A hidden crisis: Women’s mental health after the pandemic

The devastation caused by the SARS-CoV-2 (Covid-19) pandemic was – in our lifetime – unrivalled, and coupled with fear that such health system shocks may become a more regular feature of human life. Whilst researchers and governments across the globe rally to assess the damage through important statistics such as morbidity and mortality, we are unlikely to ever know the true figure of the losses caused by or attributed to Covid-19, and the associated changes to human life we had to endure.

The Covid response across the majority of the world has been – and some would argue, had to be – based on a medical model of immunity and infection, thus directly targeting the physical health of the global population. Physical and social distancing measures, including Government-mandated 'lockdowns' in many countries, were coupled with the roll-out of vaccinations and boosters. The issue with this, like with many health-related tactics which take a unidimensional approach, is that mental health has been sidelined, as something which could be picked up in the aftermath rather than dealt with immediately.

This balance was a difficult one – and no one should be suggesting blame rests with the healthcare professionals and policymakers who worked tirelessly, whilst putting themselves at great personal risk, to continue delivering both physical and mental healthcare services to those in need. 

However, there has to be an admission that many governments across the world simply mishandled the response, often to the detriment of the mental health of their nations' populous. This was especially true for governments if they found it difficult to 'reduce entropy and exact certitude' with regard to healthcare policy and interventions (Lee et al., 2021; p.367).

As early as May 2020, Director-General of the World Health Organization Tedros Adhanom Ghebreyesus warned in his World Psychiatry editorial of a potential second pandemic of mental health problems for people across the globe who were adversely affected – directly and indirectly – by the virus. An early rapid review of quarantine literature, published in The Lancet, advised that the psychological impact of 'lockdown' measures could be 'wide-ranging, substantial, and can be long lasting'. 

The paper argued that although quarantine measures should be part of a considered and robust response to any pandemic-style virus, if they were handled poorly or the outcomes were perceived to be or were indeed demonstrably poor, there might well be 'long-term consequences that affect not just the people quarantined but also the health-care system that administered the quarantine and the politicians and public health officials who mandated it' (Brooks et al., 2020; p.919).

As a psychology researcher specialising in mental health over the lifecourse, who has undertaken a considerable amount of research around Covid-19, I will argue here that whilst the concern and commitment for both physical and mental health was there, the policy and practice were either missing, not implemented, or misguided in terms of what they aimed to achieve when it came to mental health and psychological well-being.

The evidence suggests that even in countries where there have been concerted efforts (such as in the UK), mental health provision continues to lag and outcomes remain poor (Mitchell et al., 2018) – particularly for those who are worst affected and those with high levels of social complexity, deprivation, or inequity.

One such group who is usually disproportionately affected by health system shocks –natural disasters, systemic catastrophic failures, or human intervention – is women.

Women and the pandemic

Whilst we recognise some advancement in equality between the sexes, women are more often responsible for both contributing to the familial finances, but also having more responsibility for the home, children and families, and the social life of the unit – be that just between partners or for a family with children. This positions women as remaining 'time bound' – they have to account for their hours spent on different aspects of their daily life more than their male counterparts (Hochschild & Machung, 1989), with days comprising of 'shifts'.

These shifts changed through pandemic circumstances. The First Shift – Paid employment – often meant a transition to working from home. The Second Shift – Providing care to their children and spouse or partner – meant not having time away from the family home. The Third Shift – Managing family social responsibilities – often meant home-schooling and video-socialising their children, whilst also checking in on (potentially vulnerable) colleagues, friends, neighbours, and/or relatives. Given the circumstances of the pandemic, it is easy to conceptualise a Fourth Shift – Healthcare-giving responsibilities to those in their familial nucleus (or wider social circle) who became ill due to the virus.

The burden upon women during the pandemic can therefore be seen to have been increased by the re-orientation of daily life to the home, and restrictions placed on accessing wider social support they may have otherwise relied upon. Moreover, the inability to move out of the home was raised as an issue early on into the pandemic with respect to domestic abuse and violence, leading to decreased reporting despite increased incidence during the course of the pandemic (Kourti et al., 2023).

