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Esha: Okay, I think it's good. So I'm just going to start off with the first question. So, in your opinion, how would you compare the stress levels of students and the stress levels of adults? 


Dr. Agarwal: Okay. First thing, I just want to make a slight disclaimer, which is, I'm not a child psychiatrist. So within psychiatry we have different subspecialties. So I'm essentially a general adult psychiatrist. So I deal with people 16 years and over. So it kind of overlaps into the adolescent group if you like. So whatever I might say about children will be more of a general kind of thing rather than much more of an expert kind of knowledge, if you know what I mean. But, yeah, I’ll have a go. So, I think the first thing to say is what is stress, you know, it's just important to understand what stress is, and I think people have a different perception of what stress is, people obviously have very different levels of stress. What might be stressful for you might not be stressful for me and vice versa. So it's a very subjective thing, right? Stress and having understood that is also important to understand that stress actually does have a very useful function. So for lots of activity, there's good research to suggest that for, for lots of activities, if you have a certain level of stress, then that actually enhances your performance. And then if the stress level goes above a certain limit, then your performance starts to decrease. So there's almost that curious inverted U-shaped relationship between the stress and performance? Yeah, but I imagine that what you mean by your question is when the stress is really getting to a level which is uncomfortable, which is unhealthy, which is dysfunctional. Yeah. And I think it's really a good question, in terms of what stresses adults versus what stresses students. And I imagine, I mean, it's very much, you know, what kind of challenges in your life are at the time and the phase of life you're at. So, you know, children, they are, again, depending on what level of, you know, how old the child is, you know, you may have the stress of exams, which is a common kind of stress for most students. There are stresses about, peer relationships and friendships. There are stresses to do with, as your personality, as your identity is developing, particularly in the later years, sort of, you know, adolescent years, you know how you come across to yourself, how you come across to other people that can cause some stress sometimes. So I think both children and adults do become stressed, but what causes the stress could be very different depending on what it is that they are and what challenges they're facing. So, typically, you know, they start to worry about having a job, having a family, you know, are they going to have a house? Are they going to have a nice car to drive? So those kinds of things start to kind of preoccupy an adult's mind, whereas children are less aware of those kinds of things really, and other things kind of stress them out. So the short answer to that is that, you know, there are different things that stress children as students, and there are different things that stress adults. But I think both groups of people have their own stresses. There's a lot of talk these days, isn't there, about kind of, what causes more stress in students these days? And typically you kind of read, we tend to kind of blame social media a lot these days in terms of, in terms of the level of stress it produces. And I don't, I mean, I don't know. I mean, I guess there's a universal view that probably social media has increased the level of stress in people generally, not just in children. But I just don't know whether it's just transferred from, from somebody else that might have caused the stress to now, this look on the social media causing the stress, but that's probably another question, and maybe we could sort of deal with that when we come to talking about, you know, how you manage stress. But I think both groups get stressed, you know, I think both groups get stressed and both groups, I think, unfortunately think that life for the other group is easier. So, you know, so adults might say to the children, how are you getting stressed about it? And you haven't got to worry about earning money and you haven't got to worry about this, that, and the other, and students may say the same to the adults, you know, what are you stressed about? So I think it's appreciating that, you know, each group has their own reasons for getting stressed and it's important to recognize that it happens. Does that answer the question? 


Esha: Yes, it does. Thank you.


Namitha: What are some of the best ways to cope with stress?


