Call the Psychiatrists?
By tonydavid, on 15 April 2020
Call the psychiatrists?
Stereotypes abound regarding different medical specialists and their personalities. From aggressive, macho surgeons, nice-but-dim GPs to the mad-as-their-patients psychiatrists. The coronavirus outbreak has thrown other specialists into the spotlight. Critical care doctors are a new breed. Not selected for their bedside manner – their patients are usually anaesthetised. They are particularly skilled applied physiologists who understand oxygen saturation. In other words, a bit nerdy. Who knew they were brave too? The academic discipline of epidemiology – tired of explaining that theirs is the study of diseases in populations not ‘epidemics’, this is their moment to prove they have the statistical smarts to interpret the data, discern the trends and test the advice. Ironically, until COVID-19, public health specialists were perhaps the most beleaguered of all the non-coal face doctors practicing in the UK with large cuts to their budgets in recent years. Now they are effectively in charge with politicians supposedly following their advice to the letter. Even within that group’s medical specialism, the tide had long since turned away from infectious diseases – which normally account for a fraction of deaths in high income countries – towards ‘non-communicable diseases’: neurodegenerative conditions like Alzheimer’s, diabetes, heart disease, stroke, cancer, which are fast becoming the scourge of lower and middle income countries too.
Redeployment of ‘rear-guard’ staff to the frontlines followed by recall of retired healthcare workers to help with NHS cope with COVID-19 led to some amusing memes. The first was the blue woolly bespectacled face of Dr Grover being drafted in from Sesame Street to the ITU with the caption ‘stay home unless you want to be intubated by a psychiatrist’ and then Dad’s Army characters – ‘Don’t worry chaps, backup is coming’ with their pompous but insecure leader Capt. Mainwaring representing psychiatry.
We have all been asked to consider our mental health and offered myriad ways to preserve it during lockdown and social isolation. Much of the advice from the NHS has been reassuringly commonsensical and has pointed toward self-help and online resources. Do psychiatrists have particular role to play?
The biological effects of SARS-CoV-2 on the nervous system are not well understood. Experience from China does not suggest that we should anticipate cases of encephalitis and its inevitable neuropsychiatric manifestations as a result of direct infection of the brain in cases of COVID-19 but vigilance is required. The virus has been detected in the central nervous system in people with severe multi-organ disease. Common symptoms such as dizziness and headache and loss of smell and taste are best not seen as brain-based but rather general indicators of systemic unwellness and upper respiratory tract inflammation. The Association of British Neurologists is setting up a system to collate cases of suspected neurological COVID-19 and clinical neuropsychiatry colleagues from Edinburgh to Exeter have offered to help.
Experts interpret the life-threatening pneumonitis of the disease as a consequence of an all-out immunological response to the infection rather than the infection alone – it seems Boris Johnson dodged that particular bullet – and neurology textbooks have whole chapters on immune-mediated ‘post-infectious’ syndromes. But the contrast with a truly neurotropic virus such as polio which preferentially attacks motor nerve cell bodies could not be more stark. Some will remember the paralysing fear of paralysis which gripped families in the 1950’s and the dreaded spectre of the clumsy ventilators of the time – iron lungs.
The likely legacy of SARS, MERS and now COVID-19 includes psychiatric fall out. In those earlier epidemics, there were high rates of anxiety, depression and PTSD in the short term – although such outcomes never affected the majority. We know about them because people who recovered from infections serious enough to require hospitalisation were asked to fill out questionnaires on their experiences as part of simple research surveys. Few of the studies had controls groups which would allow us to conclude whether such rates were particularly high or not. PTSD is a strange one in this context. Not that being rushed to hospital and seeing the person in the next bed gasping for air and perhaps eventually succumbing, isn’t horrific and likely to etch itself on your memory. And the scene may come back to haunt you as intrusive memories and invade your sleep. But is it really best considered a direct consequence – part and parcel – of your own illness given that your sole allowable visitor, uninfected by the virus, might have been similarly traumatised?
If there are any lessons from psychiatry at times like this is it is to hang on to a kind of natural and shared immunity which we may find deeply embedded within. Natural in the sense of non-technical. Several studies on ‘psychological debriefing’ after traumatic events, have shown that, not only does this not help it makes the situation worse. Perhaps it derails the natural processes – biological, psychological and social – that have evolved to deal with major adverse events. By ‘medicalising’ the process, however unwittingly, it seems that we expose people to more harm rather than inoculating them against it. Hence the UK wide Royal College of Psychiatrists’ sensible advice to resist the temptation to offer such services to colleagues in the frontline. We don’t need the argot of traumatisation and therapy to speak to each other of loss, or bereavement and the yearning for physical contact. Those in the frontline don’t need someone to encourage them to emote in a certain way, to list the pain and guilt, the numbness or indeed the quiet victories. They do need a good night’s sleep, personal protection, reassurance that their efforts are appreciated and the above all the chance to share and fashion stories with each other.
The urge to ‘do something’ is strong and many of my senior colleagues feel at best side-lined and at worst, guilty for not practicing physical medicine. But there is plenty for us to do. Accident and emergency departments still attract a steady stream of people whose repertoire of coping with distress is limited to stereotyped and concrete demonstrations through the medium of physical self-harm. It is expecting too much of them that they will find more adaptive ways of dealing with it at the moment. It’s difficult enough for professionals to find the right words for them, or indeed any words but we are best placed to try. Suicide – since it was first studied by Emil Durkheim in the 1890s – tends to fall at times of national crisis like war perhaps because of an enhanced sense of collective solidarity. Let’s hope that applies to this pandemic. Then there are those with serious and enduring mental illnesses – such as schizophrenia. Perhaps half a million of them in the UK, living in sheltered accommodation, hostels and bedsits, if they’re lucky. People for whom companionship and intimacy are seldom seen as unalloyed good but often as harbouring threat. Social isolation for them is the default. If you live in a world where, at the best of times, religion, TV, and the internet rather than a comfort or distraction, seem arranged to undermine your sense of self, imagine what it’s like to be in the midst of a pandemic caused by invisible lethal particles invading your body – and your mind – where everyone is a bit paranoid. When AIDS was much more of a pre-occupation than it is today, one of my patients described how her longstanding nemesis, the persecutory voice that followed her every thought, announced that he was suffering from the virus ‘himself’. Eventually the voice, that personification of threat, succumbed to the disease and fell silent. My patient enjoyed a few days of blissful respite until the virus in a final posthumous category-defying leap, infected her too, at least that was her conviction. Such people are our responsibility and they need our arm’s length support not to mention maintenance medication.
For those feeling under pressure to play a more active role, the Hippocratic dictum: ‘first do no harm’ is worth remembering. I was required to take a version of the hippocractic oath when I qualified, and it always seemed to me to be a low bar and dead-weight to idealism and ambition. But now it seems aspirational. Colleagues in behavioural science struggled to come up with a useful ploy to get people to stop touching their faces; it’s not as easy as you think. ‘Sit on your hands’ was what they settled upon. Good advice all round.
14th April 2020, London.
Professor Anthony David, is Director of the UCL Institute of Mental Health and author of “Into the Abyss: a neuropsychiatrist’s notes on troubled minds.” Oneworld Publications.