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 Table of Contents  
EDITORIAL
Year : 2020  |  Volume : 22  |  Issue : 2  |  Page : 105-109

COVID-19 pandemic and mental health: From risk to resilience


1 Department of Psychiatry, INHS Asvini, Mumbai, Maharashtra, India
2 Institute of Naval Medicine, Mumbai, Maharashtra, India

Date of Submission09-Dec-2020
Date of Decision12-Dec-2020
Date of Acceptance12-Dec-2020
Date of Web Publication18-Jan-2021

Correspondence Address:
Col Seby (Dr) Seby Kuruthukulangara
Department of Psychiatry, INHS Asvini, Mumbai - 400 005, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmms.jmms_188_20

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How to cite this article:
Kuruthukulangara S, Goyal SR. COVID-19 pandemic and mental health: From risk to resilience. J Mar Med Soc 2020;22:105-9

How to cite this URL:
Kuruthukulangara S, Goyal SR. COVID-19 pandemic and mental health: From risk to resilience. J Mar Med Soc [serial online] 2020 [cited 2021 Apr 23];22:105-9. Available from: https://www.marinemedicalsociety.in/text.asp?2020/22/2/105/307333




  Introduction Top


The coronavirus disease 2019 (COVID-19) pandemic is associated with adverse mental health risks on an unprecedented scale to infected persons, to health-care professionals who care for them, and to the general population at large due to stressors such as socio-occupational disruption brought on by virus containment measures.[1] Particularly at risk are those who already have been afflicted with mental illnesses and disabilities, frontline health-care workers (HCWs), certain vulnerable sections of the society such as children and adolescents, elderly persons and women, and military personnel on prolonged deployment/extended quarantine. In this editorial, we highlight important mental health issues and challenges being associated with the ongoing pandemic which require urgent attention. We also briefly mention a few emerging evidence-based strategies for individuals, HCWs, military personnel, and for mental health services, to mitigate these risks, and to eventually build mental health resilience in the community to deal with the current and future pandemics.


  Coronavirus Disease 2019 as a Psychosocial Disaster Top


COVID-19 is now considered to be the biggest disaster of our generation, unprecedented in scale and duration, when compared to the time-limited and area-limited previous disasters in India.[2] Any disaster brings in its wake large-scale psychosocial adverse consequences, and it is particularly true with the COVID-19 pandemic with the number of people developing adverse psychosocial health far outweighing those who are actually infected with the virus, thus prompting some experts to call COVID-19 as a “psychosocial disaster” requiring “social vaccine” in addition to viral vaccine.[3]


  Mental Health Challenges Faced by General Population during Pandemic Top


Apart from severe socio-occupational disruptions during the pandemic, persisting uncertainties regarding COVID-19 have led to sustained anxiety among the public. These uncertainties include questions such as, when will the pandemic end, when will life come back to normal, will there be a risk of reinfection, will vaccine be 100% effective etc.[4] Unhealthy hype (direct or indirect) fuelled by social media about the pandemic is postulated to be another factor for increasing anxiety in the community.[5] Added to the above is a segment of population who are “worried well” – who are otherwise healthy, but are worried that they have the infection, a concept originally described with HIV/AIDS.[6] Social stigma related to COVID-19 infection is another factor adding to psychological stress.[7]

Higher levels of psychological distress (34.3%–38%), anxiety (6.3%–50.9%), depressive symptoms (14.6%–48.3%), and posttraumatic stress (7%–53.8%) have been reported in the general population during the COVID-19 pandemic, associated with risk factors such as female gender, past history of mental health issues, unemployment, and frequent exposure to social media news on the pandemic.[8] A recent meta-analysis found that the prevalence of depression was 15.97%, anxiety 15.15%, insomnia 23.87%, posttraumatic stress disorder 21.94%, and psychological distress 13.29% among the general population during the COVID-19 pandemic.[9]


  Mental Health Challenges Faced by Quarantined Persons Top


A high prevalence of psychological distress during previous infection outbreaks was reported associated with quarantine and isolation protocols routinely employed as virus containment measures. Emerging evidence during the current COVID-19 pandemic also shows a similar trend, and strategies to preserve mental health during quarantine/isolation have been recommended.[10]


  Mental Health Challenges Faced by Infected Persons Top


It is now clear that the SARS-CoV-2 virus has neurotropic properties and COVID-19 commonly leads to neuropsychiatric symptoms. Multiple mechanisms have been proposed, such as direct effects of neuroinvasion by the virus (through hematogenous or through olfactory neuronal route), effects of cytokine storm on neurons, abnormal glial activation, epigenetic modulation of stress-related genes, or neuropsychiatric side effects of medication used to treat infection or its complications.[11] Delirium manifesting as confusion (65%), agitation (69%), or altered mental status (21%) was common in patients treated in intensive care units, and 33% were noted to have cognitive impairments such as dysexecutive syndrome at discharge. Almost 40% of people having acute COVID-19 infection are likely to experience distressing anxiety, depression, or posttraumatic stress symptoms.[12]

