South Africa: COVID-19 - How Life Has Changed for Providers of Mental Health Services

Although South Africa's COVID-19 lockdown has eased to alert Level 3, the mental health of many members of the public is still a concern and so too the mental health of those providing mental health services.

A recent online survey conducted by the South African Depression and Anxiety Group (SADAG) found that while 92% of respondents supported the lockdown, 65% of the people who completed the survey felt stressed or very stressed. Fear of COVID-19 infection and financial worries also emerged as key concerns in the survey.

"It (COVID-19) has had a serious impact on people living with a mental health issue often making their symptoms more heightened. SADAG has been receiving calls from people with no history of anxiety or depression who are feeling overwhelmed, anxious and stressed," says SADAG's Operations Director Cassey Chambers in a statement.

Counselling services

Thabo Lephoto, a senior counsellor at SADAG, says on a normal day he gets between 40 to 80 calls. "Some people would want information and others would want counselling."

Asked how the number of calls compare to the days before COVID-19, Lephoto says: "I wouldn't say there is a significant difference in the calls that we got prior to COVID-19 and during COVID-19. We still get calls from people who have problems with anxiety and we always get calls with people experiencing depression."

According to Lephoto, SADAG counsellors do not provide long-term counselling, but refer callers to a doctor or a psychologist after one or two calls. "We help identify the problem that causes anxiety, then we direct where you could go for help depending on what the issue is," he explains.

Unfortunately, however, according to Lephoto there are not a lot of facilities where people can get free counselling. "We have a referral guide, so we don't turn someone away. We try to get other psychologists that can facilitate pro bono work, some hospitals help us too, so we send people there," he says, adding that during lockdown these referral appointments are mostly online - through applications like Zoom.

On why many people experience anxiety and depression during the lockdown, Lephoto says one thing that can cause anxiety is fixating on things you have no control over. "We have to think about those things we have control over," he says.

"Working remotely is hard"

Harsha Maharaj is a clinical psychologist based at MediClinic in Sandton. During lockdown, Maharaj provides online counselling to her out-patients through a tele-health App, Medici.

Maharaj says since the start of the lockdown she's had a lot more people calling to book consultations. "Some come through referrals and others got my details from MediClinic's website." She says MediClinic encouraged online consultations to ensure patient and staff safety.

"Working remotely is hard. I'm used to having one-on-ones. [Doing online consultations] is harder and a lot more draining," she says. "With therapy it's a lot about what they (the patients) are not saying, the non-verbal language is very important. You have to pay more attention while doing the online consultations."

Maharaj says her consultation room was known as a safe space for her patients before lockdown. She says it's now a huge challenge that they're not in her room. "They might not feel safe (talking in their homes) because there's a fear of who might overhear the conversation."

In May she once again began consulting with inpatients that were admitted to the clinic. "Apart from the medical and psychiatric (anxiety and depression) issues these patients present with, they also have to deal with the anxiety that COVID-19 has created," she says.

"Last week I saw a patient who had been diagnosed with bronchitis and she dealt with a lot of 'what ifs'. She tested negative for COVID-19, but she had anxiety," says Maharaj. "So, I have to help with the emotional part while the medical doctors deal with the medical stuff."

Some patients stayed away

Dr Lesley Robertson is Head of Clinical Unit: Community Psychiatry, Sedibeng District Health Services in Gauteng. She oversees community-based outpatient psychiatric services and supports primary care practitioners in the provision of integrated primary mental health care. The psychiatric services are provided by a team of nurses, medical officers, psychiatry registrars and specialists, and a clinical psychologist. The care is mainly focussed on medicine treatment of serious mental illness.

Robertson says because of the impact of COVID-19 they have decongested the waiting areas and patient queues in order to limit opportunity for transmission of the virus. They have done this by doing four things:

Issuing repeat medicines with minimal engagement or contact. Robertson says normally, the psychiatric nurses would spend time with each patient every month checking how they are and making a clinical note. "This has been stopped and limited to the briefest of queries regarding patient wellbeing."

Where possible, issuing two months of medicines at a time.

Referring only urgent, very disturbed patients for doctor consultations.

For NGO residential care centres, allowing the caregiver or manager to collect medicines on the patient's behalf, providing a report to the psychiatric nurse, and only bringing patients to the clinic if they are concerned.

Robertson says she is worried about patients relapsing. According to her, some patients stayed away during the "hard" lockdown and did not get their medication. She explains the need is to keep people with serious mental illness stable, at home, and out of hospital.

