Alicia’s story: how I reframed my perspective after my mental health diagnosis
Having a diagnosis of a mental health condition doesn’t determine the rest of your life.
Feeling hopeless
After a desperate plea to the doctor late last year, I was referred to a consultant psychiatrist and received a formal diagnosis. Sitting on the edge of my chair in the clinical assessment room, I told her how anxiety was plaguing nearly every moment of my day and how I felt too low to function most of the time. How I felt like I was dragging my body and mind around all day, doing everything I had to do, but feeling no connection or emotion to it. How I felt angry, hopeless, self-destructive and even suicidal. Things had gotten really bad this time and I had no idea how I would get out of it.
The consultant looked concerned. She stopped me and said, ‘We need to rule something out,’ then handed me a list of questions and a pen.
The diagnosis
Less than an hour later, I found myself leaving the hospital grounds in a state of shock. The consultant seemed to think I had something called Borderline Personality Disorder (BPD), also sometimes called Emotionally Unstable Disorder. I had vaguely heard of it before. Crazy, out of control, mentally unwell, unstable, dangerous… were all the stigmatising words that raced through my mind, negative connotations I felt deeply afraid of.
Shock and fear
Up until now, I thought I’d been struggling with anxiety and depression, so it came as a shock to be given a new diagnosis I’d never even considered before. I was still in a state of disbelief when I returned home to my partner and broke the news. He didn’t want to believe it either.
What sort of person had I become? Was I way more messed up than I thought I was? How could I have not been diagnosed with this before now? Was this something I could recover from or was my life, as I knew it, over? These were more of the stigmatising thoughts that initially came to mind.
I felt confused, angry, close to tears, anxious, frightened and ashamed, all at once.
But I also felt something else pawing for my attention.
A gentle relief
Finally, my struggles had been identified. Validated. Heard. Understood. Yes, I’d been given a label, and maybe that comes with both pros and cons but, truthfully, I took great comfort in knowing that other people felt this way. I have an amazing partner, the most brilliant best friend and a wonderful support network, but I often struggle to articulate how I am feeling to them. It often leaves me feeling like nobody really understands me, and never will.
The consultant had a thorough understanding of my inner world, and made sense of the whys and the how’s of what had happened to me, what was happening to me right now, and how the right treatment could, over time, help me to manage and overcome my difficulties. I felt relieved that a fulfilling and meaningful life still seemed possible, with the right professional help and support.
A ray of hope
I’d had several different types of talking therapy including counselling, CBT and long-term psychodynamic therapy. Some of these had been helpful but I still felt something was missing. I’d been in and out of the NHS system for over three years. I’d tried meditation, medication, exercise, putting my career on hold, online courses and countless self-help strategies. I had begun to give up hope of ever feeling normal again.
Although hard to digest for the first few weeks, the diagnosis gave me hope that one day things would get better. My huge highs and lows started to make sense, as did my interpersonal difficulties, self-sabotaging anxiety and highly critical inner voice tearing me down daily. The diagnosis seemed to fit. The funny thing is, I sometimes felt deep down that there was something more serious and complex happening inside of me all along.
Knowledge is power
After the diagnosis, I began searching for as much information as I could about BPD from reliable sources on the internet and soon discovered that, like any mental health condition, I was on a spectrum in terms of my symptoms and behaviours. I found out that there were many types of personality disorders and how these were split into a number of overlapping categories. I discovered the term Quiet BPD. There was a whole wealth of new information to absorb and, although scary to read at times, it felt good to feel a little back in control of my life.
I read about the different types of specialised therapy options for people with BPD, studying in-depth scholarly articles on the evidence and effectiveness of each approach. I also researched the recovery and remission rates, which helped set my own expectations of what was actually achievable and realistic.
It doesn’t need to define me
Overwhelmed by a constant whirlwind of negativity, I was completely out of touch with who I was and what I was actually like before things got so bad. I had been trying so hard to get rid of how I felt and desperately hold onto any good feelings. Feeling better had become a full-time job, and it was exhausting.
I often felt so anxious, low or self-destructive that it was easy to lose touch with the other parts of myself that make me, me. The parts of me that make me a loving partner, a loyal friend and a thoughtful daughter. The parts of me that love to meet new people, have fun, write, go to live gigs, be creative and help others. The part of me that is a little ditsy, making my partner and friends laugh (they actually write lists of hilarious things I come up with). Although I still have a way to go, slowly but surely, those parts of me are returning. All it took was to realise they were still there all along and make small positive actions to reconnect with myself.
Being given a diagnosis can help you, not hold you back. Accept it as yours, don’t let it define you and always remember it is only one part of you.
In this very insightful piece, find out what it takes to be a Mental Health Nurse and what you can expect from your role as one.
1 in 4 of us will experience a mental health difficulty at some point in our lifetime.
Whether that be feelings of anxiety or depression or experiencing low mood and emotional difficulties it is now widely accepted that mental illness is very common.
There are nearly 290,000 nurses registered with the Nursing and Midwifery Council (NMC) in England and 12% (34,000) of those are Registered Mental Health Nurses.
A similar percentage of the nursing profession are RMNs in Scotland and Wales.
There continues to be widely published concerns regarding the reduction of RMNs with recent media reports suggesting 2000 mental health staff are leaving their roles a month.
Working as an RMN it is impossible to ignore the impact of this reduction on our profession and the people we work with, yet it is still a highly rewarding and diverse career.
I have worked in a range of mental health settings for 17 years and have been an RMN for the last 12 years.
Throughout this article, I will outline how to become an RMN, what career pathways are open to you and consider how the changing landscape of modern-day healthcare may affect mental health nursing.
What does a typical day look like for a Mental Health Nurse?
The attraction for many who work as Mental Health Nurses is that no two days are ever the same.
Mental Health Nurses work in a vast array of inpatient and community settings, medical centres, schools, prisons, undertaking research or universities.
Mental Health Nurses work with individuals across the lifespan from specialist perinatal services, child and adolescent, working-age individuals, older adults and later life dementia care.
Some days will be structured with arranged appointments, others will be responding to emergencies and very much thinking on your feet!
The setting that you work in will, to a degree, provide variances in the role of a Mental Health Nurse.
A nurse working in the community may work in a more autonomous way than those who work in inpatient settings and once qualified the career as a Mental Health Nurse has the potential to be incredibly varied.
Across the UK there is a range of mental health services offered in the community.
Divided into Primary, Secondary and Specialist services there may be geographical variances in the way teams work, however, the core skills for a Mental Health Nurse remain the same.
Within Primary Care, Mental Health Nurses will receive referrals from GPs and A&E departments.
Following assessments, nurses will offer short-term interventions which may include anxiety management, support with depressed mood, advise on possible medications and work with a range of common mental health issues.
As a nurse, you will spend 1:1 time with individuals for a set, short period of time, 10-12 weeks for example. If a person requires longer-term support, you may refer them to Secondary Mental Health Services.
Mental Health Nurses working in secondary community services will work with people who have more complex or serious chronic mental health difficulties.
They may have been in a hospital or be diagnosed with an illness such as schizophrenia, mood disorders (serious depression or Bi-Polar Affective Disorder) or post-traumatic stress disorder.
As a Mental Health Nurse, you will carry a caseload of between 20-30 individuals and be responsible for coordinating their package of care whilst they are in the community.
You will build relationships with the people you support in order to monitor their mental health, watch for relapse signs, know what potential triggers they experience and support them to engage in meaningful activities.
By knowing the people you work with, you will be able to assess their ongoing mental health and adjust the input you offer them accordingly.
Some of the people you work with may be going through a crisis for example and you will increase your sessions, suggest adjustments in medications or arrange meetings with psychiatrists, psychologists or family members.
As a Community Mental Health Nurse, you will have received training in the Mental Health Act 1983, which is the legal framework for those who require admission to hospital.
Working in the community you may have to arrange assessments under the Mental Health Act in order to admit people to hospital.
Working in the community means you will often manage your own time and daily tasks.
You will support people to engage with other agencies and you will build close links with housing support, 3rd sector organisations, social services, education, and GPs.
Many areas of the UK have specialist community teams including memory clinics for those with dementia, assertive outreach services for difficult to engage patients, early intervention in psychosis services, crisis teams, mental health for the homeless, community forensic teams, police street triage and many more.
As you move through your training and career it is likely you develop an interest in a particular field of mental health.
Whether you work in the community or an inpatient unit will depend on your personal preference and local opportunities.
The national strategy for mental health, The Five Year Forward View published in 2016 places emphasis on preventive and early intervention for mental health issues with funding now focused on community services.
