Dr Shashi Sudan, Dr Twinkle Gupta
Public Mental Health is being challenged like never before by COVID-19. Whilst there are many uncertainties about how the pandemic will progress, what is clear is that the impact on the mental health and psychosocial well-being of those most affected will be significant. This is a pivotal moment in the history of mental health. How India tackled these challenges now will determine the well-being of a generation, and impact the drive to successful recovery and building back societies stronger for the future. This briefing provides an overview of some of the key issues regarding mental health and COVID-19.
India is not equipped for a mental health crisis. Prior to the COVID-19 outbreak, public statistics on mental health conditions were already bleak. Mental health conditions contribute to 25% of years lived with disability in India. Depression is a leading cause of disability affecting approximately 56 million Indians while another 38 million Indians suffer from anxiety disorders. Around half of all mental health conditions start by age 14, and suicide is the second leading cause of death in young people aged 15-29. Every 40 seconds someone dies by suicide. More than 1 in 5 people living in settings affected by conflict suffer from a mental health condition and people with severe mental disorders die 10-20 years earlier than the general population.
The impact of the COVID-19 pandemic on mental health is complex, diverse and wide ranging, affecting all parts of societies and populations. The extraordinary increase in mental health needs is taking its toll on already burdened mental health services which are under-funded and under-resourced in our country. COVID-19 has exposed the serious gaps in mental health care, and now more than ever Government of India needs to prioritise and ensure that quality mental health support is accessible to everyone, everywhere. Those with existing poor mental health are facing a number of risks including increased rates of mental ill health and disruption to treatment, medications and the lifeline of support services. Studies are showing COVID-19 is likely to exacerbate existing mental health symptoms or trigger relapse among people with pre-existing mental health illness. In an online survey in India, of those with a prior diagnosed mental health condition, some 12% identified feelings of suicide as the main challenge, and 6% indicated substance use as a difficulty.
COVID-19 has had a huge impact on mental health services and caused disruption to care and treatment. Some specialised mental health provision has been cut in order to increase capacity to treat the physical impact of COVID-19. A number of general hospital psychiatric wards have been converted into COVID-19 wards, meaning large numbers of severally ill people are moved out.
Community-based psychosocial support activities have also been severely impacted with seeing groups, associations and community-based initiatives that brought people together regularly before the pandemic and now are unable to meet for months. Physical distancing and lack of personal protection equipment (PPE) have also impacted on the capacity to continue to care for those with severe and acute conditions. Demand for face-to-face mental health services has reportedly significantly decreased due to fear of infection, especially among older people. Many services have had to switch to remote mental health care, providing consultations through digital platforms or by phone, to varying degrees of success. India is investing in innovative digital and telecommunication solutions and the appointment of more mental health professionals.
Impact on Health Workers: Frontline workers are playing a crucial role in fighting the outbreak and saving lives. But they are under exceptional stress and while deaths of health workers are rising, the mental ill health rates are rising faster still. Frontline workers, especially healthcare workers, are at particularly high risk of mental ill health, including suicide attempts, the risk of burnout and stigmatisation. Without support they will be unable to fulfil their vital role in stopping the outbreak. Ensuring the good mental health of health workers is essential. Research from the 2003 SARS outbreak indicated that 89% of healthcare workers in high risk situations reported psychological effects. A study among healthcare workers in China- the country effected by the COVID-19 the most- showed the frequency of depression (50.4%), anxiety (44.6%), insomnia (34%), and distress (71.5%).
We cannot afford to lose our health workers and must urgently support their mental health now to ensure a workforce that is sustained throughout the pandemic response and recovery. India has introduced dedicated teams providing mental health support for health workers. Initiatives include the introduction of personal screening for stress and mental health illness involving an assessment of occupational exposure to COVID-19, prior history of stress and mental health conditions, new personal and family stressors arising since the pandemic onset, and current presenting problems including increased use of alcohol or drugs. Support is being offered via workshops, support groups led by social workers and other trained staff, individual assessments and mental health treatment.
Impact on General Populations:
Across societies, even for those not directly impacted by COVID-19, the effects of social isolation and economic fallout are being felt widely. Large sections of populations around India are experiencing increased anxiety, depression, stress and loneliness as a result of the COVID-19 outbreak. No one is immune to the pressures the pandemic are placing on communities and countries. Results of initial studies confirm that fear, loneliness, sadness and anxiety are common as people are afraid of infection, dying, losing family members, losing their income or livelihoods, being socially isolated and separated from loved ones. These are risk factors not only for the short term, but also longer-term mental health problems.
