Patients with mental health problems are some of the most disadvantaged; they often rely on others for help and support. This period of self-isolation has amplified the gloom of not having any friends or family, or living in run-down areas with small living spaces and little fresh air. Being stuck at home in isolation with no routine and no one to speak to can lead to loneliness, low mood and a loss of hope. Cancelled outpatient appointments may have been some patients’ only source of face-to-face contact.
As a psychiatrist working in an inpatient psychiatric unit in London, I’ve seen how Covid-19 has made an impact on my patients’ mental health; below are my observations on how my practice as a psychiatrist has changed since the onset of the pandemic.
1. Psychosis
We have interestingly seen an increase in patients with first-episode psychosis whose psychotic symptoms revolve around the current pandemic. This is not unexpected; it is known that one’s psychotic beliefs mirror one’s society and culture. It is, however, interesting to observe how an individual’s mental illness may be moulded by the events around them. Times like these affect vulnerable groups disproportionately, and many families are facing unique challenges that have been completely unprecedented. Self-isolation, lack of contact from friends and family, lack of structure or routine and increase in drug and alcohol use can all exacerbate a psychotic episode; are we prepared to respond to this?
2. Males vs Females
In my unit, we have noticed a reduction in female admissions and a rise in male demand for psychiatric beds. We don’t know why this is. Are women still unwell but just not presenting to services? Has the pandemic in some way attenuated the mental health problems for some of our female patients? Are women more protected now that they are ‘stuck’ at home with family and friends? Or is the opposite true for men? Everyone is different; no two people with depression are alike. It fascinates me how men and women, specifically, differ in their presentations to mental health services and how they experience their illness. Everything about their presentation is different - the emotions they feel and how they express them, the thoughts that run through their minds and what they choose to disclose to others, their psychotic symptoms, their risks, being the primary carer for young children, being exposed to domestic violence and sexual abuse, the commodification of their bodies and the impact this has on their mind – everything is at odds. Perhaps, this tells us just as much about society and our expectations of men vs women as it does about underlying biological differences.
3. Assessing a patient in Personal Protective Equipment (PPE)
Communication is a vital part of psychiatry: How does the patient communicate with you and what does this tell you about their mental state? Are they too frightened to reveal their thoughts? Are they open about their difficulties? Are they apathetic about being in a psychiatric hospital? Conducting a psychiatric interview behind a mask is not easy. It limits non-verbal communication; gestures such as an understanding smile or grimace are no longer at hand. Patients feel uncomfortable, and doctors may come across as terrifying, anonymous healthcare professionals who lack emotion and humanity. To some, we are merely robots; asking the same repetitive questions behind the same plastic barrier. No wonder some patients choose not to speak with us when we are dressed up in PPE.
4. Mental health services
From anxious managers who refuse to step on to the wards, to suggestions of virtual Mental Health Act assessments (just how feasible is this?), to a trimming of services - there is chaos everywhere. In London, we have a vast array of tertiary mental health services, but most have closed down as a result of the pandemic. World-renowned professors who previously staffed these units are now sitting at home with nothing to do. The pandemic has cast a light on aspects of our service that are crucial to patient care; upholding patient rights through tribunals, psychological therapies, regular patient contact – these are things that cannot go away. On our wards, we have 18 patients trapped in a small ward; all unwell, some intrusive, some aggressive, some chaotic, some wishing that that the world would end. Psychology is limited to those who are deemed to need it the most – one or two patients out of the entire ward – and is framed through a tiny screen in the corner of a room where a psychologist’s face swivels up and down across a screen and attempts to display compassion and empathy through a virtual reality. The rest are stuck in their rooms with no occupational therapist to structure their day, sitting in rooms and surrounded by strangers.
5. Human Rights
We have a lot of legal power in Psychiatry; we can force people out of their homes and into hospital, lock them inside seclusion rooms and administer medication against their will if we deem it to be necessary. With such power, it is important that there are safeguards in place so that we do not take a patient’s liberties away unless absolutely necessary. When a patient is detained under the Mental Health Act, they have the right to appeal to a tribunal. This tribunal is usually made up of three panel members: a judge, an independent psychiatrist and a layperson. They have the power to end the section if they believe the criteria for detention are not met. Since the pandemic, these tribunals have been staffed by two and sometimes only one(!) person. This is extremely concerning. The patient’s deprivation of liberty – liberty being a right that we are all entitled to – is no longer reviewed by a tribunal; it is sometimes reviewed by just a single person. This allows bias and, sometimes, the patient finds themselves in a position where no one stands up for them. On our ward, most solicitors no longer come to the ward to speak to their patients in person. Our patients’ human rights are being eroded right in front of our eyes.
6. Privilege
There has been much written in the media about the “sacrifices” that healthcare professionals have made during this pandemic; the woeful lack of PPE and the horrific deaths of healthcare staff. However, one emotion that I have experienced repeatedly since the start of this pandemic is gratitude. I have a job that is secure. I have a structure to my day. I have a reason to leave my house and enjoy the fresh air as I walk to work. I am surrounded by a team of professionals who I speak to everyday. I receive my daily dose of human contact and am intellectually stimulated everyday. For that I am grateful. (The free food is also great.)
By Dr Gunjan Sharma