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• To acknowledge the adverse effects of COVID-19 on the mental health of service users and staff
• To recognise signs and symptoms of mental health issues that may be caused by the COVID-19 pandemic
• To locate external sources of mental health support in voluntary and professional organisations
In December 2019, a new infectious respiratory disease was reported in China, which was subsequently identified as coronavirus disease 2019 (COVID-19) and prompted a pandemic. At the time of writing an estimated 175 million people had contracted the disease resulting in over 3.8 million deaths worldwide.
The COVID-19 pandemic has had significant adverse effects on the mental health of service users and healthcare professionals. Mental health professionals have had the responsibility of supporting others while potentially experiencing adverse effects of the pandemic on their own mental health. This article describes the pandemic’s effects on mental health and explores the role and needs of nurses in supporting the mental health of others.
Mental Health Practice. doi: 10.7748/mhp.2021.e1573
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Singh S (2021) Role and needs of nurses in managing the mental health effects of COVID-19. Mental Health Practice. doi: 10.7748/mhp.2021.e1573
Published online: 10 August 2021
Epidemics and pandemics have occurred at regular intervals throughout history. For example, cholera spread globally from India in the 19th century and the 1918-20 outbreak of Spanish flu killed an estimated 50 million people worldwide (Liu et al 2018). In the latter part of the 20th century, various epidemics occurred including acquired immunodeficiency syndrome (AIDS) (Cohen et al 2008), severe acute respiratory syndrome (SARS) (Smith 2006) and Ebola (Centers for Disease Control and Prevention (CDC) 2019).
In December 2019 a new infectious respiratory disease was reported in the Chinese city of Wuhan, which was subsequently identified by the World Health Organization (WHO) as coronavirus disease 2019 (COVID-19) (WHO 2021). COVID-19 is highly contagious and has spread rapidly around the world, prompting a pandemic. At the time of writing an estimated 175 million people had contracted the disease resulting in more than 3.8 million deaths worldwide (Johns Hopkins University 2021). In the UK approximately 4.5 million people had tested positive and more than 127,000 deaths had been reported (UK Government 2021). Each country has been attempting to manage the additional demand for healthcare services while social restrictions such as physical distancing, self-isolation, quarantine, lockdowns and travel bans have been introduced to reduce or prevent the transmission of infection.
This article describes the effects of the COVID-19 pandemic on the mental health of service users and healthcare professionals, and explores the role and needs of nurses in supporting the mental health of others. For the purposes of this article, mental health nurses and other mental health staff are referred to as mental health professionals.
• The high rates of infection, severe illness and deaths seen during the COVID-19 pandemic led to elevated levels of stress and anxiety
• Social restrictions implemented during the COVID-19 pandemic have had adverse effects on the mental health of service users
• Mental health professionals need to be trained in the early recognition of the mental health effects of COVID-19 such as depression, anxiety, adjustment issues and post-traumatic stress disorder
• To support service users affected by COVID-19, mental health professionals can use short interventions based on counselling, cognitive behavioural therapy or open dialogue
• Mental health professionals need to be trained, prepared and supported to assist service users in times of crisis
• Healthcare professionals whose mental health has been negatively affected by COVID-19 need access to support
The COVID-19 pandemic has had significant adverse effects on the mental health of service users. The high rates of infection, of severe illness and of deaths and the lack of effective treatment led to elevated levels of uncertainty, stress and anxiety, culminating in significant mental health issues for some people (Dubey et al 2020). A study of 2,025 adults undertaken in the UK during the pandemic found a higher prevalence of anxiety, depression and trauma symptoms than had been reported in previous population studies (Shevlin et al 2020).
It is worth noting that there are, in the UK, disparities in the risks and outcomes from COVID-19, notably by age, sex, geography, deprivation, ethnicity, occupation and co-morbidities (Public Health England (PHE) 2020). The largest disparity found by PHE in people diagnosed with COVID-19 was by age, with people aged ≥80 years 70 times more likely to die from COVID-19 than people aged <40 years. The risk of death was also higher in males than in females; higher in more deprived areas than in less deprived areas; and higher in people from black, Asian and minority ethnic (BAME) groups than in white ethnic groups (PHE 2020). These disparities replicate existing health inequalities and, in some cases, have increased them (PHE 2020).
