Subodh Dave, Consultant Psychiatrist, Derbyshire Healthcare FT;
Anil Pillai, Consultant Psychiatrist, Bradford District Care NHS FT;
Roshelle Ramkisson, Consultant Psychiatrist (CAMHS), Pennine Care NHS FT;
Shevonne Matheiken, ST4 Dual General Adult and Old age psychiatry, East London NHS FT;
Abrar Hussain, Consultant Liaison Psychiatrist, Berkshire Healthcare NHS FT;
Manonmani Manoharan, Consultant Psychiatrist, South London and Maudsley FT;
Prof JS Bamrah, FRCPsych, Consultant Psychiatrist, Greater Manchester Mental Health FT;
cite as; Dave S, Pillai A, Ramkisson R, Matheiken S, Hussain A, Manoharan M, Bamrah JS. Mental health in the midst of a Pandemic - Practical guidance to maintain mental well-being. Sushruta 2020 vol13; issue 1: ePub 24.03.2020
The COVID-19 pandemic has become a national crisis for the NHS, and an economic crisis for the country. The physical effects of the virus, which is highly contagious, range from minor flu-like symptoms to death, with the majority only suffering milder symptoms. However, the psychological impact of this virus has either been understated or practically ignored. The sheer mental strain on NHS staff who have to balance their domestic responsibilities with their jobs during these trying times, poses additional risks. These include mental, social, physical and vocational challenges.
This guidance offers practical solutions and supports which could be vital during the coming months.
Our brains are experiencing information overload from various sources. The volume of information, some of which is very conflicting, can lead to feelings of being overwhelmed.
The uncertainty, anticipation and speculation may also lead one to experiencing feelings of fear and panic. If the epidemic worsens, the impact of COVID-19 will be felt more directly (in patients, colleagues, friends, family, self) and may worsen this fear. The emotional stress may be especially difficult when families are separated and for our international workforce living away from their families.
This is going to be a marathon not a sprint. Initial enthusiasm may not sustain as the pressure on workforce and available resources increases. Taking steps now to avoid exhaustion and burnout is critical.
It is likely that many of us will be required to self-isolate. Some may be required to move from their family home to live in accommodation arranged by their employers to continue to remain available at work. National guidance on social isolation and the closure of usual sources of de-stressing may add further pressure as physical distancing from families/friends becomes a reality or a loved one falls ill and is quarantined. Informal sources of support available in personal/professional life may not be available. Working from home, caring for dependent children or family members who are ill (physically or mentally) and even dealing with normally happy events such as birthdays etc. can be unsettling. For some financial uncertainty may add further pressure. Some individuals may turn to unhelpful coping methods including smoking, binge eating, drinking alcohol, using drugs or (online) gambling.
An important and perhaps ignored aspect of the corona virus outbreak has been the stigma associated with it. There have been numerous reports of a racial stereotyping and bullying linked to the virus. This may be particularly relevant for a multicultural, multi-ethnic organisation such as the NHS which even in normal times has its own share of problems with racial and cultural discrimination.
Ensuring enough physical activity, healthy eating and good sleep in times of social isolation, panic buying and information overload may be difficult. Ensuring that one takes the necessary preventive measures in clinical environments may not always be possible with increasing demands on certain hospital supplies. For those with underlying conditions or difficulties these challenges will be even greater. Those accustomed to regular visits to the gym or other forms of group exercise such as yoga or pilates are very likely to feel very frustrated from not being able to do so.
In the workplace a key driver of (understandable and legitimate) fear is the lack of appropriate PPE (personal protective equipment). Additional stress arises from the need to keep up to date with rapid change in information, workforce pressure, hospital supplies pressure, working in new and unfamiliar environments, familiarising with technology, new legislation to name a few. For trainees and medical students there is the additional uncertainty about training/assessments. For our international workforce, there may be concerns around visas, work contracts and finances.
Tips to maintaining mental wellbeing
It is imperative that we support each other, the community and look into our inner self for courage and innovation. Henry David Thoreau offers a guide:
“I had three chairs in my house; one for solitude, two for friendship, three for society.”
