Domestic abuse and mental ill-health: twin shadow pandemics stalk the second wave

The coronavirus crisis has been stalked by two shadow pandemics – one of domestic abuse and one of mental health. Since the first outbreak of the virus, numerous reports have highlighted a marked increase in forms of domestic violence and abuse, especially intimate partner violence and domestic homicide. The pandemic has also been linked to rising rates of mental health issues around the world.

These two phenomena are intrinsically linked: research shows there is a strong association between mental ill-health and domestic abuse. This raises significant concerns as a second wave of the pandemic crashes upon us. Cities, regions and whole countries are going back into lockdown – a measure that has previously been reported to have increased rates of both domestic violence and mental health problems. This time around, we need to be better prepared to support victims and survivors.

Lockdowns exacerbate domestic abuse

UN Secretary General Antonio Guterres has described the rise in domestic violence in 2020 as a “horrifying global surge”. Evidence compiled by UN Women from the UK, the United States, France, Australia, Cyprus, Singapore, Argentina, Canada, Germany, and Spain shows a rise in demand for access to women’s refuges and other support services this year.

The UK charity Refuge reported a 700% increase in calls during a single day in April and by June calls had risen by 800% compared with pre-lockdown figures. The charity also reported a 300% increase in visits to its National Domestic Abuse Helpline website and a 950% rise in visits to their website.

Read more: Domestic violence shadow pandemic has not gone away after lockdown

It is likely that these statistics reflect a glimpse of the overall picture given the known difficulties of reporting abuse, which are now intensified for households where the perpetrator is more frequently or consistently at home due to COVID-19 measures. The incidence and prevalence of domestic violence does tend to increase during any stressful event or emergency, whether it is a natural disaster, or whether it is man-made.

The surge in domestic violence has not just been associated with instructions to stay home, but also linked to the economic and social stresses on households that have resulted from this pandemic. These include the growth in unemployment, uncertainty around furloughing and job security and the effects of social isolation.

The toll on mental health

The results of COVID-19 measures on mental ill-health have been widely covered with concerns that further mental health devastation is imminent as we face a second wave. Infection control measures such as social distancing and shielding lead to a higher risk of mental health problems such as anxiety, fear and sleep disturbances for general populations and can aggravate symptoms for people living with existing mental health conditions.

Research shows women who experience abuse from their partner are three times more likely to suffer depression, anxiety or severe conditions such as schizophrenia or bipolar disorder. Whether these are new or pre-existing problems, this impact is likely to be severe and long-lasting, resulting in more demands placed on already overburdened mental health systems.

The conditions associated with the pandemic have presented heightened risks and barriers to those who want to seek help. People’s means and opportunity to contact services may be restricted and access to support networks might be limited or wholly unreachable.

Those with existing mental health conditions might have limited access or difficulty accessing medication or therapy which, in turn, exacerbates mental ill-health. This can trigger self-harm, substance use or suicidal ideation. Every day in the UK, almost 30 women attempt suicide and every week three women take their own lives to escape domestic abuse.

Taking on two problems at once

As we are now at the onset of a second wave of the pandemic, it is likely we’ll see another surge in domestic abuse and its associated negative impacts on mental health. Obstacles to accessing support will continue and perhaps multiply during further lockdowns and services will remain frustrated by persistent underfunding and deficient resources in the face of greater demands.

Two already overburdened systems risk becoming even more frayed at the edges in the months to come. To respond to the severe, long-lasting impacts of domestic abuse and mental ill-health following COVID-19, governments should invest in evidence-based research and mainstream interventions that target the connections between the two phenomena. This includes screening for both domestic abuse and mental health problems by practitioners across both sectors, providing online interventions and safety planning. Governments should also encourage different services to work together, through more substantial funding and a policy response which recognises and responds to these overlapping issues.

COVID-19 will not be the last emergency we face with the potential to increase rates of domestic abuse and mental ill-health. We should use the lessons we have learned from this pandemic to prepare ourselves to better respond to other crises in future. These lessons can also help us understand the impact of emergencies on those experiencing domestic violence and mental-ill health at the same time.

If you are experiencing domestic violence or abuse, help is available from the following organisations and services:

Refuge – 0808 2000 237

If you need urgent help in the UK and are worried about being overheard, you can dial 999, then 55 to indicate that you cannot speak. The police will be able to assist you.