Social restrictions implemented during the COVID-19 pandemic, such as lockdowns, self-isolation, quarantine and physical distancing, have had adverse effects on people’s mental well-being. Self-isolation and quarantine are standard public health measures to reduce or prevent the transmission of infectious diseases (Tognotti 2013, CDC 2017) and have been widely used during the pandemic. While self-isolation and quarantine both aim to reduce or prevent the transmission of infection, they have distinct characteristics. Self-isolation aims to separate individuals who have not contracted a disease from those who have, whereas quarantine aims to restrict the movement of those who have been exposed to a disease to reduce or prevent further transmission (CDC 2017). These distinctions are often not well understood by the public (Brooks et al 2020).
Studies aimed at quantifying the effects of public health measures such as quarantines have shown how they can negatively affect people’s mental well-being. A study by Jeong et al (2016) evaluated the mental health of people who had been subject to isolation during the Middle East respiratory syndrome (MERS) epidemic and found a high prevalence of anxiety and anger. Other studies have reported a significant mental health burden among people experiencing social isolation or quarantine (Brooks et al 2020, Sharma et al 2020).
A survey of the general public in Great Britain showed widespread concerns about the effects of social isolation and physical distancing on mental well-being such as increased anxiety, depression and stress (Ipsos MORI 2020). Survey respondents were concerned about the practical implications of social restrictions, such as financial difficulties, and these practical implications could be more concerning than the prospect of contracting COVID-19 and becoming physically unwell.
Survey respondents were also concerned about the exacerbation of pre-existing mental health issues, about the mental well-being of their families, of children and of older people, and about challenges in accessing mental health services during the pandemic (Ipsos MORI 2020). Self-isolation and quarantine contributed to the adverse effects of the pandemic on people’s mental health in part because they were perceived as restrictions on individual freedoms (Ipsos MORI 2020).
The rapid spread of COVID-19 led to greater numbers of people being admitted to hospital than usual, with many critically ill patients dying in intensive care (Quah et al 2020). Studies have shown that bereavement is associated with suboptimal mental health outcomes including prolonged grief disorder (Kentish-Barnes et al 2015), post-traumatic stress disorder (PTSD) and depression (Kross et al 2011, Probst et al 2016).
Restrictions on hospital visits meant that many people were unable to see hospitalised relatives, even at the end of life, which has been shown to result in distress (Probst et al 2016) and depression (Kross et al 2011, Kentish-Barnes et al 2015). Social restrictions also disrupted the grieving process, because many people were unable to attend funerals or other types of ceremonies that might have helped them to cope with their loss (Wallace et al 2020). Bereaved families experienced limited social support due to physical distancing, closure of services and lack of online infrastructure. Evidence has shown that the lack of social and community networks can exacerbate psychological morbidity during bereavement (Kun et al 2009).
The COVID-19 pandemic affected the provision of routine healthcare services, reducing the availability of face-to-face appointments and resulting in the cancellation of planned procedures. The ensuing delays in diagnosis and treatment led to elevated anxiety levels, particularly among people directly affected by physical health conditions such as cancer (Richards et al 2020).
Healthcare professionals are not immune to the adverse effects of COVID-19 on mental health. In the past, epidemics and pandemics have been shown to negatively affect the mental well-being of healthcare professionals. For example, studies evaluating the psychological effects of the 2002-04 SARS outbreak have found increased distress and symptoms of PTSD among healthcare staff (Reynolds et al 2008, Park et al 2018).
Chen et al (2020) and Duan and Zhu (2020) reported that healthcare professionals in China, the US, Canada, Taiwan and Hong Kong who were involved in providing direct care to patients during the COVID-19 pandemic experienced PTSD symptoms and elevated levels of anxiety and fear, particularly around contracting the disease and the potential consequences for their families. Many healthcare professionals involved in direct patient care worked long hours under stressful conditions, in some cases with a lack of personal protective equipment, and witnessed high numbers of deaths (Braquehais et al 2020). Many experienced anxiety, fears of contracting the disease and trauma from dealing with a high number of deaths, including those of colleagues, which in turn has affected morale, with staff reporting emotional exhaustion and burnout (Giusti et al 2020).
Psychological distress caused by financial difficulties, social isolation, bereavement and uncertainty about the future can lead to high levels of substance misuse among service users as well as elevated levels of depression, self-harm, neglect and suicide (De Goeij et al 2015). These challenges can also affect healthcare professionals, many of whom have had to manage stressful situations, work in demanding environments and maintain constant emotional availability during the pandemic.
