Mental health in Europe during the COVID-19 pandemic: a systematic review.

The COVID-19 pandemic caused immediate and far-reaching disruption to society, the economy, and health-care services. We synthesised evidence on the effect of the pandemic on mental health and mental health care in high-income European countries. We included 177 longitudinal and repeated cross-sectional studies comparing prevalence or incidence of mental health problems, mental health symptom severity in people with pre-existing mental health conditions, or mental health service use before versus during the pandemic, or between different timepoints of the pandemic. We found that epidemiological studies reported higher prevalence of some mental health problems during the pandemic compared with before it, but that in most cases this increase reduced over time. Conversely, studies of health records showed reduced incidence of new diagnoses at the start of the pandemic, which further declined during 2020. Mental health service use also declined at the onset of the pandemic but increased later in 2020 and through 2021, although rates of use did not return to pre-pandemic levels for some services. We found mixed patterns of effects of the pandemic on mental health and social outcome for adults already living with mental health conditions.

Methods for modelling excess mortality across England during the COVID-19 pandemic.

Excess mortality is an important measure of the scale of the coronavirus-2019 pandemic. It includes both deaths caused directly by the pandemic, and deaths caused by the unintended consequences of containment such as delays to accessing care or postponements of healthcare provision in the population. In 2020 and 2021, in England, multiple groups have produced measures of excess mortality during the pandemic. This paper describes the data and methods used in five different approaches to estimating excess mortality and compares their estimates.The fundamental principles of estimating excess mortality are described, as well as the key commonalities and differences between five approaches. Two of these are based on the date of registration: a quasi-Poisson model with offset and a 5-year average; and three are based on date of occurrence: a Poisson model without offset, the European monitoring of excess mortality model and a synthetic controls model. Comparisons between estimates of excess mortality are made for the period March 2020 through March 2021 and for the two waves of the pandemic that occur within that time-period.Model estimates are strikingly similar during the first wave of the pandemic though larger differences are observed during the second wave. Models that adjusted for reduced circulation of winter infection produced higher estimates of excess compared with those that did not. Models that do not adjust for reduced circulation of winter infection captured the effect of reduced winter illness as a result of mobility restrictions during the period. None of the estimates captured mortality displacement and therefore may underestimate excess at the current time, though the extent to which this has occurred is not yet identified. Models use different approaches to address variation in data availability and stakeholder requirements of the measure. Variation between estimates reflects differences in the date of interest, population denominators and parameters in the model relating to seasonality and trend.

Action on the social determinants for advancing health equity in the time of COVID-19: perspectives of actors engaged in a WHO Special Initiative.

Since the 2008 publication of the reports of the Commission on Social Determinants of Health and its nine knowledge networks, substantial research has been undertaken to document and describe health inequities. The COVID-19 pandemic has underscored the need for a deeper understanding of, and broader action on, the social determinants of health. Building on this unique and critical opportunity, the World Health Organization is steering a multi-country Initiative to reduce health inequities through an action-learning process in 'Pathfinder' countries. The Initiative aims to develop replicable and reliable models and practices that can be adopted by WHO offices and UN staff to address the social determinants of health to advance health equity. This paper provides an overview of the Initiative by describing its broad theory of change and work undertaken in three regions and six Pathfinder countries in its first year-and-a-half. Participants engaged in the Initiative describe results of early country dialogues and promising entry points for implementation that involve model, network and capacity building. The insights communicated through this note from the field will be of interest for others aiming to advance health equity through taking action on the social determinants of health, in particular as regards structural determinants.

Ethnic differences in COVID-19 mortality in the second and third waves of the pandemic in England during the vaccine rollout: a retrospective, population-based cohort study.

BACKGROUND: Ethnic minority groups in England have been disproportionately affected by the COVID-19 pandemic and have lower vaccination rates than the White British population. We examined whether ethnic differences in COVID-19 mortality in England have continued since the vaccine rollout and to what extent differences in vaccination rates contributed to excess COVID-19 mortality after accounting for other risk factors. METHODS: We conducted a retrospective, population-based cohort study of 28.8 million adults aged 30-100 years in England. Self-reported ethnicity was obtained from the 2011 Census. The outcome was death involving COVID-19 during the second (8 December 2020 to 12 June 2021) and third wave (13 June 2021 to 1 December 2021). We calculated hazard ratios (HRs) for death involving COVID-19, sequentially adjusting for age, residence type, geographical factors, sociodemographic characteristics, pre-pandemic health, and vaccination status. RESULTS: Age-adjusted HRs of death involving COVID-19 were elevated for most ethnic minority groups during both waves, particularly for groups with lowest vaccination rates (Bangladeshi, Pakistani, Black African, and Black Caribbean). HRs were attenuated after adjusting for geographical factors, sociodemographic characteristics, and pre-pandemic health. Further adjusting for vaccination status substantially reduced residual HRs for Black African, Black Caribbean, and Pakistani groups in the third wave. Fully adjusted HRs only remained elevated for the Bangladeshi group (men: 2.19 [95% CI 1.72-2.78]; women: 2.12 [1.58-2.86]) and Pakistani men (1.24 [1.06-1.46]). CONCLUSIONS: Lower COVID-19 vaccination uptake in several ethnic minority groups may drive some of the differences in COVID-19 mortality compared to White British. Public health strategies to increase vaccination uptake in ethnic minority groups would help reduce inequalities in COVID-19 mortality, which have remained substantial since the start of the vaccination campaign.

