STAYING ALIVE

Having ostensibly flattened the COVID-19 curve, Australia now finds itself on the cusp of a mental health epidemic that’s overwhelming the nation’s healthcare system.

Australia is on the cusp of a mental health epidemic after the upheaval of COVID-19.

The waiting room outside heaves with impatience while I try to assess whether the young man in front of me is suicidal. He has not made eye contact yet; his hands fidget in his lap. His right foot jiggles urgently. It reminds me that his allocated 15 minute slot is long used up. I negotiate a plan. One that involves a future. Blood tests, another appointment next week. Thirty minutes next time to delve into the dark quicksand that threatens his life most days. I reassure myself that he has enough protective factors to keep him safe for a further three days. A girlfriend. When he mentions her, his voice softens, his foot briefly still.

Here in Australia, we are slowly breathing out. Although the world media is still dominated by COVID-19, we seem to be emerging from this pandemic relatively unscathed. Yet, even as other news starts to overtake the grim statistics of deaths and new cases, another silent epidemic is emerging. One that requires a different response, one that thrives with social distancing, lockdown and vigilant hygiene measures. A growing crisis that is not confined to any particular demographic but threatens young and old, affluent and socially disadvantaged, men and women. This glycan-coated, protein-spiked virus has pierced a membrane that threatens to unleash a crisis of the mind that will not be easily contained with the careful protocols normally used to manage pandemics.

THINGS THEY DIDN’T TEACH

The Australian Medical Association, Brain and Mind Centre, and Oxygen, Centre for Youth Mental Health issued a joint statement that the COVID-19 pandemic was likely to lead to increased rates of suicide and mental illness. They predict that there may be a 25 per cent increase in suicides, and 30 per cent of these may be among young people. That is an additional 750-1,500 people per annum in addition to the 3,000 lives lost to suicide before the pandemic. Economic downturn may worsen this figure and, if the economic situation persists past 12 months, the increased risk is predicted to continue for up to five years.

There are things that they didn’t teach us in medical school. We were taught to take a directed patient history, use a diagnostic sieve, examine and investigate to confirm our suspicions then instigate treatment. In 15 minutes. Preferably less. Over the years, I have learnt to hear the unspoken fears and anxieties that simmer just below the surface. The young woman who sits in my consulting room today weeps. She clutches her face in her hands and rocks back and forth while her nearly two-year-old searches for the toys that have been hidden away as part of our new pandemic protocols. It is the fourth time that this woman in her late twenties has presented with her thriving toddler, a gregarious happy child whose symptoms mysteriously resolve in the waiting room. I probe the mother with gentle, leading questions. Fifteen minutes has ended, and I am aware of opening a Pandora’s box when I ask, “How are you going?”

I stop looking at the clock. Her husband is no longer working, she finds herself pregnant with number two. Unplanned despite taking precautions. Things are a little tense at home. She hasn’t told him her news yet. When she had her daughter, she developed a post-partum psychosis that led to a prolonged hospital admission. I pull her back to the now. Arrange the appropriate blood tests and ultrasound. I ensure I use a service that bulk bills. I negotiate for her to come back and book in a longer appointment before sending her, red-eyed, back into the world.

Just before a longed-for break for lunch, I see that one of my regulars has booked in. An elderly lady who has never married and lives alone with her beloved retriever. Before she takes a seat, she hesitates. “I know it is against the rules Doc, but I wonder if I could give you a hug?”

She embraces me so hard and long that I wonder if she will let go. She is tearful. “You’re the first person I’ve touched since March.” It is July. We go through her phone contacts. We land on a friend she used to have breakfast with every month in the good old pre-pandemic days and a niece who is busy with her own family. I contact them, with permission of course, and they agree to ring a couple of times a week. I ring her on the other days. Just to say hello, make sure she is alright. I increase the strength of her antidepressants. She agrees to start walking her dog again, to get up in the morning. We hug again.

AT TIPPING POINT

There are renewed promises of funding for mental health. An increase to cope with the unravelling inner worlds of those who find their lives irrevocably changed following measures to control the spread of this virus. On 25 May 2020, the Hon Greg Hunt MP promised an additional $20 million for suicide prevention and mental health research. The 2020 budget promised a further $74 million to bolster existing support services and target the most vulnerable Australians as well as provide support to primary health networks. While this is welcome, on the front line, it is hard to see the effects of this money splash. Who will deliver the increased mental health sessions promised when the system is already beyond capacity? One of my colleagues stops me in the corridor wide eyed. She has just spent a couple of hours trying to find a psychiatrist and a psychologist to see a 14-year-old who attempted suicide last week. She was offered an appointment in February, 2021. We agree to meet for coffee to decompress.

It is Friday afternoon. Interesting how things reach a tipping point on a Friday. I see a 19-year-old who I first saw a month or so ago. She sits, head tipped forward, long straight hair brushing her knees. She is very still and speaks in a slow monotone. She answers my probing questions with brief shrugs and a word here or there, reluctant to let me into her black world. Eventually, she confides that she has booked herself into a high-rise with the view of jumping off.

Her family are affluent, supportive. She attended an exclusive private all girls’ school and has private insurance. I contact the emergency number of the psychiatric hospital seeking urgent support; admission.

I speak to the answering machine. I ring between every patient and eventually speak to a human being. I am advised that there are no beds, that she will have to utilise the public system. I am offered an appointment four months away. She might not need it by then. I make the difficult decision

“HE IS SO ANXIOUS THAT HE VOMITS SOME DAYS EN ROUTE TO HIS DESK.”

to breach her confidentiality, one of the few circumstances that this is acceptable. I risk losing her trust and ring her mother.