For mental health support you can call the Samaritans 24-hour helpline on 116 123 or go to their website.

Michaela Rogers, Senior Lecturer in Social Work, University of Sheffield and Parveen Azam Ali, Senior Lecturer, School of Nursing and Midwifery, University of Sheffield

This article is republished from The Conversation under a Creative Commons license. Read the original article.

A radical nature-based agenda would help society overcome the psychological effects of coronavirus

More of us than ever are stuck indoors, whether we are working at home, self-isolating, or socially distancing from other households. Long periods of isolation are already impacting many people’s mental health and will continue to do so.

On the other hand, people have reported discovering outdoor spaces on their doorstep as they are forced to stay local. Many say they have felt happier for doing so.

This reinforces the surge of research exploring the psychological benefits of connecting to nature that has developed in recent years. The idea is also growing that encouraging time in and engagement with nature has enormous potential in terms of mental health and wellbeing.

There are more and more programmes explicitly aimed at helping people with experiences of distress by providing structured contact with nature. These are variously referred to as nature-based interventions, ecotherapy or green care. A growing evidence base suggests they are effective in alleviating distress and fostering recovery and resilience – for people but also, at least potentially, for nature too.

I think programmes like this need to be rolled out en masse, with a few vital provisos.

Natural connections

My work often involves evaluating nature-based interventions from a psychological perspective. I have repeatedly witnessed the benefits of time spent in nature for those involved.

One organisation I work with, called Grow, takes small groups of six to eight people – often strangers at first – into nature. Participants all suffer, or have suffered, from debilitating forms of psychological distress and are recruited on that basis. Like many such services, Grow operates with funding from sources like the National Lottery, larger charities and local council grants to run a number of programmes a year.

Clients are not yet referred through or commissioned by the health service. Your doctor might be more likely today to suggest you get outside more in a move towards green prescriptions. But institutionalised health provision is still catching up with the evidence of the benefits of structured, supported and sustained contact with nature.

At Grow, trained professionals run a series of activities to help participants connect to nature on daily trips, once a week, for eight weeks. Activities include mindfulness, silent walks, foraging, sharing food, identifying flora and fauna, building fires, arts and crafts using natural objects, and reflective diaries, alongside more traditional active conservation activity like planting, clearing and coppicing.

Colleagues and I have collected surveys, diaries and interview data about the project over a number of years. Our findings reveal how transformative the experience has been for participants. (I was so impressed I later became a trustee of the charitable organisation involved.) We found plenty of evidence of the psychological benefits of nature connection, but also, vitally, something else – a deepening of social connectedness.

For people struggling emotionally, socially or psychologically, just being in nature seems to rekindle their ability to relate to and engage with others. Feeling present and “held” by the natural environment can nurture new and positive forms of social contact, which in turn enhances experiences of nature.

So for me, while there are always important caveats (such as the need for on-hand trained professional support), the benefits of a range of nature-based projects are unequivocal. They can be used as therapeutic interventions for people struggling to cope. They also work preventatively, by helping to maintain a sense of wellbeing, happiness, awe and belonging.

A human right

The impact of coronavirus-induced isolation on mental health is already mirrored in rising psychiatric diagnoses. And so the need for these kinds of interventions has never been greater. It is not enough to just encourage people outdoors. For many, access to nature is practically difficult. For others, it is an alien concept.

There are projects like Grow across the world and they are chronically underfunded. We need more of them. We need our governments to be funding projects like this as a matter of urgency, rolling them out on a national scale. Doctors, nurses and other primary care professionals should be able to refer people to local green care services as part of a wider shift towards “social prescribing”.

This is not only a psychological issue. Access to nature is not equal. The richest 20% of areas in England offer access to five times the amount of green space as the most deprived 10%.

If nature is so fundamental to our wellbeing, it should be understood as a right rather than a luxury. This is why diverse organisations such as walkers’ rights group the Ramblers and the mental health charity MIND are increasingly calling for legally binding targets that guarantee people’s access to nature. This should be part of a radical shake up of health and care policy.

