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Psychiatry’s pandemic challenge

Mental health services are crucial in the pandemic and are facing a uniquely difficult period. David Lynch reports

In October 2020, a survey by the World Health Organisation (WHO) found that the Covid-19 pandemic had “disrupted or halted” critical mental health services in 93 per cent of countries.

The WHO warned that the demand for mental health services was increasing but Covid-19 was having a “devastating impact” on access.
Of course, Ireland is not immune to these pressures. Psychiatrists and mental health services in this country are facing exceptional challenges during the crisis.

While there is support for public health measures taken to control the spread of the virus, medical experts agree that the pandemic and associated restrictions are impacting mental health.

Dr Matthew Sadlier, a Consultant in Old Age Psychiatry, North Dublin, and former IMO President, told the Medical Independent (MI) that during the peak of Covid-19 cases in March and April 2020, and again during the current wave, mental health services witnessed a significant drop in referrals. He said this was to be expected in an “acute health crisis when populations go into crisis mode and management”.

“But it’s like a bomb and an explosion. Mental health is the fall-out from
that explosion.”

He said following the first peak last year there was an unprecedented increase in referrals, from May through to September.

“So that is how I expect this wave to affect mental health services. This wave is bigger than the last one, so it is going to affect services proportionally more… our [referral] wave comes after the general acute medical wave.”

The IMO warned in December that there are just over 1,000 acute adult psychiatric beds, which operate at almost 90 per cent capacity in the country.

Dr Sadlier said the nature of the pandemic has had a negative impact on bed capacity.

Dr Matthew Sadlier

“A lot of our psychiatric units are quite old, they are designed with dormitory type rooms,” he told this newspaper. “So our bed capacity in acute units has been dramatically hit. We have had acute units closed because of Covid outbreaks, without any alternatives put in place.

“If you closed one of the big general hospitals in Dublin to admissions for one day, the Government would find an alternative somewhere. But this has been happening in psychiatry repeatedly since March and we have just been told that we have to find beds in other locations within existing resources.

“That has been one of the significant challenges.”

Tsunami

Last month Dr Sadlier told the Oireachtas sub-committee on mental health that one-third of psychiatry posts are either unfilled or staffed on a temporary basis. He said this “stems directly from the two-tier consultant pay issue which has been a feature of the health system for eight years”.
“So we were just about toddling along prior to the pandemic,” said Dr Sadlier.

“But with the issues now with staff having to be absent because of close contacts and staff who have Covid, all this has impacted sick leave and absenteeism. This puts pressure on a system that is already down on consultant numbers.

“Going forward this will lead to huge problems with seeing the number of referrals that are coming into the system….

“In adult psychiatry we have historically run very short waiting lists, but that is going to change, because I do not see how with the current resources we are going to get through the tsunami of referrals that I’m expecting to hit us in February and March.”

Distress

Writing on the ‘Impact of Covid-19 on Mental Health in Ireland’ in the November/December edition of the Irish Medical Journal (IMJ), Prof Brendan Kelly, Professor of Psychiatry at Trinity College Dublin and Consultant Psychiatrist at Tallaght University Hospital, noted that the available evidence shows that one-in-five people have “significantly increased psychological distress”, which is likely attributable to anxiety about the pandemic and the effects of restrictions.

Self-harm hospital presentations fell by 25 per cent in April last year compared to April 2019, but Prof Kelly argued that this is not a reliable indicator of the extent of the issue as hospital presentations across the board fell by 40 per cent.

Dr Kelly also wrote that people with mental illness are at increased risk of contracting Covid-19. He highlighted a study in the United States that shows “the odds of infection with Covid-19 are over seven times greater in people with depression or schizophrenia compared to the general population”.
“Population anxiety has certainly increased over the past year,” Prof Kelly told MI.

Prof Brendan Kelly

“In addition, people with enduring mental illness, such as schizophrenia and bipolar disorder, are experiencing relapses, for various reasons. Many mental health services have been re-configured so as to be delivered safely. This has undoubtedly affected some patients who were familiar with certain patterns of assistance and support.”

Prof Kelly added that “recruitment (of consultants) is also a continual challenge”.

Echoing Dr Sadlier’s remarks, he said that the current crisis meant the challenges around staffing numbers are “compounded by the need for staff to self-isolate following exposure to cases of Covid-19”.


