As much of the world moves slowly out of lockdown and health services begin to reshape into what will pass for a kind of normality, one thing is clear – the mental health consequences of the pandemic are immense and will be long-lasting.
In the UK, specialist services and primary care alike are dreading what some are calling a ‘tsunami’ of mental illness caused directly or indirectly by COVID-19.
What makes matters worse is that it comes at a time when mental health services, pre-pandemic, were already buckling under the levels of demand, coping with the effects of recession, and desperately needing additional resources and, of course, enough staff to run them.
So how will services cope with the current and upcoming crises – and will there be any positives, or learning to be taken from the pandemic?
‘The first lesson is that it’s best not to be in this position in the first place,’ says Adrian James, who has just taken up post as president of the Royal College of Psychiatrists. ‘If you’re already playing catch-up, when a crisis hits then you’re in a much less good position to deal with it.’
He is anticipating a huge increase in demand: this includes from people who have experienced a degree of trauma as a result of having COVID-19, people who have been bereaved owing to the pandemic, and those with pre-existing mental illness who haven’t been able to access treatment in a timely way.
‘There’ll be people with depression and anxiety who won’t have been coming forward to see their GPs, so there will be untreated mental illness which we also know tends to get worse and worse and then present much later with a greater need for input,’ he warns.
Declining access to care
Andrew Molodynski, national mental health lead for the BMA consultants committee, and a consultant psychiatrist in Oxford, says that while demand is already beginning to pick up, he worries about the effect in the medium and long term. This includes ensuring that people can access care.
‘I still believe that the majority of people who get as far as mental health services get safely looked after – yes, things are sadly more stretched and less humane than they used to be, particularly in the crisis care sector, but the system is going to come under even more strain and there will be even more of a problem in terms of human rights and access. Getting to services is going to get more and more difficult, unfortunately.’
We cannot underestimate the long-term effect this will have on people’s mental healthVicki Nash, head of policy and campaigns Mind
On a positive note, specialist services have been innovating – not just by using video consultations, but also in having ‘walking’ appointments in the open air, which is safer and requires less or no PPE (personal protective equipment). Services are linking in better with voluntary groups and stronger relationships have been building between different parts of the local health and care economy.
Vicki Nash, head of policy and campaigns at the mental health charity Mind, wants action. ‘This pandemic has been as much a mental health emergency as a physical health emergency,’ she says. ‘As we look forward, we cannot underestimate the long-term effect this will have on people’s mental health.’
It is positive, she says, that mental health has been part of the national conversation around COVID-19, but she adds: ‘We know existing demand for mental health services is set to increase, and our research shows people with mental health problems already have been struggling to access the support they need in primary and crisis care. Many services turned to digital support, but 1.9 million people do not have digital access, which serves to deepen existing health inequalities. Mental health services need to be equipped to support those who have fallen through the net during the pandemic.’
Overcrowded and deprived
Primary care is also bracing itself to cope with an upsurge in demand from patients with mental health needs – indeed, according to Southampton GP and BMA council member Alex Freeman, it’s already proving a challenge.
‘It’s tough, it’s really tough. [Specialist] mental health services are running, but a lot of the mental health issues that we’re seeing in general practice are what you might call the lower level issues which normally wouldn’t access specialist mental health services,’ she says.
‘We’re seeing people presenting with a lot of anxiety, sometimes with depression. We’re seeing a lot of people who have been doing their best to survive in often very difficult circumstances – we have quite a deprived population that we cover. We’ve got families that have been stuck indoors in overcrowded situations where children haven’t been able to go out to play because they’ve got no access to the outside, so they’re finding life pretty tough at the moment. We’re also having a lot of presentations of people who feel that they are at risk from COVID-19 even though they’re not deemed to be at high risk, according to the definitions, but who are being pressurised to go back to work and are contacting us because they don’t feel they’ll be safe there, and that’s causing them a lot of anxiety as well.’
Patients who are frontline workers, including in the health and care sector, are feeling the pressure – many of them are exhausted as well as worried and anxious, she adds. Bereavement and grief are also issues.
We’re seeing people presenting with a lot of anxiety, sometimes with depressionSouthampton GP Alex Freeman
‘We’re going to be dealing with the fallout from this for years,’ says Dr Freeman. ‘In my area we weren’t hit as hard as for example parts of London, but we’ve had some patients die from COVID and their relatives find it quite difficult to cope because they don’t want their loved one to be a statistic.
'It’s tough doing bereavement calls at the moment mainly because people are saying, “well we can’t have a proper funeral” and they’re finding those initial stages very difficult – and what happens immediately post-bereavement is actually quite important for people and they’re being prevented from doing what they feel they would be doing under normal circumstances.’
Practices are already taking steps to help manage the anticipated rise in needs, including directing patients where appropriate to resources such as online CBT (cognitive behavioural therapy), she says. But she adds that more resources will have to be put into mental health services to help cope with demand in primary and secondary care.
Dr James also says more resources are needed, and is calling for money already promised in England’s Long Term Plan to be delivered and front-loaded.
‘We want to make sure the Government hears a clear message that we need at the very least the extra funding that’s been promised, but we need more down the line, and we need to empower clinicians and patients to work in innovative ways. There have to be some positives from COVID-19 and we do need to bring them out, but there will be negatives we have to look at as well.’
The BMA is calling for action to ensure that mental health services are properly funded and equipped to meet the anticipated increase in demand and to make access easier for everyone who needs it.
The association’s paper, Beyond Parity of Esteem: COVID-19 and mental health in England, warns that the pandemic is likely to have a negative psychological impact on the population, with some people developing a mental illness for the first time, while others with existing problems could find their symptoms worsening.
The BMA warns that prior to COVID-19, services were often unable to provide all patients with the services they needed because of a lack of resources – and is concerned that the likely increase in demand will make that position worse.
It also says the pandemic’s effect on population mental health could widen existing inequalities in society if attention is not paid to the specific vulnerabilities of certain groups and demographics.
The BMA also wants better preventive measures to look after the mental health of the population and the workforce.
Doctors under stress
Doctors are reporting increased levels of work-related mental health conditions as a result of the COVID-19 pandemic, a BMA survey has found.
Nearly half said they were suffering from depression, anxiety, stress, burnout, emotional distress or another mental health condition relating to or made worse by their work; this was made up of 31 per cent who said it was worse during the pandemic, and 13 per cent who said they were suffering but it was no worse than before.
More than four in 10 of those who responded (42 per cent) said they had had to access NHS wellbeing support services provided either by their employer or a third party.
Many of those taking part in the tracker survey also expressed a lack of confidence in their ability to manage patient demand as normal NHS services were resumed.
Just over half (53 per cent) said they were ‘not at all confident’ or ‘not very confident’ about managing demand in their own department or practice, while 61 per cent were not at all or not very confident in the ability of their local health economy to do the same.
There was even less confidence in their ability to manage demand in community settings such as care homes – with 23 per cent saying they were not at all confident and 44 per cent saying they were not very confident.