Iâm not going to add to the huge number of people whoâve commented on the impact of the Covid-19 pandemic, and the public health measures that resulted, on mental health. I donât have data, and there are a lot of people more qualified to talk about it, as a general proposition, than I am.
Iâm going to talk about something that only I am qualified to talk about, even if its value in learning about the more general situation is limited. Iâm going to talk about me.
I have a severe and enduring mental health condition, albeit a more âmildâ sort than others (though perhaps better terms might be âsubtleâ, âeasy to concealâ, or, as may become evident, âinsidiousâ). Several years ago (I forget how long, though it was certainly after I completed my bachelorâs degree, and that was 2007), I was diagnosed with bipolar 2 disorder. Before that, Iâd been diagnosed with depression, with various qualifiers â ârecurrentâ being one of the most common.
For the benefit of those less familiar with mental health terminology, bipolar disorder is, in many ways, a spectrum condition. Also known as âbipolar affective disorderâ, it is a mood disorder â as is depression; âaffectiveâ in fact means ârelated to mood/emotionâ. It is characterised by episodes informally referred to as âupâ and âdownâ. The âdownâ episodes are depressive episodes, with the same sort of symptoms one would expect from depression, but being episodes they often end fairly spontaneously, and may start spontaneously as well as in reaction to circumstance. The âupâ episodes are more complicated, and less familiar to most people.
(I would also note that âdepressionâ and âdepressedâ have become overused terms in everyday speech, and sometimes even in medical contexts, but that is a subject for another day.)
The âupâ episodes come in two forms, manic and hypomanic. The difference between mania and hypomania is partly one of degree, in that the features they have in common are more extreme in mania than in hypomania. There is also a qualitative difference, in that mania tends to have features that arenât present in hypomania. For instance, mania can include psychotic features â beliefs at odds with the world in general, paranoid thoughts, hallucinations, to give the classic examples. However, the difference according to some authorities is primarily that mania tends to be such that one might consider hospitalisation, while hypomania doesnât.
Hereâs where the â2â in âbipolar 2 disorderâ comes in. There are two diagnoses for bipolar disorder itself; bipolar 1 disorder, and bipolar 2 disorder. People with bipolar 1 disorder have had at least one episode of mania, while those with bipolar 2 disorder have had at least one episode of hypomania, but no mania. Both can also have âmixed featuresâ episodes, which are episodes of altered mood that have elements of both depression and hypomania/mania, as Iâll describe further shortly.
Diagnoses of bipolar 1 frequently occur during or following a first episode of mania, often while a person is hospitalised. Diagnoses of bipolar 2 are harder to make â hypomania is not always obvious, so it can just look like a person keeps getting depression and mostly recovering, over and over again â and even when they are made, they are permanently provisional. I could have a first episode of mania any time, and then my diagnosis would change. I really hope that doesnât happen.
Mixed features episodes make things even more complicated. Theyâre basically just what they say on the tin â episodes where you have features of depression, and features of mania/hypomania. The easiest example to imagine is where you have the low mood, poor motivation and diminished self-worth that is common with depression, coupled with the agitation and racing thoughts of hypomania. Hypomania or mania can include something called grandiosity, a view of oneself as special, better than others, more capable than others. It can, but doesnât always, lead to treating other people disdainfully. It can lead one to think that one has little in common with others, that you can only be understood by a few, special people.
One way Iâve seen this personally, though not in myself, is people who are genuinely exceptionally intelligent who develop the view that only people of similar intelligence â a group they think is much smaller than it really is â can really understand them (fairly common in grandiosity associated with narcissistic personality disorder, less so with hypomania), and that it is pointless or demeaning to interact with people who are less intelligent. In a mixed features episode, that can tie in to low mood by creating a sense of isolation, even though the isolation is brought on only by your own distorted view of yourself and the world.
Sometimes such episodes can even seem contradictory, with both diminished self-worth and an inflated sense of your own capabilities or specialness as found in grandiosity. That version I know well, because my hypomania often includes elements of grandiosity (though usually in a relatively pro-social way â I must use my special capabilities to benefit others, and without disdain for âless specialâ people), and my depression almost always includes low self-worth (not the same thing as low self-esteem, but Iâll save the difference between the two for another post).
