Anxious times 17.10.20

October 17, 2020 Gunn (Te) Pungpapong

Welcome to issue number 40.

For this timely and informative article, I have to thank a seasoned Plague Pit contributor, Gunn (Te) Pungpapong. Te is in the sixth form at Winchester College and right in the middle of his medical school applications. Here he considers the mental health implications of the pandemic for patients, health care staff and even his fellow Wykehamists.

COVID-19 and its hidden mental health epidemic

It’s perhaps easy to forget about the pandemic’s mental health effects when daily headlines are constantly populated with skyrocketing case numbers. As the situation evolves, with recent spikes in many countries foreshadowing a second lockdown ordeal for many, it’s important now more than ever to reflect on its potential impact on mental wellbeing.

Although earlier measures proved seemingly successful in terms of public health response, with curves being flattened and countries narrowly avoiding economic standstills, the damaging consequences cannot be neglected. With the imminent relapse into strict measures, I believe experts must no longer question the necessity of such measures but should rather evaluate on how best to implement them. In preserving our physical health (but, more importantly, of those most vulnerable and closest to us), we must consider the parallel yet often overlooked mental health crisis with a retrospective but also forward-looking point of view.

Although wildly different to natural disasters such as wildfires and floods, it may be insightful to first examine the comparisons disaster mental health experts have made regarding COVID-19 [1]. Post-traumatic stress disorder (PTSD) researcher Joe Ruzek stresses the global nature of such pandemics: the fact that “there are no safe zones” completely undermines conventional disaster response techniques such as congregating in central locations to avoid such disasters. This leaves the general public, but also the workers, helpless. Psychology professor Charles Benight outlines the pandemic’s ambiguous, invisible nature, saying that “you can’t see it, you can’t taste it, you just don’t know.” This, he claims, explains the debilitating uncertainty many experience. “You look outside, and it seems fine,” says Benight.

With the earliest introductions of non-pharmaceutical interventions (NPIs) such as mass home-confinement, mask-wearing and socially distancing, many would have struggled to adapt to the “new normal”. Undoubtedly, mental health would have been affected [2]; although the majority tend to remain relatively resilient, studies on lockdown, quarantine and social distancing amidst both the current pandemic [3] but also of ones such as the 2015 MERS [4] and multiple Ebola [5] outbreaks indicate heightened prevalence of psychiatric disorders including depression, anxiety, stress and PTSD. Other individual stressors such as financial and economic insecurities would have stemmed from the situation’s uncertainty of the situation and may even lead to further problems such as increased substance use [6].

Here, it is important to recognise the diversity of earlier pandemic experiences which ultimately led to an array of mental health consequences. For a Wykehamist, their biggest concerns may have been the impairment of their social life, and the prospects of both remote learning and centre-assessed grades. For healthcare professionals, on the other hand, their fears of frontline COVID-19 exposure [7] and, until recently, the alarming lack of PPE resources would have contributed to widespread psychosocial effects [8]. As both the pandemic and its restrictions drag on, these factors will only worsen.

Furthermore, the advent of these mass-confinement directives has impaired access to various mental health services and support platforms [9][10] critical to those newly suffering but, more importantly, to those with pre-existing conditions. Lack of funding as a result of the focus shift towards coronavirus has and will continue to pose challenges in dealing with mental health. Conversely, recent innovations in telemedicine have been met with increasing success, not just in the mental health sector but throughout various areas. Although inexperienced practitioners may have found some transitions to be challenging [11], the pandemic may very well be the unexpected catalyst in transforming the telemedical landscape of the future.

Understandably, many COVID-19 patients experience deteriorating mental health. For the most severely affected, post-intensive care syndrome (PICS) may continue to plague them, manifesting psychiatric complications such as depression and anxiety [12]. With the recent spotlight on “long COVID-19” and its lingering physical impairments, those previously diagnosed can also experience accompanying psychological manifestations. These include things such as low mood, anxiety and sleeping difficulties, and many cite factors such as inappropriate medicalisation by healthcare personnel [13], as well as scepticism from peers and family who underestimate their post-infection symptoms [14].

Emerging research [15] seems to suggest that that organic neurological changes and phenomena following COVID-19 infection may also play a part. With an increasing number of COVID-19 cases reported with neuroinflammation and brain cell damage [16][17], it is believed that these changes may combine with prevailing environmental stress to manifest psychiatric illnesses [18] such as major depressive disorder (MDD) and PTSD [19]. This relationship has already been observed previously in other illnesses [20], but further developments are needed in order to confirm its viability.

My own experiences self-isolating at home for two weeks upon arriving back from the UK drove me to devise a research study centring around the effects of social distancing and lockdown on adolescent mental health. By collecting responses from secondary school students through an online questionnaire comprised of diagnostic instruments (such as the Patient Health Questionnaire-9 to assess depression) and questions on both general demographics as well as lockdown-related variables, I was able to analyse and identify significant associations between stressors and higher levels of adolescent depression, anxiety and stress. Comparing my results and its implications with previous studies confirmed the increased prevalence of mental health illness during COVID-19, and so, after disseminating results through video infographic, I was able to create an online adolescent mental health resource featuring self-screening tools and useful self-help links (all of which can be found here: https://bit.ly/AdolescentMH).

As we approach a novel phase of the pandemic, there is a tremendous need for holistic assessment in order to both prevent and manage the negative consequences of COVID-19. More recently, movements have sprung up worldwide, including the Great Barrington Declaration [21] which advocates for “focussed protection”, its goal being to shield only the most vulnerable in order to avoid unintentional physical and mental health adversities to the rest of the population, as well as to reduce the especially debilitating consequences of the confinement measures to the most underprivileged.

And it may very well be time to start seriously considering such approaches. Blanket lockdowns, although arguably suitable for short-term responses, will struggle to be tolerated as the long-term battle against COVID-19 continues. Responses, therefore, must instead be differentiated and tailored towards specific groups and individuals, aiming to maximise compliance, preserve economic outcomes and ultimately combat spread in the most effective way possible.

Gunn (Te) Pungpapong

The Plague Pit

Science, healthcare, culture and real life

Anxious times 17.10.20

October 17, 2020 Gunn (Te) Pungpapong

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