Impact of COVID-19 on mental health: Update from the United Kingdom

Abstract

In January 2020, the World Health Organisation (WHO) declared the outbreak of a new corona virus disease, COVID-19 to be public health Emergency of International concern and by March 2020 it had progressed rapidly across several continents to be a pandemic. After COVID-19 was declared a global pandemic the U.K. Government placed strict measures in mid-March 2020 to limit spread by enforcing social distancing, travel restrictions and complete lockdown. In U.K. by end of April 2020 official estimates of confirmed COVID-19 positive cases reached 161,000 and the number of deaths has exceeded 26,000 in hospitals and in care homes. COVID-19 continues to have an impact on all aspects of life in U.K. The Royal College of Psychiatrists (RCPsych), London, a leading professional body of U.K. and global mental health professionals was prompt to act in this public health emergency. RCPsych has issued guidance for clinicians, patients & carers, organised a series of webinars to support members and undertook a membership survey. It has played a crucial role in influencing national policy decisions. This article will focus on mental health impact of COVID-19 pandemic in U.K. and the initiatives taken by RCPsych.

INTRODUCTION

In January 2020, the World Health Organization declared the outbreak of a new coronavirus disease, COVID-19 to be a public health Emergency of International concern, and by March 2020, it had progressed rapidly across several continents to be a global pandemic. Once COVID-19 was declared a global pandemic, in March 2020, the United Kingdom (UK) Government passed emergency legislation, Coronavirus Act 2020, which gave ministers the ability to restrict or prohibit events and gatherings during coronavirus outbreak in “any place, vehicle, train, vessel, aircraft or any moveable structure and any offshore installation and where necessary to close premises.” It was decided that Coronavirus Act 2020 will be in force for 2 years and will be reviewed by the parliament every 6 months. It provided police authority to force those infected with COVID-19 to self-isolate. The legal framework paved the way for reinforcing strict measures to limit the spread of COVID by enforcing social distancing, travel restrictions, and complete lockdown.

The lockdown has continued for over 4 months and has totally changed civic life in UK and the health sector is no exception. The new legislation allowed thousands of recently retired National Health Service (NHS) staff to be able to return to work without any loss of pension rights. It also made provision for Court cases to be heard through video-link.

Over the last 4 months, COVID-19 has changed how we live in everyday life. Health-care staff working on the frontline in the NHS were in a vulnerable position and so appropriate personal protective equipment (PPE) was introduced. In addition, in mental health services, protocols were put in place in place to avoid direct patient contact wherever possible (to reduce footfall) and adopt working from home (wfh) with the use of remote consultations and on-line meetings. These have become the new normal.

COVID positive cases continued to peak throughout April-May 2020 before slowing down in late June 2020. The day to day life in the UK is yet far from normal. The socioeconomic impact of the pandemic is unleashing a tsunami of challenges to mental health services up and down the country.

However, digital technology has been a savior in this pandemic and the NHS was quick to adapt this technology for day to day clinical use.

When the lockdown was announced in mid-March 2020, the Royal College of Psychiatrists stepped in quickly to provide guidance to clinicians regarding COVID. Mental health services in UK are provided by local mental health organizations who are part of the NHS and commissioned in England by NHS England under the auspices of the Department of Health (DoH) and Social Care and under the relevant health departments of respective devolved administrations in Northern Ireland, Scotland, and Wales. Over the last 4 months the UK has gone from e lockdown and social distancing to the partial lifting of lockdown measures in England since July 4, 2020.

In addition to the problems caused by the pandemic the tragic death of Mr George Floyd during a restraint by police in Minneapolis, USA and disproportionate death rate from COVID-19 in Black, Asian and minority ethnic (BAME) population in UK has generated renewed focus on the debate on racism, social inequalities, and mental health in UK.

This article will provide an overview of COVID-19 pandemic in UK and its impact on mental health services in UK.

