No aspect of our bodies or our lives is immune to the coronavirus pandemic. This is certainly the case for mental health, with some experts issuing dire warnings about an impending psychological “tsunami”, whether through having mental health problems or our extraordinary attempts to contain them.
While it’s too early to know what the long-term mental health effects of Covid-19 may be, we can seek lessons from the Sars epidemic of 2002-04 and Mers, in 2012, both caused by a closely related virus. The publication in the Lancet Psychiatry of the first comprehensive synthesis of evidence on the psychiatric consequences of coronavirus infection – encompassing Sars, Mers and Covid-19 – offers us some early insight.
This systematic review, led by the doctor and PhD student Jonathan Rogers, of 72 published studies involving more than 3,500 patients found that a quarter of people hospitalised for coronavirus infections including Covid-19 have some kind of confusion or delirium. This is most likely due to reduced oxygen reaching the brain, or the effects of fever but could – in a few cases – reflect a more direct attack on the central nervous system. Neurologists are seeing rare cases of encephalitis, most likely immune mediated.
But what of common mental disorders? Around a third had depression or anxiety which tended to subside after the acute phase. Data from the post-acute illness phase are more pertinent. Although based on Sars and Mers alone, almost one in three cases in hospital went on to develop post-traumatic stress disorder (PTSD); that’s based on 402 people from four studies but followed up for nearly three years. Rates of depression and anxiety – which overlap with PTSD – were at roughly 15% one year after the illness, and more than 15% also complained of fatigue, mood swings and sleep disorders. Although the figures suggest large numbers of new psychiatric casualties, these people had severe illnesses and any life-threatening condition is likely to require some psychological readjustment.
It isn’t all bad. A few studies describe the phenomenon of post-traumatic growth – which I’ve seen first-hand: colleagues who, while pushed to their limit, find they have never felt more vital or fulfilled.
Another longer-term outcome is suicide and some commentators have prophesied increased rates; this is dangerous as even talking about suicide can weaken a troubled person’s resolve to resist taking their life and the effect can be contagious. While there was a slight peak in suicides in older people during the Sars epidemic in Hong Kong, this might have reflected local cultural factors such as the stigma and shame some endured because they believed they were responsible for passing on the infection to loved ones. Of course, isolation and fear will add to the despair of all vulnerable people caught up in the pandemic, and strenuous efforts from mental health charities and community organisations to reach out and mitigate these effects have begun. The 19th-century sociologist Emile Durkheim surmised that social cohesion was a bulwark against suicide, which explains the near universal fall in suicide rates in times of war.
Will the “we’re all in this together” effect pull us through the current phoney war? Possibly. The bigger worry is that an aftermath of recession, unemployment, alcohol and indebtedness will be overwhelming for some.
Information from cases in hospital only gives us part of the picture but other emerging data from well-conducted population surveys can complete it. For example, the Covid-19 social survey led by social scientist Daisy Fancourt at UCL is publishing results week by week from a pool of around 100,000 people. This shows that levels of anxiety spiked around the lockdown but have since been gradually subsiding as we get more used to the situation. Mean levels of anxiety, scored on standardised scales, were well below the cut-off for even mild clinical disorder. The survey does show that those already suffering from a mental disorder before the pandemic were made worse, and for them it could be the difference between “just managing” and something else.
For the half a million people with serious and enduring mental illnesses such as schizophrenia, social isolation is the default. If you live in a world where, at best, anything from religion to TV and the internet seem arranged to undermine your sense of self, rather than offer a comfort or distraction, imagine what it’s like to be in the midst of a pandemic. One of my patients described how her nemesis, the persecutory voice that followed her every thought, announced that he was suffering from a virus “himself”. Eventually the voice, that personification of threat, fell victim to the disease. My patient enjoyed a few days of blissful respite until – so she believed – the virus, in a final posthumous category-defying leap, infected her too.
If there’s a lesson from psychiatry at times like this it is to hang on to a kind of natural and shared immunity. Studies on “psychological debriefing” after traumatic events, that is therapists carrying out assessment interviews immediately following a trauma, show that not only does this not help, it actually makes the situation worse, sometimes increasing rates of PTSD. Perhaps such clinical efforts derail natural processes – biological, psychological and social – that have evolved to deal with major adverse events. Of course, some people will require more, and competent clinicians need to be on hand to deploy all the treatments available. But most, especially those recovering or venturing out to work, don’t need to be encouraged to emote in a certain way, to list the pain and guilt. Most people will need a good night’s sleep, personal protection, reassurance that their efforts are appreciated or that they’ve come through the worst, and above all the space to share stories with each other.
Source: University College London