Life in lockdown: how the COVID-19 pandemic complicates existing mental health conditions
This article was updated on 12 May 2020
Mental health nurses discuss how social distancing is affecting service users and disrupting services
- COVID-19 lockdown presents particular challenges for people with conditions including OCD, depression and substance dependency
- Mental health nurses from diverse practice areas explain the impact of social distancing on clients and services
- Tips on how to support service users and colleagues, plus a quick guide to temporary changes to mental health legislation
While many people are experiencing heightened anxiety as they cope with the impact of the COVID-19 pandemic, the challenges of life in lockdown may be particularly complex for people with existing mental health conditions.
And for mental health nurses, lockdown means practising within new limitations that could have long-term consequences for service users.
Research needed into the effect of the pandemic on mental health
An interdisciplinary group of 24 experts, some with their own experience of a mental health condition, has warned that anxiety, depression and harmful behaviours, for example, could all escalate, particularly as a result of increased social isolation.
The group's position paper, published in Lancet Psychiatry, says that collecting data on the mental health effects of the pandemic across the whole population, as well as for vulnerable groups, should be an immediate priority.
‘Once we’re through the pandemic, we’re going to need more comprehensive mental health services, with substantial investment, because there is going to be so much trauma in the general population’
Ed Freshwater, chair of the RCN’s mental health forum
‘Most is done face-to-face but that’s now prohibited except in extremely serious circumstances,’ he says. ‘We’re making clinical decisions not to see people – they’re not being discharged, but functionally they are, because they won’t have any input.’
Disruptions to community mental health services could result in serious relapses
While consultations can be carried out by phone, there are serious drawbacks. ‘They are better than nothing, but far from ideal,’ says Mr Freshwater.
‘Alongside verbal communication, a large part of what we do is assess someone’s posture and body language. We’re missing out on that, especially for people who are in very vulnerable circumstances. We can’t pick up on those visual cues.’
Even receiving a call from a withheld number can trigger difficulties for some patients, he says. ‘For those with anxiety, it produces a flood of potentially distressing thoughts about who it could be.’
A number of people are likely to relapse – some badly – who otherwise wouldn’t if services had been able to continue as normal, Mr Freshwater believes.
Advice on helping colleagues and clients cope with anxiety
- Humour – it can be an effective tool if used wisely ‘In the right situation and used appropriately, it can be very effective,’ says Ed Freshwater, chair of the RCN’s mental health forum. ‘Nurses are renowned for humour when times are difficult. It helps to manage our emotional responses, diffusing the impact’
- Look to your team for support ‘We message each other after work, especially if we haven’t had a chance to catch up because it’s been a difficult shift,’ says mental health nurse Asha Brewer
- Acknowledge that anxiety at such a difficult time is completely normal ‘Remind your patients that how they’re feeling is understandable and they’re not alone,' advises Satwant Singh, nurse consultant in cognitive behavioural therapy and mental health. ‘Recognise we’re all affected by it and it’s global. It’s very important to normalise it’
- Prioritise your safety Mr Freshwater stresses that mental health staff should ensure they use personal protective equipment if required. ‘And if it’s not available, raise all kinds of merry hell about why not,’ he says
What mental health nurses are reporting during lockdown
‘All services are basically going through an ad hoc redesign,’ he says. ‘Staff have had the ground kicked out from underneath them and been thrust into a really difficult situation. But their response has been outstanding, showing their humanity and dedication.’
Anecdotally, he is hearing that police call-outs for mental health emergencies are going up, the number of suicides is rising and domestic violence is also increasing. Even those who may previously not have needed mental health support may seek it in the future because of the effects of social isolation.
‘Once we’re through the pandemic, we’re going to need more comprehensive mental health services, with substantial investment, because there is going to be so much trauma in the general population,' says Mr Freshwater. ‘The impact will go on for some considerable time. We have an enormous job ahead of us.’
Nursing Standard spoke to three mental health nurses about how coronavirus lockdown is making life more complicated for their clients and their services.
Here they explain how the current situation is affecting delivery of care in different settings, and the impact for those living with differing mental health conditions.
The community mental health nurse – drug and alcohol dependency
Trying to relay the significance of COVID-19 to clients who are dependent on drugs and alcohol is challenging for healthcare professionals.
‘When you have a client group who lives with the risk of death every day, the perception of the scale of risk of COVID-19 is very different to other people’s,’ says Leanne Patrick, a newly qualified mental health nurse who works for a community-based drug and alcohol dependency service run by NHS Forth Valley in Scotland.