“All told, this is a uniquely challenging time for mental health services.”
Prof Brian Lawlor, Consultant Geriatric Psychiatrist, St James’s Hospital, Dublin, warned that the current crisis was resulting in a build-up in “unmet need” in mental health.

Prof Brian Lawlor

“Many individuals are unable or reluctant to access mental health services at the moment and there is a build-up of unmet mental health needs as the pandemic continues,” he told MI.

“Acute services are handicapped by pandemic-induced reductions in bed capacity and curtailment of community services, but more worryingly, the pent-up need for assessment and care is growing across all age groups.

“Children are losing out on educational, emotional and social development and access to mental health support services through schools that may have a long-lasting generational effect on their brain health.   

“The mental health of children and young people appears to have been disproportionally affected. Older people with cognitive impairment have been isolated, restricted and unable to access supports and this has accelerated decline and triggered the emergence of distressing behavioural and psychological symptoms.”

GPs

General practice is also seeing much of the mental health fallout.
At the end of 2020, when asked about his hopes for the pandemic response this year, Dr Ray Walley, GP in north Dublin and former IMO President, told MI “we need to ensure the supports are in place for our most vulnerable especially those with mental health issues”,

“Mental health funding needs to be augmented and prioritised now.”

In December, Dr Denis McCauley, Chair of the IMO GP committee and Dr Sumi Dunne from the GP committee told the Oireachtas committee that Covid-19 has had significant psychological effects on people across the country.

The GPs recommended that investment in a clinical programme of care for mental health should be negotiated, similar to the chronic disease management programme.

“We feel that there is a huge amount of mental health issues in the community, most of which is being dealt with by general practitioners,” IMO President and Co Longford GP Dr Padraig McGarry recently told this newspaper.

Legacy

With vaccine roll-out continuing, there are some hopes that the ‘end’ of the pandemic could possibly be in sight. However, experts warn that a mental health legacy may endure once the immediate crisis passes.

“There is evidence that people who get Covid-19 are at increased risk of depression and post-traumatic stress disorder,” said Prof Kelly. “So the first step in preventing negative mental health outcomes is to follow the public health guidance and minimise risk of Covid-19.

“Much of the ongoing risk of mental ill-health could also be mitigated by enhanced mental health service provision.”

Taking a historical perspective, Prof Lawlor said the mental health impact of a pandemic can have a “long tail”.

“Pandemics also have a way of highlighting society’s many inequalities and disproportionally affecting our most vulnerable; this is not just true for those with pre-existing physical conditions, but also for those that have an underlying mental illness,” he said.

“The chronic and severe stress, loss, grief, trauma, isolation, and loneliness experienced during this pandemic has increased the rates of depression, anxiety, sleep disturbance, burnout, alcohol and substance misuse, and domestic violence and triggered relapses and recurrences in those with mental health problems.”

He added that the lessons following the 1918 Spanish influenza pandemic were that people experienced longer term mental health effects related to the experience of isolation, loss, grief and trauma, and the stress associated with job loss and financial pressures.

The mental health of our frontline health workers must not be forgotten in the viral mist

“As the pandemic ends and we begin to deal with the aftermath, we can expect an increase in the numbers of people presenting with depression, anxiety, chronic disability, due to the long-term effects of Covid and possibly increased self-harm and suicide,” said Prof Lawlor.  

“For all these reasons, we need to put a strategy in place to mitigate the mental health fallout from the pandemic and consider how we can best support mental health at a population level and bolster mental health services to deal with the predicted increased need.

“A comprehensive package of ongoing financial support, jobs and ready access to mental health services will be key in the months and years ahead. But we must act and plan now.”   


Policy

In October’s Budget 2021, Minister of State with responsibility for Mental Health and Older People Mary Butler announced that over €1 billion had been allocated to mental health. This, she said, was an increase of €50 million on the 2019 budget and comprises €38 million for new measures, including the continuation of Covid-19 supports, and €12 million to meet existing needs.

During the summer the Government launched its new mental health policy Sharing the Vision – a Mental Health Policy for Everyone. A national implementation and monitoring committee (NIMC) has been established to oversee the long-term implementation of this policy.

“The NIMC steering committee will initially meet on a monthly basis,” a Department of Health spokesperson told MI. “The purpose of the NIMC steering committee is to drive reconfiguration, monitor progress against outcomes and deliver on the commitments set out in the policy.

