As the country heads into another six-week lockdown, the public needs minding.
These quotes – just three from many accounts shared with The Irish Times from people in psychotherapy – reflect the impact Covid-19 is having on a range of people in Ireland. They tell of losing contact with others, losing loved ones, losing jobs, losing out on life opportunities, sometimes losing their grip on life itself.
The figures on Covid-19 cases and deaths, announced nightly, are a very public declaration of how the virus is infecting the population. Privately, the disease is affecting many more, with higher levels of anxiety and mental illness.
"The people who are ill with Covid-19 require immediate care, but there is silent suffering too," says Brendan Kelly, professor of psychiatry at Trinity College Dublin.
This suffering has been going on a while. The first lockdown caused more people to feel loneliness, depression or anxiety or left them in a state of what one survey called “post-traumatic stress”. It sparked an increase in prescriptions for sleeping tablets, anxiety medicines and anti-depressants.
There was an initial decline in people seeking mental health treatments, medics say, as people feared contracting the virus if they went into healthcare settings and because a sense of “group trauma” made them feel protected.
Since then – according to surveys, hospitals and mental health professionals who spoke to The Irish Times – more patients have been presenting with self-harm and other emergencies. These are often complex cases, because patients have delayed seeking help and their mental illness is complicated by other emergency health conditions.
As the Government introduces Level 5 restrictions to tame a resurgence of the virus, that silent suffering shows little sign of abating. Amid this uncertainty, however, we must not lose perspective.
“It is important not to pathologise the legitimate worries that people have – people are allowed to be anxious when things are uncertain – and the vast majority of people will have no mental illness, they are just anxious,” says Dr Stephen McWilliams, a consultant psychiatrist at Saint John of God Hospital in south Dublin and an associate clinical professor at UCD.
“There are people with existing mental illness, some of whom may relapse if they become very anxious and stressed. Some people may become ill for the first time without having any underlying mental illness previously.”
The Stillorgan hospital, specialising in mental health treatment and care, said in May that over the second month of the pandemic, half of its admissions related to the intense pressure from Covid-19 restrictions. At that time there was a “dramatic increase” in patients struggling with mood and anxiety disorders, addictions and issues stemming from severe isolation.
“Loneliness and isolation are probably the main issues. We know that families are very important for people with mental health problems. They provide a lot of support and a caring role. This is what Covid-19 has taken away from people with mental illness,” says McWilliams.
Increased isolation and loneliness can affect a person’s mental health and this, combined with the uncertainty about what will happen when the current restrictions come up for review, can bring underlying mental health conditions to the surface.
The restrictions coincide with peaks in mental health issues, requiring extra support and vigilance from services that have long been over-burdened and under-resourced.
“Going to Level 5 intensifies the anxiety that so many people feel about Covid-19, about the effect of the restrictions and about the future,” says Kelly of Trinity College.
To respond to the potential psychological stresses that another lockdown might bring, this week the Government introduced the concept of the “social support bubble” that permit households to “buddy up” with an elderly person or single adult with children to protect people at risk from social isolation or mental ill-health. This will address some of the loneliness people experienced during the first lockdown when the over-70s were told to “cocoon” at home.
A month into the last lockdown, the Irish Covid-19 Mental Health Survey, which included researchers from Maynooth University and Trinity College Dublin found that among 1,000 people, 41 per cent reported feeling lonely, 23 per cent were depressed, 20 per cent had clinically meaningful levels of anxiety, and 18 per cent were suffering the effects of post-traumatic stress.
"Being able to maintain contact for some people could be extraordinarily important," says Dublin-based clinical and counselling psychologist Eoin Galavan of the new bubbles.
“The Government is trying to weigh up the public health damage that is caused by social-isolation restrictions against the public health benefit of restricting the transmission of the virus.”
Fear of the virus in the early stages of the pandemic meant people with mental health issues were reluctant to present at hospitals because they were worried about contracting Covid-19.
Siobhán O'Neill, Northern Ireland's interim Mental Health Champion and professor of mental health sciences at the Ulster University, said that crisis helplines were reporting longer calls from distressed people, and greater levels of distress and anxiety were being detected among parents home-schooling children, a "group of people we weren't really expecting to be in the data".
