From 2 metres behind the frontline

The last couple of weeks have been trying for all of us, wherever we live. Fear of covid-19, fear of illness, fear for loved ones, fear for livelihood, fear of isolation. All of these are massive stressors in their own right, so thrown all together their impact is grim.

But it is the usual lot of those with mental illness to feel guilt, and this is no exception. As a psychiatrist, I tend to say I’m not frontline. OK, maybe that’s true – we’re not treating covid-19, not intubating, not keeping people alive in ITU. These things are vital and amazing, and I am so grateful to those who have these skills. 

But I’m not frontline. Or am I? All those fears I mentioned, what do they do? Even for those of us fortunate enough not to have any mental illness they are frightening. They may be a trigger for developing illness, and they may make it harder to cope with day to day life.

What about those of us who already have mental illnesses? In my mind there is no doubt that the current fears pose significant risks, and we are likely to see deterioration or relapse in many. Like physical illness, mental illness does not usually come out of nowhere, and stress is a risk factor. So it is likely that the coming weeks and months will see more people with mental illness, and more human suffering.

Like physical illness, this will occur at all levels: the person with ‘mild’ anxiety who now struggles to sleep at night, the person with OCD, the person with severe depression, the person with a psychotic disorder. Some of these will be very ill, and will require frontline services, and these services may save lives.

But I’m not frontline, and I don’t look after these patients. My patients are dependent on alcohol and drugs. This isn’t a choice that they’ve made, it’s no lifestyle decision. They get little if any pleasure from their use, but if they stop they will be thrust into the horrific experience that is withdrawal. Withdrawing from some drugs, including alcohol, is life-threatening, and is hideous, painful and ugly. No-one chooses to go through this. My patients also have other mental and physical illnesses, and will be at greatly increased risk from covid-19.

I understand that less urgent services are having to be scaled back to cope with the current crisis, but I weep for my patients. We will have to tell them to do things like carry on drinking – this may seem bizarre but the very real risk of this is not as great as an unplanned detox. We have to attempt to keep on supporting people whose lives have always balanced on the edge, and we have, just now, less resource to do so.

Many of our patients are on methadone or buprenorphine – not continuing this will result in withdrawal, loss of tolerance, destabilisation and even overdose. I know that many of my colleagues are having to take patients off supervision of their medication, and arrange for  less frequent dispensing; this is because of the pressure on pharmacies, but it is a risk that none of us would choose to take.

Our patients are frightened and angry, and so are we. We are frightened for them, and for ourselves, and this is over and above the fear of contracting covid-19. Perhaps we are all working at the frontline, even when we don’t quite know what we’re doing, or how to balance care and services. I truly believe that everyone is trying to do their best.

But as always it’s easier to be a doctor than a patient, and, as hopefully only a potential patient, I’m terrified. I feel guilty for being ill even though I’m not actually ill right now. I feel fear and confusion at the idea of seeking help should I become ill, and, if it’s like that for me, what must it be like for others? I feel anxious about how I would get medication, or how I would get advice. And, although I never thought I would say this, I feel great anxiety that ECT is unlikely to be available. I would hope never to have it again – but if I need it, it is frightening to think that I would not be able to get it. It is an odd thought, that ECT has often been viewed as lifesaving, yet now may not be available. Does this mean that patients will die, and will they, too, be counted as victims of covid-19?

I hope we all get through this crisis, but I know that some won’t. There will be people who tragically die of covid-19, and we must do all we can to prevent this, in turns of limiting spread and also promoting treatment and support. Covid-19 will claim other lives though, some of which will never come in contact with it at all. 

Right now the health service is pouring everything it can into covid-19, to avert disaster, but there was no elasticity in it prior to all this. Many services, for both physical and mental illnesses, are currently reduced so we can support the current crisis, and so we can avoid harm to patients where interventions are not immediately essential. But, at the end of the day, there’s not much that’s not essential in the health service, at least sooner or later, and there will be consequences for all of us. 

Social distancing and isolation may prevent viral spread, but it will be hard to maintain the mental health of a people for whom love and contact are vital and necessary.

Keep well and keep going.