Easing the disruption of COVID-19: supporting the mental health of the people of Canada—October 2020—an RSC Policy Briefing

The COVID-19 pandemic has created unprecedented upheaval for people in Canada and around the world. Millions have been confined to their homes, many having to work from home, others have lost their jobs, and many are worried about future employment. Parents of children have the demanding and unfamiliar responsibility of home-schooling their children, often while also working from home, as schools closed. Residents of long-term care facilities have been at high risk for infection and death and have been denied vital family visits. During self-isolation, some people in the community have been trapped at home in coercive or abusive situations. A number have lost loved ones to COVID-19 and been unable to engage in normal grieving rituals. Many frontline workers including personal care workers, nurses, and doctors in Emergency Departments; delivery drivers and retail clerks; and first responders have been exposed to extreme and often unremitting stress, leading to mental distress, anxiety, and traumatic stress symptoms. Many people in the community experienced symptoms and anxiously awaited test results, fearing for their own health and those they have come in contact with. Some have been diagnosed, some hospitalized, some admitted to intensive care units (ICUs) with COVID-19, and some have died.

All people in Canada have experienced thousands of health warnings, the uncertainty of changing requirements and public health measures, increased fears, and the disruptions of our social and work lives. As in previous pandemics (Taylor 2019), there has been a widespread increase in distress (Taylor et al. 2020a, 2020b, 2020c, 2020d). The Conference Board of Canada and the Mental Health Commission of Canada (2020), in a survey conducted between 27 April and 15 May 2020, found that 84% reported that their mental health had declined during the pandemic. The biggest concerns were family well-being, one’s future, isolation and loneliness, and anxiety and fear. There also appears to be an increase in mental health disorders including anxiety disorders, mood disorders, substance-use disorders, and traumatic stress for an important but as yet unknown percentage of people in Canada. Different surveys (CAMH 2020; Taylor et al. 2020a, 2020b) have described how about 20%–25% of people in Canada are experiencing moderate or severe COVID-19-related mental health problems. Emerging evidence indicates that people with pre-existing anxiety disorders may be more adversely impacted by COVID-19 than those with mood disorders or no mental health diagnoses (Asmundson et al. 2020).

A Nanos poll for the Canadian Centre on Substance Use and Addiction (Nanos/Canadian Centre on Substance Use and Addiction 2020) showed that about 20% have increased their use of alcohol as a result of the pandemic. Evidence from previous pandemics, and current evidence from other countries who are farther advanced in the chronology of the pandemic, also suggests significant increases in mental health problems and that mental health impacts can persist far beyond the acute phase of the pandemic. Much of the international evidence on COVID-19 and its mental health effects can be instructive for Canada.

The pandemic has affected the mental well-being of people in Canada differentially, however. COVID-19 is not just an illness; it also intensifies social ills that have long created health inequities. The data on mental health effects from COVID-19 are quickly emerging, and related evidence suggests that those living in poverty and adverse social circumstances will be the most impacted. Moreover, those who have been subjected to previous adverse events, especially in childhood, are more at risk (Asmundson and Afifi 2019). Even prior to the current pandemic, people in the lowest income groups were 3 to 4 times more likely than those in the highest income group to report poor mental health (Public Health Agency of Canada 2018). Human Rights Watch (Carling and Mankani 2020) emphasizes that many First Nations communities don’t have clean water and suffer from overcrowding so that handwashing and social distancing are difficult. Similarly, individuals in the LGBTQ+ community and racialized individuals are often at higher risk of COVID-19. For example, in Toronto, persons who are White make up 48% of the population and only about 17% of those with COVID-19 (Toronto 2020). Chronic illness, homelessness, imprisonment, and poverty exacerbate the risk of severe illness from COVID-19. The DepressD Living Systematic Review of Mental Health in COVID-19 (DEPRESSD Project 2020) has found initial evidence of differential effects related to pre-existing inequities of COVID-19 on mental health around the world. Prior to the pandemic, Canada was facing a serious opioid epidemic that has only been made worse by the COVID-19 pandemic. Canada has seen an increase in fatal drug overdoses since the onset of the pandemic (Wood et al. 2020). The restrictions on travel and border closures have impacted illegal drug supply chains, which has resulted in the use of more dangerous substances and more efficient, yet riskier, routes of administration (Tsai and Wilson 2020). During the pandemic, there has also been an increased risk of drug withdrawal and related complications for homeless people who use substances and an increased risk of negative health consequences in this vulnerable group (UNODC 2020).

The mental health effects of COVID-19 have occurred in the context of mental health services suffering chronic underfunding. The Mental Health Commission of Canada has estimated the prevalence of significant mental health problems at about one in five and the cost to the Canadian economy of mental health problems at about $50 billion a year prior to the pandemic (Smetanin et al. 2011). The Mental Health Commission of Canada (2017) noted that Canada spends about 7.2% of our total (public and private) health spending on mental health (cf. 13% for the United Kingdom (UK)) and well below what most other developed nations spend on mental health. Children and youth may be particularly affected as most children with mental health problems do not receive the care they need (Waddell et al. 2005). Waiting lists for child mental health prepandemic were growing and some children waited 2.5 years for service (Children’s Mental Health Ontario 2020). Waitlists for all were lengthy even before the pandemic. The disruption of services and the stress of the pandemic has exacerbated the problem.

