In lockdown with depression

let’s not pass the buck onto families in the aftermath of COVID-19

Commentators are beginning to suggest that in the aftermath of COVID-19, we face a pandemic of mental illness. Countering this call to arms for psychiatry, others have emphasised the importance of normalising mood changes and anxiety as a natural response to the situation. Here, we consider that while worry and fear may be normal, we do still need to prepare for the psychological aftermath of COVID-19. This is not because worry and mood change are abnormal. Rather the global health crisis followed on a decade of austerity and is likely to be followed by a recession.  Existing mental health policies and treatment options have not been working well and needed changes even before the crisis hit. We argue that the vital shift required is away from individualised approaches and responsibilisation of proximate caregivers and towards collective and family-based approaches which take social contexts fully into account.

The COVID-19 pandemic has the potential to exacerbate some mental health problems in the UK and Europe while simultaneously forcing people into financially, emotionally and socially precarious situations. There is, therefore, a reason to fear that the health crisis could well become a mental health crisis. The crisis has already pushed many people with complex and challenging family relations into close proximity under very stressful conditions. For some, such as those exposed to domestic violence, this will also be physically dangerous. Once the controls on movement and social contact are lifted, where will these families find themselves emotionally, socially and financially? How will mental health policy support and aid them to resolve the social and systemic issues fuelling psychological distress?

Recent policy developments have often overlooked systemic issues about depression. The dominant models of depression treatment in neoliberal societies take a primarily individual approach, whether medical or psychological. The medical model has promoted theories about brain chemistry along with a ‘diagnose and cure’ framework for intervention. The dominant psychological models also take an individual approach, focusing on the faulty cognitions, which can be modified through personal self-improvement techniques taught by a therapist and practised at home. The exceptions to this are the less dominant relational models, including family-based treatment or couples work. Yet, these are rarely offered in the NHS or European health care systems for depression.

Our recent research has focused on policies and guidelines relating to depression and the impact of depression on families. We have examined qualitative literature on the experiences of caregivers and shown that family members caring for a depressed person at home struggle significantly with role changes, stigma, reduction in social networks and lack of support. In a forthcoming paper, we have also examined the literature on the experiences of depressed people and their views on involving family members in their care and treatment. This suggests that family involvement is an intricate double-edged sword because in many cases, families (along with stigma, poverty and poor access to accurate and timely help) can be one of the sources of depression.

Neoliberal states have increasingly turned to the concept of patient and carer involvement in healthcare, ostensibly to enable more effective and patient-centred care. This policy appears to offer a route to democratisation of healthcare while empowering patients and their families. However, we have analysed depression guidelines in the UK and Denmark in terms of their reference to carer involvement, and we found that there is almost no evidence underpinning this policy. Instead, the policy itself is not so much about improving patient outcomes and family relations. Instead, it serves to pass the responsibility for monitoring patient compliance onto the caregiver. Caregivers become an unwitting arm of the medical state who informally police deviant patients. Our analysis suggests that the policy of carer involvement tries to solve a generic concern about the dangers posed by emotionally unstable patients and the risks around confidentiality and consent represented by the act of bringing family members and other non-professional actors into the workforce.

A genuine push toward patient-centred and democratised care should arguably pay more attention to the experiences of patients and carers by taking into account the types of qualitative studies we have synthesised in our research. Another forthcoming paper provides a qualitative meta-synthesis of patient experiences of psychological treatments for depression. This finds that a significant barrier to individuals benefitting from psychological treatments is their limited applicability to real-world social and family contexts. Individuals appear to struggle to apply the techniques they have been taught to manage their thoughts and feelings when their home or family context bears no relation to the context of the therapy room. This is similar to findings from Danish studies of patient education in depression management.

Since policies and guidelines for depression have been considerably lacking before the COVID-19 crisis, there is a danger that when there is a surge in psychological need, the support will not only be inadequate but will pass the buck onto patients and informal carers. This includes not only the capacity of the psychological workforce, but also the individualised nature of the evidence-based health paradigm, and the lack of social components within most psychological treatments.

We are concerned that the policy of carer involvement will be amplified as the state moves to reduce its responsibility further and pass this onto informal family caregivers.  This is not the most helpful way to support people with depression. Amid lockdown in the UK and parts of Europe, countries differ in their use of emergency powers, policing and reduction of ‘non-essential’ state functions. The UK has repealed many aspects of the Care Act 2014, which conferred the responsibility to support caregivers and required local authorities to provide care to vulnerable sections of the population. This signals a move to a future reduction of state responsibility, placing place more burden on patients, families and carers. This will be not only naïve policy-making but potentially generate more harm than good.

To conclude, we argue that in the aftermath of COVID-19, psychological and psychotherapy professions need to develop more relationally and socially focused interventions. This may include more use of couples and family therapies and democratising approaches. Going further, this implies that psychological professions should take serious account the many new diversities produced by the current crisis (e.g. old and new homelessness created by lockdown, disabled people newly abandoned by the removal of care duties from the state, and newly created benefits recipients).  We also argue that policymakers more than ever need to accept genuine (not tokenistic) patient involvement.  They also need to reconsider the application of a paradigm which excludes the type of evidence that speaks of experience; since there is much to learn from such research  in order to avoid policy-based evidence approaches that fail to serve patients.

About the Authors: Susan McPherson in a Senior Lecturer in the School of Health and Social Care at the University of Essex. Jeppe Oute is Associate Professor in mental health care in the Deptartment of Health, Social and Welfare Studies at the University of South Eastern Norway.