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Table of Contents
REVIEW ARTICLE
Year : 2020  |  Volume : 17  |  Issue : 5  |  Page : 36-40

Mental health in India in times of COVID-19


Department of Psychiatry and Psychotherapy, Indraprastha Apollo Hospital, New Delhi, India

Date of Submission13-Jul-2020
Date of Acceptance01-Aug-2020
Date of Web Publication27-Aug-2020

Correspondence Address:
Achal Bhagat
Indraprastha Apollo Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_92_20

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  Abstract 


The number of people who have been affected by COVID-19 is rising and is a public health emergency. The experience of COVID-19 is showing a universal mental health impact and an increase in number of people experiencing mental ill-health in India. The current mental health morbidity in India is significant, and its impact is compounded by a large treatment gap for mental health. In the face of COVID-19, depression, anxiety, and posttraumatic stress disorder are likely to rise. Health-care workers are likely to be at risk for mental health problems. An increase in social risks of domestic violence, unemployment, unsafe migration, decreased access to education, and challenged safety nets for those who are more vulnerable is becoming evident. This will further contribute to magnifying the mental health problems in India. The mental health impacts are likely to be significant and sustained. There is a need to emphasize on preparedness for an emerging secondary public health crisis of mental health in India.

Keywords: Anxiety, COVID-19, depression, mental health, psychosocial impact, posttraumatic stress disorder, social determinants


How to cite this article:
Bhagat A. Mental health in India in times of COVID-19. Apollo Med 2020;17, Suppl S1:36-40

How to cite this URL:
Bhagat A. Mental health in India in times of COVID-19. Apollo Med [serial online] 2020 [cited 2022 Dec 5];17, Suppl S1:36-40. Available from: https://apollomedicine.org/text.asp?2020/17/5/36/293694


  Introduction Top


It is early July 2020, and it has only been a few months since the first report of COVID-19. Coronavirus disorder 2019 has probably become the single most important determining factor in the lives of people. With more than ten million people having been tested positive for Covid 19 and more than half a million lives having been lost across the world, the human race is increasingly helpless.[1]

Nearer home, in India, the numbers continue to rise too. The numbers of people affected by Covid 19 in July 2020 is above six lacs and about nineteen thousand lives have been lost.[2] But these numbers do not even begin to explain the underlying untold agony of many who have recovered or have survived. The ripples of social and economic effects which have just about begun threaten to be a tsunami too.

With a tragedy of such grave proportions becoming a shared reality, it is only common sense that our minds are likely to be affected too. While, there has been a recent acknowledgment that the pandemic is likely to affect the mental health of people, as yet the realization that mental health impacts of COVID-19 are a looming crisis has not yet dawned.[3] This article tries to deconstruct and predict the nature of mental health impact secondary to COVID-19 in India.


  the Mental Health Needs and Resources in India in Pre-covid-19 times Top


To better understand the context of how COVID-19 would affect mental health in India, it will be useful to consider the pre-COVID-19 reality of mental health needs and resources in India.

A recent survey reported that one in every seven people in India is in need of mental health services. This survey focused on disorders as diagnosed using ICD-10 criteria. It was reported that in 2017, there were 197.3 million people with mental disorders in India, comprising 14.3% of the total population of the country. Mental disorders contributed 4.7% of the total disability-adjusted life years in India in 2017 as compared to 2.5% (2.0–3.1) in 1990.[4] The young are being affected more, and there is also a rising trend of substance use and suicide in the population.

This is coupled with reports of up to 95% of people who need access to mental health treatment and are not able to access treatment. According to the recently conducted National Mental Health Survey, the treatment gap of any mental disorder in India was reported to be as high as 83%.[5],[6] The resource allocation, inadequate human resource planning and development, and the stigma related to help seeking all contribute to the treatment gap.

The National Crime Records Bureau (NCRB) of India has reported the official suicide death rate for 2015 to be 10·6/100,000 population. This compares with the global average of 11.4/100,000 population.[7] It is usually thought that the suicide death rates based on police reports as in the data from NCRB may have an underreporting or misclassification of the number of death.[8] A study in the Lancet Public Health, using data from the Global Burden of Disease study, estimated a national age-standardized suicide death rate for 2016 as 17.9/100,000 population (14.7/100,000 among women and 21.2/100,000 among men), a likely number of 230,000 suicide deaths annually.[9],[10]

It is with this background of the unaddressed mental health needs and a virtually nonexistent public health response to mental health that we need to get prepared for the forthcoming secondary public health emergency of mental health in India.

Mental health and mental ill-health are on a continuum. The unprecedent events of 2020 are likely to affect the mental health of the whole population and contribute to increasing prevalence of mental ill-health too.[11] A significant compounding interplay between the social determinants of mental health and the prevalence of mental ill-health and suicide death rates is well documented and is being predicted this time too.[12],[13] The group of people presently living with mental ill-health would be affected directly by the psychological impact of facing the prospect of COVID-19 and indirectly due to the socioeconomic impacts secondary to the COVID-19 which, in turn, will decrease their prospect of accessing treatment and care.


