🧵Mental health and mental illness during COVID-19:

How do we think about how the pandemic has affected people's mental health and mental illnesses?

This is a part response to @helenessex2's powerful thread QTed here.

Apologies, it will be long

It's a part response as it's going to be about how to think about the MH impacts and not actual numbers. I've only cursorily followed the research measuring the impact of the pandemic on mental health and mental illness, and in any case, I'd like to take a different tack.
I'm going to try and walk you through how I'd usually think about the impact of a difficult event/experience on a person, if I was seeing them in clinic. This hopefully sets up the approach I'm going to be taking and perspectives I'm going to try and cover.
Needless to say this is from a position that acknowledges the realities of COVID-19 and thus this 🧵may be of much less use, and interest, to people who disagree with these.
Let's start.
In 2020 we all went into the pandemic with our own histories, strengths, vulnerabilities & resources (emotional, mental, financial, social etc). We're now 18+ months in. Even in 'normal' life, that is long enough for a lot of the above to have changed.
What I mean by this is, the versions of you during and at the end of the pandemic may be very different from you in March 2020, each version being shaped by the particular events you have gone through.
Of course being shaped by what happens to us is basically life. But in disasters like pandemics there are a lot more serious stressors concentrated in relatively short period of time.
It's also important to remember that 18+ months is long enough for people to move through major life transitions, especially for younger people e.g. move from primary to secondary school, enter puberty, finish schooling, important developmental milestones, etc.
It matters where you are in your life. 18 months of your life is usually a much bigger deal when you are 6 compared to 36, and the longer term effects will be different for those who were children during the pandemic compared to those who were adults.
Here’s the approach:
1.Let’s think of the pandemic as a set of significant events in a short-ish period of time.
2.Some of these may have occurred simultaneously, others consecutively e.g. you & your wife fell seriously ill at the same time, she sadly died 3 wks later.
3.Each event may have had an impact which may have influenced the impact of simultaneous and subsequent events.
4. Some impacts will be felt immediately or at least during the pandemic. Some will only be felt years later.
Let’s consider how we think about the impact of each event. I’ll list the key points and then illustrate with some examples.
1. What happened?
- What did you think/believe was happening?
- Were there other people involved/affected?
-Who was with you? (Did you go through this on your own?)
- Were you alone in your suffering? (Were you the only one who was suffering in this way?)
- Was what happened anticipated or unexpected?
- Was what happened controllable or preventable?
- How did it end?
2. What happened after?
- How did it affect you? How did it affect how you felt about/saw yourself?
- How did it affect your life?
- How did people around you respond?
- Was your suffering recognised?
-How did you make sense of what happened?
-How unfair or unjust was it?
-Who or what was responsible for it or to blame for it?*
-Did you ever receive an apology or any reparation from those responsible?*