“It was the community and voluntary sector that were picking up a lot of cases rather than hospitals in the first few months. People with existing mental health issues were distressed and there were new people developing acute anxiety and related mental health problems,” she says.
In a survey of almost 200 mostly community-based psychiatrists in June, the Irish College of Psychiatrists found that 68 per cent of respondents saw an initial lull in referrals to mental health services in the first month of lockdown from the end of March. In the second month of lockdown, almost 60 per cent of psychiatrists reported an increased demand for inpatient beds, while 72 per cent said referrals to secondary mental health services increased or significantly increased.
Psychiatrists at University Hospital Galway found that patients presenting with self-harm dropped by 35 per cent in March and April but increased dramatically, more than doubling, in May, according to a study published in the Irish Journal of Psychological Medicine.
Since the early summer, more people with mental health issues have presented with mental health emergencies. The Mater had 43 presentations in the emergency department in April; this rose to 166 in August. In September, the figure stabilised but it was still 20 to 30 per cent higher than the same month last year, according to liaison psychiatric consultant Dr Ana Maria Clarke.
“We have people with depression that started to become unwell during the pandemic and they would have delayed seeking help, and then they might have had a suicide attempt that resulted in them being admitted to hospital, and then you are dealing with the effects of the suicide attempt as well as their severe depressive illness,” says Clarke.
The psychological impact of the pandemic has concerned the HSE. Chief executive Paul Reid last month noted "a concerning trend" of people presenting to health services with "worrying levels of anxiety and in some cases mental health issues."
At Tuesday’s National Public Health Emergency Team (Nphet) briefing, Dr Siobhán Ní Bhriain, a psychiatrist and senior HSE manager, said the pandemic was affecting age groups differently.
“Older people are more likely to suffer from anxiety and loneliness. Younger people are more likely to suffer from anxiety and loneliness. Younger people are more likely to suffer from suicidal ideation or thoughts of self-harm,” she said.
This was not translating for now into actual suicide numbers, she said, but the HSE was “very conscious” of the problems and building up mental health services in preparation.
This experience is not unique to this public health emergency. Deaths by suicide increased in the United States during the 1918-19 "Spanish flu" pandemic and among older people in Asia during the 2002-04 Sars outbreak as social disengagement, mental stress and anxiety took a toll, according to the International Association for Suicide Prevention.
In recognition of the growing psychological toll of the pandemic, the Government committed an additional €38 million to mental health services in last week’s budget. Mental health professionals believe the HSE must strike a balance between investing in mental health services in the community and hospitals. Many feel that GPs provide an important first line of defence.
Prof Kelly says the Counselling in Primary Care (CIPC) programme, free through GPs for medical card holders, should be expanded to people on low incomes who are not on medical cards and to the under-18s.
Dr Galavan says that primary-care psychological services that are accessible through GPs is “almost non-existent in many parts of the country” and that the Government needs to reconsider the supports that are available. Accessing more psychological services through GPs would add a “layer of support” for people going into psychological or emotional crises during the pandemic.
“It is an easy solution which could have a big impact on addressing the anxieties, depressions and other mental issues . . . that may emerge in the wake of what is coming down the road,” he says.
Dr Brian Osborne, a GP and director of the Irish College of General Practitioners' mental health programme, says that GPs are seeing more people with mental health issues attending surgeries.
“A lot of people are coming in with disturbed or interrupted sleep, irritability, general stress and anxiety that they cannot put their finger on. A lot of parents are coming in about concerns about their children, especially during the lockdown, and the lack of schooling, the disruption to their daily routine, the loss of interaction with friends and children acting out,” he said.
Claims for antidepressants on publicly funded drugs increased during the early stages of the pandemic as patients sought medication to treat depression, anxiety and sleep loss, but dropped off in May and June.
The HSE has said that it has maintained its mental health services at about 90 per cent, some of which has been through telephone or virtual appointments such as consultations over Zoom.