I donât have solid empirical data about the circumstances that lead to diagnosis of bipolar 2, so I canât say what is most common or least common, and what I say is, Iâm sure, not exhaustive, but there are a few situations which seem to be common enough situations that make doctors look at it and potentially diagnose. The diagnosis can be very helpful, because there are treatments â pharmaceutical and otherwise â that are specific to bipolar, treating it as you would depression can be counterproductive, and even just knowing about the pattern and possibilities can make it easier to live your life. Some people are diagnosed after reading about it, seeing the description of hypomania, and feeling like it seems very familiar. Some might be having some form of analytical or cognitive therapy that leads to identifying potentially problematic âupâ patterns as well as âdownâ patterns (which is what happened to me). Occasionally, a doctor or mental health professional might notice an unusual response to starting anti-depressant treatment, which is indicative of bipolar disorder, though that doesnât seem to happen as much; if people were more on the lookout for this, I might have been diagnosed correctly at 16.
This unusual response is why treating bipolar as you would depression can be counterproductive â antidepressants tend to increase the frequency of episodes, often but not always reducing their duration, and particularly triggering hypomanic or manic episodes. It is not uncommon for a person with undiagnosed bipolar disorder to be started on antidepressants and to have what appears to be a remarkably quick and pronounced positive response to the treatment. Thatâs because a hypomanic episode has been triggered by starting the meds. Mood stabilisers â many of which were originally developed to treat other conditions, including anti-epileptic and antipsychotic medications â reduce the frequency and severity of episodes, and if a person tends to the depressive or has a more dysthymic (low mood) base state, sometimes antidepressants are used as well.
I was diagnosed with bipolar 2 years ago, but I wasnât given mood stabilisers. I was even left on antidepressants. This wasnât a result of poor care. It was, really, a good example of early shared decision making â I have a high number of comorbidities, and was managing quite well at the time with support from my wife (we werenât married at the time, but Iâm going to keep it simple and just call her my wife in any case). The other meds I was taking made adding another more risky. The psychiatrist and I discussed all of this and came to a decision together not to add in a mood stabiliser at the time. As to non-pharmaceutical treatment, I donât know if any was on offer for community patients in my area at the time, but I wasnât offered any.
So, thereâs the key background. One more bit of pre-pandemic background I need to cover so you can understand whatâs happened to me in the last couple of years. For a few years now Iâve had occasional exacerbations of my mental health that werenât the âusualâ hypomanic or depressive episodes. They were mainly anxiety, and very debilitating, but usually restricted to one part of my life. I would be behind on some sort of commitment, usually voluntary, and the whole part of my life that that commitment was connected to would become a massive font of anxiety. It would eventually get better, and Iâd catch up on the work or not. Mostly this has happened in relation to Quaker voluntary commitments, but I think thatâs just because Iâve had so many of them.
So, we come to the pandemic. There were rumblings of something going on towards the end of 2019, and, gradually, confirmed cases were showing up everywhere. The potential seriousness of infection with SARS-CoV-2, the severity of the symptoms of Covid-19, became clearer and clearer. England went into âlockdownâ on the 23rd of March 2020, a little more than two years ago. It seems much longer ago, in some ways, and much more recent in others. Due to treatment for other health conditions, I was put on the âshieldingâ list (an overabundance of caution, in my opinion, but I wasnât going to take chances my specialists said I shouldnât). I barely left the flat for months, just for medical appointments. My wife, whose physical mobility is more limited than mine, had to do all errands out.
(The fact that she had to do so may have had some insidious negative impact in itself, of course - it was physically and psychologically challenging for her, so she had less ability to care for me. She was less able to notice that I was acting differently, and even when she did she was less able to do anything constructive about it. This is not her fault, however much she might feel guilt over it - the circumstances were forced upon us, and even if she werenât also physically and mentally limited the extra burdens would have impacted her in a similar way, if less severely.)
Oddly enough, I donât really feel like that bothered me. I certainly donât think it was a trigger for the mental health decline that Iâm about to describe. I consider myself what some call an âambivertâ, neither introvert or extravert, but rather one who enjoys company but can happily do without it â and in any case, I wasnât totally isolated, I still had my wife, and I still had the internet. You see, I wasnât actually having that much contact outside the home for a little while before the pandemic began.
This is partly why I donât think the pandemic, lockdown or shielding was much of a trigger. I think, rather, that it provided a cover, a way of not noticing how things were going. We had moved home in the summer of 2019, and that reduced in-person contact a bit. I was rarely going to Quaker Meeting for Worship, having previously lived around the corner from the Meeting House and now living far enough that, for me, there was no choice but to get a bus (or a taxi, or a lift, though both of those are awkward with a rollator). So I didnât go very often. My contact with other people in person had never been that frequent, but at that stage I was still volunteering at a local intercepted food club, and I still had in-person meetings for Quaker volunteer roles.
