Editor’s note: Dr. Joe Burley is a psychiatrist who works with the Prince Edward County Family Health Team.  A Picton native who now commutes regularly from Kingston to his office at the Habourview Clinic, Burley has been a psychiatrist for 35 yrs and practiced medicine for 42 yrs. Earlier this year, Dr. Burley wrote an article about the effects of the COVID-19 Pandemic and related life changes on mental health and now presents his thoughts on pandemic-induced stress during a time when families in our community are facing the stress of the holiday season.

When her eyes opened in the morning there were a few moments of peaceful semi awareness.  Then as she came to consciousness she felt a tightening and a feeling of lethargy and dread.   Thoughts and feelings came to her, unbidden, of the day ahead….the absence of possibility, the isolation and absence of others in her life, watching her children marching off to the strangeness of school with masks and sanitizing surfaces, her mother alone in a nursing home who she had not seen in weeks.  The dread was in part, facing a day of guilt and shame about her powerlessness to do anything about these facts.  As she went down the stairs she became aware of her body.  She had given up on trying to maintain her weight and she felt heavy and ugly.  

Her mind was gluey with stunted thoughts and confusion about what she wanted to do.  Mostly she wanted to crawl back under the covers and hide.  But again, that was infused with guilt and shame for even thinking it. No, she had to drag herself from her bed and begin the push to make herself do the tasks that brought little joy or meaning.  When she went downstairs, she greeted her family with a smile that felt like someone else’s face.  When she went to her virtual job  to start her day she felt fear she would not be able to do it…..her confidence had waned in the last few weeks.  Her sleep was poor and she knew by mid day she would want to break and lie down.  When she got into her day with customers and co-workers things began to flow a little easier and the worry and negative emotions receded to the background.  But then the thoughts and fears and the awareness of her life and herself would intrude accompanied by a vague sense of fear and helplessness.  She wasn’t sure how long her company would last and when she might be out of a job.  Then there would be bills that couldn’t be paid and mortgages due.

When all of this (pandemic) had started several months ago she had not imagined being here months later still trying to do as she was told, with her life being limited by rules and masks and handwashing.  And now they say the coming storm of the COVID winter will be the worse yet.  They say the vaccine will take months to get to enough people so we can stop all of this.  The numbers are going up and there is more tension and disagreement about how we should be handling it.  More and more she heard others saying they were so tired of this and wanted it to be over.  And going out now brought with it an anxiety about who she couldn’t stop and talk to, or conflict with someone who was not wearing a mask or social distancing. She felt a tiredness….what she called the “big tired”… a feeling of soul exhaustion. The future seemed so vague, the ability to plan anything was stunted.  Winter was coming and it did not look promising.  Some days she just felt anger wanted to say “screw it” and get on a bus, train or plane and just leave it all behind.  But then where could she go that wasn’t infected by this virus and all the tragedy and fear that accompanied it.

All of this in the midst of the “holiday season”…..some holiday…..money is tight, kids are out of school for a month and my husband is away for the next two weeks.  Some days I see the winter as a long dark tunnel with no light at the end.

The above (not a real patient but typical of many)  is a description of a reaction to life and experience in the pandemic.  In large part it is a normal response to an existential crisis.   It does not refer to a specific person.  Rather it is a description of what a large number of us may be experiencing at present. 

I talk to very few people who are not aware of increased stress, decreased quality of life, loss and difficulties in feeling or functioning normally.  I think it would be fair to say more of us are struggling with worse mental health than those who aren’t.  We truly are all in this together and our experience of increased stress and worsened sense of wellbeing does not indicate we are weak or poor copers.  These feelings and symptoms are a normal response to this very difficult and unusual situation.  The sources of stress and stress response include our fear of illness and death, loss of work and financial instability, social isolation and loneliness, loss of access to material goods and services, worry about family, fear that this pandemic will never resolve, coping with daily catastrophic press reports and personal and political crises. There is increased evidence in the popular press of a mental health crisis which is expected to worsen through the winter.  Already we are seeing evidence of increased mental health problems between the first wave and the second wave.  Epidemiological research supports this impression.

We are seeing increased prevalence of depressive and anxiety symptoms, substance abuse, domestic violence and physical illness, all of which interfere with function and our day to day experience of our lives and health.  

Populations which are especially at risk include people with pre-existing mental health problems, people with chronic illness, indigenous populations, people who struggle with substance abuse and addictions, people in lower socioeconomic strata, racialized populations.

A recent poll suggests people over age 55 are reporting better mental health than younger Canadians aged 18-34 (69 per cent  and 44 per cent, respectively). Despite this, the number of Canadians over 55 who say they would rather have more social contact has nearly doubled, from 18 per cent last year to 33 per cent.

It is women aged 18-34 who report the worst mental health, with 30 per cent ranking it “poor/very poor” as opposed to 25 per cent of their male counterparts.

Combined, men and women aged 18-34 reported the biggest jump in feeling “very isolated” – just 27 per cent in 2019 but 47 per cent following the pandemic.

Substance abuse has seen a sharp increase and deaths from opioid O/D. have increased at an alarming rate to epidemic proportions. 

