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 Table of Contents  
INVITED PERSPECTIVE
Year : 2020  |  Volume : 36  |  Issue : 5  |  Page : 143-150

Strategic mental health psychosocial responses in times of COVID-19 in India


Department of Psychiatry and Psychotherapy, Apollo Hospital, Delhi, India; Chairperson, Saarthak and Aadi, India

Date of Submission24-May-2020
Date of Acceptance19-Aug-2020
Date of Web Publication02-Oct-2020

Correspondence Address:
Dr. Achal Bhagat
A1/266 Safdurjung Enclave, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_250_20

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  Abstract 


The magnitude of the mental health problems and the treatment gap has been an unaddressed concern in the Indian public health system. With the arrival of the COVID-19 pandemic, India is at the brink of a mental health crisis. An overburdened health system will have to cater not just to the existing mental health needs, but also to the added psychosocial adversities arising due to the COVID-19 pandemic. The following article aims to describe the mental health needs of the nation at a time of an infectious epidemic. It further outlines the modalities and the process of service delivery using cross-sectoral, multi-tiered, transdisciplinary human resources, and technological interventions.

Keywords: COVID-19, human resource development, mental health, psychosocial impact, psychosocial support, technology


How to cite this article:
Bhagat A. Strategic mental health psychosocial responses in times of COVID-19 in India. Indian J Soc Psychiatry 2020;36, Suppl S1:143-50

How to cite this URL:
Bhagat A. Strategic mental health psychosocial responses in times of COVID-19 in India. Indian J Soc Psychiatry [serial online] 2020 [cited 2020 Oct 28];36, Suppl S1:143-50. Available from: https://www.indjsp.org/text.asp?2020/36/5/143/297147




  The Need and Background Top


Pre-COVID-19 mental health in India

There is a high prevalence of mental illness in India. In a recent study in lancet on Burden of Mental Health in India,[1] 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 with 2.5% (2.0–3.1) in 1990.

Although there is a variance in the prevalence in various studies, a recent survey conducted across 12 states by NIMHANS reports a lifetime prevalence of 13.7%. These include lifetime prevalence of substance use disorders at 22.4%, schizophrenia and related disorders at 1.4%, mood disorders at 5.6%, and anxiety and related disorders at 3.7%.[2]

This is coupled with up to 95% treatment gap reported in various studies.[3] The young are being affected more, and there is also a rising trend of substance use and suicide in the population.[4]

This article outlines the possible psychosocial impact of COVID-19 and the socioeconomic adversity in the wake of the pandemic. It also outlines the need for urgent and disruptive strategies for the capacity building of the mental health human resource in India so as to ensure that the psychosocial impact is mitigated.


  Mental Health and Psychosocial Impact of COVID-19 in India Top


Mental health problems are going to pose a secondary public health crisis in India soon.[5] Mental health difficulties are likely to grow exponentially as COVID-19 affects India over the next few months. The mental health needs in times of COVID-19 can be divided into four groups [Figure 1] as described below. This is likely to be not only due to the direct effect of the pandemic on people but more so due to the indirect mental health impact as a result of the socioeconomic consequences of the pandemic.
Figure 1: Mental health concentric in times of COVID-19

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Group I: Universal need for mental health

There are increasing levels of anxiety among many in the general population. There is fear and anxiety among the younger people. There will be need for information, skills for strengthening resilience, and existing coping strategies for mental health awareness, need to challenge stigma for the whole population.

Group II: People facing adversity in times of the COVID-19[6]

The psychosocial realities of loss, helplessness, hopelessness, adversity and risks faced by children in difficult circumstances, gender-based discrimination and violence, disability-based discrimination and neglect, unemployment, malnourishment, caste-based discrimination, and decreased access to health care and poverty are all likely to increase morbidity and mortality related to mental health problems. Not all those who face these risks and adversities will have mental health problems, but a significant number may. The nature of the psychosocial impact is further described later in the article.

Group III: People who develop mental health problems during the times of COVID-19

Psychiatric disorders such as anxiety disorders, depressive disorder, adjustment disorders, and mood disorders are likely to rise. There are also increasing number of relapses and attempts of self-harm among those who were already unwell.[7]

There is also likely to be further increase in the incidence of alcohol and substance abuse and other risk taking and impulsive behaviors.