The intercepted food club stopped, of course. It has begun again now, and I hope to get involved again. I feel behind in some of my Quaker voluntary work, and that started my usual spiral, or so it seemed to me. I think, in hindsight, there had been some slippage in mental stability since the move in summer 2019. I donât know why, but moving home is often described as one of the most stressful things people experience, so I guess that it would make sense.
Anyway, my anxiety around Quaker things grew. And then, unusually for me, it spread. It reached out into other parts of my life. My main paid work was just about the only thing unaffected. I stopped coping properly with personal administration, not responding to mail, not picking up voicemail, scared to answer the phone. I jumped at everything. My sleep became awful, which is something for someone with narcolepsy.
In the end I was convinced to reach out for help. My GP gave me some short-term anxiety meds, and urged me to contact the local IAPT service (âImproving Access to Psychological Therapiesâ, a category of NHS service commissioned in all areas of England, though details differ, they provide basic psychological therapies like CBT, and sometimes more). I had an assessment call with the IAPT service, and they noted that I had a bipolar diagnosis but had never had any specific treatment. They offered a programme specifically for bipolar, and thought it might be appropriate, but it was only available to people currently under the care of community secondary care mental health services (known here, as in most areas of England, as the âcommunity mental health teamâ, or CMHT), so they referred me across to the CMHT, mostly so they could put me on the list so I could have therapy from the IAPT service.
I had a call from the START team (they call themselves that, though it is redundant, START standing for âspecialist triage and referral teamâ), who screen and triage CMHT referrals, sometimes diverting to other teams. They booked me in for an assessment call. Then they phoned back saying âuh, I just read your file, donât worry about the assessment call, weâll be recommending your referral go aheadâ.
I do wonder what the file saidâŠ
I ended up under the care of the CMHT, was assigned a psychiatric nurse as care coordinator, saw a psychiatrist, was prescribed a mood stabiliser. While this was happening I was diagnosed with ADHD, following a long wait from referral to assessment (more on which is to come in a later post). I was offered talking treatments from both services at the same time, and you canât be doing two at the same time from different services, so I had to choose, and did the ADHD psychoeducation course first â thinking that it might be helpful for the bipolar course. Iâm now waiting for the bipolar course. The whole time Iâve also had support from my care coordinator in terms of strategies for coping with the anxiety.
Anyway, so far so rambling (but I hope informative). Now I want to look back, even if the journey isnât complete (Iâm still far from back at baseline-for-me levels of function), and see what I have learned â and so, what other people can learn from my difficult experience.
Firstly, bipolar disorder isnât just about depressive and hypomanic/manic episodes. Anxiety is a big part of it for a lot of people, and, apparently, not always associated with obvious âupâ or âdownâ moods. While the anxiety got me down, when I managed it by avoiding all the things that triggered it (which was not practical, as so much triggered it), I didnât feel so bad. Until I thought about how restricted I was, anyway. This has just been a long, long period of heightened anxiety, that feeds on itself until I break the cycle. Iâve had depressive and hypomanic episodes during it, but they didnât really affect the anxiety so much. Hypomanic episodes sometimes make it easier to face the anxiety, but sometimes make it harder. Depressive episodes can reduce the sharpness of the anxiety, along with other emotions, or can feed off the anxiety such that the anxiety becomes a focus of the negative feelings of depression.
Another major lesson is that circumstances can have much more complex impacts on mental health than just triggering or exacerbating problems. They can also hide the early signs. The restrictions of lockdown and shielding meant that my anxieties, that Iâm sure were already building, werenât obvious. I felt fine at home, didnât even have to think about going out, and was managing to keep getting stuff done for a while. If it werenât for the pandemic, I honestly believe that the crisis point might have come much sooner.
Itâs the old fallacy, post hoc ergo propter hoc â after it, therefore because of it. Itâs a form a reasoning that is not generally true â just because B follows A, it doesnât mean A causes B. A less pretentious way of saying it, without resorting to dead languages the use of which is associated with social elites, is âcorrelation does not imply causationâ, though even in that case âimplyâ is used in a technical sense, not the everyday sense. In this case, just because my crisis happened during the pandemic, it doesnât mean it was caused by it, or even necessarily exacerbated by it.