Healthcare professionals whose mental health has been negatively affected by the pandemic need access to professional support. In England, to counter the effects of the pandemic on the mental health of healthcare professionals, the NHS Improving Access to Psychological Therapies (IAPT) programme has provided access to services such as psychological first aid and group cognitive behavioural therapy (CBT) (Cole et al 2020). In the UK, NHS staff can access support from Frontline19 (www.frontline19.com), a volunteer-run service providing remote psychological support.
Mental health professionals have had the responsibility of supporting service users and other healthcare professionals while potentially experiencing adverse effects of the COVID-19 pandemic on their own mental health.
In the author’s clinical experience, the widely reported numbers of COVID-19 infections and deaths, coupled with social restrictions, generated feelings of anxiety among service users. Mental health professionals can ensure they detect anxiety at an early stage by working collaboratively with service users to identify signs such as excessive checking behaviours (Thwaites and Freeston 2005).
A mental health professional may notice, for example, that a service user excessively seeks information on COVID-19 infection rates as a coping mechanism to reduce their anxiety. The mental health professional can offer reassurance by providing the service user with factual and evidence-based information and by conveying government guidance in everyday language. This can help reduce the service user’s anxiety and increase their engagement with public health measures.
Service users may access information from social media platforms, which are often not monitored and may conflict with official sources. This can increase their anxiety and fears about COVID-19 (Jiang 2021). Mental health professionals can support service users by prompting them to adopt strategies such as limiting the time they spend online and by signposting them to official, rather than unofficial, websites for information (Király et al 2020).
The pandemic has affected many people in terms of loss of employment, financial instability, increased debt and housing concerns, which can exacerbate anxiety and, for some people, increase levels of substance misuse (Griffiths et al 2021). Mental health professionals need to have up-to-date knowledge of benefit allowances so that they can support service users to access financial and housing benefits. Mental health professionals also need to support service users who are at risk of substance misuse to engage with drug and alcohol services, who can provide anxiety management through a range of interventions such as internet-based CBT (Käll et al 2020).
Social restrictions implemented during the pandemic disrupted service users’ daily routines and activities. The lack of regular routine can lead to feelings of demotivation, boredom and depression and to unhealthy behaviours such as excessive eating, smoking and substance misuse (Stockwell et al 2021). A survey commissioned by MQ: Transforming Mental Health and the Academy of Medical Sciences (Cowan 2020) stated that the likely adverse effects of the COVID-19 pandemic on mental health would be compounded by social isolation and loneliness, leading in some cases to depression, self-harm and increased suicide risk.
Reducing people’s feelings of loneliness can mitigate the risk of depression, suicidal ideation and self-harm (O’Connor and Kirtley 2018). To reduce isolation, boredom and engagement in unhealthy behaviours, mental health professionals can support service users to identify meaningful activities and plan daily routines, including exercising and maintaining contact with family and friends, which can lead to improvements in mood (Király et al 2020). Mental health professionals can support vulnerable individuals by maintaining regular telephone contact and by providing brief interventions using basic counselling and CBT techniques.
Social prescribing has developed as a result of policies such as Saving Lives: Our Healthier Nation (Department of Health 1999), which aim to reduce the demand on GPs to manage psychosocial issues (Zantinge et al 2005). Social prescribing can be described as a mechanism for linking patients with non-medical sources of support in the community, such as assistance from voluntary organisations and engagement with self-help groups (Adbowale et al 2014). Social prescribing expands the options available to GPs and other community-based practitioners to provide individualised care to service users.
During periods of social restrictions, joint working between mental health professionals and social prescribers has the potential to provide social connections for service users in their local communities. Social prescribers can provide support to people who are shielding or live alone, reducing their isolation by maintaining social contact, meeting their daily needs such as shopping, and connecting them with local volunteer and befriending services (Toner et al 2018). Through working collaboratively with service users, mental health professionals can assist them to access social support networks – for example, by joining the free online sketch club run by the Royal Academy of Arts (royalacademy.org.uk/event/saturday-sketch-club).
Engagement with voluntary organisations has been shown to reduce service users’ feelings of isolation (Käll et al 2020). The UK has several established voluntary organisations such as Mind (mind.org.uk), SANE (sane.org.uk) and Age UK (ageuk.org.uk) that offer professional and peer support, psychological therapies and opportunities to engage with the local community. These voluntary organisations offer various forms of support ranging from online and telephone advice to managing debt issues. Service users can access them directly or through referral from healthcare professionals.
