4. What are the implications and lessons of the COVID-19 pandemic for integrated mental health, skills and work policy?

At the onset of the COVID-19 crisis in 2020, population mental health deteriorated. This runs counter to the fairly consistent prevalence of mental health conditions among adults across the OECD since the early 2000s (OECD, 2015[1]). As shown in Figure 4.1, prevalence of symptoms of anxiety and depression in March to April 2020 was higher across all countries where data are available compared to previous years. A meta-analysis of studies published in May 2020 found that the prevalence of symptoms of anxiety and depression stood at 31.9% and 33.7% respectively during the COVID-19 crisis (Nochaiwong et al., 2021[2]). In another analysis of studies from January 2020 to January 2021 on the prevalence of anxiety and depression, researchers have estimated that prevalence of anxiety and depression in 2020 was 28% and 26% higher respectively than would have been expected without the pandemic (Santomauro et al., 2021[3]).

Monitoring of factors related to mental health – including loneliness, sleep quality, and self-harming behaviour and suicide – also provides insights into the impact of the COVID-19 crisis on population mental health, given the interaction of these factors with mental health status. Box 4.2 takes at glance at some of the findings on trends in levels of loneliness, sleep quality and suicide during the COVID-19 crisis. The interaction between well-being and mental health is also addressed in more detail in the forthcoming publication, COVID-19 and well-being: Life in the pandemic (OECD, 2021[4]).

Surveys in most OECD countries in 2021 show that population mental health is yet to recover to levels seen before the onset of the COVID-19 pandemic. Yet data from a select number of OECD countries point to a notable recovery in population mental health in 2021, and in some cases, a return to pre-crisis levels. The data therefore suggest that as of mid-2021, not all OECD countries were still experiencing a mental health crisis at the population level. Whereas the initial negative mental health impact at the onset of the COVID-19 in 2020 was evident across all OECD countries, trends in population mental health since and throughout 2021 have therefore differed widely across OECD countries.

A challenge with interpreting data from surveys is that findings may differ between cross-national and national surveys on mental health as discussed in this chapter. Whereas cross-national surveys alone point to a further deterioration of mental health in early 2021, national surveys suggest signs of recovery. To some extent, this may be due to the availability of more granular and recent data in national surveys. Data from both cross-national and national surveys nonetheless both show that specific groups continue to experience poorer mental health than others, and thus may be at risk of experiencing longer-term mental health impacts from the pandemic.

As of early to mid-2021, cross-national surveys in OECD countries pointed to a lasting deterioration of mental health. As shown in Figure 4.2, an online survey by Eurofound has found that mental well-being recovered from April/May 2020 (onset of COVID-19 crisis) to June/July 2020, but then declined significantly, reaching the lowest levels during the COVID-19 crisis in February/March 2021 in all European OECD countries where data are available (Eurofound, 2021[11]). Analysis of data from the COVID-19 Behaviour Tracker (Imperial College London YouGov, 2020[12]), which is presented in COVID-19 and well-being: Life in the pandemic, also finds that the share of respondents at risk of anxiety and depression in 15 OECD countries increased marginally when comparing data from 2020 (April to December 2020) to data from early to mid-2021 (January to May 2021) (OECD, 2021[4]).

Data from national surveys, however, indicate significant variation across OECD countries, especially in 2021, and in a number of countries (including the United Kingdom, the United States, Germany and the Netherlands), mental health has returned (partially) to pre-crisis levels. The Lancet Commission Mental Health Taskforce cites evidence from the United Kingdom and the United States to argue that levels of population psychological distress declined after a sudden rise at the onset of the pandemic (Aknin et al., 2021[13]). In the United Kingdom, data from the UCL Social Study, which uses the GAD-7 as its item on anxiety, show that prevalence of symptoms of anxiety decreased in summer 2020, then rose slightly from September 2020 through to early 2021, before declining again thereafter (UCL, 2021[14]; Office for National Statistics, 2021[15]). In the United States, two pre-eminent nationwide surveys, namely the USC Center for Economic and Social Research’s Understanding Coronavirus in America tracking survey, and the Household Pulse Survey, both of which use the PHQ-4, find that the prevalence of symptoms of anxiety and depression at the population have declined since a peak in spring to summer 2020, although the former survey finds greater improvements (USC, 2021[16]; NCHS, 2021[17]). Significant recoveries in population mental health have also been seen in Germany and the Netherlands. In Germany, by January to February 2021, average levels of psychological distress, captured by the PHQ-4, had returned to pre-crisis levels (Entringer and Kröger, 2021[18]). In the Netherlands, analysis of a survey using the five question Mental Health Inventory suggested that by December 2020, population mental health had returned to levels reported in 2019 (Siflinger et al., 2021[19]).

In many other countries and regions, however, levels of anxiety and depression peaked later into the pandemic, have remained high, or may still be rising. Although levels of anxiety and depression in Belgium and France declined after the sharp increase at the onset of the crisis, mental health deteriorated significantly again from the end of 2020, with both countries reporting high levels of anxiety and depression in spring 2021. In France, the proportion of the population reporting symptoms of depression exceeded one in five for the first time in November 2020, and remained above this level through to April 2021 (Santé Publique France, 2021[20]). In New Zealand, prevalence of psychological distress (K10) appears to have increased in early to mid-2021. Since data collection for this survey in New Zealand began in September 2020, psychological distress was in decline until March 2021, when it began to rise again, reaching the highest levels recorded in May 2021, when 11.9% of the population reported symptoms of high psychological distress (Ministry of Health, 2021[21]).

