Covid-19: Mental Health in and Beyond a Pandemic

Modern medicine has faced and overcome many hurdles, but the Covid-19 pandemic has presented a unique and critical challenge on an unprecedented scale.

Healthcare in a pandemic

Some of the impact of the pandemic is clear: postponed elective treatment, restricted access to non-essential healthcare, long waiting lists for all kinds of medical and care services are, at least, measurable and auditable. The other effects of the pandemic – those ‘soft signs’ that people are struggling – aren’t as easily quantified but are just as important and could help predict an impending crisis.

Keeping non-emergency treatment to a minimum was a pragmatic choice in a difficult time – hospital beds were at the ready and staff anticipated an influx of sick people with similar care needs and who all required similar supplies. The volume of equipment and amount of staff time used when caring for a large number of people with a highly communicable disease and specific, often intensive respiratory needs was overwhelming for NHS and wider healthcare services in the UK, and across the world.

The pandemic was an unusual situation requiring unusual tactics; healthcare campaigning switched from encouraging people to access services for medical concerns, to asking the public at large to ‘please, please stay out of hospitals and clinics’ unless they were seriously ill. There were positive results from this – every frontline care worker has seen more than enough people bringing scrapes and bruises to critical emergency care settings. There is also a serious negative side to keeping hospitals free for an expected onslaught: public feeling that hospitals were over-stretched with critically ill people, or even that they were unsafe places to be, meant that there were a number of people who absolutely should have attended hospital – but didn’t.

Now that, thankfully, most of the UK is seeing a significant fall in Covid cases, healthcare workers are also seeing a number of people who are sicker than they would have been with timely access to healthcare – reports of delayed presentations of medical emergencies abound. Many people didn’t feel that their acute chest pain, their transient hemiplegia, their tarry stools or their other serious but manageable symptoms were worth a trip to A&E in a pandemic. Now they, and the NHS, are contending with catastrophic late presentations of conditions that could have been well-controlled with timely intervention.

Mental health in a pandemic

The Covid-19 pandemic seamlessly combined a number of features that seemed almost perfectly designed to cause both immediate distress and long-term traumatic stress. Threats to health and life, mistrust and social anxiety, panic-buying, restrictive communication cues, and widespread social isolation are a dangerous combination.

Forced isolation is undeniably bad for mental health, immediately altering the behaviour and thought processes of human beings. Solitary confinement, segregation and separation is the harshest punishment used in UK prisons, and hotly contested in any debate on human rights. Solitary confinement beyond 15 days is usually considered to contravene the Human Rights Act. There is no question that the isolation many people experienced during the pandemic will have had a significant and detrimental impact on their mental and physical health. Those most vulnerable, most frail, already most alone were also the most likely to be isolated. Harsh restrictions on visiting in people’s own homes as well as all social and healthcare settings means that, through the many months of restrictions, more people lived and died alone than ever before.

Isolation goes beyond physical shielding; when everyone is wearing a mask, our natural communication cues are significantly impacted, creating huge barriers, especially for those who struggle with speech, hearing, language and communication barriers. The bearing a person’s home circumstances have on their experience also cannot be underestimated. Some people have been confined to a spacious home with a loving family, reliable income and good access to education, entertainment, and communication technology. Others have experienced overcrowding, domestic abuse, poverty and total social isolation. Food bank use and reports of domestic violence have been at an all-time high. Even the most privileged still were prone to ruminating and ‘catastrophising’ whilst confined to the walls of their homes.

It is hard to say who has been impacted the most seriously by the restrictions of the pandemic; the long-term effects have yet to be seen. Individual resilience, circumstances, and the kind of support each person had within their home or social ‘bubble’ means that no two people will have experienced the pandemic in quite the same way.

Frontline Workers in the Pandemic

The effects of the Covid-19 pandemic, particularly the measures taken to reduce the spread of disease, have had an almost universally significant and negative impact on individuals. It is necessary to focus on the experience of certain groups, but this is in no way intended to belittle the experience of any other groups or individuals.

