Pre-existing social inequalities have contributed to increased COVID-19 cases and significantly greater exposure to the negative effects of COVID-19 containment measures in marginalized populations. A discussion in Psychiatric Services in Advance highlights these disparities and offers actions that can be taken to reduce social inequalities and, in turn, better support the mental health of persons belonging to marginalized groups.
The research was led by the psychiatrist Franceso Bernardini from the University of Perugia, Perugia. Bernardini and his colleagues write:
“. . . the relevance and impact of the social determinants of health and mental health have been tragically demonstrated yet again by the disparate impacts of the COVID-19 pandemic, and many people are aware of the prominent inequities that have been revealed afresh by the pandemic.”
Social determinants negatively affect the physical and mental health of those exposed to them. Exposure to adverse events and living situations, such as conflict, violence, housing instability or homelessness, food insecurity, lack of access to health care and/or transportation, systemic inequalities, and more, have been identified by the World Health Organization (WHO) as social determinants of health.
Increased exposure to these social determinants and others, such as the increased likelihood of underlying health conditions, living in areas that make social distancing difficult or impossible, or working in job positions that are unable to be completed from home and require the use of public transportation, have been offered to explain the disproportionate amount of COVID-19 cases and deaths in racial and ethnic minorities in the United States.
Additionally, although necessary to contain the spread of the virus, measures like gathering restrictions, social distancing, and social isolation have both contributed to and worsened mental health issues like persistent stress, substance use, experiences of depression including suicidal thoughts and behaviors, anxious symptoms, and worries about health. Containment measures have also resulted in the increasing presence of social determinants like childhood exposure to adverse experiences, unemployment or underemployment, and food insecurity, all of which contribute to poor mental health.
Further, preexisting exposure to social determinants and social injustices leaves marginalized individuals at the greatest risk for negative mental health outcomes and overall exposure to the virus. Oppressed and marginalized individuals like racial and ethnic minorities, poor populations, persons with “serious mental illness” (who are often prescribed dangerous medications like antipsychotics, which have been linked to severe COVID-19 cases), among others, are caught in a bind where they are increasingly exposed to the damaging effects of COVID due to their marginalized status, which in turn exacerbates the social determinants that lead to poor physical and mental health.
The authors write:
“A damaging feedback loop has been created: each of the social determinants of health and mental health contributes to the disparate prevalence and severity of COVID-19 among marginalized and disenfranchised populations. In turn, the disparate prevalence of COVID-19 contributes to the worsening of the very social determinants that affect mental health.”
The COVID-19 pandemic has revealed how unprepared public systems are to handle a crisis of this magnitude, even in the wealthiest of countries – who lacked the appropriate equipment and coordinated efforts to stem and treat the virus.
The authors call attention to social norms, or “informal agreements that govern the behavior of members of a society,” that maintain social injustices in the United States, bringing to light the high level of infection among undervalued and underpaid workers, who are now deemed “essential,” yet are not compensated or treated by society as such. Moreover, the pandemic has shined a spotlight on how centuries of racial inequalities, discrimination, and violence, are linked to significantly higher COVID-19 cases and deaths among racial and ethnic minority populations.
Bernardini and colleagues also highlight that surges in COVID-19 cases were not limited to only marginalized populations, pointing to the example of the wealthy region of Lombardy, Italy, as being particularly hard-hit by the pandemic. They suggest that perhaps delayed lockdowns despite the spread of the virus and high air pollution levels contributed to significant numbers of cases in this region. Although Southern Italy was spared the immediate destruction of COVID, the authors suggest that it may be more negatively impacted in the long-term due to preexisting economic issues present in the South.
The authors emphasize the role that healthcare professionals can play in pushing for social reform. Elsewhere, others have offered recommendations regarding how to reduce some of the negative effects of COVID-19 lockdowns on children. Others have made suggestions about how to alter research with marginalized populations during the COVID-19 pandemic in such a way that ensures that these individuals are still represented and able to participate.
The authors conclude:
“The pervasiveness and severity of the pandemic, and its disparate population-level effects, require ongoing, urgent attention from public health authorities and organizations worldwide, including psychiatric organizations, in support of health-promoting public policies and social norms to reduce inequities and address the social determinants of general medical and mental health.”
Bernardini, F., Attademo, L., Rotter, M., & Compton, M. T. (2021). Social determinants of mental health as mediators and moderators of the mental health impacts of the COVID-19 pandemic. Psychiatric Services in Advance. DOI: 10.1176/appi.ps.202000393 (Link)