One contributing factor to the variation across countries is the differences in strictness of containment measures put in place, as well as variations in the evolution of the pandemic across OECD countries. Previous OECD analysis based on survey data from March to December 2020 has shown that, across a number of countries (Canada, France, the Netherlands, New Zealand, United Kingdom), prevalence of symptoms of anxiety and depression showed a fair degree of correlation with the stringency of policies to contain the spread of the virus, as measured by the Oxford University/Blavatnik Stringency and Policy Index (OECD, 2021[22]). A recent study of data on anxiety and depression between January 2020 to January 2021 has also found that daily infection rates of the coronavirus were associated with increased prevalence of symptoms of anxiety and depression (Santomauro et al., 2021[3]). Extending the data for this analysis to July 2021, at least for the United Kingdom (Figure 4.3), suggests that this correlation still largely holds more than one year on from the onset of the pandemic, although less closely for symptoms of depression. More details on the collection of mental health data in the United Kingdom are found in Box 4.3. There is also supporting within-country evidence of the impact of containment measures on mental health in Australia. A survey (K10) conducted as Victoria had exited lockdown in June 2021 showed that more than one in four people living in Victoria were experiencing high psychological distress (27%), compared to less than one-fifth (18%) among the rest of Australia (Australian Bureau of Statistics, 2021[23]).

The prevalence of symptoms of anxiety and depression typically increased before or immediately as lockdown measures were put in place, but there is no evidence to suggest that mental health deteriorated further during periods of lockdown (Banks, Fancourt and Xu, 2021[24]). In Germany, a survey to track levels of psychosocial distress (PHQ-4) found that during a two-month lockdown from March to May 2020, mental health remained largely unchanged (Ahrens et al., 2021[25]). In Denmark, survey results (WHO-5) show that prevalence of symptoms of depression decreased from March 2020 to July 2020 in a period when the country was under a lockdown (Andersen, Fallesen and Bruckner, 2021[26]). Evidence from France, and to some extent, the United States, also suggests that population mental health can rebound quickly upon the relaxation of containment measures. When containment measures were gradually lifted in France in May 2021, levels of anxiety and depression declined. Prevalence of symptoms of depression, for example, decreased from 22% in late April 2021 to 13% in mid-July 2021 (Santé Publique France, 2021[20]).

Across OECD countries, the mental health impact of the COVID-19 crisis has varied across population groups, and notably by age, gender, employment status, financial situation, and socio-economic status. Women and young people as well as individuals living alone, of lower socio-economic status, and the unemployed have all reported higher levels of anxiety and depression during the COVID-19 crisis than the general population (OECD, 2021[22]; OECD, 2021[4]). Although there is data from before the crisis on differences in mental health status across populations, the paucity of such data that is comparable with data collected since the onset of the pandemic poses difficulties when assessing whether these differences have widened or represent the continuation of pre-crisis trends.

The prevalence of mental health conditions differed between men and women before the crisis, with women more likely to report symptoms of anxiety and depression (Riecher-Rössler, 2017[30]), and these differences seem to have widened. In an analysis of studies on anxiety and depression between January 2020 to January 2021, researchers estimated that around two-thirds of the additional cases of anxiety and depression worldwide resulting from the COVID-19 crisis have been among women (Santomauro et al., 2021[3]). Looking at national surveys, in the United Kingdom, comparing the prevalence of depression in July 2019-March 2020 to July-August 2021, it appears that the difference between men and women has widened slightly (Figure 4.4). In the United States, one study found that stay-at-home measures in March to April 2020 had resulted in an increase in the gender differences in low mental well-being (WHO-5) by 66% (Adams-Prassl et al., 2020[31]). However, not all countries and regions show this trend. An analysis of a bi-weekly survey in Northern the Netherlands finds that while women reported greater increases in symptoms of depression than men during the COVID-19 pandemic, gender differences in the prevalence of symptoms of anxiety decreased (Vloo et al., 2021[32]).

Parental status also appears to have an impact on mental health, with evidence pointing to parents of young children, and especially mothers, reporting declines in mental health compared to before the crisis. Based on a meta-analysis, researchers have estimated that the prevalence of symptoms of anxiety and depression among mothers of children under five stood at 27.4% and 43.5% respectively during the COVID-19 pandemic, significantly above levels before the onset of the pandemic (Racine et al., 2021[33]). The postpartum period and transition to motherhood was already associated with increased risk of mental health issues pre-crisis, especially for young mothers, yet the exceptional circumstances of the pandemic have resulted in additional pressures. Contributing factors include the loss of social support and suspension of early childhood education and care facilities, with the additional burden of childcare falling disproportionately on women (OECD, 2020[34]). In Italy, while men increased their contributions to childcare at the onset of the crisis, the burden of increased childcare still fell mostly on women (Farré et al., 2020[35]). A study of dual working parents in the United Kingdom has also found that mothers were responsible for almost two-thirds of the additional childcare resulting from the pandemic (Sevilla and Smith, 2020[36]).

Lower socio-economic status – including both lower levels of education and income – has also long been associated with higher risk of poor mental health (OECD, 2015[1]), and this trend has continued throughout the COVID-19 crisis in most countries. In a survey in Japan in March 2020, both men and women with annual household incomes less than JPY 2 million were more likely to report symptoms of psychological distress than those with annual household income above this level (Nagasu, Muto and Yamamoto, 2021[37]). In the United Kingdom, higher anxiety and depression scores have been reported by individuals in households with lower incomes and individuals with lower educational attainment in both the COVID-19 Social Study (UCL, 2021[14]) and the Opinions and Lifestyle as shown in Figure 4.4. In the United States, findings differ across surveys. While the Household Pulse Survey shows that individuals with less than a high school degree have reported almost 50% higher prevalence of symptoms of anxiety or depression than their counterparts who have achieved a Bachelor’s degree or higher (Centers for Disease Control and Prevention, 2020[38]), analysis of the American Life Panel found that individuals with higher education experienced larger increases in prevalence of depression than other individuals (Wanberg et al., 2020[39]).