There are three chairs of support we can look at in this time of COVID-19:
For self and solitude (chair one) -
“Yesterday I was clever, so I wanted to change the world. Today I am wise, so I am changing myself.” ― Rumi
In these times of information overload, relying on a few key sources may be more manageable. For most NHS staff, Trust guidance, your College/professional body guidance and NHS/PHE guidance and WHO guidance should suffice. Try not to get distracted by the multiple social media groups and messages that you are getting. Practice taking time off from your mobiles and laptops. The world will not collapse if you don’t pick up messages because if anyone wants you urgently, they will find you.
Solitude need not be a mental vacuum. You can reflect and recharge. Make the best use of your time also to relax, whether it is through, exercise, yoga, reiki, reading books, music, football, cricket or any other means. Everyone has something which gives a meaning to their life, other than their work. It may be music, writing, art or something else. Every individual is born with resilience. Use it. Many of us may have spiritual or religious inclinations. Use them, if these help you to overcome existential questions.
There are also apps available, in all the domains discussed. NHS apps library at https://www.nhs.uk/apps-library/ offers a good choice. They help you with simple tips on relaxation to healthy living to overcoming insomnia, anxiety and low mood.
There will be times when you feel guilty of the self-imposed quarantine, Unfortunately, some of us will lose our patients. Feeling distressed is a normal reaction but do not suffer in silence. Seek support from colleagues and other resources during the period of crisis. Do this early. Do not let it overwhelm you.
Another unhealthy coping mechanism may be alcohol or substance misuse- the combination of stress and lack of normal structured routines may make this more likely. Doctors who seek help with substance misuse issues have excellent recovery rates. http://sick-doctors-trust.co.uk/ may be a source of help as is the https://www.practitionerhealth.nhs.uk/
Learning to work effectively from home may be one of the silver linings to this international cloud that engulfs us. Make sure you have arranged remote access to your Trust intranet and electronic patient record system. Most Trusts are also arranging for telephone and video consultations on platforms such as Zoom, Skype or Microsoft Teams. Register with this and practice how it works with a colleague. Structure your day like you might be at work- take breaks for lunch or hydration. There are more useful tips at https://www.bbc.co.uk/news/business-5186889
With these in place you should be able to provide telephone assessments and consultations from home, RCGP provides useful tips https://www.rcgp.org.uk/about-us/rcgp-blog/top-10-tips-for-covid-19-telephone-consultations.aspx
With some preparation, a majority of your work should be possible virtually – including ward rounds, care planning/discharge meetings, teaching/supervision, CPD, management including incident planning meetings etc.
While technology will offer many solutions, let’s not forget two vital defence mechanisms that do not need technology 1) kindness and 2) humour. Be kind- deliberately and with intention. Random acts of kindness are powerful – practice them. Laughter is a powerful medicine at such times- don’t forget to smile and laugh.
For friends and family (chair two):
“Your friend is your needs answered” - Khalil Gibran
Social distancing should not mean distancing oneself from society. As healthcare workers, it will be our role to alleviate the anxiety that friends/family may be experiencing by providing and signposting accurate information. Again, Public Health England/NHS are useful sources. Easy to understand formats such as stories/comic books may work better for many – e.g. https://www.mohfw.gov.in/Corona_comic_PGI.pdf
As doctors we have an obligation to society and a greater obligation to our patients and also to our colleagues, trainees and medical students. Give them appropriate advice and be honest, with what you know and what you do not know.
Support the trainees and applaud them for the commitment they show and the sacrifices they make in their training to provide a service delivery with stretched-out resources. Help them use this highly demanding situation to develop their medical leadership skills. Talk to them frequently if you can. Don't confine your discussion to their training needs. Ask them how they are coping. Ask them how their family is coping. Ask them whether you can help them in any way. Then signpost them to support available with the local trust, BAPIO, BMA, Health Education England and follow up how they are doing at a later time.
At a personal level, this may be the time to connect with friends/family. While physical congregation may be on hold, social connectedness is still possible – a range of platforms such as Skype, WhatsApp, Facebook etc. are available to allow videoconferencing across the globe.
