Building back equitably: 4 ways to address mental health inequities magnified by the pandemic, and ensure access to care

You don’t need statistics to appreciate the profound effects that COVID-19 restrictions limiting social connections and access to services have had on our collective mental health. And yet, statistics — paired with qualitative data that offer in-depth descriptions of what people are experiencing — are essential for monitoring improvements, or lack thereof, during the process of recovery from the past two years of cumulative stress.

However, aggregate trends (which combine data from all members of a population) can be misleading. Even worse, they can exacerbate inequities by giving the erroneous impression that the data apply to everyone in the same way.

For example, Statistics Canada recently reported a general worsening in self-rated mental health among Canadians. Sixty per cent rated their mental health highly in fall 2020, decreasing to 52 per cent in spring 2021. However, this trend was more pronounced among some population sub-groups. In young adults (18-34 years) the proportion rating their mental health highly dropped from 51 per cent in fall 2020 to 33 per cent in spring 2021.

Understanding how to build back equitably after the pandemic requires gathering the appropriate data and being responsive to the groups who were hardest hit by pandemic-related distress.

Responding to an ‘echo pandemic’

In the first year of the pandemic, as public health equity researchers, we anticipated a need for mental health data. Health-care leaders, policy-makers, politicians and members of the public would need access to rigorous data collected over time to monitor and respond to the mental health of groups that are unjustly disadvantaged by the pandemic in Canada.

The Canadian Mental Health Association has warned of an “echo pandemic”: a wave of intensifying mental health concerns caused by pandemic-related stress, including uncertainty, social isolation, unemployment and loss of services.

To better understand and track the differential effects of these pandemic realities, we established the B.C. Alliance for Monitoring Mental Health Equity. Using a newly developed web platform, we host findings from 15+ research studies featuring data from British Columbia, and in some cases, complementary data from the rest of Canada and international locations.

We are committed to reducing and ultimately eliminating avoidable differences in mental health status by social positions and identities. For that reason, we prioritize research that centres socially defined population sub-groups such as those who are two-spirit, lesbian, gay, bisexual, transgender and queer (2S/LGBTQ), Indigenous, Black and people of colour, young or living in low-income households.

Centring in the margins

We are inspired by activist and writer bell hooks’s call to “center in the margins,” meaning to focus first on those who have experienced the greatest social marginalization. From several studies in Canada and elsewhere, we now know that over the past two years, 2S/LGBTQ people have experienced a disproportionate worsening of mental health related to the pandemic. A similar growing disparity in mental health has been observed for those experiencing personal financial strain and those with pre-existing mental health conditions, or a combination of these factors.

A few common threads can help explain the disproportionate effect of the pandemic on these population sub-groups.

First, members of these groups may be particularly affected by social isolation. For example, before COVID-19, we knew that many 2S/LGBTQ people — who are less likely to be partnered, more likely to be living alone — experienced reduced social networks due to stigma and exclusion. During the pandemic, these networks have shrunk further, limiting the social connections that can help buffer against pandemic-related stressors.

Second, the restrictions in access to in-person appointments had a greater impact on those who routinely relied on mental health supports, including those with pre-existing mental illnesses. Before the pandemic, there was already a large gap in access to adequate mental health care. COVID-19-related service restrictions left those with chronic mental health conditions — who already experience significant stigma and discrimination — with profound barriers to care, often at the same time that their mental health symptoms were worsening.

Building back equitably

Working from the local, equity-informed data compiled by members of the alliance, we offer four urgent calls to action, with further recommendations available on our website.

1. Improve funding and programs in accessible mental health services that are tailored to reduce barriers for equity-deserving groups.

2. Adopt a population approach to mental health, with the goal of improving mental health across populations. This approach would include promotion (to build contributors to positive mental health), as well as prevention to reduce mental ill health, and treatment for those with a mental health diagnosis.

3. Strengthen mental health screening and referral pathways in primary care settings (for example, family practitioners and walk-in clinics) and support rapid access to followup for those who need it.

4. Develop guidelines to support digital mental health care solutions such as web-based resources and virtual access to care providers. These solutions must be accessible, supported by evidence, and equity-oriented.

Decisions that policy-makers make right now will determine how we, as a society, recover and build back mental health in the years to come. With equitable investments in mental health promotion, prevention and treatment, we can redress unjust differences in our population’s mental health and work to ensure that good mental health is an achievable goal for all.

Travis Salway receives funding from the Canadian Institutes of Health Research, the Social Sciences and Humanities Research Council, Michael Smith Health Research BC, the BC SUPPORT Unit Fraser Centre, SFU's Community-Engaged Research Initiative, and Victoria Foundation (donation from Andrew Beckerman).

Emily Jenkins, Hasina Samji, and Pierre-julien Coulaud do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.