scientists share unique insights into mental health presentation … · 2020-06-18 · ieso digital...

Scientists share unique insights into mental health presentation of patients during COVID-19 lockdown Written by Dr Ana Catarino

Ieso Digital Health | 2 iesohealth.com

Dr Ana Catarino, Principal Scientist at Ieso, interprets mental health data during

Covid-19 from 4,368 patients presenting to a primary care IAPT service and shares

her insights into referral numbers, clinical presentation and worry themes.

It is accepted in the psychological community that the Covid-19 pandemic will cause

mental health issues for a huge number of people, with recovery and treatment

further compounded by social distancing. The scale and complexity mean that this

is an unprecedented situation and as such we have no model to accurately predict

the scale and severity on individual and national mental health. Questions the field

have been asking are:

• How will COVID-19 affect people’s mental health?

• How many more people will need mental health treatment due to COVID-19?

• When will we start to see increases in referrals?

• What will be the impact of people delaying before accessing mental

health treatment?

Ieso Digital Health provides online CBT (cognitive behavioural therapy) as part of

the NHS IAPT programme. Patients and therapists communicate through typed

communication, creating a unique dataset that can provide insight into what is

happening to our NHS psychological therapy patients. We will share the insights

from this dataset on a regular basis during this period to aid understanding of the

mental health impact of Covid-19 and lockdown in the UK with the mental health

community. In this first white paper we looked at changes in absolute referrals, and

the types of worry that patients are describing on presentation to our service.

The Covid-19 situation is unique when compared to other disasters, since it is not

a discrete point in time, but something that is prolonged over several weeks and

months, causing trauma exposure at a global scale at various levels. There are vast

and compounding sets of triggers for mental health issues. You have people who

become ill and spend time in hospital without support from loved ones. You have

their family members at home alone, unable to be there for their dying relatives. You

have people who die from non-Covid causes and families unable to attend funerals.

There are people who are at high-risk who have to live for weeks in a state of

hyper-vigilance, constantly thinking they are going to get ill and die. You have

hospital staff and undertakers seeing thousands of bodies awaiting disposal

with no hope of giving them and their families the usual levels of respect and

time. The list goes on. To think that these issues are affecting the population as a

whole is a very daunting and unprecedented situation in terms of compounded

psychological stressors.

Reasons behind the expectation of a surge in mental health issues


Compounding this situation is the lack of ability for people suffering from anxiety

and depression to return to anything that remotely resembles “normal life”, which is

usually the primary path to recovery. An ideal mental health response to disasters

and critical incidents1 means providing a sense of normality and continuity of life

in the immediate aftermath of a critical incident, as psychological first aid. In the

immediate aftermath of disasters, people need continuity of normal life, and to spend

time with others. Successful management of a critical incident depends on the ability

to ensure that the incident does not destroy a person’s society. With social distancing

measures looking likely to continue for some time, this isn’t possible.

We saw a significant increase in referrals to our internet enabled talking therapy

service in the weeks leading up to and after lockdown started in the UK. Referrals

in the weeks leading up to lockdown hovered around 350-370 patients per week.

This jumped to 653 the week that lockdown commenced. These results suggest that

mental health services are turning to digital delivery to help them cope with changes

in how services are operating during lockdown and reduced capacity.

Following an initial surge in patient demand, we have only seen a gradual and slight

increase in referral numbers (figure 1). This raises serious concerns about the long

term impact of the current crisis on the mental health of the population. Given the

circumstances, we would expect far greater numbers of patients at this time.

Referrals to internet enabled talking therapy


This indicates that people are dealing with increased pressures related to the

Covid-19 crisis and lockdown measures and are not in a position where they can

address any difficulties they may be experiencing with their mental health. This

lack of health-seeking behaviour is suggestive of a delayed onset response that

has been observed in other critical incidents2. This type of psychological response

to a traumatic incident is characterised by mild symptoms in the immediate

aftermath of the event, which become more severe with time. More concerning is

the evidence suggesting that in these cases, early psychological interventions are

key in supporting good clinical outcomes for exposed individuals3. We suspect this

will lead to a rebound effect, where mental health difficulties increase as lockdown

measures are lifted but life does not necessarily go back to normal for some time.

The dip we see around Easter is explained by unrelated factors, such as fewer service

referrals coming in due to bank holidays, as well as a well-observed effect of fewer

people self-referring to the service around important holidays such as Christmas,

New Year and Easter.

20% to 30% of our patients are mentioning Covid-19 when describing the mental

health difficulties they are experiencing and the reasons bringing them to therapy

(figure 2). While this does not necessarily indicate that 20% to 30% of patients are

having mental health difficulties caused by the Covid-19 crisis, it clearly suggests

a significant impact of Covid-19 on patients presenting with mental illness.

Patients’ clinical presentation

Figure 1

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Figure 2 – Increase in percentage of self-assessment questionnaires mentioning Covid-19 related words with

time, for the first quarter of 2020.

