LOST IN LOCKDOWN

Mental Health Awareness Week May Be Too Little Too Late

Since March, government agencies have emphasised the importance of keeping our bodies home, keeping our bodies isolated, keeping our bodies distanced from other humans so that ours do not join the 34,000 other bodies in the cemeteries and mortuaries of the nation. But what about our minds? In the rush to respond to the physical threat presented by Covid 19, it seems our mental health, and the very real threats to it presented by prolonged lockdown, has been entirely downplayed and devalued. It has simply been missing in the C19 discourse. Regular resilience, support and coping mechanisms such as careers, family, social outings, formal therapy sessions and self support groups have all disappeared. Key psychological constructs for a healthy mind,  like perceived control, relatedness and optimism, have been impossible to practice. It is no wonder if pre-existing mental illnesses like depression, anxiety, OCD, post-natal depression and psychosis have been amplified and worsened by the prevailing crisis narrative or have appeared for the first time in those who would have previously considered themselves mentally healthy. And specific aspects of this lockdown have spawned new experiences such as a morbid phobia of infection from the outside or of other people, extreme health anxiety, and identity crises in those newly cast as vulnerable or newly solitary and unable to define who they are in the absence of interaction with others. This is storing up a whole new reservoir of pain. If we apply the war analogy beloved of writers about this pandemic, long after the guns are silent and the trenches filled in, there will be a large number of people permanently shellshocked by the process. And we would be foolish to ignore this in planning for future pandemics and the post-Covid world.

Despite initiatives like ‘No health without mental health’ from 2011, the NHS’s Mental Health Taskforce recommendations in its Five Year Forward View for Mental Health 2016, and the NHS Constitution since 2013 stating that physical and mental health problems would be treated with ‘equal regard’, the Covid 19 crisis seems to have demonstrated that there is no parity of esteem  between medical and mental health priorities. Worse, there doesn’t even appear to have been any serious acknowledgement that mental health matters at this time and that the imposition of lockdown will have led to an unbearable mental load which in its own way is comparable to the viral load we hear so much about. Yet unmet needs in those suffering mental illness can shave twenty years off life expectancy. Indeed there almost seems to be a conspiracy of silence surrounding the individual miseries people are experiencing in lockdown. Maybe, like Tolstoy’s families, it is because every unhappy lockdowner is unhappy in their own way and there is no common set of symptoms to highlight or visually engaging hospital dramas to circulate. Or maybe it is because to express discord with lockdown, and the broken bonds, forced removal of social and therapeutic support, and loneliness that it entails, somehow seems unpatriotic during this ‘war’ against an invisible viral enemy. Lone dissenting voices seem to be shouted down as calling for the old and vulnerable to be left to die or prioritising the economy before health. But what if this single exclusive focus on mitigating one acute risk exposes a significant number of people to the equal and longer term danger of a life blighted by mental illness and its results? After all, it estimated that there have been 315,000 deaths worldwide so far, yet a third of the entire population of the world is living in lockdown.

Lockdown to many has meant inconvenience, boredom, household projects, a life online, jollifying activity videos, Zoom parties, quizzes and kitchen discos and the weekly clapping for carers. But for a significant minority there has been a much darker side. They are lost in lockdown but they deserve to count. I put a call out for their stories and was overwhelmed with the response.

There are those in unaccustomed despair. Many people who have never had cause to question their own mental health have found themselves descending into patterns of behaviour and emotion that resemble the clinically depressed. Sandy, 30s, lives apart from her boyfriend and hundreds of miles from her wider family. She has been working part time but even so on her non-working days finds it hard to motivate herself to get out of bed or get dressed. She’s found herself crying all day some days and longs to be hugged. Her grandad died recently of cancer and, although she was one of 5 family members allowed to attend the funeral, she received the news alone, has had to grieve alone and had to stay separate from her family at the funeral and drive home alone. Marion feels swamped by hopelessness and a sense of her life on hold. There is no future, nothing to plan for or look forward to. She longs to see friends or family in real life and, like many correspondents, says the digital connections just aren’t the same and miss the vital element of physical touch. Gus is immunocompromised and has been on immunosuppressant drugs for 8 years which have helped him control his condition and live a normal life. He was pole-axed by receiving the government letter telling him he is one of the clinically extremely vulnerable and must not go out or see people at all and even within his family at home keep himself apart. This had a profound effect and has translated to him having to accept a new identity as weak and unsafe, although he’s a big man and had been accustomed to seeing himself as the protector of his wife and daughters: now it’s the other way round. He feels guilty that his teenage girls don’t even want to go out for fear of bringing back the virus to him. This has led to moments of despair as he can’t see how he can ever manage to resume his life as the virus will always be around and he doesn’t see a future. He’s now having panic attacks and anxiety which is causing flare-ups of his immune condition. He describes the letter as like a hand grenade arriving in the post, blowing up his family life. Harry, in his 50s, was disabled 4 years ago by an ear infection leading to him losing his ability to balance. He had been working to improve his level of mobility and just bought a puppy to motivate him to keep taking difficult walks outside. Now, however, the puppy remains caged until it can receive its vaccines and Harry feels that is a metaphor for his life which has atrophied. His only coping mechanisms – being a community rep for his estate and seeing his girlfriend – have been removed and life is bleak.

