The early impacts of the COVID-19 pandemic on Scotland’s mental health – not just one story
On behalf of the Public Health Scotland, Scottish Government and Healthcare Improvement Scotland Mental Health Analytical Hub

Summary

This paper presents an analysis of quantitative and qualitative material collected early in the pandemic looking at the impacts of the COVID-19 pandemic on mental health. This analysis has given us an understanding of how ‘everyone’, in one form or another, has been affected mentally by the pandemic. The qualitative studies, in particular, reveal the profound impacts the changes in every day and working life had on people’s mental lives.

What the evidence also underlines is not just the extent and nature of the mental health impacts of the pandemic, but also the uneven distribution of those impacts, with the potential to worsen and widen mental health inequalities across society. Where people started from, and their social and economic position may well influence the impacts of the pandemic on their mental health and wellbeing. It may also influence the emotional and financial resources people are able to draw on to recover from the pandemic.

Building on the learning from the quantitative and qualitative studies may therefore give us a way to re-imagine mental health, one that enables us to think through how social and economic factors play out at the level of individual and community day-to-day experiences and practices.

Introduction

Public Health Scotland (PHS), the Scottish Government and Healthcare Improvement Scotland established the Mental Health Analytical Hub (the Hub) in 2020. The Hub’s purpose was to coordinate requests for data and evidence on the impact of COVID-19 on mental health and to:

• share information
• reduce duplication of effort
• support collaborative work.

Since 2021, the impacts of COVID-19 have continued to be part of the context of the Hub’s work, but the focus has widened to consider mental health more broadly.

The Hub recognised the value of a summary of the early impacts of COVID-19 on mental health in Scotland, drawing on quantitative and qualitative data, and the following presents some of the emerging findings.

Structure

The report is divided into three sections:

1. Findings from two Scottish surveys that provide a quantitative (numerical) picture of the extent and type of mental health impacts of the pandemic on the population.
2. An in-depth look at a number of qualitative studies, drawing on samples from across the UK, that provide a picture of how people expressed and experienced the impact of the pandemic on their mental lives.
3. Reflections on the combined learning from the quantitative and qualitative material.

Quantitative data

Methods

Many surveys appeared during the early stages of pandemic.

In 2020, the Scottish Public Health Observatory (ScotPHO) compiled an overview of national surveys that provided information on the impact of COVID-19 and pandemic response measures on the health and wellbeing of the Scottish population. The quality and scope of these surveys was also assessed. This found that many of these surveys were not representative of the Scottish population and/or there was only a small Scottish sample within a UK survey or study.

View the impact of COVID-19 response measures on ScotPHO's website (external website).

To provide a better picture of experiences in Scotland two national surveys were undertaken by the Scottish Government:

• Public attitudes to Coronavirus: tracker
• Scottish COVID-19 (SCOVID) Mental Health Tracker Study.

These surveys:

• used good sample sizes to allow some breakdown of the data by, for example, age and gender
• were repeated throughout the pandemic
• used reasonably robust methodology (quota sampling from a large existing UK panel sample) and weightings to match the population profile, although they did not use random samples.

The following presents some of the findings from these two Scottish surveys.

Public attitudes to Coronavirus: Tracker

• The tracker used a cross-sectional online panel survey, comprising around 1,000 adults aged 18+ living in Scotland. The sample was taken from a YouGov Plc UK (‘YouGov’) panel consisting of >800,000 individuals UK-wide.
• Public opinion was assessed from the beginning of the first lockdown in March 2020 and regularly throughout the pandemic (and is still ongoing).
• Figures are weighted and representative of Scottish adults (aged 18+).
• The following draws on this data to look specifically at the trends in happiness, anxiety and coping between March 2020 and the end of December 2021. The actual period and individual sampling dates reported for each of these varies as not all questions are asked in all rounds of the survey.

View the tracker survey on the Scottish Government website (external website).

