The Lessons Learned from the Pandemic

Lesson 1: The Dynamic Relationship between COVID-19 and Mental Health

The COVID-19 pandemic took a toll on the city’s mental health. Overall, studies have shown that levels of stress, anxiety and depressive symptoms have drastically increased since the outbreak in Hong Kong. In a representative population study, unhappiness and depressive symptoms have doubled, and stress levels were shown to have increased by 28.3%². The prevalence of depression and anxiety disorders have also increased over 50%, from 10.7% to 19.8%, and 4.1% to 14%, respectively³. Moreover, mental health services have also seen an increased surge of demand across this period. In the first four months of the outbreak, a 24h community mental health support line noted a 16% increase in the calls⁴, and another online emotional support platform also reported increased traffic for its website⁵.

Despite the alarming rate of mental health problems arising from the pandemic, the publics’ psychological responses did not maintain static over the years. In the first two waves, the psychological distress of youths was shown to be highly influenced by the number of confirmed cases reported in Hong Kong⁵. More specifically, COVID-related psychological distress increased when outbreak was more severe. However, a gradual habituation process was observed in the subsequent waves. In the third wave, outbreak severity did not impact distress levels in help-seekers without common mental disorders (CMD), but impacted help-seekers with CMD. By the fourth wave, both the more and less vulnerable help-seekers were less concerned by outbreak severity⁵. This provides comforting evidence that even the vulnerable populations have eventually either learned adaptive coping strategies or developed resilience towards the pandemic over time, revealing the dynamic relationship between COVID-19 and psychological distress.

Lesson 2: The Psychological Impact of COVID-19 on Different Populations

However, COVID-19 has different psychological impacts for different populations. Who are those that might be less resilient to the COVID-19 situation? Data shows that these populations might be (1) underprivileged, and/or (2) old-aged adults. Firstly, multiple studies found the underprivileged population to experience heightened stress from COVID-19. Compared to those with higher assets, those with lower savings and no home ownership experienced greater distress from the social unrest in 2019 and COVID-19 combined, and had higher risk of probable anxiety and depression disorders⁶. This could be due to the underprivileged being most concerned about financial loss and unemployment associated with the COVID-19 pandemic, as initial concerns about PPE supplies became more readily available in the market⁷. This is further supported by a study finding that worries about economic activities and livelihood significantly mediated association between deprivation and mental health disorders, and worries about personal savings significantly mediated deprivation and subjective well-being⁷. Due to greater difficulties adapting to financial and economic strains, this population might be less resilient to the impacts caused by the pandemic.

Secondly, the elderly population has also been found to experience long-term psychological impacts from the pandemic. In a study on older adults with multimorbidity, mild anxiety increased from 13.4% to nearly 21%, and subthreshold insomnia increased from 29% to nearly 34% in 2019 and 2020, respectively⁸. Rates of default from medical appointments have also increased from 16.5% to 22% over a 3-month period⁸. This could be attributed to compliance with strict social distancing measures, as temporary shutdown of day-care and community centres could have cut their main source of social contact, and led to social isolation in this population. This was reflected in a survey on 212 older adults, which found that nearly 97% reported a lack of social life, and nearly 80% experienced increased loneliness in mid-2020⁹. Moreover, the impact of loneliness was stronger on those who lived alone, as they also experienced lowered social support from friends and family not living with them⁸. Prolonged social isolation might therefore contribute to lowered resilience in this population group. Therefore, while distress might fade without any interventions for some, additional support should be provided to those who are more susceptible to the long-term impacts of COVID-19.

Lesson 3: The Role of Technology in Current Practices

Current practices should not neglect the psychological aspects of COVID-19. Challenges in providing psychological services in the context of social distancing measures enabled us to explore the role of technology in our practices. Regarding the feasibility and acceptance of technology-based practices, a recent survey found that over 90% of those above 10 years had access to smartphones¹⁰. Furthermore, over 40% Hong Kong secondary students expressed intentions to use online counselling services, and was motivated by the service quality and effectiveness¹¹. Comparatively, after interactive sessions with social workers on digital usage, smartphone access also increased from around 50% to nearly 70% for older adults¹⁰. Although old age predicted lower likelihood of considering telehealth use, expectation of government subsidies for such services significantly increased their motivation to use telehealth even after the pandemic ends¹². Such investigations provide evidence on the feasibility of incorporating digital care in mental health service provision.

Examples of the effectiveness of technology-based interventions are also promising. A quasi-experiment found online social work intervention to have improved emotional distress and social withdrawal amongst young internet users, over a nine-month period¹³. Hidden youths in Hong Kong also found online counselling to be more effective than offline counselling in addressing individual, psychological problems, although integrative counselling achieved better therapeutic outcomes¹⁴. On the other hand, telecare interventions also improved quality of life (QOL) and medication adherence for home-bound older adults during COVID-19S¹⁵. Interestingly, the mode of delivery also impacts service effectiveness. In a 4-week study, it was found that patients with neurocognitive disorders who received telemedicine via video conference experienced improved QOL and was protected from rapid cognitive function decline, whereas patients who received telephone-only services experienced deterioration in QOL and cognitive function¹⁶. Delivering online and video-based interventions may serve as an alternative for those in remote locations to readily access psychological services, whilst overcoming barriers to social stimulation.

