Over the course of a few days in March last year, the NHS changed, quite possibly for ever. From the moment Boris Johnson announced that the country was moving from the containment to the delay phase in its response to the COVID-19 pandemic, a little-known set of NHS policies and protocols, designed only to be used in a time of national crisis, came into effect. The alert cascaded from on high down to those on the ground.
NHS Trusts declared a major incident, and emergency plans were put into action. By the time I came into work the next morning, managers, who had been up all night, had already started to implement profound changes to the way the hospital and services were run.
This was replicated in every hospital across the country. It’s difficult for those outside the NHS to appreciate how rapidly this happened. Red tape became practically non-existent. Decisions that used to take months or even years because of pointless form-filling and meetings were now made in less than the time it takes to boil a kettle.
I remember sitting in a meeting on the second day and being asked to look through the notes of several hundred patients to identify those who could safely be discharged back to their GP.
I assumed that I would have weeks to do this. I was given two hours. In just a few days, we discharged whole wards and had to make difficult, often uncomfortable decisions about redeploying staff and clearing space in preparation for the anticipated tidal wave of seriously sick patients. In less than a week, designated COVID-19-positive wards were set up and staff trained.
Looking back, there’s no doubt that mistakes were made in those early days of the pandemic but, equally, it’s easy to forget how strange, unknown and panicked the situation was. The NHS, an organisation that often gets a bad rap for being bureaucratic and sclerotic, started to behave more like a Californian start-up than a nationalised health-care system.
But this came at a cost. We couldn’t have guessed it then, but those few days in March, and indeed the lockdown that followed, set in motion a series of events – from stopping face-to-face treatment to isolating large groups of people – that had a profound effect on the mental health of the country.
We are now starting to see the true toll that COVID-19 has had on our psychological well-being, both for those with long-standing mental health problems and those with no previous history. In those first few days, mental health services up and down the country effectively shut up shop, or at least significantly reduced the services they were able to offer. Staff were redeployed or sent home for protection, so that they could act as a reserve workforce should those on the front line become sick.
Soon, we realised that this decision, while taken in good faith, left thousands of mentally ill people with virtually no support. Recent figures show that referrals to mental health services during lockdown dropped by about 40%. Yet the level of need didn’t go away. People just had to manage as best they could on their own.
If the pandemic has shown us anything, it’s how important the mental health services are. I heard something from a doctor friend over the summer that stopped me in my tracks. The pandemic was calming down at that point, though we remained in lockdown. The stream of patients had reduced to a trickle in most hospitals. In the one where he worked, he explained, there were now more people being treated for having tried to kill themselves than being treated for COVID-19. It took a minute for that to sink in.
It soon became apparent that we were seeing a wave of patients for whom lockdown had proved too much. Since then, referrals to mental health services have skyrocketed. A report in August by the NHS Confederation stated, “Some providers are predicting a 20% increase across all of their mental health services, while also facing a 10-30% reduction in how many patients they can care for at once because of the required infection control and social-distancing measures.” We are on the brink of an unprecedented crisis, the magnitude of which we can only begin to imagine. The pandemic has been emotionally challenging for everyone, but it has been especially difficult for those who were already suffering before the lockdown began. Those with severe mental health problems, many of whom were in the middle of treatment, found themselves cut adrift. Therapy stopped and appointments were cancelled. Among doctors on the ground, there’s a feeling that, as the NHS scrambled to prepare for the anticipated influx of COVID patients, it all but abandoned those with mental health problems.
Staff did what they could, but it was no replacement for a proper mental health service. During the lockdown, I called many of my own patients to check in on them, and they were eager to reassure me that they would be OK. “There are so many people worse off,” they told me. But this isn’t a game of Top Trumps. That people are dying during a pandemic doesn’t mean that others’ mental illnesses cease to exist. Even those with severe and enduring mental illness gritted their teeth and insisted that things were OK. But as the weeks dragged on into months, there was a growing sense of desperation.
For some, that desperation has led to suicidal thoughts. One patient who was unceremoniously discharged from the community mental health team she had been under for over a decade told me that it felt as if she was holding her breath. She felt guilty asking for help during the pandemic, so held it for as long as possible. “But I can’t hold my breath for ever,” she confided. “At some point, I’ll drown.”