‘Their family members and friends are dying in high numbers. It’s a fact of their lives. By comparison with the daily risk of taking street drugs, it is far less of a risk to them, which makes it difficult to encourage people to isolate. It's not seen as a big deal by some.’
Reduced, at time of writing, to providing consultations over the phone in all but the most urgent of cases, Ms Patrick and her colleagues are relying on the good relationships they have built with their clients.
‘We’re hoping they’ll be honest with us about what they’re taking, so we can give them good advice and keep them safe,’ says Ms Patrick. ‘But it’s very hard to get hold of people. Often, they don’t have the same number from week to week. We’re leaving messages with pharmacies asking them to call, but that delays things.’
Consequences for clients when drug supply lines dry up
For those who are alcohol-dependent, self-isolation can mean a vastly increased risk of going into withdrawal and having seizures, as the service doesn’t prescribe or deliver alcohol.
‘We also have people who don’t always remember that we’ve had conversations about the risks of COVID-19 because of their cognitive impairment,’ explains Ms Patrick.
Clients who use illicit drugs face other specific challenges. ‘Supply lines for some drugs, including heroin, are drying up,’ says Ms Patrick. ‘People are changing what they’re reaching out for. We would usually do regular drug screens so we can keep track of what they’re taking.
‘Shortages mean that quality is changing too – for example, heroin is being cut with cement. Purity is decreasing now, but at some time in the future it will increase again, meanwhile their tolerance will have lowered. This means there’s an increased likelihood of an overdose.’
Staff shortages compound the issues for substance misuse teams nationwide. ‘I'm disheartened by the lack of parity afforded at a UK level to all mental health services and certainly to substance misuse services that deal with high levels of risk. In Scotland, although there has been some redeployment, we are actually back to business as normal as a result of government guidance stating there should be no deployments.’
The nurse consultant – anxiety and depression
Being restricted from going outside is having a big impact on those who are living with depression.
‘Part of their treatment is having activities and structuring their day,’ says Satwant Singh, a nurse consultant in cognitive behavioural therapy and mental health in a multidisciplinary consultancy in London. ‘People are becoming more depressed because of the inactivity.’
Individuals whose anxieties centre on health concerns are particularly affected. ‘They’ve now become very concerned they may contract COVID-19,’ says Dr Singh.
‘They are also frightened about passing it on to their loved ones. Where people are not respecting the rules of social distancing, it’s also very anxiety-provoking.
‘It leaves people not wanting to go out, or feeling very panicky if they do and someone comes too close.’
‘Nurses can encourage people to recognise that despite how difficult everything is, they are coping. Work on building resilience by appreciating strengths’
Satwant Singh, nurse consultant in cognitive behavioural therapy and mental health
For this client group, daily updates focusing on the increasing number of deaths from the virus can be unhelpful, Dr Singh believes. ‘I have patients who are checking every few minutes to see how many more people have died. They are developing compulsions,’ he says. ‘As the numbers rise, so does their sense of panic and anxiety.’ Advocating limited exposure to both news and social media – possibly to once a day – can be a useful tactic.
How nurses can support service users to cope during lockdown
Structuring time is key, advises Dr Singh. ‘Encourage patients to use their time effectively,’ he says. ‘This means activities at home and going out for a walk every day. This kind of planning is really helpful.’
It’s also essential to encourage people to stay in touch with family and friends. ‘Mental health nurses can help build some form of engagement into their patient’s day,’ says Dr Singh. ‘Human beings are very sociable, and we’re always out and about. It’s very difficult when you are unable to do it. Some may need support to re-engage.’
Seeing the positive attributes of lockdown is important too. ‘It’s getting people to slow down and think about the benefits of not rushing around. Nurses can encourage people to recognise that despite how difficult everything is, they are coping. Work on building resilience by appreciating strengths and identify how they have managed to cope so far. Get them to see that they have that innate ability,’ says Dr Singh.
The secure unit staff nurse – forensic nursing
For people living in forensic mental health settings, the current lockdown is having a major impact, especially those who were once allowed to take leave from hospital under Section 17 of the Mental Health Act.
‘It’s been very hard on our service users,’ says Asha Brewer, a band 5 mental health nurse who works in a low-secure women’s unit in Leeds.
For example, one had managed to get leave to visit her mother, who was having cancer treatment, but was unable to take it because of the shielding measures for people with a reduced immune response. ‘Leave is an outlet – being able to get off the wards and see loved ones,’ says Ms Brewer. ‘Many have spent a long time and worked very hard to build it up. Now they can only go into a courtyard.’
