Health experts on the psychological cost of Covid-19 | Coronavirus outbreak
n Instagram, a friend posts a photograph of a male nurse in an intensive care ward of an American hospital. He is wearing full protective clothing and holding up a patient questionnaire on which he has scrawled a message for his colleagues. It reads: “Just going to hold his hand for a while, I don’t think he has long.”
On an Irish radio station, a woman reads a poem she has written for a loved one lost to the virus. It is called My Sister Is Not a Statistic. It begins:
Tomorrow, when the latest Deathometer of Covid is announced in sonorous tones,
Whilst all the bodies still mount and curl towards the middle of the curve
Heaped one atop and alongside the other
My sister will be among those numbers…
On Radio 4’s Woman’s Hour, a critical care nurse from Sierra Leone, who works in a hospital in the south of England, describes the frantic chaos of the first few weeks of the pandemic. “We didn’t have equipment at all, but our ordinary aprons and gloves… I’d go in there praying and hoping I don’t get infected. Then I’d go home, praying and hoping, and trying to isolate myself from my daughters so I am not passing it on to them.”
Amid the prolonged stasis imposed by lockdown, as the days drift into one another, the unreal magnitude of what is unfolding is momentarily undercut by acutely personal testimonies from the eye of the storm. These are just three examples of ordinary people who have responded in extraordinary ways. Their actions speak of selflessness, defiance and bravery in the face of the invisible threat that hovers around us in the very air that we breathe. But they also provide us with glimpses of the immense human cost of the pandemic, the great well of loss, fear, sadness and grief beneath the mounting statistics.
In Britain, as I write, 37,000 people have lost their lives to the Covid-19 virus, while 267,000 have experienced and survived the terrible uncertainty of infection. As a fragile normality slowly returns, many mental health experts are asking the inevitable questions: what will be the long-term emotional and psychological cost of such a sudden and seismic disruption of our way of life?
“How the outside impacts on the inside is something that people like me think about all the time,” says psychotherapist and author Susie Orbach. “But now we are seeing it on a grand scale. The pandemic has been a prolonged assault from outside on our community. The state of uncertainty and unsafety it has created is new and utterly unfamiliar. Unless you are a refugee who has risked their life to get here, or a survivor of childhood abuse that could not be escaped, there is simply nothing to compare it to.”
Even in the early stages of the lockdown, the World Health Organization issued a statement that noted “elevated rates of stress or anxiety” in the general population, before warning that, “as new measures and impacts are introduced – especially quarantine and its effects on many people’s usual activities, routines or livelihoods – levels of loneliness, depression, harmful alcohol and drug use, and self-harm or suicidal behaviour are also expected to rise.”
On 21 April , it was announced that 42 researchers from around the world had formed the International Covid-19 Suicide Prevention Research Collaboration amid growing concern about the longer-term mental health consequences of the virus. Leaving aside the probability of another spike, the aftershock of the pandemic is likely to last a long time and leave yet more casualties in its wake.
Jo Stubley, a consultant psychiatrist and clinical psychoanalyst at the Tavistock and Portman clinic in London, is a specialist in trauma who has worked with survivors of the London terrorist attacks and the Grenfell Tower disaster. Those kinds of emergencies, she explains, are classed as “single events that occur within a limited time-frame and affect a defined population”. A global pandemic does not fit that model.
“The word most often used is ‘unprecedented’,” she says, “and it looks increasingly likely that the long-term consequences will also be unprecedented in scale. Given that mental health services have been starved of resources for years, one can only imagine the impact that a deep recession will have on an already beleaguered sector. So there is a lot of concern among health care professionals like myself about what will happen next.”
It is in the coming months and even years, then, that the psychological effects of the pandemic will become most apparent. “Trauma occurs when you are overwhelmed by an event that you cannot process,” says Julia Samuel, grief counsellor and bestselling author, whose latest book is titled Grief Works: Stories of Life, Death and Surviving. “While the crisis is happening, you are in it and everything is uncertain and unpredictable. You don’t have the emotional freedom to allow yourself to process the trauma, so it is held in the body. The most common reaction is to shut down and just exist somehow. It is only when the external world becomes more safe and predictable again that people may feel able to reach out for support.”
Those most at risk of suffering post-traumatic stress are the frontline medical staff who, in the first chaotic weeks of the Covid-19 pandemic, may have felt overwhelmed by the dramatically increased levels of patient suffering and deaths, as well as at risk from infection from inadequate PPE and anxious about bringing the virus home with them.
