Jo Lucas has worked in the field of mental health since the early 70s when she was a Nursing Assistant at Fulbourn on the Young Peoples Unit. She is now a Non Executive Director of CPFT the NHS trust which runs Fulbourn and the NHS mental health services in Cambridgeshire and Peterborough. She also practices as a psychotherapist locally. Here, in this comprehensive overview, she explores the effect of the pandemic on mental health, highlights the underlying inequalities, and maps out some solutions which start with reducing those inequalities.
The reality is that we already know a lot about the unequal impact of mental health problems and the correlation of mental distress with poverty, inequality of access, racism. All of these factors are being exacerbated by the impact of Covid-19 as we learn more about that particular illness. It is also important to be aware that things seem to be changing almost daily in Covid related research outcomes.
Research into mental health inequalities has long shown us that children from the most disadvantaged households are four times more likely to experience mental health problems before they leave primary school than their peers from the most socially advantaged households. People with long term chronic mental health problems are likely to die some 15-20 years earlier than their physically healthy counterparts. People from BAME and other excluded communities are known to have increased risk of mental health problems and less easy access to mainstream providers as well as facing the possibility of racism within the services. Studies have shown consistent links between the experience of racism and poorer mental health and well-being. Similar clear links have been shown for the impact of poverty.
The Institute of Fiscal Studies (IFS) has reported that mental health in the UK worsened by 8% on average as a result of the first two months of the pandemic, with this being experienced more by younger people and women. It also shows that people who were already experiencing mental health problems experienced higher levels of deterioration than those with fewer preceding issues. Both women and younger people groups had poorer mental health prior to Covid so, as in other areas, these inequalities have been increased by the pandemic.
The Royal College of Psychiatrists (RCPsych) report that 43% of psychiatrists have seen an increase in urgent and emergency cases while 45% have seen a fall in their routine appointments, most notably in child and adolescent services and in those for older people. Their survey suggests that the biggest drop off in routine care has been in mental health services, especially those located in general hospitals. Experience of patients seems to suggest that routine cancer care and treatment has also been severely affected. The former may be more a response to anxiety about entering the NHS while the latter reflects a concern about the increased vulnerability of cancer patients. Some NHS Trusts are already beginning to report a significant increase in demand for services from people with increasingly severe mental health problems.
At the same time the ONS notes that currently 49.6% of the population are reporting increased anxiety. Several of the RCP survey respondents noted that older people seem to have evaporated suggesting that they may be too fearful to seek help. Those people who have been admitted with severe symptoms seem to be showing Covid related themes in their presentation. They go on to suggest that ‘many of our patients have deteriorated/developed problems as a direct result of the coronavirus disruption; social isolation, fear of running out of medication, increased stress etc.
The RCPsych’s concern is both that people are staying away and that routine services have either been ‘paused’ or have shifted to a virtual service or stopped as staff have been redeployed to other services. While some may be able follow this shift, there is a real concern that inequality of access to this kind of infrastructure will only make accessing ordinary mental health services harder.
The Mental Health Foundation suggests that the country will be coping with the mental health fallout of the pandemic for years to come in terms of fractured relationships, isolation, debt, poverty, unemployment, and grief.
Anecdotal evidence suggest’s that there has been a huge increase in demand for local helplines and that people are experiencing high levels of anxiety and distress. This may be tapering off as the lockdown continues and eases but demand is still higher than usual
Evidence is also clear that the small charities and voluntary organisations are suffering a loss both in funding, as so many resources have gone to the NHS, and capacity as volunteers and other contributions are less available. These smaller more specialist organisations often provide unique and invaluable services to those from excluded groups who often are not able to access mainstream services easily.
My own experience as a psychotherapist suggests that the impact is likely to be varied, as the impact of the virus itself has been. I believe that we will see many people with trauma related problems, with relationship issues, with significant levels of anxiety and depression exacerbated by the recent crisis situation. Those people who have lost friends and relatives and not been able to grieve in the usual way or to console themselves with the usual rites of passage to enable them to move on are likely to be looking for help. The impact of loss of social contact and isolation is likely to be seen increased anxiety and other relational trauma. The predicted recession and current massive rise in unemployment will also create a wave of people with mental health problems, as similar crises have done before.
Some recent research by a psychiatrist J Rogers, presented at a CPFT research seminar, suggests that the most likely outcome of the Covid pandemic in terms of mental health, based on the outcomes of previous corona type illnesses is that there will be significant increase in rates of Post-Traumatic Stress Disorder (PTSD) , anxiety, depression and chronic fatigue. There is currently no evidence that it has a direct impact on mental health itself though there is some suggestion that we need to be on the lookout for longer term experiences of delerium, though these suggestions are not confirmed. The impact of being on a ventilator, of being in ITU for a period of time, of social isolation, of stress and anxiety, of Covid related loss of loved ones, of income loss, are all likely to lead to or exacerbate mental health problems.