SETTING THE SCENE

It is estimated that one-third of the World's population estimated to be around 2.6 billion people are in lockdown. At the time of writing this article in the 3^rd week of July 2020, there were 295,372 cases of COVID in UK and 45,318 deaths in UK while globally, the numbers are 14,707,451 and 609,986, respectively. In UK the Office of National Statistics (ONS), UK has found that people from BAME groups are nearly twice as likely to die with coronavirus compared to white counterparts in England and Wales. The ONS provides weekly updates on social impacts on COVID-29 in Great Britain. We have included the main finding from the report July 9, 2020:

Over 50% of those surveyed said that coronavirus was having an impact on their work. The most-reported difficulties were

• Being furloughed

• A decrease in hours worked

• Concern about health and safety at work.

The DoH in each nation issued national guidelines for all NHS organizations to provide PPE such as face masks, visors for front-line clinical staff. There was suspension of visitors to the hospital. Each organization also directed staff to work from home and run services remotely as far as possible but ensure that services had critical staff available in the frontline and strategies to manage COVID positive cases within mental health services.

IMPACT OF COVID-19 IN UNITED KINGDOM

As lockdown is gradually being lifted, the social distancing rules are slowly being relaxed, though the ability to strengthen measures in certain localities in response to rising infection rates is already being used. It became mandatory to wear face covering on public transport in England on June 15, 2020.

According to the ONS survey of July 7, 2020, of those adults who had used public transport, over 80% had worn face coverings during the last week. Women and those over 70 years were more likely to wear a face covering when outside their home (49%), followed by adults with health conditions (46%). About 7 in 10 people now are very worried or somewhat worried about the impact COVID-19 was having on their life with 45% saying they were bored, 34% saying that they were spending too much time alone and 21% saying that lockdown was having an impact on their interpersonal relationship. Furthermore, a larger proportion of people are now finding it difficult to pay their household bills, with 11% reporting that they had to borrow more money than before the COVID-19 pandemic and use credit.

COVID-19 has created a burgeoning opportunity for researchers regarding its impact on mental health.

METHODOLOGY

SM reviewed the literature on mental health and COVID-19 using PsycINFO, EMBASE, Medline, Emcare, ProQuest Coronavirus Research Database, LitCovid, WHO COVID-19 Hub. In 2020 alone, there were 21 articles, 7 reports, and 5 guidelines. We have reviewed scientific literature relevant to UK context. Many COVID-19 articles are at this stage are editorials/commentaries/letters as the outbreak is still new, and the publication process can be lengthy. We did not include these in this paper and focused on full articles. All resources relating to COVID-19 are Open Access.

Lassal C et al. (2020) studied data of 340,966 adult men and women from UK biobank study, which linked ethnicity to hospitalization due to COVID during the pandemic. There were 640 COVID-19 cases and after controlling for demographic and confounding factors, they observed a higher risk in hospital admission among Black (odds ratio 1.89) and Asian (odds ratio 1.66) population.

COVID-19 AND MENTAL HEALTH

Access to mental health care in UK is usually through local General Practitioners (GPs). GP Surgeries started to advise patients not to attend GP Surgeries during lockdown, and telephone calls were screened regarding the priority of clinical need. Furthermore, in secondary care, local community mental health teams had to adapt to nonface to face contact wherever possible. Mental health services up and down the country have planned resources and services to address COVID-19.

One aspect of daily life which keeps us stable is a structured day. A structured day is also recommended by the Royal College of Psychiatrists to promote mental well-being. Being in lockdown can easily lead to feelings of confinement and lead to loneliness in some. It may not always be possible to have a “normal day” as lack of structure can give rise to developing unhealthy habits. There are reports of excessive use of gaming/online gambling, increased consumption of alcohol, overeating, and lack of exercise.

Spending more time with family could be positive for some but stressful for others. Employment issues and financial constraints are also likely to exacerbate these problems. It is of concern that there are increasing reports of domestic violence. A recent article in UK media reported a 25% surge in those calling helpline for perpetrators of domestic abuse who wanted to change their behavior. In UK the Home Office launched a public awareness campaign under twitter hashtag #YouAreNotAlone to highlight that there is help available for those experiencing or at risk of domestic violence.

