Social determinants of mental health and the COVID-19 pandemic in low-income and middle-income countries

Together with non-communicable diseases, the COVID-19 pandemic has become a syndemic, especially in the most vulnerable or excluded groups.1Horton R Offline: COVID-19 is not a pandemic.Lancet. 2020; 396: 874Summary Full Text Full Text PDF PubMed Scopus (579) Google Scholar Women with young children are one such group, since they are at a greater risk of meeting the criteria for a mental disorder or psychological distress. Psychological distress is highly sensitive to social inequalities and therefore cannot be entirely medicalised.2Shim RS Mental health inequities in the context of COVID-19.JAMA Netw Open. 2020; 3e2020104Crossref PubMed Scopus (32) Google Scholar In their cohort study in The Lancet Global Health, Andrés Moya and colleagues3Moya A Serneels P Desrosiers A Reyes V Torres MJ Lieberman A The COVID-19 pandemic and maternal mental health in a fragile and conflict-affected setting in Tumaco, Colombia: a cohort study.Lancet Glob Health. 2021; (published online June 24.)https://doi.org/10.1016/S2214-109X(21)00217-5Summary Full Text Full Text PDF PubMed Scopus (18) Google Scholar show the effect of the pandemic on the emotional wellbeing of a large sample of displaced caregivers from Tumaco, a small Colombian city with high rates of social inequalities. The majority of the population is Afro-Colombian, and the city was historically abandoned by the Colombian State, leaving weak infrastructure and high rates of unemployment and poverty. People internally displaced by conflict also face social stigmatisation.4Campo-Arias A Herazo E Stigma and mental health in victims of Colombia's internal armed conflict in situation of forced displacement.Rev Colomb Psiquiatr. 2014; 43: 212-217Crossref PubMed Scopus (23) Google Scholar Moya and colleagues found substantial increases in anxiety, depression, and parenting stress after the onset of the pandemic among fragile and conflict-affected mothers with young children in Tumaco, Colombia. The negative effect on the scores for anxiety and depression in mothers in a displacement situation shows the need to provide further relevance to social stressors as a determinant of mental health. However, it is necessary to consider that parental stress is one of the cognitive manifestations of anxiety or depression in mothers who care for one or more children. An investigation before the COVID-19 pandemic observed a statistically significant correlation between anxiety, depression, and parental stress.5Golombok S Zadeh S Freeman T Lysons J Foley S Single mothers by choice: parenting and child adjustment in middle childhood.J Fam Psychol. 2021; 35: 192-202Crossref PubMed Scopus (15) Google Scholar In addition, research on populations in vulnerable situations should evaluate beyond a list of symptoms with a measurement scale. It is necessary to bear in mind that the frequency of mental disorders is markedly reduced when symptoms are evaluated with structured clinical interviews. The clinical evaluation must fully consider social stressors to demedicalise the adversities inherent to inequity.6Hyman DA The medicalisation of poverty: a dose of theory.J Law Med Ethics. 2018; 46: 582-587Crossref PubMed Scopus (4) Google Scholar The interpretation of the findings should consider the displacement situation and all the associated adversities or stressors. The difference in symptom quantification technique must be considered; the telephone interview might induce some bias in anxiety, depression, and parental stress scores. Likewise, being a participant in a previous programme to improve psychological wellbeing and parenting skills might induce another bias since it represents a form of social support or accompaniment during a time of crisis.7Grimes DA Schulz KF Bias and causal associations in observational research.Lancet. 2002; 359: 248-252Summary Full Text Full Text PDF PubMed Scopus (974) Google Scholar Based on social stress theory, people in a socially disadvantaged situation have more stressors and an increased vulnerability to stress due to scarce psychosocial resources and risk of psychological distress or mental disorder. However, having resilience measurements for these situations would be useful. High resilience is a protective factor against new stressful situations. Resilience is enormous in populations in situations of inequity. Acute stressors, such as those associated with the COVID-19 pandemic, could affect psychological wellbeing less than chronic stressors, such as those associated with poverty, given the outstanding construction of resilience based on personal strengths, family, and community.1Horton R Offline: COVID-19 is not a pandemic.Lancet. 2020; 396: 874Summary Full Text Full Text PDF PubMed Scopus (579) Google Scholar, 2Shim RS Mental health inequities in the context of COVID-19.JAMA Netw Open. 2020; 3e2020104Crossref PubMed Scopus (32) Google Scholar, 8Akesson B Sousa C Parental suffering and resilience among recently displaced Syrian refugees in Lebanon.J Child Fam Stud. 2020; 29: 1264-1273Crossref Scopus (10) Google Scholar Worldwide, the effect of the pandemic on people in vulnerable situations has been largely forgotten. It is necessary to pay more attention to populations in vulnerable situations, particularly those who simultaneously face different stressors due to the high risk of psychological distress and of meeting the criteria for a mental disorder.2Shim RS Mental health inequities in the context of COVID-19.JAMA Netw Open. 2020; 3e2020104Crossref PubMed Scopus (32) Google Scholar A situation that further increases the possibility of stigmatisation and continuing in a spiral of adversity perpetuates poverty conditions. Poverty is a vital stressor in which a substantial number of threats and unmet needs converge.1Horton R Offline: COVID-19 is not a pandemic.Lancet. 2020; 396: 874Summary Full Text Full Text PDF PubMed Scopus (579) Google Scholar These groups require a broader approach to analyse variables associated with mental health and, consequently, specific approach strategies. The COVID-19 pandemic has sharply revealed the inequalities that already exist in Latin America in terms of gender, ethnic or racial origin, socioeconomic status, internal displacement, and migratory status.9Martínez-Salgado M Ferraris S Género y trabajo. El sostenimiento económico de los hogares en México.Rev Latinoam Pobl. 2020; 15: 179-204Crossref Google Scholar Yet the situation of poverty is the most potent syndemic that undermines mental health in the short and long term. Therefore, public mental health policy must be comprehensive, intersectoral, and cross-sectoral, and consider many health-related factors beyond simple individual aspects and health systems. Social and political conditions might be more relevant than individual characteristics in the traditional hegemonic vision of wellbeing or mental health.10Bernardini F Attademo L Rotter M Compton MT Social determinants of mental health as mediators and moderators of the mental health impacts of the COVID-19 pandemic.Psychiatric Serv. 2021; (published online Feb 17.)https://doi.org/10.1176/appi.ps.202000393Crossref PubMed Scopus (31) Google Scholar We declare no competing interests. AC-A received funding from Universidad del Magdalena, Santa Marta, Colombia. The COVID-19 pandemic and maternal mental health in a fragile and conflict-affected setting in Tumaco, Colombia: a cohort studyMaternal mental health significantly worsened during the early stages of the pandemic. Considering the vulnerability and pre-existing mental health conditions of this population, the estimated effects are substantial. Policies in fragile and conflict-affected settings targeting IDP and other vulnerable people will be important to mitigate further mental health and socioeconomic problems.