Isolating the Variants in a Mental Health Pandemic
Content warning — this article discusses suicide, self harm and mental health presentations such as eating disorders. These discussions are critical but not at the expense of individual risk. Please stop reading and contact crisis mental health services in your region if you don’t feel safe. In Australia you will find a list here. Your GP is also an excellent first point of contact. Make sure you have one!
As variants of the COVID-19 virus have taken centre stage at different times in this pandemic, so too have different mental health presentations. We have seen various ‘strains’ of mental health presentations in ourselves, our loved ones, in our friendship groups and those we see through the media. Often we don’t see the presentations that are wreaking havoc inside others. To our minds they are asymptomatic, but within their minds, hearts and body they are overwhelmed by agony, suffering and contemplating potentially life threatening outcomes.
Each time we see an outbreak of a new COVID variant strain in Australia, much is made of the phenotype, or how infection with the virus presents clinically in the human host. Most of the time, we only really learn when people become infected and unwell, and most of what will be documented document is yet for us to learn. We fear ‘Long-COVID’, we are concerned about repercussions of infections in adolescents and children. We know different strains can be more pathogenic and more contagious in different age groups. This current delta strain of COVID-19 has been proven to infect children with clinical consequences, and not just create asymptomatic carriers. Across the age demographic it is already known to be more infectious, capable of creating cases in an exponential manner from a primary source.
Each time we see cases rise and hospitals presentations increase we do a daily tally of the figures. Precious ICU beds are always factored into the tally. So are the numbers of ventilators required to breathe for the most unwell until they recover, or, tragically don’t. These tallies are critical in informing and influencing the minds of the vaccine hesitant or the COVID conspirators. Yes, ICU beds and ventilators don’t grow on trees.
It is time critical that the mental health pandemic is spoken about not as an afterthought, but front and centre alongside the physical consequences of the COVID pandemic. It should be mentioned at every official press conference occurring around Australia. What to look for, when to present for help, and what people can do to keep safe. The mental health equivalent of mask wearing, hand hygiene and social distancing.
It is also time critical that we don’t adopt such crude measures to monitor the impact of the mental health pandemic. ICU beds and ventilator supplies heralds the demise of those critically ill from COVID. We don’t just measure deaths each day.We therefore should not monitor death rates by suicide as the only crude predictor of the mental health pandemic.
Currently, suicide rates in Australia during the mental health pandemic have remained relatively stable. This has been used to temper concerns about the rise in mental health presentations and mental health burden experienced by society. But is it a snapshot, a statistical measure that does not embrace real human suffering? Does it dismiss those who seek help or choose not to suicide, or indeed try but fail? These factors, just like those we count each day in our ICUs with physical disease must be counted.
It is a very common occurrence for a patient who has overdosed on medications, or has suffered acute alcohol poisoning, or a road trauma that was an intended suicide to be treated in an ICU setting. And a life is a life. They are clinging on to life, and so are their families and loved ones. They are also in need of precious ICU beds and add to the overwhelm those working on the front line endure each shift.
Yet they are not counted. They are the invisible consequences of a mental health pandemic.
Once treated for any acute physical consequences, many of these patients need to be transferred to an acute mental health facility within our public and private mental health system. They may go home but need 24 hour support from our acute response teams. They also fall victim to bed block and an inability to find literally no room at the inn.
Yet they are not counted in our daily tally of the cases related to the COVID-19 pandemic.
Overall, in a practically strapped and fatigued public health system, both aspects of this pandemic are wreaking havoc on constraints, resources and our workforce. Only one aspect is spoken about.
Just as different variants of COVID-19 have presented with different characteristics, so too have the mental health presentations across different age, gender and socio economic demographics.
Although depression and anxiety are mentioned frequently, little is being spoken about the huge rise in presentations of eating disorders, primarily amongst adolescent females. Some of this may be as a consequence of home schooling; adolescents with restrictive eating patterns or tendencies to over-exercise to maintain an unhealthy weight range come to the attention of the parents they are trying to hide from. But there is also the element that as the external world spirals further into uncertainty, so too do the measures leading to potential starvation, in an irrational way to control something. Funding has been pledged but there needs to be a solution to the scarcity of acute hospital beds for treatment of what is such a life threatening condition.
In many who experienced grief and loss in 2020 and unable to mourn, attend a funeral or receive ongoing close support in the days and months afterwards, complicated grief reactions have emerged. This inability to grieve, a normal human process, emerges as months of doom, hopelessness and a loss that does not ever seem to get easier to bear. Not only does this leave a persistent level of suffering, it can also add to the risk of self harm or substance abuse in dangerous levels. Working at different posts in the acute mental health setting this year, I’ve seen alarming rates of misuse of substances such as alcohol with almost deadly consequences. Very rarely has this come from a deliberate attempt to engage with substances more often, but falling down the ‘slippery slope’ into regular consumption at higher levels to achieve the same effect of numbing inconsolable pain, and to stave off withdrawal symptoms. Underpinning this was often a tragic story of loss in 2020 that remained as recent as today.
Just like grief, loneliness is a human affliction, not a pathology. Yet the level to which some are experiencing loneliness is becoming pathological. Initiatives such as singles forming social ‘bubbles’ with one other single person during lockdown highlights that public health measures are addressing the harm of extended lockdowns on those who live alone. Many who live alone enjoy this time but complement their lives with socialisation, such as joining a gym or a group based hobby. Depriving many who live alone with this important part of their lives destroys their links, their connections and a lot of their own sense of purpose and meaning. Others who have busy work roles in an office or retail environment may crave times alone to recuperate. The necessity and now trend to work from home has again disrupted lives and mechanisms to live a fulfilling life.
The Harvard Happiness Study which followed male Harvard attendees (women were unable to enrol at Harvard at the commencement) since the times of the Great Depression, has shown that one of the main keys to happiness longevity was meaningful relationships with others. The director of the study and a psychiatrist, Robert Waldinger, has been quoted as saying,
“Loneliness kills. It’s as powerful as smoking or alcoholism.”
Little is known about the effects of repeated lockdowns, fears of living in a pandemic and actual COVID infection will have on some of our most vulnerable - children. Again, history will hold the secrets of what will eventuate in the years after the pandemic is over. In 2020, particularly in Victoria, Australia, school closures helped prevent asymptomatic spread by children with the Alpha strain of COVID-19. In 2021, and with the emergence of the Delta strain, school closures attempt to protect children because of the pathogenicity of the Delta strain in an almost completely unvaccinated age group. The emotional toll has begun to be investigated. Again, time will tell how this measure to keep children safe physically will lead to detrimental effects emotionally.
A lot of what is emerging is occurring in those who were previously well and relatively free of mental health concerns. An inclusive and holistic account of the mental health consequences must include those already living with a mental illness, suddenly isolated from support systems, unable to access acute services when in crisis because of crippling demand, and those who remain invisible; the homeless, those with disabilities and those in aged care facilities.
We all fear that a new strain of the COVID-19, unless by complete random luck it is a relatively benign one, will bring more risk to different demographics, while there is no vaccination strategy for Australians of all ages. One things for sure, the burden of mental illness will swamp our system and is already doing so. Different variants will suffer; areas such as mothers in the perinatal period, our ageing citizens and many facing a premature retirement. The phenotypic makeup will be revealed as those most vulnerable present for care and recovery.