Tracker results – Happiness

Participants were asked: ‘On a scale of 0–10, where 0 is “not at all” and 10 is “completely”, overall, how happy did you feel yesterday?’ A score of 0–4 indicates a low level of happiness.

• No pre-pandemic equivalent data is available for Scotland, but the Office for National Statistics (ONS) Opinion and Lifestyle Survey (OLS) (of around 2,000–2,500 adults aged 16 years and over in Great Britain [GB]) contains a similar single item question on happiness scored on a scale of 0–10 and can give an indication of the change in happiness from pre-pandemic levels. This survey found:
  • pre-pandemic 8.4% of adults had low happiness in the quarter October–December 2019
  • this rose to 20.7% in 20–30 March 2020 at the start of the pandemic and had reduced to 13% in 1–12 December 2021.
• The Public attitudes to Coronavirus: tracker found (see Figure 1)*:
  • compared to the GB pre-pandemic figures, the tracker suggests that happiness fell sharply in Scotland at the start of the pandemic, with 34% of adults reporting low happiness.
  • this swiftly recovered, but not to a pre-pandemic level (judging from the OLS pre-pandemic data) and continued to fluctuate around 15–20% of adults reporting low happiness over the period April 2020 to December 2021.

*Stage of pandemic should be kept in mind when interpreting trends.

 

Graph produced with permission from Scottish Government and YouGov.

Phases 1, 2 and 3 are from the Scottish Government route map and represent the gradual easing of restrictions in the initial stages of the pandemic.

Tracker results – Anxiety

Participants were asked: ‘On scale of 0–10, where 0 is “not at all” and 10 is “completely”, overall, how anxious did you feel yesterday?’ A score of 6–10 indicates a high level of anxiety.

• No pre-pandemic equivalent data is available for Scotland, but the ONS Opinion and Lifestyle Survey (OLS) (of around 2,000–2,500 adults aged 16 years and over in GB) contains a single item question on anxiety (scale of 0–10) and can give an indication of change from pre-pandemic level. This survey found:
  • pre-pandemic 12% of adults had high anxiety in the quarter October–December 2019
  • this rose to 49.6% in 20–30 March 2020 at the start of the pandemic and had reduced to 33% in 1–12 December 2021.
• The Public attitudes to Coronavirus: tracker found (see Figure 2)*:
  • compared to the GB pre-pandemic figures, anxiety rose sharply in Scotland at the start of the pandemic, with 60% of adults reporting high anxiety.
  • this swiftly recovered, but not to a pre-pandemic level (judging from the OLS pre-pandemic data) and continued to fluctuate around 32–40% of adults reporting high anxiety over the period April 2020 to December 2021**.

*Stage of pandemic should be kept in mind when interpreting trends.

**Although it is not possible to directly compare, this is also higher than the 14% of adults identified in the Scottish Health Survey 2018/2019 combined years data as having moderate to severe anxiety symptoms in the previous week using the Clinical Interview Schedule (CIS-R).

 

Graph produced with permission from Scottish Government and YouGov.

Phases 1, 2 and 3 are from the Scottish Government route map and represent the gradual easing of restrictions in the initial stages of the pandemic.

Tracker results – Coping

Participants were presented with the following statement: ‘I feel like I’m coping okay during the current Coronavirus situation’, with a 5-point response option scale from strongly agree to strongly disagree, where strongly/tend to agree indicates coping.

• There is no pre-pandemic equivalent data in Scotland against which to judge trends as this is a pandemic-specific question.

Assessment of coping began a month into the first lockdown, 21–23 April 2020.

• The Public attitudes to Coronavirus: tracker found (see Figure 3)*:
  • levels of coping fluctuated, with around 70% of adults reporting they were coping
  • but the overall trend over the whole time period was for coping to fall slightly from April 2020 to December 2021.

*Stage of pandemic should be kept in mind when interpreting trends.

Graph produced with permission from Scottish Government and YouGov.

Phases 1, 2 and 3 are from the Scottish Government route map and represent the gradual easing of restrictions in the initial stages of the pandemic.