The Federal government recognized the desperate need for additional funding for mental health before the pandemic. In the 2017 budget, there was pledged a modest beginning to overcome the disparity; that is $5 billion over 10 years to improve mental health care (Government of Canada 2017). Recently, recognizing the specific needs of Indigenous communities in the COVID-19 pandemic, Federal Indigenous Services Minister Marc Miller announced $82.5 million in new funding for Indigenous communities to deal with increased mental health needs as a result of the COVID-19 pandemic. The concept of linking expenditure to burden, e.g., parity between mental and physical health, has not yet been incorporated into policy.

Mental health care must meet appropriate standards. The provision of poor quality care is not acceptable in mental health, as it is unacceptable in other areas of care. The Institute for Health Improvement in the United States outlines 6 domains important for quality of care: person-centred, equitable, timely, effective, efficient, and safe (Institute of Medicine 2001) that have been widely endorsed across Canada. Mental health services must be accountable by adapting the best practices and reporting on their compliance to quality standards. Effectiveness can only be established by routine collection and analysis of outcomes. Stepped care, a hierarchy of interventions, from the least to the most intensive matched to the individual’s needs is less burdensome to those we serve and more cost effective for the system. Most will utilize the least intensive mental health interventions usually delivered in primary care. These interventions must be effectively integrated with mental health care.

Accreditation Canada (2020), in their statement of health standards, emphasized patient and family experience of, and satisfaction with, care and involving patients and other stakeholders in the design of care. A crucial dimension of quality care is to ensure culturally safe care, which respects the cultural beliefs, values, and preferences of users. In the UK, this role is played by the National Institute for Health Care and Excellence (NICE).

The Canadian Institutes of Health Research (CIHR) is the principal funder of health research in Canada. In 2018–2019, the last year that data are available, the CIHR funded grants and awards worth $1.089 billion. Of this amount, $28.1 million was allocated to addictions research and $72.1 million to mental health research for a total of $100.3 million or approximately 9% of the funding (Canada 2020). This is in sharp contrast to the population burden of mental health, which would suggest at least a doubling of this spending.

The Canadian Institute of Health Information (CIHI) is the federally funded health agency that collects and analyses data on the health system and the health of people in Canada. This type of systems information is vital to the planning and evaluation of mental health and substance use care.

As the pandemic continues to affect all people in Canada, the federal government needs to respond not only to the infection itself and the economic consequences, but also to enact policies and fund programs and services that respond to current data on mental health and ensure the people of Canada survive and thrive following the pandemic.

Pre-COVID, Indigenous people bore a disproportionate burden of mental health difficulties when compared with non-Indigenous people in Canada. Population data for the general population of Indigenous and non-Indigenous individuals using the same methodologies are not available. However, there are good data on specific issues. The national rate of suicide among First Nations communities is double that of the general public and the rate among First Nations youth is approximately three times higher than non-Indigenous people in Canada. The rate of suicide in Inuit communities is estimated to be nine times higher than non-Indigenous people in Canada (Kumar and Tjepkema 2019). Indigenous adolescents begin using substances and consuming alcohol at a younger age than non-Indigenous adolescents (Falk et al. 2006; Miller et al. 2008). Among a sample of Indigenous youth in the upper-midwest of the United States and Ontario, there was a 54% chance of meeting criteria for a substance use disorder by late adolescence (Hautala et al. 2019). Indigenous youth experiencing homelessness are more likely to develop a mental health problem or addiction than non-Indigenous youth experiencing homelessness (Kidd et al. 2017). Finally, there are cumulative impacts on mental health within families and communities; individuals with parents who attended residential schools, for example, demonstrate greater depressive symptoms compared with those whose parents did not attend (Bombay et al. 2011).

These disparities are largely understood to have emerged as consequences of systematic colonial attempts at assimilation of the Indigenous population into the broader Canadian body politic. Canadian governmental policies directed at eradicating cultural practices through disruption of communities and families through such well-documented mechanisms as the residential school and child welfare systems have led to what has been termed intergenerational trauma—the transmission of trauma across generations of Indigenous peoples. At the same time, many rural and remote communities have limited access to culturally and contextually appropriate care and experience chronically underfunded systems and services across all sectors.

Despite this multi-generational colonial effort, Indigenous peoples have demonstrated great resilience and many communities have found ways to be adaptive and innovative as a means of developing greater capacity in mental health and addiction services. Culture-based approaches have been demonstrated to be particularly important in improving wellness for Indigenous people.

As COVID-19 spread across Canada, the relative geographic isolation coupled with quick and decisive action by many Indigenous leaders led to effective quarantine of community from outside visitors, thus limiting transmission of the COVID-19 virus. This resilient and effective response highlights the need for, and the efficacy of, Indigenous leadership and approaches to health.

