In 2020, three of Ireland's leading physicians – GP professor Walter Cullen and consultant psychiatrists Professors Gautam Gulati and Brendan Kelly – wrote to QJM, An International Journal of Medicine, anticipating three psychological impacts of the unfolding Covid-19 pandemic, caused by SARS-CoV-2 infection, Mental Health in the Covid-19 Pandemic.
First, “people with pre-existing mental health and substance use disorders will be at increased risk of infection with Covid-19, increased risk of having problems accessing testing and treatment and increased risk of negative physical and psychological effects ... ”. Second, increased “anxiety and depressive symptoms among people who do not have pre-existing mental health conditions, with some experiencing post-traumatic stress disorder ... ”. Third, “that health and social care professionals will be at particular risk of psychological symptoms, especially if they work in public health, primary care, emergency services, emergency departments and intensive or critical care.”
These conjectures have been confirmed. For example, an analysis of the mental health impacts of Covid-19 in Ireland published in the Irish Journal of Psychological Medicine, Mental Health Impacts of Covid-19 in Ireland and the need for a Secondary Care Mental Health Service Response, reported both that risk factors associated with poorer outcomes in Covid-19 infection – like smoking, diabetes, cardiovascular disease and obesity – "are all more prevalent in people with established mental illness", and that "some people who have had a severe episode of Covid-19 illness may experience high levels of psychiatric symptoms and potentially illness afterwards".
Further, a study of burnout and long Covid among senior medical staff in Ireland, A Pilot Study of Burnout and Long Covid in Senior Specialist Doctors, found that 77 per cent of a sample of Irish medical consultants were affected.
Long Covid is an urgent, growing issue that demands action, and that the lingering psychological and psychiatric effects of acute infection are evident
Long Covid includes persistent symptoms such as breathlessness, fatigue, and reduced exercise tolerance in patients after acute SARS-CoV-2 infection, and researchers who investigated 50 convalescing Covid-19 patients at Dublin's St James's Hospital, Persistent Endotheliopathy in the Pathogenesis of Long Covid Syndrome, suggest that a disturbance of the endothelium – a layer of cells lining blood vessels – has a role in the syndrome's pathology.
Now, a recent report, Long Covid: The Elephant in the Room, by Professors Kelly and Gulati addresses what they term "the elephant in the room", saying that long Covid is an urgent, growing issue that demands action, and that the lingering psychological and psychiatric effects of acute infection are evident. For example, they cite one study of Covid-19 survivors a fortnight or more after recovery from the acute infection that "found alarmingly high rates of persistent psychological distress (36 per cent), anxiety disorders (22 per cent), depression (21 per cent) and post-traumatic stress disorder (20 per cent). More than one third of survivors (35 per cent) had sleeping disorders, which further diminish mental health, physical wellbeing, and social function."
Kelly and Gulati further cite a retrospective study of over 236,000 survivors of Covid-19 which reported that “the estimated incidence of a neurological or psychiatric diagnosis over six months was 33.6 per cent for all Covid-19 patients, rising to 46.4 per cent for those who had been admitted to an intensive therapy unit.”
Given the clear mental health challenges posed by long Covid in Ireland, to what extent are Irish mental health services equipped to meet them?
Report coauthor Brendan Kelly is professor of psychiatry at Trinity College Dublin and consultant psychiatrist at Tallaght University Hospital. He told the Irish Times that mental health services in Ireland receive only 5 per cent of the health budget: "Sláintecare recommends 10 per cent; the World Health Organisation recommends 12 per cent; and in the UK it is 13 per cent."
This deficit, Prof Kelly observes, is not made up for from other departmental budgets. Noting that people with mental illness are at a disproportionate risk of homelessness, he is clear that “long Covid requires a multi-disciplinary response, in which psychiatry has a key role; so appropriate resources are needed.”
Kelly and Gulati’s paper highlights the “ ... need to understand to what extent people with undiagnosed, asymptomatic Covid-19 infection can develop long Covid, and how might this be detected and distinguished from other diagnoses.”
Even in this emergency circumstance, or especially in this emergency circumstance, we neglect mental health at our peril and to our long-term detriment
But given the relatively low Covid-19-associated mortality, might placing an emphasis on undiagnosed, asymptomatic infection with SARS-CoV-2 raise a potentially divisive issue on the allocation of scant health service resources to those with non-Covid-19 conditions? In response, Kelly highlights the importance of understanding the links between long Covid and the fact of infection, symptoms experienced, and treatments provided: “All three of these factors,” he adds, “might shape the risk, nature and prognosis of long Covid. Treatment of mental ill health should be available to all, regardless of whether Covid-19 contributes to a person’s symptoms. But understanding the precise role of Covid-19 can help with understanding and service planning.”
Coauthor Gautam Gulati – adjunct professor at the University of Limerick – agrees, adding: "What is clear is that we do not know nearly enough about long Covid and scientific knowledge in respect of this is evolving. It remains the case that prevention offers the best approach, so the importance of social distancing, face masks, hand hygiene and vaccination cannot be overstated."
Given the current state of flux around the long-term evolution of the pandemic, Prof Kelly concedes that many of its consequences will be hard to measure: “Fewer people are engaging in regular exercise owing to anxiety; general physical deconditioning occurs during periods of restrictions; and we are seeing the emergence of long Covid following acute infection together with disrupted and delayed non-Covid-19 health services.”
Given this grim context, says Kelly, “it is difficult to measure the impact of, say, a delayed hip operation or a delayed cataract operation, but the impacts of both are substantial. In the same way, much of the suffering from long Covid might be silent, so awareness is important.”
As Professors Cullen, Gulati and Kelly have observed, Mental Health in the Covid-19 Pandemic: "Even in this emergency circumstance, or especially in this emergency circumstance, we neglect mental health at our peril and to our long-term detriment."