First comes the accelerated heartbeat, followed by trembling, sweating, shivering and difficulty breathing. In March 2020, 3.4 million people asked Google “am I having a panic attack?” It was the largest query on the topic ever recorded by the search engine.

The toll that the Covid-19 pandemic has taken on mental health is no longer disputed. Fear of illness, uncertainty, loneliness, stay-at-home orders, unemployment, school closures and work disruptions have led to a clear increase in levels of anxiety and stress, particularly in high-risk populations such as healthcare workers.

According to MindCovid, one of 140 research projects currently underway worldwide tracking the psychological aftermath of the crisis, almost half of Spain’s healthcare workers showed symptoms of anxiety, depression or post-traumatic stress disorder during the first wave of the pandemic. And, as the study shows, many of these symptoms remain one year later.

“Overall levels have fallen much less than we expected. They’ve largely remained stable. The impact of depression, for example, has fallen by a quarter but remains very high, and that worries us,” researcher Jordi Alonso, who heads the study, tells Equal Times. His team has detected the same trend in the general population as well as in other vulnerable groups, including Covid patients.

One year on, the scars left by the pandemic hurt almost as much as the pandemic itself. And that pain is expected to linger even after normality returns.

“Even if immunity is achieved and we all get vaccinated, the most severe mental health problems will remain. They won’t simply disappear, there’s a necessary latency period,” says Ximena Goldberg, a clinical psychologist and researcher at the Barcelona Institute for Global Health. Goldberg is participating in another study which, in addition to measuring symptoms, also looks at social conditions such as employment, housing and economic precariousness, all of which represent risk factors with the potential to aggravate any emotional disorder. This became clear one year after the 2008 financial crash, when suicide rates – closely linked to depression – in Europe rose by 4.2 per cent, especially in the countries most affected by unemployment.

“These problems are expected to increase over the course of this year and the next,” warns Goldberg. This is particularly true for the elderly, women, the unemployed, adolescents, people with chronic pain, patients with previous mental health problems, and those who saw their care disrupted during the pandemic. Alonso predicts “a small tsunami of users with complicated problems,” with which the system is not yet prepared to cope.

The poor relation of health investment

According to World Health Organization (WHO) statistics that predate the coronavirus pandemic, one in four people will experience mental health problems over the course of their lifetime. The number of people experiencing depression or anxiety has doubled since 1990 to 615 million, or 10 per cent of the global population.

We now know that these patients have higher mortality rates and that mental pain can lead to physical problems such as heart attacks and diabetes. We know that depression is the second most common cause of disability and suicide the fourth most common cause of death among young people aged 19-29.

The total cost of poor mental health amounts to between 3.5 and 4 per cent of GDP each year in OECD countries, mainly due to sick leave and disability benefits. Yet governments still spend less than 2 per cent of their national health budgets on mental health.

“Mental health is the poor relation of health investment and research,” says Antonio Cano, professor of psychology and president of the Spanish Society for the Study of Anxiety and Stress. “The problem is a lack of knowledge and understanding on the part of the population, health personnel and researchers.”

While the WHO’s latest Mental Health Atlas makes clear that a lack of investment in mental health affects all countries regardless of income, per capita spending in regions like Africa and South-East Asia is up to 20 times lower. Moreover, citizens in some of these regions have to pay for mental health services out of their own pockets.

While Europe has publicly available treatment, it has other problems including long waiting lists, mainly due to lacking personnel. Globally, the average number of mental health workers is nine for every 100,000 residents. According to the WHO, increased investment in mental health, for which it has long advocated, would also be more cost-effective. Every dollar invested in improving treatment for depression and anxiety yields a fourfold return thanks to savings from the labour and health costs that result from improper treatment.

The front line

Patients often show up complaining of headaches, intestinal problems, fatigue, insomnia and difficulty concentrating. Others, though far fewer, understand their problems to be psychological in nature.

Primary care centres are the front line of mental health. Between 40 and 50 per cent of their consultations are related to a possible depression, anxiety or somatisation disorder. “What usually happens is that patients come in complaining of several physical disorders, which are then investigated and analysed. And nothing is found. These are complicated cases that take time to diagnose,” Vicente Gasull, coordinator of the mental health working group of the Spanish Society of Primary Care Doctors, tells Equal Times.

“While there were many cases during the pandemic, I think they are really only beginning to appear now. They are very much related to health and economic conditions such as loss of employment. Then there are adolescents, with whom we are witnessing an increase in self-harm and substance use, especially alcohol.” However, the resources available to these doctors are limited, both in terms of time – primary care consultations for half the world’s population last around 5 minutes – and training. “As primary care doctors, we don’t have much in-depth training when it comes to psychotherapy,” admits Gasull.

Faced with these circumstances, and in the absence of alternatives, doctors resort to the most immediate remedy: drugs.

The use of antidepressants, anxiolytics and tranquilisers such as benzodiazepines has soared despite the dangers they pose to health, including addiction, risk of accidents and falls, and cognitive deterioration in people over 65. For these reasons, the WHO itself advises against prescribing them.

“This drug is used for panic attacks because it quickly reduces symptoms. But this is not the solution,” says Cano. “Emotional management therapy has a much higher percentage of reliable recovery, 3 to 4 times higher in fact.”

Cano’s statement is based on the results of PsicAP (Psychology in Primary Care), a trial that he directs to test the effectiveness of incorporating clinical psychologists into primary care settings. The system has been successfully applied in the UK since 2008.

Having psychologists in health centres would reduce the use of drugs, increase early detection of emotional problems and prevent them from becoming chronic. It would also lower costs: according to PsicAP, seven therapy sessions cost €27.40 per person. “It’s more expensive to have patients coming into your health centre every week. Specialists consultations and medical tests add up and patients are not cured.”

Vaccines for depression

In order to minimise stigmas around mental health, making an appointment with a psychologist at a health centre has to be as easy as going to the nurse’s office. As Gasull warns, “mental illness is still taboo, many are afraid to admit to it. Until recently it was seen as a sign of weakness, of character failure, especially among men. So they tend to hide it and it becomes chronic.”

Eliminating this taboo is one way to avoid future problems. People have to understand that treatment for mental health is a right and not a luxury.

Some countries have a more advanced approach to mental health. In Australia, the government has been working for years to prevent emotional disorders through the use of technology with its programme Head to Health. In Spain, a trial is currently underway to test the use of a mobile application for preventing depression.

“Preventative intervention has an efficiency rate of between 20 and 40 per cent when it comes to preventing new depression,” says Juan Ángel Bellón, a researcher at the Biomedical Research of Malaga who is participating in this trial.

Similarly to applications that measure steps, his application monitors factors such as physical exercise, social relations, sleep and the frequency of negative thoughts. “We use an algorithm to predict whether you are going to become depressed in a year’s time,” says Bellón. When a risk is detected, the application proposes preventative guidelines. “It works like a vaccine for depression. It’s like doing mood gymnastics.”

While mobile devices can be used for prevention in schools and at workplaces, Goldberg reminds us that mental health can also be protected through the use of public policies. “Direct aid to families to ensure that they have a place to live and something to eat is very important.” According to Goldberg, “standardising telework, ensuring that workers are protected, designing greener cities and creating spaces for mutual aid among community members” all contribute to prevention.

The WHO believes that every emergency should be viewed as an opportunity to implement better mental health care systems. This was the case during the humanitarian crises that took place in Afghanistan after the fall of the Taliban government in 2001 and in Indonesia after the 2004 tsunami. As the mental health pandemic looms, we have one significant advantage that we did not have at the beginning of the Covid-19 pandemic: this time, we have early warning.