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‘Covid-19 and Mental Health: What Lurks in the Shadows’ by Dr Candice Condon

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We have all become familiar with the daily news reporting of the numbers of Covid-19 cases and deaths and this is obviously a factual reporting of details of the physical virus. Such reports have overtaken our social media feeds, airwaves, newspaper pages and screens for almost five months now and the feelings of negativity that come with that have been unavoidable in today’s technological society. Without doubt, it has been an extremely difficult time in what is the reality of the situation in the country. But, there is also another reality that is not being reported and that is the psychological impact that lurks in the shadows of the virus, as a result of the complicated nature of this pandemic and how it is affecting the human psyche. Lurking in the shadows of the shutdown of society (as we know it) are the psychological effects of the pandemic and those people who have been struck with mental health struggles, a worsening of their mental health or battling against a relapse. The numbers and deaths associated with Covid-19, as a result of mental health challenges are rarely reported in the news. You must search and dig to find these numbers and figures. Ordinarily, mental health comes second to physical health in this country and has long since been pushed into the background, but since this pandemic has begun, we have seen it slip even further in its importance when it comes to those in power in our society. Further, at a time when it was probably needed more than ever, it seemed the invisible psychological illnesses were pushed to the back of the minds of those governing our health system. Psychological disorders do not discriminate-they can hit anyone and at any time. And this pandemic has been a catalyst for that wave of psychological destruction. In these difficult and uncertain times, nobody is immune to its destructive force and consideration needs to be given to that reality.

 

One of the common occurrences during these times of lockdown has been an increase in levels of anxiety and how could there not be? Anxiety can, and does, affect any individual, group or cohort in our society. If you have never experienced anxiety, then you are in the minority in contemporary society. Firstly, let’s consider social anxiety disorder in light of the pandemic. Those who may ordinarily struggle (but function with coping mechanisms) with everyday social anxiety may now have very new challenges to face. Shopping in large and often crowded supermarkets may have been an issue before but then these new unknowns have presented themselves and exacerbated the problem. You may be turned away from a store when shopping at a certain time, you may be checked that you are wearing a mask and you may generally have more of a spotlight on you when you are queuing and entering a store. For many, this may not even be a passing consideration but for those with social anxiety, it presents a difficulty (even when they understand it is illogical) and may force people back into the security and confines of their home. Those people may have battled for years or months to make a simple trip to the shop and have now taken a number of steps backwards. Those with children are almost treated like lepers (as are the children themselves) if their children have to accompany them to the shops. People started to judge each other and in some cases, we hear of people turning on each other or calling each other out. There was almost a forced agoraphobia put on us – a fear of leaving the safety of our homes. So, whereas previously those with such a disorder (diagnosed or undiagnosed) may have battled daily with leaving the home and facing their anxiety, now it has gone in the other direction where they must not do that. And for those who had not previously experienced any anxiety issues, they may find themselves sitting watching TV or homeschooling their children and all of a sudden they feel a quickening of their heartbeat, a shortness of breath, a feeling of nervousness/panic/fear, notice a rash on their skin, a feeling of nausea, and/or increased perspiration. The reason may not be obvious. You may wonder if you are coming down with something. This can be the invisible and often unexpected attacks of generalised anxiety. It can strike without warning whenever it chooses to do so.

 

Now, let’s look at depression in light of the pandemic, because it is considered the close cousin of anxiety and it is the (mood) disorder which coexists (comorbid) with anxiety most often. Andrew Solomon talks about depression as being unable to do the things that to others may seem like the simplest aspects of everyday functioning, like getting out of bed, having a shower, answering a call or text, or making yourself some lunch. It has been described by many metaphors such as ‘taking to the bed’ the ‘dark hole’, and the ‘black dog’ to name a few. It manifests itself in various ways from one person to another. During this pandemic, people have had much time within their own four walls, where they may have experienced racing thoughts or a slowing down of thoughts, been unable to sleep or sleeping too much, losing interest in the things that once interested them, searching through Netflix for hours on ends but being unable to concentrate on an episode or movie. All signs of mental health struggles and signs of possible depression. There are also many other aspects of mood disorders that may have been evident during the shutdown such as episodes of mania (uncontrolled cleaning/spending/exercise, or activities that are generally out of the ordinary for a person). There may be periods of just not being able to do anything at all as the days and nights stretched out ahead for an interminable times, as people had no sense of when (and at the worst point if) this pandemic would come to an end. The word normal was becoming more out of reach with each passing day.

 

During the lockdown, our individual autonomy and control was taken away from us and although it was necessary in order to contain and control the virus, the psychological effects of that resulted in many people feeling controlled. One classification of a psychological disorder that is associated with the need to take back control in some aspect of one’s life is eating disorders. Eating disorders such as anorexia nervosa, bulimia nervosa, binge eating disorder (or any combination of those) that may have been in recovery could very easily be plunged back into being an active disorder. All routine was taken from us and this includes food and eating routines. Gyms and pools were closed. We were home constantly, with only an allowed and restricted time outside. It is a given that people who have a tricky relationship with food will eat for many reasons-boredom, stress, sadness, reward, happiness and most and any emotions that we can think of. Ordinarily, Ireland’s health system struggles with treating eating disorders and at best, it is about management and a trial and error approach. But in these controlled times, I feel it is going to be something that is going to need a lot more focus and resources put into. Within mental health treatment, it comes further down the line of understanding and treatment when compared to disorders such as anxiety and depression and this shouldn’t be the case. Death from eating disorders is a reality, as is death from other psychological disorders.

