Dr Donna Cosgrove PhD MPSI takes an evidence-based look at mental health treatment, including the effects of the Covid-19 pandemic

It is estimated that up to 20 per cent of us will experience some mental or psychological health issues in our lifetime. These can range from a low or sad period, to more serious clinical depression, with a small subsection of people going on to develop severe mental health problems.1 Studies have demonstrated the role of four major modifiable health behaviours that can reduce overall mortality: Smoking, diet/nutrition, physical activity, and alcohol consumption. These types of health risk behaviours tend also to be present more frequently in those who experience depression or poor mental health, ie, one study reported that those who were depressed were more likely to be daily smokers, have low fruit and vegetable intake, and be cumulative risk-takers. 

On the other hand, co-occurrence of multiple healthy/protective health behaviours (being physically active, consuming five or more fruit and vegetable servings daily, being a non-smoker and moderate drinker) has been linked with positive mental health, better self-rated health and healthier body weight. Individuals demonstrating these four risky health behaviours (smoking, excessive alcohol consumption, poor diet/nutrition, and physical inactivity) have been found to have a significantly higher mortality rate than peers without these health behaviours — on average dying 14 years younger. 

Six distinct clusters of health-related behaviours were identified in the Irish population.2 Individuals with healthier behaviour patterns were more likely to report positive mental health, more positive perceptions of their health, and a better quality of life than those in an unhealthy cluster.

Steps

In addition to the four health behaviours, evidence suggests there are several steps that can be taken to improve mental health and wellbeing:3 

Connect with other people

Good relationships are important for mental wellbeing. They help cultivate a sense of belonging and self-worth in individuals, as well as providing an opportunity to share positive experiences. They also enable the provision of emotional support. People are advised, where possible, to connect with people through one or more of the following: 

Take time each day to be with their family.

Arrange to meet friends that they have not been seen for a while.

Have lunch with a colleague.

Visit a friend or family member who needs support or company. 

Volunteer at a local school, hospital or community group. 

Technology can be a great aid to staying in touch with friends and family, but it should not be relied on alone to build relationships. 

Be physically active 

Evidence shows that exercise can improve mental wellbeing by raising self-esteem, helping to successfully set and achieve goals and challenges, and release endorphins to boost mood. Discovering an activity that is enjoyable makes it easier to maintain — it is not necessary to spend hours in the gym. People can try different forms of activity, ie, go for walks, start running with ‘couch to 5k’ podcasts, swimming, cycling or dancing.

Learn new skills 

This can improve general mental wellbeing by boosting self-confidence and raising self-esteem, helping to build a sense of purpose, and potentially facilitating ways to connect with others.

Give to others 

Research suggests that acts of giving and kindness can help improve mental wellbeing by creating positive feelings and a sense of reward and providing a feeling of purpose and self-worth. This is another way in which to connect with other people. It can be small acts of kindness, or larger ones, like volunteering in your local community.

Pay attention to the present moment (mindfulness) 

Paying more attention to the present moment (including thoughts, emotions, and the physical body) can improve mental wellbeing. This awareness is often referred to as ‘mindfulness’. Mindfulness can help individuals enjoy life more and understand themselves better.

In public health emergencies such as epidemics like Covid-19, there can be a profound psychological impact on individuals. Feelings of fear in the general population are normal, irrespective of age, gender and sociodemographic status. Common feelings include anxiety about contracting the disease, dying, and helplessness. The detrimental impact of the pandemic on many businesses has affected employment levels, not only in Ireland, but globally, resulting in lower income levels and stress and deterioration of mental health.4 The adverse effects of the pandemic on people with mental illness — and on population mental health in general — may have been exacerbated by fear, self-isolation, and physical distancing.5

Anxiety

People with moderate anxiety levels and stronger perception of risk of virus infection are more likely to follow guidelines to protect themselves, but severe anxiety and helplessness can lead people to erratic and unhelpful behaviour. In healthy people, the stress associated with an outbreak can induce poor mental health and psychiatric symptoms, and in people with pre-existing mental illnesses, these conditions can be exacerbated.4 Those with psychiatric disorders may have experienced worsening symptoms and others may develop new mental health problems, especially depression, anxiety, and post-traumatic stress.5 Patients with certain psychoses like schizophrenia may have higher levels of avoidance-coping and report overall reduced coping ability, self-esteem, and social support than the general population in disaster settings.6 

