Evidence
Alert

Many people with mental illness did not seek help during the first lockdown; research highlights unmet need

The number of people with mental health problems such as depression, anxiety, and self-harm increased during the UK’s first lockdown. But a huge study across England found that fewer people asked their GP or hospital for mental health support. 

The research team looked at primary care records to find the numbers of people who sought help for mental illness for the first time. The numbers were much lower than expected. Researchers are concerned that the dramatic fall in help-seeking means that people’s needs were not met. Mental illness that is not addressed could lead to worsening mental health and increased risks of self-harm or suicide.

This is thought to be the first population-based study of help-seeking during the pandemic. It found that help-seeking fell most among adults of working age, women, younger people and those living in deprived areas. This suggests that existing inequalities in mental health grew wider in the pandemic. 

Ensuring that people can promptly access mental health support, diagnosis, and treatment should be an urgent priority for the NHS, the researchers say. Public health messages need to address any long-term reluctance to seek help.  

What’s the issue?

The COVID-19 pandemic increased uncertainty throughout society. People were afraid of catching the virus and needing hospital treatment. Lockdown measures disrupted normal life and prevented social interactions. People were worried about losing their jobs and about the state of the economy. 

Not surprisingly, research suggests there was an increase in mental illness after the first UK-wide lockdown began in March 2020. At the same time, people were discouraged from visiting GPs or hospitals to curb the spread of the virus. Mental health charities reported increases in people asking for help. This suggests that people were not getting the support they needed from NHS healthcare providers. 

The researchers wanted to explore whether people with mental illnesses accessed support during the COVID-19 pandemic. They focused on people seeking help for the first time. 

What’s new?

The study was carried out in England. It was based on the health records of more than 14 million people over the age of 10. The records spanned the period between January 2019 and September 2020, which included the first national lockdown. 

The team looked at how many people sought mental health help for the first time, either from their GP or at a hospital A&E department. They looked for reports of depression, anxiety, or an episode of self-harm after the first lockdown began. 

Using records from the previous decade, they calculated normal rates of help-seeking. These are the numbers that would have been expected at a more typical time, without the pandemic.  They then compared the two sets of figures.

The study found that in April 2020, one month into the UK’s first lockdown, the number of people seeking help for mental health issues was much lower than expected.  

Compared to a typical month, records for April 2020 showed:

    • 36% fewer new prescriptions for treatments for depression and anxiety
    • 38% fewer episodes of self-harm 
    • 43% fewer cases of depression
    • 48% fewer cases of anxiety
    • 75% fewer referrals to mental health services.

The biggest reductions in help-seeking for anxiety and depression were in people of working age (18-64) and those living in the most deprived communities. The biggest reductions in help-seeking for episodes of self-harm were in women and people under the age of 45. This means that some of those with the greatest need for mental health services were the least likely to receive help. 

Rates of help-seeking gradually returned to normal. By September 2020, the numbers of people seeking help for mental illness and self-harm were similar to expected levels.

Why is this important?

It is unlikely that the low numbers of people seeking medical help for mental illness meant that fewer had mental health problems. Other evidence suggests that levels of depression, anxiety, and self-harm increased during the pandemic. The authors therefore concluded that people were not seeking help from the NHS for mental health problems during the pandemic. 

Some people may not have sought help for fear of contracting the virus. Public health messaging may also have played an important role in discouraging people from seeking help.

The pandemic has widened inequalities. People living in socially deprived areas were more likely to be badly affected, and to die, of COVID-19. The quality and availability of general medical care was lower in these communities than elsewhere. The findings from this study suggest that people in deprived areas were especially likely to have mental illness that was not addressed during the first lockdown. This has implications for their GPs, who have to manage the demand for services. Ensuring that people have timely access to mental health services is a priority.

Women in particular stopped seeking help for self-harm. Issues related to the pandemic may have stopped women from seeking support. This could include having to balance work with childcare duties, making it difficult to find the time to ask for help.

It could be that many people self-managed their mental health problems during the pandemic. They may also have sought help from sources other than the NHS. Mental health charities which run helplines, such as Samaritans, reported a rise in calls.

But the researchers are concerned that people who do not get early diagnoses and treatment may present later with more severe problems. This has implications for services which may need to plan now for increases in severe mental illness. 

Public health messaging needs to stress that help from GPs and hospital mental health services is available to people who need it. 

What’s next?

This work was carried out as part of a programme of work to address the impact of the pandemic on mental health

The records used in this study did not reliably record people’s ethnicity. More work is therefore needed to examine help-seeking in different ethnic groups. 

It will also be important to explore the long-term impact of the pandemic on help-seeking. Since this study was published, researchers involved in the wider project have found longer-term reductions in help-seeking for self-harm. Research suggests that, in the nine months to May 2021, the numbers of people seeking help for self-harm was around one tenth lower than expected. This reduction is less dramatic than during the first month of national lockdown in April 2020. But it suggests there may be long-term reluctance to seek help. Patients who have harmed themselves may not be receiving recommended care.