There is overwhelming evidence that young people’s (15-29 year-old1) mental health has been significantly negatively impacted by the COVID-19 crisis, and this trend has continued through to mid-2021. The OECD previously reported that in a large number of OECD countries (Belgium, Canada, France, Italy, Japan, United Kingdom and the United States), analyses of survey evidence have shown that young people are reporting poorer mental health than the general population (OECD, 2021[40]). Survey results from other countries provide further evidence of the large impact on young people. In Austria, in April 2020, 25% of adults under the age of 35 reported symptoms of anxiety (GAD-7), compared to 19% among the general population, with a similar trend seen for depression. In November 2020, 32% of 18-34 year-olds reported high or very high levels of psychological distress in Australia (K10), compared with 21% among the general working population (Australian Bureau of Statistics, 2021[23]).

As shown in Figure 4.5, a number of countries have continuously tracked population mental health by age group during the pandemic, which provides close to real-time evidence and point to continued higher prevalence of symptoms of anxiety and depression among young people across most periods of the COVID-19 crisis. The OECD reported that in March 2021, in Belgium, France and the United States, young people were 30% to 80% more likely to report symptoms of depression or anxiety than the adult population (OECD, 2021[40]). These gaps have remained through to July 2021 as shown in Figure 4.5, and although prevalence has fallen across age groups in recent months, young people continue to report higher prevalence of symptoms of both anxiety and depression. There are also significant variations within different groups of young people, with young gender-diverse individuals and young women being among the groups reporting higher levels of mental distress as discussed in Box 4.4.

Data from a limited number of surveys from before the COVID-19 crisis show that these differences are new, or represent a significant widening of differences between young people and other age groups. In the European Union, in 2014, 15-24 year-olds were 40% less likely to report symptoms of chronic depression (PHQ-8) than the general population, although with variation across countries (Eurostat, 2014[41]). According to a national health survey in Belgium, 15-24 year-olds were no more likely to report symptoms of anxiety (GAD-7) or depression (PHQ-9) than other age groups prior to the crisis (Sciensano, 2020[42]). In Austria, there was no evidence of higher prevalence of symptoms of depression among 15-29 year-olds (PHQ-8) (Statistics Austria, 2015[43]). Yet since the onset of the pandemic, young people have become the age group most likely to report symptoms of anxiety and depression in both Austria and Belgium. In the United Kingdom, although young people were already the most likely age group to report mental health conditions before the crisis, the gap has widened substantially during the pandemic (Figure 4.4).

People with pre-existing health conditions and disabilities have also reported higher levels of psychological distress throughout the crisis, although it is unclear – and may vary from country to country – as to whether there has been a widening of differences from before the crisis. A study in the Netherlands has found that while people with existing mental health conditions experienced a decline in mental health during the pandemic, there was no widening of the overall difference in the level of mental distress between people with pre-existing mental health conditions and the general population (Pan et al., 2021[51]). By comparison, in the United Kingdom, inequalities in mental health by health status appear to have widened, as shown in Figure 4.4. A study among older people in England (United Kingdom) has also found that individuals with a physical disability were more likely to report symptoms of anxiety and depression than those without such a disability, and that the gap had widened during the crisis, even when older people who were “shielding” during the crisis were excluded (Steptoe and Di Gessa, 2021[52]). Individuals with severe mental health conditions have also been at greater risk of hospitalisation and mortality from contracting the coronavirus in at least a number of OECD countries (OECD, forthcoming[53]).

It is more difficult to draw any generalised conclusions on the relationship between race and ethnicity and mental health impacts of the COVID-19 crisis. This is in large part due to the diversity and differences in circumstances of these groups across OECD countries. In Canada, while visible minorities2 (when considered together) were more likely to report symptoms of anxiety than the white population, this gap seems not to have widened for most minority groups, with the exception of South Asians, who have reported poorer mental health than other visible minorities (Statistics Canada, 2021[54]). In the United States, the Hispanic/Latino and Black population have reported higher levels of anxiety and depression than the white population through most periods since the onset of the COVID-19 crisis. By comparison, the Asian population has reported lower levels of anxiety and/or depression than the white population (Centers for Disease Control and Prevention, 2020[38]). Varying practices on data collection across OECD countries also makes it hard to draw firm conclusions, with only around half of OECD countries systematically collecting data on ethnicity or race (Balestra and Fleischer, 2018[55]). Further analysis of the mental health impacts of the COVID-19 crisis on indigenous groups and for individuals of a migration background are covered in the forthcoming publication, COVID-19 and well-being: Life in the pandemic (OECD, 2021[4]).

Employment status during the COVID-19 crisis has also been a key factor in shaping mental health status, which is consistent with previous findings (OECD, 2015[1]). In Canada, since the onset of the pandemic, prevalence of symptoms of anxiety has been consistently higher among people who have lost their job or are no longer working due to the pandemic, with prevalence as high as 44% in March 2021 (CAMH, 2021[56]). Evidence from France also shows that individuals in employment have been less likely to report symptoms of anxiety and depression than unemployed people throughout the pandemic, and this gap is particularly notable for depression (Figure 4.6). The paucity of comparable data from before the COVID-19 crisis makes it difficult to assess whether these gaps have widened or represent a continuation of trends from prior to the crisis.

Working conditions during the COVID-19 crisis – which have differed across occupations and sectors – are also impacting workers’ mental health. The sudden shift to telework at the onset of the crisis, and its continuation, has posed new challenges for mental health. While evidence on the mental health of workers who are teleworking remains limited, a representative poll of French employees in March 2021 found that 49% of employees working from home were experiencing psychological distress, compared to 43% among employees working uniquely at their physical workplace (OpinionWay; Empreinte Humaine, 2021[57]). The Centre for Addiction and Mental Health’s COVID-19 National Survey in Canada and the CoviPrev survey in France have also collected information on mental health by work location during the pandemic. Data from both surveys show that employees who have been working from home have reported slightly higher levels of anxiety and depression than other employees during most periods of the pandemic (CAMH, 2021[56]; Santé Publique France, 2021[20]). Further evidence is needed to draw firmer conclusions on whether employees who are teleworking are at elevated risk of poor mental health, not least given the specific circumstances of teleworking during the COVID-19 crisis, which was often a decision made out of the hands of employees.