Currently, there is no evidence-based guideline available for psychopharmacotherapy in COVID-19-positive patients. Emerging and empirical evidence suggest that psychotropic medication with the least drug interactions with minimal cytochrome P450 interactions, such as antidepressants like escitalopram, antipsychotics such as olanzapine, and mood stabilizers such as valproate is to be preferred. Although efficacious for reducing anxiety symptoms, benzodiazepines are to be used judiciously for fear of worsening respiratory symptoms, and nonpsychopharmacological interventions are to be preferred wherever feasible for anxiety symptoms.[13]


  Mental Health Challenges Faced by Infected Persons Post Coronavirus Disease 2019 Top


There is emerging evidence that even after becoming negative for coronavirus following an acute illness, a subgroup of patients continue to experience distressing neuropsychiatric symptoms and sequelae for extended periods. Data from previous coronavirus outbreaks indicate that, in the postillness stage, depressed mood (10.5%), anxiety (12.3%), insomnia (12.1%), irritability (12.8%), impaired memory (18.9%), and fatigue (19.3%) were frequently reported.[12]


  Special Populations at Risk: Children and Adolescents, Elderly Persons, and Women Top


Although COVID-19-related physical complications are considered to be less in children and adolescents when compared to adults, the pandemic certainly has an adverse psychological impact on them, owing to multiple issues such as school closure, home confinement, disruption of daily routines, increased screen use, lack of avenues for physical activity, and markedly limited access to peers and teachers.[14] A recent meta-analysis found that the COVID-19 pandemic was associated with increased rates of depression and anxiety in adolescent cohorts, and also common were other mental health difficulties such as perceived psychological distress, obsessive–compulsive symptoms, somatic distress, and increasing behavioral difficulties.[15]

The elderly as such are at higher risk of complications of COVID-19 including debilitating neuropsychiatric complications. They are also particularly vulnerable to adverse consequences of measures such as mass quarantine, social isolation, reduced physical activity, and restrictions in accessing timely health care, all leading to a higher risk of poor mental health.[16]

Emerging evidences indicate that women who are pregnant, postpartum, or facing intimate partner violence are particularly at higher risk of developing mental health issues during the pandemic.[17],[18]


  Mental Health Challenges Faced by Health-Care Professionals Top


Frontline health-care professionals (HCWs) providing care to COVID-19 patients are particularly susceptible to psychological morbidity compared to the general population or other professionals. One meta-analysis found high levels of anxiety (median prevalence: 24%), depression (median prevalence: 21%), insomnia (median prevalence: 37%), and overall psychological distress (median prevalence: 37%) in HCWs during the COVID-19 pandemic.[19] Important factors associated with poor psychological well-being in HCWs have been postulated to include frontline status, inadequate training, perceived stressful work environment including perceived higher risk of contracting infection, fear of sharing infection to near and dear ones, poor peer and social support, past physical or mental health issues, quarantine, stigma, social isolation, and poor coping skills.[20] Another factor postulated to play an important role is the concept of sustaining “moral injury” while caring for patients – psychological distress resulting from own actions (or lack of them) which are perceived to violate one's own ethical/moral codes.[21]


  Challenges for Military Mental Health during Pandemic Top


COVID-19 has affected all strata of society, and military personnel are not immune from increased risk of poor mental health during the pandemic. Psychosocial factors contributing to distress among the general population also play a similar role in increasing the vulnerability of military personnel to the distress of the pandemic – which include extended deployments, travel restrictions, prolonged quarantines, increased social isolation, worry about near and dear ones at home facing unemployment/financial difficulties, or contracting infection.[22] Naval personnel operating in very confined spaces with heightened risk of viral transmission, could be at special risk. Currently, limited literature exists on the effects of pandemics on military mental health, however, military personnel involved in disaster missions have been previously noted to develop adverse psychological outcomes such as boredom, anger, guilt, depression, anxiety, and posttraumatic stress symptoms.[23]


  Challenges Faced by the Mentally Ill and Persons with Disabilities during Pandemic Top


Disasters disproportionately affect vulnerable sections of the society, and people with serious mental illnesses and other disabilities are likely to be at increased risk to develop COVID-19 infection and its complications, due to factors such as delayed detection, preexisting poor health, increased substance use, and poor social support.[24] The closure of outpatient departments and rehabilitation centers during the pandemic has added to their morbidity and distress.[25]


