'You can't sleep, you can't do anything, it's literally all consuming'.
These are the words of Anandi Ramamurthy, describing life caring for a relative with a severe mental health condition. Her loved one's deterioration was rapid.
"It's very hard to describe the level of distress," she explained.
"If you've got someone and you feel that you can't keep them safe and they can't keep themselves safe it's horrible.
"Before I experienced this I had never come across someone who had that level of distress, I'd never seen it in my life - most people don't. I was very unprepared to know what to do, I could just see things disintegrating around me," Anandi added.
The situation was worsened, Anandi says, by the difficulty the family had accessing mental health treatment. That was back in 2017, but it's a situation many others will be facing this year - when the thinly-stretched system has come under even greater pressure than usual.
Mental health care systems in Greater Manchester and across the country are facing unprecedented challenges, with rising numbers of patients presenting with complex needs.
The fallout from the pandemic, and associated lockdowns, has created further demand for mental health admissions and referrals. Mental charity MIND has called the national situation 'a second pandemic', as the number of calls to its helpline surges.
The charity points to rising numbers of urgent and emergency referrals for mental health care across the country since the start of the first national lockdown. A total of 2,276 more urgent and emergency referrals were made in July alone this year compared to the same month last year.
A workforce report on the mental health sector penned by the British Medical Association (BMA) in September last year found that demand for services nationally was rising even before the pandemic - between 2016-2019 there was a 21 percent increase in people who contacted the NHS for help - but that staffing levels have not been keeping up.
The number of nurses, midwives, health visitors and support staff has fallen across the country since 2009 and the BMA says workforce shortages are affecting staff workload, wellbeing, morale and the ability for staff to provide good quality of care.
Locally, in the months before the pandemic, Greater Manchester Mental Health NHS Foundation Trust (GMMH) - the body responsible for providing support to tens of thousands of people in most of the central and northwestern parts of Greater Manchester - was challenged by hundreds of vacancies.
Minutes from one of the trust's board meetings - in March 2020 - detail a gap of more than 300 people out of a total staff of 4,731 in January 2020. Subsequent meetings have been streamlined because of Covid-19 and do not include a full account of current vacancies.
When asked by the M.E.N. what the position with staffing was now and whether it was affected by the pandemic, the trust wouldn't tell us, but a spokesman did say that the current situation 'is one of the most challenging climates we have ever had to face'.
However, one senior member of staff told the M.E.N. that 'barely any' of the various community teams in the region can boast a full complement of nurses.
She believes this means that there are hundreds of people who have approached their GP and been assessed for care but are now stuck in limbo awaiting treatment.
Community nurses - who provide support for people with manageable conditions - can have 30, 40 or even 50 patients relying on them for regular visits, she says, some with serious mental health conditions which could make them a danger to themselves or others if they are not properly cared for.
"You get disciplined if you don't do your notes and you can't let your patients down so you have to see them," the staff member explained.
"But you can't do both so you end up constantly trying to compromise and prioritise and you don't end up doing either. People are constantly having to focus on who's the most important.
"Staff won't even go off for a week's holiday even if they're desperate to because they know they've got that caseload and they're not sure it'll be alright if they're not there.
"You don't notice it getting worse, you just find yourself not sleeping as well and worrying about work and patients."
She described attempts to reorganise local teams as 'like rearranging deckchairs on the Titanic'.
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When mental health patients do not get the care they need, the results can be disastrous, as two recent, tragic cases have demonstrated.
Paranoid schizophrenic Zak Bennett-Eko repeatedly went to A&E and had even asked to be sectioned because he knew his mental health was deteriorating. The system did not catch his worsening condition until things were too late.
In September 2019, he threw his 11-month-old son into the River Irwell in Radcliffe, believing he was 'the devil'.
Six months later, seven-year-old Emily Jones was riding her scooter through Queens Park in Bolton when she was grabbed by a stranger who fatally cut her throat.
Her attacker, Eltiona Skana, also suffered from paranoid schizophrenia and was being treated in the community by mental health services.
But, when her nurse went off sick, she was not seen by any mental health professional for three months before the attack. During this time she stopped taking her medication and likely veered towards a psychotic episode, a jury was told.
An internal review by GMMH found the incident 'could not have been foreseen', although the service has so far refused to release the contents of the review to the M.E.N.
The trust itself was handed a rating of Good in its last inspection by the Care Quality Commission - the health equivalent of Ofsted.
However, the trust was rated as Requires Improvement in relation to its community mental health services for young people and working-age adults.
For Paul Reed, community care in Greater Manchester is at its lowest ebb.
He chairs the Manchester Users Network, a group of people who have been patients in the mental health care system and use their experiences to try and support others.
"The teams simply haven't got enough staff," he said
"There are nurses now who have as many as 40 patients and they simply cannot see all of them.
"That means lots of people who should be seen twice a week maybe seen once a month if they're lucky."