You may be interested to read

This NIHR Alert is based on: Carr MJ, Steeg S and others. Effects of the COVID-19 pandemic on primary care-recorded mental illness and self-harm episodes in the UK: a population-based cohort study. Lancet Public Health 2021;6:2 

Self-harm and COVID-19: the first year of the pandemic and beyond - a blog about the impact of COVID-19 on self-harm presentation rates, written by one of the lead authors of this study. 

Coronavirus and your mental health: information and support for mental health during the pandemic, from the charity Mind. 

Related papers from the same authors on: 

Trends in self-harm up to May 2021: Steeg S, and others. Temporal trends in primary care-recorded self-harm during and beyond the first year of the COVID-19 pandemic: Time series analysis of electronic healthcare records for 2.8 million patients in the Greater Manchester Care Record. EClinicalMedicine 2021;41:101175

The impact of the pandemic on self-harm: Kapur N, and others. Effects of the COVID-19 pandemic on self-harm. The Lancet Psychiatry 2021;8:2 

 

Funding: This research was co-funded by the NIHR Greater Manchester Patient Safety Translational Research Centre. One of the authors was supported with funding from the NIHR Applied Research Collaboration, West Midlands.  

Conflicts of Interest: One author has received grants and personal fees from the UK Department of Health and Social Care, the NIHR, the National Institute for Health and Care Excellence (NICE), and the Healthcare Quality and Improvement Partnership, outside the submitted work. 

Another author has received grants and personal fees from the UK Department of Health and Social Care, NIHR, NICE, and the Healthcare Quality and Improvement Partnership, outside the submitted work. 

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Commentaries

Study author

We knew that there had been sharp decreases in the take-up of healthcare for a range of common health conditions. However, evidence suggested mental health across the population had deteriorated in response to the pandemic. So we were surprised to see reductions in mental illness and self-harm recorded in primary care.

It is quite possible that people turned to other sources of support during this time, such as charities, online networks, and helplines. The Samaritans reported an increase in the number of calls related to self-harm during the pandemic, for example. But the reductions point to unmet need for mental health treatment by the NHS.

Prioritising health services to manage shifting demand and potential unidentified need in some groups is crucial. People who have self-harmed need prompt, personalised and widely accessible primary care, outpatient and community services. These services are essential in the suicide prevention response to COVID-19.

Sarah Steeg, Presidential Research Fellow, Centre for Mental Health and Safety, University of Manchester 

Samaritans 

These findings chime with those from a Parliamentary inquiry into the support available for young people who self-harm, which Samaritans supported last year. 

Sadly, this decline in help seeking is unlikely to correspond with a decline in rates of self-harm. Instead, experts attributed the decline to people who self-harm not wanting to overburden already stretched services. 

This phenomenon is not restricted to self-harm. There are concerns about people deferring presentation at hospitals for a range of issues. However, the persistent stigma faced by young people who self-harm adds a layer of complexity over whether or not to present, especially at particularly busy times. Any drop in presentations during the pandemic should be viewed cautiously. 

We know that rates of self-harm have risen dramatically over the past two decades, particularly in young women. Encouragingly, studies have indicated that rates of self-harm have remained stable throughout the pandemic. But we are yet to understand its full impact. 

Levels of help-seeking among people who self-harm are unfortunately very low. More needs to be done by health services to better understand and support people who self-harm. This includes tackling stigma and taking the behaviour seriously. The focus must be on the person and their needs. It needs to be more than an assessment of the risk they pose to themselves.

Joe Potter, Policy Manager, Samaritans 

Researcher   

This study raises awareness of the impact of national lockdowns on people’s help-seeking behaviour. It also highlights the negative longer-term consequences of people not accessing mental healthcare when they need it. The findings cover the first six months or so of the pandemic. It would be interesting to revisit the results in light of the second and third national lockdowns that have occurred since. 

This study shows how the common fear of troubling your GP can have adverse longer-term consequences. My own reaction to the pandemic was replicated on a large-scale.  People need reassurance that they have the right to seek GP advice for mental health – even in a severe national healthcare crisis. 

But it is not fair to expect GPs to manage this unprecedented level of demand for mental and physical health care across the population. At a time of national crisis, the Government needs to do more. We need tools and resources for people with severe anxiety related to pandemics.

Rebecca Hutten, Associate Lecturer in Psychology & Counselling, The Open University 

Member of the public

This study adds to the generally helpful publicity which is currently being given to mental health. It provides evidence to support what has been understood intuitively. It should encourage service users to seek appropriate help at the right time and not put things off. It should give clinicians a better understanding of their patients’ needs and conditions.

Finite resources and the difficulties of recruiting sufficient staff could limit the impact of the study. But it could give policy makers greater insight into where the expansion of resources is most needed. There is still a need to level up in mental health in order to address health inequalities. These findings support the case for additional resources for mental health.

John Chapman, Public Contributor, Hereford