It’s probably not an understatement to say that the last four months have been, for most of us, the most unusual and professionally challenging period of our careers to date. Most things that we took for granted in both our personal and professional lives suddenly changed, with no sense, at least initially, of the likely outcome.
As we look back now at the tail end of the first wave of COVID-19 in Ireland, it’s tempting to feel that the worst is behind us, and, indeed, it may well be that in at least one sense (absolute numbers of confirmed cases and fatalities), it is. But a new set of challenges are already emerging, which are different in nature and will require different responses.
Opening up is more challenging than locking down
It was always likely that the process of easing restrictions would be more challenging than imposing them for a few reasons. First, restrictions were applied relatively uniformly across society so, although challenging, there was a sense of equity and unity of purpose. Second, there was a sense of necessary urgency in our preparations and response to the incoming virus; we almost had no time to process or think through the consequences of what we needed to do. Third, it was a novel situation and nobody had a clear idea of what living in lockdown would feel like or how long it might last. Finally, there was little real choice in terms of our response, unless one considered the possibility of inaction and pinned our hopes on herd immunity.
Now, as we ease these restrictions, it is clear that a more complex set of issues is emerging. Opening up is less evenly distributed; for example, some businesses and services have been able to open again both sooner and with less adaptation than others. The population has endured almost four months of multiple restrictions and, as restrictions are further eased, understandably longs to act as if things are almost back to the old normal. We know already from nations who have eased restrictions before us that clusters and even more widespread resurgence can happen only too easily.
In short, it seems very likely that we will be living with uncertainty and some degree of threat, albeit of a somewhat different nature and scale, for some time to come. Thus, both primary and secondary care services need to prepare for, and manage, the mental health consequences of both the last four months of restrictions and also the ongoing uncertainly that lies ahead.
Mental health challenges over the next two years
All the available evidence points to the overwhelming likelihood that the pandemic has, and will continue, to result in a significant increase in a wide range of mental health disorders. Our own service, in June (broadly coinciding with the gradual easing of restrictions), has experienced greater demand than the same month last year. This is due, almost certainly, to the increase in referrals from primary care, which, in turn, is due to people beginning to return to see their primary care physicians in greater numbers. It may also reflect an increased need for services by a greater number of individuals than usual, and people now feeling more comfortable leaving their homes to seek help and, if necessary, to be admitted to hospital.
It may be useful to consider broadly the groups that are likely to present with mental health issue related to the COVID-19 situation in order to both provide the best advice and treatment options and also to consider what resources might be required over the next year and beyond. These are detailed below.
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The general population
Nobody has escaped the consequences of the measures introduced since March. From staying at home, physical distancing, fear of contracting the virus and its consequences for both oneself and close contacts, the lack of usual outlets (including retail and leisure) and being separated from friends and family to profound changes to work practice (or indeed losing one’s job and livelihood), closure of schools and creches and the consequent effects on childcare arrangements and on one’s children, the effects have been widespread and significant. Any one of these alone would normally count as a major life stressor. But, for many of us, we have had to somehow manage several of these at once.
Unsurprisingly, data from a survey conducted from Maynooth University recently confirm high levels of symptoms consistent with anxiety, mood disorders and trauma in the general population. They point to 41% of people feeling lonely, 23% endorsing clinically meaningful levels of depression, 20% reporting clinically meaningful levels of anxiety, and 18% reporting clinically meaningful levels of post-traumatic stress. Although one interpretation of the findings of this ongoing survey is that some of these rates are not significantly different to levels found in ‘normal’ times, they do give an indicator of the likely scale of the mental health issues facing the population at present.
It is therefore likely that we will see. and are already seeing, significant numbers of people presenting with issues related to these multiple stressors. Probably the best approach in these situations is to deal with each person as an individual with their own set of stressors. These need to be identified and a mental state examination performed to determine if they reach the threshold for a treatable mental health condition. In essence, this is exactly the same approach that one would normally adopt; what’s different is that the scale and severity of stressors and symptoms are likely to be greater than one would normally encounter. Marrying these two domains of information - identification of stressors and of symptoms - allows one to formulate a coherent, individually tailored care plan which may include a combination of lifestyle measures, counselling or psychological input and/or medication as appropriate.
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People with pre-existing mental health disorders
Individuals who already had an established metal illness prior to the COVID-19 pandemic will be at increased risk of relapse. It’s not hard to imagine what the impact of social distancing and isolation, the fear of infection and its consequences, the need for scrupulous sanitizing, the increased stress of financial insecurity, or the difficulties in accessing medical help, and possibly their usual medication, might have on many people across a wide range of mental health conditions. Hopefully, as restrictions ease and both primary and secondary care services become more readily accessible, those who need it will present for help and support.