With a reduction in hospital beds, inpatient mental health units now admit people who are in acute stages of serious mental illness, with a high percentage being detained legally under the Mental Health Act 1983.
As a Mental Health Nurse working in an inpatient unit, you will work as part of a ward team to deliver care and treatment to those in crisis.
Inpatient settings often mirror services within the community, with child and adolescent units, working-age acute mental health wards, specialist dementia wards and Psychiatric Intensive Care Units.
There are also national units for psychosis, eating disorders, mood disorders and therapeutic communities for those with personality disorders and emotional difficulties.
There are longer-term inpatient settings for patients involved in the criminal justice system (forensic mental health) and rehabilitation units where people can stay for up to two years.
Historically, Mental Health Nurses would always begin their careers working in hospitals.
The skills you develop working in acute wards are transferable to all settings and help nurses build confidence and knowledge.
You will be required to assess people admitted to the ward and develop plans of support accordingly.
You will work closely with Psychiatrists and other professionals to establish pathways for individuals and maintain a therapeutic environment on the ward through group work, 1:1 time and facilitating time off the ward.
What kind of person and soft skills make a good Mental Health Nurse?
Working in mental health requires a level of emotional resilience and self-awareness.
As nurses, we walk alongside individuals in their darkest and scariest times.
Often people’s behaviour can be difficult to understand or explain and can cause distress.
Mental Health Nurses try and help individuals find meaning and understanding of their experiences and build coping mechanisms to prevent further relapses.
You will need compassion and empathy, qualities which you may have developed from your own experiences in life.
Human beings are fragile and as a Mental Health Nurse, there will be a recognition that anyone at any time can be susceptible to vulnerability and mental illness.
Listening is a skill, we can all sit and have a conversation, but to actively listen to another person requires patience, a non-judgmental attitude and the ability to put our own minds and thoughts out of the way.
As a Mental Health Nurse, you will receive on-going supervision in order to support you developing these skills and help you make sense of your own mind and lives so that you can support others.
What hard skills and qualifications are required to become a Mental Health Nurse?
Alongside the soft skills required to be a Mental Health Nurse, which can often seem intangible, there are specific qualifications and quantifiable skills needed.
Nurse education has changed substantially over the last decade, with a move to university degree courses.
Undergraduate Mental health Nursing degrees are offered at most universities across the country with applications via UCAS.
You will usually need A Levels or complete an access course.
Previous experience in a healthcare setting is an advantage so it is always beneficial to work as a Support Worker or Health Care Assistant prior to applying if possible.
Mental Health Nursing degrees are three years long and are split between academic modules at university and practice placements in a variety of community and inpatient settings.
The first year of any nursing degree is a common foundation program (CFP) which all nurses do no matter what the speciality.
The final two years will be solely mental health and you will learn about mental illness theories, practical assessment skills, pharmacology, physical health and treatment approaches.
Whilst on placement you will be supernumerary, meaning you won’t be counted as part of the nursing numbers.
This gives you an opportunity to develop your interpersonal skills, write care plans, use assessment frameworks and learn how to document all interactions professionally.
The experiential learning which occurs whilst on practice placements is invaluable and as the course progresses you will discover which area of mental health interests you and help you build an idea of the career ahead of you.
You will have a combination of academic essays to complete alongside practice portfolios which match your placement skills with the Nursing and Midwifery Council competencies.
The Nursing and Midwifery Council (NMC) are our professional body and once you have completed and passed your degree you will join the NMC professional register.
Once on the register, you will receive a unique pin number, allowing you to legally work as a Mental Health Nurse.
Keeping your nursing registration up to date Mental Health Nursing is a journey of lifelong learning.
It is both a professional and personal responsibility to keep up to date with the ever-changing evidence base in nursing practice.
You will be required to pay a registration fee yearly to the NMC and you will be asked to provide evidence of continuing professional development (CPD) every three years when you revalidate.
CPD can be the range of essential training your employer requires such as intermediate life support, moving and handling, health and safety, infection control and information governance training.
It is a good idea to keep your own records of any training completed so you can provide evidence to the NMC if requested.
As a Mental Health Nurse, you can develop more specialist advanced assessment skills, undertake courses in the Mental health Act 1983, specific treatment approaches such as cognitive behavioural therapy or dialectical behavioural therapy or return to university to undertake a Masters or PhD.
Becoming a registered mental health nurse or RMN is often just the beginning.
It is an excellent qualification to have and often provides the foundation for many other career pathways.
Many Mental Health Nurses undertake further training to become therapists, teachers, lecturers, managers or researchers.
Stress can be defined as the degree to which you feel overwhelmed or unable to cope as a result of pressures that are unmanageable.
What is stress?
At the most basic level, stress is our body’s response to pressures from a situation or life event. What contributes to stress can vary hugely from person to person and differs according to our social and economic circumstances, the environment we live in and our genetic makeup. Some common features of things that can make us feel stress include experiencing something new or unexpected, something that threatens your feeling of self, or feeling you have little control over a situation.1
When we encounter stress, our body is stimulated to produce stress hormones that trigger a ‘flight or fight’ response and activate our immune system 2. This response helps us to respond quickly to dangerous situations.
Sometimes, this stress response can be an appropriate, or even beneficial reaction. The resulting feeling of ‘pressure’ can help us to push through situations that can be nerve-wracking or intense, like running a marathon, or giving a speech to a large crowd. We can quickly return to a resting state without any negative effects on our health if what is stressing us is short-lived 3, and many people are able to deal with a certain level of stress without any lasting effects.
However, there can be times when stress becomes excessive and too much to deal with. If our stress response is activated repeatedly, or it persists over time, the effects can result in wear and tear on the body and can cause us to feel permanently in a state of ‘fight or flight’ . Rather than helping us push through, this pressure can make us feel overwhelmed or unable to cope.
Feeling this overwhelming stress for a long period of time is often called chronic, or long-term stress, and it can impact on both physical and mental health.
Stress is a response to a threat in a situation, whereas anxiety is a reaction to the stress.
What makes us stressed?
There are many things that can lead to stress. The death of a loved one, divorce/separation, losing a job and unexpected money problems are among the top ten causes of stress according to one recent survey 5. But not all life events are negative and even positive life changes, such as moving to a bigger house, gaining a job promotion or going on holiday can be sources of stress.
What are the signs of stress?
Emotional changes
When you are stressed you may experience many different feelings, including anxiety, fear, anger, sadness, or frustration. These feelings can sometimes feed on each other and produce physical symptoms, making you feel even worse. For some people, stressful life events can contribute to symptoms of depression.6 7
Work-related stress can also have negative impacts on mental health 8. Work-related stress accounts for an average of 23.9 days of work lost for every person affected 9.
Behavioural changes
When you are stressed you may behave differently. For example, you may become withdrawn, indecisive or inflexible. You may not be able to sleep properly 10. You may be irritable or tearful. There may be a change in your sexual habits 11.Some people may resort to smoking, consuming more alcohol, or taking drugs 12. Stress can make you feel angrier or more aggressive than normal 13. Stress may also affect the way we interact with our close family and friends.
Bodily changes
When stressed, some people start to experience headaches, nausea and indigestion. You may breathe more quickly, perspire more, have palpitations or suffer from various aches and pains. You will quickly return to normal without any negative effects if what is stressing you is short-lived, and many people are able to deal with a certain level of stress without any lasting adverse effects.
If you experience stress repeatedly over a prolonged period, you may notice your sleep and memory are affected, your eating habits may change, or you may feel less inclined to exercise.
Some research has also linked long-term stress to gastrointestinal conditions like Irritable Bowel Syndrome (IBS), or stomach ulcers14 as well as conditions like cardiovascular disease15.
Who is affected by stress?
All of us can probably recognise at least some of the feelings described above and may have felt stressed and overwhelmed at some time or another. Some people seem to be more affected by stress than others. For some people, getting out of the door on time each morning can be a very stressful experience. Whereas others may be able to cope with a great deal of pressure.
Some groups of people may be more likely to experience stressful life events and situations than others. For example, people living with high levels of debt, or financial insecurity are more likely to experience stress related to money16, 17, people from minority ethnic groups or whose who are LGBT (lesbian, gay, bisexual and transgender) may be more likely to experience stress due to prejudice, or discrimination18,19,20, and people with pre-existing or ongoing health problems may be more likely to experience stress related to their health, or stress due to stigma associated with their condition.
How can you help yourself?
There are some actions that you can take as an individual to manage the immediate, sometimes unpleasant, signs of stress and identify, reduce, and remove stressful factors that may cause you to feel overwhelmed and unable to cope. If you feel comfortable, talking to a friend or close colleague at work about your feelings can help you manage your stress.
