Show Hide image Health 19 May 2020 The other epidemic: how coronavirus triggered a surge in mental illness The behaviours necessary to fight Covid-19 are having painful psychological consequences. By Emily Bootle Follow @@_emilybootle Early coronavirus Britain was a nation unduly preoccupied with toilet paper and rigatoni. Photographs of bare supermarket shelves swirled around social media. In late March, some supermarkets implemented restrictions on how many items customers could buy. As much as the stockpilers were framed as selfish, most of us anxiously wondered if we should do it too, given the stockpilers were themselves causing a lull in supply. On 15 March, an article in the Psychologist warned against even referring to “panic-buying” for fear it would make more people panic-buy: “Stories that employ the language of ‘panic’ help create the very phenomena that they are written to condemn.” The collective urgency we felt then may have been relatively short-lived, but it threw into stark light the profound effect of the crisis on our collective psyche. Now, the narrative of “panic” is less prevalent. Supply chains for basic amenities are mostly restored. However, the grim reality of a new Britain has set in. Households are struggling to stay stocked with food not because of widespread shortages but as a result of the dramatic loss of income caused by the crisis, as the New Statesman reported earlier this month. The future of work in many industries remains uncertain, while economic forecasts are apocalyptic. As we have watched the UK’s death toll climb above every other country in Europe, anxieties about pasta have been usurped by anxieties about whether family and friends will be part of that steadily growing number. For others, for whom the worst has already happened, this is a period of grief and loss, the pain only exacerbated by being isolated from those sharing their experience. On 5 May, the Office for National Statistics reported that the number of people suffering from high levels of anxiety has almost doubled since the end of 2019, to over 25 million, with 49.6 per cent of people rating themselves higher than six out of ten on an anxiety scale between 20 and 30 March. Similarly, a survey of young people by the mental health charity YoungMinds found that 83 per cent of respondents said the pandemic had made their mental health worse. With some of the most vulnerable having to isolate alone, loneliness has increased, widely cited as a risk factor for clinical depression. Behaviours that for obsessive compulsive disorder (OCD) sufferers would be strongly discouraged as part of a therapeutic response – rigorous handwashing, extensive googling, thoughts about one’s propensity to cause others harm – have become, for many, normal parts of daily life and some won’t know when or how to stop. On social media sites and in government campaigns, we are encouraged to look after our mental health during these “unprecedented times”. Doing so is far from straightforward. Those who already suffer from common mental health problems such as anxiety and depression are likely to see an increase in symptoms. Those who are usually mentally healthy may be tipped into neurosis by the sheer stress of this unknowable situation. Plenty will experience shattering grief from the loss of loved ones and further trauma from not being able to say goodbye. Where those furloughed from their jobs have empty days to fill with rumination and worry, NHS staff are burned out and breaking down – the military veteran charity Help for Heroes has compiled an advice package for health workers on how to deal with post-traumatic stress. Many of those who suffer from severe mental illness are limited in their access to their usual support systems and medication. Under the surface of coronavirus, there is another epidemic. *** The causes of clinical mental health problems are complex – but it is often the combination of a genetic predisposition and an environmental trigger that causes the onset of symptoms. The pandemic could, for some, be that trigger. “At an individual level people will have a certain vulnerability that they bring into this crisis,” says Guy Goodwin, professor of psychiatry at Oxford University. “Then the crisis itself will have a whole series of potential impacts.” Selali Fiamanya, a junior doctor in psychiatry at Cross Lane Hospital in Scarborough, agrees: “With mental health issues, everyone is on a spectrum. And what we might see [as a result of the crisis] is everyone being pushed slightly to the right of that spectrum. A small percentage may be pushed over the threshold from functioning normally to having a mental health issue.” There are many ways in which the pandemic is affecting mental health, aside from anxiety about the virus itself. Paul Atherton, a film-maker and artist being housed in emergency hotel accommodation for the homeless, has suffered from panic attacks and depression throughout his life. He has been housed in a ground-floor hotel apartment in a block under construction and is finding his mental health adversely affected by the lack of natural light and constant noise. “If there is no construction noise