Dr. Agarwal: So again, I suppose really different people, Namitha, have, probably, different strategies to cope with stress. Something might work for one person and it may not work for another person. So very often it is a question of working out what it is that works for the individual. There are some common sort of “stress busters”, as we call them, you know, for students and for adults, really. I would say, you know, things that are commonly kind of acknowledged as things that are going to release your stress are things like taking regular exercise, you know, sleeping well, all really important. I think, you know, we all know, don’t we, that if you haven't slept well, it will increase. You know, they're tired the next day and that would of course, increase our stress levels. So just those sort of good habits surely, if you like, you know, trying to kind of be very disciplined about the good habits, I think is a really good thing. We can all do that. And if we make a concerted effort to do that, that's quite easy to do then because it's within our control. You know, there are so many things that stress us out that we don't have control over, but these things we do have control. So I would say, you know, regular exercise, sleeping well, a good diet, drink plenty of fluids. You know, there's a lot of evidence coming through about hydration these days and actually, drinking plenty of fluids and keeping yourself well hydrated, that'll kind of, you know, keep your chemicals in your body in balance, which will reduce your stress levels as well. And really something fun, you know, find something fun to do every day, I would say, you know, life can become very, very boring. Sometimes, it can become very mundane because there are so many tasks that we have to achieve. And we are constantly trying to kind of achieve those tasks, but try and find some time in the day to just laugh, to have fun. I think laughter is a really good stress buster as well. So those are some of the more sort of general things that you can do to reduce stress. Then, of course, you’ve gotten the understanding of what it is that is stressing you, coming to more kinds of specific things. The first step is to understand, you know, what it is that's naturally stressing you out. Once you understand what it is, then you start to kind of say, you know, what is it that's going to help me to manage that stress.Very often people will try and develop some strategies themselves. So if they recognize that I'm doing too much of something, I'm doing too little of something, maybe I just need to redress that balance, they can try and just do it themselves. Once they become aware that this is what is causing the stress, if that self-help hasn't helped, then seeking help from somewhere else is a good idea. Talking to someone, we say it's the simplest thing to do, but sometimes it isn't. When you are feeling very stressed, sometimes it's quite hard to kind of, you know, muster that courage to go and talk to someone. So don't allow that stress to get too much to that, you know, you kind of lose that sense of trying to do something about it. But if you can recognize the stress early and you've tried to do something yourself, and it isn't working, then talking to someone, you know, find a confidante, you know, somebody you feel comfortable to talk to, whether it's a friend, whether it's a parent, whether it's a teacher, whether it's anybody else, try and reach out to someone because very often when we are stressed into a vicious cycle, when we are in a loop, when we're trying to find a solution and we just go around the same ideas and we can't get out of that. We are stuck in our own head, if you like, with that stress. So, just talking to someone will just give a different perspective. They might just say something really simple that you hadn't even thought about, and you might say, “Oh my goodness, you know, why didn't I think about that? I'm going to try that out”. So, talking to someone in this phase is really helpful. That’s still kind of informal help that you're reaching out for. If that doesn't help, if it feels like, you know, there are issues that perhaps you can't talk to a friend about or a parent about stressing you out, then you may need to kind of seek professional help. That's again, you know, depending on where you are and who you are. I mean, if you're a student within a school or a college or university environment, then it's just thinking about whether you have any help or resources within that organization where you can seek help. So yeah, I think I would, I'd kind of break it down into those things, you know, sort of, prevention of stress as a first step. So, doing things that are going to not get you stressed, and then recognizing the stress early, seeking, you know, trying some self help stuff. There are some, some websites as well. So yeah, I don't know what the situation in the U.S. is, but in the UK, there are some self-help websites that people can access free. So yeah, kind of, sometimes those can be quite helpful to give you some tips about, you know, what you can do. Yeah, that's, in a nutshell, really what you can try and do to manage stress. I don't know whether that answers the question or whether there was anything else. 


Esha: Yes, I think it does. 


Dr. Agarwal: Okay. 


Esha: So I guess this next question, the next few questions actually, kind of tie into your answer there. So, for my third question, what are some signs of anxiety, depression, and stress that students could look out for? 