However, sometimes individual actions on their own are not enough to reduce long-term stress for everyone. We can often be affected by factors that are beyond our direct control. Communities, workplaces, societies, and governments all have a role to play in tackling these wider causes of stress.
1. Realise when it is causing a problem and identify the causes
An important step in tackling stress is to realise when it is a problem for you and make a connection between the physical and emotional signs you are experiencing and the pressures you are faced with. It is important not to ignore physical warning signs such as tense muscles, feeling over-tired, and experiencing headaches or migraines.
Once you have recognised you are experiencing stress, try to identify the underlying causes. Sort the possible reasons for your stress into those with a practical solution, those that will get better anyway given time, and those you can’t do anything about. Take control by taking small steps towards the things you can improve.
Think about a plan to address the things that you can. This might involve setting yourself realistic expectations and prioritising essential commitments. If you feel overwhelmed, ask people to help with the tasks you have to do and say no to things that you cannot take on.
2. Review your lifestyle
Are you taking on too much? Are there things you are doing which could be handed over to someone else? Can you do things in a more leisurely way? You may need to prioritise things you are trying to achieve and reorganise your life so that you are not trying to do everything at once.
3. Build supportive relationships
Finding close friends or family who can offer help and practical advice can support you in managing stress. Joining a club, enrolling on a course, or volunteering can all be good ways of expanding your social networks and encourage you to do something different. Equally, activities like volunteering can change your perspective and helping others can have a beneficial impact on your mood.
4. Eat Healthily
A healthy diet will reduce the risk of diet-related diseases. There is also a growing amount of evidence showing how food can affect our mood. Feelings of wellbeing can be protected by ensuring our diet provides adequate amounts of nutrients including essential vitamins and minerals, as well as water.
5. Be aware of your smoking and drinking
If possible, try to cut right down on smoking and drinking. They may seem to reduce tension, but in fact they can make problems worse. Alcohol and caffeine can increase feelings of anxiety.
6. Exercise
Physical exercise can be an excellent initial approach to managing the effects of stress. Walking, and other physical activities can provide a natural ‘mood boost’ through the production of endorphins. Even a little bit of physical activity can make a difference, for example, walking for 15-20 minutes three times a week is a great start.21
7. Take Time Out
One of the ways you can reduce stress is by taking time to relax and practicing self-care, where you do positive things for yourself. Striking a balance between responsibility to others and responsibility to yourself is vital in reducing stress levels.
8. Be Mindful
Mindfulness meditation can be practiced anywhere at any time. Research has suggested it can be helpful for managing and reducing the effect of stress, anxiety, and other related problems in some people22. Our ‘Be Mindful’ website features a specifically-developed online course in mindfulness, and details of local courses in your area.
9. Get some restful sleep
Sleep problems are common when you’re experiencing stress. If you are having difficulty sleeping, you can try to reduce the amount of caffeine you consume23 and avoid too much screen time before bed24. Writing down your to do list for the next day can be useful in helping you prioritise but also put the plans aside before bed25. For more tips on getting a good night’s sleep read our guide ‘How to sleep better’.
10. Don’t be too hard on yourself
Try to keep things in perspective and don’t be too hard on yourself. Look for things in your life that are positive and write down things that make you feel grateful.
If you continue to feel overwhelmed by stress, seeking professional help can support you in managing effectively. Do not be afraid to seek professional help if you feel that you are no longer able to manage things on your own. Many people feel reluctant to seek help as they feel that it is an admission of failure. This is not the case and it is important to get help as soon as possible so you can begin to feel better.
The first person to approach is your family doctor. He or she should be able to advise about treatment and may refer you to another local professional. Cognitive Behavioural Therapy (CBT) has been shown to be helpful in reducing stress by changing the ways we think about stressful situations26, this might include focusing on more positive aspects of a situation and reassessing what their likely impact might be. Other psychosocial interventions that can be helpful include brief interpersonal counselling, which can give people the opportunity to discuss what causes them to feel stress and develop coping strategies; and mindfulness-based approaches27.
Vicky talks about her experience of Seasonal Affective disorder (SAD) and the misconceptions that surround it, how getting a diagnosis has made a big difference and things she does to support her own mental health.
Vicky is from Cardiff. She enjoys keeping fit and spending time with her family.
Imagine spending half the year happy and then one day waking up and feeling different.
You can’t work out why and you try and continue on with your day. The next few days seem darker, longer and the overwhelming sense of ‘why is everything such a struggle?’ it hangs over you like a dark cloud.
“Then it hits you, it’s the time of year.”
Seasonal Affective Disorder or SAD affects thousands of people every year but it is clouded in misconceptions and a lack of awareness and understanding. I have SAD and have struggled with it ‘officially’ for the last four years, although unofficially I have probably experienced the disorder for a lot longer.
I think that SAD has always been a part of my life. As some of my family members suffer from the same disorder it makes it easier to admit to feeling down and I have people who understand what it feels like and know it’s real.
I love the summer, I love the sun and warm weather. Winter, on the other hand, fills me with dread. Even though I love fireworks, Christmas and other winter festivities I will never understand how people can love the winter months and find the nights cosy. For me, SAD creeps up on me during October and begins to ease in March…
“During this time I feel down, upset and ready to cry at even the tiniest thing.”
Depressed and anxious , I don’t see the fun in anything. I have a lack of appetite and getting out of bed every morning feels like climbing a mountain.
Things I would normally do, like going to a gym class and socialising with friends, are a struggle. Putting on a mask every day at work to try and act ‘normal’ and ’ok’ is tiring.
So what has helped me? There have been numerous ways I have learnt to control my SAD. The biggest being accepting that I suffer with it and becoming more aware of when it hits so I can get help.
A wake up lamp, which gradually lights up the room before my alarm goes off so I wake up to a bright environment has worked wonders at making the darkest of morning bearable and helping me to start the day with a positive mindframe. Staying active, not isolating myself and trying to keep to the same routine as summer has also been key.
Before I was diagnosed with SAD, I attended the odd exercise class but wasn’t exactly active. But SAD has completely changed this.
“The year I got diagnosed I was at my lowest and I didn’t want to do anything involving leaving the house.”
During this time my mum told me if I joined a gym she would help pay for the membership. This changed my life.
I started going to classes a few times a week and not only did it push me to live a healthier and active life but it became a hobby I love and became a mental release.
For me that hour in the gym became an escape, I didn’t worry about anything and once I was there I felt more positive and optimistic thanks to the endorphins.I’ve never looked back.
“SAD doesn’t have to be negative, it can also be a positive.”
Now I keep this up in the summer months and push myself to stick on my trainers and go even when all I want to is lie in a ball and feel sorry for myself.
Something else that I have had to accept is the use of anti-depressants. There is such a stigma around these tablets and this was the hardest part for me to come to terms with. I didn’t want to take them and truthfully still don’t feel 100% happy about the fact I do or other people knowing I do.
My GP understands my problem and has helped me gain access to counselling. The best advice I was given about SAD was the Dr’s analogy:
“If you had winter asthma then we would give you an inhaler, you have SAD so we give you tablets to help for a few months”
There are many misconceptions surrounding SAD, I’ve heard them all and have outlined 5 of my favourites.
Misconception #1: “The weather can’t affect you that much” and “SAD isn’t real”
Whilst it is correct to say the weather doesn’t affect me, the changing seasons do. SAD is often triggered by the short days and less exposure to sunlight rather than the rain or cold – although this I find doesn’t help.
Misconception #2: “Winter never made you sad out when you were younger so it can’t do now”.
I have been suffering for around four years and had my first onset in my early twenties. This is typical for most sufferers and I’ve always felt down in winter, I may just not have be aware of it at the time.
Misconception #3 “Everyone experiences low energy during the winter months you can snap yourself out of it.”
Yes, the winter months can be a gloomy time of year but suffering from SAD is a lot different to just feeling sad and is something which impacts lives, relationships, careers and for some can be as debilitating as a physical illness. SAD is just as bad as depression. The only difference is SAD is a version of depression that happens at a specific time of year.
Misconception#4: “You’re still showing up at work on time every day, so you must be fine”.
I am a prime example of how this is untrue. In the four years I have taken medication for my SAD, I have not had one day off relating to it. Putting on a smile and acting cheerful and happy can be what I’m best at. There are no external symptoms and most people would say that they would never think I suffered from any mental health problems but just because it doesn’t show and I’m functioning doesn’t mean SAD isn’t real or should be ignored.