Scottish COVID-19 (SCOVID) Mental Health Tracker Study

Data for the Scottish COVID-19 (SCOVID) Mental Health Tracker study was collected by an online panel survey of individuals living in Scotland aged 18+ over five survey waves during the pandemic (see Table 1). The sample was taken from an existing online UK panel (Panelbase.net).

Table 1: Timing of the Scottish SCOVID survey waves

 

• This survey was designed to follow people up over time (longitudinal) but due to difficulties in doing this (attrition), the survey results are reported for those responding at each wave (cross-sectionally).
• Attrition meant:
  • the sample became less representative of the Scottish population
  • sample sizes became too small to analyse some subgroups, e.g. for people from Black, Asian and Minority Ethnic communities
  • booster samples of young adults were included at waves 3 (n=327) and 5 (n = 130) to allow continued analysis.

For further information, see Scottish Goverments Covid-19 mental health tracker study.

Trends in mental wellbeing, depression, anxiety, and suicidal thoughts were assessed using the following measures:

• mental wellbeing – Short Warwick-Edinburgh Mental Wellbeing Scale (SWEMWBS)
• depressive symptoms – patient health questionnaire (PHQ-9)
• anxiety symptoms – Generalised Anxiety Disorder (GAD-7)
• suicidal thoughts – single question ‘How often have you thought about taking your life in the last week?’ scored on a Likert scale from never to nearly every day.

Results

No pre-pandemic equivalent data is available for Scotland, but data from the Scottish Health Survey and Scottish Surveys Core Questions (SSCQ) data can give a sense of whether there has been a change compared with pre-pandemic mental health outcomes. However, the methodology used in these surveys is not directly comparable, so caution is required in drawing concrete conclusions about the size of any changes.

• mental wellbeing (SWEMWBS) was included in the SSCQ in 2017, at which time the mental wellbeing score was 24.2.
• depressive symptoms: assessed in the Scottish Health Survey using the Clinical Interview Schedule (CIS-R), combining 2018/2019 data, this identified 12% of adults as having moderate to severe depression symptoms in the previous week.
• Anxiety symptoms: assessed in the Scottish Health Survey using the Clinical Interview Schedule (CIS-R), combining 2018/2019 data, this identified 14% of adults as having moderate to severe anxiety symptoms in the previous week.
• Suicidal thoughts: there is no pre-pandemic data on the level of suicide ideation in Scotland.

The mental health tracker study found (see Figure 4 and Table 2):

• For the mental health outcomes assessed, population mental health worsened during the pandemic, although, as noted above, caution must be exercised in making comparisons with available pre-pandemic measures.
• Worsening of mental health outcomes was sustained.
• However, trends suggest some improvement occurred between early in the pandemic (wave 1, May/June 2020) and 15 months in (wave 5, May/July 2021)*:
  • mental wellbeing increased
  • rates of depressive symptoms decreased slightly
  • suicidal thoughts remained about the same
  • rates of anxiety symptoms decreased slightly, although anxiety symptoms in wave 5 were higher than the previous 3 waves, suggesting a continuing impact upon people’s mental health.
• People reported poorer mental health at times of higher restrictions (survey waves 1, 2 and 4) and better at times of less restrictions (survey waves 2 and 5).

*Stage of pandemic should be kept in mind when interpreting trends.

Table 2: Findings from Scottish COVID-19 (SCOVID) Mental Health Tracker Study and pre-pandemic figures

Copied with permission from Scottish Government.

Key subgroup analyses

Various factors that may be associated with a higher risk for poor mental health were also determined in this survey. At-risk population subgroups that consistently reported the poorest mental health in the study compared with their subgroup counterparts were:*

• young women (aged 18–29 years old)
• young men (aged 18–29 years old)
• young adults (aged 18–29 years old)
• women.

