How can I keep calm during self-isolation?BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1376 (Published 02 April 2020) Cite this as: BMJ 2020;369:m1376
All rapid responses
It seems that exercise is the “miracle cure”, that keeps getting forgotten.
Despite evidence that exercise reduces disease specific and all-cause mortality (1), there has been little change in Physical Activity levels in the U.K since the flagship 2012 Olympics. The “lethargy” towards change, must at least be directed towards us as clinicians; all too often exercise is written off as a “footnote” to chronic disease management plans. The very place it could have the biggest impact!
If we are to instil change in patients, we must first instil change in our own medical attitudes towards this evidence-based intervention. As with other medical treatments, it must be prescribed, at a set dose, with enough detail to allow the patient to undertake the exercise and it must be followed up with objective review measures.
To make a start, I suggest that all clinicians should familiarise themselves with the Frequency, Intensity, Time, Type, Volume & Progression (FITT-VP) principle of exercise prescription (2). These allow patients to be guided through a graded exercise programme and gives specific directions as to how to achieve progress. Whilst I welcome national guidelines on exercise, 80% of GP’s reported that they were unfamiliar with them and 72% do not discuss the benefits of exercise with patients (3).
I propose a plea to modernise our approach to exercise, individualised medicine and to integrate new technologies. There is growing evidence that even small amounts of objectively measured Moderate or Vigorous exercise (5min/day average) from doing none is associated with a 30% reduction in all-cause mortality (1). In addition, Physical activity is inversely proportional to mortality in a dose dependent relationship (4,5).
In order to monitor exercise and progress, we suggest a move away from subjective patients reported outcomes to objective markers of physical activity. Hand grip strength and maximal oxygen uptake (VO2 max) are two clinically relevant tools that can be used to measure strength and aerobic capacity respectively. In the case of VO2 max this may be estimated by data collected by common smartphones or activity watches. We hope that’s both these clinical measures become more widely adopted when prescribing and evaluating exercise.
1. Ekelund U, Tarp J, Steene-Johannessen J, Hansen B, Jefferis B, Fagerland M et al. Dose-response associations between accelerometry measured physical activity and sedentary time and all cause mortality: systematic review and harmonised meta-analysis. BMJ. 2019;:l4570.
2. ACSM's guidelines for exercise testing and prescription. 10th ed. Philadelphia: Wolters Kluwer; 2018.
3. Chatterjee R, Chapman T, Brannan M, Varney J. GPs’ knowledge, use, and confidence in national physical activity and health guidelines and tools: a questionnaire-based survey of general practice in England. British Journal of General Practice. 2017;67(663):e668-e675.
4. Celis-Morales C, Lyall D, Anderson J, Iliodromiti S, Fan Y, Ntuk U et al. The association between physical activity and risk of mortality is modulated by grip strength and cardiorespiratory fitness: evidence from 498 135 UK-Biobank participants. European Heart Journal. 2016;:ehw249.
5. Chudasama Y, Khunti K, Zaccardi F, Rowlands A, Yates T, Gillies C et al. Physical activity, multimorbidity, and life expectancy: a UK Biobank longitudinal study. BMC Medicine. 2019;17(1).
Competing interests: No competing interests
In response to your article I have explored some of the ways that COVID-19 can cause a negative impact on the mental health of individuals.
In the mid-1300s, as global trade was increasing, a strange plague originating in China swept across Europe. It left death and destruction in its path. Yet, it also shifted the political order, particularly in Western Europe, where peasants, who were now in high demand, expected higher wages.
History has a way of repeating itself. In 2020, COVID-19 has swept across the world, leaving death and destruction in its aftermath. Beyond the human tragedy, is an impending recession and a change in the global order. If it is unclear by now, health affects all aspects of society. In response, governments have been forced to act, from imposing Draconian lockdowns to recommending people remain at home and self-isolate. Yet, lost in the discourse over what should be implemented for the “public good”, has been a lack of consideration about mental health.
During this essay, I shall particularly focus on depression and anxiety, exploring the impacts of social isolation, irrational behaviour and a poorly performing economy on mental health.
Health Anxiety, Significant Life Events and Depression:
COVID-19 has halted normality. It is at the front of all news media outlets. Therefore, it will undoubtedly be at the forefront of individuals’ minds, causing them to worry about their health. This fear of illness or the unknown may worsen pre-existing anxiety, cause health anxiety itself or even lead to paranoia.
Within days, schools have been closed indefinitely. University students have been sent home. Employees are now working from home. People have been advised to undertake social distancing. These are major changes in people’s lives, a known risk-factor for depression and it would be unsurprising to see numbers increase. Undoubtedly, people with pre-existing mental health conditions will be unable to access their support groups and find accessing their GP to be more difficult. This feeling of isolation and lack of social support will also worsen their mental health.
Economies and Mental Health:
However, the impact of COVID-19 extends to its deleterious effects on the world economy, with it likely to cause a global recession. Job losses, the threat of losing one’s job and poorly performing stock market investments will also cause additional stress. Likewise, the additional pressure on businesses, business owners and corporate management will increase stress, worsening mental health of the population.
Quarantine, Isolation and Social Distancing:
The UK government is promoting a policy of social distancing for all, encouraging it in both the vulnerable and healthy to stop potentially asymptomatic carriers from transmitting disease. It is also advocating social isolation for those with symptoms of the disease. These measures will limit social interactions and physical exercise, reducing exposure to fresh air and green spaces. These are all risk factors for depression so it is unsurprising that quarantining during the SARS outbreak increased the likelihood of having depression and suffering from psychological distress. Current UK government measures will likely worsen mental health.
Irrational Behaviour: Panic Buying and Discrimination:
Over recent weeks, panic has ensued. People are acting in an irresponsible and unusual manner. They are panic buying goods, with supermarkets unable to keep up with this increased demand, and shops running out of basic amenities. In response to seeing empty shelves, people further increase purchasing, causing a self-fulfilling cycle of panic buying, causing stress and consolidating any pre-existing anxiety. In response, there could be price rationing which increases the price of goods, impacting the poorest people within society most, causing them additional stress and anxiety.
In these troubled times with stressed, anxious people feeling heightened emotions, there is likely to be more discriminatory behaviour. These have included both physical and verbal racial attacks. Experiencing these traumatic events will cause serious mental health complications, including higher rates of PTSD, depression, panic disorder and increased substance abuse.
COVID-19 will inflict immense human suffering across the UK and further immobilise the NHS. Yet, we must not forget the mental health consequences too, with social distancing, discrimination, the economic impacts of disease and significant life events all worsening mental health. To overcome these challenges, the health system and social networks, including technology, will be called upon. If the NHS is able to cope, it will be a testament to the system and the will of its staff and hopefully, the beginning of a new era.
Thank you for taking the time to read some of the thoughts I have had.
Competing interests: No competing interests