The RAMP study has shown that a lot of participants have experienced worsening symptoms of anxiety and depression since lockdown was announced.EDIT Lab PhD student, Jess, interviewed four clinicians to help understand the ways in which the pandemic may be impacting mental health


 

Over the last 16 weeks, the RAMP study has been monitoring symptoms of common mental health problems associated with the COVID-19 pandemic in over 8,000 individuals. From the beginning, it was clear that the lockdown had the potential to trigger mental illnesses for many individuals, as well as heightening symptom severity for those with pre-existing conditions. This has been confirmed by preliminary results from the RAMP study which show that 70% of participants report having experienced worsening symptoms of  depression and anxiety since the lockdown was announced. Reasons behind the high reporting of negative emotional consequences associated with the pandemic are complex and often dependent on individual circumstances. Nonetheless, common sources of reduced mental wellbeing are emerging. 

I interviewed four clinicians who have worked closely with patients (both before and during the COVID-19 pandemic) to understand the ways in which the lockdown may be impacting symptoms of anxiety and depression.

I would like to thank Dr Georgina Krebs, Dr Victoria Rodriguez, Dr Evangelos Vassos and Dr Richard LeBeau for kindly allowing me to interview them for this EDIT Lab blog post. Dr Krebs is a MRC Clinical Research Training Fellow at King’s College London (KCL) and an Honorary Principal Clinical Psychologist in the SLaM OCD & Related Disorders Clinic for Young people. Dr Rodriguez is an Honorary Psychiatrist at the Maudsley Hospital and a PhD student at the Department of Psychosis at KCL. Dr Vassos is a Consultant Psychiatrist at Oxford Health NHS Foundation Trust and a Senior Clinical Research Fellow at KCL. Dr LeBeau is a clinical psychologist and researcher in the Anxiety and Depression Research Center at the University of California, Los Angeles (UCLA).  

“What risk factors for depression and anxiety might be exacerbated by the lockdown?”

 

Virtually everything that people with depression and anxiety are encouraged to do to keep themselves mentally healthy is harder to do in the lockdown, noted Dr LeBeau. For instance, things like physical exercise, socialising with friends and family, community involvement, and spending time outdoors have become much more challenging. These activities are recommended because they are known to buffer against negative emotions. 

In addition, Dr Krebs mentioned that since the lockdown began on March 23rd, many people may have found that they are unable to engage in activities that normally give them a sense of achievement and pleasure, whether that is work, socialising, or engaging in leisure activities. Dr Vassos emphasised the significance of work in maintaining emotional wellbeing. The act of going to work everyday offers many benefits; it gives people a chance to regularly socialialise, it grants some degree of financial security and for certain individuals, provides a sense of purpose. The sudden removal of work (for those who have lost their jobs or been furloughed) could fuel feelings of anxiety and depression in particular. Additionally, Dr Krebs and Dr Rodriquez mentioned that the lack of social stimulation and time spent outdoors can mean people are not as tired when it comes to bedtime, which may be a reason for the noted increased rate of insomnia. This on its own is a key factor in both anxiety and depression. 

It is not only the nature of lockdown and changes to daily routine that have the potential to exacerbate symptoms of anxiety and depression, but the COVID-19 pandemic more generally. Dr Krebs and Dr Vassos both highlighted personal stressors including job loss, job insecurity, financial hardship, reduced social interaction, and bereavements. These experiences can increase risk for depression and a range of anxiety problems. 

Dr Rodriguez also mentioned pandemic-associated cognitive issues, such as high levels of self-perceived risk and feeling a loss of control. Dr Krebs added that the high amount of uncertainty can be incredibly anxiety-provoking and may exacerbate symptoms in those who are already susceptible to these feelings. Similarly for depression, Dr Vassos added that uncertainty regarding the future, including job insecurity and financial concerns (such as the ability to pay the mortgage or bills), is a key stressor which may lead to risk for depression, as individuals may not be able to see a future for themselves post-pandemic. For those with emotional disorders, the open-endedness of the pandemic may be a key source of distress. Dr LeBeau said that depression and anxiety are associated with a number of negative social outcomes, including poorer relationship quality and economic problems. As a result, the stress of the pandemic may disproportionately impact these demographic groups.

“The high amount of uncertainty can be incredibly anxiety-provoking.”