Dr. Agarwal: Okay, yeah, a really good question. I think it is probably important to try and differentiate those three things. It’s not always easy to kind of say, what is stress and what is anxiety and what is depression. So, let's try and sort of break that down a little bit. So, let's talk with anxiety, that's the first one that you've mentioned. So, anxiety, the way I kind of see anxiety, anxiety is an anticipatory thing. It's a worry about something that is going to happen in the future. Just generally, I'm just generalizing that now. So that's the nature of anxiety, you're actually worrying about an exam or you’re worrying about an event that's going to come up. So yeah, it's something that is likely to happen in the future. And there's an anticipation of that, and a worry about that, which then manifests with anxiety. So, you can just typically imagine that if you are actually worrying about something that is likely to happen, and that is on your mind, and you're now trying to sleep. What do you think is going to happen to your sleep? You're probably not going to be able to sleep because you're worrying about whatever it is that is making you anxious. So one of the first symptoms or signs of anxiety, is not being able to sleep. So, typically we have some people that you just have difficulty falling asleep. It takes me typically half an hour or some time before I can fall asleep, whereas previously, I would be out like a light as soon as my head hit the pillow. So, sleep disturbance, not being able to fall asleep is a very common symptom of anxiety. People can become quite irritable sometimes, so they might not actually manifest with anxiety, but they can become a little irritable. So the anxiety is there, they’re feeling the anxiety, but when you try to talk to them, they become very snappy and very irritable. That might be another symptom of anxiety. Anxiety also manifests with lots of physical symptoms. So, when the anxiety becomes a little bit more severe, you can develop physical symptoms like palpitations. So, your heart kind of beats faster and that uncomfortable feeling in your chest, you can develop chest pain sometimes. You can develop some sweating, you can develop headaches, and very dry mouth. And this really queasy, funny feeling in the pit of your tummy. So, anxiety has a lot of these kinds of physical manifestations as well. And of course, the most severe forms of anxiety can then manifest with panic attacks. So, I don't know if you know what a panic attack is, or I hope neither of you have ever experienced a panic attack, but that's a very intense feeling of anxiety, and it's a very quick event. It's a feeling of dread, it's a feeling as if something dreadful is going to happen, I'm going to die. I'm going to have a heart attack, I'm going to faint, that kind of feeling, which manifests with all of these physical symptoms, which is with the palpitations and difficulty breathing, and sweating and a headache and feeling very tense. And it kind of crescendos very quickly within five minutes, and then it comes down again very quickly as well. So a panic attack is a very scary kind of a pain, but that's the severe end of anxiety. Yeah, generally sort of just apprehension, really, and I just worry,, can’t settle, can’t sleep, constantly worrying about whatever is on your mind. Yeah. Depression is a bit different. So depression and anxiety sometimes share features, so, sometimes there can be common symptoms for anxiety and depression. Sleep disturbance can also be a first feature of depression. The sleep disturbance is a little bit different in depression compared to anxiety. I remember I said anxiety is very much about worrying about what's going to happen. So, typically people with anxiety find it very difficult to fall asleep. Whereas, in depression, that could be a problem as well, but very often people find that they can't stay asleep. Typically, in depressed people, they often tend to get up very early in the morning. And when they wake up in the morning, they wake up with a feeling of dread and then are not able to fall back asleep again. So the sleep disturbance in depression is a little bit different to that in anxiety. Sometimes people oversleep when they're depressed. So, sleep can become a way of escaping the way you're feeling. So, sometimes people have hypersomnia or increased sleep. And in anxiety, usually you don't get increased sleep. So, that's another sort of clue, really, if people are saying that I'm sleeping more than I usually did because I'm just escaping from something, or I don't like the way I'm feeling and sleep gives them some relief. Then it can almost have the opposite effect with sleep. The three core symptoms of depression are a low mood. You can feel really low in yourself and your mood. Then, the second is a decrease in energy, so, you feel very tired, you feel very fatigued. It will say to us, you know, I haven't really done anything all day and yet I feel very tired. And, the third is a loss of interest, so things that normally interest you, you suddenly find that you’ve lost interest in things that normally would interest you. So, low mood, loss of interest, and easy fatigability, those are the core symptoms of depression. And then you may have some associated symptoms, which is a lack of appetite. Again, sometimes depressed people will not eat. They often lose a lot of weight because they don't eat, similar to the sleep situation. Sometimes people who are depressed will tend to overeat, what we call comfort eating. So very often depressed people will find that they get comfort so they will tend to overeat and tend to put on weight. Other symptoms of depression are kind of, just a feeling of loss of confidence. So, you know, you're normally a confident person, you like kind of, meeting people. When depression hits you, you kind of lose your confidence. You tend to become very isolated. You don't want to speak to people. You don't want to talk and become very withdrawn. So that's, again, you know, that could be something if you, particularly in a school or college environment, if you're finding that a friend has become quite withdrawn, they're not talking as much as they normally do. Just think, are they getting depressed, here, and that might be one of the symptoms of depression. Another one, again, people will often say that, you know, they become more tearful than usual when they become depressed. So, normally I don't cry as quickly as that, but I've just found that the smallest things make me very tearful. I'm watching a program on television that is slightly emotional, I burst into tears. So easy tearfulness is another symptom of depression. Feelings of guilt, feelings of unworthiness, feelings of hopelessness, feelings of helplessness. This can occur, again, these tend to occur when the depression starts to deepen a little bit and, you know, people can just feel unduly guilty about something they may or may not have done,or they, you know, they feel very hopeless or helpless. And of course, as you can imagine, when those feelings of hopelessness, helplessness, become much more severe, of course those feelings that I don't want to live, you know, because you can't tolerate those feelings, and suicidal thoughts can sometimes occur with depression. Sometimes, it can manifest with self harm. So, we see, particularly in young people, we see a lot of self harm, and not everybody who self-harms is depressed, but certainly one of the symptoms of self harm, could be depression. So, if somebody is self harming, then we want to make sure that they're not depressed. There could be other reasons they’re self harming, but certainly we want to make sure that they're not depressed. So those would be the more common symptoms of depression. So, a little bit different from anxiety. Yeah. And stress, I mean, stress can manifest with different things, really, again different people have different thresholds for stress. Stress, it's a very subjective thing, so there's no common kind of description of stress. You know, different people will manifest differently when they’re feeling stressed. Typically again, you know, there will be some common features with anxiety and depression where people who are stressed will typically have a sense of apathy sometimes, they're not interested in what they're doing. Stressed people tend to be very irritable at times, they become very snappy, they're not fun to be around with. You know, you can tell that a person is very stressed because they are just not happy and they're just not fun to be around with. But I think there are no specific symptoms of stress, it's a very subjective thing. If someone comes to me and tells me “I'm stressed”, I'm not going to say “no, you're not stressed”, you know, I’d want to explore with them more about what is it that's causing the stress, why do you feel stressed. So, there aren’t specific symptoms of stress as such, really. Did that answer the question?