Lockdown is pivotal in keeping each one of us safe, but it means separation from loved ones, loss of freedom, uncertainty over disease status and can potentially be a source of boredom. In ONS survey, the main concerns which people reported were personal well-being (8.5 million), employment/jobs (6.2 million) followed by the impact of COVID-19 on finances. About 49.6% of survey respondents reported higher levels of anxiety; other areas of relevance were impact on education, relationships, and caring responsibility. Mental health problems have multi-factorial origins and usually involve an interplay between biological, psychological, and social factors. In disasters such as COVID-19 pandemic, all the factors are likely to come into play at the same time.

In a cross-sectional survey of self-isolating UK adult respondents, Smith et al. (2020) concluded that self-isolating females, younger age groups, those with lower annual income, current smokers and those with physical multi-morbidity were associated with higher levels of poor mental health. A survey undertaken by the mental health charity, Rethink, in U. K as part of mental health awareness week in May 2020, highlighted that 42% of responders who were living with mental illness were of the view that their mental health had got worse during lockdown.

Children and adolescents are at higher risk of anxiety and depression due to social isolation and lockdown as evidenced in a rapid systematic review undertaken by Loades et al. (2020).

The college has provided specialty specific guidance regarding the management of COVID-19. It is beyond the scope of this article to outline the full guidance. We suggest that readers visit the Royal College of Psychiatrists (RCPsych) website www.rcpsych.ac.uk for further details. We have included snapshots of the guidance, which may be helpful to psychiatric colleagues in India.

COVID-19 AND MENTAL HEALTH LEGISLATION IN UNITED KINGDOM

The Coronavirus Act 2020, which received Royal Assent in March 2020, included provisions to allow for changes to mental health legislation across the UK, including the Mental Health Act 1983 (England and Wales).

The new legislation allowed a reduction of the number of approved doctors required to complete a Mental Health Act assessment from two to one. However, this was only to be introduced if necessary due to extreme staff shortages and has not been activated.

Face-to-face medico-legal hearings were suspended for a 6-month period beginning March 23, 2020, to limit the spread of COVID-19. This was to manage and allow tribunals to manage their workloads appropriately. Pilot Practice Direction was issued by the senior President of Mental Health Tribunals (MHTs), Sir Ernest Ryder on March 26, 2020 informing that all future tribunal applications will be listed before a Judge alone (rather than a panel consisting of a Tribunal Judge, a medical member and a lay member). It was mentioned that the Judge will seek specialist advice from the medical member and specialist lay member, but the sitting will be in front of a Judge alone. These hearings would be by phone or video rather than face to face MHT hearings. Prehearing examinations were suspended.

In England and Wales, Section 12 (2) and Approved Clinician (AC) approval is for 5 years. Psychiatrists who would like to renew their Section 12 and AC status usually have to complete a face to face refresher's course in the last years before renewal was due. Due to COVID-19 Section 12 and AC re-approval have been extended by a further period of 12 months and online training courses have been approved.

ETHICAL DILEMMAS IN COVID-19

COVID-19 pandemic has also raised ethical dilemmas regarding patient care and management in this extraordinary circumstance. While clinicians are working hard to provide the best care for their patients, there is a need to ensure that individuals with mental disorder, learning disabilities, and autism are able to access COVID assessment, testing and treatment. Assessment of mental capacity, involving patients and families in clinical decision making is paramount during COVID-19. Some mentally ill patients admitted on the COVID-19 ward and under the care of physicians will require an assessment from liaison psychiatrists. Individuals with a mental or developmental disorder should not be discriminated against in access to life-saving treatment.