The COVID-19 pandemic has highlighted, and in many cases exacerbated, known gaps in services, equitable access to resources, and human resource capacity to manage mental health related crises. Vitally important community programs and service organizations were forced to suspend services as a means of preventing viral spread to isolated communities with limited resources to care for the ill in the event that COVID-19 arrived in the communities. Many communities have reported increases in child welfare related issues (e.g., abuse, neglect), domestic violence due to suspending of residential treatment facilities and shelters for women, and acute withdrawal episodes as a result of disruptions in illicit substance supply chains (due to community check-point screening) combined with limited access to medically assisted withdrawal services. With the well-documented rates of chronic disease comorbidity, many communities were at great risk from the virus. Moreover, social crowding from limited housing capacity, and in some cases poor access to clean running water, made social distancing and handwashing recommendations lack relevance and applicability for many communities. This with the cultural importance of Elders and community wellness, places Indigenous communities in a desperate situation.

Access to culturally and contextually appropriate care is essential for Indigenous communities in Canada. Certain non-Indigenous approaches to mental health care (e.g., psychological, psychiatric, medical) have shown effectiveness in addressing the disproportionate burden of mental health. Culture-based and on-the-land or land-based approaches have also demonstrated improvements in wellness in addition to improvements in culturally based wellness outcomes like improvements in purpose, hope, belonging, and meaning.

Recommendation 7: That the federal government work closely with Indigenous governance structures to find exemplar Indigenous communities, Indigenous-specific programs, and Indigenous-governed organizations that are leading the way in mental health and in Indigenous communities. These culturally and contextually appropriate services need to be funded for expansion to other communities.

Recommendation 8: That in consultation with First Nations, Metis, and Inuit communities, the federal, provincial, and territorial governments implement solutions to remedy the across-the-board public services inequities and structural discrimination that contributes to over-represented rates of mental illness.

Recommendation 9: That the federal government facilitate and resource connected and holistic approaches to mental health care, inclusive of child welfare, housing and social services, education, justice, and other overlapping domains that often exist in silos and are sometimes at odds in terms of approach.

The COVID-19 pandemic has precipitated the cessation of most nonurgent, in-person mental health and substance use care, compounding the pre-existing problem of access to mental health and addictions care for people in Canada (Findlay et al. 2020; Koushik 2020; McIntyre and Lee 2020). These public health measures tasked entire health care systems to change the way they deliver mental health services, including a large-scale shift away from in-person care to digital or virtual delivery of care for many mental health services. As a result, we saw rapid and large increases in use of technology for the delivery of mental health care (Fisk et al. 2020; Ohannessian et al. 2020; Torous et al. 2020). Digital health and virtual care have been on the horizon for decades now in Canada, but always struggling to come into full ascendency. Digital health is the integration of electronic material and compilation of health data, decision support tools, and analytics using technologies to deliver preventive, diagnostic, and treatment services (Canadian Medical Association 2019). Virtual care is any interaction between patients and (or) members of their circle of care, occurring remotely, using any forms of communication or information technologies to achieve patient care (Shaw et al. 2018). Despite a large evidence base demonstrating equivalency with in-person mental health care across many diagnoses and evidence-based interventions (Hilty et al. 2013; Hubley et al. 2016; Langarizadeh et al. 2017), prior to COVID-19 virtual modalities had low rates of adoption (Canadian Medical Association 2019). In a recent study in Ontario, for example, <1% of adult patients in need received care via telepsychiatry, and only 7% of psychiatrists provided it (Serhal et al. 2017). This low rate of implementation occurred despite the potential of virtual care to address bridging large geographic distances and maldistribution of heath human resources (Wozney et al. 2017). These challenges contribute to health inequities across the country, with those in rural areas bearing the added barrier of finding funds to travel long distances to access services. Prior to COVID-19, virtual care was a relatively untapped resource. Some of the reasons suggested for this lack of adoption and penetration of virtual care are: poor implementation, health governance and funding that does not contribute to care across regional or provincial boundaries, lack of funding and remuneration for virtual care, and inadequate training for health care providers (Serhal et al. 2017; Cowan et al. 2019).

In response to COVID-19, the rapid implementation of virtual care has been facilitated by relaxed regulations and a quick funding shift in many provinces. Many have rightly lauded the flexibility of this modality of care to allow patients to continued access to many essential health services. For example, recent guidelines recommend a shift to greater use of virtual care in combination with greater flexibility in prescribing practices for opioid agonist therapy during the pandemic (e.g., allowing more flexibility in take home privileges combined with patient monitoring via telemedicine). This would allow the system to respond to the increased demand for access to methadone to manage exacerbations in the opioid epidemic (Bruneau et al. 2020).

