores in both groups (69.6 vs 70.8, respectively). A difference-in-differences estimation revealed a small but statistically significant effect of lockdown on MHI-5, with a steeper decline among Victoria residents in 2020 than for the rest of Australia (difference, -1.4).

Stratified analyses found that the lockdown effect was greater for females (-2.2 points) than for males (-0.6) of all ages and even more so for women with children younger than 15 years (-4.4) and women who lived in an apartment (-4.1) or semidetached house, rowhouse, or townhome (-4.8).

Overall, lockdowns were tied to a modest negative change in mental health, the researchers said. "The results suggest that the mental health effects of lockdowns differ by population subgroups and for some might have exaggerated existing inequalities in mental health," they wrote. "Although lockdowns have been an important public health tool in suppressing community transmission of COVID-19, more research is needed into the potential psychosocial impacts of such interventions to inform their future use."

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