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Opinion The mental health impacts of this pandemic are yet to be understood

Dr Stephen McWilliams says mental health difficulties should be taken into consideration as we emerge from the past 18 months of trauma.

HERE ARE FINALLY signs of improvement in the battle against Covid-19, at least in Ireland. We have seen 18 months of restriction (and sometimes chaos), over 360,000 diagnoses and some 5,155 deaths.

Across the world, over 220 million people have been diagnosed and almost 4.6 million have died. But equally, we have witnessed a triumph of the human spirit not seen since World War II.

There are currently 114 vaccines in clinical development, according to the WHO, while four have been licensed for use in the EU. In Ireland, around seven million doses have been administered meaning that over 83% of the population over the age of 12 is now fully vaccinated. And it appears booster doses may be in the offing for some groups of vulnerable adults.

The trauma of a pandemic

But the pandemic has taken its toll, not least on mental health. From the outset, it was clear from studies worldwide that Covid-19 was not just a physical concern. One study in China noted the pandemic had a moderate or severe psychological impact in almost 54% of respondents. Of these, 29% and 16.5% reported at least moderate anxiety and depressive symptoms respectively.

A much larger study in Spain examined 21,207 people (mostly with no prior mental illness) during lockdown and found depressive symptoms, avoidant behaviour and stress in more than 41%, 39% and 27% respectively.

Ireland has not been spared. The impact of Covid-19 on suicide rates here is not yet clear because coroners’ reports take time, but the effect on mental health generally is easier to judge.

An Irish study involving 1,000 people during the first lockdown showed 41% reporting loneliness, 23% reporting major depression, 20% with generalised anxiety and 18% reporting post-traumatic stress. In May and June of 2020, the College of Psychiatrists of Ireland surveyed 195 psychiatrists, of whom 79%, 72%, 54% and 57% reported an increase in referrals for generalised anxiety, health anxiety, panic and depression respectively.

Other Irish studies have echoed these results and, having worked in frontline psychiatry throughout the pandemic, I am in no doubt that the statistics represent the reality. Some people are experiencing psychiatric illness for the first time while others are succumbing to a relapse of an existing illness that they might not have had without the stress of the pandemic. But it is important to remember that most people who are anxious, stressed, lonely or simply fed up with the implications of Covid-19 are not mentally ill; they are experiencing normal and appropriate human emotions in response to a prolonged crisis. These are legitimate concerns that should not be pathologised.

The reasons for mental health issues over the past 18 months are manifold. Initially, collective anxiety accompanied the relentless media coverage, NPHET briefings and daily statistics. This was followed by physical distancing and other restrictions, including self-isolation and quarantine, limiting the close supports people need to cope with a crisis.

There was government advice to close some businesses and work from home where possible. Loneliness has been a particular issue for many. Conversely, essential workers such as nurses, doctors, Gardaí, shop assistants and cleaners were asked to work regardless, often leading to high levels of stress and burnout.

Emotions generally ran high, with anxiety, anger, confusion, frustration and boredom particularly prevalent. Despite the Pandemic Unemployment Payment, serious financial concerns were inevitable for many, and debts will have mounted on both personal and national levels. Taxes will inevitably rise. Compound this with bereavement, particularly the loss of so many older relatives and the restrictions that prevented loved ones holding their hands at the bedside during their final hours.

Fear of ‘normal’

At long last, the government has announced the lifting of almost all Covid-19 restrictions by 22 October 2021. But the prospect of opening up brings its own set of worries. Healthcare workers and others may ruminate about the fourth wave, new variants and the risk of vaccine immunity wearing off in the absence of boosters. With the start of a new school term, teachers are worried about the risks inherent in reopening schools.

Many ordinary people in society will have “regressed” over the past 18 months, losing some of their self-confidence. Unemployment has a tendency to do this. As such, anxiety may actually increase for some people now faced with reintegrating with a functioning society.

But, for others, the removal of restrictions means a remedy for loneliness and an opportunity to reconnect with family and friends. Business owners, people in financial difficulty due to the restrictions, and young people cut off from their friends have all been keenly waiting for life to return to normal. Finally, there are some signs that this might happen.

Alas, the mental health consequences of Covid-19 will not all suddenly abate with the removal of restrictions. Previous epidemics have borne this out. In Hong Kong, one study followed patients originally hospitalised for SARS in 2003 and found that, 30 months later, 59% had a mental illness, most commonly depression or post-traumatic stress disorder.

Evidence emerging from the Covid-19 pandemic suggests we might see a similar aftermath. And then we have the emerging evidence of post-viral syndromes (often referred to as “long Covid”) involving fatigue, breathlessness, palpitations, joint and muscle pain, and other symptoms.

Many people will worry about their existing physical and mental health conditions where normal care has been severely disrupted by the prioritisation of Covid-19 over the past 18 months. And the mental health of countless others will have been adversely affected by increased rates of domestic violence during the pandemic, alcohol and other addiction issues, and other social problems.

A recent report by the OECD entitled “Tackling the Mental Health Impact of the Covid-19 Crisis: An Integrated, Whole-of-Society Response” highlights the marked worsening of population mental health during the pandemic, with the prevalence of anxiety and depression doubling in some countries.

It points out that that the mental health of unemployed people and those experiencing financial insecurity has been particularly affected. It adds that mental health services were already over-stretched before the pandemic began, but that “the scale of mental distress since the start of the pandemic requires unprecedented levels of mental health support if it is not to lead to permanent scarring”. In Ireland, this means adequately resourcing community mental health teams, in addition to firm measures to protect jobs and incomes.

There remains a lot of work to be done. But then, people with mental illness are among some of the most resilient people I know. As a society, we have done tough stuff before. And, inevitably, things will get better.

Dr Stephen McWilliams, Associate Clinical Professor at UCD and Consultant Psychiatrist at Saint John of God Hospital, Dublin. His book, Psychopath? Why We are Charmed by the Anti-hero, is published by Mercier Press.

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Dr Stephen McWilliams
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