Abstract
Since the earliest times, pandemics have had the capacity to terrify populations and have been associated in the public mind with catastrophes wreaked on the innocent by outside forces. Whether characterised by Old Testament legends of plagues of frogs, lice, boils and locusts or the more modern visitations of cholera, typhoid, influenza, Ebola and COVID-19, the sense of helplessness in the face the potential speed of their impact has brought people face-to-face with their own insignificance compared with the natural forces of the cosmos.
Despite the wonders of modern science and the prospect of vaccines, this sense of impotence still persists and can be manifested not only by the magical over-dependence on instant nostrums but also in its obverse to be found in the flat-earther science deniers.
Casualties of these fixations are to be found in the neglect of the collateral damage resulting from a narrow view of the impacts of a threat such as the Coronavirus responsible for COVID-19, which extend from the neglect of other important medical and surgical interventions to the potentially massive impact of the pandemic on population mental health. So far we have only had a glimpse of this potential impact but as the tsunami of death recedes in the months ahead, the long-term burden of mental and physical sequelae begins to loom into view.
During the early days of the pandemic in 2020, concerns were expressed in the popular media about the prospect of an increase in suicide rates among those affected in one way or another by the Coronavirus. Initially, Louis Appleby, the joint chair of the National Suicide Prevention Strategy Advisory Group for England, was at pains to play down such prospects, perhaps in part because he has always been concerned not to fan the flames of suicide outbreaks arising from sensational publicity. However, Appleby and his colleagues have recently published a review of the current situation, which indicates that matters may be more subtle than was initially thought. 1
The received wisdom on the epidemiology dating back to the classic work of Emile Durkheim in the 19th century holds that war and other external threats to the population reduce suicide through greater social and political integration and solidarity.2,3 In recent times, this hypothesis has been questioned in part by reference to the Northern Ireland experience during the ‘Troubles’, where claims of reduced suicide rates during the period of political violence and widespread murder do not appear to be a consistent finding; broadly speaking, suicide rates were higher when conflict deaths were lower, but there was also a period in the early years when conflict deaths rose sharply while suicide deaths went down. 4
In their recent BMJ paper, Pirkis et al., who have been tracking and reviewing the evidence linking suicide to the COVID-19 pandemic, raise a number of caveats to drawing early conclusions, suggesting that changes in the risk of suicide with COVID-19 may be dynamic. 1 Certainly it would seem that the social solidarity that was such a feature of the first COVID-19 lockdown, and which Durkheim might have predicted to be protective of population mental health, does not appear to have been sustained in the more recent lockdowns which have been characterised by a fraying of trust with government and authority and increasing public unwillingness to follow official guidance and instruction.
Notwithstanding the extreme COVID-19 mental health outcome of death by suicide, we must now begin to prepare for the wider range of longer-term physical and mental health consequences. Quite apart from the direct potential long-term effect of the Coronavirus on the brain, reminding us of the Parkinson’s disease legacy of the Spanish flu of 1918/19, there are likely to have been widespread effects on the general population that have played to premorbid predispositions such as obsessive compulsive disorders, a range of phobias, diffuse anxiety and post-traumatic states and paranoid tendencies.
The collateral damage on individuals, families, workforces and communities through the economic impact is yet to be fully felt and the impact on both NHS staff and the services they have endeavoured so hard to maintain during the crisis has yet to be made explicit.5,6
In recent years, there has been an increasing emphasis on achieving parity between physical and mental health services. 7 This agenda has struggled during the pandemic and it is unlikely that more of the same will deliver what is needed rather than a comprehensive approach to protecting and restoring population mental health.