  Universal Mental Health Impact Top


It is becoming evident that mental health impact of COVID-19 is going to be “significant and sustained.”[14] An ongoing documentation of lived experiences during the times of COVID-19, through interviews with individuals and review of media,[15] and a quick review of mental health and social medicine literature there are some early emerging patterns in the way people are thinking and behaving in the wake of COVID-19 public health emergency.

The mental health impact is also going to continuously change in its nature too. Like in other disasters, the initial response in the community could be equated to a normal grieving process due to loss of control and people.[16] A significant proportion of the population seems to have been benumbed by the overwhelming and ongoing experience of living with COVID-19, and people seemed to be busy trying to cope with “the now and how of life” through focusing on everyday activities as if nothing has happened.

There are also other variations in the way people have responded to this public health emergency.

The process of survival seems to be of prime importance. Most narratives and conversations focus on the effort to understand and put in context the experience of the pandemic. There is no respite from “the COVID narrative” as it is all pervasive and global, for example, online school activities for children are focused on corona, cartoons, jokes, news, social media, restructuring of the place and nature of work, advertising, comedy, various other forms of communication, and experiences all seem to have a COVID-19 reference.

Some other people are externalizing their anger toward the governmental systems, the health-care systems, many are aggressive and blaming toward those identified as “the other.” The “process of othering” is broad, and it seems to include everyone who the person does not identify with, for example, “othering” on the basis of caste, gender, economic status, occupation, poverty, ethnicity, geographical location in a city, and on the basis of religion.[17]

There is perhaps an intolerance of uncertainty and a need to reframe one's predicament in terms that are controllable and changeable. Some people are very definitive and inflexible, and this is perhaps their way of coping with the significant loss of control that the communities are faced with. There is an increasing degree of risk-taking behavior and impulsiveness reported among some.[18] There are reports of people not wearing masks, organizing parties and social gatherings, using substances, and overlooking the consequences of their behavior on their health. This impulsiveness is also perhaps a response to overcome uncertainty.

There are also reports of alarming rise of maltreatment and domestic violence indicating the patriarchal society's need to reinforce a gender-based power hierarchy using the public health crisis. This is coupled with lack of access to support and safety nets for women.[19],[20]

People are also showing a generalized belief of vulnerability. The sense of dissolution of the natural belief of “personal invulnerability” (“it cannot happen to me”) is evident. There is all-pervasive fear. The thought process seems to be “if this has happened, anything can happen” and “if this has happened once, it can happen again.” This along with social reality of lack of resources to access health and lack of access to shelter and livelihood contributed to millions of people walking back to their villages to find some safety. The unfathomable trauma of such journeys will continue to impact not only the individuals but also the communities they belong to.[21]

There is a change in the perception of time. There is a flurry of activity parallel to a complete inertia. Everyday seems the same to people. There is also a lack of sense of purpose and meaning that some people are reporting.

Some people seem to have self-questioning cognitions. They seem to seek reprieve in a “just world” hypothesis in which some people perceive themselves as the cause of the pandemic. “It is for our sins that we suffer.”

This is also coupled with negative self-appraisals. A number of people are labeling themselves as weak and helpless with little control over their fate. There seem to be a significant number of people who have given up effort and are passive even in their effort to survive.

There are some narratives of strength too,[22] for example, that of a child cycling so that her father can reach back home, of people setting up safety nets in the community, of people surviving the traumatic experiences and returning to support others. However, this “posttraumatic growth of psychological strength” is the less heard narrative.


  Mental Ill-health Secondary to Trauma Top


Psychiatric Disorders, including common mental disorders such as anxiety disorders; depression; somatization and somatoform disorders; obsessive compulsive and related disorders; substance use; mood disorders; schizophrenia and related disorders and disorders of cognition, have a significant current prevalence in India.[23]

In the analysis of a general hospital practice service utilization data, the number of people seeking help for common mental disorders shows an early rising trend, even though the services are being offered through telemental health and the face-to-face services are not functional presently.[24] An initial survey by the Indian Psychiatric Society in India and research from other countries such as China, the UK, and the US report a rising trend of people experiencing psychiatric disorders (up to 20%).[24]

The disorder, that is, most often reported, is the depressive disorder. This is characterized by low mood or irritability, lack of interest, inability to enjoy, ideas of helplessness, hopelessness, worthlessness, and decreased sleep. Generalized anxiety disorders, characterized by apprehension, avoidance, autonomic features of anxiety, and catastrophic thinking, were diagnosed too. An increased number of people are reporting the presence of isolated symptoms of increased insomnia and reversal of sleep cycle.

While initially, as the public health measures for limiting transmission of virus were popularized, there was a normalization of obsessive features and compulsive features for those living with obsessive-compulsive disorder. However, as the time has elapsed, the distress levels experienced by people who have had obsessive and compulsive symptoms have now again increased.