 How can we cope with this?  Possibly the best way is to talk with each other and reflect openly about how we are feeling and what in particular we are worried about.  This has the double advantage of being more aware of how we are coping as well as being therapeutic in that we can problem solve together, comfort one another and know we are not alone in this.  Discussion potentially helps us be more rational and hopeful about getting through this global and personal crisis. 

The Patient Health Questionnaire (PHQ-9) and the General Anxiety Disorder questionnaire (GAD-7) are two brief resources that can be accessed on the internet and which might give you a clearer idea about whether you should seek help.    

What can we do to protect ourselves and increase our resilience against the ubiquitous stress of the fallout from the pandemic?  Below are some suggestions that have clear and potential value in caring for ourselves and each other and decreasing the risk of disabling psycho-social effects.  I would recommend you do these things even when you don’t feel like it (otherwise they won’t get done).

• Eating:  In this pandemic many of us are struggling with eating a healthy diet and caring for our bodies and souls.  There is increasing evidence linking depression and anxiety to diet and gut metabolism.  Reliable research has found that eating a healthy diet and avoiding fast and processed foods improves mental health and reduces symptoms of anxiety and depression.  The mediterranean diet or a close variation has been specifically linked to improved mental health and this includes diet favoring whole grains, fruit and vegetables, legumes, low-fat dairy, nuts, fish, lean red meat, chicken, eggs, and olive oil while reducing sweets, refined grains, fried and fast food, processed meats, and sugary drinks.
• Get moving: There is ample evidence exercise and body movement prevent and improve symptoms of anxiety and depression.  Do something that you enjoy and that increases your heart and respiratory rate for 30 minutes five days a week.  I recommend exercising with someone (remember social distancing) and going to a place of nature because both of these factors have been found to be mentally and physically therapeutic
• Interact with others.  This is a hard one with quarantine and social distancing.   We need to be creative and intentional in reaching out to  others.  We need to be willing to “bother” each other and if necessary, say we are calling because we feel isolated and alone.   Social interaction has been found to be preventative and therapeutic for depression and anxiety.  When we feel less well we tend to withdraw and do less.  These are common symptoms of anxiety and depression that inevitably worsen symptoms and function.  Pushing ourselves past the lack of motivation and interacting is linked to recovery and prevention.  Within the bounds of safety find people you can hug and touch and cuddle 
• Keep a daily routine with tasks that promote feelings of pleasure and achievement.  Routine helps be more mindful of our bodies and our environment and it promotes healthier sleep-wake cycles which are linked to our mental and physical health. Difficult as it may be in these times it helps to create a project which enhances our sense of competence and confidence.
• Breathe mindfully.   This includes activities such as yoga or tai chi or meditation.  These have been shown to increase a sense or relaxation and well being and encourage mindfulness.  They help maintain healthy blood pressure, improve heart health and decrease symptoms of mental distress.  There are many accessible and free internet activities including free yoga routines and meditation routines.  A favourite of mine is the UCLA Mindfulness Awareness Research site which has downloadable voice guided meditations.
• Act kindly toward others. Whether or not we are suffering we all need kindness and compassion from others.  Pay it forward.  This increases our contact with others and improves our sense of compassion purpose and meaning.  In many cases it brings kindness and compassion back from others. Kindness and compassionate acts toward children and adolescents and the elderly and isolated are especially necessary now.  
• Avoid the media.  Most media presents morbidity and mortality data in a catastrophic tone. It helps to be aware of the virus but limiting our media intake protects us from messages which worsen our sense of helplessness and being overwhelmed.
• Maintain a sense of community and connection to others with the goal of protecting and caring for each other.  It encourages working together toward coping, creating and maintaining the institutions which keep our communities working.
• Count your blessings:  this may sound trite but it is impressive how reflecting on what we are thankful for improves perspective and meaningfulness of our lives and improves mood and stress levels (another process where daily mindfulness is helpful).
• Think and talk about the coming vaccines and that there will be an end to this
• If you feel overwhelmed, helpless, hopeless or even suicidal, tell someone. Call the crisis line, talk to your physician or go to the emergency room.

These suggestions are a few behaviours and practices which may help us cope with the stress of pandemic life.  If you are aware of others share them, talk about them and practice them.  

Below are some links to mental health supports and tools which may be helpful.

https://www.crisistextline.ca crisis line for kids

https://www.ementalhealth.ca links to mental health supports in Ontario

https://www.canada.ca/en/public-health/services/mental-health-services/mental-health-get-help.html

http://www.qhc.on.ca/mental-health-services-c71.php connection to Quinte Health Mental Health service, information and connection to various services

https://bouncebackontario.ca/ free, guided self-help program that’s effective in helping people aged 15 and up who are experiencing mild-to-moderate anxiety or depression, or may be feeling low, stressed, worried, irritable or angry.

https://www.smartrecovery.org/intro/ a four point on line program to help those with substance abuse problems/ access to on line interactive forums

https://www.uclahealth.org/marc/ useful mental health information including free downloadable meditations

https://www.cci.health.wa.gov.au/ a free website from Australia which offers cognitive behavioral workbooks on a number of mental health problems

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30460-8/fulltext article from Lancet: The psychological impact of quarantine and how to reduce it: rapid review of the evidence

www.smartrecovery.org/smart-recovery-toolbox/ provides a variety of methods, worksheets, and exercises to help you self-manage your addiction recovery and your life

www.selfhelp.on.ca/tag/domestic self help for domestic violence