COVID-19 has affected clients in other ways too. ‘It has fed into some delusional beliefs,’ says Ms Brewer. ‘One service user thought she couldn’t be affected by the virus as she held the cure. Another thought it was a conspiracy. It’s caused a great deal of concern. It’s an unbelievable set of circumstances and even we as professionals struggle to get our heads around what’s going on.’
Staff need to enforce the lockdown but that can cause resentment
As service users’ precious freedom is curtailed, and in spite of generally good trusting relationships, resentment builds up, she says.
‘As front-line staff, we’re getting people's anger,’ says Ms Brewer. ‘You spend so much time with them, you become like their family. But the negative side is that all their frustration can be focused on us. We are experiencing lockdown and it’s hard, but it’s ten times worse for them – we’re not locked in a hospital. There is already an increase in incidents of aggression towards other service users too.’
As the majority of service users have co-morbidities, including obesity and diabetes, and many also smoke, the unit has put physical care plans in place and all visits from family and friends have been stopped. To help keep in touch with loved ones, the unit is allowing service users to use smartphones for two hours each day.
With many staff self-isolating, the toll on staff can be high. ‘The last few shifts I’ve done, I’ve come away feeling really stressed,’ says Ms Brewer. ‘At the end of the day, you’re a human being and it’s upsetting when you’re being shouted and screamed at.’ But staff are supporting each other through the crisis. ‘Our team is really close,’ she says.
COVID-19 and obsessive compulsive disorder
People with obsessive compulsive disorder (OCD) face particular challenges.
‘For those with OCD or conditions involving cleanliness, neatness, phobia of germs, tidiness or obsessive behaviours, COVID-19 may actually have reinforced beliefs that such behaviours were what kept them safe,’ says Birmingham City University professor of occupational health psychology Craig Jackson.
Associations made between obsessive or repetitive behaviours and staying free of infection could make conditions more difficult to treat in the future, he says. ‘The longer this behaviour is in place, the harder it may be to change,’ he says.
For healthcare professionals, reassurance and understanding are key. ‘The vast majority of people with OCD are aware of the irrationality of what they do and how it must appear to other people,’ says Professor Jackson.
OCD groups offer support for isolated people
Charities such as OCD UK and OCD Action have seen significant spikes in requests for help. ‘We’ve had a huge increase in demand for our support groups,’ says chief executive officer of OCD Action Leigh Wallbank. ‘Social distancing is making people more isolated, with difficulties accessing their usual support networks.’
The charity has increased its number of online and phone groups from 30 to 45.
OCD can affect a person's ability to access their basic needs, says Ms Wallbank. ‘It can be hugely debilitating. For instance, they may become very concerned about contamination and find it difficult to go to a supermarket.’
With much treatment postponed or delayed, nurses can signpost people to other sources of support. ‘A lot of our callers are saying their therapy has been affected,’ says Ms Wallbank.
Mental health legislation: emergency changes in a nutshell
Emergency legislative changes due to the coronavirus include a reduction in the number of healthcare professionals needed to detain someone for assessment and treatment.
Usually, the Mental Health Act requires that three professionals must agree: an approved mental health professional (AMHP) and two doctors. Under new provisions, the say-so of just one doctor is required. The AMHP must record the reason for the decision to detain someone on the recommendation of only one doctor.
The decision should only be made if staff shortages caused by COVID-19 mean it would take too long for a second doctor to make an assessment.
Lack of consultation about changes to legislation
‘There doesn’t seem to have been very much in the way of consultation on these changes and they are fairly significant,’ says RCN mental health forum chair Ed Freshwater. ‘Of course, we expect major disruption and there won’t be the same access to doctors.
‘But the nature of this sweeping legislation is quite open-ended. If we had enough nurses and medics in place already, we wouldn’t be needing this.’
Other changes include:
- Extension to the initial period the police can hold someone in a place of safety if they are concerned about their safety or that of others and they have a mental health condition. It was 24 hours, now it’s 36 hours
- Extension of the period for emergency detention of voluntary patients already in hospital. In some cases this was up to 72 hours, now it’s 120 hours
- Removal of the 12-week upper limit for those remanded to hospital by a court, although a review must take place every 28 days
Source: Coronavirus Act 2020
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Lynne Pearce is a health journalist
- Coronavirus Act 2020 – Mental health and mental capacity
- Rethink Mental Illness – temporary changes to mental health legislation explained
- Public Health England: COVID-19 guidance for the public on mental health and well-being
- RCN mental health forum
- Rethink Mental Illness – coronavirus and clozapine
- @WeMHNurses – twitter group
- OCD Action – forums, support groups, information and helpline