- Since early 2020, the world has become familiar with the impacts of COVID-19, isolation, mask-wearing and for far too many, disease and death.

Today's guest says there's another impact we are just beginning to grapple with.

The way the pandemic has affected global mental health.

He's Dr. Shekhar Saxena, this week on Story in the Public Square.

(upbeat music) Hello and welcome to Story in the Public Square where storytelling meets public affairs.

I'm Jim Ludes from the Pell Center at Salve Regina University.

- And I'm G. Wayne Miller with The Providence Journal.

- This week, we're joined by Dr. Shekhar Saxena, who is Professor of the Practice of Global Mental Health at the Department of Global Health and Population at the Harvard T.H.

Chan School of Public Health.

Dr. Saxena thank you so much for being with us.

- [Dr. Shekhar] Pleasure to meet you.

- There's a lot that we wanna talk to you about today.

We wanna get to the conversation about the pandemic, but I'm curious to know a little bit more about you.

What drew you to psychiatry in the first place?

- Well, I'm a psychiatrist by training.

I did that about 40 years ago and worked for the next 20 years in clinical practice, seeing patients off one after another one, but also did teaching and research.

And then I joined the World Health Organization based in Geneva and did public mental health, advising governments, making use of research, scaling up services, advising organizations, in how to strengthen the mental health care system.

Before I joined Harvard University for the last three years, I've been working there and again, doing something very similar but also teaching, and currently the COVID pandemic actually is keeping me very busy because the mental health consequences of that are quite substantial.

- And we wanna talk about that, but I wonder for folks at home that might be generally familiar with public health because of the events of the last two years, mental public health is in the same vein but it's focused on mental health, is that right?

- That's correct.

We look at mental health systems and services, and mental health of populations rather than mental health of individuals.

Obviously, mental health of population consist of the aggregate of mental health of individuals, but the focus is on, how can systems be better?

How can policies be better?

And how can people get the care that they need in a very timely manner, but also for US I must add, in an affordable manner.

- So long before the pandemic and certainly continuing and maybe exacerbated now, social determinants of health, overall health including physical and mental health have been very important.

Things such as food and housing, and economic insecurity, and depending on what part of the world or what part of the country you live in, also your race and ethnicity.

Talk about those social determinants and how they are so important to a person's overall well-being or lack of well-being.

- Indeed Wayne, social demographic and economic determinants are very important for the overall area of health, but even more for mental health and well-being.

In fact, I would even go ahead and say that the services part which is helping people very practically with the problem that they have is actually only a small part of looking after people's health, because some of the policies and some of the determinants at a larger level have much more impact on people's health and mental health, and actually play a very big role in why and how people become more distressed, go into mental disorders, go into disabilities, have decreased functioning, and how they finally seek help, but much happens before that actually.

And just to give you an example, there are very clear relationship between, say for example, poverty, lack of appropriate education, lack of job opportunities, discriminations of all kinds, whether they are based on gender, whether they're based on gender identity, based on race, ethnicity, and other factors, and all of them have an impact.

I'll give you two examples.

One is of the immigrants and refugees which the world is facing in a very large manner.

And these people have undergone some of the most shocking stresses in their life, and that really impacts their mental health.

In fact, mental health of people, of normal people in extremely difficult circumstances is something that is a major area for research because it impacts people.

And take the other example of COVID of course, which we've talked more about.

It has affected almost all of us, I myself affected, and that is the kind of impact that is not much to do with myself, is to do with the external environment and the situation that I find myself in.

So those things have been less talked about, but are extremely important.

- So, we're gonna get into age groups a little, a little bit further into the program, and then obviously as you mentioned into the pandemic, but I've written and a lot of people have written about the lifelong effects, impact of childhood stress and trauma.

And as you know, many of the immigrants and refugees around the world are children today.

Can you just talk sort of generally about the possible long-term negative impacts of stress and trauma during childhood?

- Sure, in fact, childhood is a period of formative growth and development.