The scale of outbreak of the pandemic has also placed a heavy burden on health care workers, especially during periods of high pressure on the health system. It is thus unsurprising that meta-analyses find that health care workers are reporting very high levels of psychological distress (Li et al., 2021[58]). In Canada, workers at high risk of exposure to the coronavirus have reported higher rates of anxiety symptoms through most periods of the crisis (CAMH, 2021[56]). There has also been much discussion on the role of other key and front-line workers during the COVID-19 crisis, and analysis of survey evidence in the United Kingdom suggests that impacts also differ among this group, with workers in essential services, such as utility, transport and public security, reporting higher levels of symptoms of anxiety and depression through to February 2021 than public service workers and teachers (Paul et al., 2021[59]).

Job retention schemes, which were introduced or adapted in response to the pandemic to protect jobs, appear to have cushioned the mental health impacts of the labour market crisis, and moderated the impact of loss of work on mental health (OECD, 2021[60]). These schemes involve temporary financial support to employers to help them retain employees in cases where employees would otherwise work reduced hours or be laid off. In the United Kingdom, furloughed workers in long-term insecure jobs from before and during the pandemic reported no increase in mental distress, whereas workers who were not furloughed reported significant increase in mental distress, which suggests a strong protective effect of furlough (Smith, Taylor and Kolbas, 2020[61]). In Switzerland, analysis of a survey of young men showed that whereas job loss during the COVID-19 crisis was associated with symptoms of depression, psychological trauma and fear, partial unemployment was associated only with symptoms of depression (Marmet et al., 2021[62]).

Analysis of surveys from Australia and Germany offer a similar yet more nuanced picture, with findings suggesting that job retention schemes helped protect mental health, but were not able to fully offset the impact of reduced work. In Australia, the retention of employment while not working was estimated to have reduced the mental health impact of job loss by around a half (Griffiths et al., 2021[63]). Likewise, in Germany, these schemes alone were not able to fully offset the impact of reduced work on mental health, as individuals on job retention schemes have reported poorer mental health than individuals who are in employment and not supported by such schemes (Schmidtke et al., 2021[64]). Workers on job retention schemes may be reporting poorer mental health than their counterparts who are continuing to work, as the temporary nature of these schemes could be perceived as a sign of elevated job insecurity.

Integrated and cross-sectoral policies are the key to responding effectively to the impact of the COVID-19 crisis on population mental health. This requires changes not only in the health system, but also in a range of other policies. The remainder of this section looks into cross-government responses taken across OECD countries in the past 18 months in selected areas of concern.

Given the sudden and negative impact of the COVID-19 crisis on mental health, countries have had to increase the availability of mental health support provided outside of traditional health, educational, workplace and social protection settings. Such support has taken the form of provision of information and self-help materials, strengthening and establishing of mental health hotlines, and the reinforcement of drop-in centres and services.

Many OECD countries have developed and shared information and tips on how to manage mental health together with guidance on how to access support. In Finland, for example, the Institute of Health and Welfare provides information on maintaining everyday routines, managing risk and stress, and guidance on how to seek treatment (THL, 2021[65]). Multiple international agencies such as the World Health Organization, the Inter-Agency Standing Committee and the European Commission have produced guidance and tips on how to stay in good mental health during the pandemic (OECD, 2021[22]). These efforts have often been targeted at health care workers who have been at elevated risk of experiencing mental distress. In Mexico, a specialised website was set up to provide mental health guidance to health care workers during the COVID-19 crisis, through which users could also access online mindfulness sessions designed by psychologists from the Salvador Zubirán National Institute of Medical Sciences and Nutrition.

Most OECD countries have established, reinforced or increased funding to mental health and crisis hotlines, which have been heavily used across OECD countries (OECD, 2021[22]). In Portugal, for example, a free phone line providing 24-hour mental health support from 63 psychologists was launched by the Ministry of Health with the financial backing of the philanthropic foundation Fundação Calouste Gulbenkian. In Colombia, the 192 phone line was established in response to the COVID-19 crisis, including a line reserved for people seeking emergency mental health assistance. Mental health hotlines have also often targeted children and young people (OECD, 2021[66]). In Poland, a 24-hour hotline dedicated to providing mental health support to young people was launched in January 2021. In Austria, the Vienna Government provided additional funding to the RatAufDraht (Advice on the Wire) emergency hotline for children and young people in March 2021 to help increase access to confidential support and advice.

Drop-in centres providing easily accessible psychological support outside of the formal health system have also been strengthened in OECD countries, and especially for young people. Finland, for example, has provided additional funding to the Onni project, which provides low-threshold psychological support and services that are integrated into one-stop youth centres known as Ohjaamo centres that offer guidance and integrated support for young people under 30. In Australia, the government announced an additional AUD 5 million in funding in August 2020 to headspace centres, which offer non-stigmatising support to young people aged 12 to 25, specifically in order to increase outreach to young people experiencing distress in the state of Victoria, which was subject to regional lockdown measures in mid-2020 (OECD, 2021[67]).

The closure of schools and the resulting disruptions to learning have had significant implications for mental health, as schools offer more than just a place for academic development. The sudden shift to remote learning eroded many protective factors offered by in-person attendance, including routine, social contact and sense of belonging to a community, as well as access to exercise (OECD, 2021[40]). Closures of schools and educational institutions has also increased risk of mental health issues among young people going unidentified. Schools serve as a primary point of access to mental health services for many young people, and front-line actors such as teachers are often well-placed to identify early symptoms of mental health issues through repeated absence and behavioural changes in day-to-day school activities.