There are a number of things being suggested to respond to these concerns but it is important to be aware that we are still in the middle of this crisis and we need to base any plans on up to date information and build in the flexibility to respond to changes in research outcomes.
The underlying theme is around reducing inequality as it is known that this also has a distinct impact on the mental health of the nation. This is of course partly about funding; the term parity of esteem has been around for a while now indicating that mental health services need to be funded in way that is fair and creates parity between physical and mental health services. This also reflects the need to recognise that mental and physical health are inextricably linked. The belief, long held by the medical profession it would seem, that the body is distinct from the mind has been shown to be misplaced. It is also about recognising and actively mitigating, all the other inequalities that have become so obvious with the onset of this virus. A new contract for mental health services integrated with physical care is critical. This must go alongside a post crisis specific focus on addressing the backlog and unvoiced needs of older people and children and adolescents. Any response must also be informed by our understanding of trauma and its impact on us and the most effective ways of responding to it.
Specifically in terms of mental health and illness, it means recognising that the NHS cannot and indeed should not be expected to provide all the answers. Many of them are personal, social and economic and any response must reflect those. Support for the third sector and the development of truly integrated working across the boundaries of health and social care, and making sure that coproduction, involving people with lived experience of whatever is being addressed, is embedded at the heart of this is critical. It is clear that those with pre-existing conditions must continue to be offered a service as they are likely to have experienced the impact of the pandemic more severely. This must also include those who, previous to the pandemic have been on the edge of services, with long term chronic but low-key conditions as their quality of life is likely to have deteriorated significantly. A specific trauma orientated response is probably going to be necessary, integrating an individual response to this experience. This should also integrate support for smaller and more specialist organisations which are more able to meet the needs of socially excluded groups.
A new kind of social support service could be developed with a focus on building the relationships that people need and supporting their capacity to thrive. Amartya Sen described this as the capability approach, Hilary Cottam talks about Radical Help to revolutionise the welfare state.
The focus of activity could then shift to a broader social care agenda which will have a far greater impact. This would involve recognition of the well-known impact of early childhood adverse events as well as poverty and inequality. This requires a focus on and support for people rather than focusing solely on their problems or the risk they present.
For those people with identified mental health problems the health services need to focus on providing physical care as well as psychiatric care, to reduce the 15-year morbidity gap between those with mental health conditions and the rest of the population. Increasing the quality of life of this group is a social and economic issue rather than purely a medical one.
A universal basic income could have profound effect on the economic impact of mental health problems. A recognition of and active mitigation of the impact of racism, both at a social and institutional level and the everyday wear and tear of it, needs to be addressed rapidly.
The pandemic has rapidly activated a widespread use of virtual services and technology. This has been real boon for those who have the necessary access and skills but serves only to exclude those without it even more actively. This structural inequality of access to the hardware and the software and the support needs to be addressed. It also must be recognised that for some people face to face contact is crucial part of their recovery. This would suggest that the role of peer workers must be developed and integrated across the system, not just in mental health but across all health issues.
The Cambridgeshire and Peterborough NHS system is beginning to respond to some of these issues. The System Transformation Partnership body is talking about inequality in a way I have never seen before, CPFT which runs the community and mental health services is gearing itself up to responding to an increase in demand following the crisis but cannot guarantee that the funds will be available to enable them to put this into action. The decisions around the NHS Together funds are including looking at inequality and access to technology as well as ways of supporting smaller groups locally.
At a community level a response could be supported by building on the community actions that have developed over the last months, facilitating small scale local activity which would enable people to be engaged locally and would hopefully also ensure that people are less likely to fall through the net. Given the development in Cambridge of “Silicon Fen” maybe it could mean engaging with that local community to see if they can be involved in ensuring access to IT, (hardware, software, technical support and training) for people who are currently excluded
This pandemic has increased the awareness of inequalities in mental health and it will be important to harness this awareness into developing new and accessible solutions that ensure that people can access the help they need when they need it. That help must be focused on increasing people capacities rather than solving specific problems.
Mental Health Foundation: A new social contract for a mentally healthy society.
Bullmore E. The inflamed mind. A radical new approach to depression.
Centre for Mental Health COVID-19: Understanding inequalities in mental health during the pandemic. Centre for Mental Health Briefing Paper. June and July 2020
Cottam,Hilary. Radical help.How we can remake the relationships between us and revolutionise the welfare state.Virago 2018
NHS Providers. Mental health services need support to meet extra demand in care.
The mental health effect of the the first two months of lockdown and social distancing during the Covid-19 pandemic in the UK. Banks J and Xu X. Institute of Fiscal Studies IFS Working Paper W20/16
Royal College of Psychiatrist. Psychiatrists see an alarming increase in patients needing urgent and emergency care. Press release.
Sen, Amartya. Development as Freedom. Oxford University Press. 1999