and it is warm, I leave the front door open to connect to the outside world,” he says. “But if that’s not the case, the small space is incredibly oppressive.” John Bailey, a landscape gardener from Silver End, Essex, has found his mental health affected more than he could have imagined. “I normally pride myself on being quite a mentally strong person, I’ve never really had any issues before,” he tells me over the phone. "But the last couple of weeks I’ve found it really difficult.” John is self-employed, and although he has continued working through the lockdown – adhering to social distancing guidelines – he is concerned that his services as a landscape gardener are a luxury rather than a necessity and that business may plummet during a recession. He is also feeling generally down, a mood that is ever present, and has had trouble sleeping. “I think it’s from missing social interactions with people, and being stuck in a routine of work and home,” he says. “I’ve never felt like this before. I like to get everything off my chest and then move on. But you can’t really do that at the moment. With everyone feeling the same way, you don’t really want to burden others with your feelings.” The Department for Health and Social Care has provided an extra £5m in funding for the voluntary and community sector in mental health to help with the increased demand for services. But this increase will inevitably put pressure on an already overstretched part of the NHS. The Improving Access to Psychological Therapies (IAPT) programme, devised by the last Labour government in 2009 to treat common mental health problems, led to an 80 per cent increase in referrals between 2011/12 and 2018/19. Though the scheme has undoubtedly succeeded in its aim of improving access, with over half a million people completing their course of IAPT treatment in 2018/19, it is functioning at capacity and may be unable to cope with a post-lockdown surge in referrals. According to the mental health director for NHS England, Claire Murdoch, there has been a 30 to 40 per cent drop in referrals to mental health services: evidence of the public’s reluctance to “burden” the NHS – a mood also apparent in the 63 per cent reduction in urgent two-week suspected cancer referrals – rather than a lack of demand. Wendy Burn, president of the Royal College of Psychiatrists, said: “Our fear is that the lockdown is storing up problems that could then lead to a tsunami of referrals. Mental health services will be at risk of being overwhelmed unless we see continued investment.” IAPT has had to cancel appointments since the lockdown began: social distancing measures generally preclude face-to-face talking therapies (though after discharge from hospital, the clinical need may sometimes be too great to deny face-to-face treatment, says Fiamanya). Though many private counsellors and psychotherapists are treating clients on video calls, some people do not find it as effective. Paul Atherton would normally go to the Caravan, the free walk-in counselling service at St James’s Church, Piccadilly, which is currently closed. It is offering a phone service, but this wouldn’t necessarily help Atherton. “One of my coping methods is distraction, and engaging with those around me,” he tells me. He does not find talking to friends on Zoom has the same effect, failing to provide the same emotional connection. Similarly, the benefit of therapy would be the face-to-face contact, something that is now impossible. John Bailey feels similarly. “Zoom and Skype and phone calls are not the same as going out for a meal or a quick pint and chatting your problems out,” he says. The tragedy of the mental health epidemic is not simply that it is running in parallel to that of coronavirus, but is being actively caused by the behaviour necessary to fight the virus. For the elderly, for example, the psychological effect is twofold. “The elderly know that the thing’s coming down the track straight at them,” says Guy Goodwin. “They’re often living alone and lonely and their access to social activity has been cut off. They’re limited in how they can use the ways of connecting socially that younger people find easier. The very age group that are most likely to die are the group who are most at risk of being frightened, alone and unable to adapt.” A care home manager in Wiltshire told the New Statesman earlier this month that she was watching her residents “lose the will to live”. Similarly, cautious behaviours and thought processes that are currently necessary – even government-mandated – could be habit-forming. In some cases this could give way to or exacerbate symptoms of OCD. David Adam observed in the Guardian in March the impact of past epidemics on OCD sufferers and how in some cases they actively caused the onset of symptoms: in the 1980s, anxiety surrounding HIV became a major theme for OCD patients; in the 1920s there was a surge in “syphilis-phobia”. OCD patients, whose compulsions are an attempt to solve, preclude or eradicate their obsessions, tend to cling to shreds of evidence their obsessions are rational or real in order to justify carrying out the compulsion that brings them solace. In the