According to a recent survey, 38% of people in Canada would prefer to continue receiving virtual health care, and the majority would like to see virtual care continue as an option (Abacus/Canadian Medical Association 2020). And yet there are evident challenges with virtual care that urgently need to be addressed to sustain this initial rapid scaling. The first relates to unintended health equity impacts of virtual care, with many vulnerable groups unable to access care (Crawford and Serhal 2020) amplifying mental health disparities that predated COVID-19. The second has to do with the implementation and integration of virtual care at both local and health systems levels, made more challenging because of pre-existing fragmentation and poor integration of health services.

We need to shift our thinking and approaches from the urgent response to the pandemic to sustainability and integration. There are opportunities here to finally harness the underused potential of virtual care, granting more freedom and choice to persons accessing mental health care. While virtual care options were critical to maintaining access to services, as we move out of the acute crisis phase, we need to attend to the quality of care provided and whether it meets the needs of patients, families, and communities. Quality of care is as important in virtual care as it is in face-to-face care.

Of particular importance is ensuring digital health equity. While virtual care can increase access, it may pose barriers related to other social and structural inequities, making virtual care inaccessible or ineffective for groups who are experiencing poverty or homelessness, or who have poor digital literacy skills (Levesque et al. 2013; Crawford and Serhal 2020).

Recommendation 10: That the federal government, in conjunction with provincial and territorial governments, track digital health equity and improve funding and infrastructure to create virtually connected communities.

Often when we speak of virtual care, we only consider care at the provider–patient level of care. Technology within health care is part of an ecosystem of care that includes not only the organizational setting, but also all stakeholders, community, health systems, and governments (Wiljer et al. 2020). As with other health services in Canada, provincial and regional funding and governance makes integration across health systems challenging. Virtual care directly challenges this status quo because of the capacity to easily provide care across jurisdictional lines. However, providers are faced with a complex system of jurisdictions, licensures, and regulators to navigate. Poor integration leads to poor care transitions and poor follow-up. We need to plan systems of virtual care that ensure an acceptable, efficacious, and efficient blend of in-person and virtual care. Navigating care, transitioning between care providers and settings, and receiving appropriate follow-up all require systems planning.

Virtual care can facilitate the delivery of collaborative or integrated care across distance, integrating mental health providers into primary care teams. We can start thinking about digital health and virtual care as the collection of support tools (Fortney et al. 2013; Adaji and Fortney 2017; Hilty et al. 2018) and technology that can provide care along the continuum of health including prevention, diagnosis, and treatment. Stepped care provides patients and primary care providers access to increasing levels of care based upon need. Preliminary research shows the feasibility and value of these models, which can also introduce efficiencies. Further research into and funding of these models of care, including studies on return on investment, is critical to the penetration of virtual care, and to systems integration.

Recommendation 11: That the federal, provincial and territorial Governments ensure that systems, including technology, records, professional licensure, and funding are harmonized and interoperable to support integration across points of care and across the health system in Canada.

Most provinces have provided temporary reimbursement or billing codes to physicians for the practice of telemedicine during COVID-19, including for telepsychiatry, and have transferred most care by nonphysicians to digital care. Funding will be critical to sustainability, and patients will likely demand ongoing access. But funding is also needed at program and organizational levels to support the administration of virtual care. Economic analysis of different models of care will be important to determine the relative value of virtual care. A recent study, a cost comparison between telepsychiatry, in-person care, and a travel subsidy program for patients found telepsychiatry to be the most economical (Serhal et al. 2020). Virtual care must be covered in a systematic way within health professions education at all stages of training and continuing professional development.

Virtual care can also be used as to establish alternative models of care such as paraprofessionals delivering care (McGrath et al. 2011) and communities of learning and practice that can facilitate the learning and evidence-based practice of providers (Sockalingam et al. 2018).

Recommendation 12: That the provincial and territorial governments develop stable funding models for virtual mental health care with remuneration aligned to in-person care, including funding for collaborative, indirect care and intervention models that employ peers and paraprofessionals.

Recommendation 13: That training in the implementation of virtual care become standard for all mental health professionals in their education and via continuing education.

Despite a longstanding call to governments and health systems from the World Health Organization (WHO 2004) and the Institute of Medicine (Muñoz et al. 1996) to provide a more proactive and preventative approach to mental health, our policies and practices in Canada remain largely reactive. Primary preventative interventions can be effective and cost effective (WHO 2004; van Zoonen et al. 2014; Furber et al. 2015; Arango et al. 2018; Carbone 2020). And yet, Canada invests very little in the primary prevention in mental health, despite indications that our current approach is not sustainable (Roberts and Grimes 2011).

Mental health prevention strategies as a response to COVID-19 are needed to flatten the cost and alter the curve (Carbone 2020; Moreno et al. 2020). Prevention aims to reduce the incidence, prevalence, and recurrence of mental disorders and addictions and their associated disabilities. Interventions are based on modifying known risks, and strengthening capacity to cope, and can be understood as: (i) universal prevention, applied to entire populations; (ii) specific prevention, aimed at groups with specific risk factors; or (iii) indicated prevention for individuals who are experiencing current or recurrent symptoms or diagnoses (Muñoz et al. 1996). The Mental Health Commission of Canada, and other health advocacy groups, support the idea that the continuum of care should also include health promotion and illness prevention through virtual means (Mental Health Commission of Canada 2014).