While health professionals are potentially at increased risk of COVID-19 by virtue of their work if they are in contact with COVID positive patients, we have professional obligations to care for our patients. The professional duty as a doctor and psychiatrist is laid out in the General Medical Council (GMC) guidelines of Good Medical Practice and RCPsych Good Psychiatric Practice. Social distancing measures are likely to restrict individual's freedom and liberty is already restricted for those being detained under the Mental Health Act 1983. Even if working remotely through digital technology, psychiatrists must adhere to a duty of confidentiality toward their patients. In UK we have secure digitals platforms such as Microsoft Teams with a registration process provided by the organization. It is essential that when using digital technology, even whilst wfh strict adherence to confidentiality and adherence to general data protection rules must be followed.

RCPsych has developed a “Digital policy” to guide psychiatrists when using digital technology for clinical consultations. A qualified doctor is required to deliver safe, ethical care to patients wherever they may be. The standards expected of doctors by the GMC apply equally to digital and conventional settings. NHS-X, (a joint unit bringing together teams from DoH and Social Care, NHS England, NHS Improvement, and digital transformation of care) has also published pragmatic guidance on information governance during the COVID outbreak. Changes in accessing presentation, including assessment and management of risk based on remote consultation pose another ethical dilemma.

COVID-19 AND ROYAL COLLEGE OF PSYCHIATRISTS

RCPsych has produced a suite of information for mental health workers and patients all approved by the relevant national bodies. This is published with open access on the College website. We have liaised closely with Government and other bodies to influence policies and highlight mental health issues during COVID-19 pandemic.

IMPACT ON ROYAL COLLEGE OF PSYCHIATRISTS MEMBERS

RCPsych has published guidelines on mental well-being as well as highlighted the Psychiatric Support Service facility available to its members.

In April 2020, RCPsych issued a survey (first of the three) to its members working in NHS across the UK regarding the impact of COVID-19. This was to collect baseline data regarding access to the appropriate level of PPE, testing and working patterns. Overall, in the UK more than 1 in 5 psychiatrists surveyed reported that they did not have correct level of PPE.

Regarding access to COVID-19 testing for patients, themselves or their symptomatic households, 53% of psychiatrists surveyed reported that they were able to access testing for their patients, a mere 30% of respondents were able to confirm that they were able to access testing for their symptomatic households, 67% respondents confirmed that they could access testing for themselves if required.

The findings from this survey were influential in highlighting the need for more PPE and testing for frontline staff.

In terms of job plans 59.4% of respondents confirmed that they were working their normal job-plans while the remaining respondents cited that their job-plan was altered time-table due to COVID-19 pandemic with changes in rota or self-isolating due to a member of family symptomatic for COVID.

A second RCPsych survey was carried out in May 2020, this looked at indirect harm. Members were asked how about their workloads had changed over the past fortnight in relation to five categories of interventions or appointments. These included emergency interventions or appointments such as Mental Health Act assessments, community treatment order recalls, urgent safeguarding orders. 42.6% of the respondents in UK reported increases in workload in one or both categories in the past fortnight while 22.2% reported decrease in workload during the same period. At the same it was reported that there was a decrease in workload in UK for appointments and interventions usually undertaken between 4 weeks and 3 months (nonurgent).

In June 2020, RCPsych undertook it's third RCPsych members' survey regarding COVID-19. This time it focused on support for staff from BAME groups, risk assessment processes and in raising concerns, comfortability of redeployment to acute general hospital and impact of COVID lockdown on mental wellbeing. 62.2% of respondents in UK said that their employing organisation was supportive or very supportive in COVID in accommodating needs of minority groups. A small proportion, 9% of respondents reported the organisation where they were employed was unsupportive or very unsupportive of the needs of minority groups. Across the UK 48% of respondents felt that they were confident or very confident regarding risk assessment process while 20% reported that they were not confident or not very confident about the risk assessment process.

Overall, over 60% of respondents felt uncomfortable if they were to be deployed to acute care hospital settings to deal with medical complications. 54.4% of respondents reported that their wellbeing had suffered or severely suffered due to COVID and lockdown.

ROYAL COLLEGE OF PSYCHIATRISTS GUIDELINES AND COVID-19

RCPsych has produced guidance re COVID-19 on following areas:

• Wellbeing and support

• Patient engagement

• Digital

• PPE

• Community and in-patient services

• Workforce

• F Trainees

• Guidance on risk mitigation for BAME staff

• Information for patients and carers

• Legal

• International resources.

