If you are suffering from pandemic-related stress, you are not alone; lots of people just like you are experiencing stress-related symptoms of mental distress, including anxiety and depression.Only nine months ago, we were inhabiting a very different and less stressful world from that which we find ourselves in today. On December 31, 2019, the World Health Organisation was notified by clinicians in Wuhan, China, of a novel and severe respiratory virus — later called Severe Acute Respiratory Syndrome Coronavirus 2 (Sars-CoV-2). A pandemic was subsequently declared on March 11, 2020. The last time humans had to deal with something such as this was the Spanish flu of 1918.So this is a 100-year storm.On March 18, the first confirmed cases in Bermuda were announced. Like most, but not all, countries around the world, the Government moved quickly to close down potential transmission points such as retail outlets, bars, restaurants, schools, etc. On April 4, the Government announced a 14-day, 24-hour shelter-in place. During this lockdown, residents were allowed to leave home only for groceries, pharmaceuticals, medical emergencies and exercise within half a mile of their residence. This placed severe restrictions on social contact, employment, recreation and greatly reduced access to health services. The lockdown lasted for 28 days before Bermuda moved to a phased reopening approach, which continues to date — the new normal. Another lockdown may or may not be necessary if we get a second wave.I may be in danger of pointing out the obvious, but this situation has multiple, and ongoing, layers of mental health stressors. These include social isolation, fear of infection — especially for key workers — fear of relatives, some overseas and inaccessible, contracting the disease, acute financial strain, looking after young children not attending nursery or school and massive uncertainty about the future.Other effects pertinent to the lockdown included reported increases in domestic violence. Those with an already underlying mental health condition were vulnerable to destabilisation of their mental state owing to stress, and were restricted in their ability to access health services, as were those with physical health conditions. Unsurprisingly, anxieties about infection risk were particularly high in those with pre-existing anxiety disorders and obsessive compulsive disorder. The latest evidence published in the scientific literature from around the world confirms that the stressors of Covid-19 have, indeed, resulted in a pandemic of mental distress. Britain’s Office of National Statistics published a report last week suggesting that the prevalence of depression in the adult population doubled to 20 per cent during the pandemic. Adults who were young, female, disabled or unable to afford an unexpected expense were the most likely to experience depression during the pandemic.Another study among US adults in April 2020 compared with the same cohort in 2018 found increased rates of serious psychological distress — 14 per cent versus 4 per cent — and that the increase was, again, greatest in young adults and females.Finally, analysis of the UK Household Longitudinal Study in April revealed a substantial increase in mental distress in the British population with the prevalence of mental distress higher in people with pre-existing health conditions, those living in low-income homes, people of Asian ethnicity, younger age groups, women, and those living with young children.The data quoted here suggests that, although Covid-19 presents the greatest mortality health risk to older people, the mental health of the young may be disproportionately affected by the pandemic response of governments and the measures taken to curb its spread.The greater increase in mental distress among females versus males and ethnic minorities widens already established mental health inequalities, and emphasises the importance of providers maintaining access to domestic violence and reproductive health services.Unfortunately, the pandemic is not over and the continuing economic stressors are likely to have further impact on the mental health of the population. The symptoms most commonly experienced by humans exposed to stress for a prolonged period of time are anxiety and depression. What we call “depression” is a universal human response to stress and is among the most common types of mental disorder experienced by adults. The symptoms of depression are usually, but not always, directly proportional to the stressors and their duration. The single most important consideration in the treatment of depression is to identify and minimise or eliminate the stressor. However, this may not be possible because the pandemic is mostly out of the control of the individual.Depression can affect people in different ways and can cause a variety of symptoms, including low mood, negativity, disturbances of sleep, loss of appetite and concentration lapses. Ironically, many patients suffering from depression don’t report feelings of sadness, but describe themselves simply as “stressed” or “overwhelmed”. The way they are feeling is likely to be unpleasant or distressing. They will have stopped engaging in their normal leisure activities and are finding social contact and work commitments difficult.Family and friends will observe a gradual withdrawal from the world. If not diagnosed and treated, depression inevitably will get worse until the person ceases to function completely or dies by suicide. Tragic outcomes are more likely during the first episode, as the person does not recognise what is happening to them — in the case of depression — and diagnosis and treatment