The over-arching result of both thought and empirical evidence – reported and synthesised – is that women, often due to the restriction to free movement during the pandemic, were subject to 'accentuated disparity' related to gender, especially in the cases of those who worked, provided care, and/or were lone parents, suffered from social complexity, or lived with one or more disabilities (Almeida et al., 2020).

One population amongst women who were still able to be in contact with healthcare services was those who were pregnant at the time of the pandemic. Although they experienced changes to their care, the birth of 'Pandemi-Kids' or 'Covid-ials' could not be delayed in the same way as (non-emergency) routine operations could, and so women and birthing people were able to leave the home to access antenatal, intrapartum, and postnatal care – albeit in somewhat restricted form. 

These restrictions to maternal health services were, in and of themselves, cause for some women to birth outside of the system (Greenfield et al., 2021), particularly in response to the injustices they perceived when the rest of the population was subject to relaxed social and physical distancing policies, and yet maternity settings continued to impose tight restrictions (Silverio et al., 2024).

Perinatal women therefore found themselves with a 'triple burden' of protecting themselves and their baby from the virus, navigating healthcare services which had increased restrictions, and the decision-making process of when and whether to be vaccinated (Silverio et al., 2024). A resounding finding from much of the mental health research undertaken with this population during the pandemic is that perinatal mental health suffered due to the circumstances, the lack of provision of care, and the general uncertainty the pandemic brought with it (Jackson et al., 2024).

New problems mean new burdens

Emerging research suggests the additional burden of the pandemic fell incumbent on women to absorb. However, it is, of course, important to also address women's mental health outside of the relationship with the family or the perinatal period. Too often, we see 'women's mental health' held synonymously with 'perinatal mental health', which presents a flawed logic and does not account for the lifecourse mental health of women outside of their (re)productive role (Silverio, 2021).

For those in work, 'a series of new telematic violence against women' (de Gennaro et al., 2022; p.1373) occurred, encompassing 'disproportionate financial, physical and emotional struggles' culminating in 'a "shadow pandemic" with medical, economic, and social resources and infrastructure urgently needed' (Özkazanç-Pan & Pullen, 2020; p.675). For older women, keeping busy, sometimes at the detriment or risk to their own physical health, was seen as a key route for protecting mental wellbeing (Forward et al., 2023).

Older women of the Global North who continued to engage in communication, new activities, and philanthropy were less likely to experience emotional and/or psychological distress (VoPham et al., 2022). These findings contrast with those from the Global South, where research has shown that older women took on primary roles at home, in the workplace, and within the broader economic framework during the pandemic. They acted as caregivers, leaders, and mourners; navigating not only their families, but also their social and occupational networks through these unprecedented and challenging times, often with little consideration given to the impact on their mental well-being (Chatterjee et al., 2022).

And of course, we must not forget the women who mourned through the pandemic, be they mothers suffering a pregnancy loss or whose babies had died (Silverio et al., 2021; 2024); frontline healthcare professionals whose patients died as a result of the virus (Cabarkapa et al., 2020); those who lost family members (Beigler et al., 2023); or those who became widows over the course of the pandemic (Wang et al., 2022). Grief resulting from the enormity of loss associated with the pandemic remains ambiguous (Santikarma & Wagner, 2024), complicated (Khoury et al., 2022), and has lingered well beyond the official declassification of pandemic status.

The (post-pandemic) future of women's mental health

Growth must follow a trauma in order for an entity to not dwell in the despair. Growth, however, often requires support, care, wisdom, and guidance for it to occur in a way in which it can then be sustained. Given the differing ways in which the pandemic has affected women across the globe, it is imperative for countries and international policymakers to consider the gaps in health and social care provisions across different regions, as well as the expectations placed on women within different cultural backgrounds. 

The need will be greater in some places than in others, but we must also not turn a blind eye to the new abuses which have emanated from pandemic circumstances – such as the pervasiveness of domestic abuse (Thubaut & van Wijngaarden-Cremers, 2020), sharp increases in suicidality (Giménez-Llort et al., 2022), new forms of work-based violence (Gennaro et al., 2022), and enforced reproductive injustices (Greenfield et al., 2021; Silverio et al., 2024).

