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Coping with severe mental illness during COVID-19

Dr. Lade Smith discusses severe mental illness and steps to take during COVID-19. Jo Stubley describes some case studies for us to think about.
My name is Doctor Lade Smith and I’m a senior consultant psychiatrist at the South London & Maudsley NHS Foundation Trust, where I’m the Clinical Director for Forensic services. I’m going to talk you a little bit about severe and enduring mental health problems and COVID-19 people with severe mental illness (SMI) - that’s people with diagnoses such as schizophrenia, bipolar illness and other psychoses. And when I say psychosis, I do not mean violence. That’s not what psychosis means. Psychosis means being detached from reality, and it’s characterised by people experiencing hallucinations and  delusions. And that actually goes to one of the fundamental issues for people with SMI. There is very little information, and education about the conditions and so they are frequently misunderstood.
They are stigmatised and they are marginalised. In fact, people with severe and enduring mental health problems, say, 87% of them say that they have been that they’ve experienced stigma and discrimination. And what that translates into is that they are less likely to own their own home, more likely to live in inappropriate and inadequate accommodation In houses which are more crowded with living with other people who they don’t know, houses multiple occupancy, they are more likely live in urban areas, with high levels of deprivation, high levels of crime and substance misuse. Also, people with SMI are less likely to be employed. In fact, something… that there’s some evidence….
There’s some evidence that less than 15% of people with SMI actually have a job. And people are far less likely to have a life partner Essentially, having an SMI increases the likelihood of people being very socially disadvantaged. In addition, we know that people with severe and enduring mental health problems have a 15 to 20 year shorter life expectancy than general population, and that is not because of suicide or accidents. In fact, people with SMI are more likely to die from the same kind of conditions in the general population, but at a much earlier stage of their life. And, and that’s things like cardiovascular disease, heart disease and strokes, they are more likely to die from respiratory disorders.
And we also know that before they die, this group of people have really high rates of co-morbid conditions that increase the likelihood of dying early from Cardiovasc Disease and spiritual disorders, i.e.; things like diabetes, chronic obstructive lung disease, obesity and hypertension. The other really important thing, is that people from black, asian and minority ethnic groups, that’s BAME groups, are much more likely to attract diagnoses of psychosis. And are up to four times more likely to be detained under the Mental  Health Act because of severe and enduring mental illness. So what you’ll notice is that a number of factors there associated with having a severe and enduring mental illness are also factors that are associated with having poorer outcomes with Covid-19.
What that means, is that actually people with severe, and enduring mental illness are actually a really high risk group for the effects of Covid-19, not just the immediate effects of the disease, i.e.; more likely to experience the adverse outcomes of the disease itself and death, but also. the aftermath of the disease. Because we know that unfortunately, Covid-19 has been associated with economic decline and recession, and those people who are already so to disadvantaged are going to have the worst outcome to the results of that recession. So what it means is that we have to be aware of the fact that people would SMI are those people who have real…
those people who are really at high risk of the impact of Covid-19 because of SMI itself, because they are much more likely to be socially disadvantaged, and because they are more likely to be from a BAME background.

Dr. Smith has just explained how severe and enduring mental illness (SMI) make some members of our societies especially vulnerable at the moment. Let’s think more about the risk to this group and what we can do to help.

In Week 1, some of you expressed concerns that Kevin might become so low he would consider harming himself.

Remember in the previous steps that we talked about what happens when we experience heightened emotional states?

Our attention narrows, the idea of “later or tomorrow” goes out the window, and therefore so does the idea that “this mood will pass”. We lose the ability to have some psychological distance from our current state of mind.

This is one reason why sleep deprivation and substance misuse are associated with self-harm: perspective and inhibition are impaired. Kevin is thankfully not at this stage currently. But others are.

Alongside the risks from the socioeconomic and physical health stressors that Dr. Smith described, individuals with SMI are also more vulnerable in this respect. Services and organisations play a key role in the care of these individuals, but some of what has helped Kevin with his depression will be especially important for more vulnerable individuals with SMI.

Do you recall how Kevin has things written down from his service?

This may seem like a small thing, but often people keep important numbers pinned somewhere where they can see them easily. This is helpful when we are attempting to implement any new behaviour, whenever we know we might be pulled toward old habits.

We make use of our surroundings, almost like an extension of our minds, in the way that we store phone numbers rather than trying to remember them. This is especially important when we are overwhelmed. Therapy offers this also – we have available another mind, or several other minds to assist our own.

More formally in mental health services, particularly when thinking about people with SMI, we refer to the joined-up thinking that can support a vulnerable individual as a care plan or a crisis plan. Now will be the time to ensure that such individuals have an updated version of their care plan. This should ideally involve their friends and family, or others in their network, as well as professionals who are important in their care with specific plans or actions to do when in crisis.

In clinical work, case-based discussions are a common way that professionals come together to think about individuals. Below, Dr. Stubley draws on two case studies to illustrate why, for individuals with severe mental health difficulties, the current context can really exacerbate their conditions, and why we really need to have individuals and services linked and thinking together.

This is an additional video, hosted on YouTube.

Download Transcript of Jo Stubley on severe mental health difficulties (right click or tap/hold and open in new tab)

You will appreciate, as we describe the impact of the current situation on individuals with PTSD and SMI, that many of the methods for staying well that we have described so far will not work alone.

For many individuals who are unwell in this way, what they need to do individually to cope is so entwined with what services need to do to assist them that it is unhelpful to separate the two.

For some of these individuals, a capacity to engage in strategies to stay well will be closely linked to ongoing input and support – we will, therefore, revisit this group of individuals when we discuss therapy settings and the concept of containment in the coming steps.

This step has included especially emotive content – please take a break if you need to.
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COVID-19: Psychological Impact, Wellbeing and Mental Health

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