Misconception #5: “There is no cure you just have to ride it out”.
SAD is treatable and can be managed. I do numerous things to lessen the severity of my symptoms which can range from talking about my feelings, staying active, keeping a gratitude journal, mindfulness, using light boxes and seeking help from a doctor.
SAD can make you sad and it is a hard concept to grasp that you feel fine for half the year and depressed, at what feels like the click of a finger, for the rest. Knowing there are other people out there who suffer and understand has been a huge help. So whilst I embark on another dark winter, I can see the light at the end of the tunnel.
Autism is a lifelong developmental disability that affects how people perceive the world and interact with others.
Autistic people see, hear and feel the world differently to other people. If you are autistic, you are autistic for life; autism is not an illness or disease and cannot be ‘cured‘. Often people feel being autistic is a fundamental aspect of their identity.
Autism is a spectrum condition. All autistic people share certain difficulties, but being autistic will affect them in different ways. Some autistic people also have learning disabilities, mental health issues or other conditions, meaning people need different levels of support. All people on the autism spectrum learn and develop. With the right sort of support, all can be helped to live a more fulfilling life of their own choosing.
How common is autism?
Autism is much more common than most people think. There are around 700,000 autistic people in the UK – that’s more than 1 in 100. People from all nationalities and cultural, religious and social backgrounds can be autistic, although it appears to affect more men than women.
How do autistic people see the world?
Some autistic people say the world feels overwhelming and this can cause them considerable anxiety.
In particular, understanding and relating to other people, and taking part in everyday family, school, work and social life, can be harder. Other people appear to know, intuitively, how to communicate and interact with each other, yet can also struggle to build rapport with autistic people. Autistic people may wonder why they are ‘different’ and feel their social differences mean people don’t understand them.
Autistic people often do not ‘look’ disabled. Some parents of autistic children say that other people simply think their child is naughty, while adults find that they are misunderstood. We are educating the public about autism through our Too Much Information campaign.
Diagnosis
A diagnosis is the formal identification of autism, usually by a multi-disciplinary diagnostic team, often including a speech and language therapist, paediatrician, psychiatrist and/or psychologist.
The benefits of a diagnosis
Getting a timely and thorough assessment and diagnosis may be helpful because:
it helps autistic people (and their families, partners, employers, colleagues, teachers and friends) to understand why they may experience certain difficulties and what they can do about them
Persistent difficulties with social communication and social interaction
SOCIAL COMMUNICATION
Autistic people have difficulties with interpreting both verbal and non-verbal language like gestures or tone of voice. Many have a very literal understanding of language, and think people always mean exactly what they say. They may find it difficult to use or understand:
facial expressions
tone of voice
jokes and sarcasm.
Some may not speak, or have fairly limited speech. They will often understand more of what other people say to them than they are able to express, yet may struggle with vagueness or abstract concepts. Some autistic people benefit from using, or prefer to use, alternative means of communication, such as sign language or visual symbols. Some are able to communicate very effectively without speech.
Others have good language skills, but they may still find it hard to understand the expectations of others within conversations, perhaps repeating what the other person has just said (this is called echolalia) or talking at length about their own interests.
Autistic people often have difficulty ‘reading’ other people – recognising or understanding others’ feelings and intentions – and expressing their own emotions. This can make it very hard for them to navigate the social world. They may:
appear to be insensitive
seek out time alone when overloaded by other people
not seek comfort from other people
appear to behave ‘strangely’ or in a way thought to be socially inappropriate.
Autistic people may find it hard to form friendships. Some may want to interact with other people and make friends, but may be unsure how to go about it.
Restricted and repetitive patterns of behaviours, activities or interests
REPETITIVE BEHAVIOUR AND ROUTINES
The world can seem a very unpredictable and confusing place to autistic people, who often prefer to have a daily routine so that they know what is going to happen every day. They may want to always travel the same way to and from school or work, or eat exactly the same food for breakfast.
The use of rules can also be important. It may be difficult for an autistic person to take a different approach to something once they have been taught the ‘right’ way to do it. People on the autism spectrum may not be comfortable with the idea of change, but may be able to cope better if they can prepare for changes in advance.
HIGHLY-FOCUSED INTERESTS
Many autistic people have intense and highly-focused interests, often from a fairly young age. These can change over time or be lifelong, and can be anything from art or music, to trains or computers. An interest may sometimes be unusual. One autistic person loved collecting rubbish, for example. With encouragement, the person developed an interest in recycling and the environment.
Many channel their interest into studying, paid work, volunteering, or other meaningful occupation. Autistic people often report that the pursuit of such interests is fundamental to their wellbeing and happiness.
SENSORY SENSITIVITY
Autistic people may also experience over- or under-sensitivity to sounds, touch, tastes, smells, light, colours, temperatures or pain. For example, they may find certain background sounds, which other people ignore or block out, unbearably loud or distracting. This can cause anxiety or even physical pain. Or they may be fascinated by lights or spinning objects.
Over the years, different diagnostic labels have been used, such as autism, autism spectrum disorder (ASD), autism spectrum condition (ASC), classic autism, Kanner autism, pervasive developmental disorder (PDD), high-functioning autism (HFA), Asperger syndrome and Pathological Demand Avoidance (PDA). This reflects the different diagnostic manuals and tools used, and the different autism profiles presented by individuals. Because of recent and upcoming changes to the main diagnostic manuals, ‘autism spectrum disorder’ (ASD) is now likely to become the most commonly given diagnostic term.
The exact cause of autism is still being investigated. Research into causes suggests that a combination of factors – genetic and environmental – may account for differences in development. Autism is not caused by a person’s upbringing, their social circumstances and is not the fault of the individual with the condition.
One of the most significant public health measures implemented during the COVID-19 pandemic has been extended periods of ‘lockdown’ where whole populations have been advised to remain in their households other than to collect necessary supplies, to care for others, or to exercise.
There are increasing calls to understand the impacts of this lockdown, and of subsequent school closures, on the mental health and wellbeing of children and young people during the COVID-19 pandemic1-5. As lockdown measures begin to ease, we require an understanding of what children and young people have been experiencing during the lockdown period1 as well as how children and young people can be best supported to resume to normal life, or the ‘new normal’, over the coming months and years. This understanding can inform responses to recovery implemented at the policy level and by those working directly with children and young people. Such responses are beginning to be formalised in other countries. For example, the New Zealand Government have published a national psychosocial and wellbeing recovery framework with a focus on prevention and early intervention upheld through the principles of collectivity, empowerment, community solutions, assets-focus, and support for community and specialist services.
In this evidence overview, we consider empirical studies of the impacts of lockdown of both COVID-19, and of similar previous health-related disasters, to identify important considerations about the mental health and wellbeing impacts of lockdown, both positive and negative, on children and young people. By similar health-related disasters in the past, we refer to previous pandemics, epidemics, and other health disasters. Given that much of the literature in this space is not focused specifically on the mental health and wellbeing of children and young people1 , we consider the empirical evidence of impacts across three areas:
1. The individual: Direct impacts on children and young people’s mental health and wellbeing
2. The interpersonal/family: Impacts within the family context
3. The school: Impacts within the context of education
Based on our findings, we consider policy and practice recommendations that can help to inform solutions and responses to the challenges facing children and young people, their families, and those who work with these groups. As a result, this overview is focussed predominantly on the problem. This is an emerging situation evidence of effective interventions are limited. As such, we hope that by broadly contextualising some of the mental health impacts and challenges for children and young people, that decision-makers have more informed scope to develop effective programmes and interventions to support children and young people going forward.
Approach to reviewing literature
This evidence overview used the following structured approach to identify key pieces of empirical literature to include. The focus was on empirical research and therefore we include both primary research articles and articles analysing secondary data or conducting systematic/ rapid reviews of empirical literature.
To begin with we focussed on a wide set of events which could be considered similar to COVID-19. Initially, this included pandemics, epidemics, health disasters, natural disasters, and conflict zones. The hits on this wide search were large, so we decided to focus on health-related disasters more narrowly. Indicative search terms relating to health-related disasters include: pandemic OR endemic OR covid OR coronavirus OR SARS OR MERS OR H1N1 OR ebola OR health NEAR/2 [N1] disaster OR outbreak OR isolate* OR quarantine OR social distanc* OR home confin*. Searches were then refined to focus on mental health and wellbeing impacts and children and young people. This overview includes only articles printed in English. Searches were undertaken in the Web of Science and PsychInfo databases. Thereafter, the reference lists of relevant articles were reviewed to identify additional relevant articles. In the overview of evidence, we also consulted available findings from several large-scale surveys of the mental health impacts of COVID-19 that relate to the potential impacts of lockdown. The surveys include but are not limited to: Mental Health in the Pandemici , Lockdown Lowdownii, Co-SPACEiii & Co-SPYCE studies, Office for National Statistics routine survey of 16+iv, and the Carers Trust Survey of Young carersv.