Namitha: Yeah, thank you. How might a student reach out for help if they're experiencing symptoms of anxiety, depression, or stress? 


Dr. Agarwal: Yeah, really good questions. I suppose, yeah, as Esha was saying, I probably answered a little bit of that with the second question. So, the first step is to recognize it, and of course anxiety and depression aren’t things that you typically self diagnose as that's the diagnosis that a professional generally makes, but it's recognizing those very early signs, and that's the first step. Very often, people don't know that they're stressed or if they're anxious or if they're getting depressed. They just know they're feeling very different. So just knowing that they're feeling different from how they normally feel, that's often the first thing. Now that might be a temporary thing, so you wouldn't necessarily go out and seek help if that's just happened as a one off because, you know, there's something difficult that happened that particular day, you’ve had a difficult conversation with a tutor or something is not fair in an exam, and you know the reason for that stress on that day, you just let it be really. It's when that persists, it's when you can tell that this is happening day after day, and I'm not really feeling any better from this. So I just say, you know, you're trying to do something about yourself, you're trying to recognize what it is that's causing you to feel anxious or feeling low, feeling stressed. And then try and do something about yourself. If that doesn't work, you seek help, you know, talk to people. If talking to people who are close to you hasn't helped them, then seeking professional help is what you need to do now, again depending on which situation you're in, you need to think about where you're going to get that help from. I imagine again, in the States they will be a similar sort of service that we have over [in the UK]. So there's a service called Samaritans in the UK. It's a free phone number that you can ring and, you know, most people are aware of the Samaritans, so you can actually ring the Samaritans and you’ll get somebody at the end of the line who you’ll be able to talk with about whatever is troubling you. That could be the first step, you know, they're trained counselors who are non-judgemental, they don't know you, you don't know them, so it can sometimes feel like a safe place to talk to someone. So I don't know, do you have anything similar in the states?