Information on each of the headings is available on RCPsych website. In this paper we include a snapshot of some of guidance to:

1. Community mental health services

2. In-patient mental health services and

3. Elderly mental health services.

The guidance was developed for use in the UK, with some variations across the devolved nations. However, it may be of help to clinicians in other countries. It needs to be mentioned that guidance is be reviewed on a regular basis and readers are advised to always refer to latest information on the Royal College of Psychiatrists website.

ROYAL COLLEGE OF PSYCHIATRISTS GUIDANCE FOR COMMUNITY MENTAL HEALTH SERVICES SALIENT POINTS

Identify those with high need based on the following criteria

• Risk

• Mental health acuity

• Physical health acuity

• Accommodation/home environment

• Support network

• Other concerns/vulnerabilities (substance misuse, chaotic life-style).

Consider need by diagnosis

• Psychotic illness including those who may be adversely affected by incorporating COVID-19 situation into their delusional beliefs

• Intellectual disability and those lacking capacity

• Anorexia nervosa and substance misuse disorder (who may require enhanced support with physical health monitoring)

• Anxiety disorders and substance misuse disorders

• Cognitive impairment.

Impact of medication

Particularly patients on medications who may be high risk of side-effects such as those on:

• Lithium

• Clozapine

• Valproate

• Antipsychotics (high dose).

Potentiality of COVID-19 susceptibility to certain group of patients

• Adults over 70 years

• Those with severe and enduring mental illness who smoke, misuse alcohol and are in poorer physical health

• Existing respiratory disease e.g., chronic obstructive pulmonary disease, asthma

• Malnourished for any reason

• People with substance misuse disorder

• People with underlying psychotic mental illness with poor insight who do not adhere to self-isolation advice secondary to delusional beliefs and chaotic lifestyle.

Managing care pathway with limited staffing resources

Make plans to ensure continuity of treatment particularly those on depot antipsychotic medication and those requiring physical health monitoring.

Identify groups of patients who are less likely to have access to technology, have difficulty in hearing well on phone.

Regular information to patent and families.

Maximising capacity

Ongoing risk stratification and development of risk registers.

Upskilling of staff regarding physical health matters.

Home visit

Public Health England (PHE) recommend informing patients of change in protocol of telephone screening prior to home-visit.

Consider door-step assessment.

If patient is symptomatic of COVID-19 then advise medical consultation.

GUIDANCE FOR PSYCHIATRIC IN-PATIENT MENTAL HEALTH SERVICES

General principles

• Limit contact between individuals

• All admissions should be screened for COVD-19 including complete swab and isolating symptomatic patient

• Asymptomatic patients awaiting results of swab advised to self-isolate and follow social distancing guidelines until results are offered.

How do we isolate suspected/confirmed cases?

Appropriate to isolate patients with mild symptoms. If symptoms do not resolve after 7 days review safety on the ward. In the UK most in-patient units have single rooms with en-suite facility rather than dormitory accommodation. So, patients are advised to isolate in their own bedroom under local infection control guidance.

Guidance for visitors

National Health Service England had nationally suspended visitors to psychiatric units until June 5, 2020. However, this has been reviewed and the responsibility is delegated to local Trusts. Local Trusts advised to supporting visits (including number of visitors, PPE, virtual visits).

GUIDANCE FOR OLD AGE PSYCHIATRY SERVICES

Older people are vulnerable to chest infections and those with suspected or actual COVID infection may find being in an intensive care environment and/or being cared for by staff taking precautionary measures extremely anxiety-provoking or distressing. Attempts need to be made to make the environment less threatening, more familiar and reduce the number of investigations, if possible. Education of care staff of nonpharmacological ways to address distressed behaviour is crucial.

Older people will often be at increased risk of delirium. Staff should be encouraged to consider risk reduction strategies early on (e.g., nutrition, hydration, constipation and pain, etc.,).