Key findings
The individual: direct impacts on children and young people’s mental health and wellbeing
The direct impact of lockdown on the mental health and wellbeing of children and young people yields mixed findings. Findings center on the mental health and wellbeing impacts of lockdown and the factors affecting mental health and wellbeing.
Mental health and wellbeing impacts of lockdown for children and young people
In some cases, where quarantine was not at the population level, e.g. only required for those with contact with infected persons, one study on the impacts in the context of the H1N1 influenza found no immediate negative psychological effect of quarantine for undergraduate students7 . However, in the case of the SARS epidemic, stress scores for Post-Traumatic Stress Disorder (PTSD) were reported by parents to be 4 times higher in children quarantined than those not quarantined8,9: in this case, criteria for PTSD was met by 30% of quarantined children. A study from India, during the COVID-19 pandemic, yields similar results10 and further studies conducted in China find that young people report increased depressive symptoms and anxiety symptoms11 and can experience negative psychological consequences as a result of the COVID-19 pandemic12.
Qualitative evidence indicates a number of reasons for these findings including the perceived threat of the virus, confusion, disruption, and isolation imposed by this type of health-related crisis8. Other studies have found that levels of distress were higher in young adults as a potential consequence of increased consumption of social media for example13,14. Emerging evidence from the COVID-19 pandemic in the UK suggests similar trends that young people, in particular teenagers, in the UK are feeling more anxious than they did before the outbreak, a trend which is up to 10% higher for black and mixed race participants15. Further evidence of the mental health and wellbeing impacts of this kind of quarantine related to both the fear of stigma and the stigma experienced by those young people who had been quarantined and returned to college16 which this study identifies as a risk factor for maintaining social support mechanisms with friends, classmates, or roommates post-quarantine.
Young carers are one group whose mental health has been negatively impacted by the lockdown restrictions. A survey of nearly 1000 young carers in the UK found that over half of young carers have felt overwhelmed and stressed and have, as a result, suffered worsened mental health during the a. The individual: direct impacts on children and young people’s mental health and wellbeing 7 lockdown period17. Around a third of those surveyed said they struggled to get emotional support with some respondents saying they had increased their alcohol intake as a result of the stresses they were feeling, and were struggling to take care of themselves. The survey identified that young carers require more practical support in coping with day to day life, but also more access to peer support, either online or in-person.
Factors affecting the mental health and wellbeing of children and young people
Loneliness
Loneliness is considered as a key risk factor of lockdown for the mental health and wellbeing of children and young people. A rapid review of the links between loneliness and mental health highlights the potential for increases in children and young people experiencing loneliness to link to mental health problems in children and young people18. However, it is important to note that experiences of loneliness involve some form of social comparison, and in the UK case, the shared experience of lockdown might mitigate the negative impacts of loneliness to some extent18. Yet, emerging evidence of the impact of the COVID-19 pandemic suggests that, despite the shared experience of lockdown, children and young people are experiencing loneliness. Emerging evidence suggests that, amongst the general population in the UK, the proportion of adults experiencing loneliness is highest amongst young adults aged 18-2419, with another survey identifying that 50% of 16-24 year-olds have experienced ‘lockdown loneliness’20. This could, as the literature suggests, be a consequence of the loss of peer group support during this important developmental stages where peer interaction is important for brain development, self-concept construction, and ultimately mental health and wellbeing18,21. #
Worries about school and the future
Emerging evidence from the COVID-19 pandemic also suggests several other factors influencing the mental health and wellbeing of children and young people including: worries and concerns around their education (all ages), missing school (all ages), transitions and being away from school (primary school age), academic pressures (secondary school age), their career (young adults), and uncertainties about the future more generally (young adults)19,22,23. Similarly, in the case of children and young people currently in contact with youth justice systems, it has similarly been reported that lack of contact with others, boredom, not being able to attend school, financial worries and general uncertainty about the future are key factors impacting mental health and wellbeing24.
Supporting mental health and wellbeing
One study has found that a majority of participating parents report that their children are keeping in regular contact with family and friends via video-chat and are getting regular physical exercise25, factors that can support the mental health and wellbeing of children and young people21. However, this was not the case with pre-school age children in one survey, where parents had concerns about their children’s lack of communication with others outside the household26.
The interpersonal/family: impacts within the family context/on parents and carers
An important consideration about the impact of quarantine is the impact on both the relational family contexts in which children and young people are isolating, and the impacts on the mental health and wellbeing of parents/ caregivers more generally. This is particularly important to consider given the wide range of literature evidencing the long-term health and wellbeing impacts of traumatic events that occur during childhood27. Such traumatic events include but are not limited to the experience of or witnessing violence, abuse, and neglect in the household, substance abuse, mental health problems, and parental separation and, overall, a lack of sense of safety, stability and bonding within the household28.
Mental health and wellbeing impacts of lockdown on parents/carers
For a variety of reasons, quarantine can be traumatising for some parents8. In a study on post-traumatic stress disorder in health-related disasters, criteria for PTSD was met in 25% of isolated or quarantined parents8. The same study found links between PTSD criteria in adults and their children having PTSD symptoms8. Duration of quarantine and consequent lack of social and physical contact with friends/family and the outside world has been shown to be associated with increased PTSD symptoms29. Similarly, it has been shown that social isolation and associated loneliness have a negative impact on mental health outcomes for adults30. Other factors that have been shown to have an impact on stressors and wellbeing9 include the duration of quarantine, fear of infection, frustration and boredom, inadequate supplies and information (guidelines, rationale for actions, and level of risk), loss of work or working more than usual31, or COVID-19 related stressful life events e.g. bereavement/having an acquaintance infected14,31,32. The links between experience of COVID-19 related stressful life events and increased stress were shown to be the case in one study regardless of previous mental illness or childhood trauma31.
Impacts on key workers
The psychological impacts are particularly important to consider in cases where parents are front-line workers4 with much evidence showing that those working in health care in particular, experience negative psychological consequences during health emergencies33,34. Moreover, in the case of healthcare workers, quarantine has been associated with distress, exhaustion, detachment, anxiety, and PTSD symptoms over time9, all of which will impact upon the home environment. Worryingly, the same study identified that alcohol abuse and dependency, and avoidance behaviours were positively associated with workers having been quarantined9 , all of which have been shown to have negative effects on the mental health and wellbeing of children in such households28. One UK-based study has found that children (aged 13-24) of key workers have experienced greater levels of COVID-19 anxiety and trauma and also report more somatic symptoms15.
Factors affecting mental health and wellbeing in the context of the family
Groups disproportionately affected by lockdown
There is mixed evidence of the factors associated with pre-quarantine predictors of impact on mental health and wellbeing. Some factors associated with negative effects on the mental health and wellbeing of adults include those that are younger9,13,31,35, female9,13,14,31,32,33,35,36, with a history of psychiatric illness or chronic illness/ poor health (diagnosed or selfreported) 14,31,32,33,35,36, and single parent adolescents1 . There is mixed evidence on the impact of education level as a predictor of impact of lockdown on mental health9,13,36. Post-quarantine stressors can include: finances9,37 and stigma for healthcare workers9 . At a broader level, Harkins has identified that there are several groups who have experienced, and are still experiencing, disproportionate vulnerability to the ‘lockdown’ public health measures32. These groups include: disadvantaged communities, people with disabilities, BAME groups, people experiencing homelessness, those affected by violence, older people, and frontline health and care staff32. Particular note should also be given to the increases in both calls and referrals to domestic abuse charities38,39, with the mental health impacts this has for the victim, and to the children and young people witnessing or experiencing such abuse, being of primary concern as we emerge from lockdown.
Worries about financial security, homelife, and the future
Emerging evidence from the COVID-19 pandemic suggests that in general, many adults are feeling anxious or worried about the future. In particular, adults who are unemployed have reported not coping as well19 with a quarter of this group feeling hopeless with primary concerns around financial security19. Parents who are working have also reported difficulties in balancing the needs of their child with the demands of working23. Moreover, parents with children with special educational needs/ neurodevelopmental disorders have reported that they were experiencing higher levels of stress and require more support to cope with changes in their children’s behaviour23. One study has reported that difficulties in relationships and conflict within the family home are problematic for children and young people, particularly those with experience of the youth justice system24.
