September 5, 2020 0 By FM

Even as the whole world focuses all its energy on preventing the transmission of COVID-19 infection, one of the most pressing concerns related to the pandemic that is either getting grossly deflected or gravely ignored is the psychosocial repercussions of the outbreak.

It is not surprising that healthcare professionals, scientists and managers are currently focused on the pathogen and the attendant biological risk. It is also not unusual that the psychological and psychiatric dimensions of the outbreak have been relegated to secondary status while we struggle to delineate the underlying pathophysiological mechanisms of the infection and come up with ways for preventing, containing and treating it.

However, as the pandemic progresses, the alarming mental health dimensions of the pandemic are also becoming more and more apparent. The picture appears to be quite startling, with a much-wider implication for emotional and social functioning than initially estimated. Not surprisingly, many are now predicting a mental health crisis to follow in the footsteps of the pandemic.

Myriad of stressors 

COVID-19, as a disease, has an uncertain prognosis. Isolation, which is an inevitable consequence of the disease, cuts off people from their usual support networks. Most people find the unfamiliar public health measures imposed by authorities as an attack on their personal freedoms. They are also riled by a myriad of stressors such as a potential loss of their jobs or means of income, insecurity, confusion, emotional isolation, stigma, looming shortages of resources for testing and treatment, an increasing toll on frontline health workersworkers, financial losses and conflicting messages from authorities.

This emotional distress is not specific to certain individuals. Rather, it is ubiquitous in COVID-19 affected populations, as has been established by extensive research. 

A recent review of psychological sequelae in samples of quarantined people and of healthcare providers has revealed numerous emotional outcomes, including stress, depression, irritability, insomnia, fear, confusion, anger, frustration, boredom, and the the stigma associated with quarantine. Some of these problems persisted even after the quarantine was over. 

The concerns included a greater duration of confinement, inadequate supplies, difficulties in securing medical care and medications and financial losses.

In the current pandemic, home confinement was forcefully imposed on large swathes of the population and this lasted for indefinite periods. The stress was further intensified by differences among the stay-at-home orders issued by various jurisdictions and conflicting messages from government and public health authorities.

Researchers said their preliminary data suggested that patients with COVID-19 were very likely to experience delirium, depression, anxiety and insomnia.

Patients infected with COVID-19 or suspected of being infected may experience intense emotional and behavioural reactions, such as fear, boredom, loneliness, anxiety, insomnia or anger. 

Such conditions can evolve into disorders, such as depression, anxiety including panic attacks and post-traumatic stress and psychosis or paranoia, and can even lead to suicide, studies say. 

Quarantined patients are more prone to these conditions as their psychological distress tends to be higher. Uncertainty about the infection, death and about infecting family and friends can potentiate dysphoric mental states in some cases.

Almost one-third of the people in India sustained significant psychological impact during the initial stages of COVID-19, according to a study published in PLOS ONE. 

The study, which was conducted from March 26th to 29th, surveyed a total of 1,106 respondents from around 64 cities in the country.

“The pandemic COVID and the associated concerns about its spread and the lockdown has had extensive impact on the mental health status of the general public,” says Dr Arun B Nair, Consultant Psychiatrist, Medical College, Thiruvananthapuram. 

Kerala is the place where the illness was first reported in India, in a medical student returned from Wuhan, China — the epicentre of the outbreak.

Anxiety about the cause of the illness was quite rampant at that time. People were apprehensive, sleep was disturbed and they had something called illness anxiety disorder in which whenever they get some sleep disturbance, they would think that they are going to die, he elaborates.

According to a study published in The Lancet on the psychological impact of quarantine and isolation during epidemics, 72% of the people who are in isolation or quarantine suffer from depressive symptoms, 58% have anger disproportionate to the stimulus and 20% get anxiety. The study also found that 18% of the people suffer from fear, especially fear about the illness and its natural course, and about 10% of people have intense guilt regarding whether they are the cause of the spread of illness to near and dear ones.

The psychological status of an individual, according to Dr Nair, is worsened by three important factors. One is the lack of a chance to mingle with near and dear ones directly. Lack of physical freedom, and concerns about the illness — especially in the wake of reports in traditional and social media regarding deaths and complications — are other contributors. 