Esha: We have a couple health lines in the US, so I don't know if that's the exact same thing as the UK, with the Samaritans, but it's something.


Namitha: There's like numbers you can text or you can call, and I think they're always available, something like that.


Dr. Agarwal: Right, and what's the general perception, Namitha, are they helpful? Do people report that they're helpful? 


Esha: Yeah, they’re helpful.


Namitha: Yeah for sure, like at schools and stuff, they always tell people, they have little cards with their number on it, so they'll always give them out.


Dr Agarwal: Okay, so that's good, it sounds like a similar sort of thing. So that could be a good first step, really if you’re, you know, seeking some professional help. There's Samaritans, obviously, they’re usually at the end of a line or a text so you don't usually get to see the Samaritans in person as such, but that itself could be just helpful in there. They're often trained to sort of guide you into what the next steps might be, so of they themselves can't help you, they might be able to signpost you to the right place then. So it's always good to kind of, you know, utilize that service, more specifically than if you're, for example, if you’re in a school environment. Now in the school, I'm also governor of an independent school here, we have a full-time counselor in the school who students can access. So, I don't know whether you have some things similar in your schools there. 


Esha: Yeah, I think a lot of schools here have counselors for a lot of different things.


Dr. Agarwal: And is that helpful? Is that something that students do access? 


Esha: Namitha, I'm not sure about your school, but I know at my school it is pretty helpful, so I've heard. I know a lot of students go to them.


Namitha: We have one at my school too. And it's like, it's helpful to a certain extent.There's not much that they can do, like legally, they can't diagnose you with anything. They're just mostly there to like, listen to you and give general advice. So, I don’t know, it depends on the person; for some people, it does help, and for some people, it doesn't really, they need like a bit more than that.


Dr. Agarwal: Yeah, absolutely. And that would be the rule, I suppose, of the counselor, wouldn't it. To recognize what it is that they can help with, and then what it is that you need further help with, and hopefully they might be able to advise you that, look you know this is not something I can help with. It sounds like you might be developing an anxiety disorder or you may be developing depression and therefore you need to go and seek professional help for that. That could be a good first port of call, really, for a student, wouldn't it? Now, I don't know enough about how accessible these counselors are, and if every school will have a counselor. I imagine not every school probably has a counselor. Certainly in the UK, I would say that probably state schools are probably not that well-resourced and they may not have that, independent schools may choose to have counselors in their service. So, it can vary, but it's good to know if you do have that counselor and whether you can access them. And that could be a good first step. In the UK, here, the way the health services are structured is that your first port of call, if you are going to then seek help beyond that counselor in the school, is to go to your own GP or your general practitioner. So every citizen in the UK is registered with the general practitioner, because we have this national health service over here, which is kind of a free service for everybody. So, your first port of call is usually your general practitioner who works with primary care set up. So you'd make an appointment to go and speak to your general practitioner who then, you know, they're quite well-trained of course, they're the doctors so, they would either be able to make the diagnosis if there's anxiety or depression and then treat you for it, or then they might refer you to a specialist if it is kind of beyond that expertise. So we have that, we're quite lucky, I suppose, in some ways in the UK, where that service is available to everybody. I know the system and services are different in the US, isn't it?


Esha: Yeah.


Dr. Agarwal: Well, how would you kind of, I know there's another question later on about the affordability and accessibility to health care, but kind of, what would you do? So, if you saw a counselor, for example, there, or said that you need professional help, who would you go to, do you know?


Esha: So, I know at my hospital last time I was there for a checkup, I know that the doctors have the ability to refer you to, I want to say, psychologists in the hospital. Yeah. So I know that's one form of something you could do, but then again, I don’t know how affordable that could be. 


Dr. Agarwal: Yeah, how do you see that first doctor though? How do you get referred to the first doctor? Do you just see them privately?


Esha: It would be a check-in


Namitha: Yeah so, usually they do this at your annual checkup with your pediatrician. Then, they’ll have you fill out like a few forms by yourself. 