The school: Impacts within the context of education
Lockdown related school closures has been one of the most significant public health measures across the world. For children and young people in the UK , this has been the first extended closure of schools in recent history and as such, its impact on their mental health and wellbeing is important to consider, particularly given the already contentious nature of the effectiveness of school closures on disease containment1,40 and the fact that school is often the first place that children and young people can and do seek support for their mental health and wellbeing4.
Worries about education
An extended period of school closures will no doubt impact curriculum delivery over the coming years and as such, school is an emerging source of distress and worry for children and young people17,19,41. In particular, young adults are experiencing concerns about their education being interrupted and their future career opportunities19. Young carers have also reported concerns about their education, with half of those surveyed in one study reporting that their education has suffered as a result of increased caring responsibilities and associated stresses17. With respect to returning to school, children and young people have reported having worries over losing the enjoyable aspects of school and the impact of social distancing on friendships. In particular, one surveyreports that primary aged children worry about being away from home and transitioning between schools, whereas secondary aged children worry about increased academic pressures as well as catching COVID-1942. Moreover, a case study of a group of quarantined students during the SARS outbreak found that the students experienced stigma upon returning to their studies due to their contact with infection16, a factor which is important to consider should we experience more localised lockdown measures during future outbreaks of COVID-19.
Factors affecting the delivery of education
Disadvantage and engagement with curriculum
In terms of the delivery of education during lockdown, there has been concern over the exclusion of children without digital access, physical space, and other resources to support their learning43. Emerging evidence from England suggests that there has been a substantial deficit in curriculum coverage across schools, that just over half of parents are engaged with their children’s home learning, and that less than half of pupils had returned their last piece of work at the time the survey was undertaken43. In this particular survey, teachers expressed concern over the engagement of the most disadvantaged pupils with the analysis finding that the level of disadvantage of the school being influential on pupil engagement43. Variability in engagement with the curriculum will potentially have differing effects on both the development and mental health of pupils returning to school43. Moreover, those receiving free school meals may have experienced increasing food insecurity, although recent policy changes reflect governments’ commitment to continuing such funding over the summer break this year44.
School responses
In previous outbreaks, there has been variability in school responses to public health measures. In one study, despite highly consistent evidence of duty of care, schools varied in extent to which information was shared openly and transparently; in how responsive school decision-makers were to the changing situation45. In this study, schools had reservations about the need for closures/quarantine, including a lack of understanding about the rationale for this action45. The study concludes that there needs to be high levels of trust between schools, public officials, and governments. School closures worked where there were high levels of trust between key players. The findings here highlight the importance of schools as agents of public health and the significance of their role in response to such crises45. This variability in response may have implications for parents and children. For example, there may be parental concerns about going back to school23, particularly worries around the child being upset and not understanding social distancing measures and so increasing their chances of catching/transmitting COVID-19. In this survey, these findings were particularly relevant in cases where children has special educational needs/ neurodevelopmental disorders, or for parents with lower incomes23.
Policy and practice implications for suppor ting children and young people
The overview of evidence presented here highlights some of the needs children and young people may have going forward, as lockdown measures begin to ease, and children return to school. Echoing earlier calls1, there seem to be several areas where attention is required, highlighting the need for a multi-disciplinary and multi-sectoral responses going forward3. Given the emerging nature of the COVID-19 pandemic, evidence for effective support mechanisms for children and young people is lacking. Nevertheless, we use the findings presented here, on the evidence of the problem, to highlight several areas for consideration for those developing programmes, interventions, and support for children and young people going forward.
a. Supporting the mental health and wellbeing of children and young people
Validating experiences
Many children and young people have likely experienced loneliness during lockdown and in particular, been affected by lack of physical contact with their friends, families and peers, and the boredom and frustration associated with a loss of all the activities they have been used to taking part in. Moreover, many children and young people have experienced worries and distress about their education and returning to school. It therefore seems important to facilitate support for children and young people that allows them to talk through some of these shared experiences and in turn, validating their experience of lockdown, whilst simultaneously informing them of what is being done to ensure their return to school and education is impacted as little as possible. For example, in one post-quarantine study of young students, students benefited from sense of connection developed with group and validating their experiences with peers, and through gaining reliable information to ease early anxieties16. Success factors associated with this particular case of group work included a combination of psychoeducational, interpersonal, and effective elements introduced in a phased, structured approach over 5 weeks16.
Continued communication about COVID-19
It is important that there is continued provision of clear information about COVID-1946, the rationale and guidelines for both public health measures and for supporting mental health and wellbeing for children and young people, in terms which are accessible for these groups. It is recommended that such communication continues for the foreseeable, beyond the easing of lockdown measures and return to school. Young Scot for example have provided access to a ‘jargon buster’ webpage on their website which communicates information about coronavirus in accessible ways: https://young.scot/ get-informed/national/coronavirusjargonbuster and provides information on the ways in which coronavirus is directly impacting children and young people.
b. Identifying and supporting vulnerable groups of children and young people
This overview has also identified that those children and young people living in families where the experience of lockdown may have been particularly difficult and challenging may require additional support to deal with the mental health and wellbeing impacts of lockdown. For example, the findings from several of the studies presented suggest that families that are young, have parents with a long-term physical or mental health conditions, have low household incomes/unemployment, or those that have experienced a COVID-19 related stressful life experience may have had particularly difficult experiences of lockdown. These are groups that may require additional support in making sense of and coping with their experiences of lockdown, particularly within the context of family support.
One study included in this overview highlights that those working with vulnerable groups should adopt a traumainformed approach to understanding the impacts of lockdown on such groups during health-related crises8 in order to understand the different biopsychosocial reactions to the pandemic. The authors here suggest utilising a traumatic stress framework to organising response to provide appropriate evidence-informed care to vulnerable groups. From a policy perspective it will be important to continue to support vulnerable groups as we move out of lockdown. For example, informing policy through a trauma-informed perspective will be an important part of adequately supporting vulnerable families to begin shifting out of lockdown, especially in cases where the experience of lockdown has been particularly difficult. Similarly, some have highlighted the value of community responses to recovery32 whereby policy should: incorporate the views and insights of community members, particularly the most vulnerable; policy should work with communities to identify and develop responses that are innovative and flexible to local circumstances and to build social cohesion; and should endorse community-based support to enhance mental health and wellbeing.
c. Returning to school
Clear communication about returning to school
This overview has identified evidence that both parents and children and young people are experiencing worry and distress about the return to school, both in terms of the process of returning to school safely and the impact on their educational experience, curriculum delivery and future prospects. Therefore, providing clear information and communication to both parents and children about the return to school will be important. This will include ensuring clarity over processes for returning to school safely, what the school-day will look like, and curriculum delivery. Evidence from experiences during the H1N1 pandemic suggest that clear communication and support from government (national and local) in facilitating the safe re-opening of schools is important. The study highlights that trust between schools and government officials will be central to enabling a safe re-opening of schools in a consistent way for all children and young people45. Young people have also expressed worries about how lockdown will affect their educational and career prospects. It is therefore also important to ensure that schools are providing support and reassurance to children and young people on how schools will support them to continue to sit exams and apply for further education/higher education/jobs.
Supporting those who have struggled to engage with the curriculum during lockdown
Additional guidance and support at the policy level will help schools support those children and young people for whom lockdown has been particularly challenging in terms of engagement with virtual learning, including those with no access to digital technologies and physical space to do school work, or those children and young people with special educational needs.
Research implications
There are many studies emerging of the impact of COVID-19 on the mental health and wellbeing of the population. We can also learn from similar events in the past, but evidence in such cases should be interpreted with caution given the differences between events and subsequent localised policy response. Based on the findings of this study, there is a need to understand the mental health and wellbeing impacts for children and young people, and particularly those in vulnerable groups and for whom lockdown has been particularly challenging.
The long-term effects for these groups will also require attention. In the case of education, research should continue to track the impacts of this extended period of lockdown on the delivery of the curriculum and of the process of returning to school. This learning is important for future outbreaks, but also in terms of coping with subsequent periods of lockdown should they be required in the case of a second wave of COVID-19. Moreover, as support is developed for children and young people and their families, careful attention should be paid to the evaluation of the effectiveness of such support, particularly for those groups mentioned above, for whom experiences of lockdown may have been particularly difficult.
Limitations
There are several limitations of this overview of evidence:
Whilst a structured approach to searching the literature was adopted, this was not a systematic search and as such, some relevant literature may have been omitted. Nevertheless, by searching the reference lists of identified studies, we hope that this overview provides a good coverage of empirical literature.