Mutual healing

We also cannot ignore the fact that nature is in retreat, decimated as ecological devastation is wrought across the globe. In this context, contact with nature might seem futile, contradictory even. There is arguably something perverse about asking nature to make us well at the same time as we are destroying it.

But the movement is evolving rapidly. One of the most promising developments I’ve seen is the growth of “reciprocal restoration” projects – interventions explicitly designed to combine restoring people with restoring natural environments.

The potential for more collective forms of green care, such as the mass mobilisation of volunteers, is well worth exploring. Evidence also suggests that the more access to nature we have, the more we come to care for and want to defend the natural world.

There are already signs that we are at last more willing to face up to the realities of ecological crisis – if the shift in nature documentaries, the rise of Extinction Rebellion and the growing youth climate movement are anything to go by.

So perhaps it’s possible that an ambitious push for nature-based interventions might further encourage a groundswell of action that is truly restorative – of both humans and nature.

Matthew Adams, Principal Lecturer in Psychology, University of Brighton

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Coronavirus: why aren’t death rates rising with case numbers?

It is a conundrum. For much of the past two months, many people have been convinced that mortality associated with COVID-19 would rise as the number of people testing positive with the disease increased. But this has not happened so far. Why? A look at government data from England and Wales can provide some clues.

By late summer 2020, the UK government had finally managed to produce a consistent definition of precisely what constitutes a positive case of coronavirus. It is defined as a person with at least one lab-confirmed positive COVID-19 test result (individuals who tested positive more than once are only counted once, on the date of their first positive test).

The first graph below shows cases by the day on which they were initially reported – represented by the blue line. Cases peaked at 5,451 on April 5, reached a low of 101 on June 10 and very recently have appeared to be rapidly rising again. The most recent rise in cases, to more than 2,600 a day, is particularly unsettling. The red line shows deaths per day, which have been very low for many weeks now and also still falling in number.

It’s important to remember that the number of cases has not been rising because the number of people carrying the disease has been increasing, but instead because more tests are being carried out, and especially in areas where the rate at which people have the disease is found to be higher.

The main reasons why we know that the number of deaths has not been rising is that the actual number of cases in the population has not been rising when measured per million people tested. We know this because the Office for National Statistics (ONS) is running a properly constructed surveillance programme which estimated that by August 25 only one person in every 2,000 in England had the disease, and each week only one person in every 27,000 was catching the disease (this proportion having been essentially stable for several months). The proportion in Wales was even lower at one in 2,200.

The ONS is currently increasing the sample size of its surveillance programme to 400,000 people in England with 150,000 being tested each fortnight in October.

A question of demographics

It is likely that among the steadily rising number of people who have tested positive for the disease since June, an increasing proportion are young and a declining proportion are older, so that having the disease is dramatically less lethal for each person with it. In March and April (before the June minimum was reached) younger adults aged 18-34 had the highest prevalence in antibody testing so we should not be surprised that outside of the most rigorous lockdown, cases are higher among the young.

Your chances of dying with COVID-19 depend primarily on age. Those chances are greatly reduced if you are younger – as the table below shows.

According to this data, by the end of August, someone aged 20-24 had a one in 100,000 chance of having died with a mention of COVID-19 on their death certificate; that risk doubles to one in 50,000 for people aged 30-34 and is more than one in 1,000 for men by age 65 and for women by age 75.

Another way of describing what the table reveals is that a grandmother in her early 90s is 120 times more likely to have died of the disease than her daughter aged 52 who, herself, is 259 times more likely to die than her 14-year-old daughter. Currently, mortality rates for all ages are very near zero as deaths per day are so low.

Cases increasing in the young and decreasing among the elderly is how the number of deaths can continue to fall even if cases found by the ONS surveillance study remain the same or even rise slightly, as long as fewer older people have the disease as compared to more younger people over time.

There is growing concern of younger people passing the disease to older people, but if a young person has had the disease, and is then very unlikely to have it in future, their chance of passing it on to an older person in future is much diminished. This is another reason for not hitting the panic button when case numbers rise.

Reaching a true mortality rate

Eventually, mortality rates from COVID-19 will fall as the proportion of people who have had it rises. The final graph below tries to illustrate just how far away from that point we are, but how we have clearly been moving towards it over the course of the past two months.