Pathways of distress 

Going by the evidence of psychiatric manifestations of SARS and MERS, researchers hypothesise that survivors of COVID-19 “will show a high prevalence of emergent psychiatric conditions including mood disorders, anxiety disorders, PTSD, and insomnia.”

Studies say that as many as 35 percent of COVID-9 patients suffer from psychiatric morbidities in the post-illness stage. Gender-wise, females — especially those with previous psychiatric ailments — are usually the worst-affected. The manifestation of psychiatric problems has also been found to be inversely correlated to the duration of hospitalisation of the patients. While younger patients showed higher levels of depression and sleep disturbances, the elderly suffered from more serious conditions like post-traumatic stress disorder (PSTD), depression, anxiety and symptoms of obsessive-compulsive disorders. 

PTSD, which is more common with “conventional” natural disasters, technological accidents and intentional acts of mass destruction, has not usually been connected with medical conditions from natural causes such as life-threatening viral infection. 

Nevertheless, one recent survey conducted on 402 patients that survived the disease reports that at least 28 percent said they suffered from PTSD.

Some studies show PTSD prevalence in the general population to range from 4% to 41%. The prevalence of major depression has reportedly increased by 7% after the outbreak. 

Researchers explain two possible pathways for the psychopathological presentation of COVID-19 in those infected by the virus. One results when the SARS-CoV-2 directly affects the central nervous system (CNS) and the other is the indirect outcome through an immune response.

As soon as the pathogen enters the body, it triggers the immune system, leading to stress-associated inflammation in patients suffering from the psychological stress of being afflicted with a fatal disease. Psychiatric symptoms could also be the result of extreme immune responses like “cytokine storms” as the body strives to make all possible efforts to expel the virus.

At the same time, the neurological impact of COVID-19 is well-documented by several studies. 

A Wuhan study reported that 36.4 percent of COVID-19 patients suffered from some sort of neurologic symptoms. The study, which appeared in JAMA Neurology, found that symptoms associated with CNS were more common in patients with severe infection.

Besides CNS issues such as impaired consciousness, other manifestations included acute cerebrovascular disease, ataxia and seizures, peripheral nervous system symptoms like the taste and smell impairment and vision impairment.

Neuroimaging studies conducted by researchers from three Italian institutions published in the journal Radiology in May found that 59 percent among 725 hospitalised patients with COVID-19 reported an altered mental state while 31 percent experienced a stroke. Altered mental status was more common in older adults. Patients also reported headaches, seizures and dizziness, among other symptoms.

The psychological impact of COVID-19 was seen at higher rates among younger patients, females and those with comorbid physical illnesses.

The psychosocial effects of pandemics are particularly heavy on certain vulnerable groups, including those who contract the disease, those at heightened risk for it (including the elderly, people with compromised immune function, and those living or receiving care in congregate settings) and people with pre-existing medical, psychiatric or substance use problems.

Family members of infected patients and residents of high-incidence areas frequently face social rejection, discrimination, and even xenophobia. 

Stigma, information overload

Stigma is an all-encompassing phenomenon with contagions. It comes from a morbid fear of isolation and abandonment. Stigma has a direct impact on mental health.

In India, the problem is much worse, especially in its heartlands. Unjustified public fear often leads to discrimination, stigmatisation and scapegoats. If misinformation or lack of information is the cause among the rural folks, it is too much information that is leading to discrimination among their urban or semi-urban counterparts. 

“In the fight against COVID-19, it is necessary to create awareness among the public. But it has a side-effect – ‘infodemic’. Like pandemic, infodemic is also dangerous,” opines Dr John C J, Senior Consultant Psychiatrist, Medical Trust Hospital, Kochi. 

Currently, there is an information overload and it may come from points other than verified sources.

Overeagerness to provide the latest information has resulted in the generation of stigma, he says, adding that the publication of personal details of COVID-19 victims has also contributed to it. 

According to Dr John, if prominent personalities who were infected with the virus come forward to give a positive public message, it will help to address the stigma caused by the disease. A campaign in this regard wouldn’t be a bad idea, he adds.

Some experts, however, find that the stigma around COVID-19 is declining, albeit gradually.