Posttraumatic stress disorder (PTSD) is reported in studies of people who have been discharged from intensive care unit. In a meta-analysis of research, 20% of people who were discharged from intensive care units reported PTSD.[25],[26] It is assumed that a similar or even higher number are likely to report PTSD after living through the experience of critical care. First-person accounts by people who have had a severe form of COVID-19 are narrating the trauma of isolation and the uncertainty regarding access to treatment, fear of losing a loved one, fear of dying. This is further compounded by stigma of being considered as 'dangerous to others'.[27] Some survivors are probably more likely to have features of PTSD and comorbid depression.

The usage of alcohol and other substances such as cannabis and opiates decreased initially probably due to nonavailability of substances in the lockdown, and this decrease of use was accompanied by the symptoms related to withdrawal. Now, there is an increased incidence of relapse.[28]

Most people who are experiencing loss have the likelihood experiencing a complicated grief process as they have not been able to complete the mourning process or the rituals.

There are already media reports of death by suicide of many people,[29] while such reporting cannot be taken at face value, yet the risk of suicide does increase with multitude of factors such as psychiatric disorders, loss of relationships, financial loss, unemployment, low access to treatment, and loss of hope, purpose, and meaning.[30]


  Mental Health Impacts on Specific Groups Top


People living with mental illness

People, who were living with mental illness before the COVID-19 pandemic, are likely to show worsening of symptoms partly due to the lack of access to medicines and treatment, partly due to increased levels of stress for themselves and their care providers. There are case reports of neuropsychiatric symptoms during the course of the COVID-19, though most common features seem to include delirium and confusion. The risk of relapse is likely to increase also due to effects of drugs used for the treatment of COVID-19, for example, dexamethasone could clearly lead to worsening of mood disorders.[31]

Health-care workers

Health-care workers are working in extremely difficult circumstances in the COVID-19. The process of protecting oneself from being infected by the virus, the risk of carrying the virus to the family, and working in uncertain and underresourced environments is leading to exhaustion, anxiety, and guilt in health-care workers.[25] Health-care workers are also reporting survivor guilt as they lose colleagues and experiencing the loss of patients, they may report “moral guilt.”[32] A study from West Bengal has reported up to 39% incidence of anxiety disorders in health workers in India with high levels of comorbid depression and PTSD.[33] Mental health-care workers may find “the shared reality” with their clients both helpful and retraumatizing at the same time.[34]

Children and adolescents

Children are experiencing stress due to the loss of protective factor of being in schools. Being isolated, fear of loss of parents or adults, and experiences of quarantine are traumatic for children and may present as anxiety, depression, oppositional behavior, or conduct difficulties.[29] There is also a normalized excessive use of digital content and media. Unsupervised online access may expose the child to increasing risks of online bullying and abuse.[35]

People with disability

People with disability are at a greater risk to be affected by COVID-19 illness, and they have least access to resources for help. Family-based caregiving is being affected because of multiple roles that the caregivers have to play. Neglect and maltreatment may be a clear fall out of the economic hardship being faced by the family and the community.[36] The disabled people living in Institutions are more vulnerable to be affected by the virus as there is overcrowding, poor training, and low access to health care.[37]


  the Social Determinants and Long-term Post-covid Mental Health Impact Top


While it is difficult to predict the future in a dynamic and evolving situation, the sociological impact of COVID-19 is that individual boundaries become sharper and the sense of community decreases. The existing social divisions within the community may become sharper. The poor have less access to resources for health and nutrition. Poverty is also linked to increased risk for mental health problems.

Increase in the incidence of gender-based discrimination, domestic violence, and its resultant impact on women's mental health is documented. There is likely to be increase in child labor, human trafficking, and increase in unsafe migration of a younger population. There is also likely to be increased incidence of unsafe sexual behavior which may further the spread of HIV. There is likely to be a changing trend of economic options with a need for reskilling and a question mark on sustainability of livelihood.

These experiences may further contribute to long-term impacts like 'characterological' changes in the value framework of the communities.

The core beliefs of helplessness and disempowerment are likely to rise after any disaster. There may be a foreshortened view of the future. This will co-exist with a sense of generalized vulnerability and anger toward any event or person that heightens this helplessness. This may contribute to two phenomena: there will be a need to control one's immediate context. The goals may be short term, and the need for gratification will be immediate. Second, there may be disregard toward any structure and systems. All contingencies and consequences will pale in contrast to what people have survived.[38]


  Conclusion Top


Negative mental health impacts on individuals and psychosocial impacts on communities are being documented in the early months of the world experiencing COVID-19. While the early anxiety and worry about being affected by the illness will settle down, the rising number of people living with mental ill-health, worsening of preexisting mental health problems, and lack of preparedness of the mental health systems in India to address such a rise in numbers may stymie the recovery from COVID-19. There is a risk of increase suicide death rates too. There is a need to strengthen the communities and their safety nets so as to ensure that realities such as discrimination, exploitation and lack of access to health, and violence do not leave a permanent impact on the communities' mental health.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  In this article
Abstract
Introduction
the Mental Healt...
Universal Mental...
Mental Ill-healt...
Mental Health Im...
the Social Deter...
Conclusion
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