Under typical circumstances, all of this would have been less of a strain on her. But this time it was too much. Jacqueline Krützmann was ill, with a cough to boot. So she preferred not to leave the house and not to expose herself to the suspicious looks of others. Not at this time.

With the unerring sense that children have for such exceptional situations, her son saw his chance and really turned up the heat, running up and down the living room and jumping tirelessly on the sofa. Krützmann soon had no choice but to sit down on the floor and let the situation pass. To wait until it was over.

"People with a mental illness carry a rucksack on their back," says Ute Lewitzka, senior physician in the Department of Psychiatry and Psychotherapy at Dresden University Hospital and chairwoman of the German Society for Suicide Prevention. "There are times when this rucksack is relatively light, and they get along quite well in their everyday life. And then again there are times when the rucksack becomes very, very heavy: When external stress factors occur or stress situations last for a long time. And, of course, this whole story that we're experiencing is part of that."

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Quarantine during the coronavirus pandemic can be highly stressful

450 million people affected

The world seems to have gone mad. This is particularly stressful for people for whom it sometimes seems less than inviting anyway. There are currently 450 million people who suffer from mental health conditions worldwide. For Krützmann, too, the backpack is nothing new. She is 33 years old and has shared 20 years of that time with a post-traumatic stress disorder that manifests itself in depression and anxiety.

Normally, however, she feels quite stable. She and her disorder have undergone extensive analysis during stays in hospital and outpatient therapies, and she takes anti-depressive medication.

Then came the coronavirus. Suddenly, Krützmann's daily structure broke down. The university she is attending closed. Her everyday routine has disappeared. She is now working from home. Krützmann finds it more difficult with each day to get up in the morning. It has become a great effort to call friends; she has to summon up all her energy to do so. Because she has problems with her self-esteem, she avoids situations in which people might look at her askance, such as if she coughed in public, for example.

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Just getting out of bed can be difficult for those with depression.

Depression, anxiety and obsessive-compulsive disorders

With her symptoms of depression and anxiety, Krützmann belongs to two of three patient groups that are particularly at risk during coronavirus lockdown periods: For those with depression, the sudden loss of everyday routines can lead to social withdrawal and loss of daily structure; for anxiety sufferers, the current catastrophic news triggers circular thinking, sadness or irritability.

For the third at-risk group — people with obsessive-compulsive disorders or tendencies — the constant calls for meticulous hand hygiene are a breeding ground for irresistible urges to wash or carry out constant checking routines. "After all, it's a diffuse fear," says Dietrich Munz, the president of Germany's Federal Chamber of Psychotherapists. "We don't see the viruses. We can only fantasize about all the places they could be."

Lost structures

At the same time, protective measures against the spread of the coronavirus lead to the collapse of familiar structures and to changes in the type of care on offer.

Ruth Belzner, who works for a telephone helpline in the southern German city of Würzburg, says that the number of calls has increased from 32 to 50 per day. One reason she sees for this is that social psychiatric services are no longer available: No more drop-in gatherings, no more group meetings or trips.

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"In the same way some people have an addictive memory, anxiety patients have a mechanism in the brain that is stronger than usual: A fear memory," explains Lewitzka. "Compared with healthy people, people with anxiety disorders have to expend much more energy to prevent the fear stored in this memory from becoming too strong.”

It is very possible for people with anxiety disorders to keep the fear under control, and therapy, for example, can help them to do so. However, the process takes time and is particularly fragile whenever stressful situations occur, because stress can weaken the anxiety control centers. In such situations, those who already have experience with therapy are forced to recall the things they learned there and how they can apply them.

Additional risks to physical health

However, as researchers from Harvard and Shanghai have shown in the journal Lancet Psychiatry, the threat to mentally ill people in the current pandemic affects more than just their psyches. They point out that mental illness can also increase the risk of physical infections if patients have cognitive limitations, a lower risk awareness and are less able to take care of themselves. It is also more difficult for these people to receive physical therapy, as discrimination against them is still very pronounced.