The most important lesson, though, is one that is perhaps most important for clinicians and commissioners. In my experience, people with long-term conditions that are variable, or have a relapsing-remitting course â including those with symptom âflaresâ â are often left to judge for themselves when they should tell a doctor about a particularly bad time. There are plenty of physical conditions that fit this description, including many autoimmune conditions, fibromyalgia and ME/CFS. Itâs also inherent in bipolar disorder, and a common pattern even with good pharmaceutical treatment in schizophrenia.
A patient, once they are used to the condition, is largely left to themselves, learns to manage things, and only even lets a doctor know about a flare or relapse if it is beyond what they feel able to manage themselves â if they think they need, or would benefit from, extra treatment (even if it isnât actually available â though if that happens a lot they wonât bother telling doctors about even a bad flare). For physical conditions, this works reasonably well â a person who is mentally largely the same as ever, except perhaps more fatigued, and low in mood as a consequence of physical symptoms, but who is in a lot more pain, or loses full use of a part of their body, or so on, probably will realise that the situation has gotten worse, and go to a doctor about it. Well, maybe not âprobablyâ on going to the doctor, but thereâs a decent chance. Most importantly, the condition itself doesnât usually impact their ability to do so.
A person with a mental health condition of this sort, as in bipolar disorder or schizophrenia, among others, is a whole other matter. The very nature of the relapse or variation is such that we are less likely to realise thereâs a problem, or less able to do something about it. If it werenât for my wife, or indeed the people I was working with in volunteer roles (though they might be fobbed off more easily), I donât know how long it would have taken me to seek help. Iâm not sure if I ever would have done, until perhaps I did something that brought me to the attention of health services who would then wonder why I didnât get help sooner.
I wouldnât have gotten help sooner because I couldnât face the prospect of contacting people to get help. I didnât get help as soon as there was a problem because it wasnât obvious. I got help when I did because my wife, and a few others, all but forced me to â and Iâm glad they did.
Perhaps, as a matter of policy, itâs not such a good idea to wait for people with severe and enduring mental health conditions to let you know things are getting bad. Yet that is what happens in most cases. Even people with schizophrenia are often discharged by secondary mental healthcare services once they are relatively âstableâ, have been on a set dose of medication for a while, not having had relapses and without positive or negative symptoms that are having a major impact on them. Most people Iâve known who had ongoing CMHT contact once they were âstable on medicationâ were those for whom it had been decided the best course was to have medication by depot injection, for example due to poor compliance. They see someone every time they have their depot done, and thereâs often a brief check â fairly superficially â to see if thereâs any problems brewing.
I donât know whether this policy is a result of principle â which I can see some arguments for â or a result of cost-saving. But perhaps, in terms of value for money (and maybe in terms of total costs, given the greater resources needed if a relapse isnât caught early), it would be best not to discharge us. We should stay under CMHT care, with infrequent proactive contact, and still have an allocated care coordinator. When care is being more active, we develop relationships with our care coordinators, and usually positive ones. If we know we can get in touch with someone who knows us and our problems, that makes it less daunting to reach out when we start to have some greater difficulty.
Some time after my referral, for reasons not related to my own care, I learned that the START team, in their role as a single point of access (which was actually what they used to be called) actually accept referrals that donât come from clinicians. Not only can people self-refer, but carers and relatives can âreferâ someone into the service. For those of us fortunate enough to have someone close to us who can spot when things are going downhill, this could be very useful, provided that the reaction leads to joined-up care making use of existing records, and especially provided that people actually know about it. My wife was never going to make contact with them, with or without my knowledge, when she didnât even know it was possible. It could be made even easier, if it didnât require a phone call â a simple web form would be ideal. It would be even better if she could do the same with the CMHT while I am under their care, so it doesnât rely on me to tell them if things get worse again.
I donât set healthcare policy, and maybe Iâm not qualified to do so even if I had the opportunity. I think I am qualified to comment on it, though, and I do think that people who do set policy should have a good think about this. The disruption to a personâs life when they have a major crisis â suicide attempts, breakthrough active psychosis, acute mania, debilitating anxiety â is huge. The disruption to their loved ones is huge. The disruption to their neighbours or colleagues can be pretty huge. And the work by health services to bring things back under control are pretty huge. An ounce of prevention is worth a pound of cure, as the saying goes (some attribute this to Benjamin Franklin, but Iâm sure the sentiment predates him by a long way). Perhaps more proactive prevention would lead to better outcomes without the costs being disproportionate. Perhaps mental health teams should be adequately resourced and managed to help us, people with severe and enduring mental health conditions, to need less care.
Thatâs not my call, but thatâs what I think.