Community Mental Health – Before & After COVID-19

Dialogues in Psychiatry

Dr Roberto Galea discusses a local study investigating the impact COVID-19 had on community psychiatry.

While society is attempting to return to its previous conventional customs, we cannot but notice that despite our efforts, remnants of behavioural and psychological changes brought about by COVID-19 persist. COVID-19 required several containment measures which disrupted our daily activities and interactions with an attendant impact on mental health, as well as health services. The first wave of the pandemic hit Malta between 6 March and 24 April 2020 while public health measures were first announced on 12 March 2020. During the first wave, psychiatry outpatient clinics at Mater Dei Hospital were suspended with telepsychiatry taking over followed by significant restructuring of community mental healthcare services. A recent local study investigated the effect COVID-19 had on first contact community psychiatry referrals to a local Mental Health Clinic (MHC) before and after the onset of COVID-19 looking into; referrals, case presentation, demographics, as well as the respective adequacy of the service response.

Participants were identified through the MHC register from 11 March 2019 to 31 December 2020. Data was cross referenced with electronic medical records, while the imposition of public health measures on 12 March 2020 was used to separate the before and after the onset of COVID-19. A total of 236 new cases were identified (92 before & 144 after COVID-19).

The proportion of new case referrals for men aged 60-80 and women aged 60–70 years old have increased, reflecting health-related anxieties, the associated isolation of older persons due to both COVID-19 and public health restrictions together with the increased vulnerability and fragility of this population. However, the proportion of working age adults remained stable. This may be due to a lag and would thus benefit from further research.

Throughout the study most clients attending this MHC were Maltese nationals. Individuals from central and Eastern Europe significantly decreased following the onset of the pandemic, while the number of British citizens remained unchanged. Such numbers were in keeping with the authors’ expectations. Tendentially, central and Eastern Europeans are younger/middle aged workers who would return home if their job security were threatened while UK citizens tend to be longer-term residents.

Following the onset of COVID-19 there was a shift in the presenting complaints received. The commonest, anxiety dropped from 38% to 32% while depression increased from 33% to 40% – becoming the predominant presentation. Similar variations were also noted in psychosis (2 to 4%) and alcohol misuse which also dropped by half.

The study differentiated between three phases – before the onset of the pandemic, during the first wave and six months after. The closure of the Psychiatric Outpatients Department at Mater Dei Hospital meant that clients had to be redistributed to community mental health clinics. While this shift achieved better social distancing, limited potential COVID-19 transmission, and allowed service provision in the clients’ communities (bringing services into close-knit communities); the increased psychological impact COVID-19 had on our communities resulted in increased appointment rates, which put further strains on community mental health services, requiring service to adapt to these new requirements.

Service alteration secondary to disruptions due to pandemic-mandated isolation measures were significant confounding factors in the waiting time for appointments and thus this study. These changes resulted in a collective rise of a fivefold increase in demand in MHC services. To meet these challenges, clinic frequency was increased and staff re-deployed, increasing the monthly capacity of new case appointment reviews from 7 to 20 cases. A threefold increase in new case appointments has increased the burden of the clinic that was met through a fivefold increase in clinic frequency. Waiting time has decreased from a mean of 21.6 weeks before the onset of COVID-19 to 7.4 weeks. Constituting a 66% drop in waiting time despite a threefold increase in workload.

In conclusion, the COVID-19 pandemic resulted in significant challenging changes and difficulties for the community, health-service provision, and the staff who without faltering endured through such times. However, through major restructuring these challenges were tackled with psychiatric services being de-centralised into community MHCs and increased clinic frequency, successfully meeting a three-fold increase in new case appointments while decreasing the waiting time between referral and review by two thirds. This study investigated the associated impact early stages of the COVID-19 pandemic had on our community, further research investigating this pandemic had throughout its course is warranted.

L-anzjetà, il-kalmanti u l-fejqan

serrah il-menti

Aqra l-artiklu miktub minn Dr. Patrick Abela li gie ippublikat fuq in-Nazzjon.

Ladarba kulħadd jgħaddi minn żminijiet diffiċli fil-ħajja, kulħadd għandu l-mod tiegħu kif ikampa mas-sitwazzjoni li jinsab fiha. Iżda xi kultant, l-istrateġija li nużaw biex intaffu ftit mill-uġigħ tal-ħajja ma tkunx waħda għaqlija. Kemm-il darba fil-prattika naraw individwi li jkunu għaddew minn perjodu iebes fil-passat imbiegħed u li għadhom sal-lum, bosta snin wara, imkissrin bi ħsibijiet li ma jistgħux iwasslu għall-paċi interna. Sfortunatament, din hija sitwazzjoni verament komuni f’pajjiżna għax l-għodda meħtieġa biex wieħed isib sabar għat-toqol tal-ħajja ma jingħatawx fl-iskejjel bħal ma jingħataw is-suġġetti tal-matematika u l-lingwi. Is-sengħa tas-serenità hija waħda li tiġi mgħallma bl-eżempju fl-ewwel snin tal-ħajja, normalment mill-ġenituri li jkunu taħt l-istess saqaf. Dan il-proċess ta’ tagħlim jista’ ma jitwettaqx sew fis-snin kruċjali taż-żgħorija, u l-individwu jidħol fl-adoloxxenza armat b’apparat emozzjonali limitat u batut. B’hekk meta bniedem ma jsibx ruħu kapaċi jtaffi l-anzjetà, ma jsibx triq oħra ħlief li jmewwet id-djieqa flimkien ma’ kull emozzjoni oħra bl-għajnuna tal-kalmanti.  