Characteristics that also appeared to increase the risk of poor mental health within the overall sample and within some of subgroups listed above included those with:

• pre-existing mental health condition
• pre-existing physical health condition
• unpaid caring responsibilities
• young dependents
• vaccine hesitancy
• lower social-economic group.

*Note: sample sizes did not allow some sub-group analyses, e.g. for people from Black and minority ethnic communities.

Quantitative data summary

The pandemic has impacted the mental health of the Scottish population and although there has been some recovery, it had not returned to pre-pandemic levels by the end of 2021.

Some socio-demographic groups consistently experienced worse mental health over the pandemic. These groups include women, young people (18–29 years), people with pre-existing mental health or physical health problems, people in lower socio-economic groups, carers and those with young dependents.

Qualitative data: what lies beneath

To get ‘under the skin’ of the quantitative surveys we undertook an analysis of studies undertaken in the UK early in the pandemic, which focused on people’s lived experiences.

We wanted to understand how people experienced and expressed the impact of the pandemic on their mental lives.

Qualitative data: selection process

To select studies for inclusion in the analysis, we undertook a systematic search of databases to identify studies published between March 2020 – April 2021 (including pre-prints and ‘grey’ literature) that:

• comprised UK-based populations
• addressed COVID-19 and mental health (mental wellbeing and mental health conditions)
• included qualitative data (including from in-depth and mixed methods studies).

Following screening for relevance, 33 papers were included in the analysis. The population groups covered included adults from the general population, people with mental health conditions, people with long term physical health conditions and health, social care and other frontline workers.

Qualitative data: Overview of themes

From an analysis of the 33 articles, we identified five main themes:

• Feeling safe?
• Everyday life
• Socially connected?
• Mental health care
• The impacts of wider social factors.

Each of these are described in the following pages.

Feeling safe

‘Staying safe’ was one of the key turns of phrase in the early stages of the pandemic, used on the Scottish Government lectern and in people's e-mail sign offs.

The qualitative studies show:

• People expressed real worries and concerns about their own and others’ safety from infection.
• Some groups, e.g. frontline workers and people from Black and minority ethnic communities, had particular reasons for being fearful.
• People were having to put in a lot of practical and emotional ‘work’ to keep themselves and others safe.

‘[I feel] Very lonely … I’ve been with [wife] since 1990. We’ve always been together, always done things together and to suddenly be sitting in a room on your own is quite dire. It upset me at first. I cried myself to sleep for a few nights, you can’t believe this is happening.’ (May et al, 2021:7)

Safety was perceived to be affected by:

• others’ behaviour
• racism and discrimination
• organisational management and practices
• government practices.(i)

All of these took a mental toll.

In addition, people spoke about increased insecurity of income, home, and access to food. Feeling unsafe or insecure was experienced at an individual level but there was an awareness of wider social factors at work.

‘People were genuinely scared because the government was saying this and your manager’s going, no, you do this or you don’t have a job … you can’t afford not to be there or to lose hours or to lose your job.’ (May et al, 2021: 19)

‘I am really worried about ever-changing information from the government on how to act during this pandemic ... Honestly, it really makes me anxious.’ (Nyashanu et al, 2020: 4)

Everyday life

The extent to which the infrastructure of everyday lives and routines had changed for people as a result of the pandemic, and the impact that this had on people’s mental health was a key theme across the qualitative studies. The studies highlighted that:

• Routine is important as a coping mechanism for mental health and was even more so during the pandemic.
• Some people used the time to make positive routine changes, whilst some were debilitated by the loss of routine.
• People experienced the loss of structure and interactions that are built into everyday life and that people find help their mental health.