While many young people have been able to maintain connection with peers through digital means, the loss of in-person interaction resulting from school closures could have long-term negative consequences for mental health, not least as young people are particularly reliant on interaction with peers (Orben, Tomova and Blakemore, 2020[68]). Whereas early childhood is characterised by a reliance on parent-child attachment, as individuals emerge out of childhood, they become more reliant on peer interactions (Burns and Gottschalk, 2019[69]). This impact may be particularly relevant for students of older ages as higher levels of education have been subject to more disruption across the OECD. While there are significant differences across and within countries, across the OECD, on average, more than half (56%) of instruction days were not held in-person at upper-secondary level from January 2020 to May 2021, around double the share of instruction days closed at the pre-primary level over the same period (OECD, 2021[70]).

Disruptions to learning due to the COVID-19 crisis have put students at risk of becoming disengaged and leaving education altogether, with a disproportionate burden falling on young people from disadvantaged backgrounds. Keeping young people in school protects against poor mental health, and brings benefits for both the individual and society in terms of improved long-term employment prospects. Most OECD countries are reporting implementing such measures, often with a focus on disadvantaged groups and young people at risk of dropping out. Almost three-quarters (73%) of OECD countries reported implementing remedial measures at the upper-secondary level to make up for learning gaps between January and May 2021, and more than half reported introducing more targeted measures at students at risk of dropping out of education (OECD, 2021[70]).

While there may be consideration of use of grade repetition to address learning losses and close skills gaps for students experiencing mental distress, the broad use of such measures should be avoided. Policy makers and educational institutions should instead focus on supporting students through the crisis. There is no guarantee that grade repetition helps to close learning gaps, and it can place significant costs on the individual in terms of lost income due to delayed labour market entry. Moreover, grade repetition can disrupt social connections of students with their peer group and thus increase the risk of mental distress (La Greca and Harrison, 2005[71]). As outlined in Chapter 2, even prior to the crisis, students indicating mental distress were 35% more likely to have repeated a grade, and thus targeted support to make up for learning losses for this group are particularly important.

Supporting young people in education also requires policies to ensure teachers and front-line actors in the education system are appropriately trained, and the involvement of parents, especially for younger students. For example, in February 2021, the United Kingdom launched a free training course for people who work with or care for young people under the age of 25. The government also later announced a mental health grant of up to GBP 1 200 for schools and colleges to provide senior leaders with the skills and understanding to implement a whole-of-school approach in their educational institutions. More targeted interventions and treatments must also be made available for students experiencing clinically significant mental health conditions. This may take the form of provision of educational support with mental health services together, through close co-operation of educational institutions and mental health services.

Recognising the important role of educational institutions, many countries across the OECD have also allocated funding to expand mental health services available in education institutions, although the increases have often been moderate (OECD, 2021[66]). In Iceland, the government allocated ISK 150 million in April 2021 to strengthen mental health services in upper secondary schools, colleges and universities. In France and Austria, additional psychologists have been placed in the education system. In France, the government announced in late 2020 that 80 additional psychologists would be hired in university mental health services, while in Austria, the government allocated funding in June 2021 to hire 205 additional psychologists in schools. For countries seeking to adjust their budgets on education, this should not come at the expense of programmes that promote the mental health of students.

Since the onset of the COVID-19 pandemic, millions of workers have experienced job loss, and most have seen significant disruptions to how their work is organised and experienced. Some workers are still on job retention schemes, and may not have been at work for 18 months. Other workers such as those in essential services have had to continue to work in-person throughout the pandemic, in some cases facing increased risk of exposure to COVID-19 infection and in all cases needing to take new steps to protect their health at work. Still others suddenly shifted to telework often full-time and across many months.

Given the increased risks to the mental health of employees amidst the COVID-19 crisis, employers can take proactive steps to provide and strengthen mental health support available to employees including for both in-person and remote employees. Many employees in the United States feel that their employers are not taking sufficient measures to address the mental health issues arising from the pandemic. In a recent survey of remote workers in the United States by PricewaterhouseCoopers, for example, employees were 26 percentage points less likely than executives to say their companies were successful or very successful in supporting the mental health of workers (PwC, 2021[72]). While large employers in the United States are reporting expanding access to virtual mental health services for their employees amidst the pandemic, small and medium size employers may face greater challenges in making mental health support available.

Whole-of-workplace initiatives – comparable to whole-of-school initiatives – can help ensure work contributes to better mental health. A key component of such initiatives is mental health training for line managers and executives. A Deloitte survey in the United Kingdom in 2017 found that while around half of line managers believed basic training in mental health would be useful, less than a quarter reported actually receiving training. Effective management by line managers can contribute to a workplace culture that is conducive to open discussion of mental health, help prevent workplace conflicts that are major risk factors for poor mental health, and promote earlier identification of potential mental health issues.

Given that teleworking rates are likely to remain above pre-crisis levels even once the COVID-19 pandemic subsides (OECD, 2021[73]), further examination of the impact of teleworking on mental health is necessary. Evidence from before the COVID-19 crisis on the interaction between teleworking and mental health was mixed. When well-managed, telework offers benefits such as flexible working arrangements, elimination of commuting time, and the possibility to balance work and family commitments. However, telework can also blur the boundaries between work and home, increase usage of digital technologies, and contribute to extended working hours, and result in a sense of detachment from the workplace, all of which can have a negative impact on mental health. A better understanding of the link between work-life balance and mental health may also provide valuable insights into the impact of the changing workplace on mental health. Data from a survey in the EU, for example, has found that teleworkers have been significantly more likely to report working during their free time compared to other workers (Eurofound, 2020[74]), which could have significant implications for mental health.

The rise of teleworking may demand new protections for workers’ mental health, and policy makers have responded rapidly in a number of countries in this emerging policy area. In December 2020, lawmakers in the European Parliament called for a law to give workers the right to digitally disconnect outside working hours without repercussion. This measure followed in the footsteps of France, Italy, Spain and Luxembourg, which already had such legislation in place, and since then, Greece and Slovakia have also amended their labour code to include a right to disconnect (Eurofound, 2021[75]). While countries have moved to rapidly implement such policies in part due to the rise in telework amidst the COVID-19 crisis, this response also reflects policy makers’ attempts to mitigate the negative mental health impacts of the digital transformation on the workplace.