In terms of articles included in this review, there was no assessment of the quality of empirical studies. Moreover, the findings of different studies cannot be compared due to differences in methodology and measurement tools. This means that findings presented should be interpreted with caution.
The use of survey data is useful to contextualise academic research. However, it should be noted that included survey data are from a number of surveys, using different methodologies, and sampling strategies which are not necessarily representative of whole populations.
The findings and recommendations of this overview should be interpreted given differences of past pandemics and differences in international policy responses. Direct comparisons between events and policy responses is therefore not possible. For example, findings from the SARS epidemic should be interpreted considering a particularly high mortality rate when infected with SARS. Moreover, in past events the definition of ‘quarantine’47 may refer to individualised instances of isolation, rather than the population level lockdown experienced in the UK during the COVID-19 pandemic.
As this is an emerging phenomenon, and even though research on the impacts of COVID-19 is developing at great pace, there is still much to learn about this phenomenon, particularly its long-term impacts. These longerterm impacts should be the primary focus of researchers going forward.
Conclusions
This overview sought to provide an overview of evidence on the mental health and wellbeing impacts of lockdown for children and young people during both the COVID-19 pandemic and during similar events in the past.
Whilst studies yielded mixed findings, the findings presented here reflect not only evidence on the direct impacts to the mental health and wellbeing of children and young people but also Impacts of lockdown on the mental health and wellbeing of children and young people 16 how the challenges in the context of families and education can influence their mental health and wellbeing. As a result, it is recommended that policymakers and those working with children and young people develop and support multidisciplinary and multisectoral responses that ease the anxieties and worries of this group more broadly, but also identify and support those for whom lockdown will have been most challenging.
Schizophrenia is a chronic and severe mental disorder affecting 20 million people worldwide (1).
Schizophrenia is characterized by distortions in thinking, perception, emotions, language, sense of self and behaviour. Common experiences include hallucinations (hearing voices or seeing things that are not there) and delusions (fixed, false beliefs).
Worldwide, schizophrenia is associated with considerable disability and may affect educational and occupational performance.
People with schizophrenia are 2-3 times more likely to die early than the general population (2). This is often due to preventable physical diseases, such as cardiovascular disease, metabolic disease and infections.
Stigma, discrimination and violation of human rights of people with schizophrenia is common.
Schizophrenia is treatable. Treatment with medicines and psychosocial support is effective.
Facilitation of assisted living, supported housing and supported employment are effective management strategies for people with schizophrenia.
Symptoms
Schizophrenia is a psychosis, a type of mental illness characterized by distortions in thinking, perception, emotions, language, sense of self and behaviour. Common experiences include:
hallucination: hearing, seeing or feeling things that are not there;
delusion: fixed false beliefs or suspicions not shared by others in the person’s culture and that are firmly held even when there is evidence to the contrary;
abnormal behaviour: disorganised behaviour such as wandering aimlessly, mumbling or laughing to self, strange appearance, self-neglect or appearing unkempt;
disorganised speech: incoherent or irrelevant speech; and/or
disturbances of emotions: marked apathy or disconnect between reported emotion and what is observed such as facial expression or body language.
Magnitude and impact
Schizophrenia affects 20 million people worldwide but is not as common as many other mental disorders. Schizophrenia also commonly starts earlier among men.
Schizophrenia is associated with considerable disability and may affect educational and occupational performance.
People with schizophrenia are 2 – 3 times more likely to die early than the general population (2). This is often due to physical illnesses, such as cardiovascular, metabolic and infectious diseases.
Stigma, discrimination and violation of human rights of people with schizophrenia is common.
Causes of schizophrenia
Research has not identified one single factor. It is thought that an interaction between genes and a range of environmental factors may cause schizophrenia.
Psychosocial factors may also contribute to schizophrenia.
Services
More than 69% of people with schizophrenia are not receiving appropriate care (3). Ninety per cent of people with untreated schizophrenia live in low- and middle- income countries. Lack of access to mental health services is an important issue. Furthermore, people with schizophrenia are less likely to seek care than the general population.
Management
Schizophrenia is treatable. Treatment with medicines and psychosocial support is effective. However, most people with chronic schizophrenia lack access to treatment.
There is clear evidence that old-style mental hospitals are not effective in providing the treatment that people with mental disorders need and violate basic human rights of persons with mental disorders. Efforts to transfer care from mental health institutions to the community need to be expanded and accelerated. The engagement of family members and the wider community in providing support is very important.
Programmes in several low- and middle- income countries (e.g. Ethiopia, Guinea-Bissau, India, Iran, Pakistan and United Republic of Tanzania) have demonstrated the feasibility of providing care to people with severe mental illness through the primary health-care system by:
training primary health-care personnel;
providing access to essential drugs;
supporting families in providing home care;
educating the public to decrease stigma and discrimination;
enhancing independent living skills through recovery-oriented psychosocial interventions (e.g. life skills training, social skills training) for people with schizophrenia and for their families and/or caregivers; and
facilitating independent living, if possible, or assisted living, supported housing and supported employment for people with schizophrenia. This can act as a base for people with schizophrenia to achieve recovery goals. People affected by schizophrenia often face difficulty in obtaining or retaining normal employment or housing opportunities.
Human rights violations
People with schizophrenia are prone to human rights violations both inside mental health institutions and in communities. Stigma of the disorder is high. This contributes to discrimination, which can in turn limit access to general health care, education, housing and employment.
WHO response
WHO’s Mental Health Gap Action Programme (mhGAP), launched in 2008, uses evidence-based technical guidance, tools and training packages to expand service in countries, especially in resource-poor settings. It focuses on a prioritized set of conditions, directing capacity building towards non-specialized health-care providers in an integrated approach that promotes mental health at all levels of care. Currently mhGAP is being implemented in more than 100 WHO Member States.
The WHO QualityRights Project involves improving the quality of care and human rights conditions in mental health and social care facilities and to empower organizations to advocate for the health of people with mental disorders.WHO’s Mental Health Action Plan 2013-2020, endorsed by the World Health Assembly in 2013, highlights the steps required to provide appropriate services for people with mental disorders including schizophrenia. A key recommendation of the Action Plan is to shift services from institutions to the community.
Cherie became a mental health nurse after suffering post-natal depression as a teenager. Her career took off from there and she isn’t looking back.
Cherie LawrenceMental health nurseEmployer or universityNottinghamshire Healthcare NHS TrustSalary range£20k-£30k
What made you decide to become a mental health nurse?
I became a mother unexpectedly at 17 and suffered from (post-natal) depression both during and after my pregnancy. Unfortunately at the time there wasn’t really that much information out there and neither me or my family really understood the condition. My doctor couldn’t offer much help either.
To try and understand it better I did a community mental health course and discovered a passion for the subject – I found it really fascinating.
At school, like many teenagers I didn’t really know what I wanted to do, but I had from quite a young age always admired nurses, after all we trust our lives with them don’t we – they’re the backbone of the NHS. So when I discovered a passion for the subject of mental health, becoming a mental health nurse seemed like the obvious thing to do. I also felt like becoming a mental health nurse would help me be a really positive role model for my daughter.
How did you become a mental health nurse?
I studied for my degree in mental health nursing at Nottingham University – I was actually the first person in my family to go to university, which was a little scary but I needn’t have worried as there’s so much support out there for nursing students.
I really enjoyed my degree and particularly the variety of placements I was given – I was able to get really valuable experience of working in hospital and community settings, with young people and old, including placements in forensics and working with people with functional dementia.
Nurses and particularly mental health nurses are really in demand so I was contacted about job opportunities all the way through my degree and was offered a choice of four jobs when I graduated! Being a nurse means that unlike quite a lot of other professions, you have a guaranteed job for life, which means I’m never going to have to worry about getting a job and providing for my daughter.
I’m so glad I chose to work for Nottinghamshire Healthcare, as they offer so much support and help for newly qualified nurses. I think some people worry about the responsibility they’ll have once they’re doing the job for real but Nottingham, like other Trusts runs an amazing preceptorship programme which helps bridge the gap between being a student nurse and a qualified nurse. They make sure you’re really supported, with regular group meetings and one to ones where you can discuss anything you need to and they make sure you have access to further training, such as safeguarding training.
I also love that I have a guaranteed job for life, which I enjoy – a lot of my friends are jealous!
What I do
I get to work with a variety of people and importantly, no two days are the same, I go to work each day never knowing what to expect, which keeps things really interesting.