are delayed. Once the person is engaged in treatment, the risk of suicide is reduced significantly.For many people, the uncertainty of the Covid-19 situation is the hardest part. We simply don’t know how long this will last and what the outcome will be. We don’t know what the optimum strategy is, yet, to balance the health and economic risks. However, there are many things you can do to manage your anxiety and fears, and to top them spiralling out of control:• Accept that your anxieties are understandable. You are not alone. This is an unprecedented situation in our lifetimes — literally a 100-year storm — but it’s not the black death• Stay informed about what’s happening in your community, but minimise your exposure to the 24/7 media barrage of numbers of cases and deaths. Big numbers grab our attention and sound scary, but they are rarely put in context — numerators without denominators — and are, therefore, mostly meaningless• Focus on the things that are within your control: regular hand-washing or sanitisation, mask-wearing, avoiding touching your face, avoiding crowds and gatherings, minimising non-essential shopping and travel, and maintaining social-distancing• Stay connected even when self-isolating: humans are social animals, hard-wired for connection. Make it a priority to stay in touch with friends and family. Schedule regular phone, chat or Zoom sessions• Take care of your body and spirit: eat healthy meals, get plenty of sleep and regular exercise, especially in nature if possible. Maintain a routine as best you can. Even if you’re stuck at home, try to stick to a regular sleep, school, meal or work schedule. Take time out for activities you enjoy. Avoid self-medicating with alcohol or other substances. Reach out to others in need if you can — particularly the elderly or disabled. Taking concrete and positive action in the face of a stressor reduces feelings of helplessness and other depressive symptoms. What self-help techniques can you deploy to manage anxious thoughts and feelings?• Meditation is free, easy and effective for managing anxiety, insomnia and unwanted thoughts and feelings. There are a number of very useful and free apps that can be downloaded to your mobile phone such as Headspace, Insight Timer, Calm, Dare, Rootd and SAM. These provide information about anxiety, guided meditations, breathing exercises and anxiety-management techniques. Here is an example of a simple yet effective mindfulness technique: i, Bring your attention to your body; ii, Become aware that your body is breathing; ii, Focus all of your attention on your breath in the here and now; iv, Pay attention to the sights, sounds and smells around you, and what you’re feeling in your body; v, Focus on breathing slowly in and out; vi, Acknowledge the thoughts that come into your mind and interrupt your focus, but immediately refocus on your breathing, body and environment in the present moment. This allows you to mentally step back from the thoughts and avoid engaging with them. The thoughts will go, like a train leaving the station withoutyou having got on it. Continue this process for five minutes• Distraction can also be helpful for managing anxiety: do something, preferably exercise, speak to someone, make a cup of tea, listen to music, watch TV, pet your cat• Slow-breathing techniques are effective for controlling anxiety. Here are some examples that can be used to counter feelings of anxiety or panic: i, Stop what you are doing and sit down or lean against something; ii, Hold your breath and count to 10; iii, Breathe out and mentally say the word “relax” to yourself; iv, Breathe in and out slowly over a six-second cycle — breathe in for three seconds and out for three seconds. This will produce a breathing rate of ten breaths per minute. Say “relax” every time you breathe out; v, At the end of each minute — after ten breaths — hold your breath again for ten seconds, and then continue breathing in the six-second cycle; vi, If you continue breathing in this way, the symptoms should subside within a minute or two. The more you practise, the better you will become at using it to bring your anxiety under control. Your goal should always be to stay calm and prevent the anxiety and fear from developing into panic.When should I seek professional help?If you are unable to bring your symptoms under control by yourself and are experiencing distress or difficulty coping, you should seek professional treatment. Anxiety and depression are distressing and potentially lethal but also temporary, reversible and highly treatable conditions.In Bermuda, treatment for mental health problems are available from general practitioners, the Mid-Atlantic Wellness Institute and multiple providers in the private sector. The main modalities of treatment provided are talking therapy and medications, which are safe and effective in the management of depression and anxiety disorders. During the lockdown, insurance reimbursement was provided for telemedicine appointments and was used extensively. It’s uncertain whether this will be extended beyond the end of this month.If you are in crisis or feeling suicidal, then emergency treatment is available by calling the MWI 24-hour mental health crisis line on 239-1111 or by attending the emergency department at King Edward VII Memorial Hospital and asking for help.Remember: you are not alone.• Grant Farquhar, MD, consultant psychiatrist with Kindred, a collaboration between treatment providers to provide integrated treatment for physical and mental disorders has more than 20 years of clinical experience in psychiatry. He has practised at consultant level in Britain, Australia, New Zealand and Bermuda