During March 2020 we observed a significant increase in worries about viruses,

including coronavirus and Covid-19 (figure 3). Approximately 15% of worries

in therapy sessions in March were about viruses, coronavirus or Covid-19.

Surprisingly, the 40% of worries about family and 5% of worries about finance

have so far remained stable. We can’t be certain why, but perhaps this lack

of change in level could be caused by delayed onset of financial and family

worries, dual presentations compounding worries, or financial worries paling into

significance versus other Covid-related worries.

Worry themes in therapy

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Percentage of self-assessment questionnaires mentioning Covid-19 related words


Figure 3 – Percentage of different worry themes in therapy sessions mentioning worries, across time, for the

first quarter of 2020.

Given the global scale of the Covid-19 crisis, it is likely in the next few weeks that

mental health services will experience an unprecedented surge in demand.

The mental health emergency that is expected to follow the Covid-19 crisis will

likely be aggravated by the psychological impact of social isolation, confinement

and financial loss, experienced by a large proportion of the population at an

unprecedented scale.

We have a rapidly growing problem as the majority of people are unable to access

treatment. Before Covid-19 started the UK mental health system was already

struggling to reach its target of treating 25% of sufferers. With the scale of patient

need that we anticipate we’re going to see services under incredible pressure. There

simply aren’t enough therapists. Many services are switching to remote therapy

delivery but haven’t had sufficient time to train in this mode of treatment. We need

to innovate and look at other ways to help patients if we are to have any chance

of resolving this issue.

A growing problem

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% T

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% Sessions tagged as worr ied about v iruses, including coronavirus and Covid-19 % Sessions tagged as worr ied about money

% Sessions tagged as worr ied about family


Our findings are a result of preliminary analysis of the impact of the Covid-19

crisis on data collected by Ieso Digital Health, which contains over 300,000 hours

of anonymous therapy transcripts. We will continue to monitor and explore these

data in more detail during the next stages of this crisis, including investigating

the impact of the Covid-19 on other variables, such as distribution of disorders

and symptom severity for patients presenting to our service, changes in average

treatment duration, and changes in clinical outcomes including engagement,

improvement and recovery.

Large-scale disasters are almost always accompanied by increases in depression,

posttraumatic stress disorder (PTSD), substance use disorder, a broad range

of other mental and behavioural disorders, domestic violence, and child abuse4.

People experience one of four responses to a traumatic event5:

• Resilience: depending on the nature of events, most people are psychosocially

resilient. They experience usually mild distress that reduces in severity over time.

• Recovery: some people experience distress of moderate or greater severity

initially and then recover over time.

• Delayed onset: some people experience little distress initially but have a delayed

onset of symptoms.

• Chronic course: some people may have high levels of stress after events (at

above a level that is consistent with a psychiatric diagnosis). The symptoms,

signs and dysfunction remain high with only minor evidence of remission.

From looking at depression, anxiety and PTSD symptoms in adults following other

disasters such as the 2017 Manchester Arena incident we know that people

presenting earlier to mental health services have less severe symptoms and tend

to respond better to treatment6.

Key facts

Ongoing analysis of data to understand the impact of Covid-19 on mental health


1. https://www.bmj.com/content/bmj/suppl/2017/06/30/357.jun21_2.j2981.DC1/

BP_emergency_response.pdf

2. French, P. et al. (2019) ‘Psychological screening of adults and young people

following the Manchester Arena incident’, BJPsych Open. doi: 10.1192/bjo.2019.61.

3. Norris, F. H., Tracy, M. and Galea, S. (2009) ‘Looking for resilience: Understanding

the longitudinal trajectories of responses to stress’, Social Science and Medicine.

doi: 10.1016/j.socscimed.2009.03.043.

4. https://www.ncbi.nlm.nih.gov/pubmed/17803838

5. https://journals.sagepub.com/doi/pdf/10.1177/1529100610387086

6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6788223/

References

Dr Ana Catarino is Principal Scientist at Ieso, leading the clinical science work on

patient profiling and prediction of clinical outcomes. Ana has a special interest in the

development of personalised treatment protocols to improve treatment effectiveness

and clinical outcomes, as well as use of cognitive and behavioural biomarkers for the

detection of the early signs of mental illness. Prior to joining Ieso she worked as a

post-doctoral neuroscientist at the Medical Research Council and the University

of Cambridge, working on research projects investigating atypical brain function

in various mental health and neuropsychiatric conditions including post-traumatic

stress disorder, epilepsy and autism. Ana completed her PhD at the University

of Lisbon, Portugal, in collaboration with the Department of Psychiatry at the

University of Cambridge, UK. Her doctoral thesis focused on the anatomical

and functional study of the autistic brain using magnetic resonance imaging

and electroencephalography.

About the author


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scientists share unique insights into mental health presentation … · 2020-06-18 · ieso digital...

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