  Challenges for Mental Health Research and Training during Pandemic Top


Population mental health consequences of COVID-19 are still largely unknown; there is an urgent need for research addressing pressing questions such as which sections of population are more vulnerable and which strategies can effectively prevent or mitigate or treat mental health issues related to the pandemic. However, constraints imposed by the pandemic on overall research conditions have been hampering mental health research already reeling from shrinking resources and growing disinterest by pharmaceutical firms.[26] Online surveys, though convenient during the pandemic and very popular nowadays, have limitations as a research tool.[27]

India, who has been facing a massive shortage of mental health professionals (MHPs) already, now has to produce a large number of MHPs quickly to address the so-called “mental health pandemic” – mental health issues attributable to COVID-19 affecting much more people than those who are actually infected with the virus. A few leading institutes have taken novel initiatives in imparting mental health training during the pandemic, which, it is hoped, will be scaled up.[28]


  From Risk to Resilience: Strategies at Individual Level Top


A recent review postulated an integrated model to explain fear experiences during the pandemic which in turn lead to psychological vulnerability and distress in the population. As per this model, four interconnected domains, namely, fear of/for the body, fear of/for significant others, fear of knowing/not knowing, and fear of taking action/fear of inaction interact to produce fear experiences.[29] Based on this model, mitigating strategies are recommended at individual level, which include effective use of electronic/social media to communicate during the pandemic, healthy expression of emotions, limiting exposure to pandemic-related news, focusing on the positive, improving skills, structured daily activities, regular physical exercise, regular sleeping and eating habits with balanced diet, and regular relaxation exercises such as yoga and meditation.[30]


  From Risk to Resilience: Strategies for Health-Care Workers Top


Strategies have been recommended for HCWs to mitigate risks to their mental health – apart from the above recommendations for individuals, these include steps to recognize and deal with moral injuries, seeking mental health support early, and provision of aftercare for those HCWs in need for continued mental health care.[21] Learning the skill of effectively breaking bad news during the pandemic is another important step in preventing burnout in HCWs.[31]


  From Risk to Resilience: Strategies For Military Mental Health Top


Ensuring optimal mental health in operationally deployed military personnel is challenging even during nonpandemic times and is especially challenging during the pandemic. Similar to physical measures recommended for naval platforms to be battle-ready at all times during the pandemic,[32] mental health strategies have been recommended to mitigate risks and foster resilience in military personnel during the pandemic, such as by the US Department of Defense, which include measures such as ensuring basic self-care despite constraints at all times, and the role of clear, consistent, concise, and timely health risk communication.[33]


  From Risk to Resilience: Strategies for Mental Health Services Top


A recent systematic review identified the following interventions by mental health services to be effective during infectious epidemics – increasing mental health literacy of the public, psychological first aid, group-based cognitive behavioral therapy, community-based psychosocial arts program, and similar culturally adapted, cost-effective, accessible interventions integrated into existing local/national health-care services.[34]

COVID-19 has highlighted the need for accessible, widely spread, and efficient mental health services, especially for people with complex mental health needs. Currently, such services are woefully inadequate in a resource poor country like India. An emerging strategy supported by evidence over the past two decades to address this issue is “collaborative care model,” integrating mental health care into primary physical care. This model is based on a concept called “task shifting” – use of trained lay health workers to deliver health care in nonspecialist settings – and relies on trained behavioral health managers (usually social workers or nurses), working in tandem with primary care practitioners, providing mental health screening and basic interventions at primary care, supported by psychiatrists at secondary/tertiary care services.[35]

Another strategy with great potential in transforming mental health-care delivery in a resource-poor country such as ours is telemental health services. Telepsychiatry, supported by artificial intelligence, has the potential to make mental health care accessible to even the remotest or isolated communities in our country which has good mobile phone penetration. However, several technical challenges like digital divide currently remain for its widespread implementation, limiting its scaling up, but indigenous efficient solutions are expected in a decade or so.[36]

A recent position paper by a collaboration of international experts summarized strategies which can be adopted by most countries to effectively mitigate mental health risks during the current pandemic by adapting existing mental health services, mostly focusing on infection control, modifying access to mental health diagnosis and treatment, ensuring continuity of care for existing users, and close monitoring of new cases of mental illnesses and populations at greater risk.[37]

Guidelines for reorganizing mental health services with standard procedures during the current period of unlockdown in India have been proposed.[38]

Finally, there is an obvious need for greater investment in mental health services in the country for dealing with the tsunami of mental health issues in the wake of the COVID-19 pandemic, aptly highlighted by this year's world mental health day theme “mental health for all: greater investment, greater access – everyone, everywhere.”[39]


  Conclusion Top


The COVID-19 pandemic has been associated with increased risk of mental health issues, especially in vulnerable populations, with debilitating consequences to individuals, families, and to the nation as a whole. Research from previous pandemics and emerging research on the current COVID-19 pandemic, support the efficacy of psychosocial interventions in mitigating risks for vulnerable populations developing adverse mental health, and also in fostering resilience in coping with the distress, which should now inform policy decisions.[40]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Introduction
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