A tsunami is how some Western Cape psychiatric clinics and hospitals describe the state of mental health in the province after the first lockdown.
The lockdown saw a dramatic increase in suicide attempts, relapse of mental health disorders, increase in drug use by smokers who could not get cigarettes due to the smoking ban and early discharge of mentally ill patients to make way for Covid-19 patients.
“After those deceptively quiet weeks, those five deceptively quiet weeks, the mental health storm started. Our patients were coming in with a variety of stresses. Every single mental healthcare user that came in was very unwell,” said a psychiatrist at a public psychiatric hospital.
“The adolescents were also very stressed in addition to all the other stresses that were going on. We were seeing very sick adolescents. Additionally, we have seen very serious suicide attempts,” said the psychiatrist, who took part in the University of Cape Town (UCT) study examining the consequences of pandemic lockdowns since 2020.
The study investigated 17 public sector psychiatric clinics and hospitals and how lockdown measures affected the availability, accessibility and continuity of mental health services across the province. Not only were mental health services disrupted but the pandemic “exposed and worsened the existing gaps and challenges in mental health service provision”.
After the first lockdown early in 2020, district hospitals admitted fewer psychiatric patients and stopped treating or containing psychosis patients as containment units closed down to make way for Covid-19 care.
Only specialist hospitals attended to such patients, where they were “warehoused” without appropriate treatment due to increased pressure and a lack of specialists.
Such a move ballooned waiting lists, and at one particular hospital the waiting list increased from an average of 25 patients to 89.
“Patients were referred straight to specialist hospitals, but this increased the pressure for beds at hospitals that were already over capacity.
“The plan was to empty the hospitals, to make beds for emergencies. So we had to discharge people who were really sick and hope for the best,” said a psychiatrist from a district hospital.
But it was after the easing of lockdown that the mental health tsunami really hit home. Facilities started seeing scores of patients who had relapsed, resulting in acute admissions. Some included smokers who resorted to using drugs because of the smoking ban.
Writing in PLoS ONE lead researcher Thandi Davies and colleagues from UCT’s department of psychiatry noted: “From June 2020, national restrictions were eased somewhat, and by August, admissions had returned to pre-Covid-19 numbers. However, this occurred over a very short period, resulting in what service providers described as a mental health storm with dramatic increases in patient load that ‘felt like a tsunami’.”
Specialists said as Covid-19 waves changed they also observed a “psychiatry wave” characterised by an increased number of patients relapsing because they could not get treatment.
“Hospitals attempted to cope with this by adding mattresses on floors and accelerating discharges, but these strategies were limited by safety concerns,” noted a psychiatrist from a specialist hospital.
While psychiatric patients were given treatment to last several months during the lockdown, many were not physically assessed and instead sent straight to pharmacies due to limited face-to-face contact between doctors and patients.
Only emergencies were seen face-to-face by doctors, and appointments were spaced out to lengthen the time between visits for patients.
Study participants also reported that psychological treatment and psychosocial group therapies were put on hold in all facilities to prevent face-to-face contact. Staff from these therapeutic wards, which dealt with post traumatic stress disorder (PTSD), eating disorders and substance abuse problems, were deployed to Covid-19 wards to manage the influx of medical patients.
Further, measures taken to mitigate the spread of Covid-19 led to a loss of financial, food and health security for already vulnerable mental health care patients and compounded anxiety around Covid-19.
Researchers said not only did mental health problems increase due to strict travel restrictions, a lack of money for transport and fear of catching Covid-19. Smokers were also affected.
“The five-month cigarette ban compounded psychological distress and led to relapses of more severe substance abuse for many mental healthcare users. This occurred while detoxification and substance abuse centres were closed.”
The five-month cigarette ban compounded psychological distress and led to relapses of more severe substance abuse for many mental healthcare users.
— Thandi Davies, lead researcher
Apart from limited face-to-face contact between healthcare workers and patients, researchers said a notable factor that affected mental health service provision was the series of extended periods of stock-outs of certain psychotropic medications.
“Before the pandemic, South Africa already faced stock-out challenges, particularly in rural areas. During the lockdown, the availability of medications such as lithium, haloperidol and lorazepam was compromised due to supply-chain issues.
“This caused many adverse consequences and relapses for patients, and issues for the psychiatrists and nurses who had to try to find replacement medications, which were not optimal for their patients and which required new scripts every time stock-outs occurred.”
The study concluded that Covid-19 policies were developed with minimal consideration for mental health patients and their vulnerabilities.
“Similarly, policies concerned with mitigating the social and economic impact of Covid-19 on households did not consider patients,” said the researchers.
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