“The purpose of the NIMC specialist group panel is to provide specialist input at various points in the implementation of the policy, including being a member of specific themed specialist groups, as envisaged in the policy.”

In his recent IMJ article, Prof Kelly wrote that up to 86 per cent of healthcare workers globally reported feeling stressed and in Ireland up to 40 per cent of the radiographers surveyed showed signs of burnout and 30 per cent considered changing jobs or retiring.

Speaking to MI last month, Executive Director at the WHO Dr Mike Ryan said that “burnout among healthcare workers is a serious issue during the current pandemic”. (see panel, p4)

“We do know that patient outcomes are worse when we have overcrowded facilities, when we have less time per patient with the clinical team, where the clinical team are tired or don’t feel protected or are burnt out.”

The impact of burnout and stress on doctors and others is something that Prof Lawlor said requires a national and “joined-up response”.

“The mental health of our frontline health workers must not be forgotten in the viral mist,” he told MI.

“These individuals have shown incredible resilience over the past 12 months, but we know that even in those with the most robust mental health, chronic and severe stress can result in burnout and mental health issues.

“Again, we need a joined-up approach at a national level to provide all of our frontline health workers with ready access to the preventive mental health supports they deserve.”

Caring for the carers

Throughout the pandemic there have been growing concerns voiced over the impact of the crisis on the mental health of doctors and other healthcare workers. In June 2020, the Irish Journal of Psychological Medicine (IJPM) published a special edition on the mental health impact of Covid-19.

Dr Íde Delargy

At the time, the data on potential increased stress and anxiety among healthcare workers in Ireland during Covid-19 was not yet available.
However, on its publication, the IJPM’s guest editor and Consultant Child and Adolescent Psychiatrist Prof Fiona McNicholas noted that international evidence suggested a psychological toll on healthcare professionals relating to Covid-19.

“In terms of what we know from the data that came from SARS and MERS… frontline care workers or healthcare workers in these pandemics are not only faced with the anxiety of can they cope with what is coming,” Prof McNicholas told MI at the time.

“But there is also that personal anxiety from the infection and risk in the beginning that there wasn’t sufficient personal protective equipment (PPE) and that added additional layers of stress.”

In the months since, concern has only increased. Last November, Dr Íde Delargy the Medical Director of the Practitioner Health Matters Programme (PHMP), which provides confidential treatment services for health professionals who have mental health or addition issues, said she expected more presentations due to the increased mental health burden of the pandemic.

“Last year (2019) saw the highest number of practitioners presenting
to the Programme, and we expect presentations to rise due to Covid-19 because health practitioners have never had to work under this kind of strain before,” said Dr Delargy.

“Everyone is working flat out to get through this pandemic, and it is only when the dust settles that people will properly be able to process what they have been through. It is crucial that doctors, dentists and pharmacists access help if they are feeling overwhelmed.”

Child and old age psychiatry services impacted

While all psychiatric services are facing difficulties, some areas are more affected than others. For example, services for older people and children face unique challenges.

“Child psychiatry has had even more significant problems with recruitment than adult psychiatry, so child psychiatry waiting lists coming into the pandemic were already at a significant level,” Consultant Psychiatrist Dr Matthew Sadlier told MI.

“I’m not criticising any of the public health regulations that have been brought in to deal with the virus. These are necessary regulations.

“But they will have knock-on effects especially on children with learning disabilities, children with behavioural problems, there will be longer term problems as they adjust back to school and to normal life, so I imagine waiting lists for child psychiatry will become even worse than they were prior to the pandemic.”

In his own area of psychiatry of old age, Dr Sadlier said even before the pandemic “it has been very poorly resourced and quite small in comparison to other aspects of the psychiatric and other medical services”.

“We have been particularly hit by this pandemic. Because of the closure of day centres, closure of activities for elderly people. Elderly people not being able to see their family, having to cocoon, bereavements. That has put a huge pressure on the emotional side of the old age psychiatry service.

“The other part of the service which I work in is neuropsychiatry, which is dealing with dementia and physical health problems that create psychiatric symptoms and issues. The Covid virus is what we call neuro-invasive, so it affects your brain. So with people with dementia it can make their dementia worse, it can worsen behavioural problems among people with dementia who have behavioural problems… so in our area, our referrals have tripled and we are absolutely swamped.”

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