Secondary prevention may also be achieved through virtual care. Keeping people with mental illness connected and connected to care virtually, through programs such as remote monitoring, virtual communities of care, etc., can also reduce relapse. Suicide prevention is another obvious target for virtual intervention. The promise of these interventions is great because they can impact many people in a cost-effective manner; however, they are relatively new and require greater research and evaluation.

Recommendation 14: That the federal government undertake a national task force on the prevention of mental illness and the promotion of mental health and wellness with special reference to pandemics and similar national emergencies.

Although compliance with the restrictions posed by COVID-19 has varied during the course of the pandemic, there is an important subgroup of about 20% of the population, that have psychological characteristics that influence them to disregarded public health demands and may present serious barriers to future public health initiatives as the pandemic continues. In April 2020, about 20% of adults worldwide were failing to comply with public health viral containment measures like physical distancing (Lavoie 2020). Nonadherence is higher among males (DeGrace et al. 2020; Litton 2020) and among younger people (Lavoie 2020; Moore et al. 2020).

Major epidemics and pandemics are managed by (i) risk communication (i.e., providing information to the public about the outbreak and how people can protect their health and safety), (ii) vaccines and antiviral therapies (if or when available), (iii) hygiene practices (e.g., washing hands, wearing facial masks), and (iv) physical distancing (e.g., staying 2 m apart). Willingness to be vaccinated is a major issue affecting the success of vaccination programs. Most people do not adhere to vaccination recommendations (Taylor 2019). Data from Taylor and Asmundson’s CIHR funded multi-wave population-representative survey of approximately 7000 Canadian and US residents indicates that 20% would not get a COVID-19 vaccine once it is available (Taylor et al. 2020e). There may be hesitation to be vaccinated because concerns over safety of the vaccine, a fear of needles, or beliefs that vaccination programs infringe on civil liberties.

Psychological factors play a vital role in the success of each of these methods (Taylor 2019). Willingness to participate in activities such as hygiene practices and physical distancing are critical in the mitigation of viral spread. Unfortunately, many people do not adhere to handwashing recommendations (Pfattheicher et al. 2018). During the 2009 H1N1 pandemic, people who viewed themselves as having a low risk of infection were less likely to wash their hands (Gilles et al. 2011). Likewise, many people fail to adhere to social distancing recommendations. During the 2009 H1N1 pandemic, many in the UK and US (79% and 44%, respectively) made no effort to avoid being near someone who had influenza-like symptoms (SteelFisher et al. 2012). In the context of COVID-19 there have also been challenges with respect to hygiene practices and physical distancing, with a substantial number of Canadians and Americans failing or refusing to follow recommendations (S. Taylor et al., unpublished data).

Psychological factors, including amongst other things, low perceived vulnerability to threat and unrealistic over-optimism bias, may play a major role in these disease-spreading behaviours. In such cases, getting people to adhere to recommendations that ultimately diminish infection rates and mortality—getting vaccinated, following recommended hygiene practices, physical distancing—may require public health officials to take a strategic approach to messaging that calls on the public’s altruistic sense, that is, messages that emphasize that a person should be doing these things not for themselves but to protect potentially vulnerable family members, friends, and neighbours (World Health Organization Writing Group 2006; Taylor 2019).

Personality characteristics also appear to be associated with greater nonadherence. For example, impulsivity (Baptist-Mohseni et al. 2020) and sensation seeking (DeGrace et al. 2020) have both been associated with higher levels of nonadherence to public health COVID-19-prevention strategies. Moreover, higher sensation seeking in males has been shown to help explain gender differences in nonadherence (DeGrace et al. 2020). Again, public health messaging and prevention programming may need to be targeted toward these higher-risk groups.

Public health policy response to the pandemic closed schools and workplaces, leaving families “sheltering in place”, often in close quarters, with parents facing far greater home responsibilities than ever before, including homeschooling their children. In April of 2020, UNESCO (2020) data showed that more than 90% of children around the world were out of school. Parents faced mandatory homeschooling often with little support from the educational system, while many also struggled to work from home with heightened uncertainty and stress about their children’s education, household finances, and family health. Parents were in an impossible situation (Lyons 2020; Mandel 2020) because of conflict between the demands of work and home, role strain that contributes to mental health problems and addictive behaviours (e.g., Abbey et al. 1993). The mental health consequences of the pandemic are predicted to be especially severe for families, even more so for women and children (Brooks et al. 2020; Wenham et al. 2020).

The consequences of this confluence of forces on family well-being intersect with pre-existing social inequities. For example, the effects of having children at home during the pandemic and of homeschooling appear to be amplified for women (Rodriguez et al. 2020), potentially due to traditional gender roles where women still bear most of the burden of household chores and childcare. Adding the work of homeschooling, COVID-19 has compounded pre-existing gender inequalities in household labour (UNSDG 2020). Recent articles, including Minello (2020), suggested that increased household workload in recent pandemic times has largely fallen to women, validating predictions from UNESCO (2020) and other organizations. A recent largescale survey in the US (Miller 2020) showed that women do most of the homeschooling, with similar data emerging in Canada (Elgendi et al. 2020). Further, higher levels of COVID-related psychological distress were recently associated with greater drinking, particularly among women, providing evidence for important gender differences (Rodriguez et al. 2020).