This may have contributed to many reacting to disaster and uncertainties with heightened anxiety, and social distancing can contribute to isolation and worsening depression. Cognitive limitations may also impact such patients, posing challenges to appropriately handle information overload in times of crises. Extensive coverage of the pandemic by the media impacts public response, potentially exacerbating psychological stress and apprehension, even when used to encourage precautionary and preventive measures for protection.4 Higher levels of satisfaction with health information correlate with lower psychological distress in individuals. If there is confidence in the measures introduced by the authorities, there is better adherence, which will encourage the wider community to work together to combat the outbreak.

A survey7 conducted in China early in the Covid-19 outbreak showed that over half the respondents (n=1,210) rated the psychological impact of the situation as moderate-to-severe. Moderate-to-severe depressive symptoms were reported by 16.5 per cent, and 8.1 per cent reported moderate-to-severe stress levels. Healthcare workers may experience even higher levels of anxiety and depression due to numerous reasons, including an increased risk of being infected from increased exposure, a fear of infecting families and loved ones, and feeling conflicted due to the expectations of professional duty and altruism. 

In general, the high levels of anxiety and depression were associated with severe economic loss and poor self-perceived health conditions.8

During the Covid-19 global pandemic, the potential of digital health for mental health has become apparent.6 Making evidence-based online resources and interventions freely available at scale could benefit population mental health. 

Some mental health services are developing ways to deliver interventions remotely (by phone or online); these practices are being implemented more widely, but not all people feel comfortable with phone/online interactions.5 They may also present implications for privacy. 

To facilitate treatment of psychological issues during the outbreak, online and smartphone-based interventions like cognitive behavioural therapy (CBT) and mindfulness-based cognitive therapy (MBCT) are very useful.4 CBT can help people who are overly-concerned about contracting and dying from the virus through challenging their cognitive biases, ie, identifying maladaptive coping behaviour like avoidance, antagonistic confrontation, and self-blame, while improving stress management. MBCT employs various mindfulness meditation techniques to encourage non-judgemental awareness in the present. When presented through virtual platforms, these can benefit many groups of people, including those who are infected, isolated, or quarantined, with no access to traditional mental health services. Online connectedness can also enable sharing of peer support and sharing challenges and resolutions during the outbreak, increasing resilience.

Services

The HSE provides a range of community- and hospital-based mental health services in Ireland,1 however, face-to-face mental health services have been limited because of the coronavirus outbreak. Several available services are providing online and phone services, such as online counselling and support, phone support and text support.9The HSE site also offers some practical tips on how to look after mental health, particularly during the pandemic.10 Keeping a realistic perspective of the situation based on facts is important, ie, staying informed by using trustworthy and reliable sources to get news. Too much time on social media may increase worry and anxiety: Limiting how much time is spent on social media may help.

Where possible, it is important to instigate or maintain healthy routines, such as:

Regular exercise (in keeping with the guidelines on social distancing).

Regular sleep routines.

Maintain a healthy diet.

Avoid excess alcohol.

Practice relaxation techniques, such as breathing exercises.

Search for online exercise or yoga classes, concerts, religious services or guided tours.

Avoid smoking and drinking any more than usual as it won’t help in the long-term.

Eating habits can often be linked to your emotions, with people potentially turning to food for comfort during the pandemic. Long-term comfort-eating can lead to weight gain and affect your health.

Staying connected to other people is also helpful: During times of stress, friends and families can be a good source of support. If we are unable to physically meet with people, we can stay connected to people in other ways, such as through e-mail, social media, video calls, phone calls and text messages. Talking things through with someone can help lessen worry or anxiety.

If things become difficult for an individual who is using mental health services for an existing mental health condition, it can be helpful to have a plan to help, ie:

Have a list of numbers of mental health services and relatives or friends who can be called for support.

Keep taking any medication.

Continue with any counselling or psychotherapy sessions. 

Limit news intake and only use trusted sources of information.

Use relaxation techniques and breathing exercises.

If the condition gets worse, contact the mental health team or GP.

Most people with mental health problems can be treated by their GP and are referred to HSE mental health services when necessary.1

References on request.