The expectations of significant increases in the prevalence of mental health conditions following the covid-19 pandemic have been confirmed globally, in particular for common mental health problems such as depression and anxiety. Some of these consequences were already evident during the first year after the outbreak, such as health anxiety in relation to contagion and chronic concern about the disease, or trauma-related mental health disorders among front-line healthcare professionals that were involved in traumatic situations. Still, the largest increases in mental health conditions were predicted in the middle and long term in association with sustained high levels of stress and uncertainty that are known to accompany health. Pre-existing problems may also worsen a person’s response to an unstable social situation, and those with pre-pandemic mental health diagnoses were at higher risk of severe symptoms of covid-19 and mortality by SARS-CoV-2. 

In light of these considerations, the authors set up a large population-based study on adult participants in Catalonia, Spain. The study was designed to prospectively assess mental health in the post-confinement period. Pre-pandemic electronic health records from public health care registers served as baseline data and allowed a comprehensive description of previous mental health diagnosis and treatment. 

After the first outbreak of the covid-19 pandemic in Catalonia in March 2020, participants were re-contacted, and mental health state data was collected between May and October 2020. This dataset made it possible to describe mental health in the Catalan general population immediately after the first outbreak of the covid-19 pandemic and subsequent lockdown, whose most restrictive phase lasted until the end of April 2020. Participants were again re-contacted in 2021 for follow-up. This report offers the results of the 2021 assessment, which included 7,255 participants. A third wave of assessment is running in 2023.

In 2021, over 7% of the participants presented severe symptoms of depression, and over 12%, severe symptoms of anxiety. Participants with a pre-pandemic mental health diagnosis were overrepresented among the participants with severe depression and severe anxiety groups, as were women, participants aged 49 or below, those with a lower level of education, and those with a diagnosis of covid-19. These proportions were somewhat higher than those found for 2020: 5.9% for severe depression and 11.8% for severe anxiety. Only in Catalonia, the post-pandemic prevalence in the total adult population was 305,207 cases of severe depression and 653,229 cases of severe anxiety. 

In 2021, 2% of participants who had reported no depression in 2020 presented severe depression, and 12.9% declared moderate depression symptoms. In turn, 17% of the participants who had reported severe symptoms of depression in 2020 showed no indicators of depression one year later. Approximately half of participants with severe depression in 2020 remained in that state in 2021, and over 85% of participants with no depression in 2020 remained not depressed in 2021. 

Results for anxiety were similar, although the proportion of participants with no anxiety during 2020 who remained not anxious in 2021 was lower compared to depression rates (76% for anxiety, 85% for depression). Around half of those reporting severe anxiety in 2020 remained in this severe state in 2021. 

A screening question was used to identify experiences of traumatic events : “Since the start of the pandemic in March 2020, have you experienced events that you considered to be very stressful or traumatic?”. Of the total number of participants, 521 (7.2%) responded “yes” to this question. Subsequently, symptoms of post-traumatic stress disorder (PTSD) were explored among those who identified exposure to a traumatic event. Over 30% of these participants presented clinically relevant symptoms of PTSD, such as re-living the traumatic experience, changing behavioural patterns to avoid reminders of the traumatic event, or experiencing changes in their relationships and mood due to such experiences. These participants represented 2.4% of the total sample. 

Policies and interventions aimed at mitigating the impact of covid-19 were implemented in 2020, but their effectiveness with regards to mental health impact remains unknown. In the study, participants were asked to describe their use of mental health services and to rate the quality of the assistance. Out of the total sample of 7,255 participants, 1,151 (15.9%) reported needing the help of mental health professionals since the start of the pandemic. Among those in need, only 23.9% accessed public mental health services, while 24.8% visited a private mental health specialist, and 51.3% did not consult any mental health service. The main reasons for not accessing mental health services were not knowing who to ask for help (30%), being afraid of confronting past situations (17%), and being afraid of getting infected with SARS-CoV-2 (3.6%). Nearly half of respondents (47%) cited non-specified other reasons. The mean score of the quality of the mental health services received was 6.3, on a scale from 0 to 10. 

The COVICAT/CONTENT study shows that it is urgent to raise awareness about the mental health consequences of the covid-19 pandemic and subsequent lockdown. The mental health consequences of the pandemic were evident in the short term. Now it is obvious that these effects have lasted for at least one year and have affected multiple aspects of mental health. Severe cases require clinical assistance, and an increase in rates of severe depression, anxiety, and PTSD increases the burden of an already overstretched healthcare system. Mental health conditions have long latency periods, so preparedness strategies need to consider not only the emergency responses they require, but also the long-term effects they may have.