COVID-19 is also exacerbating pre-existing educational inequalities (Andrew et al. 2020). Parents with higher levels of education and income had more resources offered by schools during COVID-19-related shutdowns, even within the public education system (Andrew et al. 2020). Another study in the US showed that Black, Native American, and Latino students had less access to internet connectivity, electronic devices, and quality virtual learning programs during the pandemic (Winter 2020). School closures place additional strains on disadvantaged families who may rely on schools for more than just education (e.g., meal programs) (Dooley et al. 2020).

Children are a vulnerable group. With school closures, children cannot access the first place that they would normally seek help for psychological distress: the school (Sellers et al. 2019). As such, parents’ effectiveness in maintaining their own mental health may be even more important to children’s mental health during pandemic times. And, with mandatory homeschooling increasing family conflict (Elgendi et al. 2020), observing parental conflict due to homeschooling (e.g., about division of the homeschooling workload) is likely to negatively affect children’s mental health, given established adverse effects of parental conflict on children’s psychological distress (Barletta and O’Mara 2006). Additionally, parent–child conflict may increase with mandatory homeschooling as children resist parents taking on the role of teacher. As one 9-year-old told CBC’s Cross-Country Checkup, “It’s horrible to have your parent as a teacher because there’s no difference between school and home” (CBC Radio One 2020).

Parenting through a pandemic has mental health consequences. Recent data from the UK found that adults with children in the home during the COVID-19 lockdown were far more likely to suffer anxiety and depression than were those without children (Shevlin et al. 2020). In another study of 754 adults in the US, having children at home during the lockdown was associated with increased alcohol use (Rodriguez et al. 2020). This effect is the reverse of that evidenced in nonpandemic times in which having children is a protective factor against heavy drinking (Bowden et al. 2019).

Homeschooling mandated in response to a pandemic is a unique context (Dalton et al. 2020; Holmes et al. 2020; Lee 2020), about which there is little associated evidence. Most of what we know about the effects of homeschooling on parents and children comes from research outside of the pandemic on voluntary homeschooling. During the recent shutdowns, a study was conducted with 760 Canadian couples in June of 2020 (Elgendi et al. 2020); participants were asked to retrospectively report on the month of April 2020, close to the time when schools were first closed. After controlling for parental age, those homeschooling children (n = 203 couples) reported less optimism, more role strain, and more cannabis use to cope than those without children at home. In addition, more hours spent homeschooling was associated with greater anxiety, depression, COVID-related traumatic stress, and more frequent cannabis use. There were also some gender differences observed with greater effects of increased hours that mothers (vs. fathers) spent homeschooling on the frequency of drinking by both parents. These pilot data with 203 couples homeschooling children illustrate the effects that mandatory homeschooling during a pandemic has on parents’ psychological well-being (Elgendi et al. 2020). These findings are cause for concern given that increased psychological distress and increased substance use among homeschooling parents is likely to impede their ability to cope and support their families in these challenging times.

Unfortunately, there is little research yet conducted to address the impacts of mandatory homeschooling on children’s mental health. However, we do know that the COVID-19 pandemic more generally is having an adverse impact on children’s mental health. Data from China show increased rates of both depression and anxiety in children during the first COVID-19 outbreak (Dalton et al. 2020), perhaps due at least in part to exposure to increased stress in their parents.

Going into the 2020–2021 academic year with the pandemic ongoing, jurisdictions have been struggling with how to handle schooling of the nation’s children, given predictions of future waves of COVID-19 (Scher 2020), as has happened elsewhere around the world (Bensadoun 2020; Euronews 2020; Gutiérrez and Kirk 2020). According to a recent Kaiser Family Foundation report (Michaud and Kates 2020), most countries that have reopened schools have not experienced consequent COVID-19 outbreaks, but most of those countries had low community transmission rates. Some countries, including Canada, did experience school-based outbreaks upon school reopening requiring schools to close a second time (Michaud and Kates 2020). This implies that jurisdictions reopening schools must carefully prepare for the very real possibility that they may need to close again in the event of an outbreak. Indeed, going into the 2020–2021 academic year, mandatory homeschooling is included in most planned responses to predicted second waves. And yet, with this option in hand, we are left with a core question: Is it better to keep schools closed to prevent viral spread at the expense of the mental health costs to families and to our economies? Or should we open schools doing our best to ensure public health strategies are followed within the schools? When schools are opened, efforts to reduce viral transmission must be implemented. These methods include ensuring physical distancing within the classroom through smaller class sizes; mandatory mask wearing by children, teachers, and support staff; alternating days of learning at school vs. at home; or alternating half days of learning at school among other options. Such efforts could reduce viral spread as well as stress on families many of whom are anxious about appropriate public health measures being taken as children return to schools (Kroshus et al. 2020).

