Insights from publications | COVID-19: Health and Social Care Learning in Scotland

Exploring published literature of emerging practice as a response to challenges due to COVID-19

11 September 2020

The summaries below are of articles that might help thinking about what has been learned from the COVID-19 experience so far, along with suggestions on how this might be used to support improvement in future.

This week, all the featured articles are about how COVID-19 is affecting experiences of social isolation. We look at the risks of social isolation and how COVID-19 has impacted this, looking at risk factors by profession and age, as well as exploring how these are being mitigated. The topics below include:

risk by profession
risk by age, and
how recommendations have been implemented to avoid a mental health catastrophe.

Overview
At the start of the COVID-19 outbreak there were concerns about the psychological impact of imposing quarantine on specific groups. These included those people who have been or are likely to have been exposed to COVID-19, those recovering from COVID-19, or more generally those at risk of contracting COVID-19, i.e. the general population.

Brooks and colleagues noted that "Health officials charged with implementing quarantine, who by definition are in employment and usually with reasonable job security, should also remember that not everyone is in the same situation" and mitigating the health risks of the disease must be traded-off against the health risks associated with the longer-term impact on society of such mitigation measures¹.

It is important to separate the direct effects of social isolation from the wider effects of mitigating COVID-19 on mental health. Both have important ramifications for the short to longer-term mental wellbeing of the population. Evidence from previous SARS pandemics indicates that boredom¹, rejection², loneliness and disconnectedness³, and depression and anxiety⁴ are likely. People may fear infection and may also be at risk of not being able to access supplies of food or find reliable information important to wellbeing - all are considered stressors during a quarantine¹. A deterioration in someone’s health may be missed or misidentified if depression and anxiety are also present⁴. In addition, if someone contracts COVID-19 and survives, during recovery they may have difficulty in dealing with the psychological effects of that experience (including post-traumatic stress symptoms and the stigma of having had the disease)⁵.

Everyone who is quarantined will inevitably see their routines and expectations disrupted in some way⁶. Therefore, although social isolation itself does not necessarily lead to adverse effects, imposing the strict isolation measures required by lockdown could have negative impacts on people who had not previously feel lonely in their isolation.

Furthermore, in the long-term there is evidence from studies that had predominantly older populations (i.e. aged 50 and over) which indicates generally that social isolation is associated with an increase in mortality of almost 29%⁵.

It is important to address the impacts of social isolation to guard against them having as catastrophic an effect on the population as the disease itself. The idea that social isolation can have catastrophic effects may seem extreme, but studies in Hong Kong and Taiwan following SARS indicate increased rates of suicide, particularly among the elderly^{3, 7}.Elevated prevalence of psychiatric morbidity was also noted among the general population in Taiwan following the SARS pandemic, particularly among healthcare staff^{8, 9}.

At risk by profession
The impact of COVID-19 on healthcare staff has already being seen in early findings on psychological distress among more than 70% of healthcare workers surveyed in China by Lai and colleagues¹⁰. In the Lai study, being a nurse, female, a frontline health care worker and based at the epicentre of the outbreak were increased risk factors.

Staff may feel vulnerable, not able to control what happens, be concerned about the spread of the virus, its morbidity and mortality rate, their own health and the health of family and others (and potentially risking infecting them). They may face increased isolation and/or stigma if they choose to stay away from loved ones at this time for their safety. Changes at work and potential shortages of supplies can also exacerbate high stress and anxiety levels¹⁰.

At risk by age
While healthcare staff are at elevated risk of psychological harms because of their increased exposure to witnessing the effects of the disease, older people are at increased risk from the effects of social isolation in trying to avoid the disease. In Scotland, a third of the population lives alone and 40% of this group are of pensionable age⁵.

Older people may be less likely to use online communications. This could potentially put them at particular risk⁵ since disparities in digital access make it more difficult to combat the loneliness attributable to social isolation¹¹.

More generally, as one frontline clinician working in a long-term care facility for older adults noted "my patients have become prisoners in their one-bedroom homes, isolated from each other and the outside world. This extreme loneliness should raise concern as it is a known risk factor for poor health outcomes, including anxiety, depression, malnourishment, and worsening dementia"¹². Other studies^{11, 13} agree that older people are at particular risk, especially if they are frail and already struggling to leave the house.

Losada-Baltar and colleagues found some evidence indicating that older adults may be more resilient to distress and loneliness during COVID-19, as long as they had positive self-perceptions of ageing¹⁴. One potentially positive effect of lockdown may be that other age groups in society now better understand what life can be like for older people who were more likely to face isolation in their own homes outwith the context of a global pandemic¹⁵.