Mental health professionals can access support for their own mental health from professional bodies such as the Royal College of Nursing (rcn.org.uk), the Cavell Nurses’ Trust (cavellnursestrust.org) and the Royal College of Psychiatrists (rcpsych.ac.uk). These professional bodies offer a range of support options such as information on managing stress, psychological therapies such as CBT, and legal representation when managing work-related issues.
Open dialogue is a relatively new intervention offered by mental health trusts in England. Originally developed in Finland to meet the population’s mental health needs, open dialogue is a community-based method of engaging with a person’s relatives or social network within 24 hours of a mental health crisis (Seikkula et al 1995).
Open dialogue interventions are based on seven principles: immediate help, social network perspective, flexibility and mobility, responsibility, psychological continuity, tolerance of uncertainty, and dialogue (Seikkula et al 1995). Mental health professionals can adapt this approach to enable service users to enhance their social support networks. This can be achieved, for example, by encouraging service users and their relatives to express their concerns around COVID-19 and signposting them to relevant local resources such as online exercise or social clubs.
Identifying and developing protective factors against psychological distress during challenging events such as the COVID-19 pandemic can support service users to find coping mechanisms. Protective factors are elements that enable a person to feel psychologically safe and secure. They include, for example, spiritual or religious beliefs, relationships with significant others and contacts with pets (Naeem et al 2020). Identifying and developing these protective factors can enhance people’s resilience.
To develop service users’ resilience, mental health professionals can also use CBT techniques, which challenge negative beliefs and thought patterns such as catastrophic thinking and mental filtering, whereby the person focuses on the negative aspects of their situation.
Mental health professionals can also use communication skills such as open-ended and exploratory questions to emphasise the service user’s positive attributes, which in turn can reinforce their self-esteem (Naeem et al 2020). Supporting service users to focus on positive attributes during periods of stress enables them to better manage negative feelings such as anxiety.
There is abundant evidence that the COVID-19 pandemic has created and exacerbated mental health issues, while evidence from previous epidemics and pandemics has demonstrated that they have long-term psychological effects. The COVID-19 pandemic has also changed the way in which mental health services are delivered, increasing reliance on online platforms and virtual communication. This has implications for mental health nursing practice in the future.
It is important that mental health professionals receive effective psychological and emotional support during challenging events such as the COVID-19 pandemic – for example, through clinical supervision. Maintaining staff’s mental well-being is crucial so that they are able to meet the additional demand for mental health support prompted by the pandemic. Mental health professionals need to be trained in the early recognition of the mental health effects of the pandemic such as depression, anxiety, adjustment issues and PTSD (Dubey et al 2020). Important areas for staff training include managing the psychological effects of the pandemic, treating service users who have developed limitations to their functioning, treating prolonged grief disorder, developing service users’ resilience, and delivering short mental health interventions using counselling, CBT and open dialogue techniques.
Emerging data show that some people experience long-term effects of COVID-19, a condition which has become known as long-COVID and manifests mainly as fatigue, shortness of breath, chest pains or tightness, memory and concentration difficulties (SeyedAlinaghi et al 2021). People affected by long-COVID may experience psychological issues such as depression and anxiety, adjustment issues such as difficulty accepting the limitations created by the condition, and trauma (Serafini et al 2020). Mental health professionals need to be prepared to support service users with long-COVID by identifying and managing its psychological manifestations.
The COVID-19 pandemic has had significant adverse effects on people’s mental health and evidence from previous epidemics and pandemics has demonstrated that they have long-term psychological effects. Policymakers need to incorporate lessons from the COVID-19 pandemic into preparations for possible similar events in the future, while service providers need to develop strategies aimed at supporting and training staff to respond to the mental health needs of service users in times of crisis.
To support service users, mental health professionals can use innovative interventions such as open dialogue and social prescribing. Collaboration across organisations and disciplines is required to ensure that the needs of service users during challenging events such as the COVID-19 pandemic are met.
Age UK
Mind
Royal Academy of Arts sketch club
royalacademy.org.uk/event/saturday-sketch-club
Royal College of Nursing
Cavell Nurses’ Trust
Royal College of Psychiatrists
SANE
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