Robertson also expresses concern about people with mental illness contracting COVID-19 and how people with severe mental health issues will cope with it. "For those with severe disability, it may be difficult to observe social distancing, masks, personal hygiene," she says. "People with mental illness often have physical health comorbidities, especially obesity, diabetes, hypertension, and HIV infection. (They) are also more likely to be smokers and have more intense nicotine addiction than the general population. So [there is a] high risk for severe COVID-19."

She is also concerned about people not accessing care and potentially relapsing during the "hard" lockdown. "We do use community health workers to trace patients and encourage them to come to the clinic, but do not have resources to deliver medicines to private homes for people with severe mental illness or to bring them to the clinic," she says.

Robertson also cites the global lockdown that caused stock-outs of some medicines, making it necessary to change treatment . "This always increases the risk of relapse," she says. "The stress and uncertainty of COVID-19 may increase the risk of relapse even when medicine is taken," she warns.

"Something else that we are bracing ourselves for is dealing with bereavement and family loss. We are particularly concerned about loss of child-carers when children return to school and transmit [the] virus home to grandparents or high-risk parents. We are aware that some of the children and adolescents with mental illness at our clinics are cared for primarily by grandparents - [so] this is going to increase our number of orphans in the country."

Mental health of healthcare workers

Although she has been seeing patients, Robertson says she has also been doing a lot of listening to colleagues. "The workload stress is getting to people. We listen and debrief a little bit in an informal setting. We talk to colleagues trying to support them (the health care workers)."

She says nurses are under a lot of stress. "They're fearful of getting the infection. It would be interesting to hear how they get themselves going. My focus recently is to go to the hospital staff, ask the sisters how they are doing, but I find that they don't come to me so I go to them. [The counselling] is done in a less intense manner, it's like peer support. My role is to support the patients, so the staff are referred for therapy (to someone else)," she says.

Although there are professional counselling services available for health care workers, she suspects that they are not taking the time to see the psychologists. "They want to get on with their job."

Self-care is essential

Dr Antoinette Miric is a Johannesburg-based psychiatrist and spokesperson for Healthcare Workers Care Network (HWCN). Miric in a statement says healthcare workers are not used to reaching out for support for themselves. "Still, I hope that this pandemic helps them to realise that they need to look after themselves first physically and emotionally, before they are able to look after others. Looking after oneself is not natural for the healthcare worker, who in their nature help selflessly. However, in these circumstances, self-care is not just a buzzword - it is essential."

The Healthcare Workers Care Network (HWCN) is a nationwide healthcare worker support network launched on 3 June this year. According to its website, the HWCN has over 500 volunteer mental health professionals, including psychiatrists, psychologists, GPs, registered counsellors, and social workers, who will provide help, intervention, and support to all healthcare workers.

Lephoto admits some cases can take a heavy mental toll on the councillors, which is why it is therapeutic to talk to a colleague. Lephoto, who says he is a gym fanatic, says since the lockdown he has been doing jogging and home exercises which includes cardio and push ups. Lephoto is also a father of a one-year-old boy. He says bonding with his son or watching something funny on TV relaxes him.

"You cannot spread yourself thin"

Maharaj says after years of practising she doesn't feel guilty about not taking on too much work. "If my plate is full, I tell the patients, I'd rather refer them to a colleague of mine. You have to be honest with yourself as a psychologist. You cannot spread yourself thin."

Maharaj says having a support system at home helps. When she has a bad day, her husband steps in. "He'll take care of the children when he sees me coming in with a frustrated or sad look on my face. It's just so that I can have a few minutes to myself to take care of me."

The mother of two says she practices a lot of mindfulness techniques; she exercises often and goes for a run. She says she believes that one should not work in isolation, which is why she and her colleagues (psychiatrists and specialists at MediClinic Sandton) work in a team. "We do talk to each other even if we don't see each other. We talk on WhatsApp or talk over the phone. It's to have a degree of normalcy... We share patients too."

Robertson admits it's not been easy to take care of herself. She takes an online yoga class or spends time with family to relax. "Yesterday I felt like calling a colleague to do debriefing. I should do it. The thing is there's never the time."

She says for her it is about being mindful of what you are doing in the moment. "If you're cooking, be present, don't think about work-related things. My husband and I debrief a lot. He works at Charlotte Maxeke Hospital."

*For more information visit: https://mentalhealthsa.org.za/surviving-the-covid-19-lockdown/

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