Those workers who have been on the frontline of healthcare services throughout the pandemic have met certain specific challenges and have had an experience which needs to be addressed when considering the impact on people’s mental health. There are positives which should not be undervalued – critical healthcare workers were almost unique in having a reliable income, childcare provision, and a renewed public appreciation. They were also uniquely able to maintain some level of normality, even camaraderie or ‘Blitz Spirit’ in their lives, being able to leave the house, interact with colleagues, and maintain a life beyond themselves and their home. Essential training and workforce management and rostering was rapidly moved to remote and electronic format to help keep workers safe and manage staffing levels.

Those frontline workers also, however, saw the worst of the pandemic. Even the lack of visitors in hospitals put an extra burden on staff – patients suffering with serious physical or mental illness or reduced function had no familiar support or friends and family to help them feel safe and loved. With an increased workload and a sicker than average patient population, NHS nursing and medical teams were also the only human interaction these very poorly people might have. People who were unable to advocate for themselves became reliant on care workers where they would otherwise have had the support and advocacy of the people who knew them best – sometimes creating issues around mental capacity and deprivation of liberty. Training for workers experiencing these challenges had to be adaptive, targeted, and accessible despite restrictions – eLearning became the norm, with the Mental Capacity Act (MCA) 2005 and Mental Health Awareness becoming even more essential offerings.

Attempts to control infection rates meant not only that bad news was usually given over the phone, but that the person receiving that news was more likely to receive it alone, and then to be unable to seek support and human comfort.

The practical changes brought about by the pandemic – extra handwashing, PPE, constantly-changing guidance and protocol, and an ever-present threat from the sheer amount of exposure to patients with Covid – have been significant, but manageable. Other challenges include movement of staff to fill critical areas, redeployment of staff to from non-clinical to ward-based roles, bringing qualified healthcare professionals out of retirement, and fast-tracking students to gain registration. In addition, the altered workload – the actual types and conditions of patients in hospital – meant that new skills had to be learned, and fast. NHS workers who had chosen to specialise in one area found themselves having to re-familiarise themselves with long-forgotten disciplines. Workers were frequently out of their comfort zone, over-worked, feeling that they simply were not able to perform to the standard they expected of themselves – all alongside the same depression and anxiety that was so common among so many throughout the pandemic.

Moving Forward from Covid-19

The rapid and effective rollout of vaccination programmes and the prioritisation of the most at-risk has been very successful so far, and is a glimmer of hope after a long, bleak, often tragic year. NHS and wider healthcare services are again working through their elective and non-emergency backlog, and – perhaps most crucially – people are beginning to see their loved ones again.

As much of the world returns to some semblance of normality once again, as the dust settles, the longer-term emotional and psychological effects of living through a pandemic are becoming clearer. Some of these may be positive – people who have lived through a shared traumatic event may have a certain bond, a level of resilience and a unique perspective. Some of the effects of the pandemic and lockdown are undoubtedly negative, of course. Mental health services everywhere must be poised and ready to receive those with increased need for support. People who have been socially isolated; those with pre-existing mental health conditions; those who have been unwell or who remain unwell; who have lost loved ones; people with any number of imaginable effects of living through a pandemic; people with unimaginable effects of living through a pandemic.

The ongoing mental health and wellbeing of healthcare providers – our NHS workforce across the UK – is paramount; some have arguably seen the worst of the pandemic, experienced personally, professionally, and vicariously. Individual, group, and online support can help – a robust resilience training package can help people as individuals and help teams support and understand themselves, each other, and their patients.

Valuing the wellbeing of NHS workers benefits everyone – it is the workforce that cares for themselves, each other, and the public. Strategies for caring for the health of the nation at large, and post-pandemic key workers, need to be developed and undertaken. These will include promoting and developing careers in mental health nursing and improving workers’ understanding and awareness of mental health, mental illness, and options for support.

The pandemic was fast-paced, unexpected, and largely unpredictable, creating significant challenges for everybody. With the wisdom of hindsight, the limitations and shortfalls of existing healthcare structures are clearer. The support and training needs that the NHS workforce developed through the pandemic had to be identified and offered on the fly. Sometimes the only option in an emergency is to respond to problems as they arise, rather than anticipate them as abstract concepts.

Hopefully, those of us who lived through the pandemic will not experience anything quite like it again, but the lessons we have learned along the way will empower an adaptive and robust healthcare workforce through any challenges.