The graph shows the ratio of deaths to every 1,000 cases recorded each day. This is a crude measure, as mortality lags behind positive cases, but it is still a useful guide.

We can see that the number of people dying of COVID-19 falls from 217 for every 1,000 testing positive across all of England and Wales on June 24 (when so few people were being tested), to four by the end of August and just two per 1,000 by September 4. The fall is so fast and so great that a log scale is required to encompass it in one graph.

The fall cannot continue at this rate for much longer, and where the ratio eventually settles will be below the theoretical upper limit for the actual final overall mortality rate from this disease; a rate which we do not yet know.

Danny Dorling, Halford Mackinder Professor of Geography, University of Oxford

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Coronavirus reinfection – what it actually means, and why you shouldn't panic

Scientists in Hong Kong have reported the first confirmed case of reinfection with the coronavirus that causes COVID-19, reportedly backed up by genetic sequences of the two episodes of the 33-year-old man’s infections in March and in August 2020. Naturally people are worried what this could mean for our chances of resolving the pandemic. Here’s why they shouldn’t worry.

Nearly nine months after the first infection with the novel coronavirus, we have very poor evidence for reinfection. However, virologists understand that reinfection with coronaviruses is common, and immunologists are working hard to determine how long the hallmarks of protective immunity will last in recovered patients.

The rare reports of reinfection so far were not accompanied by virus sequencing data so they could not be confirmed, but they are quite expected and there is no cause for alarm.

Inhospitable hosts

Our bodies do not become impervious to viruses when we recover from infection, instead, in many cases, they become inhospitable hosts. Consider that beyond recovery, our bodies often still offer the same cell types – such as cells of the respiratory tract – that viruses latch onto and gain entry for a cosy haven to uncoat and begin producing more viruses. These target cells are not altered in any substantial way to prevent future infections months after the virus has been cleared by the immune response.

If antibodies and memory cells (B and T cells) are left behind from a recent infection, however, the new expansion of the virus is rather short lived and the infection is subdued before the host suffers too much – or even notices at all.

This appears to be the case with the Hong Kong patient, who did not present any symptoms of the second infection, which was discovered following routine testing at the airport. Would he ever know that he had been reinfected had he not travelled? Probably not. A more interesting question is, was he contagious during his asymptomatic second infection?

There is mounting evidence that asymptomatic and presymptomatic people are contagious and this is why the sensible official advice is to wear face coverings to avoid infecting other people and to keep our distance to avoid getting infected. Coronaviruses from previous colds have endowed some of us with memory T cells that can also mobilise against the novel coronavirus, and this could explain why some people are spared severe disease.

Three potential outcomes

So how should we receive the news on reinfection of recovered individuals? There are three possible outcomes of reinfection with a similar virus: worse symptoms that lead to more severe disease, the same symptoms as the first infection, and improvement of symptoms leading to milder or no disease.

The first outcome is known as disease enhancement and is noted in patients infected with similar strains of viruses such as dengue. There is no evidence for this for the novel coronavirus, despite over 23 million confirmed cases of COVID-19 worldwide.

The second outcome, where the patient suffers the same disease twice, indicates that there is no sufficient immunological memory left behind to protect from reinfection. This could happen if the first infection did not require antibodies or T cells to be resolved, perhaps because other rapidly deployed immune defences were enough to control it.

The final outcome is milder infection thanks to a healthy immune system that generated antibodies and memory B and T cell responses that persisted long enough to be of value during the second exposure. Given the diversity of antibody and T cell responses reported in different COVID-19 patients, we anticipate that immune protection – if efficient – may vary in different people.

Of course, this has implications for the potency and duration of herd immunity, the idea that when we reach a large number of recovered patients immune to reinfection, this will protect the most vulnerable. Therefore vaccination is critical to induce and sustain protective immune responses in the long term.

Vaccination can elicit more potent and longer-lasting immune responses compared with natural infection, and these can be sustained by booster vaccinations when necessary. This is why scientists were not surprised to hear of evidence of reinfection. The lack of symptoms experienced by the Hong Kong patient is very good news.

Zania Stamataki, Senior Lecturer in Viral Immunology, University of Birmingham

This article is republished from The Conversation under a Creative Commons license. Read the original article.