The Covid-19 pandemic and the mitigation strategies put in place to curb the spread of the virus caused widespread economic and social disruptions, impacted people’s daily lives, and impeded many individuals’ ability to generate income.

Indeed, many people will feel the brutal economic consequences of the pandemic for some time to come, and economists speculate that a global recession may follow on the heels of the pandemic.

Mental health professionals and lay people alike anticipated that the pandemic would have a devastating impact on mental health. We were told to expect a tsunami of depression and suicide, while being warned about a second epidemic of mental health problems in the wake of the pandemic.

But has this been the case?

No massive increases

A recently published systematic review in the British Medical Journal concluded that the pandemic did not cause a ubiquitous or devastating deterioration in mental health.

The scientists who conducted the review examined all studies they could find that assessed general mental health, anxiety symptoms, or depression symptoms measured before and during the pandemic. Studies were included in the review only if 90% or more of the same participants were assessed before and during the pandemic, or where robust statistical methods were used to account for missing data. They identified 137 unique studies from 134 cohorts.

Across all these studies, most changes in prevalence estimates for general mental health, anxiety and depression symptoms were close to zero and not statistically significant. Where significant changes were observed the magnitude of the change was negligible or very small.

However, small but significant negative changes were observed for female participants across all domains. In a few instances, a slight deterioration in mental health was observed early in the pandemic but by the end of 2020, these had returned to the pre-Covid levels.

Very similar findings have been reported for suicide rates. A publication in The Lancet Psychiatry examined suicide data from 21 countries and found that in high-income and upper-middle-income countries, suicide numbers remained largely unchanged or declined in the early months of the pandemic compared with the expected levels based on the pre-pandemic period.

Subsequently, a study of data from 33 countries showed that during the  first nine to 15 months of the pandemic, suicide rates in most countries did not change significantly, although there was a very small number of countries and a few areas within countries where overall suicide numbers were greater than expected.     

Similarly, a systematic review of suicide and self-harm in low- and middle-income countries during the pandemic concluded that the most robust evidence, from time-series studies, showed that rates of suicide and self-harm either declined or remained unchanged.

Closer to home, a paper published in the South African Journal of Science with data collected in 2015, 2017 and 2020 from first-year students at Stellenbosch University and the University of Cape Town found that while rates of mental disorders among students have been increasing since 2015, the increases observed between 2017 and 2020 were no larger than those observed in prior years.

Making sense

How is it possible that a pandemic can cause such social and economic disruptions without precipitating a flood of mental disorders and suicide?

One possible explanation is that it is simply too soon to assess its full impact on mental health and that the data reported in the studies above were collected early in the pandemic before the real impact could have been felt.

Another possible explanation is that the quality of the available data is too poor and too incomplete to draw any firm conclusions, and that any findings should be interpreted with severe caution.

Yet another possibility is that most data on mental health comes from high-income countries, where most people were buffered from the pandemic’s psychological impact because of their access to medical and social resources.

However, it is far more likely that the available data is good enough to conclude that the pandemic has not yet precipitated huge increases in rates of mental illness or suicide.

It is true that the pandemic caused mental distress for many people. But mental distress is not the same as having a mental disorder, although the two concepts are often conflated.

We all experience mental distress occasionally because of the unavoidable ups and downs of everyday life. Who among us has not felt the devastating sadness that comes from a broken heart, the shock of witnessing a serious motor accident, the stress of trying to balance work and family commitments, the relentless pressure to perform at our best, or the deep-felt loss of bereavement?  

As distressing as these feelings are, they are not the same as having a mental disorder. And importantly, mental distress typically subsides with time and with appropriate social support from family and friends without the need for any professional or formal intervention.

According to the World Health Organization, a mental disorder is characterised by a clinically significant disturbance in an individual’s cognition, emotional regulation, or behaviour.

Mental disorders are associated with serious and enduring impairments in important areas of functioning including interpersonal relationships, family life and work. Mental disorders are serious, and the symptoms are severe, debilitating and enduring, often requiring treatment from a mental health professional.

Confusing mental distress and mental disorders

The language of trauma has become commonplace and there is an increasing tendency to view all uncomfortable situations through the lens of trauma, creating the impression that we are all constantly being traumatised, and we are only one step away from developing post-traumatic stress disorder.

When we use the word “trauma” to refer indiscriminately to the struggles of everyday life, we minimise the profound and enduring impact of events like sexual assault, severe childhood neglect and deprivation, and physical abuse.  

Being asked to observe social distancing or wear masks in public can be very upsetting and disruptive, but it is not necessarily traumatic in the way that sexual assault or living in a war zone is traumatic.

Other psychiatric terms like depression, anxiety and panic attack are also becoming part of everyday speak. While talking openly about depression and anxiety can help to normalise these mental conditions and reduce stigma, it also runs the risk of trivialising serious mental illnesses.

A major depressive disorder is not the same as feeling sad for a while. And panic disorder is not the same as feeling stressed about a looming work deadline. When we use the language of psychiatry to talk about everyday experiences, we often confuse mental distress with a mental disorder.

The ubiquitous rise of “psychiatric speak” has occurred alongside a global trend to medicalise everyday life by seeing daily struggles as illnesses that require medical treatment.  

The medicalisation of our normal emotional reactions to difficult situations can easily lead to over-diagnosis and over-treatment of mental disorders, a phenomenon called psychiatrisation. The psychiatrisation of society is a topic which bears further examination beyond questions of Covid and mental health.

For us as mental health practitioners and researchers, there is an uncomfortable irony in what we see as psychiatrisation. For a long time, we have been part of struggles to destigmatise and make visible real mental health challenges, challenges for which there are effective solutions. 

But along with this activism comes the danger of pathologising social, political, and interpersonal problems. 

Psychiatrisation is a global problem but takes on a particular importance in contexts where there are low rates of provision of care for mental disorders, such as in South Africa.

It is crucial that scarce resources are used when they are needed and can make a difference, and not for transient states of emotional distress which may well resolve on their own, possibly in the context of community or family support.

Although the pandemic was stressful and many of us felt mental distress, the data shows that this has not yet led to a massive jump in rates of mental disorders globally.

Maybe this is worth remembering the next time we are tempted to view our daily struggles through the lens of trauma or medicalise our own feelings by referring to a transient experience of stress as a panic attack.

This is not an argument against psychiatric and other treatments when needed, nor is it our intention to restigmatise mental disorders. 

There are effective treatments available for mental disorders and suicide is 100% preventable. If you are struggling with your mental health, reach out and ask for help. DM

Prof Jason Bantjes is a chief specialist scientist in the Alcohol, Tobacco and Other Drug Research Unit at the South African Medical Research Council. He also holds an extraordinary appointment at the Institute for Life Course Health Research at Stellenbosch University and is an honorary professor in the Department of Psychiatry and Mental Health at UCT.

Prof Leslie Swartz is a professor in the Department of Psychology at Stellenbosch University and Editor-in-Chief of the South African Journal of Science.