Studies have also shown that, in ordinary times, patients who have spent time in intensive care are at a 20% increased risk of developing PTSD. “Already with some of the support initiatives that have been put in place, we are seeing survivors of Covid-19 showing post-traumatic symptoms,” says Stubley. She explains that there is an accepted timeline for the treatment of post-traumatic stress. “Time zero is the moment the trauma itself ends. In the first months or so afterwards, around 90% of those who experienced trauma will have PTS symptoms including feeling edgy or constantly on guard, sleeplessness, irritability and acute anxiousness. The Nice [National Institute for Health and Care Excellence] guidelines state that we should not treat people in that first month as these symptoms can often pass.”
The second stage is altogether more serious: flashbacks, nightmares, intrusive thoughts or images that are triggered by anything that reminds you of the trauma. The third stage, PTSD, which will affect around 10% of those who have experienced a traumatic event, is a kind of prolonged shutdown. “People dissociate from their feelings, go numb,” says Stubley. “It can last for years and years.”
Her main concern, though, is for those already in the mental health system, for whom lockdown has already had a major impact. It is an anxiety shared by many therapists, who have been unable to see their patients face to face throughout the lockdown period, instead hosting online sessions.
“For those with a history of trauma,” says Orbach, “it has been a particularly difficult time, not just because of the loneliness and isolation, but because it may also have re-stimulated past traumas. There is so much about the pandemic that is disturbing and distressing on so many levels.”
The Royal College of Surgeons recently carried out research into the effects of the coronavirus pandemic on healthcare workers, gathering personal testimonies from nurses and doctors on the frontline. Many reported experiencing increased levels of anxiety, stress, depression as well as panic attacks and bouts of guilt about the amount of people who have died. “I can’t see how I can keep doing this…” said one. “I really wish I wasn’t a doctor,” said another.
Writing in the Guardian, lead researcher and NHS doctor Ankur Khajuria noted that even before the pandemic around 50% of doctors and 40% of nurses were suffering from stress-related psychiatric illness. “A perfect storm is gathering,” he warned.
Lucy Warner is chief executive of NHS Practitioner Health, a confidential service that treats doctors with mental health issues. They expect to treat around 3,500 doctors a year. When I spoke to her a few weeks ago, she said they had already treated about a third of that annual number in the preceding few weeks – “mostly through online spaces where people can connect, talk to each other, share their feelings and reflect.”
In the early stage of the pandemic, she says, “there was a lot of anticipatory anxiety. It was new and people didn’t really know what was happening or how long it would go on, but they knew it was frightening.” As the weeks have passed in long shifts and rising numbers of the sick and the dead, that gave way to “a lot of emotional fatigue, a kind of mental and physical exhaustion. It was becoming a toil, it was becoming difficult for doctors to go on while not knowing how the pandemic would play out.”
Over the last months, that state of mental and physical fatigue has for many become the default mode. “In a way, it no longer feels like a break with the norm,” says Warner, “it just feels normal.”
Like Stubley, Warner thinks the psychological fallout of the pandemic will be a huge and protracted challenge for an overstretched and underfunded health system.
“This is a long game. We are seeing the beginnings of a surge in mental health issues among frontline staff, but over the next year or more we are going to see a lot of people who thought they were OK suddenly realising that they are not. There will be some nurses and doctors suddenly thinking: ‘My God! What did I go through?’ That’s when we may have to deal with a surge in PTSD symptoms, and those people will need individual support but also support on an organisational level.”
While the government and some media were quick to apply the language of wartime to the pandemic – heroic British frontline warriors battling an invisible enemy – Jo Stubley told me of her and her colleagues’ discomfort at that kind of distracting rhetoric. “The NHS is not the military,” she said quietly, “and nurses are not soldiers.”
Like several others I spoke to, Warner was also uncomfortable with what she called “the hero narrative” that has taken hold of the public imagination during the long weeks of lockdown. “It is unhelpful in some ways because you don’t want doctors and nurses to feel they are superheroes, who have to pat themselves on the back when they are on the line and not sleeping or even having time for a pee. What can tend to get overlooked is that they are human beings who are entitled to a rest as much as we all are. They are ordinary people doing their very best, but we need them to be well to do their jobs well.”
In response to the emergency of the last few months, several psychotherapists have set up online drop-in support groups for NHS staff, who may be feeling overwhelmed or emotionally exhausted. I spoke to one who, with a colleague, has created “a support group for clinical staff” in London. She asked for anonymity.
“The first thing to stress is that it is drop-in support, not psychotherapy – the midst of a crisis is not the time to start psychotherapy for clinical staff. What they need is a safe space to come together, share their thoughts and anxieties and listen to others experiencing similar challenges. To this end, everyone uses first names only and they do not have to say where they work. They can also choose to be seen on a screen or not.”