Thus begins a long weekend of suicide watch. I am home with my family, but carry my phone with me and make contact with her every couple of hours. Several times she does not respond. I text. I phone. Am flooded with relief whenever she texts back. I ring her mother who is tagging me and doing the same thing. My sleep is wakeful, filled with dreams of failure and loss. We survive the weekend and on Monday, I start ringing psychiatrists again. My persistence pays off. She now has an appointment and the promise of admission. I breathe out.

A new week and the caseload of sadness and madness continues to grow. In June 2020, Lifeline chairman John Brogden launched a national emergency appeal in response to the increased pressure the organisation is facing due to COVID-19. The busiest its been in its 57-year history, Lifeline is receiving a phone call every 30 seconds, and Brogden expects that this number will continue to rise.

SLEEPLESSNESS AND FEAR

I consult with a fellow in his early forties, the sole breadwinner in the family. He has a high-powered, high-earning job in finance. Retrenchment and downsizing threaten. He is so anxious that he vomits some days en route to his desk. Like many, he is now working from home. Constantly taunted by uncertainty, by a workspace now imbedded within the former safe haven of home. His body convulses with overwhelming panic until he curls over like a foetus, exhausted. He slips into his son’s room at intervals overnight, terrified that he will no longer be able to provide.

Sleeplessness and fear manifest in bursts of anger. His wife rings me, begs me to do something. Asks that I prescribe a pill to bring her husband back. Again, I attempt the fraught route of ringing the private psychiatric hospital, keen to utilise this fellow’s years of private insurance.

Ironically, if his heart was squeezed from lack of oxygen, I could ring any hospital, public or private, and have him admitted within the hour. He would follow the predictable pathway of cardiac investigations and find himself in a catheter lab. Any obstruction in the plumbing around his heart would be relieved and he would be home to a fresh start. Sadly, there is no similar swift response to the heart that pummels from fear; from threats imagined and real.

Meanwhile, I attempt to explore the tangled pathways in his head that tell him he is not enough and threaten to spin him into a vortex of panic so severe that his lips go blue, while his fingers tingle and his heart squeezes like a tight fist behind his ribs. Over the years, I have learnt to listen, then keep listening without interruption or judgement. Sometimes, it is enough to avert tragedy. Being well-resourced also helps. My efforts to find him an appointment with a psychiatrist are successful and he is admitted to a private facility for intensive support.

My young man returns for his results, for a plan that will help him navigate his way out of depression. He has been open about his selfmedication, his efforts to numb his pain. He adds that at times he is overcome by the urge to drive his car into a tree at high speed. His confession hovers in the space between us. I write out a mental health plan, commence medication to stabilise his moods, to help him sleep. The psychologists are booked up for four months. He can’t afford a psychiatrist. I cross my fingers that together with his girlfriend, we can keep him alive. I negotiate a plan to see him next week.

My young pregnant woman has told her husband. He is supportive, reassures her that they will be okay. She is not able to afford a psychiatrist but is seen by one of the midwives at the maternity hospital. I take it in turns with one of my colleagues to ring her each week and check in. She is usually tearful when I speak to her. My elderly lady has reached out to her friend and went out for lunch for the first time in months. She has ventured back to the dog park and says hello to people most days. I think of my colleagues in Melbourne who were in lockdown for what seemed like forever.

My 19-year-old has just been discharged. She still has many bleak days but fewer where she thinks about harming herself. I make contact once a week. She is a long way from being out of the woods, but I hope that with support, kindness and medication she will find a reason to live, to embrace each new day as an opportunity.

We understand so much about how this miraculous body of ours works. We have sophisticated ways to assess its biochemistry, the strength of the heart’s contraction, the ratio of expired gases from the lungs. While this does not always guarantee success, it is reassuring and enables us to intervene when things go awry.

Likewise, we have unravelled the genetic code of this virus that has shut down the world. The medical journals bulge with a growing knowledge base about its impact on our inflammatory pathways, its long-term effects on our bodies as survivors emerge fatigued, short of breath or cognitively impaired. Yet the intricate play of electrical impulses and neurotransmitters that allow us to express our thoughts and emotions remain elusive.

HOPE FOR THE FUTURE

Perhaps one benefit of this mental health crisis will be more research into understanding the complexities of our emotions and thoughts. Perhaps we just need more knowledge, more resources to support the increasing number of sufferers and their families, more empathy and kindness in the community. My hope is that one day, there will be protocols about how to manage mental health issues, with clear pathways of investigation and intervention so that the abnormal can be intercepted and treated before it is too late. That like myocardial infarction and pneumonia, needless death and suffering from mental illness will be relieved. Most of the time.

While we breathe a sigh of relief that we can again venture outside the safety of our homes and congregate in public areas to see friends and family, we are only at the start of this second, more insidious pandemic. It is already overwhelming the systems that we have in place and has highlighted the fragmented and often inefficient way that mental health care is delivered. The necessary measures to keep us safe from COVID-19 – isolation, lockdown and social distancing – have unleashed a tsunami of mental health-related illness. In general practice, we brace ourselves for the daily onslaught of pain and suffering that comes through our doors, holding our finger in the dyke for as long as we can.

VISIT MiNDFOOD.COM

Amid the chaos of 2020 has emerged a new set of words and phrases in our vocabulary. Among them are those that describe new emotions and feelings we haven’t felt before. mindfood.com/pandemic-emotions