Dr. Agarwal: Right. 


Namitha: And, sorry, they have you fill out like a few forms, and then I think I saw somewhere that your response, it's like those forms where it'll ask you a question. It's like how often do you relate to this, and then each response has like a certain number of points. And then, I think, adding up all your points, if it's higher than healthy, then they'll talk to you privately. And then based on your responses they’ll refer you, like your pediatrician themselves would refer you to like a therapist.


Dr. Agarwal: Okay, that's really good. So, that sounds like there's a little flow chart, which is a screening tool, which then detects what your level of illness or disorder reason, then they will direct you accordingly. That's quite a good system and that's something that actually, as we're getting more and more digital, you know, in the UK, we were kind of looking to develop these kinds of algorithms on these kinds of flow charts so that initial assessment can be done, you know, quite reliably through these kinds of electronic systems or forms, if you like. So yeah, so that would be the order in which I suppose you would kind of seek help. And then, of course, once you get to the doctor, once you get to the specialist then their job will be to diagnose whatever the condition is and then treat it accordingly. So that's how I would suggest a student reaches out really, you know, informally first, or self-help first informally, and then the counselor, if you got a counselor within the school, and then professional help. There are also kinds of, I don't know how it works, in terms of pastoral care in schools. So, if in schools that don't have a counselor, you might still have a good pastoral service where there might be some teachers or some tutors who are more trained and most skilled in dealing with mental health issues like that. So, sometimes that may also be available to the students in the school. I was, interestingly, I was talking to my son, who's nineteen at the moment, and just kind of picking his brains on this particular issue, and he had a very interesting take on it. He said that you think it's a very interesting and difficult dilemma, sometimes, the students have, if there's a tutor who also teaches them a particular subject, for example, but that tutor is also assigned as your pastor tutor, sometimes students might feel quite hesitant to go to that tutor to talk about their emotional difficulties, because they might kind of see them, either the tutor might see them as struggling with something. Maybe sometimes they're not performing so well in that particular subject, which is what is causing them distress. So, then kind of going to that tutor sometimes can become quite tricky because the tutors actually, on the one hand, are telling them to kind of pull their socks up and perform better because their, you know, their grades aren't good enough. So they find it very difficult then to talk to the same tutor about their emotional difficulties. So, that was quite an interesting kind of take on that, and I guess the answer to that is that, you know, if that doesn't feel comfortable, then you’ve got to look somewhere else. But if you've got a good relationship with that tutor, you can talk to them, you know, and then you might try that as well. I think that those are the levels of kind of help you can get, I suppose.


Esha: Perfect. So yeah, we did have a question about advice for people who can't afford or have access to therapy, but I think we can skip over that now, because I think we've touched on that plenty, right. Okay. So, the next question kind of strays from what we were just focusing on. So, in your experience, what methods of motivation have you seen work well for people in challenging times?


Dr. Agarwal: Yeah, it’s a really good question. There's something called motivational interviewing, so it's actually quite a skill, and professionals are often, you know, well-advised to try and learn techniques of motivational interviewing, because it requires that certain skill to get people to address their challenges and their problems, if you like. So, I think the first thing for me is developing a rapport and empathy. Say I want to put myself in the person's shoes in terms of what is challenging them. So, empathy is the first step. Once you've got the rapport built with the person, they're going to trust you, and they're going to kind of, you know, hopefully go along with you in the next steps. Very often where people are stuck, they're stuck in that particular situation, they haven't got the motivation to do something, but this is a problem for them. They've come to you for help because they know that they're not able to motivate themselves to do whatever it is that they want to do. So what's useful is to try and draw out a discrepancy between what their values and goals in life are, and what their behavior is. So you try and kind of think about, you know, so what is it that you want to achieve? So they might come up with, you know, I want a good job, I want this, I want this. And you ask them, so what are you doing at the moment? And they'll tell you that oh, I'm playing, you know, my PlayStation, two to three hours a day, I'm sleeping four hours in the daytime, and so you got that discrepancy already. You say your goals and this is where this is what you're doing, but there's a big gap between what you're doing and what your goals are. So we need to try and narrow that gap now. So just getting them to see that discrepancy is a good way to get them to see that they need to do something different to try and reach their goals. I try and avoid getting into arguments with them or in confrontations with them. It's not what I think is right, so I'm not going to impose my views on them about what's going to kind of motivate them. The idea is to kind of listen to them and see what's going to get them out of it. So we just try and avoid any kind of arguments or confrontation, because that's not going to help. It doesn't it doesn't go hand in hand with the empathy that you want to develop with them. And then I want to ultimately sort of once I get them kind of moving towards their goals, then really just engendering that sense of self-help. So, giving them some tools and strategies that, once you've stopped seeing myself, if you've come to see me as a professional, then what's going to keep you motivated, what's going to keep you going. So giving them that toolbox that they can use themselves and leading them to that sense of optimism that, okay, you know, you've not got to your goal or your aim yet, but you're on your way. And just giving them that optimism, that they're on their way. So, those are some of the techniques that we might use in a motivational interviewing kind of situation, is that helpful?


