Mental Health consequences of lockdown are absolutely no reason to limit COVID related restrictions.
I have been wanting to write something for a few weeks in response to what I keep seeing as spurious arguments against the escalation of COVID restrictions in Victoria, and around the world, which use “mental health” as a reason to suggest we should not be increasing social restrictions.
As I understand it, the argument goes that the mental health consequences of the damage to the economy, job losses, unemployment and social dislocation resulting from enforced economic and social lockdown will exceed the impact of COVID infections themselves. Suicide rates will rise and the resultant loss of life may exceed that associated with COVID related deaths, or at least mitigate the reductions in death we achieve through tighter restrictions.
I think this is just a somewhat more complex extension of the binary argument that has been presented now for several months: that we have a simple choice. We shut down the economy to fight the virus with harsh economic consequences (and effects on mental health) or we do the opposite to support the economy at a cost to physical health / higher rates of viral infection and COVID deaths.
This is a completely false choice.
The Prime Minister gathered all his expert advisors around him. He had just been told that finally a vaccine was available for the terrible disease that afflicted the country. But there were not enough doses for everyone: what was he to do?
“Vaccinate the doctors first, we have to treat all the patients” said his chief medical officer.
“Vaccinate all the epidemiologists first, you need us to understand the disease” said his top public health officer.
“Vaccinate all the economists first, without us you won’t be able to understand the financial problems this disease is causing” said the head of the Treasury.
“What about the factory workers”: said the Industry head, “without them we wont be able to make anything”.
“STOP” shouted the PM, exasperated and at his wits end. What do you think he said to the junior aid who was trying to avoid his gaze. “What would you do?”
“I…I..” stammered the aid. “I don’t want it, I don’t care who you give it too first, I am not a fool — I have read about these things on the internet — these vaccines, they do more harm than good”.
The PM pondered this for a while and then commanded. “Find everyone who doesn’t want to be vaccinated. Find a way to persuade them to have it: they are the ones we need to have vaccinated first”
So I think pretty much everyone sees the development of an effective vaccine as the way we get out of the predicament of the COVID-19 pandemic. Whether you are for locking down for the long term, graded reopening or want to open the economy and damn the health consequences, I think pretty much everyone now accepts we don’t get back to a world that resembles anything like the one we all used to know without an effective vaccine. Sure some places, New Zealand being the outstanding example, have effectively eliminated the virus for periods of time. But for how long can countries remain isolated. Like personal isolation this will eventually take its toll: on the economy and on the individual desires and freedoms of the population. This is not a long term future we desire.
There is fortunately, a remarkable effort going on around the world to develop an effective and safe vaccine. In fact, given the number of competitive development programs it is quite feasible that we might end up with more than one, and possibly even quite a number of useful vaccines. It is sobering to realise that we haven’t ever successfully developed a vaccine in less than 5 years before — imagine what it would be like living in a COVID prevalent world for half of the next decade — but the intensity and breadth of the vaccine efforts at the moment gives me optimism that we won’t just beat, but will obliterate, this record.
What can we learn from the tortuous path to widespread clinical approval of the use of TMS therapy for depression?
The development of transcranial magnetic stimulation (TMS) as a therapy for patients with a depression, has been one of the most important fundamental advances in psychiatric therapeutics since the 1960’s. This is not just hyperbole. Almost all of the drugs we use in psychiatry today are derivative of approaches developed in the 1950s and 1960s. Psychotherapy has certainly improved and evolved but again, the forms used today are direct descendants of approaches developed decades ago. Finally, ECT certainly has improved but remains fundamentally connected to its past. TMS, in contrast, is one of the few essentially new treatments that have developed de novo, and one already helping many thousands of patient.
TMS is really not new, but is only making headway as a treatment in many places around the world now, and only slowly. In fact, the time it has taken for TMS to develop as a treatment has really been quite considerable. The first TMS machine was developed in 1985 but we can’t really date therapeutic TMS from this time as that device could not provide the repetitive stimulation need for treatment applications. Machines that could, however, were developed within the following decade and the first meaningful trials of TMS in depression were published in 1995. It took 13 years until a TMS machine was first approved by the FDA in the US but it is has taken many more years than this, in the majority of cases well over another decade, for approval and widespread uptake to occur in most other countries. This is still not universal.
The escalating publication of redundant, unnecessary and misleading meta-analyses is a growing blight which requires containment.
As a journal editor and reviewer I am repeatedly receiving, and now frequently recommending rejection for, meta-analyses of studies in the brain stimulation field. For a long time these were studies of transcranial magnetic stimulation (TMS), but now meta-analyses of transcranial direct current stimulation (tDCS) studies are propagating faster than the studies exploring the use of the technique themselves. Why is this a problem, why am I ranting and why should anyone care?
Over recent years there has been a laudable and impressive effort to reduce the stigma associated with mental health conditions such as depression, and to engage more people with these conditions in treatment, especially here in Australia. However, this has not been accompanied by a clear reduction in the consequences of depression, such as suicide, in our community. There are lots of possible reasons for this failing but a completely under-recognised one concerns the limited effectiveness of the treatments we currently have available.
Whilst there are also issues with access to, and the effectiveness of, psychological treatments, I want to focus here on the limitations of existing antidepressant medication treatments. I want to make really clear up front that some patients are helped extremely well by these medications, they can change the lives of patients who respond to them, restoring their ability to function and lead fulfilling lives.