Osborne has said that much of the health system has been “very slow to reopen”. While online services offer some support, the “nuances and complexities of face-to-face consultations is what is needed”.
“The challenges have multiplied during the pandemic. The health service really does need to open just like general practice has,” he said.
Dr Philip Dodd, national clinical adviser at the National Office for Suicide Prevention and a Dublin-based psychiatrist, says that the current level of demand for CIPC services and other mental services are not higher than would normally be at this time of year.
“That does not mean we are not entering into a very anxious period for the whole population,” he says.
The HSE has set up much more specific “psycho-social” supports across its nine community health organisations network, including targeted health guidance and online counselling. “If there is an increased level of demand associated with these increased levels of restrictions, we are in a position to monitor that increased demand and potentially respond to it,” Dodd says.
The economic fallout from the pandemic has an impact on mental health that is both immediate and longer term. The loss of a job creates financial problems but can also cause isolation and loneliness, leaving people feeling cut off. Anxiety levels have been raised by the threat of economic hardship, and the full economic impact may be only starting to be felt.
“We are in the middle of that part of the pandemic in the sense that we don’t think all of the impacts economically have fully happened yet, so there could be a whole lot more pressure on suicide rates in an upward trend,” says Galavan.
Kelly says the economic situation can have delayed effects on mental health and that unemployment in particular can have a “corrosive” effect; an increase of 10 percentage points on the unemployment rate can have “spillover effects” on everyone’s mental health, even on the employed.
The Government’s wage subsidy scheme that allows employers to maintain a link with employees when businesses are shut down is not just an important financial support, he says.
“It has a huge mental health benefit: being employed brings far more than income. It brings connection, it brings self-worth and it brings the notion of being part of a workforce,” he says.
Dodd says that Government measures to protect people’s incomes during the pandemic have a critical additional mental health benefit.
“One of the biggest predictors of increased levels of suicide is economic hardship, so what the Government and our country is doing around people’s income is a really important support around their mental health. Sometimes we can lose that connection,” he says.
Dodd says that encouraging a strong sense of social cohesion, as happened during the last lockdown, would help make the impact of the pandemic less severe on people’s mental health.
“That sense of 'we are all in it together' is somewhat protective of people who are at risk of developing psychological or mental health problems as a result of the pandemic,” he says.
This lockdown is more complicated. Public tolerance has weakened since the “in this together” approach shown by the public to the March-May shutdown. Presenting it as being temporary in nature made that lockdown more tolerable. This time around it seems less temporary because of the acceptance now that Level 5 will merely suppress the virus, not eliminate it.
"Early in the pandemic people were told that if they stick with restrictions for a few weeks, things might return to normal, but this time it is different and more difficult to accept. It is the unknown and the unpredictability of how it might work makes it difficult," says Dr Ana Maria Clarke at the Mater Hospital.
Even the reward that compliance might lead to a more normal Christmas may not help.
“When a pandemic is at play, and restrictions are imposed, all of the research suggests that it has the potential to increase suicide rates and it can have severe implications, psychologically and emotionally, for people. I think a certain amount of that is going to happen, regardless of the social bubbles, regardless of keeping Christmas in play,” says Galavan.
To help over the weeks ahead, Kelly would like to see greater emphasis from the Government and State officials on the “permissions” rather than the “prohibitions” in the public guidance, given the awareness of the mental health implications of Covid-19 and the restrictions.
“I would like to see the message that going out for a walk every day with members of your household is permitted for physical and mental health. That message needs to be stronger and clearer. There are sectors of the population that need the permission emphasised to them,” he says.
McWilliams of Saint John of God Hospital says it is important to remember that people with severe and enduring mental illness can be among the most resilient of people.
“A lot of people will manage generally. We have done tough stuff before as a country. We went through an economic crash 12 years ago and we have the ability to deal with hardship if we need to,” he says.
The reward of “more leeway around Christmas time” and the ability to take “a bit of a break” from the public restrictions, amid the longer wait for a vaccine for Covid-19, will offer hope.
“It is important to maintain hope,” he says. “Things will get better.”
Quotes from people in therapy come from a psychotherapist in private practice
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