Anita Link was in hospital when the coronavirus pandemic blew up earlier this year.
At the time she was recovering from a manic episode.
Anita has lived with bipolar 1 disorder, which includes episodes of mania, psychosis and depression, for 14 years.
She was first diagnosed after experiencing post-natal psychosis at the age of 32.
With medications and ongoing professional support she's mostly well, but every two or three years she has an episode that can last weeks or even months.
After her latest episode, which lasted five weeks, she emerged into a different world.
"When you leave hospital you're certainly better than where you started but there's still a lot of rehabilitation and reintegration to do to get back into your normal routine and life, so that is a bit of a vulnerable time," she says.
"Hearing all the news while I was still in hospital I was wondering how that was going to go."
Back in March, that question was also playing on the minds of mental health researchers such as counselling psychologist Ellie Brown.
Dr Brown and colleagues at Orygen Youth Health and the University of Melbourne wanted to know whether the numbers of people presenting with psychosis would increase either from coronavirus itself or from social isolation, and how people with complex mental health issues would cope.
"We wondered what was out there in the evidence, and what could we pick out that might help us understand what was coming down the track," Dr Brown says.
Early studies warn COVID could increase psychosis
While it was still very early days in the pandemic, evidence from a handful of papers from other viral diseases, including SARS and MERS, and studies from the unfolding situation in Asia suggested coronavirus might actually lead to an increase in people experiencing psychosis.
The onset of psychosis is usually seen in people in their late teens to early 20s.
But the data coming out of China suggested there was also a significant increase in people in their 50s and 60s experiencing psychosis for the first time.
"It's really the older people who were more isolated who were presenting with a first episode, which was very unusual," Dr Brown says.
But it's not just the pandemic's potential to trigger a first-time episode that health professionals are worried about.
Isolation, the mass psychology of fear, and other stressors can exacerbate symptoms or cause relapses for vulnerable people already living with chronic illness.
While the numbers are hard to pin down, months down the track there is a sense that there has been a rise in the number of people accessing mental health services.
According to Orygen there has been a 17 per cent increase in referrals to youth mental health services in north-west Melbourne over the past four months, up 8 per cent from the same time last year. There has also been a 14 per cent increase in contacts with clinicians compared to the months before the first lockdown began.
"We're just getting the data in the increase in the number of people presenting with psychosis. And that's just going to be the young people," Dr Brown says.
Carmel Pardy, who oversees the telephone and online support centre for mental health charity SANE Australia, which supports people 18 and upwards, has also noticed an increase in people accessing the service since the pandemic began.
"We have had an interesting cohort of people who've come to us for the first time during COVID," Ms Pardy says.
The charity is also seeing an increase in the number of carers calling.
But, she says, we won't truly see the fallout of COVID on mental illness until next year.
The impact of isolation and anxiety
Isolation, disrupted routines, and lack of access to care are some of the themes emerging.
"A lot of people we work with struggle with relationships, so a relationship with a therapist might be the one constant and safe relationship in their life and if they can't do that it's been really, really problematic," Ms Pardy says.
When SANE set up new services for COVID-19, they found many people needed a daily chat.
"You have to remember some of the people we work with may not get incoming calls, so this is an opportunity for someone to call and just check in on them."
Increasing anxiety is a common report.
Cameron Solnordal has lived with schizophrenia for 20 years.
"My diagnosis came through smack bang in my early to mid-20s ... so I've been living with that for a long time," says the Melbourne dad and mental health advocate.
"My medication is well-managed and I self-regulate pretty easily."
In some ways, he says the extended lockdown in Victoria has relieved some of his feelings of isolation and stigma.
"I would have this slightly difficult interaction in daily life, and I would have quite a heightened anxiety of talking to people or being amongst the general population," he explained.
"There has been a bit of respite from that because everyone's going through it."
On the flipside, he has become more anxious and hypersensitive.
He finds himself constantly questioning whether there is more he can do to prevent spreading the virus. And he is concerned about the precautions others are taking.
"With the idea of the virus getting out there, I also had to assume that everyone else had it so I could take as many precautions as necessary but that over exacerbates itself to a level of paranoia," he explains.
Getting through the second wave in Melbourne has been tough, especially when he sees people refusing to wear masks or breaking curfews.
Staying healthy in a pandemic
Managing complex mental health issues is challenging in a pandemic, says Dr Brown.
"How do we keep people safe, but also make sure that they don't become isolated? she asks.
Cameron copes by taking time out with his family and uses strategies to manage his thoughts.
"I just have to let the thought sink through my head and let it pass.
"It sounds like an amateurish coping strategy, but it seems to work because I'm not fighting the thought.
"As soon as I engage with it, it will exacerbate, and then I will exacerbate it and it turns into a mental jousting match of me and my head."
He has also started seeing a psychiatrist again for the first time in 15 years, having a mix of face-to-face and phone appointments, and connecting with others on SANE Australia's online forums.
"I can't even fathom the difficulty some people must be going through when a) they're not completely balanced in their medication and b) they are not having constant professional support," he says.
Although Anita was still fragile when she came home from hospital, she is coping well with the pandemic.
In fact, the Brisbane-based vet and mental health advocate believes her experience dealing with the uncertainty of mental illness has been a major factor in her recovery, and she has been writing about her experience on her blog.
"I've had that practice in navigating my way through a difficult circumstance that has no set end point, and I sort of viewed COVID as the same."
Regular exercise and rationalising media consumption has also helped, she says.
And, she acknowledges, she is fortunate to have had very good ongoing medical care since she was first diagnosed.
"I've always got appointments with my psychiatrist and psychologist booked ahead of time."
She says stress of COVID has precipitated the first episode of mental ill health for some people.
"If you don't quite know what you are dealing with when you are coming down with it — and most of the time you don't — it's really difficult to have insight into symptoms the first time you experience them."
Early support can make a difference
Getting professional support and treatment early is important so people don't transition into a full-blown episode of psychosis, says Dr Brown.
"[Psychosis] can be treated well, and quickly and often with a good outcome."
But identifying whether someone's thoughts are becoming more disordered, especially if they have never had a mental illness before, can be challenging, she says.
"One of the problems of how hard it is to work with psychosis and identify it and manage it is that it is different for everyone and the presentations can be so complex."
"You have to really spend time with that person to get to the bottom of it."
"Family members are in a good place to do that because they are already having conversations," she says.
But sometimes it can be hard for carers to convince their family member to seek help, Ms Pardy says.
"That's something that has presented to us a lot during COVID where carers are really calling out for help."
"We encourage them to reach out to services like us, we encourage them to call the hospital and flag their person to say this is what's going on."
"Both the family and the person with the mental health issues need support."