I work with a range of patients on the ward, some of whom are very vulnerable and I work as part of a multi-disciplinary team, who are really supportive of each other. I think some people have a view that mental health nursing must be really tough and whilst there are challenging times there are also lots of lovely things that we get to do with patients as well, on a 1 to 1 basis, like taking them out for a walk or shopping in town. This helps give them some normality and experience of life outside the ward and I really enjoy this aspect of the job.
The best bits
I love my job so it’s difficult to know where to start – I love the variety and how rewarding it is to see the difference we make to the lives of our patients. I also love that I have a guaranteed job for life, which I enjoy – a lot of my friends are jealous!
What’s next and top tips for others
Nottingham is a fantastic pace to work, not only is there lots of ongoing training to take part in but other opportunities as well, so I’ll definitely be here for the foreseeable future. I’ll be becoming a mentor in the next six months and hope to complete a Master’s in the next three years.
I think it’s really important for students to understand how much support and help there is out there for student and newly qualified nurses, how varied the job is and the opportunities that are out there for developing your career in the direction you want to and continuing to learn new skills.
If your primary care provider suspects you have bulimia, he or she will typically:
Talk to you about your eating habits, weight-loss methods and physical symptoms
Do a physical exam
Request blood and urine tests
Request a test that can identify problems with your heart (electrocardiogram)
Perform a psychological evaluation, including a discussion of your attitude toward your body and weight
Use the criteria for bulimia listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association
Your primary care provider may also request additional tests to help pinpoint a diagnosis, rule out medical causes for weight changes and check for any related complications.
Treatment
When you have bulimia, you may need several types of treatment, although combining psychotherapy with antidepressants may be the most effective for overcoming the disorder.
Treatment generally involves a team approach that includes you, your family, your primary care provider, a mental health professional and a dietitian experienced in treating eating disorders. You may have a case manager to coordinate your care.
Here’s a look at bulimia treatment options and considerations.
Psychotherapy
Psychotherapy, also known as talk therapy or psychological counseling, involves discussing your bulimia and related issues with a mental health professional. Evidence indicates that these types of psychotherapy help improve symptoms of bulimia:
Cognitive behavioral therapy to help you normalize your eating patterns and identify unhealthy, negative beliefs and behaviors and replace them with healthy, positive ones
Family-based treatment to help parents intervene to stop their teenager’s unhealthy eating behaviors, to help the teen regain control over his or her eating, and to help the family deal with problems that bulimia can have on the teen’s development and the family
Interpersonal psychotherapy, which addresses difficulties in your close relationships, helping to improve your communication and problem-solving skills
Ask your mental health professional which psychotherapy he or she will use and what evidence exists that shows it’s beneficial in treating bulimia.
Medications
Antidepressants may help reduce the symptoms of bulimia when used along with psychotherapy. The only antidepressant specifically approved by the Food and Drug Administration to treat bulimia is fluoxetine (Prozac), a type of selective serotonin reuptake inhibitor (SSRI), which may help even if you’re not depressed.
Nutrition education
Dietitians can design an eating plan to help you achieve healthy eating habits to avoid hunger and cravings and to provide good nutrition. Eating regularly and not restricting your food intake is important in overcoming bulimia.
Hospitalization
Bulimia can usually be treated outside of the hospital. But if symptoms are severe, with serious health complications, you may need treatment in a hospital. Some eating disorder programs may offer day treatment rather than inpatient hospitalization.
Treatment challenges in bulimia
Although most people with bulimia do recover, some find that symptoms don’t go away entirely. Periods of bingeing and purging may come and go through the years, depending on your life circumstances, such as recurrence during times of high stress.
If you find yourself back in the binge-purge cycle, follow-up sessions with your primary care provider, dietitian and/or mental health professional may Dechelp you weather the crisis before your eating disorder spirals out of control again. Learning positive ways to cope, creating healthy relationships and managing stress can help prevent a relapse.
If you’ve had an eating disorder in the past and you notice your symptoms returning, seek help from your medical team immediately.
Lifestyle and home remedies
In addition to professional treatment, follow these self-care tips:
Stick to your treatment plan. Don’t skip therapy sessions and try not to stray from meal plans, even if they make you uncomfortable.
Learn about bulimia. Education about your condition can empower you and motivate you to stick to your treatment plan.
Get the right nutrition. If you aren’t eating well or you’re frequently purging, it’s likely your body isn’t getting all of the nutrients it needs. Talk to your primary care provider or dietitian about appropriate vitamin and mineral supplements. However, getting most of your vitamins and minerals from food is typically recommended.
Stay in touch. Don’t isolate yourself from caring family members and friends who want to see you get healthy. Understand that they have your best interests at heart and that nurturing, caring relationships are healthy for you.
Be kind to yourself. Resist urges to weigh yourself or check yourself in the mirror frequently. These may do nothing but fuel your drive to maintain unhealthy habits.
Be cautious with exercise. Talk to your primary care provider about what kind of physical activity, if any, is appropriate for you, especially if you exercise excessively to burn off post-binge calories.
Alternative medicine
Dietary supplements and herbal products designed to suppress the appetite or aid in weight loss may be abused by people with eating disorders. Weight-loss supplements or herbs can have serious side effects and dangerously interact with other medications.
Weight-loss and other dietary supplements don’t need approval by the Food and Drug Administration (FDA) to go on the market. And natural doesn’t always mean safe. If you choose to use dietary supplements or herbs, discuss the potential risks with your primary care provider.
Coping and support
You may find it difficult to cope with bulimia when you’re hit with mixed messages by the media, culture, coaches, family, and maybe your own friends or peers. So how do you cope with a disease that can be deadly when you’re also getting messages that being thin is a sign of success?
Remind yourself what a healthy weight is for your body.
Resist the urge to diet or skip meals, which can trigger binge eating.
Don’t visit websites that advocate or glorify eating disorders.
Identify troublesome situations that trigger thoughts or behaviors that may contribute to your bulimia, and develop a plan to deal with them.
Have a plan in place to cope with the emotional distress of setbacks.
Look for positive role models who can help boost your self-esteem.
Find pleasurable activities and hobbies that can help distract you from thoughts about bingeing and purging.
Build up your self-esteem by forgiving yourself, focusing on the positive, and giving yourself credit and encouragement.
Get support
If you have bulimia, you and your family may find support groups helpful for encouragement, hope and advice on coping. Group members can truly understand what you’re going through because they’ve been there. Ask your doctor if he or she knows of a group in your area.
Coping advice for parents
If you’re the parent of someone with bulimia, you may blame yourself for your child’s eating disorder. But eating disorders have many causes, and parenting style is not considered a cause. It’s best to focus on how you can help your child now.
Here are some suggestions:
Ask your child what you can do to help. For example, ask if your teenager would like you to plan family activities after meals to reduce the temptation to purge.
Listen. Allow your child to express feelings.
Schedule regular family mealtimes. Eating at routine times is important to help reduce binge eating.
Let your teenager know any concerns you have. But do this without placing blame.
Remember that eating disorders affect the whole family, and you need to take care of yourself, too. If you feel that you aren’t coping well with your teen’s bulimia, you might benefit from professional counseling. Or ask your child’s primary care provider about support groups for parents of children with eating disorders.
Preparing for your appointment
Here’s some information to help you get ready for your appointment, and what to expect from your health care team. Ask a family member or friend to go with you, if possible, to help you remember key points and give a fuller picture of the situation.
What you can do
Before your appointment, make a list of:
Your symptoms, even those that may seem unrelated to the reason for your appointment
Key personal information, including any major stresses or recent life changes
All medications, vitamins, herbal products, over-the-counter medications or other supplements you’re taking, and their dosages
Questions to ask your doctor, so you can make the most of your time together
Some questions to ask your primary care provider or mental health professional include:
What kinds of tests do I need? Do these tests require any special preparation?
What treatments are available, and which do you recommend?
Is there a generic alternative to the medicine you’re prescribing for me?
How will treatment affect my weight?
Are there any brochures or other printed material I can have? What websites do you recommend?
Don’t hesitate to ask other questions during your appointment.
What to expect from your doctor
Your primary care provider or mental health professional will likely ask you a number of questions. He or she may ask:
How long have you been worried about your weight?
Do you think about food often?
Do you ever eat in secret?
Have you ever vomited because you were uncomfortably full?
Have you ever taken medications for weight loss?
Do you exercise? If so, how often?
Have you found any other ways to lose weight?
Are you having any physical symptoms?
Have any of your family members ever had symptoms of an eating disorder, or have any been diagnosed with an eating disorder?
Your primary care provider or mental health professional will ask additional questions based on your responses, symptoms and needs. Preparing and anticipating questions will help you make the most of your appointment time.
Disablities & Mental Health Issues 