Could the COVID-19 Pandemic Have Led to Increased Rates of Psychosis?
Earlier this week, the Guardian reported that the number of people referred to mental health services for a first suspected episode of psychosis rocketed during the Covid-19 pandemic. The article originally claimed there had been a 75% increase in such referrals between April 2019 and April 2021, but subsequent investigation by James Kirkbride, Professor of Psychiatric & Social Epidemiology at UCL, revealed that the real figure is probably closer to 30%.
Although such a substantial correction should give us all pause for thought about rushing to conclusions, this nonetheless appears to be a very significant increase. These are referrals rather than confirmed cases of psychosis, but it does suggest many more people have been experiencing significant struggles with their mental health.
I am an independent expert on mental health and social policy, previously working in Parliament, for Mind, and in the civil service. I retrained as a Mental Health Social Worker in 2018 and now work in the NHS alongside freelance writing and research. I co-host the podcast Notes on the Mind, and I have previously written for InSPIre the MInd about the concept of “madness”. I was fascinated by this Guardian article and wanted to write about it.
Clearly, the most pressing concern in response to this news is whether people have been getting access to the support they need. But I also think it’s worth stepping back and considering why the conditions we have been subjected to during the pandemic might have led to more people seeking support for suspected psychosis.
We can all relate to the distress caused by Covid-19, the social constraints it necessitated, and the economic fallout — many people reported poor and deteriorating wellbeing as the pandemic progressed. It is also widely recognised that groups already facing social and economic disadvantages experienced the harshest impacts of the pandemic. Psychologically, it seems to have been a particularly tough time for young people.
It is easy to see how these conditions might have led someone to become anxious and depressed, but I suspect many people will find it harder to join the dots to the more unusual experiences that are associated with psychosis. Exploring these connections might therefore offer insights into why people have such experiences, and what lessons we can draw to help reduce the number of people becoming unwell.
I should be clear from the start that I am offering reflections on this subject based on my experience of supporting people as a Social Worker in mental health services, rather than as an authority on the subject of psychosis. However, many of the people I support hear, see or believe things that others don’t, and I have a strong personal and professional interest in psychosis and the relevant academic evidence.
There is a broad consensus about the type of ‘risk factors’ that can make it more likely that people experience psychosis, even if the relative role of each is disputed: genetic inheritance, trauma, social and economic disadvantage, substance misuse. However, there is much less clarity and agreement about how and why exposure to these factors leads to experiences such as hearing voices and holding unusual beliefs.
The explanatory framework I’m most attracted to, and that fits best with what I have observed when supporting people in frontline practice, is known as the ‘cognitive model of psychosis’. This suggests that unusual sensory and perceptual experiences that we all might experience from time to time can be reinforced and sustained as a result of how someone’s predispositions and circumstances shape their thinking, understanding, emotions and behaviour. In essence, psychosis can emerge as a result of how someone interprets and responds to ‘psychosis-like experiences’. I will refer back to this model as I explore how the impact of the pandemic might have shaped people’s risk of becoming unwell.
When Covid-19 first hit, I was working as a care coordinator in a community mental health team. This meant I was responsible for supporting a caseload of people with long-term mental health problems, most of whom had experience of psychosis. I spent much of those early days helping people to understand what was going on and what restrictions they needed to abide by.
The thing that sticks in my memory about this period is how many people joked with me that the unfolding events of the pandemic weren’t actually having a huge impact on their day-to-day lives. They were used to spending much of their time alone at home, fairly cut off from the outside world. They weren’t suddenly cut off from work, friends and family. Their mental health problems, their economic circumstances, and their social marginalisation had left them locked out, long before the pandemic had put them in lockdown.
In contrast, for many people, the pandemic rapidly and dramatically altered their lives. The social isolation, particularly for people living alone, was acute, only mitigated slightly by virtual social contact. Young people, still developing and passing through significant milestones, have perhaps lost the most from the restrictions on social contact. People with limited social networks may have previously relied entirely on incidental interactions as they went about the day-to-day activities that were now heavily restricted under lockdown
Studies suggest that social connection supports our psychological health by reducing stress and helping us to maintain a shared sense of reality. In the absence of social contact, the brain may be more likely to produce the types of thoughts and experiences that could develop into psychosis. People are more likely to have these types of experiences when they are alone, and it is easy to imagine how unsettling and confusing this could be with no one to talk to or seek reassurance from.
Living with others during this period was a source of great comfort for many, but it trapped some people in abusive relationships and situations. The pandemic has seen increased reports of domestic abuse from partners and family members. The trauma of such abuse is known to make people more likely to develop mental health problems, and it is thought that dissociation from these experiences could form part of a journey towards psychosis.
Many people have also experienced immense pressure and stress around their finances during the pandemic. Millions had to turn to the benefits system for support after losing their jobs, often facing a huge drop in income as a result. Financial difficulties have been shown to increase the risk of psychosis. Stress connected to such difficulties can be mentally all-consuming, and the cognitive model of psychosis suggests that maladaptive coping mechanisms can exacerbate and accelerate the development of psychosis.
Alongside all of these consequences of the pandemic, it is important not to forget just how terrifying the threat of Covid-19 itself has been. Over 8 million people in the UK have had the virus and over 160,000 people have had Covid-19 mentioned on their death certificate. It has been a period of huge collective trauma but also many individual ones, whether through being unwell or losing loved ones. It has also been a profoundly strange couple of years and it isn’t hard to see how these things in combination could throw someone’s thoughts and perceptions out of kilter — few of us have found it easy to take it all in our stride.
Even though referrals for support with psychosis have significantly increased over the last two years, it also seems likely that many people will have put off seeking help, or lacked the encouragement from others to do so, because of the context of the pandemic. Since the start of 2021, I have been working in a mental health crisis team where I have seen people presenting with severe problems that may well have been picked up earlier in normal times before they had progressed to include psychosis-like experiences.
Given the vast and sprawling impact the pandemic has had, and the fact that I have approached this question with a particular explanatory framework in mind, I am sure there are many other factors I’ve failed to consider. But the apparent links between the pandemic and increased rates of suspected psychosis suggest that the types of social and economic determinants I have touched on have played a critical role.
As well as properly funding mental health services and ensuring timely access to support, we need to be addressing the social and economic problems the pandemic has both highlighted and exacerbated. We also need to improve awareness and understanding of what psychosis is and how it might develop, so that we are better able to support ourselves and each other to endure difficult circumstances, as so many have had to over the last couple of years.