“In the initial days of the COVID-19 outbreak, there was stigma,” comments Dr PK Dalal, President, Indian Psychiatric Society. “There were several incidents of people not allowing healthcare workers to enter their rented houses or flats. It was due to the stigma and fear caused by the disease. But after the government gave strict directions, no such incidents happen now.”

As most of the COVID-19 cases are asymptomatic or mildly symptomatic, there is nothing to worry about, he says. People should take proper precautions. Even after taking precautions, if a person gets infected, there is nothing to worry, he adds. 

‘Burnt-out’ frontline

The major group which is particularly vulnerable to emotional distress in the current pandemic are healthcare providers. Frontline health care workers are particularly vulnerable as they are the ones who are directly exposed to the pathogen.

They also have much bigger concerns due to the novel nature of SARS-CoV-2, inadequate testing, limited treatment options, insufficient PPE and medical supplies and extended workloads. 

“Many of the doctors and staff nurses are getting burned out. That is a huge problem, because the workload is unparalleled, especially when a large section of the society is reasonably relaxed,” points out Dr Arun Nair. 

Although some protocols for clinicians are in place, most health professionals who work in isolation units and hospitals are neither trained to provide mental health assistance during pandemics nor receive specialised care, experts say. 

However, at the beginning of the pandemic, certain institutions in the country did take the initiative to impart training to frontline health professionals to handle mental health issues. 

The department of psychiatry at Medical College, Thiruvananthapuram, for instance, conducted month-long training for all the staff who were on COVID-19 duty, including doctors, nursing staff, attenders, cleaners and everyone involved in frontline care during the initial phase of the COVID-19 spread itself, explains Dr Nair. 

They were taught the importance of psychological first aid and how to provide it to patients. 

The second part of the training was to take care of their own stress. “We empowered them with regard to identifying the signs of stress, simplifying stress management strategies, identifying the signs of problems like depression in order to seek timely help. We have got a helpline for frontline COVID warriors also. Whenever they have got a psychological problem, they can approach that helpline number and the department of psychiatry will give appropriate guidance”, he adds. 

Experts say that prevention efforts — such as screening for mental health problems, psychoeducation and psychosocial support — should be focused on these and other groups at risk for adverse psychosocial outcomes. 

Several studies underscore this need as they have found high rates of anxiety and stress symptoms, as well as mental disorders such as post-traumatic stress, among frontline workers, especially among nurses and doctors. 

Essential care critical 

Studies say that the COVID-19 crisis threatens the basic human need for connection and interaction, which might explain the overall insult to our mental health.Therefore, addressing this problem becomes a greater necessity. 

As Dr Arun Nair highlights, providing psychological first-aid is an essential care component for populations that have been victims of emergencies and disasters, but there are no universal protocols or guidelines for providing the most effective psychosocial support practices. Although some reports on local mental health care strategies have been published, comprehensive emergency guidelines for such scenarios are yet to come out. 

Opportunities to monitor psychosocial needs and deliver support during direct patient encounters in clinical practice are greatly curtailed in this crisis because the patients are, largely, in home confinement. In most places, psychosocial services, which are increasingly delivered in primary care settings, are being offered by means of telemedicine. 

Since most COVID-19 cases are identified and treated in healthcare settings by workers with little to no mental health training, it is imperative that assessment and intervention for psychosocial concerns be administered in those settings. 

One of the ways to achieve this, opines Dr Arun Nair, is by integrating mental health into the primary healthcare system, as is happening in many countries worldwide. “We have to integrate mental healthcare into primary healthcare so that persons don’t have to travel a long distance to go to tertiary care institutions to avail mental healthcare facilities,’’ he contends. However, there are certain places such services are simply not available. 

The integration of mental health should be addressed through state and local planning. It should ensure mechanisms for identifying, referring, and treating severe psychosocial consequences, besides creating the capacity for consulting with specialists. 

It has become one of the important jobs of healthcare providers to monitor the psychosocial needs of the patients and deliver the required psychosocial support, and this may even end up overburdening the already stretched healthcare system. 

But it is very important, warns Dr Arun Nair, because the pandemic may settle down, but its psychosocial and the economic repercussions may be long-lasting. Post-pandemic problems, such as depression, substance use disorders, child and adolescent behavioural problems and suicides, are likely to follow in its wake. Unless we address that possibility pertinently, they could trigger another crisis, he warns.