In times of health, economic and social crisis, the country has moved forward fearlessly, using preventive measures to protect public health, breaking through the barriers of isolation and gradually resuming activity in the most diverse sectors of the economy. We were given permission to leave home and return to the street. This step, in literal sense, is in itself an easy gesture. However, it is more difficult to regain confidence in the outside world, anchored on the safety that has become a distant oasis for many Portuguese, intimidated by a virus that, although invisible, lives among us. Calm and confidence in returning to hospitals was requested, reinforcing the existence of different areas and limiting areas exclusive to the treatment of patients with Covid-19. However, leaving the lockdown seems not to have spread to the hospital environment, thus delaying the establishment of normality in an era that many already call post-Covid.
About three months away from the start of the pandemic in Portugal, we tried to find out how medical specialties, particularly Psychiatry, resumed their normal activities, which were forcibly interrupted or the target of serious constraints, due to the emergence of Covid-19. Thus, we interviewed Professors Daniel Sampaio, to whom Psychiatry and Mental Health in our country owe a lot, especially for the pulsating of new ideas and decisive advances in an area that is strongly overshadowed in the national health panorama, and Diogo Telles Correia, who on different occasions elucidated with great clarity and precision the risks and consequences of the pandemic in the mind. With their rigor and professionalism, both present their views about the present moment, with a view to the future of mental health in Portugal.
Professor Diogo Telles Correia, Associated Professor with aggregation at FMUL, psychiatrist and psychotherapist, confirms that “in the field of psychiatry and mental health, as in all other areas of medicine, there was an impact on the monitoring of patients, especially in the early days of the pandemic”. This translated into “postponing the so-called 'non-urgent' consultations, but also into the patients’ decision to avoid going to hospitals” in the context of outpatient and emergency consultations, explains the Professor and vice-president of the Liaison Psychiatry section of the European Psychiatric Association, recalling that psychiatric emergencies suffered a drop in demand during the initial period of the pandemic.
Gradually, and similarly to what happened with other medical specialties, psychiatric consultations “adapted to this new reality and began to resort to teleconsultation techniques in less urgent cases, and in person in more urgent cases”, with “psychiatric emergencies having returned to receiving patients” as the end of lockdown became a reality.
But the question that arises for many is whether or not we can return to hospitals safely and calmly? Are the patients, effectively, resuming the proper medical acts? Diogo Telles Correia argues that hospitals have made a great effort to resume their usual activity, reinforcing that “the strategies to protect patients and health professionals are now much more active than at the beginning of the outbreak, when the most effective ways to prevent the transmission of this disease were still unknown”. However, he stresses that "there is still much to know about this new virus", casting doubt on a new suspension of the "gradual return to normality that we are witnessing today", in the face of a possible "reactivation of the outbreak".
Daniel Sampaio, Jubilee Full Professor of Psychiatry and Mental Health at FMUL, who contributed decisively to the promotion and activity of Espaço S, says that there is now a slow resumption, "but there is still some fear in the trips and face-to-face consultations". On the other hand, “the public services of Psychiatry and Mental Health have many needs (human resources and facilities) and the private ones are not organized from the perspective of the MH team (doctor, psychologist, specialist nurse, social assistant). As an example, it is important to know that two important units of the Psychiatric Service of HSM/CHULN had their space occupied by Covid-19 and continue to be unable to operate, leaving dozens of patients without adequate follow-up. I am referring to the Adolescents Unit and the Project Unit for Long-Term Patients that are without facilities and without functioning. This is an example of how Psychiatry and Mental Health are not a priority in the NHS, unfortunately, says Professor Daniel Sampaio, responsible for the direction of the Psychiatry Service at Santa Maria Hospital between 2014 and 2016, having dedicated part of his career to study the problems of young people and their families, through research work in the field of Psychiatry and Adolescence, creating, at Santa Maria Hospital, the clinic for young people with Anorexia Nervosa and Bulimia Nervosa.
According to Daniel Sampaio, “the pandemic left many people with mental disorders less likely to be well cared for. Despite the online consultations carried out, nothing replaces a face-to-face consultation”, he assures, revealing that the lockdown has led to an increase in complaints related to anxiety (especially insomnia), aggravating pre-existing depressive disorders.