Esha: Yes, one hundred percent.


Dr. Agarwal: Okay.


Namitha: During COVID-19 and working from home, have you seen a noticeable impact on people's mental health due to isolation?


Dr. Agarwal: What a fantastic question. That is a really good question. Absolutely, I mean, there are two bits to the COVID scenario. One is, uh, about whether isolation has actually caused more mental problems and more mental illness. Now, I don't know that, because we've not seen an increase in the referrals to mental health, just due to COVID and due to the isolation of COVID. And I think in terms of looking at, what would be interesting to look at, is kind of the what we call the epidemiological studies, which is to look at the whole population studies, you know, in the next two or three years time, are we going to see an increase in the number of people with mental health problems, and can we relate that to an effect of COVID? I think that data is not yet quite clearly out yet, but what I have noticed is the people who do already have mental health problems who are under our care, the effect that the isolation from COVID is causing for them. So people who have depression, who have anxiety, the isolation has really hit them badly because one of the ways that people with depression and anxiety often coped with their anxiety or depression, was to be able to go out and socialize a little bit, meet with their friends, to just go for a run, to go for a walk, to go have a nice meal at a restaurant. You know, those are the things that actually help reduce stress, help reduce anxiety and depression. And because people haven't been able to do that, it has had a negative impact on their anxiety and their depression. So it clearly has had an impact. I've seen a curiously opposite effect happen as well, only in a small proportion of patients. And I was quite surprised when I heard that some patients who have a lot of anxiety, particularly anxiety who are quite socially anxious, so they would find the busy lives, busy supermarkets, really a hectic life, really quite anxiety provoking, and they would actually avoid going out because life was just so hectic and busy out there for these people who were socially anxious, COVID has actually given them some relief, funnily enough. They find that now when they go out, there are not so many people. When they go into the shop, they're not heaving, and they're actually feeling a lot less anxious because of the effect of COVID. So it's had a very interesting paradoxical effect on a small proportion of people. But yeah, I think in the main, isolation has caused quite significant problems, and we've had wider effects, you know, look at bereavement, for example, you know, ones who've been in hospital and died in hospital, and relatives haven't been able to come and see them. That's been just absolutely devastating for a lot of people, people with dementia who are in care homes, you know, who, the only contact that they had, the only memories they have of the family members, you know, they could at least recognize the family members to some extent and could relate to them, they haven't been able to see them, so that isolation within that group of people has been really quite devastating. So now I think that that has quite a significant effect really on a lot of people in all sorts of ways.

Dr Manoj Agarwal is a consultant psychiatrist in the UK. He has been working in the field of mental health for over 30 years and spent most of his career working in General Adult Psychiatry. He has been closely involved with post-graduate medical education for most of his career, having held positions of Director of Medical Education and Head of School of Psychiatry. Since taking partial retirement in 2017, he has been specialising in adult ADHD (attention deficit hyperactivity disorder). He is also a School governor and a Non-Executive Director in the National Health Service (NHS).

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