So that child is developing physically, that child is also developing in the child's brain development in terms of cognition, in terms of emotional well-being, in terms of social relationships and skills that children acquire.

And if something happens during that stage, it can have not only immediate effects, but it actually makes them vulnerable for later mental health problems, and earlier that happens, the worse it is.

For example, abuse of children, whether it's physical abuse or sexual abuse can have major impact on the lifelong mental health and well-being.

Also neglect of all kind, in terms of not getting enough nutrition, not getting enough social stimulation, emotional neglect, all of them actually can have major problems in life.

There are research now to suggest that children who have in some way undergone major stresses during childhood can have three to four times the prevalence of depression in their later life, and it's not only depression, they can have alcohol problems, drug problems, trauma related psychiatric illnesses.

And it's a vicious cycle because if there is a traumatic event during childhood, obviously even the family sometimes is in some way disturbed and that continues, and then the child's education gets impacted, child's earning capacity gets impacted, which by themselves also have an impact on mental health.

So these are very major determinants of later life mental health.

And as Wayne you said, some of the children find themselves in extremely difficult situations because they are refugees or they are in some refugee camps or immigrants with very serious issues before they became refugees and sometimes even after that, and that can have a very lasting impact.

In fact, a whole generation can get affected because of some of the events that we're seeing every day in the world.

- And of course, it's not just children who are refugees or immigrants during the pandemic, there are many kids around the world and in much of the US who for almost two years now have not been able to lead a normal life.

And I'm thinking in terms of schools particularly but in many other aspects as well.

Talk about that, on that group of children during the pandemic and their mental health.

- Yep.

In fact, there have been some studies and a large estimation about how children's education, in terms of its interruption but also in terms of the way it is now being delivered quite often by virtual means, can have an impact on those children, and we are talking about hundreds of millions of children.

UNICEF has suggested that this will have a very lasting impact on the children's education and on children's earning capacity and mental well-being.

In fact, there is a report which was published just a week back from UNICEF, which is focused on the mental health of children and that group of children who have missed school or are not able to get educated because there is no IT infrastructure, they don't have access to for example, equipment or websites, and that can impact them.

Take the fact that 50% of children all over the world have not gone back to the normal education pattern even now, 18 months since the pandemic started, and 20% children are not actually attending school at all.

In some of the poorer sections of society in the US but also more so internationally, will actually never go back to school because the interruption has been too long and sometime their families have got them into some kind of jobs, so that education for them, especially for girl children, becomes a nonentity now, and that's going to have a major impact on their life.

So, it is the effect of some traumatic events, but also the long-term environment in which they are living and COVID has affected that a lot, so that some children it's catastrophic reaction and so for other children, it is an incremental deficit that they're going to have throughout the life for their socioeconomic well-being, as well as their psychological and emotional well-being.

- To Saxena, if we turn our attention to adult populations now, how has the pandemic, and I realized we're speaking on a global scale here, but how has the pandemic effected adult mental health in the last couple of years?

- I think it will not be an exaggeration to say that in one way or the other, all adults have been affected by the pandemic, more so in those countries where the COVID pandemic has affected more, and also the restrictions imposed because of the pandemic have been more severe and take some examples that many people have lost jobs, many people have been confined to their homes, many people have to rediscover different ways of working, sometime the income has been decreased, some students find themselves not having access to education and so on.

And also, let's not forget that a very large number of people have died and it's their families, and it's their colleagues who have also suffered because of the trauma of losing somebody in their family or in their workplace.

And all of that has affected in a very major way.

In fact, CDC for US maintains a survey that is done periodically and their findings suggest that the anxiety and depression amongst adults has been extremely high during this period, between two to three times the prevalence in the pre-pandemic period, almost 30 to 40% people are having anxiety and depression that is affecting their life in some way, and many more are having symptoms.

To me, it demonstrates a couple of things.

One, that mental health has to be seen as a dimension and not as a binary between some people who have a disorder and many others who don't.

It's not about them, it's about all of us.

And that is very clearly demonstrated by the COVID because most of us are affected in a small or in a larger way.