current situation, for those with contamination fears in particular, it can be very difficult to know what is “rational” and what isn’t. On a web page on how to cope with the coronavirus pandemic, OCD UK advises: “It’s perfectly normal for people to wash their hands to minimise the risk of a highly contagious virus, it is a normal rational response to a genuine and significant threat. But when that hand-washing becomes extreme, then the safety seeking behaviour is arguably causing more harm than the virus itself.” *** Perhaps even more troublingly, the pandemic is already having a profound effect on those with diagnoses of severe mental illness. In March, emergency legislation altered the Mental Health Act so that only one doctor – rather than three – needs to recommend detainment, in anticipation of staff shortages. Awareness-raising campaigns surrounding general wellbeing during this period are in danger of leaving behind the severely ill, according to Guy Goodwin. “We shouldn’t forget the severely mentally ill group,” he says. “They’re the most stigmatised. While our effort to think about mental health as a societal issue is great for destigmatisation, I’d personally be a little concerned that in ‘normalising’ mental illness we’ve taken away the true threat of it to the small number of people with a severe condition.” Simon Kitchen, the chief executive of Bipolar UK, agrees. “For some people to maintain their good mental health they need to be able to keep in regular contact with a psychiatrist, know their medication supplies are guaranteed, and to get a proper routine in place. Mindfulness and keeping in contact with friends might help, but it’s not enough in and of itself.” Kitchen tells me that Bipolar UK’s users are struggling to access GPs and psychiatrists during the lockdown. This is crucial for a condition for which the most effective treatment is medication, he explains, and where patients need to be able to alter their dosage depending on their symptoms. Community support groups put in place by the charity have had to be replaced by digital ones. The logistics of running these groups via Zoom is slightly limiting: fewer people can attend, they are shorter, they cannot be open to all for safeguarding purposes. But they are helping people, says Kitchen: “You have an emotional intimacy with other people with the condition, and simply being on a call with people you know have got it makes a big difference in itself.” Again, the effect of the crisis is twofold: people living with mental illness are likely to see an increase in symptoms just at the time they are less able to access these services. “What we’re seeing is these extra tensions – be it being enclosed in family situations, having the kids home from school, the general stress and anxiety surrounding coronavirus, or not being able to get access to medication because of lockdown – tipping people into relapse of their other underlying conditions, be that a psychotic illness, destabilising a personality disorder, or relapsing into a bipolar episode,” says Fiamanya. Kitchen explains that a lot of people who can usually “self-manage” their bipolar are finding it harder to predict their moods: uncertainty can be destabilising. Routine is crucial to managing the condition, and unclear messaging surrounding lockdown restrictions may prove extremely unsettling. Bipolar is characterised by extreme moods: mania, which can lead to psychosis, and severe depression. Kitchen says Bipolar UK has seen more people than usual becoming manic during the lockdown period, which means they are more likely to need hospital treatment. At Cross Lane, the workload of crisis and community teams has been ramped up to prevent more people coming into hospital than is absolutely necessary. “In the inpatient unit we’ve been having fewer admissions. That is down to the excellent work of the community and crisis teams, who are doing really well at maintaining people outside hospital,” Fiamanya tells me. However, across the board it seems there has been an increase in urgent cases, with new data from the Royal College of Psychiatrists indicating that 43 per cent of psychiatrists have seen an increase in emergency referrals since the lockdown began. Fiamanya says that although it’s rare for someone to be hospitalised solely because of anxiety, some patients have a significant fear of coronavirus, with it sometimes featuring in psychoses. Paranoia about being infected might deter some patients from going into hospital. *** When an individual experiences trauma, it can shatter the fabric of their psyche. The way they understood the world no longer makes sense; trauma can trigger the onset of symptoms of mental illness. Traumatic events that occur on a societal level can increase rates of anxiety and post-traumatic stress among individuals, causing a wave of mental illness. (It was only in 1980 that post traumatic stress disorder was given a psychiatric definition in the Diagnostic and Statistical Manual of Mental Disorders, propelled by the high rates among US veterans of the Vietnam War.) But these events – wars, natural disasters – can also have an impact on society at its