The COVID-19 crisis has also profoundly impacted the employment landscape with the large-scale use of job retention schemes. In the early stages of the crisis, countries acted swiftly to put in place or modify these schemes, and in this process, supported over 60 million jobs across the OECD, accounting for around 20% of dependent employment. As explained earlier, job retention schemes have also indirectly contributed to protecting beneficiaries from a deterioration in their mental health.

From a mental health perspective, it appears preferable for individuals on job retention schemes to work reduced or partial hours, as opposed to seeing their hours cut to zero. An analysis of the United Kingdom and EU countries has found that employees can gain most of the mental health benefits that come with employment with just eight hours of work a week (Kamerāde et al., 2019[76]). While most OECD countries already had some form of job retention scheme in place, all new job retention schemes, with the exception of Iceland’s, could only initially be used for employees whose work was cut to zero hours (OECD, 2020[77]). In some countries, including Denmark and the United Kingdom, schemes were later amended to make compensation for reduced hours, rather than for zero hours alone.

What is less known are the consequences of prolonged furlough or short-time work, with some workers having been on such schemes for over a year. Past OECD research has shown that returning to work becomes especially difficult for individuals after three months of sick leave (OECD, 2015[1]). Similarly, re-employment chances fall with the duration of unemployment. While being on job retention schemes may not entail the same circumstances, prolonged periods on such schemes could have a similar effect of increasing the risk of detachment of the employee from the workplace.

Moreover, policy makers across OECD countries should be wary of a potential increase in unemployment and demand for mental health services as they seek to phase out job retention schemes. Although the share of workers on job retention schemes has declined sharply since the early months of the crisis, 6.5% of dependent workers were still on these schemes in February to March 2021 on average across the OECD countries (OECD, 2021[60]). For individuals on these schemes who are able to find work, the transition back to work may bring significant mental health benefits, but some individuals will not be able to find work easily (ibid).

Given the scale of unemployment and joblessness seen across OECD countries, promoting good mental health and providing access to mental health services for the unemployed should be considered a priority. There were 22 million more people who were jobless for more than six months at the end of 2020 compared to the end of 2019, indicating a significant increase across OECD countries in long-term unemployment (OECD, 2021[60]). Unemployment rates are also expected to remain above pre-crisis levels through to the end of 2022 in many OECD countries (OECD, 2021[78]), suggesting that tackling joblessness will remain a challenge beyond the short-term.

Supporting jobseekers back into employment through job-search support, counselling and training opportunities remains a key lever to promote better mental health among the working population. The mistakes of the global financial crisis must not be repeated, when the increase in unemployment far outpaced the rise in spending on active labour market policies, resulting in a 21% decrease in time spent with each client (OECD, 2011[79]). While employment services may still be stretched by the increase in clients during the pandemic, the provision of mental health support should not be compromised or reduced.

Even prior to the crisis, public employment services offered little access to support for individuals experiencing mental health conditions. Measures offered in employment services need to combine mental health support with employment support as evidence shows that mental health support is effective in improving employment prospects for individuals experiencing mental health conditions only when it is provided together with employment support (OECD, 2015[1]). As outlined in Chapter 3, large-scale implementation of integrated mental health and employment support still remains lacking in most OECD countries, and this has remained the case even during the COVID-19 crisis. In Norway, for example, an Individual Placement and Support programme has been launched for under 30-year-olds as part of the 2021 National Budget, to provide young people experiencing mental health issues with mental health and employment support together. Given the ample evidence that points to the effectiveness of such integrated supports from before the crisis, countries should go further than trials by scaling up and rolling out these schemes to reach out to a larger number of unemployed jobseekers.

Active labour market programmes themselves can also help to cushion the impact of damaging effects of unemployment on mental health. A study in the United Kingdom found that participants in these programmes are likely to self-report better mental health outcomes than other unemployed individuals, although still likely to report poorer mental health than those in work (Wang et al., 2020[80]). Participation in active labour market programmes shares some aspects of employment such as providing routine and structure to daily life, offering opportunities to meet new people and socialise, and supporting the development and maintenance of social networks. While supporting jobseekers back to work should remain the focus of active labour market policies, there is thus also scope to consider the mental health implications when assessing the effectiveness and success of such policies.

These challenges are particularly pronounced for young people. Young workers often hold less secure jobs due to shorter job tenure and greater reliance on non-standard forms of work, and are also over-represented in customer-facing industries – such as accommodation, tourism and food services – that have been hard hit by the COVID-19 crisis. New graduates, meanwhile, are often looking for work for the first time at a time of limited vacancies and high competition from jobseekers with experience, and account for a significant proportion of increase in joblessness among young people (OECD, 2021[60]). While all workplace and employment service policies to promote good mental health also apply to young people, the need for outreach of employment services is particularly pronounced for disadvantaged young people (OECD, 2021[66]). Opportunities to get in touch diminish over time, as young people become more disengaged from education and the labour market, and thus outreach is vital to support young people into training or work, and to strengthen future labour market outcomes.

The COVID-19 crisis has shed light and renewed attention on long-standing issues such as the paucity of data on mental health, and the scale of mental distress across OECD populations, while also showing the urgency of addressing the social determinants of mental health. The crisis has also accelerated trends such as the digital transformation, which presents both opportunities and risks for people’s mental health, and resulted in new attention placed on policy issues related to mental health such as rising loneliness. Given the scale of the challenge facing OECD countries, an integrated approach to mental health policy that takes into account the education, employment and welfare dimensions of mental health is more urgent than ever, with a focus on groups hardest hit by the COVID-19 crisis, to ensure people across the OECD are able to lead mentally healthy lives.