Paul, who had his first experience of the mental health system as a patient in 1997, says he worries about 'revolving door patients' who are seen by services and then discharged once their initial concerns begin to level-out, only to return to care some time later.
Some people who visit their GPs asking for help can wait up to two years to be referred, he claims.
"It's become a revolving door, people are are treated when they're struggling, they're given medication and then sent away," Paul explained.
"Some of these people have had lots of help in the past and then suddenly it's been taken away."
He added: "It's a house of cards and it's already falling down. There are many people getting out of nursing who find it's just not what they wanted to do.
"They don't want to be just giving people medication, they want to actually talk to people and care for them but they don't have the time."
Paul believes that services are keen on 'stepping down' patients where possible - discharging them out of frontline mental health care and allowing them to return to their GP for a new assessment if they begin to show symptoms again.
The issue was highlighted by the Manchester branch of MIND in a report released last year, which pointed to patients left 'shocked, puzzled and angry' at being discharged from services before they felt ready.
Following her own experience with the service, Anandi Ramamurthy decided to set up CHARM, a support group which works with patients, families and mental health professionals.
She said: "It's the system - not the people who work in it. We have members of CHARM that work in the service and there was one person who I spoke to and asked if they were going to change something what's the one thing you would want to change?
"He said I would like to be able to go home at the end of the day and feel that I've made somebody's life better. At the moment I can't do that."
Anandi wants to see services in Greater Manchester pursue a different approach to care involving more open dialogue and discussion, as well as focus on the traumatic events which can trigger mental health conditions.
She added: "We want them to rethink the approach and look at other ways of working to try to help those for whom the system they currently have doesn't work.
"For example the only approach we seem to have when it comes to psychosis is to dole out medication - but now it's generally recognised that one of the reasons people end up having psychotic breaks is to do with trauma and stress and these are very often related to a whole series of issues."
Samaritans (116 123) samaritans.org operates a 24-hour service available every day of the year. If you prefer to write down how you’re feeling, or if you’re worried about being overheard on the phone, you can email Samaritans at [email protected] , write to Freepost RSRB-KKBY-CYJK, PO Box 9090, STIRLING, FK8 2SA and visit www.samaritans.org/branches to find your nearest branch.
For support for people feeling suicidal, if you are concerned about someone or if you are bereaved by suicide see http://shiningalightonsuicide.org.uk
CALM (0800 58 58 58) thecalmzone.net has a helpline is for men who are down or have hit a wall for any reason, who need to talk or find information and support. They're open 5pm to midnight, 365 days a year.
Childline (0800 1111 ) runs a helpline for children and young people in the UK. Calls are free and the number won’t show up on your phone bill.
PAPYRUS (0800 068 41 41) is a voluntary organisation supporting teenagers and young adults who are feeling suicidal.
Beat Eating Disorders: Beat provides helplines for adults and young people offering support and information about eating disorders. These helplines are free to call from all phones. Adult Helpline: 0808 801 0677, Studentline: 0808 801 0811, Youthline: 0808 801 0711. www.beateatingdisorders.org.uk
Anorexia & Bulimia Care: ABC provide on-going care, emotional support and practical guidance for anyone affected by eating disorders, those struggling personally and parents, families and friends. Helpline: 03000 11 12 13. www.anorexiabulimiacare.org.uk/
Students Against Depression is a website for students who are depressed, have a low mood or are having suicidal thoughts. Bullying UK is a website for both children and adults affected by bullying studentsagainstdepression.org
For information and links to charities and organisations that can help with substance abuse, visit https://www.supportline.org.uk/problems/drugs/
The M.E.N. asked GMMH about the number of patients who had been assessed and not assigned a nurse and about the number of patients community nurses are expected to care for but did not receive an answer.
Andrew Maloney, Director of HR and Deputy CEO for the trust, did explain how the organisation was working to adapt to the challenges posed by the pandemic.
He said: “Like all NHS trusts, we are operating in one of the most challenging climates we have ever had to face. Despite this, our services have remained safe, service users well-cared for and we have maintained safe staffing levels throughout the COVID-19 pandemic.
“Our services have not just remained open but have innovatively adapted to meet demand, so that the increasing number of people requiring mental health treatment receive care when they need it.
"We have also made rapid progress in areas, with the transition to digital working and online consultations for our service users, providing COVID-19 secure locations and work spaces as well as the setting up of a 24-hour mental health helpline and five urgent care centres based in A&E departments across Greater Manchester.
“Our first priority is to our service users and their carers and our staff and volunteers have risen to this unprecedented global health challenge with dedication and commitment to ensure the safest levels of care for all of our patients can be maintained.”
A spokesman for the Department of Health and Social Care added: "NHS staff are on the frontline of this pandemic and we are doing everything possible to support their mental health and wellbeing during this extremely difficult time.
“Nationwide there are over 120,000 people employed by the NHS mental health workforce – with 8,400 people added in the last year alone – and we have invested an extra £15 million through NHS England to provide practical mental health support for staff.”