The mental health risk of being 'vulnerable' during COVID-19 pandemic

Gradual release from lockdown means the most at risk will endure social isolation the longest and experience risk to their mental and physical wellbeing.

People identified as "vulnerable" to the virus, are also vulnerable to the "cure"—which at this moment in time is limited to continued social distancing. But there are strategies that could be implemented during this stage that can prevent or reduce the impact of continued isolation.

Management of the coronavirus pandemic relies on statutory regulation to enforce social distancing, but also behavioral "nudging"—communicating to citizens to encourage compliance and acceptance that our behavior is for the benefit of others.

Evidence from other deadly outbreaks such as Ebola and SARS shows that communicating risk needs to get the balance right—presenting facts on the real threat to avoid under-reaction, while not causing panic. It is also clear that people tend to trust scientists more than politicians at these times, and we can see the UK government went a long way to put the science, and the scientists, front and center of the message.

Avoiding othering

However, in the rush to protect, people labeled as "vulnerable" have received a less balanced message.

From early on it was apparent from the statistics that older people carry more risk of serious impacts from COVID-19. Further evidence from Public Health England indicated a higher risk for people with health conditions and people from black and minority ethnic (BAME) communities. Indeed, some people labeled 'extremely vulnerable' by the four nations of the UK were given particular instructions to self-isolate and receive support for deliveries of groceries and medications.

Highlighting who is at risk may help promote unselfishness in the majority but raises anxiety among anyone identifying with the at-risk groups.

The "vulnerable" have been championed as our parents and grandparents, or portrayed as suffering the greatest impact from social distancing. But categorizing at-risk groups divides society and creates "othering"—it stigmatizes, labels and separates "others" from the majority, creating an 'us' and 'them."

In the early days of the COVID-19 pandemic, older people were referred to by politicians, the media and health professionals as "they," while referring to the rest of society as "we." This has diminished somewhat in later stages of lockdown and the broadcast media at least appear to have played a part in highlighting their resilience (i.e. "the war generation") and the predicament of those shielding, rather than focusing on their risk.

Of course, social distancing means reduced social contact, which will be felt more so for people who are less likely to use social media. This can create the feeling of isolation, which is strongly linked to depression, anxiety and cognitive decline—and reduces resilience factors such as self-worth, sense of purpose and feeling valued.

Importantly, depression and anxiety also provoke social withdrawal itself, creating a downward spiral of isolation, low mood, lack of motivation, anxieties and worry, and provoking isolation through avoidance behavior.

People shielding due to COVID-19 have to date spent nearly 14 weeks socially isolated, and many will need assistance to change their shielding behavior to regain their social connections. Social connectedness reduces the impact of a sense of isolation, particularly among the elderly, which is of course a challenge during the COVID-19 pandemic.

Those deemed clinically extremely vulnerable can now go outdoors, but this coincides with doubt being expressed by many, including members of the government's scientific advisory team SAGE and the British Medical Association, that the easing of lockdown is going too fast. Parents and teachers expressing fears about a return to school has been highlighted by news media and crowding on beaches and in parks fuels further concern and doubt about relaxing social distancing.

Social distancing does not mean social isolation

It is for individuals to judge their own degree of safety, however there is a danger that those anxious about their risk will remain in isolation and have this reinforced by continuing risk awareness messages, both through official channels and by our new socially caring society, who are switched on to caring and protecting others.

Some people self-isolating for several weeks will find it difficult to return to normal functioning in the longer term, but action now is likely to prevent anxieties affecting general health and wellbeing. It will require behavior change from avoidance to proactive social connecting—taking small steps to change what is now an established avoidance routine.

Targeting social behavior is simple and effective using the principles of "positive psychology and behavioral activation." This is a simple strategy that an individual can use, or be promoted by friends, family and the wider community to identify pleasurable activities that are easy but rewarding to do.

The first step outside into the fresh air, a short walk, or a visit by a family member or friend are the sort of first steps than break the habit of avoidance and withdrawal. The reward also breaks the cycle of anxiety and depressive thinking and prompts the person to repeat the behavior.

It is an approach everyone can adopt for themselves and may help prevent the downward spiral of isolation. This could be recommended by support agencies for older people, bereavement support, charities, support groups for specific health conditions, churches and guides from the NHS or Public Health England on social distancing for those who are shielding.

Additionally, news media has a role in modeling behavioral activation by ensuring the message is to take up safe social connecting opportunities now that lockdown is easing and not reinforce negative thinking and fears by focusing on the dangers and labeling 'the vulnerable' as disadvantaged or "other."

Social distancing does not have to mean social isolation. Going forward, friends, family, neighbors and community volunteers can encourage social connectedness and positivity through safely managed visits and 'small step' behavior change.

Government and the SAGE spokespeople could consider mental health advice for the shielding and older citizens, and broadcast media could contribute through role-modeling social connection activities, especially for people who do not use social media.