In retrospect, Diogo Telles Correia claims to have witnessed, during this period, “an initial phase of great fear on the part of patients and professionals”, marked by a “very significant drop in the demand for mental health professionals (either in consultations or as emergencies), but also due to a drop in the availability of these services”. However, positive signs of change have emerged in recent times, says the Professor, noting that "people are turning more" to specialists in mental health, joining the range of existing patients, "new patients who failed to overcome all the consequences of the epidemic”. “We are now also seeing the victims of the economic and labour situation resulting from this whole process, namely many cases of severe depression resulting from situations of serious economic difficulties, and of complete annihilation of life and professional projects, which were reaching balance before the pandemic”, explains Diogo Telles Correia.
And what are the main fears of patients in the current situation? In the opinion of Daniel Sampaio, the greatest fears are related to “the fear of contagion, of infecting other people and of the worsening of their previous psychopathological situations”, advances the psychiatrist and writer, observing with particular attention the two groups of the population who have reacted with greater difficulty to the pandemic. “In young people, there is a strong need to go out and be with friends, because that is part of their psychosocial development. In the elderly, very worrying isolation situations persist and the situation of homes is far from being resolved”, affirms Daniel Sampaio, one of the starters of Family Therapy in our country.
In turn, Diogo Telles says that "there are several factors that can influence mental health in this pandemic moment", the most expressive of which are related to "the fear of being contaminated". “A fear of the unknown, of suffering, a fear of death that is reactivated in this circumstance. This fear can cause new situations of anxiety to arise and reactivate or aggravate previous conditions”, explains Diogo Telles Correia, who attributes to anxiety the leading role in many of his books, understanding the reality behind it and how to fight it.
On the other hand, in his opinion, the lockdown led to the isolation of certain groups, namely the elderly and all those who live alone, "which can also precipitate mental suffering, because human beings do not exist without social contact", he reinforces, citing philosopher Martin Heidegger: “We are here with others. And isolation, physical and symbolic, brings psychological suffering in the form of depression or anxiety, for example”. In the case of families that completed the period of isolation together, "there were some family conflicts that resurfaced and the parents reached levels of extreme tiredness, for example when accumulating telework with school support for their children".
For Diogo Telles Correia, it is obvious that this scenario of exhaustion can contribute to the appearance or worsening of mental disorders, but the greatest risk lies with those who had the Covid-19 infection and all those who dealt with the coronavirus closely, “due to the physical and psychological suffering related to the new virus, as well as the fear of imminent death”. We are talking about “cases that may constitute situations of Post-Traumatic Stress in the future”, he warns, also pointing to the potentially high risks in all those who lost family members and were unable to mourn. “They are also another group of special risk”, says Diogo Telles, like health professionals, “especially those on the front line”. “The fear of contamination, aggravated by the initial difficulty in having access to adequate PPE's, overwork, witnessing so many deaths and suffering of the sick, the isolation of family members, are undoubtedly precipitating mental illness in this group, and they will in the future continue to plague it with these issues", he says, understanding that "adequate recognition by the governmental bodies could at least appease the doctors and other health professionals so sacrificed in this fight".
In fact, health professionals are of great concern at the moment. In a recent interview with the newspaper Expresso, the Chairman of the Portuguese Medical Council, Miguel Guimarães, acknowledged that this period has been of “excessive work and pressure” for health professionals, who have gone from a work situation accentuated by the overtime that they have already done and by “an excessive workload” as a result of the pandemic. Therefore, he considers it urgent to implement a plan for the “mental, physical and even family recovery” of all health professionals, guaranteeing that “the number of cases of anxiety, exhaustion and depression will increase and be more serious, not to mention other even more serious risks”, feeling seriously concerned about the post-pandemic. “While the battle is going on, the feeling of helping people works as a stimulus. The worst will be later”, he reiterated.
The increase in the consumption of antidepressants and anxiolytics in the first three months of this year was also recently reported. According to Diário de Notícias, 400 thousand more packages were sold than in the same period last year, and this quantity continues to be higher than that of other European countries, confirms Diogo Telles. “It is too early to find justifications for such an increase. However, this trend that accompanies the high prevalence of mental disorders, such as anxiety disorders and depression, which are very high in Portugal, has been happening for a long time”, affirms the President of the Portuguese Association of Psychopathology, saying that there may be several reasons for this evidence, "but there is still no complete explanation". “Interestingly, suicide rates in Portugal are less expressive, compared to most other European countries”, says Diogo Telles, posing the question: “Will the Portuguese people, the 'people of soft customs' and 'fado', be a suffering but resilient population? One that suffers but persists and struggles?”.