Past epidemics have highlighted the negative impact of outbreaks of infectious diseases on the mental health of those exposed. The 2003 SARS outbreak in Asia had substantial consequences on the mental health of those exposed with surveys showing up to 50% of recovered people with anxiety symptoms and 20% of rehabilitated people showing depression. The SARS epidemic was also associated with a peak in suicide deaths among those aged 65 years and older.
To deal with these stressors, people use different coping mechanisms some of which are harmful including rising alcohol consumption which can exacerbate issues such as Interpersonal Violence, drugs, or spending more time on potentially addictive behaviours such as gaming and gambling.
Relationships are being tested as some family members are being forced to spend much more time together which, whilst for some, can strengthen relations, for others is adding additional strain. Domestic violence, which has a very negative impact on mental health, has increased.
There is evidence that if national authorities manage quarantine well then, although it is frustrating for people, it does not cause long term mental health problems. But if it is done badly it has short and even long term mental health impacts. Although the challenges faced are unparalleled, natural resilience is showing through – something that will be essential to ensuring societies can function and people recover from the impacts of the pandemic. It is possible the experience of COVID-19 could bring us together and make us kinder to one another. During COVID-19 we are seeing an increase in the awareness of mental health. Positive coping mechanisms are reported to be emerging in different countries and communities. Actions are being taken and organisations are introducing innovative initiatives to help overcome challenges and working to help meet mental health needs during these extraordinary times. The mantra “We are all in this together” signals the universality of this shared experience and many are offering psychosocial social support to one another.
RECOMMENDATIONS:
What needs to be done :
* Apply a whole of society approach to promote, protect and care for mental health. We believe this must include upholding the right for all to good physical and mental health, ensuring mental health support is maintained for those with pre-existing mental health conditions during the pandemic. For those in psychiatric institutions and care homes the necessary infection prevention and control measures must be provided to stop the spread of COVID-19 while giving care for those affected by COVID-19, without discrimination.
* Ensure widespread availability of emergency mental health and psychosocial support. This need to ensure additional support is scaled up especially for those most at risk of mental ill health during the pandemic including health care workers and other first responders, those economically impacted, COVID-19 survivors, and society’s most vulnerable. Mental health services and support needs to be incorporated in all aspects of the response including conducting national public health campaigns that promote mental health and psychosocial wellbeing, that explain COVID-19 and signpost mental health services. These must address misinformation, stigma and discrimination for all citizens.
* Funding announced by governments and multilateral organisations has been focused primarily on physical health, although funding for mental health is included in at least some of the financing packages already announced, and corporate and philanthropic donors have made contributions. But it is critically important that funding rises now. More funding is urgently required at the public and national level to prevent, respond and recover from the pandemic. Overall mental health services during this pandemic are still very limited, at a time when the needs are great. Investing in mental health now is an opportunity to build back better for society as a whole, and mental health in particular.
* Support recovery from COVID-19 by building mental health services for the future. We are calling for the scaling up of support and services for the future, recognising the increasing need post-crisis to build back better, more evidence-based, and stronger mental health services that are integrated into Universal Health Coverage plans.
* Sufficiently funding mental health is necessary to make the COVID-19 response Publicly and nationally more efficient and effective. We need a comprehensive, well coordinated approach that swiftly responds to immediate needs to prevent a substantial increase in mental ill health. Moreover, mental ill health is going to require long term investment to help societies build back better once the outbreak is ended.
* Rapid innovation has also been seen in the transition to community-based working. COVID-19 means partners have no choice but to rely on the people on the ground. This has encouraged mental health experts to train more people in the community to support one another rather than rely on professionals.
* Ensure Mental Health is Built into Universal Health Coverage (UHC) o Access to quality essential health services is a human right and has been recognised as key to sustainable development as outlined in the Sustainable Development Goals that include the target to “Achieve Universal Health Coverage (UHC), including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all. However the world is a long way from achieving this as at least half of the world’s population still do not have full coverage of essential health services. The poorest and most vulnerable have paid the price for this during the COVID-19 crisis. There is no health without mental health, and any implementation of UHC needs to have a mental health component. Action from governments is needed to accelerate implementation of UHC, including a strong mental health component.
(The author is Principal Government Medical College, Jammu and Associate Professor, Government Ayurvedic Medical College, Jammu)
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