Wednesday, 1 April 2020

COVID-19: The public health emergency and the disproportionately disadvantaged

Flattening the curve has its costs: understanding the mental health and psychosocial impact of social distancing

Johanna Badcock

Johanna Badcock highlights some of the possible unintended consequences of social distancing, quarantine and self-isolation for the mental health of the broader population and, in particular, for those who are already experiencing higher levels of loneliness.

The emergence of the coronavirus pandemic has been disorienting.

Government responses, in Australia and overseas, have centred on a range of measures to decrease the rate of spread of COVID-19, including self-isolation (of those known or reasonably believed to be infected), quarantine (of those reasonably believed to have been exposed, but not yet symptomatic) and social distancing for nearly everyone else (e.g. avoiding mass gatherings, working from home, social-density controls and maintaining a safe distance from others when possible).

It’s important to be clear that loneliness is not a disorder: it’s part of the human condition. However, evidence shows that loneliness is a common response to the social turmoil and restrictions arising from pandemics.

In the absence of a vaccine, our ability to contain and control transmission of the virus is critical. There has been substantial variation across countries in the stringency and timing of social responses to COVID-19, generating debate amongst policymakers, and rapid accumulation of data, about which measures are effective (and which are not) in preventing transmission. Emerging evidence suggests that social distancing measures will be effective in reducing the spread of COVID-19, which in turn will help to lower the pressure on the healthcare system.

However, the unintended psychological effects of social distancing, quarantine and self-isolation are now rapidly taking hold and seem likely to become more serious over time. Put simply, social distancing measures are highly disruptive; they deeply challenge our usual ways of interacting and connecting with others.

Previous studies of viral epidemics indicate that the psychosocial impact can be substantial, pervasive and long-lasting, with frontline workers being at increased risk. The wide-scale implementation of social restrictions, including ‘lockdown’, across the Australian community will need to be accompanied by a range of well-coordinated, evidence-based strategies to reduce, as much as possible, the negative effects on mental health and wellbeing.

Public health systems also need consistent and robust data-collection strategies that capture the psychological as well as the medical impact of pandemics, so appropriate help can be provided in a timely and effective way.

In fact, there has already been a marked increase in the levels of stress and anxiety being reported in the Australian community, leading mental-health organisation Beyond Blue warn that the global pandemic could result in a rise in suicides. Unsurprisingly, the need for longer periods of social distancing may result in lower levels of compliance, and the current uncertainty surrounding the duration for which social-distancing measures will be applied seems likely to further fuel anxiety. Consequently, public messaging may now need to change from explaining why social distancing is needed, to emphasising what the benefits of complying are for stopping the pandemic in the shortest possible time.

Many people are also struggling with feelings of loneliness.

It’s important to highlight the distinction between social isolation – the objective state of being alone – and loneliness , which is the distressing feeling we experience when the quantity, and especially the quality, of our social relationships is less than we desire. These are two separate issues, which means that social isolation (e.g. when managing COVID-19) doesn’t inevitably mean you will feel lonely.

However, the coronavirus pandemic has come at a time when loneliness is a widespread problem both in Australia and overseas. Those who were already experiencing loneliness are likely to be disproportionately affected by the social-distancing, quarantine and social-isolation measures required to manage the current crisis, since they do not take into account individual differences in social needs.

This pre-existing level of loneliness cannot be separated from the necessary government response to COVID-19. However, it highlights the need for government and public-health responses to be grounded in the context, including pre-existing issues in the community. That is, to provide effective interventions for loneliness in the context of the pandemic, we need to understand the needs of specific and vulnerable groups who might experience difficulties accessing information, care and support, or who might be at higher risk of infection.

For example, many clinicians have shifted from face-to-face to online delivery of psychological services, while community advice has largely relied on ways of communicating and meeting online to stay socially connected. But many people dealing with loneliness have no-one in their community with whom they could meaningfully connect online, and many vulnerable people do not have access to digital health services. They do not have an easy method to connect to any digital service either because of the cost involved, inadequate or no internet service, or because of lack of digital literacy. This points to the need for immediate programs to facilitate virtual connection – digital equity – as part of a broader policy response to tackling loneliness.

The US Inter Agency Standing Committee Guidelines for mental health and psychosocial support in emergency settings recommends “that multiple levels of interventions be integrated within outbreak response activities”. Similarly, in Australia, mental-health and psychosocial support needs to be strengthened in response to COVID-19, and incorporated as a core component of the Australian Health Sector Emergency Response Plan for Novel Coronavirus (COVID-19), to increase our preparedness for future infectious disease outbreaks. The National Health Commission China has also been developing policy guidance to integrate the psychosocial impact of COVID-19 into public-health preparedness and emergency response plans.

Feelings of loneliness normally prompt us into action to find new social relationships or reconnect with old ones. But loneliness can become a serious issue when it becomes recurrent and persistent. It can impair our thinking, willpower, and perseverance, which can affect our willingness to comply with social-distancing measures. It can disrupt our blood pressure, sleep, immunity and stress response, which could impair our ability to recover from the virus. Loneliness is also linked to developing symptoms of depression and dementia in the future, increasing the risk of long-term repercussions of COVID-19. Finally, loneliness is associated with increased use of healthcare services. With the pressure on our health system rapidly mounting, this would be a bad time to increase both the short- and long-term demand on these services.

Undoubtedly much will be learned from this outbreak; such knowledge will help us to improve our preparedness and resilience for the future, including action at government, public health and community levels. For example: increased use of, and investment in, behavioural and psychological science, to improve the effectiveness of measures to reduce virus transmission and better understand the long-term consequences of social-distancing measures; providing resources and structures to enable a rapid and coordinated scale-up of mental-health and psychosocial support during an emergency, while remaining adaptable to individual needs; and developing evidence-based interventions to reduce the high levels of loneliness in our community, strengthening community resilience prior to and during times of stress.

Johanna Badcock is Adjunct Professor at the UWA School of Psychological Science, Research Director of the Perth Voices Clinic, and a deputy chair of the board of the Australian initiative ‘Ending Loneliness Together’. She is passionate about psychological science and its value in everyday life. She believes the diverse skills of academic and professional psychologists are essential to tackling global, local and individual human problems, and building stronger, more socially connected communities.


UWA Public Policy Institute