Inequalities in excess premature mortality in England during the COVID-19 pandemic: a cross-sectional analysis of cumulative excess mortality by area deprivation and ethnicity.

OBJECTIVES: To examine magnitude of the impact of the COVID-19 pandemic on inequalities in premature mortality in England by deprivation and ethnicity. DESIGN: A statistical model to estimate increased mortality in population subgroups during the COVID-19 pandemic by comparing observed with expected mortality in each group based on trends over the previous 5 years. SETTING: Information on deaths registered in England since 2015 was used, including age, sex, area of residence and cause of death. Ethnicity was obtained from Hospital Episode Statistics records linked to death data. PARTICIPANTS: Population study of England, including all 569 824 deaths from all causes registered between 21 March 2020 and 26 February 2021. MAIN OUTCOME MEASURES: Excess mortality in each subgroup over and above the number expected based on trends in mortality in that group over the previous 5 years. RESULTS: The gradient in excess mortality by area deprivation was greater in the under 75s (the most deprived areas had 1.25 times as many deaths as expected, least deprived 1.14) than in all ages (most deprived had 1.24 times as many deaths as expected, least deprived 1.20). Among the black and Asian groups, all area deprivation quintiles had significantly larger excesses than white groups in the most deprived quintiles and there were no clear gradients across quintiles. Among the white group, only those in the most deprived quintile had more excess deaths than deaths directly involving COVID-19. CONCLUSION: The COVID-19 pandemic has widened inequalities in premature mortality by area deprivation. Among those under 75, the direct and indirect effects of the pandemic on deaths have disproportionately impacted ethnic minority groups irrespective of area deprivation, and the white group the most deprived areas. Statistics limited to deaths directly involving COVID-19 understate the pandemic's impact on inequalities by area deprivation and ethnic group at younger ages.

Ethnicity, household composition and COVID-19 mortality: a national linked data study.

OBJECTIVE: To estimate the proportion of ethnic inequalities explained by living in a multi-generational household. DESIGN: Causal mediation analysis. SETTING: Retrospective data from the 2011 Census linked to Hospital Episode Statistics (2017-2019) and death registration data (up to 30 November 2020). PARTICIPANTS: Adults aged 65 years or over living in private households in England from 2 March 2020 until 30 November 2020 (n=10,078,568). MAIN OUTCOME MEASURES: Hazard ratios were estimated for COVID-19 death for people living in a multi-generational household compared with people living with another older adult, adjusting for geographic factors, socioeconomic characteristics and pre-pandemic health. RESULTS: Living in a multi-generational household was associated with an increased risk of COVID-19 death. After adjusting for confounding factors, the hazard ratios for living in a multi-generational household with dependent children were 1.17 (95% confidence interval [CI] 1.06-1.30) and 1.21 (95% CI 1.06-1.38) for elderly men and women. The hazard ratios for living in a multi-generational household without dependent children were 1.07 (95% CI 1.01-1.13) for elderly men and 1.17 (95% CI 1.07-1.25) for elderly women. Living in a multi-generational household explained about 11% of the elevated risk of COVID-19 death among elderly women from South Asian background, but very little for South Asian men or people in other ethnic minority groups. CONCLUSION: Elderly adults living with younger people are at increased risk of COVID-19 mortality, and this is a contributing factor to the excess risk experienced by older South Asian women compared to White women. Relevant public health interventions should be directed at communities where such multi-generational households are highly prevalent.

Religious affiliation and COVID-19-related mortality: a retrospective cohort study of prelockdown and postlockdown risks in England and Wales.