‘Before the coronavirus, the gym became my life and went there 3, 4, 5 times a week and was my structure ... it helped me cope with my isolation ... with coronavirus, it removed my structure. Just gone. And I don’t function well like that ... As a person living on my own, it’s the lack of external structure that’s the most destructive thing.’ (Gillard et al, 2020: 6)

• Changes to routine, for example through loss of jobs or changes to work patterns, could lead to increasing insecurity with impacts on mental health.
• Having home, work, school and leisure all in the same space also took its toll, either because it left people feeling socially isolated and disconnected from colleagues, or because people were having to juggle paid employment, home schooling and household management all in the same physical space.
• There were deeper changes to identity and people’s sense of self. For some people the pandemic had provided an opportunity to pause, to take stock and to reconfigure routines positively. However, at the same time, people talked about a sense of profound loss of their everyday lives from before the pandemic and expressed a real sense of grieving.

‘Just trying to work out whether that means that I have to renegotiate where I place my purpose, whether that comes from a different career, or whether that comes from staying in what I’m doing … so, there is quite a lot of thinking, I would think I’ve still a lot to do around, and at the moment, it’s probably manifesting itself as generalised anxiety about the future.’ (May et al, 2020: 23)

Social connections

The pandemic and restrictions created substantive changes to people’s social connections with families, friends, colleagues and within communities. The impact of social connection and disconnection on mental health was a key theme across the qualitative studies.

• People spoke about isolation and feeling disconnected from the ‘outside world’ due to the pandemic. Feelings of loneliness and isolation were often not resolved by online connections with other people. For people with pre-existing mental health problems, living alone and having less social contact led, for some, to a worsening of their condition. Healthcare workers could feel particularly isolated due to the impact of the pandemic on existing working relationships and their relationships outside of work.
• People spoke about the mental health impacts of the lack of in-person contact with others, including not being able to hug those close to them or to say goodbye to dying relatives.

‘I live alone and always spend a lot of time alone, but being totally isolated is really hard and making me realise how much I actually need people and how much I miss touch. I really need a hug. I feel so lonely, and feel like this is going to put my agoraphobia progression back. It makes me feel like giving up. I am fighting so hard not to.’ (MIND, 2020: 18)

• People experienced changes to relationships, including some feeling more intense and the loss of others. For some people, spending a lot more time with partners and family was a positive experience, while for others spending more time with family at home in constrained circumstances could prove stressful.
• Connecting with friends and family was commonly talked about as an important strategy for coping mentally, but one that had been affected by the restrictions.

‘I’m a very social person and probably seeing people is the thing that makes me less anxious. Those are the things that make me feel better. So obviously I couldn’t do any of them, and I think the more time I spend on my own, the more anxious I am and the more my mental health suffers.’ (Burton et al, 2021: 4)

• The pandemic highlighted to people the importance of the social relationships that are embedded in communities, e.g. interactions with teachers, colleagues, shop assistants, yoga teachers, and their loss was hard-felt, as was the loss of community based mental health support groups.
• There was a feeling of uncertainty around what the future holds in terms of social contact and connection.

Mental health care

The qualitative studies identified the care and treatment concerns of people with mental health conditions, people with physical health conditions and health and social care staff.

The perspectives of people with mental health conditions

• The qualitative studies suggest that, across the UK, people with mental health conditions had very different experiences in terms of accessing mental health services during the pandemic.

‘Not getting my mental health support since the lockdown. My CPN not returning your calls. It has made me a lot worse. I try to talk to my husband so I am not keeping everything inside.’ (Dickerson et al, 2021: 12)

• Views were very split on the value of online consultations: some preferred online services, others felt that it made things more difficult for them. People described issues of privacy, as well as the impact on their symptoms.

‘I find video calls can be quite draining and I find it hard to be honest about how I am feeling on them.’ (McCombie et al, 2020: 4)

• Some people turned to peer or third sector support – and found this to be a positive experience

The perspectives of people with long-term physical health conditions

• People with long term physical health conditions were similarly divided about the value of online consultations.
• For this group of people, an additional source of anxiety was whether they would continue to receive healthcare treatment now, and in the future.

‘Healthcare is my main priority, that really worries me, that I’m not going to get the same level of treatment as I was getting before, because there won’t be sufficient money around, and a lot of services will be cut.’ (Fisher et al, 2020: 15)

• Even if they received treatment, some were concerned about the risk of infection.

