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For Primary Care| View from the ground

Distress Isn't Always Mental Illness

View From the Ground, by Dr Emma Nash

Doctor, I’m struggling to cope.’ It’s a phrase that we’re increasingly hearing from the other end of the phone. Without the visual cues of face to face, much more dialogue is needed to work out what is going on and what ‘not coping’ really means for that person. Reduction in face-to-face contact is just one aspect of the effects of COVID-19 for clinicians, but for our patients, the consequences are broader. Few would disagree that mental health difficulties are more than ‘a fault with neurotransmitters’. The psychological and social components are significant, and COVID-19 brings them in bucket loads.

My experience has been that anxiety predominates, due to a multitude of factors: fear for the health of loved ones, the potential consequences of relaxation of restrictions, financial implications due to work changes, and the effects of social isolation are some of the most common. I am a GP with a particular interest in mental health, and the GP lead for mental health for two CCGs, so mental wellbeing has never been far from my mind during the COVID-19 pandemic. Of course for some people, the reductions in demands for interaction and activity have been a blessing, but these are the ones who now seem most troubled as life edges a little closer back to normality.

As doctors, our overwhelming desire is to help. However, in doing so, we may potentially medicalise normality, and this must be avoided. Applying labels of depression, anxiety, or post-traumatic stress disorder (PTSD) may facilitate our desire to ‘do something’ as we have evidence-based guidelines to follow and licensed medications to offer. Actually, in many cases, what is needed is an explanation that what the person is feeling is normal. Reassurance that it will subside, signposting to third-sector organisations such as Mind and Anxiety UK, who have COVID-19-specific advice, and involvement of social prescribers are all strategies that can be used to help manage the distress. Distress and mental illness are not the same thing, although the former can exist as part of the latter. Distress should not be mislabelled as illness, but illness should be recognised. Although we should be cautious in the application of psychiatric diagnoses—not least because of potential future implications for work and insurance—failure to identify pathology can be very damaging.

I have heard many informal comments about people having PTSD due to COVID-19. However, if you carefully examine the experience they’ve had and consider how you or others might respond, PTSD may not be the appropriate diagnosis here. Acute stress reactions or adjustment disorders may be present, but the diagnosis of PTSD is very clearly set out in both DSM-V and ICD-11. The latter has a requisite of ‘exposure to an extremely threatening or horrific event or series of events’.1 Re-experiencing, avoidance behaviours, and persistent hypervigilance are present. Most of the patients who are struggling due to COVID-19 have a normal reaction, not psychopathology. This is not to say that as doctors we don’t have a role. Recognising normality has always been a key component of general practice, and articulating this, with active listening and a healthy dose of empathy, can go a long way. Living through such a dramatic and persistent life event, alongside the withdrawal of common coping strategies such as exercise, socialising, and recreation, is tough for most people.

As a mother, wife, and daughter, I have found COVID-19 tough and distressing at times. The loss of support from my parents, the changes to my working hours, and the impact on my children of schooling including the guilt that goes with their attendance at ‘key-worker school’ have all been hard to bear. Few of us have escaped unscathed, and it’s understandable that people are struggling; the mantra ‘it’s okay to not be okay’ absolutely applies here, and to all of us.

Dr Emma Nash

GP and CCG lead for mental health, Hampshire