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We need to shift the curve too for the mental distress generated by Covid 19

April 25, 2020



There has been much concern about the level of mental distress which may emerge out of the Covid 19 pandemic. We know, both from the specific evidence coming back from China and Italy about this pandemic, but also from the general experience of many other major traumatic events, some of the issues which are likely to emerge. In this case, it is likely in addition, that there will also be the impact of major economic dislocation. All of this was well described in a recent position paper in the Lancet.

It is one of the gains from all the work we have done in reducing the stigma around mental health problems that we can be much more open talking about them in the current context. In the past we might have ignored such issues or left them undealt with them until they presented in more extreme forms of distress. That said, how do we ensure that we can respond as effectively as we can in the current circumstances to an anticipated surge in requirements for help.

My argument, in this blog, is that there is much to learn from the public health strategy of “flattening or shifting the curve” which has been applied in managing the physical health consequences of the pandemic. We should indeed expect and plan to respond to a significant increase in presentations but we can also take steps to reduce the level of need for clinical level interventions so as to ensure services are not overwhelmed and that those with the greatest needs are able to get help in a timely way.

There are a number of elements to such a strategy.

The first is not to confuse, in our thinking, distress and trauma with enduring mental health problems which require ongoing clinical treatment. There are many groups who are going, in differing ways, to come out of the pandemic with experiences of significant distress whether as a result of social isolation (likely to be particularly acute amongst some of the vulnerable groups who have been shielded to protect their physical health) grief or bereavement, their experience as key workers or the impact of sudden economic dislocation and loss. Such experiences are risks factors for the development of mental illness, but they are not necessarily translate into ongoing issues and we can intervene to reduce the resulting burden of enduring problems.

To do so we need an effective and dynamic public mental health strategy, co-ordinated at national and regional level and informed by research but delivered locally in communities and organisations to support messages about how individuals protect their wellbeing and process some of the difficult experiences they have been through. There are many good digital and other resources to help support individuals but there is also a need, as has been the case in physical health, clear and consistent messages about what to do.

Notwithstanding what I have said before about stigma, one of those consistent messages will need to be to encourage people to see as normal and talk openly about any distress they are feeling. Sharing issues in a supportive environment is often an effective first line of response. This message, though, needs to be presented through a wellbeing lens which avoids pathologising distress and which supports personal and collective agency in looking after our mental health. Strong consistent messaging is crucial here, as with physical health, to counter some of the unhelpful and alarmist messages which circulate in the media.

The second is to recognise the importance of segmentation of audiences and need. Experiences of distress will manifest in different ways for different groups and understanding context will be crucial to responding effectively. Children and young people are a good case in point. There will be some shared experiences of lockdown for all young people but for some distress will be greater because lockdown has triggered or exacerbated underlying risk factors, for instance in relation to domestic violence, abuse or neglect. Young people with some neurodevelopmental issues may have found parts of the experience of confinement especially difficult and may also struggle with the return to school when that happens. In looking at the health and care workforce there will be the need to focus differentially on a range different groups not just those who have been working “on the front line”.

The third is to enable an integrated response between public health interventions and service responses. We can work together around events such as children returning to school to combine effective programmes of support to young people, families and teachers with clear routes on how these with more severe difficulties are offered help quickly. Services need to stratify the populations known to them to identify those who might be at most risk and target help, where possible, proactively. We need to very mindful of the impact of the pandemic on inequalities and where differential experiences may have potentially lifelong consequences, for instance in terms of poorer educational or employment outcomes and greater vulnerability to chronic mental health problems. Statutory providers in the NHS and local government should work with partners in the voluntary sector to ensure the best use is made of all the resources available to support those in distress.

Our strategy needs to be innovative and adaptive as services have shown themselves so capable of being in the first weeks of the pandemic. We need learn from experience and be prepared to develop new models of service to meet new needs and to respond to existing needs presenting at greater scale.

My final point is about longevity. It is clear that we will have to work around different phases of the pandemic with different needs and responses at each stage. That applies as much as to psychological consequences as it does to physical ones.
What we also know about trauma suggests that it is not necessarily at the outset that the most difficult issues are experienced. Indeed, ironically, it may be at the point of return to some kind of normality that some individuals are most at risk. What we put in place must be sustained and take account of the different waves of psychological strain which may be experienced. This also applies to resources and the same promises which have been made to do what it takes to help the NHS manage the pandemic must be apply equally to action taken to manage its psychological consequences.

Beyond that, indeed, there is a stronger message which is that we must take the experience of the pandemic to make sure that we make a proper focus on mental health and wellbeing a central and integral feature of how we go about things whether in health and care services, schools or workplaces. Just as shell shock a hundred years broadened, and to some extent normalised, the public understanding of mental distress we must use the current collective experience to put mental health at the centre of our response.

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