The COVID-19 crisis has highlighted the continued relevance of an integrated approach to mental health policy and the principles set out in the OECD Recommendation on Integrated Mental Health, Skills and Work Policy (Box 4.5). Improved data collection on population mental health will provide countries, policy makers and researchers with greater insights into the value of education and employment interventions in promoting good mental health. Raising awareness of mental health issues and tackling continued stigma towards mental health will require action across health systems, educational institutions, workplaces, social protection systems and broader society as called for in the Recommendation. Increased attention to mental health during the pandemic should also facilitate the shift to more integrated policies and practices.

The OECD will continue its research into effective integrated mental health, skills and work policy, and follow the emerging policy priorities outlined in this chapter as countries look to recover from the COVID-19 crisis. As the impacts of the digital transformation and the emergence of loneliness as a policy priority are not explicitly mentioned in the Recommendation, further analysis and research of these long-term impacts will provide a picture of how these new developments could be reflected in the current version of the Recommendation if considered appropriate. The next scheduled review of the implementation, dissemination and usefulness of the Recommendation in five years’ time will also provide an opportunity for amendments or updates to the Recommendation as the longer-term impacts of the COVID-19 crisis on integrated mental health, skills and work policy become clearer.

Recognising the potential psychological and mental health impacts of the COVID-19 crisis, there has been a significant increase in country-level monitoring of population mental health status, and this should be sustained going forward. Across many OECD countries, as expanded upon in recent OECD work, most notably, A New Benchmark for Mental Health Systems (OECD, 2021[67]) and in the upcoming COVID-19 and Well-being Evidence Scan (OECD, 2021[4]), national statistical offices and researchers have collected stratified data on prevalence of symptoms of anxiety and depression, as well as on measures related to mental health status such as loneliness, sleep quality, and self-harming behaviour.

Such data has made it possible to examine how population mental health has changed during the COVID-19 crisis, as well as to show which population groups have been more heavily affected. This is a welcome change, as availability of mental health status data was scarce prior to the pandemic (Hewlett and Moran, 2014[82]). Yet it will only be possible to see the long-term impacts of the COVID-19 crisis on mental health if countries strengthen and sustain these surveys and data collection efforts, including by integrating mental health questions within existing surveys. Through the Mental Health and Well-being Project, the OECD will work closely with national statistical offices to improve the availability of disaggregated data on mental health going forward.

There is also a shortage of trend data on public awareness and stigma surrounding mental health in OECD countries. Although most OECD countries reported having one or more national programmes on improving understanding of mental health and reducing stigma in the Mental Health Benchmarking Questionnaire, data on awareness and stigma is measured infrequently, with only a few exceptions, limiting the possibility for cross-country comparison (OECD, 2021[67]). In England (United Kingdom), the Time to Change campaign has collected data on attitudes on mental health regularly from 2016/2017 to 2020/2021, and found significant improvements in awareness and reductions in discrimination against people experiencing mental health issues (Time to Change, 2021[83]). Yet such country-specific data is not comparable with findings in other OECD countries, as each country has adopted different indicators of measurement. Meanwhile, although the data presented in Chapter 1 show that stigma surrounding mental health remained prevalent in many OECD countries in 2019, the data offer no insights into how levels of public awareness and stigma have changed over time.

Collecting evidence on changes in public awareness and stigma of mental health issues is crucial for at least two reasons. First, such evidence could be used to assess progress in tackling stigma and raising awareness of mental health, which in itself is highly valuable information for policy makers (OECD, 2021[67]). Second, since mental health surveys rely on self-reported data, increases in prevalence of self-reported symptoms of mental health conditions could be partially explained by a reduction of stigma. Such evidence is particularly important in the context of the COVID-19 crisis, as the widespread impacts of the crisis on mental health may have normalised discussions around mental health and resulted in increased public awareness, although evidence remains limited. In a survey commissioned by AXA and conducted in June 2020 on attitudes to mental health in 7 European OECD countries, 60% of respondents stated that their view on their own mental well-being had changed during the COVID-19 crisis (AXA, 2020[84]). It is only by accounting for and overcoming stigma that more robust data can be obtained on the prevalence of mental health conditions; data which reflect the true prevalence of mental health conditions and allow robust comparisons over time and between countries.

The COVID-19 crisis accelerated and amplified the ongoing digital transformation, resulting in significant changes in how we live, learn, and work, with significant implications for mental health. Stimulated by countries and employers putting in place facilitating measures, almost half of all employed persons reported teleworking at some point in 2020 in Australia, France and the United Kingdom (OECD, 2021[85]). In many cases, employees have been able to adapt rapidly, breaking perceptions about the ineffectiveness of teleworking, but for others, the transition has been more difficult. While evidence dating from before the COVID-19 crisis on the mental health impacts of teleworking compared to in-person work is mixed, concerns have been raised about evidence of longer and more irregular working hours, as well as the challenges associated with the blurring of boundaries between work and home (OECD, 2021[22]).

Tackling the mental health impact of teleworking has emerged as a priority for a number of OECD countries. While a majority of jobs are still difficult to perform from home (OECD, 2020[86]), surveys across a number of OECD countries also indicate that workers, executives, and employers would like to employ hybrid working arrangements that combine teleworking with in-person work beyond the pandemic (OECD, 2021[22]). There remains scope for further analysis on the implications of increased teleworking for mental health, and the changing organisation of work resulting from the broader digital transformation. Given the scale and speed of the digital transformation, even workers whose jobs cannot be performed from home may be affected, and the flexibility provided by telework may result in additional inequalities.

The shift to remote learning has also opened up long-term opportunities and consequences for how learning is organised and experienced. Remote learning may have implications for mental health practice and policy in schools, universities and other educational institutions, including adult learning organisations (OECD, 2020[87]). This may include, for example, changes in the nature of risks that may be associated with harms to mental health, such as cyberbullying and online harassment as outlined in Children & Young People’s Mental Health in the Digital Age (OECD, 2018[88]). Given the growing role played by the digital environment in daily lives and interactions, policies to ensure young people are able to safely and productively engage in the digital environment, such as those set out in the Recommendation of the Council on Children in the Digital Environment (OECD, 2021[89]), will be vital. Through such policies, countries will be able to realise the benefits and seize the opportunities offered by the digital transformation, including for young people experiencing mental health issues, while minimising the potential risks for mental health.