Perhaps surprisingly, the take-up rate has been low and almost all those who have used the service are doctors rather than nurses. “I think there are various reasons for that,” she says. “First, they are in it, and when they get home, they are utterly exhausted. Also, they are perhaps not aware of what help has been made available to NHS staff, even though there is actually a lot of help out there.”
The other more positive reason is that they may already be receiving support from their fellow workers, from the strength of being part of a team that is responding well in extremely difficult circumstances. “The way the nursing profession works is that you tend to get on with it,” says Jo Stubley. “You are to a degree encouraged to feel that way, so even when the normal rules don’t apply there is the sense that this is what you have been trained for. It’s amazing in many ways, but it means that everybody seems to be coping on the surface, while underneath they may well be struggling.”
In the first chaotic weeks of the Covid pandemic, many nurses and doctors felt not just overwhelmed, but threatened and unsafe. There were serious issues over the lack of adequate PPE, leading to increased anxiety about contracting the virus and passing it on to family members. Both the workplace and the home thus became places that were unsafe and uncertain.
The nurse from Sierra Leone quoted at the beginning of this article recalled her feelings of being alone, at risk and anxious. “Initially it was chaos – we didn’t have equipment, we didn’t have senior support, we were short-staffed.”
For two long weeks, she and her colleagues worked in an environment she compared to a war zone, tending to patients who were “very unwell, very unstable, very sick… We didn’t even have masks. We were tired, dehydrated, thirsty,” she continued, still sounding traumatised. She recalled returning home each night to her daughters, thinking: “What is happening? How far will this go?”
That anonymous nurse belongs to the BAME community who make up 20% of the NHS workforce. On 25 May, the Guardian reported that 200 healthcare workers had died from Covid-19. More than six out of 10 victims were from BAME backgrounds. One of their number was urologist Abdul Mabud Chowdhury, whose 18-year-old son voiced what many inside the NHS were feeling. “It’s good to see NHS workers getting the recognition they deserve,” he said, “but they should not have to give their lives, they should not have to go as martyrs. They did not sign up to battle on the frontline and give up their lives.”
In the coming second pandemic of mental health issues, it may well be those we heralded as heroes who will be among the most vulnerable, alongside key workers on low incomes who also toiled through this long emergency at considerable and often unnecessary risk to their health, their lives.
“If we were prepared to clap for our health workers, we should also be insisting that they are looked after in the wake of this emergency,” says Jo Stubley. “I want to be optimistic about that, but the market economy has been a disaster for the health service and, within it, mental health has always been the poor sibling. I have spent years saying to my managers, we need more resources, too many people are waiting. If there was no room in the system before this began, what will happen when it ends and we are in the middle of another recession?”
Julia Samuel concurs: “The fear is that the system will be overwhelmed, not least because there is not the parity of resources in mental health that there is in physical health.”
When this is over, how will we acknowledge the haunting presence of the dead, the thousands of lives lost unexpectedly and in often extremely upsetting circumstances for loved ones? In time to come, hard questions must surely be asked about the British death rate and the practical ways many thousands of those deaths might have been prevented. For now, it is the hardest aspect of the pandemic to grasp, much less make sense of. Only months ago, it would have seemed like the stuff of dark imaginings: gothic fiction or apocalyptic sci-fi. How swiftly it has become real; all too real.
On Sunday 24 May, The New York Times filled its entire front page with death notices from across America, a bold statement that nevertheless only hinted at the immensity of the human toll: 1,000 victims symbolising around 100,000. Outside of wartime or other historical pandemics like the Spanish flu in 1918, there is no precedent for the number of lives lost within a relatively short period.
The global virus has, in the most insidious and cruelly indiscriminate way, turned our world upside down, denting our faith in the infallibility of science and medicine, global capitalism and in progress itself. It has made us fretful for our lives and the lives of those around us, while simultaneously robbing us even of our traditional way of death. Relatives have not been allowed to visit their loved ones in their final days or to be present when they breathed their last. Some have been forced to keep a vigil on their computer screens via live feeds from a Covid ward. Funerals have been limited to small groups of people, all keeping the requisite two metres from one another.
If distance and isolation have become the new touchstones of daily life, they have also intruded even on people’s heartbreak and their grieving. “The thing that makes grief tolerable for many people is the love and affection of others,” says Samuel, “We need to be held when we feel broken.”
In her heartbreaking poem, My Sister Is Not a Statistic, Dorothy Duffy remembered her sister, Rose, who
died without the soft touch of a loved one’s hand. Without a feathered kiss upon her forehead.