What is certain, he adds, is that, as the DN mentions, “self-medication is very high”. "I don't know, but it was interesting to see if the rates of self-medication in Portugal are also higher than in other countries", says Diogo Telles, explaining that "within self-medication, there are different types of patients". “Those who start psychiatric medications on their own initiative (and get them through friends, or at the pharmacy without a prescription) and there are those who are initially prescribed medication by a doctor, for a limited period, but continue using it without a prescription, or convincing a doctor to write one ('because they say they feel good taking them').
This is a fact that we, psychiatrists, verify in our clinical practice”, he says, guaranteeing that there are many patients taking psychiatric medication without medical supervision. For his part, Daniel Sampaio is not surprised by the published data on the consumption of antidepressants in our country. “In Health Centres, where less serious disorders (anxiety and depression) could be treated, there are no psychologists or mental health nurses who can give different answers in the scope of psychotherapy. Even in Psychiatric Services, consultations are widely spaced, there is no regular monitoring of families and the quickest response, which is to prescribe a medication, predominates. Now, there are studies that demonstrate that minor disorders can be treated in primary care through brief psychotherapy interventions. The use of benzodiazepine anxiolytics should be reduced due to the risk of dependence, he warned.
Regarding the possibility of a new patient profile or new psychiatric problems arising from the current pandemic, Professor Daniel Sampaio is adamant in disagreeing, stating that “the situations are the same”. “Serious mental illnesses (bipolar disorder and schizophrenia) are likely to remain with similar numbers, but there will be an increase in anxiety disorders, depressive disorders and post-traumatic stress disorders. The most affected are the elderly, who were previously in a vulnerable situation, without the necessary support. We need to take care of the elders in our families and try to maintain or improve affective relationships with everyone who is significant to us”.
In the opinion of psychiatrist and psychotherapist Diogo Telles Correia, it is inevitable that psychiatric disorders will increase in Portugal, as well as in the rest of the world, as a result of the Covid-19 pandemic. “Due to all the factors I mentioned earlier, this pandemic, as expected, is greatly increasing psychological distress and, at present, I am sure that the prevalence of mental disorders has increased. However, I think that this prevalence will continue to increase years after this situation”, he declares, pointing to examples of previous epidemics, such as SARS or the Spanish Flu, “which, several years after the outbreak, had mental health consequences. The psychological suffering brought by this period did not end with a vaccine”.
Daniel Telles also stressed that the impact of an unknown virus (and all the fear associated with it) and the effect of all the conditions that ensued (of which lockdown is an example), and “the economic and labour consequences, will have a considerable impact on our mental stability”.
Author of a wide range of international scientific publications and several technical books that are a mandatory reference in many medical and psychology faculties in Portugal and abroad, Diogo Telles Correia stands out for his work in the area of the dissemination of topics related to mental health, namely several books for the general public, such as "Ansiedade nos Nossos Dias" ("Anxiety in Our Days") and "Guia prático para vencer a ansiedade" ("Practical Guide to Overcoming Anxiety"), both published by Bertrand.
The great knowledge and experience he has on the matter, despite the predictive nature of the present analysis, leave no room for doubt about the strategy to be implemented. Diogo Telles Correia believes that it is necessary to redouble attention and “provide support in terms of psychiatry and mental health, in order to lessen the consequences that the pandemic may have on the population”.
Is there a less dark side that has brought something positive to this pandemic? Diogo Telles Correia responds, quoting Cardinal Tolentino Mendonça, in his statement about the possibility of this epidemic being the "... relaunch of our being in the world". “This slowdown in the incessant speed at which Mankind has walked, can act as a means to stop and reflect on our individual and world priorities, globally. What is really important for us and for the world? Why should we fight and live?”, asks Diogo Telles, inviting us to reconsider our relationship with ourselves, with others and with the world, from a global and ecological point of view.
In turn, Daniel Sampaio, who publicly referred to having lived the lockdown “with deep concern and renewed hope”, reminds us that in a time of pandemic “we will have to find new relationship forms, always with some care”, nurturing “the most intimate affective relationships”. As he stated in an interview with Expresso when the first pages in the history of the pandemic that dictated the country’s lockdown were being written, “we can always imagine, dream, talk. And be sure that the epidemic will go away, as history teaches us”. For the sake of mental health.