 

Reports from agencies and organisations that assist with victims of domestic abuse have reported a significant increase in the amounts of calls to their services. Such agencies and organisations reported a steady rise in the need for their assistance as the country went further into lockdown. When the initial lockdown was put in place, it was a very worrying time for such organisations with the restrictions being set out by government to not leave our homes, except for food shopping or exercise within the phased restrictions of the time. In such situations where there is domestic abuse (physical, psychological, emotional), there is a feeling of being trapped and with few options so this negatively effects the mental health of the victim and the mental health of children in the home who are experiencing it either directly or indirectly. It was a very stressful time for people in those situations and exacerbated by the pandemic restrictions of the time. An Garda Siochana issued statements that the restrictions did not apply to those who were escaping abusive and harmful situations at home. There was a positive development that in response to the increase in domestic cases that most Garda stations put in place (or already had) a dedicated liaison officer and follow-up service for any domestic cases that were reported to them.

 

So, why are these occurrences and pressures on mental health happening during this pandemic? There are a multitude of complex reasons and combinations of those reasons interlinking with each other. Huge changes were forced on us in a very short space of time. It all happened in the blink of an eye. Working from home became a reality for some and for others, the loss of a job or loss of a business (temporarily or permanently) was their reality. The financial stress began, with no way of knowing how long it was to continue. Childcare and crèches closed, sports were cancelled, GAA pitches were shut, dance studios were locked, older people were ‘cocooned’ and people were generally forced into a situation where they were in each other’s pockets. Students at all levels, from 1st to 3rd level were affected. There were pressures on parents to become teachers overnight and engage with homeschooling and new technologies, whilst also caring for family members and trying to work from home. The leaving cert debate continued for many months. College students had to adjust to having taking their final exams online or a change to continuous assessment. Children in junior infants were still settling into their new reality of primary school. Those who had started secondary school and were still adjusting were now faced with the reality of having to use Google classroom or some other app to learn new work and be assessed. The reality was an increased screen time for all, whether it be Zoom or some other video app, increased time in front of a computer, or increased phone time whilst continuing to check on the progress of the virus. All of this equated to significant stress and strain on people and could become overwhelming. Families were together all of the time, morning, noon, and night. The best relationships may be strained under those conditions. Social isolation and ‘cocooning’ led to a key human need not being met and that is the need for social contact and the consideration that as social animals, it is part of our well-being that we regularly interact with people. We know that mental health is improved whenever we get the chance to share or talk about it with someone we trust. People who may not have experienced mental health challenges previously may have found themselves in a new and scary frame of mind. Our every move was being controlled and there was no endpoint in sight for a significant period of time. All of that is very difficult for the human mind to comprehend and cognitively process because most of us have never experienced such measures and control being put on us. For most people, there would have been ups and downs on a daily basis.

 

Let’s consider the supports that were actually there for people when they found their minds in a dark and lonely place, during these unprecedented times. Financially, the government stepped in quickly and put the Covid-19 payments and supports in place, which probably served to alleviate some (but not all) financial pressures. However, it appears there was very little put in place to tackle the realities of a new mindset for people, in an ever-changing landscape. These are the overlooked or even ignored effects of this pandemic. Most HSE psychiatric outpatient appointments between March and June were cancelled or rescheduled. This is extremely anxiety inducing and worrying for people who rely on these services, either weekly, fortnightly or monthly. Those appointments can be the thing that keeps them going through the most difficult times. Some services such as CAMHS continued or resumed for children/adolescent appointments but many were reduced or had schedules altered. We heard of the awful and worrying cancellations of many outpatient services such as oncology services and cancer screening services but we heard little about the mental health appointment cancellations. The HSE have a small link on their website for mental health for children and older people during Covid-19 but is this enough? They have a new advertisement that shows emoticons to highlight that if you can’t talk that you can text if you need help. Pieta house may be available to those with suicidal thoughts or ideation but it is by appointment only. The question is-Has our government ensured that there are supports for those suffering from mental health pain as a result of Covid-19 in the same way as they have addressed the physical coronavirus? Is one more important than the other? People generally didn’t attend their emergency departments during the lockdown due to the fear of catching the physical virus. A lot of the mental health responsibility during the pandemic has fallen to non-government agencies, not-for-profits and charities such as Aware, Spunout.ie, Jigsaw, Samaritans, Childline, and Pieta house as well as other specialist and dedicated support groups and organisations.

 

In recent days, we are starting to hear about the ‘new normal’ but no one really has any perception of what that might be. For those who struggle with the challenges discussed above, either continually or sporadically, this can be a very daunting concept. The nature of mental health is that there is probably a feeling of relief now that there is a loosening of restrictions and less forced isolation but what may remain is the trauma and stress that has come with the past few months. Now, there must be a focus on those people who have not recovered from the mental strain of the pandemic. We must remember that the ways that Covid-19 has affected us is very complicated and all aspects of this must be considered in our recovery plan. Physical health and mental health are not mutually exclusive, they often coexist and affect people in equal measure and this must be reflected in our health system. Post-viral disorders (such as ME/CFS) where anxiety and depression exist alongside the physical symptoms are on the increase and it is expected that it will continue to be the reality in the aftermath of this virus.  The visible (physical) and invisible (psychological) waves will continue long into the future if  these are not given the attention they deserve. Mental health has been forced into the shadows for long enough. That being said, let us take one significant and hugely positive thing away from the devastation of this pandemic, and that is that with support and help when needed, we are a resilient people and we will adjust to whatever the ‘new normal’ sends our way.

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