SOME TIPS FOR OLD AGE PSYCHIATRY IN-PATIENT UNITS

1. Ensure that oxygen cylinders are available and knowledge and skills of staff regarding their use are as updated as possible

2. Check care plans reflect any updated lasting power of attorney documentation and advance directives

3. General guidelines on management of Delirium in Elderly.

ASSESSMENT OF DELIRIUM

Delirium is important in the context of COVID-19, because

1. Delirium may be a symptom at presentation and/or during management, and

2. The behavioural changes commonly seen in delirium, particularly agitation, may make management including delivery of care and reducing the risk of cross-infection more challenging

3. Consider enhanced implementation of screening for delirium in at risk groups and also regular assessment for delirium using a recommended tool (e.g., the 4AT)

4. Reduce the risk by avoiding or reducing known precipitants e.g., regular orientation, avoid constipation, treat pain, identify and treat superadded infections early, maintain oxygenation, avoid urinary retention and medication review

5. For behavioural disturbance, look for and treat direct causes (e.g., pain, urinary retention, constipation, etc.,). If ineffective or more rapid control is required, it may be necessary to move to pharmacological management earlier than would normally be considered

6. Consider referring to National Institute of Clinical Excellence guidelines for rapid tranquilization interventions, monitor side-effects, vital signs and level of consciousness. Be mindful of use of benzodiazepine in respiratory depression

7. Take caution with use of medication in elderly especially certain medications in people with Parkinson's disease or dementia with Lewy bodies (e.g., antipsychotic medication).

ROLE FOR VITAMIN D SUPPLEMENTATION

There is much discussion in scientific forums regarding the role of Vitamin-D in COVID. Observational studies have suggested that Vitamin D deficiency may be linked to nonskeletal illnesses, including psychiatric disorders and respiratory illness. Randomised controlled trial evidence, has not consistently shown a benefit in Vitamin D supplementation for these disorders. PHE has recommended that everyone should consider taking 10 μg of Vitamin D a day to keep healthy, particularly those who may not have enough exposure to sunlight. The dose of Vitamin D recommended by PHE is 10 μg or 400 IU for prevention of Vitamin D deficiency only.

A rapid review by the Centre for Evidence-Based Medicine found no clinical evidence relating to Vitamin D deficiency predisposing to COVID-19 or studies of supplementation for preventing or treating COVID-19 (search date up to April 4, 2020, clinicaltrials.gov searched up to on April 23, 2020). There is some (limited) evidence that daily Vitamin D3 supplementation may prevent other acute respiratory infections, particularly in people with low/exceptionally low Vitamin D status.

The Royal College of Physicians, British Dietetic Association, and Society for Endocrinology have issued a joint statement (May 26, 2020), which concludes that there is currently no evidence for recommending high doses of Vitamin D for the general population. Both support the advice of PHE that everyone should consider taking 10 μg (400 IU) of Vitamin D a day to keep their bones and muscles healthy. This advice is particularly important for people from a BAME background (the higher the amount of melanin in the skin, the less it absorbs ultraviolet radiation, which converts Vitamin D into its active form).

ROYAL COLLEGE OF PSYCHIATRISTS EVENTS AND CONFERENCES

COVID-19 has had enormous impact on the functioning of RCPsych. As the leading Organization for setting standards for education and training in Psychiatry, we had to adapt to the challenge swiftly. The college has moved to remote working and held series of webinars on COVID-19 as well as on other topics. These are available on the website.

All our educational events up to the end of 2020 remain canceled. Most of the College staff are wfh, which is now the new normal. The International Congress scheduled to take place in Edinburgh, between June 27, 2020, and July 1, 2020 had to be canceled, the first time in modern history that this has happened.