This is why the response from the UK's psychological community has, for me, been so disappointing. It has relied on outdated assumptions that: a) attempting to change behaviour actually changes behaviour, and, more importantly, b) that these behaviour-change interventions genuinely and directly improve mental health. This is once again falling into the trap of applying a 'blanket rule' to a complex issue – no better than the blanket rulings of 'social distancing', of 'lockdown', and of 'mandatory vaccination', all of which were proven too narrow in their scope to solve the nuanced issues arising as a result of the pandemic.

The British Psychological Society's Senate was recently briefed by eminent Psychologists from across the UK, where the emphasis was on behaviour change in order to become 'Covid Safe' (The British Psychological Society, 2024; and see also this issue). The fact of the matter is, that we will never be 'safe' from a pandemic. We can only work to reduce the impact of it on the populous. Providing the population with the false hope that they can be 'safe' from a pandemic if they do certain behaviours is not only grossly misleading, it borders on dangerous. 

It also juxtaposes behaviours as those which are 'safe' and those which are 'unsafe', therefore providing the opportunity for people to pit against one another. The definition of 'safe' when used in this context is also far too narrow: it equates 'safety' with 'not dying'; which will inevitably cause confusion when those who undertake those supposedly 'safe' actions are in fact afflicted by a pandemic such as Covid-19, or even die because of it.

Whilst I appreciate there is more than just perinatal women's mental health to consider, if we take perinatal women as a point of focus: The future of maternity care, particularly in the UK, remains uncertain for a multitude of reasons, including not only the pandemic, but grave workforce issues precipitated by an NHS system working at full-tilt, 'Brexit' leading to masses of staff leaving the NHS, and attractive offers from foreign climes now willing to accept UK-training standards. 

Work is underway to deliver a new roadmap for more equitable maternal healthcare services (Silverio, Dasgupta, et al., 2024). However, this is a population whose mental health, we know, benefits from specific and targeted interventions based on experiential evidence provided by the woman herself (Alderdice, 2020); and we have evidence suggesting behavioural interventions extrapolated from algorithms and general population studies are ineffective and have little meaningful effect (Locke, 2023).

Cultural competence and humility

With respect to women's mental health, there have long been calls for a more nuanced approach, arguing for understanding overdiagnosis (Ussher, 2010); a negotiated and tailored mental healthcare service (Slade, 2017) – which treats at an individual level and accounts for sex and gender (Pattyn et al., 2015); and for parity of representation between men and women in research – both as participants and as the researchers conducting it (Howard et al., 2017). 

The whole system therefore must be culturally competent and engage with cultural humility (Greene-Morton & Minkler, 2020); iteratively monitoring the presentation and course of mental health amongst the populus, taking 'affirmative action'. This can be defined as 'positive acts to increase the representation of women and other minorities in areas from which they have been historically excluded, under-represented, or misrepresented' (see also Lippert-Rasmussen, 2020) – to ensure the best possible support, care, outcomes, and prognoses, as defined by women themselves and not enforced upon them (Silverio, 2021).

Ultimately, we know the theory of how to improve women's mental health already, and it does not lie with 'one size fits all' behaviour change techniques. We must instead allow women to narrate their own understanding and experiences of psychological health; by taking time to understand what causes poor mental health, and likewise what might improve women's psychic resistance, by finding what can help to resolve women's psycho-emotional conflict.

In taking this approach, we have a better chance of avoiding a second, unprecedented (and unnecessary) pandemic in women's mental health, whilst building both stability from which women can grow and plasticity with which women's mental health can flourish. In this way, women's mental health can absorb the shocks associated with such global health crises, as they climb out of this pandemic as the most injured party, and prepare for a future where pandemics are not only possible but probably commonplace. 

If we abandon our seemingly compulsive desire to rely on thinly evidenced behaviour change tropes and provide women-centred care, compassion, and support, women can still be – as they were through Covid – a central tenet of strength for their families, those around them, and society itself.

Sergio A. Silverio is a Chartered Psychologist, and Lecturer in Medical Psychology & Lifecourse Health at the University of Liverpool and a Research Fellow in Social Science of Women's Health at King's College London
[email protected] 

Acknowledgements

I would like to extend my sincere thanks to Elana Payne (King's College London) for her critical reading and careful editing of an earlier draft of this manuscript.   

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