The second thing which is demonstrated is that something could be done about all of these.

People who are hoping just a little bit less than earlier, people who have clear mental health symptoms and functional problems, and people who have a clear disorder and need clinical health, and some other people who are disabled because of mental illness, for all these four categories on this dimension, something can be done.

We can all promote our mental health.

We can prevent mental disorders.

And if we happen to have a disorder, we need treatment and that can also be done.

So these two things, the realization that is about all of us and the realization that there is a COVID pandemic going on but also there is a mental health pandemic going on, is something that I think are clear lessons from the current situation.

- Yeah, one of the things that I learned or relearned in the course of the pandemic was that public health is less about individual health outcomes and more about preserving and protecting the healthcare system that serves all of society.

In the pursuit of public health in the aggregate, you mentioned the lockdowns and the negative mental health consequences of that, was enough attention paid to the consequences for mental public health?

- I think the short answer is no, because we were too preoccupied especially the policymakers, about preventing illnesses and preventing deaths.

And in many cases, the reaction, the lockdowns, the closure of schools and workplaces, closure of entertainment facilities, was a kind of knee-jerk reaction.

Obviously, many of them were needed, but there is a balance between avoiding infections and avoiding hospitalizations and deaths, and also seeing to it that the mental well-being of the general population is protected and promoted.

And I think in some cases, those balances were not easy to find, and the impact on the mental health and well-being has been very large.

Now, there is an increasing realization that this has to be considered as a part of policy for both things.

One, the restrictions have to be in some way, there has to be evidence that these restrictions are more helpful than harmful.

So, you know, clarity about that is very necessary with mental health and well-being part of the equation.

And the second is that even if restrictions are needed, there has to be something else happening so that the impact of that on mental health and well-being is decreased as much as possible.

And I will mention two more things if you permit.

One is there are vulnerable sections of society, which are impacted much more than others.

So for example, for me, it is possible to work in a virtual environment, but for many other people it is not, and their income and their work suffers much more.

So what are we doing about those people and also people who are generally discriminated against?

And the second factor I would like to mention is, that the people who are in the frontline of public health response are dumpsters affected in a very major way.

So we have doctors and nurses and other staff of healthcare services who are working around the clock in very difficult environments.

Sometimes shortage of staff is there, sometimes shortage of safety equipment is there, and the stresses and the impact on them has to be very carefully monitored and corrected.

Otherwise, we will have on top of all the crisis that we have, we will have a public health services crisis because many people are going to get burned out and leave the services, or work at less efficient manner than others.

And those are considerations that policies have to take care of and have to take care of now.

- So, one of the obstacles to creating that balance that you talked about before, and that looking at the entire person, the mind and the body has been stigma.

And you have studied this, many people have studied this and are well aware of this, and it's been well known for decades.

Why do you think that stigma still persists?

I mean, in some senses, the attitudes on the part of at least some people are almost medieval when it comes to people living with mental challenges or with mental illness.

What's the reason if you know?

- You're right Wayne, the stigma is there, the stigma persists and it is global.

It's there in all communities, all countries.

I don't think I'll be able to answer satisfactorily why stigma is there, but I do know it's there and also it leads to not only people's attitudes being negative but also people's behavior being negative, and that is actually more of a problem because we don't talk about our mental health problems, but also we discriminate against people who have come out with the fact that they have a mental health problem or a disorder or a disability, and they are very damaging.

It affects the way we think, it affects the way we behave, and it also affects the policies actually all over the world.

And in fact, WHO just launched its Mental Health Atlas last week, which is the data from 2020 for all countries.

It turns out that the world is spending far too little money on mental health as a part of the overall health package.

It's between one to 3% when the burden of mental disorder is more than 10%.

So there's a huge gap between what we need to do and what we are doing and part of that is because of the stigma, but there are other instances where stigma is really very detrimental.

Imagine a workplace where on an average one could imagine that out of a hundred people five will have a serious mental health issue and about 10 we'll have some more minor mental health issue, and disclosure that somebody has a problem is very, very small, is less than 1%.