Luckily her mental health team has now started up again, but many others are still waiting. There is a daunting backlog of cases. A social worker I know described the community mental health service they work for trying in vain to contact a patient whom no one had seen for months. Neighbours had complained about a smell from his flat. When they eventually broke down the door, he had been dead for at least two months.
Many friends in mental health services around the country have had patients attempt suicide. Crisis teams – groups of doctors and nurses who work in the community with those who are experiencing severe issues or having suicidal thoughts – have remained open. Many desperate and scared people have had no alternative but to turn to these teams, with the result that they have been inundated with referrals.
A friend of mine who works for an inner-city crisis team said they had so many referrals that they were unable to help people unless they had actually tried to kill themselves. That seems beyond barbaric. We should have been better prepared for this. There was evidence that deaths by suicide increased in the US during the 1918-19 influenza pandemic and in Hong Kong during the 2003 SARS epidemic.
A Rising Tide
The pandemic hasn’t just affected those with existing mental health problems. As the dust settles, we are starting to see how lockdown and anxiety about the infection have triggered mental health problems in previously well people. A paper published in the Lancet in April last year raised concerns that, those with psychiatric disorders “might experience worsening symptoms, and others might develop new mental health problems, especially depression, anxiety and post-traumatic stress”.
What’s more, this raised concerns that the pandemic could trigger an increase in things such as divorce, alcohol abuse, domestic violence and unemployment, all of which are known to result in mental health problems. Speaking at a conference on coronavirus in September, Professor Vikram Patel of Harvard University warned about a “tsunami” of mental health patients that will overwhelm health services around the world. “The 2008 recession… was followed by a wave of ‘deaths of despair’ in the US, driven by suicide and substance use,” he said. “Without huge levels of government support for both the mental health sector and a whole host of other sectors, we are tragically facing a repeat of this, but perhaps on a much greater scale.”
Many mental health professionals feel that the government failed to take into account the wider ramifications of lockdown. For too many people, it wasn’t all Zoom yoga and baking banana bread. Studies that have examined trends in previous pandemics found that those who had experienced isolation or quarantine were five times more likely to require mental health services afterwards. A study by the Office for National Statistics, published last June, found that incidences of depression had doubled during the pandemic.
Now, with tiered lockdowns, strategic circuit breakers and escalating cases, many service providers are reluctant to open fully again. We doctors soon discovered that telephone calls are a poor substitute for face-to-face contact when someone is acutely mentally unwell. While an in-person appointment can easily take 30 minutes, most of my phone appointments last just a few minutes. It isn’t the same.
However, it’s not just lockdown that has caused problems. There is something else that is impacting on mental health, and it is something that no one had predicted: the virus itself. Doctors are now observing a spike in mental health problems among those who have been infected. The sensation of being unable to breathe has left many with panic attacks or crippling anxiety that remains long after the initial symptoms have passed.
Where I work, about half of the front-line staff has been infected. Of that number, about a quarter of them have subsequently experienced at least one panic attack, with a significant number reporting multiple – enough for a diagnosis of panic disorder.
One colleague has had to take extended sick leave because he has developed anxiety, with vivid dreams of being unable to breathe that cause him to wake up gasping for air. There is also an uptick in rates of depression in those who have been infected. This may be linked to anxiety, but it may also be related directly to the virus.
Over the past few years, there has been mounting evidence that, in some cases, depressive illness may be related to inflammation. There is no doubt that it is also linked to complex social and psychological factors, but studies have shown that inflammatory markers – chemicals that can be detected in the blood – are closely linked to the degree of depression. Other studies have shown inflammation in postmortem brain samples of depressed individuals.
We know that COVID has a direct effect on the brain. One of the cardinal symptoms is a loss of smell and taste. This is because it affects cranial nerve I, which sits at the top of the nose and is a direct extension of the brain tissue. Neurologists have started questioning whether COVID-19 could be invading the brain, causing an inflammatory response and triggering symptoms, including mental health problems such as depression.