The perspectives of health and social care staff

• Health and social care staff were very much in the eye of the pandemic storm.
• They experienced increased workload, possibly in unfamiliar settings, or using unfamiliar routines, and in contexts of high risk of infection. All of these could have impacts on their mental health.

‘We should have been amongst the first to be tested because we are also exposed to the community ... you can imagine the panic and anxiety of staff, relatives and all.’ (Nyashanu et al, 2020: 4)

• Staff spoke of ‘vicarious trauma’ through their experiences of supporting family members of patients who were dying and who they couldn’t be with.

‘The thought of people saying ‘bye to relatives via Skype, just absolutely broke me every single day, and I cried and cried and cried about it when I got home.’ (Bennett et al, 2020: 3) 

• Staff also felt they experienced ‘moral injury’ from not being able to deliver the quality of care that they would want to provide.
• Psychological support may have been made available, but not necessarily at a time that fitted around shifts.

‘… there is a psychologist who’s offering sessions, but they are in the middle of the day. So, you wouldn’t be able to go if you were on nights or if you are clinically busy you can’t really attend that in the middle of the shift. But informal peer-support groups are starting which has been quite good.’ (San Juan et al, 2021: 5)

• Staff looked to family and peer support to help them cope.

The impacts of wider social factors

People were aware of how social and economic factors outside of their control could impact their mental health. How these were experienced could depend on where people were pre-pandemic, but could include:

• changes in working life, including job loss, changing working conditions, and changes in the work environment (e.g. home working).

‘I felt stressed. I felt uncomfortable. I felt vulnerable. I felt neglected. I felt everything because the company still doesn’t think it’s serious.’ (May et al, 2021:18)

• changes in income, including loss of or reduction in income, or increased insecurity of income.
• different levels of access to positive physical environments (e.g. private gardens, green space) and to other resources such as digital technology, with implications for social connectedness.

‘Those two things: no garden and no car – have made a vast and negative difference, highlighting the many vulnerabilities of disadvantage and poverty from which many mentally vulnerable people suffer.’ (Advocard, 2020:15)

• increased racism or discrimination towards people from Black and minority ethnic communities, and the risk of double or triple jeopardy. For people with pre-existing mental health conditions, for example, the intersections of ethnicity and mental health could be experienced as doubly stigmatising. The combination of being a healthcare or social care worker from a Black or minority ethnic community could also mean being exposed to an even greater risk of infection.

‘With the news that people from Black and minority ethnic communities are more likely to get it, and die from it ... a fear of a lot of people has been that we’ll go into hospital, and they’ll look at me and say “You’re not really worth that much, and we just won’t give you a ventilator if we don’t have enough”.’ (Gillard et al, 2021:7)

The emerging narrative: Not just one story

The qualitative and quantitative data give us an understanding of how ‘everyone’, in one form or another, has been affected mentally by the pandemic. These impacts could be influenced by the degree to which people’s lives have been turned upside down, their routines disrupted, their income or job affected, their social connections lost or strengthened, and their ability to access health and social care and other resources for health and wellbeing. The qualitative studies reveal just what the changes could mean for people and the profound impacts these could have on their mental lives. 

However, what the evidence also underlines is not just the extent and nature of the mental health impacts of the pandemic, but also the uneven distribution of those impacts. The quantitative and qualitative data unquestionably bear witness to the ways in which the pandemic may have worsened and widened some of the fundamental mental health inequalities in and across our society. Some people and groups of people seem more greatly, and negatively, affected than others. Where people started from, and their socio-economic position may well influence the impacts of the pandemic on their mental health and wellbeing. It may also influence the emotional and financial resources people are able to draw on to recover from the pandemic.

Building on the learning from the quantitative and qualitative studies may therefore give us a way to re-imagine mental health, one that enables us to think through how social and economic factors play out at the level of individual and community day-to-day experiences and practices.

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