A psychosis pandemic

If someone had told me as a medical student that I would experience psychosis, I would never have believed them. Psychosis is probably closest to most people’s idea of “madness,” in its oldest and most frightening sense: people who have lost touch with reality. According to recent headlines, cases of psychosis—which represent the most severe end of the spectrum of mental illness—are rising.

Psychosis may mean different things to different people, and words used for mental illness have become increasingly stigmatising over the years—in the past, “lunatic” was probably considered acceptable. But, like many diagnostic terms, psychosis spans a wide range of experiences, and is more a constellation of symptoms than one illness. When asked to define it, most psychiatrists will point to hallucinations, such as voice-hearing or delusional beliefs. But many people will experience hallucinations at some point during their lifetimes, and odd beliefs can depend on the context. In other words, these experiences can be normal, and situational factors may influence whether a person is seen as ill or not.

Someone with schizophrenia may, for example, hear people talking about them, and conclude that this is caused by conspiracy. Someone who is bereaved or traumatised may hear voices but be able to understand or interpret what is happening to them, however distressing it is. The actual experience of psychosis will depend on the individual and their circumstances and may include fear or elation—or just the sense that things are different, in a way that is hard to understand.

As a psychiatrist with bipolar disorder, when I have been very depressed, my thoughts have often veered towards believing the impossible, and for people like me the pandemic has posed a particular challenge. All the things one would normally do to keep well—exercising, eating properly, doing constructive activity and, above all, being with others—have been harder. And psychiatric services, always the poor relation in the NHS, have been diminished. As both psychiatrist and patient, I despair at the thought of phone consultations. Though as a doctor I make the same recommendations over the phone as in the consultation room, as a patient I know first hand the value of being seen and listened to face-to-face.

Some years ago, I studied admissions to a Scottish asylum over 10 years in the late 19th century and made a curious discovery: while psychotic patients were affected by similar conditions to those we diagnose today, the content of their delusions was different. Their thoughts reflected contemporary concerns, like religion and the then-new discovery, electricity.

Current events can thus shape our experience of mental illness and may even be the cause of it. We don’t know whether Covid-19 can cause mental illness directly, but we do know that both biology and psychosocial aspects influence many mental illnesses. Long Covid has been compared by some to ME, a condition which is the subject of polarised conflict. Professionals are divided on whether it has largely biological or psychological causes, with some implying that the psychological is less real. The more I live, the more I believe that all these aspects are inextricably intertwined. What is life if not biology, and what is biology if not more complex than we can know?

In many ways, the rising number of psychiatric referrals—particularly for psychosis—is hardly surprising, when triggers like persistent fear and stress have been the hallmarks of pandemic life. There has been a pervading helplessness and lack of control. Some have—in misguided efforts to make themselves feel better—used more alcohol and drugs, including cannabis, to which they may be more susceptible than they realise—especially to the stronger varieties like skunk.

As the fog lifts from the darkest days of the pandemic, we can begin to assess the damage. I think there is more mental illness, and more demand for services now, but it’s hard to know exactly how much. There is far more self-awareness regarding mental health nowadays, and less tolerance of mental distress. I don’t mean to suggest that those in distress should be denied support, but the reality is that not everything I see in my clinic is illness, and this may be contributing to the crushing overload of psychiatric services. Many of my patients have terrible social circumstances and have experienced things that no one should; some of them do suffer illnesses that can respond to medical intervention, but many don’t, and we need to stop treating them—particularly with medication that may compound their difficulties.

Should we expand mental health services so that we can respond to all unhappiness and distress, or will this only create a demand that we can never meet? I think we should do what we can, and not try to be everything to everyone. People who are unwell must be treated but, as a society, we must also try to address all the stresses of the pandemic that have brought us to this point. ♦

Mindful life

What is life if not biology, and what is biology if not more complex than we can know?