So, what are the other people doing?

They are either not seeking help which is itself not a good thing to do, but otherwise they're seeking help in a manner that is very private and the workplace doesn't know, the manager doesn't know that there is a problem.

And so, that is the impact of a stigma because preventive measures, promotive measures, and sometimes very clearly needed treatment and care is not being provided and that leads to much higher level of disability and sometime problems becoming chronic, and it's not only in the workplace, it's also there in their other lives also in schools.

And those are the pernicious impacts of the stigma and discrimination that are there, and we need to take that into account.

I should also say, there is a small silver lining to the pandemic.

Since, as I talked about earlier, most of us seem to be affected in one way or the other, the realization that mental health is something that is important to us and for all of us has actually increased.

So there is a little more receptivity, a little more inclination to share one's own mental health issues, even at the workplace or in the community, and that is really at least a step in the positive direction.

- So, one of your passions is suicide prevention, and I think there's no question the pandemic has exacerbated that situation.

Talk about the importance of suicide prevention.

- Suicide is unfortunately an extremely common event, including the attempts for suicide or self-harm.

About 700,000 people die all over the world because of suicide every year, and in some countries, and I should also mention in USA, the suicide rate is high and it's increasing as opposed to many other countries including China, where it is decreasing actually.

And suicide of course has a multiple reasons.

And as we talked about earlier, some of the social economic reasons are quite prominent, but also presence of mental health problems like depression or psychosis or alcohol problems are important causes for suicide.

Suicide prevention strategies need to be very clearly applied.

And during COVID time, a lot of people are becoming more lonely and are more prone for attempts.

We still don't have data about whether the rate has actually increased or not, but the chances are that with the same lag period, it might show actually quite an increase and we need to act now on that in terms of policy, but in also terms of providing help.

And when I say help, I don't only mean clinical help.

Help is somebody who's around, family, colleagues, they need to go and ask, how are you feeling?

And sometimes even that simple discussion really helps.

It's a myth to say that if you talk about death to somebody, their chances of suicide will increase and actually they are quite willing to and keen to talk, and that really is the first step towards seeking care and getting care.

- That there Saxena, there we've got just about two and a half minutes left in the show.

It's probably worth noting now that, to remind our viewers and listeners that in the United States anyways, anyone who is in immediate dangerous should call 911.

But I'm curious if you have any advice, we we've seen colleges and universities this year have been struck by, I don't know if it's a statistically higher number of suicides, but schools are grappling with a mental health crisis across the United States right now.

Do you have any advice for administrators who are grappling with these issues?

- Absolutely a very important issue.

In fact, the anxiety and depression that I talked about earlier is much higher amongst young adults and adolescents than in the middle age and an older age group.

They are perhaps coping up better.

So the young people's mental health is a major concern, students in schools, students in colleges, and in sports clubs and other places have to be really looked after in a very careful manner.

And I think the administrators as you asked, have a major responsibility to create the kind of environment which is inclusive and open so that people can talk about their emotional well-being together with other things, and also provide services when needed.

Generally in the university and school setups, mental health services are really very deficient and so we need to refurbish that and we need to also then create the environment where people who come in contact with young people, for example, teachers, professors, they need to be aware that these are problems which are becoming very common and provide some basic advice and counseling, and if needed refer to the more specialist resources.

That is urgently needed.

- So we have very little time left here but if you could very quickly, what would you advise to the general public people who are watching and listening to this show who have mental health challenge?

What should they do?

The first step, the second step, what should they do?

- [Jim] About 15 seconds.

- Pay importance to your own mental health and have people around you, look for early signs, talk to them and refer them for care if needed.

- That's the place to leave it Dr. Shekhar Saxena.

Thank you so much for being with us.

That is all the time we have this week, but if you wanna know more about Story in the Public Square, you can find us on Facebook and Twitter or visit pellcenter.org where can always catch up on previous episodes.

For G. Wayne Miller, I'm Jim Ludes, asking you to join us again next time for more Story in the Public Square.

(upbeat music)