As we consider the potential options for schooling children, we hope this report shines a spotlight on the very real mental health consequences on families of requiring parents to homeschool. These consequences include evidence of increased levels of role conflict between demands of home and work, increased substance use, and heightened depression and anxiety, amongst other adverse impacts. Many of these impacts may be lasting, for example with increased substance use often continuing beyond pandemic times. We need to weigh these mental health consequences against the potential benefits to physical health of school closures. Closing schools has a very real cost to families and one that we need to consider in public discussion and policy making. Returning children to school will be important to our nation’s economic recovery, including from the “she-cession” with women disproportionately impacted economically by COVID-19 (Queisser et al. 2020).

The main arguments against returning children to schools are concerns for children’s health and concerns that infected children may carry the virus home to family members or infect teachers and school support staff. The recent review by the Kaiser Family Foundation (Michaud and Kates 2020) concluded that, although children are much less likely than adults to become severely ill, they can transmit the virus to others. This suggests that if children are to be returned to schools, extraordinary efforts will be required to ensure that schools closely follow public health recommendations (e.g., adequate physical distancing, mask wearing, and frequent handwashing). These efforts will be incredibly difficult to implement, particularly for younger children who may not understand the public health context and also for adolescents who have been particularly unlikely to adhere to public health recommendations (Moore et al. 2020). Some jurisdictions have considered enhancing physical distancing between children within schools through either part days or oscillating days (CBC 2020; Rocca and Dhanraj 2020; The Canadian Press 2020). Such policies would still require families to partially homeschool with unknown consequences to family well-being.

Offering a choice of schooling option to parents does not solve the debate. In a recent US survey in June 2020 (Kroshus et al. 2020), 31% of parents reported they would keep their child home even if in-person schooling were provided. Those more likely to want to keep children at home had lower incomes, greater rates of unemployment, more flexible jobs, increased fears of COVID-19, fewer perceived challenges to homeschooling, and lower confidence in schools (Kroshus et al. 2020). However, many parents do not have the luxury of flexibility within their jobs or the resources to enable children to engage in virtual learning (Dooley et al. 2020) and so voluntary homeschooling is simply not an option for many families. Jurisdictions must resource increased educational and mental health supports to parents in the event another period of mandatory homeschooling should be required.

A further complication is that the return to school protocols often are not friendly to children with neurodevelopmental challenges and will often preclude their return to school. This will leave them at greater risk of falling further behind and their parents at greater risk of the dramatically increased stress of homeschooling their children.

Recommendation 15: That provinces and territories should attempt to keep children in school and carefully weigh the cost/benefit ratio of closing schools in the event of another wave of COVID-19.

Recommendation 16: That the federal, provincial and territorial governments adequately fund efforts to minimize viral transmission within schools to reduce the chances that children will become ill and (or) spread the virus to their teachers, school support staff, and family members.

Recommendation 17: That, should schools need to close again due to second or more wave(s) of the virus, parents be better supported in the education of their children at home. This includes supporting the increased mental health service needs of parents during mandatory homeschooling.

Recommendation 18: That if schools close again, provincial and territorial governments have mental health and substance use supports ready to stabilize family well-being using the vehicles used to deliver school curriculum to families.

The impact of the unintended consequences of the COVID-19 pandemic response on vulnerable populations and their families related to social and physical distancing policies remain unknown. One example includes the vulnerability of neonatal populations and their families and potential adverse effects of uniform pandemic response measures. The impact on persons in extended care homes has been treated in “Restoring Trust: COVID-19 and The Future of Long-Term Care” (Estabrooks et al. 2020) and is not repeated here.

Nearly 400 000 babies are born in Canada each year (Government of Canada 2020). Of these, approximately 8% will be born preterm (<37 weeks gestational age), with the majority requiring neonatal intensive care and 10% of babies overall are admitted to neo-natal ICU (NICU), equating to 30 000–40 000 Canadian babies requiring hospital care annually (Government of Canada 2020). Babies born extremely preterm are the most vulnerable, but even those delivered one to two weeks early are at risk for immediate and long-term negative outcomes, including developmental delays, social, emotional, and behavioural problems (Moster et al. 2008; Woythaler et al. 2019). As a result, prematurity is the leading cause of infant disability and death, costing the Canadian health system in excess of $8 billion annually, with the length of stay over 100 d for the sickest and smallest infants (Lee et al. 2020).

Beyond infant outcomes, there is strong evidence that the parents of these infants report higher levels of immediate stress, anxiety, depression, posttraumatic stress, and greater adverse parenting outcomes than parents of healthy newborns (Roque et al. 2017; Schecter et al. 2020). To improve the outcomes of vulnerable infants and their families and ease health care system burden, strong parental presence and education along with family integrated interventions have been shown to be a beneficial component of care in the NICU (O’Brien et al. 2018a, 2018b; Cheng et al. 2019; Franck and O’Brien 2019; Tandberg et al. 2019).