OECD countries are also looking to take advantage of the growth of digital mental health services, supports and tools. Digital mental health services – ranging from specialised services such as eCBT to lower-threshold services such as apps – were an area of rapid growth and expansion even before the COVID-19 crisis, and the importance of leveraging data and digital technologies to achieve health objectives was widely acknowledged (OECD, 2019[90]). As outlined in the Mental Health System Performance Benchmark, a key element of a future-focused and innovative approach to mental health policies is to embrace the possibilities offered by technological developments (OECD, 2021[67]). To ensure that the digitalisation of mental health services and supports benefits individuals of all backgrounds, policies to close inequalities in digital skills and access to internet and digital devices will also be vital.

Young people increasingly use digital platforms and tools, including social media and the Internet, yet assessing the impact of this trend on mental health is not straightforward. Almost 95% of 16-24 year-olds reported using the Internet every day or almost every day in 2019, and between 2012 and 2018, the time spent by 15-16 year-olds on the Internet outside of school rose by 50% (OECD, 2020[86]). While concerns have been raised about the mental health impacts of this transformation, existing research shows that the impact of digital technologies on mental health is mixed (OECD, 2018[88]). A meta-analysis on the mental health impacts of social media on 13-18 year-olds has also found that while there is a correlation between social media and mental health issues, the impacts are likely to depend also on the nature of use, with moderate use correlated with higher mental well-being (Keles, McCrae and Grealish, 2019[91]). The impact of factors that explain the heterogeneity of social media usage such as time spent, nature of use (e.g. comparing passive use of social media to use of social media for engagement), and addiction or dependence on social media should be examined in further detail.

As people across the world have limited physical contact to limit the spread of the coronavirus, loneliness has been a subject of public conversation, and emerged as a renewed policy priority across many OECD countries. In the EU, for example, the proportion of people reporting feeling lonely ‘more than half the time’ in the early months of the pandemic (25%) was more than double the proportion reporting the same feeling in 2016 (Baarck et al., 2021[6]). As loneliness – defined as the gap between desired and actual degree of social connectedness – is a risk factor for a range of health issues including mental health conditions such as anxiety and depression (Beutel et al., 2017[5]), interventions that tackle loneliness can play an important role in preventing the development of mental health issues. Such interventions should thus be seen as a key pillar of integrated mental health policies going forward.

Policies to address loneliness should recognise that loneliness affects all age groups. While it is a commonly held belief that older age groups are at highest risk of loneliness, this is not necessarily the case. Loneliness appears to peak at two different life stages, namely youth and early adulthood, and very old age (80+ age group) (Qualter et al., 2015[92]). The drivers of loneliness also differ significantly across age groups (Jopling and Sserwanja, 2016[93]). Loneliness among young people is often driven by challenges of establishing one’s identity, as well as the school-to-work transition, which typically involves displacement from established social networks. By comparison, loneliness among older age groups is primarily driven by factors such as the loss of partners and friends and reduced mobility resulting from health conditions (Qualter et al., 2015[92]). As expanded on in All the lonely people: Education and loneliness, schools play an important role in protecting against loneliness at young age, as well as in developing socio-emotional skills that can help combat loneliness (OECD, 2021[94]). Loneliness among older adults is better understood, yet there is a shortage of research and knowledge on loneliness for all age groups, and especially for young people (Eccles and Qualter, 2020[95]).

A number of OECD countries are newly prioritising addressing loneliness amidst the COVID-19 pandemic and increasing international co-operation. Before the pandemic, loneliness measures were largely implemented at the local level, and could be broadly divided between community support programmes that treat loneliness as a public concern, and individual measures focused on addressing the psychological impacts of loneliness (Baarck et al., 2021[6]). The United Kingdom launched its Let’s Talk Loneliness campaign in April 2020 to tackle loneliness and social isolation during the pandemic through a GBP 750 million funding package and the establishment of a network on tackling loneliness involving more than 70 organisations (Macdonald and Kulakiewicz, 2021[96]). Japan appointed a Minister of Loneliness in February 2021, driven in part by a spike in suicide rates among young people and women, and outlined the direction for measures to address loneliness and social isolation in its Basic Policies on Economic and Fiscal Management and Reform 2021. In summer 2021, Japan also signed agreements with both the European Commission and the United Kingdom to raise awareness of loneliness in the global community and share knowledge and best practices on policy interventions going forward (European Commission, 2021[97]; UK Government, 2021[98]).


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← 1. The definition of 15-29 year-olds as “young people” is consistent with the definition used in the updated Youth Action Plan, and is mentioned here without prejudice to other definitions used by OECD member countries. It is understood as the age range at which young people experience “youth”, which resembles the period of transition from childhood into adulthood. The lower age limit of 15 falls under the age range at which compulsory education typically ends, and the upper age limit of 29 reflects socio-economic trends of recent generations of young people continuing education for longer, entering the labour market later, and marriage and parenthood occurring at an older age. Where possible, evidence cited on the mental health of young people looks at 15-29 year-olds, but this is limited by differences in categorisation of age ranges by countries. Data on young people cited in this chapter therefore ranges from 15-24 year-olds for the European Health Interview Survey to 18-39 year-olds for the COVID-19 National Dashboard in Canada. Different instruments to those cited in this chapter (PHQ-8, GAD-7 and PHQ-4) are also often used to examine the mental health of children under the age of 15.

← 2. The term “visible minority” is widely used in Canada, including by Statistics Canada, and is defined under the Employment Equity Act as “persons, other than Aboriginal peoples, who are non-Caucasian in race or non-white in colour” (Statistics Canada, 2021[99]).

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