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Particularly vulnerable groups
Although this crisis has taken its toll on all of us in different ways, it is likely that some groups in society will have been disproportionately affected. Older people had to isolate themselves in a more extreme form that the rest of the population and, over the coming months, we may see many of them presenting with mental health issues related to this isolation and its consequences.
At the other end of the age spectrum, the effects of the pandemic on younger people, both children and younger adults. has yet to be fully elucidated, but, again, it would be surprising if we don’t observe increased presentations in these age groups with a variety of mental health issues. A recent survey of almost 1,500 parents found that “70% of parents of young children are concerned about the impact of the pandemic on their children’s mental health, with 25% of parents either ‘very’ or ‘extremely’ concerned.” Further, 17% of the children of parents surveyed had received mental health support from places such as schools, private counselling, helplines, Health Service Executive (HSE) local community support, local clubs or inpatient care. It remains to be seen to what extent these concerns will translate into more formal presentations and referrals to primary and secondary care services.
Finally, while the effects of the last four months on other vulnerable groups, such as the victims of domestic abuse and other forms of abuse, remain to be fully clarified, they must not be overlooked.
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The bereaved
One of the many truly affecting issues related to events of the last four months has been the fact that the families and friends of the over 1,700 people who have died of COVID-19 were not able to be with their loved ones during their final hours, except under very limited conditions. They were not able to have unshielded physical contact or to mourn their passing with a normal funeral and gathering together. We know that a large proportion of the deceased were elderly, and many will have left extended families and close friends behind who have not had the opportunity to grieve appropriately. Over the next six months and beyond, it will be important to check for signs of an abnormal grief reaction in those who lost loved ones during the initial wave of infection and to manage it appropriately.
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Survivors of COVID-19 infection
We know from previous studies on the effects of Severe Acute Respiratory Syndrome (SARS) and other infections, that the survivors of such infections have a remarkably high rate of trauma symptoms that can persist for two years and more. Indeed, we know that rates of Post-Traumatic Stress Disorder (PTSD) are markedly raised in people, regardless of COVID-19, who survive being on a ventilator in an intensive care unit for any reason. Thus, we can predict with some degree of confidence, that there will be significantly raised rates of trauma-related symptoms and PTSD in this substantial cohort for some time into the future.
A recent systematic review and meta-analysis (Rogers, JP et al, 2020) found that, in the post-illness stage of survivors of SARS and Middle East Respiratory Syndrome (MERS) outbreaks, the rate of PTSD was 32.2%, of depression was 14.9% and of anxiety disorders was 14.8%. We need to be alert to these possibilities in any of our patients who may have survived COVID-19 infection, regardless of severity. Those with trauma symptoms do not always volunteer to discuss their distress, so we will need to proactively check for the presence of such symptoms and access the appropriate support and treatment when such symptoms are elicited.
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Healthcare workers
Another group for whom there is strong evidence of raised rates of trauma-related symptoms and PTSD is frontline health workers. Many will have experienced significant distress and suffering in a short time, while also balancing all the other pressures that society has had to endure. A cross-sectional survey of 1,379 frontline healthcare workers in Italy performed in late March 2020 (Rossi et al, 2020) found that 49% endorsed post-traumatic stress symptoms, with a further 25% for symptoms of depression, 20% for symptoms of anxiety, and 8% for insomnia. This group will need extra support and, hopefully, formal services will be established that ensure that they receive the same high standard of help and treatment that they strove to give to their fellow citizens.
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Ourselves
Glance up at the six categories above and take a quick note of how many categories you fall into at this moment. As doctors, we are trained, and perhaps self-select, to be altruistic, professional and decisive. But we also know that doctors suffer high rates of burnout and a range of mental health disorders. We are not invulnerable. We have a job to do, albeit one that is, at times, challenging and rewarding and puts us in a privileged position with those whom we treat; in the current pandemic, that job just happens to be one of those handful of critically important professions.
Thus, we owe it to those around us, as well as to ourselves and our loved ones, to take care of ourselves and one another. It is in these times when we are particularly busy and overloaded that it is vitally important that we stand back and honestly ask ourselves if we are giving ourselves, or permitting ourselves to have, the same level of care that we try to give to our patients.
My colleague, Professor Jim Lucey. has given an excellent talk in one of our online modules on GP and Physician Mental Health, which is more relevant now than ever.
Preparing for times ahead
As we move towards the next phase of the COVID-19 situation, we are likely to see increased numbers of people with mental health issues presenting for our help from a broad range of groups. Determining which vulnerability group an individual may belong to may assist us in identifying the optimal approach to treatment. We cannot afford to neglect our own health and welfare during these times and need to pace ourselves for what is likely to be a busy, protracted and, at times, uncertain road ahead.