Deprivation of liberty
Deprivation of liberty significantly increases bio-psycho-social risk for many adults and young people; negatively affecting behaviour, thoughts, beliefs, emotions, physical health and social risk with negative consequences for the immune system, general health and mental health, increasing morbidity and mortality.
Lockdown, stay at home and shelter in place are associated with significantly increased social risks for many such as relating to domestic violence (80% increase), child abuse (30-65% increase), economic challenges, poverty and unemployment (the World Bank estimates that an additional 88-115 million people will fall into extreme poverty in 2020, 150 million in 2021), along with an inability to access clean water or food (89% increase, resulting in 12 000 deaths per day, exceeding 10 000 deaths a day recorded from COVID-19 in April 2020) and social isolation (87% of Young Minds respondents) in most countries (see reports from Childline, NSPCC, Young Minds, United Nations, UNICEF, NCMEC, Oxfam, The Trussell Trust, Stop UK Hunger, England’s Children’s Commissioner and the WHO, recently published). These increased social risks, frequently associated with a high mortality rate, also significantly and negatively affect the immune system, general health and mental health, which affect clinical health outcomes in every culture.
Deprivation of liberty affects behaviour for many which contributes to social risk, general health and mental health in most cultures. Consider statistics illustrating significantly increased figures reported by organisations such as the UN, UNICEF, WHO, NSPCC, Alcohol Change UK, England’s Children’s Commissioner and RCPCH in the UK in recent months relating to aggression, violence (300% increase in one study in February 2020), alcohol abuse (400% increase), along with child abuse, suspected child sexual exploitation (90% increase reported by NCMEC, US) and non-engagement in hospital activities required to maintain or protect health (93% increase). Public Health England identified a drop in Emergency Department visits, particularly by children. UNICEF and the WHO reported that children in many countries were not receiving necessary childhood vaccinations before the pandemic, and the pandemic and restrictive initiatives have increased these concerns markedly; this has a worldwide impact relating to serious infectious diseases. These are significant risk factors that negatively impact on the immune system, general and mental health for every nation.
Deprivation of liberty has direct effects on thoughts and beliefs for many that negatively impact on the immune system, general health and mental health. Statements starting with “I can’t” and ending with “so there is no point” are frequent and relevant. One young person recently reported “I can’t leave home, because we are weak and this flu is scary, we will get sick if we leave home, what is the point of caring” and “the world is not safe for us”. Thoughts affect immediate and long term clinical outcome directly and significantly. What the mind believes often transpires; many evidence-based therapies are based on this principle.
Deprivation of liberty in any context causes high levels of stress and chronic anxiety within many or most individuals. Emotions such as anger, hostility, panic, low mood, hopelessness and depression are also frequently observed. Negative experiences and emotions such as chronic anxiety are risk factors that significantly and negatively impact on the immune system, which cause increased susceptibility to infections and a poorer general health prognosis through increased morbidity and mortality. Chronic anxiety also affects mental health morbidity and mortality in children and adults. We have observed a significant increase in referrals relating to tic, anxiety and mood disorders of children of all ages during the last few months and the profile of referral has changed; children with no previous concern or family history are presenting for the first time.
We have also observed an increase in referrals relating to possible ADHD (Attention Deficit Hyperactivity Disorder) and ASD (Autism Spectrum Disorder); however, in our experience, 30-60% of all ADHD and ASD referrals or caseloads typically do not present with ADHD or ASD, but rather with mood or anxiety disorders or histories of trauma or abuse. Children with ADHD and ASD often present similar to children with anxiety disorders, such as PTSD, or depression, along with child abuse or trauma (differential diagnoses), and preliminary diagnoses or diagnoses are often made by professionals with limited training in Child Psychiatry. Children with mental health problems often present differently compared to adults. Paediatricians often report that they have had no training in child psychiatry to differentiate between eg anxiety disorders, ADHD or ASD. Misdiagnosed children often wait 6-8 years before receiving appropriate treatment. This is of particular concern to us in the context of the pandemic.
Mental health morbidity is markedly increased for many in the context of deprivation of liberty. Consider statistics illustrating increased figures reported by organisations such as Young Minds, Samaritans and MIND in recent months relating to increased mental health problems in adults (80% increase) and young people (75% increase) with relevant mental health histories and an increase in mental health presentations in young people with no previous mental health problems (55% increase). 10% of adults presented with suicidal ideation within the first week of lockdown and 2% attempted suicide or self-harmed. Research indicates that living or feeling alone along with feelings of hopelessness are significant risk factors for suicide. MIND reports that 33% of young people with mental health difficulties self-harmed to cope during lockdown, which is a significant risk factor associated with suicide. These numbers are likely to be underestimated. The NCMD reports 25 child suicides in the first 56 days of lockdown. In 48% of the 25 post-lockdown deaths, factors related to COVID-19 or lockdown were thought to have contributed to the deaths. Mental health problems, associated with its own morbidity and mortality, also significantly affects the immune system and clinical outcome relating to general health.
Many children and adults who presented with neurodevelopmental or mental health problems before the pandemic now present with decreased impairment and distress, due to recommendations to remain at home and subsequent non-engagement in challenging, social and normative activities within the public and community; this does not encourage recovery or maintenance of positive progress.
An indirect effect on the immune system via multiple pathways has been illustrated in this section, however, a direct effect is also relevant and important for many; most systems in the human body including the endocrine, haematological, cardiovascular, respiratory, gastrointestinal and neurological system can be directly affected by deprivation of liberty. This is emphasised and repeated because it affects susceptibility or resistance to infections and subsequent prognosis in terms of morbidity and mortality; degree of illness, associated complications, recovery times and outcomes during the pandemic.
General health morbidity is also affected by direct effects on general health, not relating to indirect pathways such as via chronic anxiety and the immune system, for many, although these are major factors. Confinement or the impression of confinement or ‘being trapped’ often leads to agitation. Agitation is not necessarily associated with anxiety, particularly as a medical or psychiatric term. Agitation is often associated with irritability and restlessness, and is often seen in psychiatry units, emergency departments and care facilities secondary to eg head injuries. Concerns in this context can extend to, but are not limited to, increased blood pressure, heart rate and respiratory rate, poor attention, concentration and memory, as well as chronic headaches, digestive problems, fatigue, lethargy, loss of appetite, weight loss, insomnia, muscle and joint pain. General health and mental health morbidity and mortality can be affected directly and indirectly by these presentations, which contribute to clinical outcome during this pandemic.
As illustrated, deprivation of liberty in any context therefore increases social risk, mental health risk and general health risk for many, and can be associated with very strong messages to the mind and body for every individual, high and low risk groups, which can significantly and negatively affect prognosis. Doctors in every medical discipline will be aware of these risks. There are important evidence-based clinical, ethical and legal reasons why liberty should be considered and safeguarded where possible for every individual.
Initiatives that prevent chronic anxiety, support the immune system and prevent harm are essential if health is to be protected for the general public in the context of this pandemic. Initiatives should protect, not harm, and this needs to be evaluated and weighed on a regular basis. The outcomes of deprivation of liberty for vulnerable and at risk children and individuals, along with the general public, relating to serious mental health, physical health and social risks, are of significant concern, not only in the UK, but worldwide, as per recent statistics published.
A systemic approach is important; relevant evidence-based bio-psycho-social risk and protective factors should considered. A systemic approach implies that all things are connected and that every factor must be considered. Deprivation of liberty is one of the risk factors that can cause the most stress and chronic anxiety for many, and clinical outcome can be significantly affected for most in this context.
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