foundation. In his 2018 paper “Collective Trauma and the Social Construction of Meaning”, the political psychologist Gilad Hirschberger writes: “Collective trauma is a cataclysmic event that shatters the basic fabric of society. Aside from the horrific loss of life, collective trauma is also a crisis of meaning.” When I speak to Hirschberger over the phone in April, he tells me that the coronavirus pandemic already constitutes collective trauma for specific communities who have felt its effects the most, such as those of Wuhan, New York and northern Italy. He considers that most other places are so far experiencing the threat of trauma, rather than the reality, but that this is still impactful on our collective psyche. Its prolonged nature makes it, in a sense, even more difficult to process. “There’s a difference between this and a very severe trauma that is quick and short, something like 9/11 or Pearl Harbor,” he explains. “These are events that are earth-shattering, and they have huge effects. But the event itself is very short lived. Here we seem to be in an event that is more moderate in its effect, but could be very prolonged. And that has a huge psychological effect.” The trauma of coronavirus is affecting our sense of meaning globally: we are being forced to reconsider sociological and economic systems that no longer work on a socially distanced planet. But coronavirus is powerful precisely because of its contagiousness, so we cannot always operate as one global community. “This pandemic is creating a tension between national identity and a common humanity,” says Hirschberger. “On one hand, to provide all the services you need to deal with this pandemic, you need a strong nation state. But at the same time, it’s becoming very clear this is not an issue that can be resolved at a national level: you need international cooperation. Viruses don’t care about borders and fences. All of a sudden, the wellbeing of the ‘other’ becomes a vital interest of the group.” This is reflected on an individual level, deepening the psychological tension. “When people are threatened and afraid, what they want is to be with other people. But now, being with other people is the threat,” says Hirschberger. The anxious behaviour of individuals in response to the threat affects not just them but the fabric of society. Relationships and bonds fragment, causing further problems: not just anxiety about the virus, but feelings of detachment, loneliness and depression that – just like compulsive behaviours caused by anxiety – feel justified. Collective trauma is different from individual trauma because it can persist in subsequent generations, according to Hirschberger, becoming part of the identity of the group and represented in its collective memory. When group traditions are established to eliminate threat, behaviours and beliefs can become embedded. It is impossible to predict if and how this idea will manifest post-coronavirus. But it is possible that anxiety could persist as a more pronounced facet of our culture, given the role of such behaviour in controlling the virus. *** In this age of “self-care”, with pop-psychology infiltrating every corner of the internet, hardship is often framed as an opportunity for personal growth. The coronavirus pandemic can be similarly interpreted: the upheaval causing what Hirschberger would call a “crisis of meaning” and subsequent narrativising. In a world so profoundly changed, some outcomes are bound to be positive. There is the opportunity, for many, for a slower pace of life. We are recognising the importance of community. And for mental health professionals and services, there is the opportunity to find new ways of working with patients. Phone and video consultations becoming the norm could help increase access to services. As ever, an increase in diagnoses may help “raise awareness”. But alongside the growth opportunities, there are gaping holes in support. Bipolar UK has seen a spike in community members who feel suicidal or are self-harming, but expects a 60 per cent drop in income over the next year. “We’re having to make difficult decisions about what services to continue and what services to cut,” says Kitchen. “We’ve had numerous calls – but no money yet.” For the homeless community, the “piecemeal” approach may not be enough, according to Atherton: “Many who have been emergency housed have returned to the street because they were not getting the mental health support they needed. If you’d lived as part of a community on the streets for 20 years and then suddenly found yourself locked in a room, it would be more akin to imprisonment than self-protection.” Just as Britain was unprepared for the scale of Covid-19, it was unprepared for an outbreak of mental health problems on this scale. The outbreak is less visible. It is not infectious. There is nothing about it that prompts us to rush out and buy spaghetti. But as we adapt to living with the virus, the UK must also urgently find ways to manage this other epidemic. Emily Bootle is the New Statesman’s editorial assistant. Subscribe For daily analysis & more political coverage from Westminster and beyond subscribe for just £1 per month!