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Business Post: Mental health must come first when this crisis is finally over
Dr Karen O’Connor, consultant psychiatrist, discusses how the economic fallout, intense media coverage and social distancing measure of the COVID-19 pandemic will contribute to a wave of mental health vulnerability months and years after the pandemic’s end.
Read the article below which appears on the Business Post’s website.
The Covid-19 pandemic is a global health emergency, the scale and nature of which is beyond anything any of us have experienced in our lifetimes. The mental health burden associated with it is also likely to surpass anything we have previously experienced.
A tsunami of mental health need will arise some time after the initial pandemic peak, and will persist for months to years afterwards. It will be amplified by the economic fallout, pervasive media coverage and the impact of social distancing.
Social distancing measures do not impact on all equally. Those with the fewest social and economic resources are impacted the most – those living in deprived areas, with insecure and or low-income jobs and insecure housing; single-parent households; and those in abusive relationships.
It also acutely affects those with existing mental health problems, whose symptoms may worsen when access to social networks and healthcare support is constrained.
This pandemic will be associated with an increase in people presenting with significant mental health difficulties for the very first time.
Several groups are likely to be particularly vulnerable. These include Covid-19 survivors and their families, people bereaved during the pandemic, frontline health workers, those who have fewer social and economic resources, older people, students and young people, individuals with intellectual disability, and women throughout the perinatal period.
One study in Hong Kong found that four years after the Sars pandemic, 43 per cent of survivors had a diagnosable mental illness, with post-traumatic stress disorder and depression being most prevalent.
Social distancing itself may be a significant risk factor for increased levels of anxiety, depression, addiction, self-harm and suicide.
Leading theories of suicide emphasise the critical role that social connections play in suicide prevention. The economic impact of the pandemic is likely to further compound this vulnerability and increase these risks.
Older people who are at higher risk of developing a severe form of Covid-19 may be experiencing more anxiety and loneliness. Disrupted routines and reduced activity levels may undermine independence, and exacerbate frailty and poor health outcomes in this population.
Young people who have had their school and college lives disrupted, and their state or college exams altered, may struggle to cope with the disruption and uncertainty.
Rates of mental illness are already known to be high and increasing in young people in Ireland. Funding has been prioritised for non-stigmatising youth organisations in the community, in the hope that raised awareness and light-touch interventions will prevent deterioration and the need for secondary care services.
But this has not proven to be the case thus far. There is now an urgent need for investment in specialised services in secondary care for the significant proportion of young people – more than 30 per cent – whose needs are not met in primary care services.
Individuals with intellectual disability may struggle to understand the requirements of social restrictions, and may find the disruption to their routines and reduced access to usual social supports such as day programmes very distressing.
There may be a particularly significant impact on people with autism within this population, whose vulnerability to changes in routine can be incredibly significant.
Some individuals with intellectual disability live in congregated settings. Similar to those in nursing homes, this may result in increased risk of infection and the opportunity to witness the impact on others of this pandemic.
Maternal mental illness is one of the leading causes of maternal mortality. For women who are pregnant or post-partum, the Covid-19 pandemic is associated with a range of factors, including worry about infection, social isolation and financial strain, that are likely to increase the prevalence of mental health difficulties.
People with established mental illness are likely to be particularly vulnerable to relapse and deterioration in the context of Covid-19.
This pandemic is already taking its toll on existing service users, many of whom are reluctant to meet health professionals due to concerns about infection, or not wanting to burden staff.
Once people do start presenting for care, individuals will be more unwell and require more complex interventions. Crisis presentations will predominate.
Those of us providing secondary care can anticipate increased demand from our existing service users and an increase in referrals from primary care of people with established mental health difficulties who now need specialist intervention. This will be in addition to the new wave of mental health needs among vulnerable populations.
Rapid and early access to expert assessment, and a range of holistic and evidence-based interventions, have been central tenets of successful mental health service transformation initiatives in recent years.
These include the national clinical programmes in mental health, which were developed in areas of known service deficit or indeed service absence, such as psychosis, eating disorders, self-harm and attention deficit hyperactivity disorder in adults.
It is critical that implementation of these programmes is accelerated in the context of Covid-19. We cannot fall back to a time when it took more than two years for a person with psychotic symptoms to get access to specialist healthcare.
Neither can we regress to a period when people presenting with psychosis only got access to medication, with little to no access to evidence-based treatments such as psychological therapy, behavioural family therapy, peer support or dedicated support workers.
I worry about our ability to manage what is coming. The funding of mental health services in Ireland has remained consistently low, at about 6 per cent of the overall health budget, compared with 10 to 12 per cent in Germany and Britain.
We have the third-lowest number of psychiatric beds per 100,000 population in the EU; only Italy and Cyprus have fewer. The staffing recommendations set out in A Vision for Change, the 2006 national policy document, have never been achieved.
We now need a ring-fenced budget to support secondary mental health services, to build capacity, and to innovate so that care can be delivered to all those who need it, and primary and secondary mental health services are not overwhelmed.
Now is not the time to fall backwards in the delivery of high-quality and accessible care. Instead we need to accelerate service transformation, and build and strengthen capacity in our mental health services.
Early action will ensure that, like the intensive care units and the acute hospitals, we can build capacity, and strengthen the mental health services where they are weakest.
By doing so, we can face this tsunami that is bearing down on us.