Being in an intensive care unit can also trigger a specific condition called post-ICU syndrome, a cluster of symptoms including generalised weakness, memory problems and low mood. Post-traumatic stress disorder (PTSD) is also being seen in patients who were very sick, as well as in staff who cared for the sick and dying.
There’s another complication of COVID-19 that we are only just observing. For some who are infected, the symptoms – particularly severe fatigue and shortness of breath – appear to linger. This appears similar to a condition that is seen following infection with other viruses, such as Epstein-Barr, which causes glandular fever. As COVID-19 is a novel virus, we have no idea about its long-term effect on the body, or why it appears to have such dramatically different effects on different people.
Initially, doctors didn’t understand these longer-lasting symptoms, and it was down to sufferers to mobilise and come together, mainly online, to share their experiences. They termed their condition “long-tail COVID”, or just “long COVID”, to describe the symptoms that continue after the initial infection ends. Many of these patients are reporting low mood, anxiety and PTSD symptoms. If the virus does indeed become something we have to live with in the long term, this manifestation of the illness will pose a unique challenge to mental health services and likely require specialist clinics to deal with the needs of these patients.
The Time for Action
There is a bright side to all this. As Professor Patel has said, “The pandemic presents a historic opportunity to reimagine mental health care, by realising the science which demonstrates that we must reframe mental health beyond a narrow focus on ‘diagnoses, doctors and drugs’.” The virus has disrupted the NHS and the way we live, but it has also provided us with an opportunity to do things differently.
One example: in those early few days at the start of the pandemic, a group of psychiatric nurses had the idea of trying to reduce the pressure on A&E in central London by diverting all the mental health patients to a single unit. This kind of reorganisation would ordinarily require years of planning.
It was done in a few weeks. Before that, if you were in a mental health crisis, you were taken to a local A&E and assessed by a psychiatrist on call. There was a lot of waiting around for different services or teams to arrive and make an assessment. Often, very distressed patients would have to wait for hours, which only made things worse for them.
But under the new arrangement, everyone went to one central place, termed the Mental Health Crisis Assessment Service, where all of the teams that might be able to help became based. The venue wasn’t ideal – it was hastily established in a former out-of-hours GP clinic that happened to be based on a psychiatric hospital site at the back of King’s Cross. Staff complained that it was a bit draughty and the corridors were too narrow. But it worked. It was hugely popular with patients as it was quieter and, unlike in A&E, everyone there worked in mental health, so it felt non-judgemental. The staff weren’t spread out across several A&E departments, so patients were seen more quickly. At first, patients who went to A&E were transferred there, but soon they learned that they could turn up there themselves.
It has been such a success that it has just received funding to continue for a further year, relocated to customised premises and with a full-time consultant psychiatrist to oversee things.
This is just one of many innovations that have resulted in better care for patients. We know that mental health isn’t purely about therapy and medication. Patients can benefit hugely from other forms of treatment, such as access to support workers, day centres, classes and training. These are usually provided by a dizzying array of different organisations. In a north London trust, however, they were combined to form one network, making it easier for GPs and psychiatrists to refer their patients. Patients prefer it because it means that they can have just one assessment and then choose from a range of services, rather than requiring multiple referrals.
There have been other, more subtle, changes. During the pandemic, with so many staff members taking sick leave, many of the younger and – dare I say it – more enthusiastic members of staff took on leadership positions. This breathed fresh life into services. Meetings that served no real purpose and took clinicians away from their patients were cancelled, and few have been reintroduced. In the service where I work, features such as daily debriefs were introduced, in case staff went off sick the next day. This has resulted in fewer errors and better, more joined-up care for patients. They have stayed.
We were given a glimpse into how we could operate and realised that things could change with speed when needed. There’s a real sense that circumstances can change for the better. I hope we can hold on to this feeling for the challenges ahead.
The information in this story is accurate as of the publication date. While we are attempting to keep our content as up-to-date as possible, the situation surrounding the coronavirus pandemic continues to develop rapidly, so it’s possible that some information and recommendations may have changed since publishing. For any concerns and latest advice, visit the World Health Organisation. If you’re in the UK, the National Health Service can also provide useful information and support, while US users can contact the Center for Disease Control and Prevention. (edited)
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