Il-kalmanti huma klassi ta’ mediċini li jnaqqsu t-toqol fuq il-menti saħansitra anke fi ftit minuti mill-ħin li jiġu ngħatati. Minħabba l-effett immedjat tal-kalmanti fuq l-anzjetà, din il-klassi ta’ mediċini rebħet popolarità qawwija fi żmien qasir. Sal-1977, kienu l-iktar mediċini mibjugħa mad-dinja kollha u żammew it-titlu għal bosta snin. F’dan il-perjodu, ir-riċerka fuq il-mediċini kienet limitata ħafna u ma kienx hemm daqshekk informazzjoni fuq l-effetti ħżiena ta’ dawn is-sustanzi. Illum il-ġurnata però, wara ħafna studju fuq nies li kienu ilhom bosta snin jużaw il-kalmanti, saru iktar magħrufin l-effetti ħżiena ta’ dawn il-mediċini fuq il-moħħ u fuq il-fwied.  Biż-żmien beda jidher ukoll li min kien qed jipprova jtemm l-użu tal-kalmanti, kien iħoss dwejjaq u anzjetà kbira u b’hekk kien jerġa’ jaqa’ lura fil-vizzju, ħafna drabi fuq dożi ogħla biex ipatti għall-effett tan-nuqqas tagħhom.

Illum il-ġurnata, it-tobba huma ħafna iktar attenti li l-kalmanti ma jintużawx għal perjodi twal ta’ żmien. Dawn is-sustanzi xorta għandhom użu tajjeb kemm fil-qasam psikjatriku, kif ukoll oqsma oħra tal-mediċina u l-kirurġija, filfatt nużawhom ta’ spiss meta jkun hemm attakki tal-paniku, tal-epilessija u tal-aggressjoni.  Però hija r-responsabbiltà tat-tabib li jkun kiteb dawn il-mediċini għall-pazjent tiegħu, li jara li ma jibqgħux jiġu miktuba għal tul ta’ żmien. Fil-preżent, il-kura ta’ l-anzjetà saret ħafna inqas perikoluża bl-għajnuna tal-mediċina moderna. Sfortunatament, xorta naraw numru sew ta’ klijenti li jagħmlu użu regolari tal-kalmanti u li saħansitra jkunu ilhom jużawhom għal bosta snin. Dawn isibuha diffiċli ħafna li jneħħu l-vizzju u jispiċċaw jgħixu kuljum bil-kalmanti f’dożi għoljin u bl-effetti koroh tagħhom bħal sturdament, dimensja u l-ħsara tal-fwied.

Allura, kif jista’ bniedem li qed ibati mill-anzjetà joħroġ min-nassa? L-ewwelnett, irridu nifhmu li l- anzjetà dejjem ikollha raġuni għall-eżistenza tagħha. Meta nesploraw il-passat mal-klijenti tagħna, bosta drabi jkunu jistgħu jgħidulna sad-data u l-ħin li tkun bdietilhom din it-tensjoni. L-avvenimenti li jwasslu għall-anzjetà jistgħu ikunu bosta. L-iktar sitwazzjonijiet diffiċli ħafna drabi jkunu dawk ta’ mewt jew separazzjoni fil-familja, però anka sempliċiment li wieħed jiżżewweġ jew li jirtira tista’ tkun kaġun ta’ nervi kbar. Il-karattru tal-individwu ukoll jagħmel differenza kbira. Hawn min jingħata aħbar kerha u jirnexxilu jkampa bla problema ta’ xejn, u hawn min iġib id-dinja fit-tarf fuq inkwiet żgħir daqs nitfa. Minkejja l-individwu u l-istorja li wasslitu għat-tensjoni, l-aħjar għodda li għandna llum il-ġurnata kontra l-anzjetà hija l-psikoterapija.  

Il-psikoterapija tinvolvi li wieħed jiltaqa’ ma’ terapista sabiex jiftaħ qalbu fuq il-problemi li jkunu qed joħolqu d-dwejjaq. Il-fatt li bniedem jesprimi l-anzjetà bil-mod tiegħu u mingħajr ma jingħata ġudizzju ikrah jew jiġi mifhum ħażin, hija diġà biżżejjed biex wieħed jibda jifhem kif jista’ jtejjeb il-kwalità ta’ ħajtu. It-terapista jservi wkoll ta’ kritiku għall-ħsibijiet tal-klijent u jipprova jgħallem l-għodda neċessarja sabiex l-individwu jistrieħ mid-djieqa tiegħu u jerġa’ jsib kalma u sodisfazzjon personali minkejja l-isfortuna u t-traġedji tal-passat. 

Dan l-artiklu huwa parti minn sensiela ta’ publikazzjonijiet informattivi marbuta mas-saħħa mentali. Bħala parti mill-kampanja “Serraħ il-Menti”, it-tobba li qed jispeċjalizzaw fil-psikjatrija qegħdin jaħdmu biex iżidu l-għarfien pubbliku dwar is-saħħa mentali tagħna. Għal iktar informazzjoni, tistgħu tikkuntatjawna fuq publicrelations.mapt@gmail.com. Tistgħu iżżuru wkoll is-sit uffiċjali tagħna, http://www.mapt.org.mt. 

Serraħ il-Menti Launch

serrah il-menti

The Serraħ il-Menti campaign is aimed at promoting mental health to the general public. Through a series of newspaper articles and media event, psychiatric trainees will be working to promote how individuals with mental health disorders deserve our society’s understanding and compassion. The campaign will focus on a number of commemorative dates, linked with mental health, so as to offer a comprehensive overview of the myriad of issues related to this important medical field. It will conclude with an outreach campaign and a press conference detailing the effect which this initiative had on the general public.