Conclusion

As observed, the COVID-19 pandemic has led to an unprecedented mental health crisis in Hong Kong. On an optimistic note, we should be comforted that a majority of the population were able to develop resilience and relevant adaptive coping strategies to face pandemic-related distress. Nonetheless, we should also be more aware of those who may not develop resilience – the underprivileged, and the older-aged. This ensures that policy measures and health care provision can prioritise the psychological needs of these populations groups, and provide better support at times of crisis. The role of technology should also be considered in future mental health practices to increase accessibility and availability to different target populations, especially the hard-to-reach or home-bound populations.

References

1. Wong, S. M., Li, Y. Y., Hui, C. L., Wong, C. S., Wong, T. Y., Cheung, C., ... & Chen, E. Y. (2022). Impact of restrictive COVID-19 measures on daily momentary affect in an epidemiological youth sample in Hong Kong: An experience sampling study. Current Psychology, 1-10.  2. Zhao, S. Z., Wong, J. Y. H., Luk, T. T., Wai, A. K. C., Lam, T. H., & Wang, M. P. (2020). Mental health crisis under COVID-19 pandemic in Hong Kong, China. International Journal of Infectious Diseases, 100, 431-433.  3. Choi, E. P. H., Hui, B. P. H., & Wan, E. Y. F. (2020). Depression and anxiety in Hong Kong during COVID-19. International journal of environmental research and public health, 17(10), 3740.  4. Li, J. T. S., Lee, C. P., & Tang, W. K. (2022). Changes in Mental Health among Psychiatric Patients during the COVID-19 Pandemic in Hong Kong¡XA Cross-Sectional Study. International Journal of Environmental Research and Public Health, 19(3), 1181.  5. Chan CS, Yang C-T, Xu Y, He L, Yip PSF (2022). Variability in the psychological impact of four waves of COVID-19: a time- series study of 60 000 text-based counseling sessions. Psychological Medicine, 1¡V12.  6. Hou, W. K., Lee, T. M. C., Liang, L., Li, T. W., Liu, H., Ettman, C. K., & Galea, S. (2021). Civil unrest, COVID-19 stressors, anxiety, and depression in the acute phase of the pandemic: a population-based study in Hong Kong. Social psychiatry and psychiatric epidemiology, 56(8), 1499-1508.  7. Chung, R. Y. N., Chung, G. K. K., Chan, S. M., Chan, Y. H., Wong, H., Yeoh, E. K., ... & Marmot, M. (2021). Socioeconomic inequality in mental well-being associated with COVID-19 containment measures in a low-incidence Asian globalized city. Scientific reports, 11(1), 1-10.  8. Wong, S. Y. S., Zhang, D., Sit, R. W. S., Yip, B. H. K., Chung, R. Y. N., Wong, C. K. M., ... & Mercer, S. W. (2020). Impact of COVID-19 on loneliness, mental health, and health service utilisation: a prospective cohort study of older adults with multimorbidity in primary care. British Journal of General Practice, 70(700), e817-e824.  9. Lingnan Touch. (2020). APIAS study reveals how COVID-19 affects services for the elderly and their psychological health. https://ln.edu.hk/lingnan-touch/103/lu-study-reveals-how-covid-19-affects-elderly-services-and-their-psychological-health/  10. Zhang, D., Sit, R. W. S., Wong, C., Zou, D., Mercer, S. W., Johnston, M. C., & Wong, S. Y. S. (2020). Cohort profile: the prospective study on Chinese elderly with multimorbidity in primary care in Hong Kong. BMJ open, 10(2), e027279.  11. Li, T. M., & Leung, C. S. (2020). Exploring student mental health and intention to use online counselling in Hong Kong during the COVID-19 pandemic. Psychiatry and clinical neurosciences.  12. Choi, M. C. Y., Chu, S. H., Siu, L. L., Tse, A. G., Wu, J. C. Y., Fung, H., ... & Mok, V. C. T. (2021). Elderly acceptance of telemedicine use in Hong Kong during and after the COVID-19 pandemic: a cross-sectional cohort survey. medRxiv.  13. Law, Y. W., Kwok, C. L., Chan, P. Y., Chan, M., & Yip, P. (2019). Online social work engagement and empowerment for young internet users: A quasi-experiment. Journal of Affective Disorders, 250, 99-107.  14. Chan, G. H. (2020). A comparative analysis of online, offline, and integrated counseling among hidden youth in Hong Kong. Children and Youth Services Review, 114, 105042.  15. Wong, A. K. C., Wong, F. K. Y., Chow, K. K. S., Wong, S. M., & Lee, P. H. (2021). Effect of a telecare case management program for older adults Who Are homebound during the COVID-19 pandemic: a pilot randomized clinical trial. JAMA network open, 4(9), e2123453-e2123453.  16. Lai, F. H. Y., Yan, E. W. H., Yu, K. K. Y., Tsui, W. S., Chan, D. T. H., & Yee, B. K. (2020). The protective impact of telemedicine on persons with dementia and their caregivers during the COVID-19 pandemic. The American Journal of Geriatric Psychiatry, 28(11), 1175-1184.