ROYAL COLLEGE OF PSYCHIATRISTS TRAINEES AND MEMBERSHIP EXAMS

We had to postpone Royal College Exams Part A (to be held on June 16, 2020) and Part B (due to be held on March 31, 2020) across all centers. Face to face exams are postponed during the lockdown and will be replaced by online examinations. Due to high demand, there will be an extra sitting of the written Paper B. The Pearson Vue system will be used to deliver Papers A and B. The College is planning to run an MRCPsych CASC examination this Autumn on the published dates of 8–11 September 2020 using the Fry IT system. Videos demonstrating how both systems will work will be uploaded to the RCPsych website shortly.

COVID-19 AND BLACK, ASIAN AND MINORITY ETHNIC GROUPS

There is widespread discrepancy in deaths following COVID in BAME health-care staff. Two-thirds of health-care staff who sadly died from COVID are from BAME background while they compromise 20% of health-care workforce. By April 2020, there was concern that among those who lost their lives in the initial few weeks, there was a higher prevalence of COVID-positive cases in front-line clinicians from BAME groups. Cook et al. (2020) reviewed 106 COVID-related deaths of NHS staff until the 1^st week of April 2020. The observed that BAME health-care workforce accounted for disproportionately high percentage of deaths. For example doctors accounted for 44% of the workforce, but 94% of deaths and similar figures for nurses and midwives were 20% and 71%. The RCPsych has developed a risk assessment tool for BAME staff, which is available on the RCPsych website www.rcpsych.ac.uk. This may also be of use to psychiatry colleagues in South Asian countries.

COVID-19 has highlighted issues of discrimination and racism faced by BAME staff in the NHS. The RCPsych has taken a firm stance against any form of racism and recommended that risk assessment should be carried out as a matter of priority for BAME staff so that personalized risk mitigation plan can be put in place by NHS employers.

MAINTAINING STAFF MORALE AND DEVELOPING HOPE AND KINDNESS A WAY FORWARD?

In crisis it is not unusual for the public to look up to leadership for emotional support. Her Majesty Queen Elizabeth II did exactly that in April 2020 by addressing the nation. Her Majesty, who has witnessed several natural and man-made disasters over the years, was able to give that much needed hope that “better days will return; we will be with our friends again; we will meet again.”

The second example is that of Captain Mr. Tom Moore, from Bedford. Captain Moore, who turned 100 years in April 2020, served in World War II in India and Burma, walking 100 lengths of his back garden (25 m) with his Zimmer frame to raise around ≤32 million for NHS. He certainly played a huge role in recognizing the hard work by front-line clinical staff and improving the morale of NHS as well as giving everyone hope for future.

In another act of kindness, supermarkets across the country showed their respect to front-line NHS staff by offering them special times for shopping or having quick checkout so that they could buy essential household items without worrying about running out of them whilst treating and caring those who suffered from ill-health.

Disasters offer a unique opportunity to unite people, develop a better understanding in communities. (SM) found an interesting quote in one of the units at his place of work “Remember each person is fighting his own battle unknown to you so be kind to others.” It's so true and important for us all to be kind and compassionate towards our fellow human beings.

The authors are aware that there is a rise in COVID-positive cases in India at the time of writing this article. We would send our good wishes to all psychiatry colleagues and staff teams in India, fighting the COVID-19 pandemic.

CONCLUSION

COVID-19 pandemic has presented all the citizens of the world with a unique set of challenges in terms of morbidity and mortality not encountered in our lifetime. Although public health strategies to limit the spread of disease by enforcing lockdown and social distancing, use of PPE and testing are being employed in UK the pandemic has presented enormous challenges to mental health services in UK. This paper highlighted the steps taken in the UK to counter challenges posed by COVID. The situation is dynamic and evolving on a day-to-day basis. We are concerned about the excessive deaths in the BAME population from COVID in the UK. Comprehensive local implementation of risk assessment, and mitigation tool is likely to be of help in this vulnerable group.

As restrictions are gradually being lifted in UK and European countries there are concerns regarding the possibility of second wave in UK. More recently there is a hope that an effective vaccine will be developed over the next 6–12 months. In the meantime, staff in mental health service need to remain vigilant and continue to adopt safe working practices to ensure patients are treated with professionalism, kindness, and compassion.[13]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.