Overall, a number of factors associated with the pandemic have the potential to exacerbate symptoms of anxiety and depression. These range from changes to daily structure, limited time spent socialising all the way to cognitive factors such as fear, uncertainty and self-perceived risk. It is important for anyone experiencing anxiety and depression to understand that this is a very normal response to the stressors that have been ushered in by the pandemic. Furthermore, anyone facing these difficulties should seek help as soon as possible through their GP or IAPT service (links are available at the end of this blog post).  

“For someone who is undergoing talking therapy for depression and anxiety, what aspects of the lockdown might act as a barrier to their recovery?”

 

First and foremost, Dr Krebs emphasised that while it is definitely a challenging time to be undergoing talking therapy for depression or anxiety, it is critically important that people experiencing such symptoms are being well-supported. For this reason, as mentioned by Dr Rodriguez, there have been huge efforts from the different healthcare providers to continue assisting and supporting patients via the telephone or video calls. 

Dr Vassos talked mentioned that all types of talking therapies, whether psychodynamic, family, behavioural or cognitive, are placed within a social context which often represent the root of the problem. Suddenly, due to the pandemic, our social situations have changed dramatically. For many individuals, triggers for depression and anxiety may no longer be present. This shift in social context is problematic for therapy outcomes in two ways: 1) certain psychological therapies are not currently applicable, and 2) the alleviation of these symptoms is short-term only, and they are likely to continue to be a problem once life returns to normal post-pandemic. Therefore, it is critical that patients who are undergoing talking therapies maintain contact with their therapists and continue their treatment plans, if possible, even if the situation appears to have improved. 

As well as these issues, a number of practical concerns due the lockdown may arise; namely acclimatising to the new methods of communication, getting used to the lack of face-to-face interaction with therapists, as well as the reduced access to talking therapies. 

Nonetheless, many individuals will be continuing with therapy using alternative platforms. Dr Krebs pointed out that cognitive behaviour therapy (CBT) is equally effective whether it is delivered in the traditional face-to-face format, or via telephone, video-conferencing or specially developed internet programs. CBT is currently the most evidence-based talking therapy for anxiety and depression, despite being challenging at times and involving quite a high level of commitment to practise implementing coping techniques. 

Since the lockdown situation is proving highly stressful for people prone to anxious or depressive thinking patterns, these individuals might feel that they just do not have the time, energy or emotional resources to undertake this kind of treatment at the moment. One demographic group highly impacted by the lockdown are parents of young children, who are extremely busy adjusting to working from home, balancing the demands of round-the-clock parenting as well as managing their own mental health needs. Preliminary results from the RAMP study demonstrate that 67% and 68% of parents with children under 16 living at home report worsening depression and anxiety symptoms respectively. Therefore, it is hugely important that parents experiencing feelings of anxiety and depression have access to therapies despite their intensified daily schedule.

“67% and 68% of parents with children under 16 living at home report worsening depression and anxiety symptoms respectively.”

Dr Krebs mentioned that it is completely understandable if people feel unable to engage in talking therapies at the moment, but anyone feeling this way should have an open conversation about it with their therapist to decide the best next steps. Even for those who are feeling able to continue with their treatment plan, there may be logistical barriers to implementing cognitive behavioural strategies in the usual way. For example, CBT often involves practicing techniques in a range of settings outside the home, which might be difficult at the moment. Dr LeBeau agreed, saying that one of the biggest barriers facing individuals in therapy are likely to be difficulty in engaging in practise/homework assignments given the restrictions that are in place. He pointed out that cognitive behavioral therapy for depression and anxiety involves therapists encouraging patients to approach things that they would otherwise avoid, while working alongside them to develop skills to reduce their negative emotional response, which might be difficult at the moment. However, as pointed out by Dr Krebs, none of these challenges are insurmountable and a creative therapist will help to think of ways around them. 

Results from the RAMP study demonstrate that feelings of depression and anxiety are currently very common among many different individuals, and anyone experiencing these mental health problems is certainly not alone. For anyone facing difficulties, the current pandemic should not discourage you from seeking help from your GP or IAPT service. These web links may also be useful: 

www.nhs.uk/conditions/clinical-depression/treatment/

https://www.nhs.uk/conditions/generalised-anxiety-disorder/treatment/

https://www.nhs.uk/oneyou/every-mind-matters/coronavirus-covid-19-anxiety-tips/and-stories/b ogs/2020/03/managing-your-mental-health-during-the-coronavirus-outbreak/

Additionally, in the second part of this blog post, I will interview the four clinicians about ways in which we can adopt helpful strategies to cope with or prevent feelings of depression and anxiety throughout the pandemic.

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