Nevertheless, older people may be more likely to face stigma from younger populations, with hashtags such as #BoomerRemover trending on social media. Well-meaning communications from healthcare professionals about anticipatory care planning could inadvertently contribute to feelings of worthlessness among older people¹¹. This could potentially be exacerbated by the 'othering' of at risk groups by the media and others (e.g. politicians, health advisors) in order to heighten the general population's understanding of the gravity of the threat that COVID-19 presents and prevent under-reaction¹³ that would further spread the disease. This is particularly an issue when governments try to appeal to the population's sense of altruism in averting the disease¹, as doing so may better incentivise more of the behaviours that mitigate the disease but could be condescending about vulnerable groups.

Other at risk populations include those with pre-existing conditions including HIV^{16, 17}, those in long-term care facilities¹², quarantined students¹⁸, new mothers⁶ and those socioeconomically disadvantaged¹⁷. It was also noted that sedentary behaviours in young people (imposed by lockdown) may also be an important cause of depression and anxiety⁴.

How have recommendations been implemented to avoid a mental health catastrophe?
The literature recommends many ways of trying to avert a mental health catastrophe at population level as a result of trying to mitigate COVID-19. Broadly these fall into six categories and in many cases there are examples of work already undertaken locally and nationally.

1. Self-regulation, whereby people learn new skills, take up volunteering, create and build on routines and keep active during lockdown¹⁹. Some examples of how this has been seen in practice include:

2. Digital inclusion to integrate technological advances in the care of populations at risk of being excluded during health outbreaks^{12, 16}, even just by providing smartphones⁴. Some examples of how this has been seen in practice include:

Of note, as Ransing points out, when it comes to mental health it is important to understand the ease with which negative mood can spread online ('emotional contagion'), not to mention how easily and far misinformation can spread – this may also negatively impact people's mental health²⁰. This is also easier if more people have access to the internet.

3. Needs assessment of at risk populations, whereby staff can be trained and tools provided for them to help assess¹⁴ and monitor specific at risk populations. This is particularly important given that the stigma towards people with mental health disorders can serve as an additional barrier preventing those who are distressed to obtain help^{20, 21}. Some examples of how this has been seen in practice include:

4. Interventions to reduce isolation by encouraging either online^{5, 11} or telephone^{7, 22} (or both¹⁵) support for vulnerable groups and community-based provision of adequate supplies (e.g. food, water, clothing)^{1, 5}, including medicines⁴. Some examples of how this has been seen in practice include:

5. Specific mental health support interventions. Some interventions may be provided online for people to self-refer, although it is unclear in most cases whether they were originally designed for COVID-19 or adapted to help support people in a crisis²³. The original purpose may not matter. The literature alludes generally to providing 'psychological first aid'²⁰ and general community-based psycho-social interventions²² since basic cognitive behaviour therapy (CBT) can increase people's resilience¹³. Group interventions may be useful for those at risk of post-traumatic stress disorder (PTSD) e.g. those who may be recovering from the experience of having COVID-19, or providing care for someone with the disease, as it can help give a sense of connection and feelings of validation to people^{1, 18}. An example of how this has been seen in practice include COVID-19: the challenge of patient rehabilitation after intensive care.

6. National support. Communication and provision of accurate information is vital¹, and anxiety can be further reduced by keeping the duration of quarantine short if possible, as well as protecting the population against financial loss⁵. Organising/coordinating health and social care services and experts is required^{4, 20}. Providing increased funding to support people who need to access services is also important, particularly for marginalised individuals who may have previously been less able to access digital/telemedicine alternatives to face-to-face contact¹⁶. Governments and national organisations can also support guidelines on mental health interventions and epidemiological research into the scale of mental health problems being experienced as a result of COVID-19, particularly for at risk groups e.g. healthcare workers^{1, 10, 20}, COVID-19 survivors and elderly individuals²⁰. Some examples of how this has been seen in practice include:

Looking to the future
Ransing and colleagues note that just as the COVID-19 infection rate may show peaks and troughs. Society may also experience multiple peaks in mental ill-health associated with dealing with the pandemic as outlined below.

In the first phase, the mental health risks were from inadequate communication, misinformation and fake news, coupled with an exponential growth in cases causing fear, distress, anxiety, depression, sleep disorders, panic attacks, adjustment disorders (whereby people have a disproportionately hard time coping with the events of COVID-19) and suicidal ideation/behaviour.
Community resilience diminishes this and what follows is a rapid reduction of distress.
However, this is then followed by a more unpredictable and complex 'second peak' in mental health issues occurring as people come to terms with, for example, the death of loved ones, job loss, economic damage and the marked social disruption caused by the disease. The effects may include PTSD, grief, depression and relapse of pre-existing mental health conditions²⁰.

We should also note that stigma is known to be problematic when some people are quarantined while others are not^{1, 2}. It is less likely to be a significant issue when an entire population is affected by the same lockdown. Stigma could therefore become an issue as localised lockdowns are put in place and specific areas, venues and/or individuals are placed under scrutiny by the local community and public health organisations. Even where stigma is not an issue, changes to plans as a result of public health measures could be frustrating for people if they perceive others around them not having to also experience the new rules.

References