*If there is an agent of some kind involved.
There are a lot of things that happened to people during the pandemic but even if we consider just a specific event, with a population level disaster you experience it in multiple roles: as an individual, as member of a family group, as a member of different communities.
And the more people that are involved and affected, the more you experience indirect impacts e.g. my neighbour lost his son, my daughter never got to graduate, my dad's cancer treatment was delayed.
Let’s look at each of the points in a bit more detail:
What happened?
Here is a non-exhaustive list: lost loved ones, become seriously ill themselves, seeing a family member becoming seriously ill, not being able to visit/say goodbye to family before they died,...
....seeing themselves or a loved one suffering the loss of who they used to be because of LongCOVID, loss of jobs, financial stability, health, loss of schooling, loss of major aspirations and plans. And many people will have experienced more than one.
What did you think/believe was happening?
In the UK the information was so unclear and the messaging so inconsistent that it was difficult to know what exactly was happening and why. Even in a scary situation, it is easier to manage if you know what’s happening and why.
This is for multiple reasons, including that it easier to manage if you know there is someone who is responsible and in charge, who knows what's going on (exactly what one thinks of when one thinks of our govt)
Some people understood what was happening at points, some people may have been too overwhelmed and were just swept along at some points, some people may have latched on to some explanation of what was happening that may have been very clear but was just plain wrong.
Were there other people involved?
It is usually easier to deal with a difficult event when it is not just you who are being affected. Shared adversity can be easier to bear and can bring help people together. Many of us know of others who are also affected like we are.
Who was with you? (Did you go through this on your own?)
It is generally easier going through a difficult situation with someone than on your own. That can be very different if the other people are dependent on you (a child, an elderly parent, a sick family member).
It can also mean that you have more people to worry about than just yourself. Equally you are also likely to experience second hand the impacts of the event on the people with you (as they are yours) e.g. seeing the impact of disruption and illness on your children.
Were you alone in your suffering?
The same event occurring to everyone in a household, may affect each one in very different ways and ‘Everybody in the house is going through this but I am the only who is affected like this’ can be a very lonely position indeed.
Was what happened anticipated or unexpected?
Higher level events e.g. freedom day, lockdowns could beconsidered as anticipated to certain extents. But closer to the ground things are more mixed. You can prepare for school closures, not for losing a job or parent.
Was what happened controllable or preventable?
In the aftermath of difficult events, people often find themselves wondering this, could something have been done that would have meant I did not have to go thoruhg this?
We have a mixture of controllable/preventable and not. However overall the fact that so much of what we went through could have been prevented if the govt had controlled transmission will rankle for a long time to come.
How did it end?
The pandemic has not ended yet.
Some things may have ended e.g. you've recovoered from acute COVID, that is a relief.
Some things don’t really end e.g. the death of a child, the premature death of a parent.
2. What happened after?
- How did it affect you?
These can be myriad: I lost my health, I lost my sense of safety and stability in the world, I became incredibly anxious, I started to feel very angry at people, how could they be so selfish?
How did it affect how you felt about/saw yourself?
'I thought I was someone who could cope with a fair bit of adversity.'
'I thought I was fairly independent and could easily manage on my own.'
'It made me feel like I was dispensable and my death was an acceptable loss.'
How did it affect your life?
'I liked working from home, it made work a lot easier.'
'I had to give up so much that I would have wanted to do because my health would not longer allow it.'
'I had worked so hard to attain these goals and now they're gone.'
How did people around you respond?
Having a supportive response from those around and finding solidarity with others can be hugely supportive. On the other hand:
'People treat me like I'm the crank for being worried, for taking precautions.'
Was your suffering recognised?
Did your family and friends understand?
Were work supportive and understanding?
Were you dismissed as someone who was just anxious and fearful?
How did you make sense of what happened?
This is a vital part of responding and adapting to what happened. You could understand it as being failed by a govt that didn’t care what happened to you . This would be true, make sense, but could leave you angry and frustrated.
You could blame scientists or ‘lockdowners’ or the govt (because they didn’t let life go back to normal). You’d be wrong but it would give your anger and frustration more focus. This is important not just in the moment but also for the future.
It will shape your view of the world and how you approach things in future but for some people it will do that with some powerful misconceptions and prejudices.
How unfair or unjust was it?
Events that feel more unjust/unfair are harder to deal with and bring a much stronger sense of being singled out, they shake one’s view of the world more severely.
One example here is the treatment of CEV and disabled folk who are widely talked about as if they were dispensable and indeed actually treated as such.
Who or what was responsible for it or to blame for it?*
If there was someone or something responsible for what happened, what did they do? Did they cause it, did they fail to stop it, did they fail to act while you suffered?
This links in very strongly with how you made sense of what happened.

Did you ever receive an apology or any reparation from those responsible?*
Receiving amends is an acknowledgment of the wrongness of what happened to one & a recognition of your suffering.
We’ve not got one thus far from the govt and given the scale of this disaster we are unlikely to get one. In fact, quite the opposite may be very likely i.e. we'll get a major spin campaign to repackage the pandemic and all that has happened.
The govt will not want to deviate from its plans to use the combination of Brexit and COVID to push through its agenda. They have already taken measures to reduce liability and will be keen to avoid reparation of any kind.
This will serve to both gaslight people and justify why there is no need for change, apology or reparation.

In short, these will likely be events that will have a huge impact on people and with little in the way of explanation, amends, reparation or resolution.
Some of you will recognise this as the approach to traumatic events & one can think of the pandemic as a collection of acute (e.g. becoming seriously ill, bereavement) & subacute (traumas occurring over a protracted period.
BUT see next tweet.
The reason I have not described these generally as traumatic events (even though some like sudden loss of loved ones definitely are) is that whether something is experienced as traumatic is generally something to be discussed and understood with the person experiencing it.
There is one other class of experiences that I would single out for separate consideration and those the experiences of moral injury, namely where we feel have failed other people, like failing to save our patients, failing to protect our children.
With particular regards to the latter, this is something may only hit fully sometime into the future when we discover the full range of long-term sequelae of COVID infection in children. And people who go through this will hurt.
They will feel very responsible but just as helpless. As helpless as they felt trying to protect their children with a pandemic running wild with no mitigations in schools and no vaccinations for kids, etc.
Now that I'm on tweet 51, I feel like I should let you know that this is a very complex matter to consider.

How might we think about what the potential impacts of all of the above might be?

Let's start with thinking about immediate suffering.
There is a lot of immediate suffering that relates to the ways life has changed so much:
-Everyone acknowledges we simply can’t do everything like we used to before, but we still have to do everything we used to do before and with less support.
-We have even less control over even our immediate world than we used to have.
-We are constantly having to make decisions to survive now, aware that there may be partly foreseen consequences in the future that we don’t know and can do little to mitigate.
-Plans for surviving a couple of months can’t hack it for a year.
-Vital supports (especially social), resources, benefits and strengths have been lost or worn down but previous disadvantages and inequities have become more marked.
-The new ‘normal’ is increasingly become more and more like the old ‘normal’.
-The blurring and work and non-work selves (you work all day at the dining table, you have dinner with the family at the dining table).
-It is increasingly difficult to trust that major things will be taken care of.
-There have been losses that have had to be simply carried because there has not been the time or the space.
In terms of immediate suffering, you would expect to see a lot more distress, unhappiness and grief. You would see a small increase in new incidences of depression, anxiety, etc as people who were vulnerable/close to becoming unwell before, get worse.
A proportion of people who had pre-existing illnesses will relapse and this will partly relate to the loss of usual supports adn structures. But I wouldn't expect to see the much talked about tsunami of mental illness occurring now and we don't really see this.
Similarly with suicide rates, we'd expect to see small drops and that is what we find.