Psychologists recognise that social isolation is a key factor in depression, leading to fixation on negative thoughts, hyper vigilance to social threats, insomnia, chronic stress, cognitive decline and poor decision making. Research on touch shows that it is vital to physical health and development and its absence leads to higher levels of cortisol and poorer immune function. A Lancet review in February 2020 documented the effects of just two weeks’ quarantine as low mood, anger, depression, exhaustion, anxiety and lethargy. How much more profound must be the lengthy withdrawal from the world that is lockdown? One therapy for the depressed is to model happy people’s behaviours but this works in reverse – if we are modelling the ways of the depressed by withdrawing from the world, not socially interacting, staying in bed, having nothing to feel excited about, feeling helpless, then it’s not surprising if we will see a rise in clinical depression and in turn suicidal thoughts and tendencies. The Mental Health Foundation Longitudinal Study has found that  nearly a quarter of adults were experiencing loneliness in lockdown, rising to 44% for the 18-24 year old age group. Simon Kempton, of the Police Federation, said in April that there was an early indication of a rise in suicides during this lockdown, supported by anecdotal information that charities such as Sane, Headspace, Unmind, Samaritans, Calm and Shout are all experiencing higher volumes of calls from people with suicidal thoughts. Indeed, previous research on the SARS outbreak in Hong Kong has confirmed that this seems to be a by-product. The Zero Suicide Alliance reported that over half a million people have accessed their online suicide prevention course since lockdown, indicating a rise in concern for loved ones. This is particularly worrying as suicide was on the increase even before the pandemic – up 11% last year in UK – and the International Covid 19 Suicide Prevention Research Collaboration have warned that the consequences for mental health will be present far longer and peak later than the outbreak.

The effects are likely to be worse on those already suffering mental health problems. The lockdown scenario seems to have amplified many of the negative thoughts and behaviours of those with pre-existing conditions. Emma has struggled with mental health issues since her teens with PTSD, anxiety and depression diagnosed. She has found herself succumbing to extreme health anxiety and fear for her children, panic attacks and paranoia during lockdown, with no recourse to the reassurance of her mum, who lives in Wales, or her usual face to face therapy. With only telephone appointments  with both her therapist and the health visitor, and the lack of reassuring body language afforded, she finds her anxiety is heightened. Without being able to see them, she has thoughts that they might be judging her, or think she’s strange or lying, so such support is a poor replacement. Abbie has post natal depression with a 2 and a half year old and 6 month old. This has manifested itself since lockdown as extreme fears that she won’t be able to protect her children, or that she might die and leave them motherless, that she’s inadequate, and in an extreme reluctance to go out or even allow the children into the garden as the air could be contaminated. There’s an element of not knowing what is real and what is hype and this mirrors the psychosis that can go along with PND. It’s quite difficult to rationalise your way out of such thoughts when public health and the media is actually reinforcing that they have a factual basis. Again, although her husband is there working from home, she misses her family and her regular outings that made it easier to get through the days, the familiarity and solidarity of her social groups which stopped her dwelling on negative thoughts. She had been hoping to avoid medication but has had to start on anti-depressants since lockdown. She has access to a therapist on the phone but, like Emma, this doesn’t work well from home with the children in the house so she can’t concentrate. Summer has had OCD and conquered it in the past but now finds herself lapsing again into the OCD extreme cleaning routines, this time reinforced by the media and public health narrative of infection and cleanliness. She is trying to stop herself descending into dark thoughts but the uncertainty of when she can expect to go back to work – she’s a hairdresser – has been preventing her setting alternative goals or developing a healthy routine as a coping strategy. Maxine has borderline personality disorder and has spent time in mental institutions. Without the presence of her family or boyfriend, lockdown is replicating the experience of incarceration. The solo surreality of the situation plus the concerns about where the virus is and where is safe is playing exactly to the psychotic and neurotic poles of this illness, exacerbating her symptoms, after several years on top of it.

All correspondents mentioned being affected by the government and media communications which are using risk elevating messages that inflate individual anxieties into a broader public anxiety cloud and seem to validate negative mindsets. In the meantime many of the services people rely on for positive mental health – day centres, support groups, personal therapy appointments – have been suspended. There is an absence of information or messages that challenge negative thoughts, which is what is normally recommended by cognitive therapists for many disorders. Furthermore there is an absence of images, discourse and narratives in the media depicting people struggling with mental health issues during lockdown reinforcing the feelings of many that they are not normal. The WHO has recommended that mental health should play a part in the public health response but clearly this has not transpired. Yet, as the World Economic Forum pointed out in April, this is the world’s biggest psychological experiment with people restricted on a scale never before seen. Why has no one assessed the likely effects of prolonged lockdown on the range of mental illnesses people are living with? Why was there no public education campaign about the likely effects and feelings induced by it? Why wasn’t a list of people vulnerable to lockdown drawn up in the same way the list of those to be shielded was, and monitoring systems put in place to check how their lockdown was going? Why are people with known conditions not receiving tailored information? For example, Gus mentioned he wasn’t sure whether immunosuppressive drugs might have a protective effect against the worst aspects of C19 and such knowledge could make all the difference to him. How can we hope to assess lockdown as a strategy now or for the future if the only criterion is the number of cases of infection or death from one illness, when clearly it has effects on the proliferation of many other illnesses both physical and mental?