BACKGROUND: COVID-19 mortality risk is associated with demographic and behavioural factors; furthermore, religious gatherings have been linked with the spread of COVID-19. We sought to understand the variation in risk of COVID-19-related death across religious groups in England and Wales both before and after the first national lockdown. METHODS: We conducted a retrospective cohort study of usual residents in England and Wales enumerated at the 2011 Census (n=47 873 294, estimated response rate 94%) for risk of death involving COVID-19 using linked death certificates. Cox regression models were estimated to compare risks between religious groups. Time-dependent coefficients were added to the model allowing HRs before and after lockdown period to be estimated separately. RESULTS: Compared with Christians, all religious groups had an elevated risk of death involving COVID-19; the largest age-adjusted HRs were for Muslim and Jewish males at 2.5 (95% CI 2.3 to 2.7) and 2.1 (95% CI 1.9 to 2.5), respectively. The corresponding HRs for Muslim and Jewish females were 1.9 (95% CI 1.7 to 2.1) and 1.5 (95% CI 1.7 to 2.1), respectively. The difference in risk between groups contracted after lockdown. Those who affiliated with no religion had the lowest risk of COVID-19-related death before and after lockdown. CONCLUSION: The majority of the variation in COVID-19 mortality risk was explained by controlling for sociodemographic and geographic determinants; however, those of Jewish affiliation remained at a higher risk of death compared with all other groups. Lockdown measures were associated with reduced differences in COVID-19 mortality rates between religious groups; further research is required to understand the causal mechanisms.

COVID-19 related health inequality exists even in a city where disease incidence is relatively low: a telephone survey in Hong Kong.

BACKGROUND: We examined whether COVID-19 could exert inequalities in socioeconomic conditions and health in Hong Kong, where there has been a relatively low COVID-19 incidence. METHODS: 752 adult respondents from a previous random sample participated in a telephone survey from 20 April to 11 May 2020. We examined demographic and socioeconomic factors, worry of COVID-19, general health, economic activity, and personal protective equipment (PPE) and related hygiene practice by deprivation status. The associations between deprivation and negative COVID-19 related issues were analysed using binary logistic regressions, while the associations of these issues with health were analysed using linear regressions. Path analysis was conducted to determine the direct effect of deprivation, and the indirect effects via COVID-19 related issues, on health. Interactions between deprivation and the mediators were also tested. RESULTS: Deprived individuals were more likely to have job loss/instability, less reserves, less utilisation and more concerns of PPE. After adjustments for potential confounders, being deprived was associated with having greater risk of low reserve of face masks, being worried about the disease and job loss/instability. Being deprived had worse physical (ß=-0.154, p<0.001) and mental health (ß=-0.211, p<0.001) and had an indirect effect on mental health via worry and job loss/instability (total indirect effect: ß=-0.027, p=0.017; proportion being mediated=11.46%). In addition, significant interaction between deprivation and change of economic activity status was observed on mental health-related quality of life. CONCLUSION: Even if the COVID-19 incidence was relatively low, part of the observed health inequality can be explained by people's concerns over livelihood and economic activity, which were affected by the containment measures. We should look beyond the incidence to address COVID-19 related health inequalities.

Ethnic-minority groups in England and Wales-factors associated with the size and timing of elevated COVID-19 mortality: a retrospective cohort study linking census and death records.

BACKGROUND: We estimated population-level associations between ethnicity and coronavirus disease 2019 (COVID-19) mortality using a newly linked census-based data set and investigated how ethnicity-specific mortality risk evolved during the pandemic. METHODS: We conducted a retrospective cohort study of respondents to the 2011 Census of England and Wales in private households, linked to death registrations and adjusted for emigration (n = 47 872 412). The outcome of interest was death involving COVID-19 between 2 March 2020 and 15 May 2020. We estimated hazard ratios (HRs) for ethnic-minority groups compared with the White population, controlling for individual, household and area characteristics. HRs were estimated on the full outcome period and separately for pre- and post-lockdown periods. RESULTS: In age-adjusted models, people from all ethnic-minority groups were at elevated risk of COVID-19 mortality; the HRs for Black males and females were 3.13 (95% confidence interval: 2.93 to 3.34) and 2.40 (2.20 to 2.61), respectively. However, in fully adjusted models for females, the HRs were close to unity for all ethnic groups except Black [1.29 (1.18 to 1.42)]. For males, the mortality risk remained elevated for the Black [1.76 (1.63 to 1.90)], Bangladeshi/Pakistani [1.35 (1.21 to 1.49)] and Indian [1.30 (1.19 to 1.43)] groups. The HRs decreased after lockdown for all ethnic groups, particularly Black and Bangladeshi/Pakistani females. CONCLUSION: Differences in COVID-19 mortality between ethnic groups were largely attenuated by geographical and socio-demographic factors, though some residual differences remained. Lockdown was associated with reductions in excess mortality risk in ethnic-minority populations, which has implications for a second wave of infection.