Without the muted murmur of familiar family voices gathered around her bed…
In composing that sad, defiant elegy, Duffy found a way to express her tumult of emotions in the face of the virus’s assault on our collective sensibilities. In this, though, she was undoubtedly the exception. Countless others have not found a way to articulate their sorrow, their isolation and their disorientation. “You don’t expect to lose someone in this way,” says Orbach, “to not be able to say goodbye and then to be forced to grieve alone.”
For Orbach, the pandemic has also brutally exposed our culture’s collective denial of the final inevitable. “The rituals are there to help us get through it,” she elaborates, “but also because death is such a problematic idea in our culture, an almost impossible idea. We don’t live with death, as it were. Instead, we live to a great degree in denial of it, particularly our own death. And suddenly, we are witnessing death on a grand scale. It has in effect cut through our belief systems, our expectations of what life is.”
As someone who specialises in grief, what does Julia Samuel think will be the lasting collective impact of so many deaths, but also of our prolonged proximity to the threat of death?
“The impact will by no means be the same for everyone,” she says. “For an older person to lose a long-term partner so suddenly and unexpectedly is a different experience to a family who have lost someone young who was expected to survive. Both traumas will leave a deep and lasting imprint on their family members.”
Samuel points out that guilt is often a component of grief, and may be exacerbated by the ways in which people have died during the pandemic. “To be the only family member permitted to be present in an ICU is heartbreaking of itself, but then to have to be in full PPE, while your loved one is on a ventilator surrounded by medical staff who also look like astronauts. It is as good as it can be, but it is not the death that anyone would wish for.”
I ask Julia Samuel if there is any way to accurately predict what the long-term fallout of the pandemic will be…
“As humans, we are born to adapt,” she says. “But while we are still in it and so much is still uncertain, I don’t think we have a clue what the long-term consequences will be.”
When pressed, she mentions one of the possible beneficial effects of our time in lockdown. “One thing I sense is that many people are questioning how they lived before. The badge of busyness, for instance, has to a degree lost its lustre. Being busy was somehow being important, but maybe people have realised that busyness is essentially an anaesthetic to feeling.”
I ask Susie Orbach the same question. She, too, attests to the power of not being frantic. “The lockdown certainly changed our relationship to time. In the beginning, there was a kind of panic about time running though our hands – it was two o’clock and suddenly it’s five o’clock. How did that happen? I think not being frantic was a challenge for some people, but for others, the not-doing and simply being became almost mindful. To just be is actually quite liberating.”
Will these small epiphanies be enough for the reorientation of our social and political values that some have suggested will be the necessary outcome of this global emergency? Writer and activist Arundhati Roy has described the pandemic as “a portal, a gateway between one world and the next”. We can, she suggested, “choose to walk through it, dragging the carcasses of our prejudice and hatred, our avarice, our data banks and dead ideas, our dead rivers and smoky skies behind us. Or we can walk through lightly, with little luggage, ready to imagine another world. And ready to fight for it.”
Orbach cautiously agrees. “Part of me thinks that this is somehow a moment of possibility. Many of us who believe we need to work together to democratise our institutions saw that actually happen when the doctors and nurses took control on the ground, while management did not have a clue.”
She pauses for a moment, gathering her thoughts. “In terms of our political culture, we entered the pandemic with a government born of fright. Brexit was essentially an act of fright, and the climate of fear that was created left so many people feeling marginalised in this swashbuckling, Darwinian, self, self, self culture. And yet, against all that, when the pandemic happened and real fear spread among us, people wanted to make a contribution, they wanted to be decent.”
The experts agree that the psychological fallout of the Covid-19 pandemic will be felt for some time to come and that, as ever, the most vulnerable, no matter their recent sacrifices, will be most at risk. In the new normal, will we find ways to be fairer, kinder, more decent when this is all over, if it can ever be said to be truly over? Or will today’s “heroes” become tomorrow’s overlooked victims like the traumatised veterans of so many wars we willed ourselves so quickly to forget?
Will we hold our political leaders to account when the coming economic crisis inevitably takes precedence over the psychological one and already limited resources are channeled away from a beleaguered NHS that nevertheless saved us from an even deeper, darker abyss? Or will we simply get on with it as before, finding ways to forget that, for a long, uncertain time, when time itself seemed out of joint, we lived amid the mounting dead in a world turned upside down. Ultimately, how we respond to this looming second pandemic may be the measure of how much the first one really taught us about ourselves and the kind of world we want to live in.
• In the UK and Ireland, Samaritans can be contacted on 116 123 or email email@example.com or firstname.lastname@example.org. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at www.befrienders.org