Although a concern in newborn infants, COVID-19 appears to be a very mild disease that is usually asymptomatic in this population. To date, evidence supports the lack of vertical transmission of the coronavirus during pregnancy (Choi et al. 2020; Qiu et al. 2020). However, in contrast to adults, infants and children under 10 only account for 1% of COVID-19 cases (Wu and McGoogan 2020). In Wuhan, only three confirmed cases of COVID-19 have been identified in neonates, with all infected neonates having mild or no symptoms (Choi et al. 2020). These milder cases suggest that there may be a mechanism that regulates how the immune system interacts with the virus in the respiratory system in children potentially pointing to the host adaptive response involvement in cases of more severe illness.

Despite this apparent reduced risk, restricted parental contact and extensive infection prevention and control measures have been instituted in neonatal units across Canada and worldwide to prevent COVID-19. It is not known if such approaches are effective nor if they lead to unwarranted side effects. Specifically, the development and maturation of neonatal gut microbiome are largely determined by maternal–neonatal microbial exchange and it plays an integral role in the immune and metabolic health of the infants (Prince et al. 2014; Mueller et al. 2015). Having limited contact with the mother and being exposed to other bacterial sources is likely to increase the chances of the baby being colonized with pathogenic organisms. There is some evidence that in addition to numerous other life saving benefits, the provision of breastmilk may protect newborns from contracting COVID-19, yet institution of universal public health social distancing policies restricting parental presence has been linked with reduced breastfeeding (Dong et al. 2020).

The mental health of at-risk parents of sick newborns has been exacerbated by universal social distancing restrictions that have not taken into consideration the potential risk and consequences in this vulnerable population (Mahoney et al. 2020). No parent wants to be separated from their baby. This is especially true for parents of premature or sick infants requiring hospitalization in a NICU, already with heightened risk for adverse mental health outcomes. Yet, given the restrictions of the COVID-19 global pandemic response, this is the reality for many mothers and almost every father of our smallest and extremely vulnerable patients. Changes to care standards at most Canadian NICUs do not permit both parents to remain with their infant for the duration of stay if they are admitted. Partners are not permitted to return to the hospital following attendance at the birth. Mothers who must leave to care for other children or relatives at home, are unable to return to the NICU. As a result, up to half of infants receiving care may not have a parent present due to COVID-19 restrictions. If one parent is allowed to remain in the NICU with their infant, they lack access to their usual social support systems, their partners have little engagement, and usual in-person support, education delivery, and discharge teaching has been disrupted.

Environmental restrictions and modifications have been put in place to prevent COVID-19 in babies, families, and staff based on universal public health social distancing policies. They may exacerbate mental health outcomes in already at-risk parents and adversely impact later infant development and emotional well-being and may promote dysbiosis and abnormal immune system development of babies in the NICU. To prevent or limit the spread of COVID-19, the majority of NICUs have limited or eliminated parental presence and contact with their infant leaving most infants with limited or no parental contact during their hospitalization. The tension between protection of infants and caregivers from serious infection and the desire to maximize the developmental outcome of newborns and reduce parent mental health concerns forces consideration of several options for restricted interaction, rather than relying on a universal approach. While neonatal COVID-19 disease appears relatively uncommon, the risk–benefit calculation for restricting NICU access remains unclear.

Recommendation 19: That provinces should attempt to keep high risk families of vulnerable neonates together and carefully weigh the cost–benefit ratio of restricting family presence during neonatal intensive care admission in the event of another wave of COVID-19.

Recommendation 20: That the provincial and federal governments adequately fund efforts to determine the impact of family presence restriction on family and infant mental well-being and health outcomes.

Recommendation 21: That if hospital family restrictions are implemented again, provincial governments have mental health supports ready to stabilize family well-being using virtual care delivery similar to school curriculum to families.

The COVID-19 pandemic has had a detrimental effect on mental health of people in Canada, but the impact has been variable, impacting those facing pre-existing structural inequities hardest. Those living in poverty and in some socially stratified groups facing greater economic and social disadvantage, such as some racialized and some Indigenous groups and those with preexisting mental health problems, have suffered the most. Some occupational groups have been more exposed to the virus and to psychological stress with the pandemic. The mental health care system was already overextended and under resourced. The pandemic has exacerbated the problems. The care system responded by a massive move to virtual care. The future challenge is for Canada to strengthen our knowledge base in mental health, to learn from the pandemic and provide all in Canada the support they need to fully participate in and contribute to Canada’s recovery from the pandemic.

The headquarters of the Royal Society of Canada is located in Ottawa, the traditional and unceded territory of the Algonquin nation.

Established by the President of the Royal Society of Canada in April 2020, the RSC Task Force on COVID-19 was mandated to provide evidence-informed perspectives on major societal challenges in response to and recovery from COVID-19.

The Task Force established a series of Working Groups to rapidly develop Policy Briefings, with the objective of supporting policy makers with evidence to inform their decisions.