Ashley Curry, Jo Edge and Ruth Ann Harpur
CW: references to suicide, mental illness and psychiatry
Lucy Johnstone’s assertion in her Guardian letter (25 March 2020) of needing a ‘normalising approach’ to COVID-19 and that we are ‘all in this together’ risks minimising the enormous impact of the pandemic on mental health and mental illness across the population. Johnstone’s letter is based on a truism that is impossible to deny: it’s normal to feel sad, anxious, or any other strong emotion during such an uncertain and difficult time. But this approach fails to take into account the people who were already suffering with mental illness or experiencing mental distress before COVID-19 broke out; and those who will be tipped over the edge of what can be regarded a ‘normal’ experience by the pandemic. COVID-19 might impact on existing mental illnesses either directly – for example, a flare-up of OCD manifesting in contamination obsessions and handwashing compulsions – or indirectly, such as the halting of face-to-face therapies. Another crucial concern is for pregnant people, or new parents, who may face sudden-onset perinatal illness such as PTSD, OCD or psychosis, trying to manage on top of the responsibility of caring for a baby during COVID-19. So contrary to Johnstone’s assertion, these are ideal conditions for an epidemic of severe mental illness.
In the same letter, Johnstone states that we should first rely on each other and have confidence to cope rather than placing a ‘burden’ on already overstretched NHS services. Firstly, the language of ‘burden’ applied to people in severe distress needing to access professional help is extremely problematic. And this statement ignores the need for mental health services to respond to the new demands that COVID-19 has placed on the mental health of the population – both in people who were already experiencing mental illness and those in whom COVID-19 will trigger illness – and on services.
A further issue with Johnstone’s letter is her statement that ‘The drug companies must be rubbing their hands at the prospect of all these new customers’. Calling medication ‘drugs’ does nothing for those of us who experience pillshaming day in day out from medical professionals and laypeople. Comparing medication to recreational drugs that we are simply addicted to is insulting and ignores our experiences. Yes, many people have had adverse reactions to medication. Yes, many people are medicated against their will. That doesn’t mean that all medication is bad, or that we are simply addicts waiting for our next hit.
It is important to remember that all of this is happening at a time when the mental health of the UK population was already in decline and when funding cuts across mental health and social care have impacted on the ability of services to provide accessible, holistic and compassionate care to those who need it. And, whilst we all grapple with living through the uncertainty and distress of the COVID-19 pandemic, those with existing or new mental illnesses have been unable to see their care team since the UK went into lockdown measures. When not postponed, psychiatric assessments and psychological therapies are being conducted virtually or in some cases by mental health staff wearing PPE such as masks. These measures create physical barriers, difficulties in reading emotional expression and for some people an intimidating encounter with mask wearing mental health professional at a time where they may already feel distressed, disconnected or paranoid. Support groups, group therapies and social projects that are a vital lifeline for some people with mental illness have been indefinitely postponed adding to the isolation and loneliness of lockdown and social distancing. More recently medication shortages have threatened peoples’ ability to access medication creating a real risk of relapse and unwanted side effects from stopping or changing medications suddenly.
We recognise the enormous work and efforts involved in the rapid adaptations services have made to try to sustain some accessibility to mental health care through the pandemic and indeed we hope that some of these changes will be here to stay (for example, the option for virtual consultations where they both meet clinical need and are desired by the patient). We also accept the need for social distancing measures and for mental health professionals to have adequate PPE to protect themselves and patients from exposure to COVID-19. However, we also wish to acknowledge the adverse effects the reductions in service provision are likely to take on people with existing or new needs that require help from mental health services.
The impact of COVID-19 itself represents another challenge and living with the threat of an unknown and potentially fatal new illness presents a psychological burden. In addition, lockdown measures to manage the spread of infection and their economic and social impact are likely to have a profound effect on people’s mental health. Whilst, some level of anxiety is indeed normal during these uncertain times and many people will cope well, perhaps even finding new sources of strength and resilience as they weather this storm, we should not underestimate the potential impact of this on others. A recent paper looking at the potential mental health effects of COVID-19 highlights in particular the likely burden on already vulnerable groups including children and young people affected by school closures, crowded housing, effect of lockdown on alcohol consumption, domestic violence and child maltreatment, older adults, people with existing conditions who are deemed to be more at risk for serious illness or death as a result of COVID-19 infection and being asked to ‘shield’ for a prolonged period of time, socially excluded groups such as prisoners, homeless people and refugees and people facing job insecurity and financial uncertainty.
Looking to previous epidemics for clues as to how mental health might be affected by COVID-19, the 2003 SARS outbreak was associated with a 30% increase in deaths by suicide amongst older adults in Hong Kong attributed to the stress, anxiety and social disengagement caused by the outbreak. Additionally, the economic effects, unemployment and uncertainty generated by the COVID-19 response are likely to contribute to an increased risk of suicide in the population at this time and it is recognized that a strategic response to the mental health effects of the pandemic and to prevent suicide is necessary to mitigate the effects. People who survived severe and life threatening SARS illnesses during the 2003 epidemic were at risk for anxiety and PTSD responses. Indeed, there is increasing recognition of the lasting effects of experiencing critical illness and ICU treatment including increased risk of depression, anxiety, PTSD and neuropsychiatric symptoms alongside the demands of physical recovery for both patients and their families. One particularly cruel aspect of COVID-19 is the separation of families from people at the end of life and social restrictions precluding gathering for funerals and comforting one another during bereavements which may contribute to complicated grief reactions.
In addition to all of this, health care staff may be at risk for experiencing moral injury and overwhelming stress from caring for patients with COVID-19 as well as facing contracting the illness themselves and/or seeing colleagues becoming seriously ill and in some cases dying prematurely of an infection that they likely acquired at work. This strain is worse on BAME staff, who are disproportionately represented in the death toll of NHS workers dying from COVID-19. This is a matter that needs to be urgently addressed.
There’s a lot happening to all of us but while we may be weathering the same storm, it is certainly not the case that we are all in the same boat. Some of us will find new sources of strength during the pandemic, ways to maintain good mental health and social connections. It may be that future working arrangements and health care provision will make more use of technological interventions becoming more flexible and accessible for everyone in the future. However, whilst some are adapting well to the challenges in their comfortable boats, others are in precarious life rafts or clinging on to drift wood for dear life. However understandable extreme reactions may be to the circumstances we now find ourselves in, we need to be careful not to minimize the distress and reactions that many in our society are likely to face. We need to plan and build a fleet of well-equipped lifeboats to provide a comprehensive rescue package to the worst affected. That has to include financial aid, social supports, medical care including psychiatric medications and psychological therapies for those who need them. The NHS expanded its ICU capacity to care for people severe COVID-19 infections. Now it must rise to a new challenge of meeting the needs of those whose mental health has been severely affected as a result of the pandemic.
We end with a plea for both anti-psychiatry and pro-psychiatry circles to move away from polarised debates which help nobody and work together for the good of all people experiencing mental distress at this extraordinary time.
Ashley Curry is a recovered OCD sufferer who also has a diagnosis of Tourette’s. A full-time barber, he is also a keynote speaker for the NHS, a lay member of the scientific advisory board for Tourette’s Action and an expert by experience teacher for therapists and teachers in education.
Jo Edge is a mental health campaigner who spent three months in an acute psychiatric ward. She has a diagnosis of depression and OCD. She is a precariously-employed medievalist who is about to start as Women’s Rep on UCU’s National Executive Committee. She is a founding member of MadCovid.
Ruth Ann Harpur is a clinical psychologist who has worked in a variety of NHS settings and independent practice.
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