This however is the immediate state, the pandemic is still going on and the longer it goes on, the more general level of mental distress and suffering will rise.
But where I suspect we will see a lot of mental morbidity and illness will be in the years afterwards and these are some of the sources/factors:
- traumatised and burnt out healthcare workers and other essential workers
- sufferers of LongCOVID
- the bereaved and multiply bereaved
- those impacted by the economic uncertainty and downturn that will very likely follow.
- subgroups of those who were children during the pandemic (see 63, 64)
- the marginalised groups who were far more heavily impacted by the pandemic and whose health inequities will worsen. I'd particularly mention disabled people here.
There are some common risk factors for mental illness that the pandemic will likely affect: early life adversity, deprivation, early parental loss to name a few. We may not see the impacts of these in the immediate aftermath of the pandemic.
I suspect that in few years time we will be specifically asking at least teenagers and young adults about the impact of the pandemic on their early lives and development.
There was and still is a lot of opposition in the UK to making schools safer and protecting children.
To think about the impact of the above failures on kids:
- How has the pandemic shifted the way their life was going to be? (educations, aspirations)
- What and who have they lost? At a conservative estimate 1.5 children worldwide have lost a primary caregiver to COVID.
And if we want to think about how to ameliorate these effects, it would require us to acknowledge these impacts on them and take steps to repair them.

Not hopeful that £50 per kid per year will quite say or do that.
- There are multiple impacts of the pandemic on mental health and these are likely to be cumulative.
- Some of this can be thought of in terms of repeated adversity/trauma
- The mental health impacts will only become fully evident over the coming several years.

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More from @HZiauddeen

14 Oct
🧵Living in survival mode:

Survival mode can be thought of as a state of living in which managing each day takes pretty much all the capacity you have. And by the time you are in survival mode, you're already working with a significantly depleted capacity.
You can end up in survival mode because:
1. The demands on you have been heavy and unrelenting and have exhausted your spare capacity.
2. Your capacity has been diminished by illness/stress* (mental or physical).
3. A combination of both of the above over time.
In reality often things may start with either 1 or 2 but then over time the other one will get involved so you end up with 3 anyway.

* Re: stress, it's important to consider environmental stresses including poverty, precarity and discrimination (ableism, racism, etc).
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🧵Some reflections on the responses to this thread👇

This is about some of the criticisms I received for this thread. This is not meant to be a massive subtweet, apologies if it feels like it. I think that some of the points raised were worth airing and addressing.
1. A fair few people took 'the people in power' to mean the government. I certainly do include the govt in this category but it's not just the government. There are a lot of powerful players who are not part of the govt and we have known about them for a long time.
A COVID example: the Koch Brothers, AIER and GBD (check out @NafeezAhmed's work for @BylineTimes)

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'I hear what you're saying but remember there are two sides to every story.'

🧵 'Two sides to every story' is a common technique used to dismiss victims.

Actually there are as many sides to a story as there are involved parties.
However, the more important point is: 'How many sides have you listened to?'

Because 'two sides' is used in multiple ways:
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2. To stop other sides being voiced by implying the person is vexatious, unreliable or has malicious intentions.
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*Everyone trying to control the pandemic & save lives.
In fact looking back, I am not sure if ever came close at any point to a temporary draw, let alone a win but now there is no doubt.
The GBDers, the 'herd immunity through natural infection' proponents, the individual freedom fighters, the eugenicists, they've won.
Their misinformation and disinformation campaigns have so muddied the situation that despite the huge amounts of evidence (and deaths and illness), the basic realities of COVID-19 and controlling it remain somehow contentious.
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Mini 🧵: Is the idea of women's intuition misogynistic?
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'Is it your female intuition telling you we should consider that in our plans?'

'So you were right, must be that women's intuition.'

The implication of both statements is that there is no 'rational' reason why the woman would have suggested that and then got it right.
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🧵Long COVID, this tweet and these kinds of psychological approaches:

Long COVID is a multi-system condition with microvascular damage, immune dysregulation, clotting abnormalities and neuronal damage being amongst the mechanisms implicated.
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There are clearly neuropsychiatric aspects to Long COVID (neurological, psychiatric and cognitive symptoms) and important psychological aspects (dealing with severe, chronic, disabling, life-altering illness). Both will require psychological research and treatment.
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