Psychiatrist Dr Martina Di Simplicio shares insights into how the coronavirus pandemic is changing the landscape of mental health.

Dr Martina Di Simplicio is a Clinical Senior Lecturer in Psychiatry at the Department of Brain Sciences, Imperial College London, and an Honorary Consultant Psychiatrist at the West London NHS Trust. Dr Simplicio’s research centres on mood instability and the role of cognition in mood swings and behaviour. Her work also focusses on using mental imagery to improve mood instability and translating these interventions into digital applications. 

We spoke to Dr Simplicio about her experience so far of working in a community mental health facility during the lockdown, and how she envisages the coronavirus pandemic will impact mental health in the coming months and years. 

How have you seen your day-to-day work as a psychiatrist change during the coronavirus pandemic? 

Initially, work within our community practice changed because all of our routine work was interrupted. Lots of staff were getting ill and we weren’t able to provide our normal services and support; we also couldn’t see people face-to-face. Everything had to be transformed and we had to switch our focus to providing emergency mental health care. Generally speaking, I think that people who previously received regular support from mental health teams probably haven’t had that kind of contact since the lockdown.  

At the moment, the volume of cases is lower than it would be normally, as those who would visit A&E with acute mental health problems are now worried about going to hospital. We’ve heard reports in the media about people not seeking help for non-COVID related physical health problems, and I think the same is probably true of people and their mental health right now. There’s a sense that it’s not a priority in the context of the pandemic, and there's fear about reaching out. 

We can’t be sure yet if there has been an increase in anxiety or depression or other mental health symptoms, but we believe that there probably will be. The lockdown has made it harder to access the typical support mechanisms and this will have an impact. The mental health community expect there to be quite a big rise in

"The mental health community expect there to be quite a big rise in mental health problems in the future months, and if not years." Dr Martina Di Simplicio

mental health problems in the future months, and if not years. Some of this will be a consequence of the socioeconomic aspects of the pandemic rather than the pandemic per se. However, we don’t know whether there is something about the virus itself - for instance, its impact on inflammation in the body - which might, in turn, affect the brain and mental health. These are all things that we will need to research. 

Why is it that living in lockdown, or living in the context of a pandemic, can trigger certain mental health conditions? 

With depression, our mind starts experiencing what’s called negativity bias. We are more likely to remember negative things and to start paying attention to negative cues in our environment. A lot of interventions that help people recover from depression – for instance, antidepressants or cognitive behavioural therapy (CBT) – will try and shift these negative biases and thought patterns. 

In a lockdown situation, you’re experiencing much less social contact, and all you hear is negative news about the pandemic. It makes it much harder to see positive cues, and if you’re already dealing with depression it will be much harder to get out of this mindset. It also makes it more likely that you will fall into a depressive state and dwell on negative thoughts (ruminate). At the moment, we’re less able to engage in distracting activities or see the people that might usually distract us, whether at work or socially. Therefore, we're left alone with our thoughts more often.  

Living in a pandemic also amplifies our feelings of uncertainty: we don’t know what will happen and we don’t feel like anything is under our control. This is exactly how anxiety operates. If someone is already anxious, this context will likely intensify their sense of uncertainty to the maximum.

What kind of support do you think needs to be offered to vulnerable groups in our society whose mental health may be more acutely affected by this pandemic? 

We will need to offer specialised support to groups that we expect to be more vulnerable, like front-line workers, homeless people, children and young people and older adults. I think we'll need to engage with existing interventions that we know work, but at the same time research new and different approaches that are specific to the context of the pandemic. We'll need to be very flexible in adapting our approaches.  

Front-line workers are likely to have experienced a lot of traumatic situations. We can draw on research from similar contexts, for instance, soldiers and veterans who have post-traumatic stress disorder (PTSD). However, we don’t yet know how these specific circumstances might change things, as a nurse’s experience of working in a COVID ward will be very different from the experiences of a soldier. A lot is going on already to try and understand how to best help front-line workers. There are interventions that we know we can apply, but we also need to understand the specifics of this situation to create effective approaches. 

You work closely with young people – have you found that the pandemic is affecting their mental health differently compared to adults? 

This is a really important question, but the honest answer is that we don’t yet know. We know that young people, particularly adolescents, rely a lot on connections with their peers. Adolescent brain development is strongly influenced by increased social connections with other young people. We’re not sure what the impact of the current situation will be, where you have young people suddenly cut-off from having face-to-face interactions with their friends. Research in animals has shown that if you deprive an adolescent animal of social interaction, it will negatively impact brain development and behaviour. Of course, we don’t know if the same would apply to young people in lockdown.  

Another way to look at it is that children and young adults are now very connected on a digital level, and that could be helpful in the current circumstances. Equally, this could mean that young people who are already vulnerable in this setting could become even more so, for instance in terms of being bullied online. 

What do you think the landscape of mental health will look like when lockdown ends? 

"The risk is that the mental health burden will become more acute and more complex, and more resources and funding will be needed in an already resource-poor period."   Dr Martina Di Simplicio

I think lockdown and the pandemic will make those who are already vulnerable even more vulnerable. Mental health services have been underfunded for years, as has mental health research. As it’s likely we’ll be falling into an economic recession, this will probably get worse. The risk is that the mental health burden will become more acute and more complex, and more resources and funding will be needed in an already resource-poor period.  

It seems likely that there won’t be enough support for those who are already more vulnerable than most, for instance, refugees, homeless people, and people with a history of trauma. Right now, a phone call from a mental health team might be the only contact these individuals have; the only support network they have. We will need to be vigilant and make sure that we look after these people even more. We’ve heard how the lockdown might have made some vulnerabilities even more acute, for instance with the loss of community spaces, so we will need to be even more targeted with our interventions in the coming months and years. 

Can you offer any coping strategies to help protect our mental health during this time? 

One of the difficult things about living through a pandemic is that there is a lot that we can’t control and a lot of uncertainty. So, I would say that one of the first strategies to use is to focus on dealing with what we can control. We should try to focus our attention on the small things that we can influence, and not try to do all the things that we were doing in our lives before the lockdown.  

As we’ve discussed, we’re more physically alone now and spending a lot more time inside, which can mean we tend to get stuck in our own thoughts. A way of getting out of that is to engage with things that are very practical and sensory, for instance going out and spending time in nature. If you can’t go out, you can try and do things in your home that are more sensory-based, for example, cooking. 

Another thing that comes to mind is optimism: we know from previous research that being optimistic (as much as one can in this context) is generally a protective factor. People who are a bit more optimistic and can think positively about the future have greater resilience against mental health issues. To this end, try to imagine every day something positive about a controllable aspect of your life. It might just be imagining that nice walk that you’ll take at the end of the day, or thinking about catching up with a friend over the phone. These are small things, but I think that they can make a difference.  

Support and resources at Imperial

• All College staff and members of their family living with them can get free professional and confidential help from Confidential Care, the College's Employee Assistance Provider, 24 hours a day, 7 days a week.
• The College also provides a Counselling and Mental Health Advice Service for students, which is currently operating remotely.
• Imperial's network of Mental Health First Aiders are also working remotely and can help to facilitate a confidential conversation about your mental health and signpost you to the most appropriate support.