In some respects, a pre-existing mental illness may also be a strength, says Jacqueline. Many people with mental health concerns are careful about what they do and don't believe. Some may have been hospitalized, and therefore will be familiar with social isolation. Some therapies require patients to avoid contact with other people in the first few weeks, so that is not so different from quarantine. Also, a therapy can be a preventative or mitigating measure against full mental illness.

Psychiatrists, psychotherapists and crisis services are now faced with the task of coping with the increased vulnerability of mentally ill people in what is virtually a parallel mental pandemic. "These are really difficult times," says Lewitzka. "Quite a number of people often tend to see everything in a negative light and notice only the worries and fears. We try to guide these people a bit away from this way of looking at things and get them to see what is still going well despite the circumstances. That can also help people."

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People often tend to see everything in a negative light

Caution with therapy via video or phone

At the same time, therapists also have a problem in that the current protective measures apply to them as well, including maintaining a certain physical distance to others. Munz and Lewitzka report that inpatient work is being maintained, emergency treatment is being kept up and outpatient psychotherapy is often continuing with the prescribed protective measures in place. In consultation with the patients, however, the therapy can be shifted to telephone or video, they say.

Lewitzka admits that in such cases she misses the personal impression that is so important in psychiatry and psychotherapy, "but I get an idea of how my patients are doing, and if necessary, I can suggest they come to me in person after all."

But Krützmann does not like the idea of therapy at a distance. "This is not something I want to associate with my bedroom or something like that," she says. "I want to do it in a neutral space, where I can go out and process it for myself afterward." She would rather establish a stable daily structure. "That you get up, have breakfast and think: What do I have on my schedule today? And then actually do it, instead of saying, 'Oh, I could do it tomorrow.' That you give yourself a kick in the backside and say: I'll do it now. Or just find some tasks to do."

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Jacqueline Krützmann keeps a record of her activities and feelings

Online training as support

David Daniel Ebert is the founder and scientific director of the online platform "HelloBetter," which aims to support people in coping with mental illness and counteract the development of such illnesses with digital online training. He is also professor of clinical psychology at the Free University of Amsterdam and one of the pioneers of digital psychotherapy. In these times of the coronavirus pandemic, he and his colleagues are working on adapting their online services to the current needs to cope with the high demands. They have set up a free psychological telephone hotline (Tel.: 0800 000954 in Germany) and present regular digital question and answer sessions with psychologists and psychotherapists.

In an online community moderated by psychologists, it is easier to exchange information and share concerns and strategies, Ebert says. For him, "social distancing" is also the wrong term. He says one should rather speak of "physical distancing" and try to find creative ways to be together at a distance: "We humans are not made for social isolation."

The next crisis could come

Lewitzka, as chairwoman of the German Society for Suicide Prevention, also pleads for more community spirit. She greatly appreciates the solidarity that is just beginning to emerge. "What we are now experiencing in so many small ways, this help, this creativity, is a potential that sends the signal: 'We can do it. We'll get through this together.'"

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"Dear elderly neighbors - I'm glad to go shopping for you! Just ring at my door. Cheers Irene"

At the same time, she warns of the time after the current coronavirus pandemic. "In times of natural disasters, we see that suicide rates can even temporarily drop. Things can get critical when the event is over: when it's no longer a matter of surviving but of how life will go on now and when people realize what has been destroyed during such an event. Suicidal tendencies can definitely increase again then."

Of course, this is not meant as a prediction, since suicidal tendencies are rarely due to a single cause. But things would be difficult if society were to revert to the old, familiar individualism after the crisis, she says: "That, I think, is what we have to watch out for the most.”

If you are suffering from serious emotional strain or suicidal thoughts, do not hesitate to seek professional help. You can find information on where to find such help, no matter where you live in the world, at this website: befrienders.org