For the society (chair three):
“An ounce of practice is worth a thousand words.”- Mahatma Gandhi
Reinforcing and modelling PHE advice on hand washing, self-isolating will help break the chain of spread by facilitating the spread of good practice. At such vulnerable times, you may come across people who are experiencing mental health problems. Many people including health care workers and doctors find it awkward to have conversations about mental illness. Rehearse how you might initiate such conversations – “how are you feeling? – I know it is a very stressful period”; “Are you OK? – can I be of any help?” “I imagine it’s been a difficult time for you – just wanted you to know that I am available to have a chat” – might be the kind of phrases that may help. A range of sources of support are listed below. Acquaint yourself with these. Share them. Many, if not all of you, will also have your own peers and mentors. These might be work colleagues or specialty-specific peer groups. Some of you may have active alumni organisations from your medical colleges. This is the time to make sure they are meeting (virtually) regularly, and if you do not have access to these than it is vital that you make enquiries. There is nothing worse than working in isolation.
It is also likely that we may be asked to work in environments and clinical areas unfamiliar to us. Your Trust or employer should provide you with appropriate induction to do so safely and effectively. Below is a list of resources that may give you a head start. It is not comprehensive and is obviously not tailored to your individual requirement but may provide a useful first step.
There is no doubt that these are unprecedented times, with most of our generations never having faced anything like this. Without being too melodramatic, we are in Darwinian times, and so our continued existence as human beings predicates on adapting to the current situation, and making us all fit enough to survive the COVID-19 pandemic. This is a physical disease that can also wreak havoc on our mental wellbeing. And the effects could be long-lasting as some studies have shown. Members of BAPIO are urged to utilise some of the coping strategies that are mentioned here so that you can make yourself more resilient and so that those who rely on you feel able to draw on your strength to meet the worst challenges that we are yet to face in the coming months. There are helpful resources, for personal (Appendix 1) and professional use (Appendix 2), as well as tips in this guidance which we hope you will put to good use. Ultimately, do not suffer in silence as social distancing does not mean complete isolation.
PERSONAL SUPPORT RESOURCES
Comprehensive list of support resources for physical and mental health, legal and financial issues
- https://www.practitionerhealth.nhs.uk/ A free, confidential NHS service for doctors and dentists across England with mental illness and addiction problems
- https://doctorssupportgroup.com/ Support for doctors facing suspension, exclusion, investigation of complaints and/or allegations of professional misconduct
- Samaritans Freephone 24hrs/day 365 days/year: 116123 https://www.samaritans.org/ A free confidential counseling/support service not just a "suicide helpline"
- Tea And Empathy Facebook Group for NHS staff. Popular peer support group https://en-gb.facebook.com/groups/1215686978446877/
- Helpline for sick doctors http://sick-doctors-trust.co.uk/
- For trainees – many deaneries have a Professional support and Wellbeing Unit (PSW/PSU), which usually needs referral via Supervisor/TPD but some have made self-referrals open in the light of COVID19 outbreak e.g HEE East of England. PSWs have access to various forms of support including private counselling sessions.
- For Psychiatrists of any grade, dedicated service at Psychiatrists Support service email@example.com or the helpline on 020 7245 0412.
PROFESSIONAL SUPPORT RESOURCES
- Useful modules on RCPsych CPD online (E.G ECG, geriatric medicine basics, Advanced directives, Assessment and management of Delirium) http://www.psychiatrycpd.co.uk/
- Local general hospital's protocols on topics like 'Care of the dying patient', 'Treatment escalation pathway and CPR decisions', 'Prescrbing in Palliative care', 'Antibiotic protocols'.
- Delirium in COVID19 – https://www.bgs.org.uk/resources/coronavirus-managing-delirium-in-confirmed-and-suspected-cases
- Palliative care resources compilation https://docs.google.com/document/d/1HR1ulUBbCjlITkuB-sUQJZ90yx9l2v3N_JUqPMm7qpw/mobilebasic
- Free respiratory e-learning module https://www.nhsglos.com/nlms/Respiratory/RespCareShell.html
- Updates from the Academy of Medical Royal Colleges https://www.aomrc.org.uk/#