Furthermore lockdown has created a whole new wave of mental health issues to do with its lifting. Amy, a school teaching assistant, had been struggling with social anxiety in her 20’s. The discourse of social distancing has validated this in her mind and now she has extreme anxiety about lockdown ending and having to venture out again. She feels very insecure about people in groups and worries both that her colleagues won’t accept her again and that they could infect her. She knows she now has to start the recovery process all over again but doesn’t know how she can get over her fear of other people when they might actually present a real health threat. Abbie, with the post-natal depression, doesn’t want to emerge from what she sees as the safe bubble of the home and lockdown life. She fears what the world has to offer and feels she is not equal to the task of protecting her children from it so has developed agoraphobia. Gus, with autoimmune issues, literally fears for his life when lockdown ends. He will have to go back to work but, as a commuter, cannot see how he can ever enter public transport again. Considering he had lived for 8 years with a philosophical approach to his level of risk from the world, this is a major, and he feels permanent, change in his outlook which could impact his career, livelihood and sense of self. Harriet doesn’t feel she can trust people collectively to keep her and her family safe. She worries that social distancing will break down and people will get too close and so is petrified of going back into society.

Meanwhile, there are some people in our midst for whom lockdown is nothing new. Those affected by isolation through existing disabilities or difficulties and who hope now people might see what they are dealing with. Harry had found his world had shrunk anyway and describes his disability as training for life in lockdown. Olivia is living with her son, who has SEN, and feels she has been living in lockdown since he lost his place at a special school last October as he is difficult to manage outside.   She went through a crisis of social isolation before ever lockdown started and explains this is how a number of people are silently having to live when there are insufficient support services for social integration for groups with physical or mental challenges.

So what’s to be done? The starting point has to be a national conversation about these issues. It’s a bit late for this to be Mental Health Awareness Week two months after enforcing a lockdown policy. The issues should have been broadcast from the outset.  So many of the correspondents I spoke to felt they were probably the only ones to be affected so badly and indeed even felt guilty about failing at something we are supposed to be doing for the public good. There needs to be widespread dissemination of the known facts about the effects of quarantine, isolation, social distancing and lack of touch so people understand that theirs is a normal reaction to an abnormal situation and that people are really struggling at a level well beyond the abilities of the likes of Joe Wicks to remedy. Let’s publicly acknowledge that the world does not make sense right now and this is not an individual failing. 

Furthermore we need data. The physical and mental health risks of lockdown need to be weighed up against its infection control credentials. There is little point in reducing deaths/hospitalisations from C19 in the UK to below 40,000/250,000 when in the process millions more lives are blighted or shortened. We have daily updates on the progress of the C19 outbreak but where is the real-time tracking of suicide, self-harm, addiction, abuse, mental illness symptoms and new incidences of stress-related illness?  It is simply not good enough to accept that the true toll of the lockdown will only be known afterwards when the policy has been implemented allegedly for the greater public good. We also need to bring back perceived choice and agency into people’s lives: psychological constructs widely accepted as crucial to positive mental states. This means allowing people to make their own decisions about the level of risk that exists for them personally and that they are willing to accept. And this in turn means moving away from soundbites and nursery style slogans for all and towards providing tailored information that people can engage with on an intellectual rather than emotional level.  Information that covers not just epidemiological aspects but also the range of socio-economic and psychological effects of possible choices for grown-up, personally and socially responsible decisions.

For the future we need to acknowledge and assess the differential psychological impact of measures proposed on the population. This means researching and accommodating the different identities thrown up by various health states; understanding individual coping mechanisms and whether they are removed or facilitated by the measures; highlighting, rather than dismissing, the risks involved in the remedy; organising interventions from the outset rather than leaving help to emanate from underfunded, sporadic and fragmented charity initiatives; and developing better mechanisms for inclusivity and belonging. A position paper in Lancet Psychiatry recently called for the mental health sciences to join together in developing multi-disciplinary research to define the optimal structure for a mentally health life within the confines of the social and physical distancing of a pandemic. This is all well and good and may help us next time round. But for now we need to acknowledge that, just as the C19 virus produces such a variety of effects as no symptoms through to cytokine storms, there is a qualitative difference between those who are merely feeling bored or moody while confined to home and those feeling truly lost in lockdown, whose deleterious effects will have repercussions  long after the pandemic fades. Let’s listen to their voices and ensure mental health is a priority for the ‘new normal’.