Group IV: People living with mental illness developed prior to COVID-19

In any population, there would have been people living with preexisting mental health problems. Of these some would be common mental health problems, some would be major psychiatric disorders and many would be substance use problems. The preexisting illnesses are likely to worsen during this period.[8] There would be decreased access to treatment, decreased access to medicines, and increased levels of stress. There are preliminary reports of increasing care-giver stress among those caring for people living with chronic illness.[9]


  Conceptual Framework for Mental Health, Social Risks, and COVID-19 Top


Earlier experiences of complex emergency situations such as Tsunami at the beginning of the century, or the Bhopal Gas tragedy, or the economic downturn in 2008, though significantly smaller in proportion to COVID-19 may be extrapolated to inform us that the mental health/psychosocial impact is likely to be significantly more complex than absence or presence of mental illness [Figure 2].
Figure 2: Relationship between mental health psycho-social impact and COVID-19

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Every society has “pre-disaster” vulnerabilities such as gender-based discrimination and violence, caste and religion-based exclusion, childhood neglect, abuse and maltreatment, institutional incarceration, unemployment, and invisibilization of the disabled and poverty.

These “pre-disaster” realities have an impact on the mental health of people. These adversities and the impact thereof are likely to be further magnified by the pandemic. These mental health and psychosocial factors become magnified, and many a time go unaddressed in the relief and recovery efforts in the wake of the focus on the more proximate impact of the complex humanitarian crisis. This further escalates the mental health impact. The more distressing and disabling the mental health impact, less likely is the participation of people in containment and recovery.[10],[11],[12],[13]

As the current psychosocial impact evolves, the preliminary reports from the community are worrying. The ILO reports an increase in the unemployment rate worldwide.[14] According to these reports, the number of lost working hours in the first quarter of 2020 was 5.4% of the global working hours relative to the last quarter of 2019 (equivalent to a loss of 155 million full time jobs). This has now further increased in the second quarter to about a loss of 14% of global working hours (equivalent to loss of 400 million jobs). The unemployment figures in India were reported rise up to 24% in April and May 2020, and now are showing the signs of settling down to 7.43% in July 2020. The estimated employment in India was 374 million, which is lower by a 30 million of the average employment in 2019–2020.[15] A longitudinal analysis of suicide risk related to unemployment found it to be elevated by 20%–30% when associated with unemployment during 2000-2011.[16] The same model is being now used to predict a rise of suicide numbers as a result of unemployment due to the pandemic.[17] In addition, a previous WHO research reports that for every completed suicide there are likely to be more than 20 suicide attempts.[18] Thus, if this projection is applied to the post-COVID times in India, the suicide rate is likely to rise and will need immediate preventive interventions.

In May and June 2020, many of India's 450 million internal migrants walked back home. In its coverage on the reverse migration crisis, “India Today” describes that the Indian Railways have put into service about 500 trains called “Shramik Specials” to ferry nearly five lakh migrants back to their home states in May.[19] According to some press reports, the number of people ferried back on these special trains reached about 60 lakhs and number of train journeys upward of 4000 by July 2020.[20] The harrowing images of men, women, and children walking thousands of miles to reach their home are the potential predictors of the reality of the psychosocial impact of COVID-19.[21] Reports from Stranded Workers Action Network document the narratives of the migrant workers who were left without money and support.[22] In a household survey conducted researchers from Azim Premji University, of the 5000 households surveyed, 77% had been consuming less food than before and nearly 50% did not have money to last them more than a week.[23] However, another survey done by the Dvara Foundation reported food, health, and financial insecurity.[24] For a person who out of fear of death or because of the reality of hunger and poverty walked back “home,” and for the households who are likely to be facing insecurity for food and health the long-term mental health impact can only be extrapolated from other traumatic experiences faced by communities in the past. The impact may be somewhat mitigated by the policy initiatives like “Atmanirbhar Bharat.”[25] However, many may not be able to access the safety nets being provided due to the exclusion because of the mental health and psychosocial impact.

An all India helpline for children in distress (The Childline) has reported a record number of phone calls by children in distress in the month of April.[26] Further, the government reportedly prevented nearly 5000 child marriages.[27] The closure of schools could have contributed to the decreased safe spaces that children have. Another voluntary organization, working with children in difficult circumstances, “The Railway Children,” has called nearly 6500 families and have reported potential abuse, marked anxiety, lack of food and nutrition, and alleged reports of child marriage.[28]

Preliminary findings from a UNODC stocktaking report highlight the risk of human trafficking. It is postulated that an increased police presence on the streets may be driving human trafficking further underground or into the cyberspace. In the times of COVID-19, it is suggested that criminals “are adjusting their business models to the “new normal” created by the pandemic, especially through the abuse of modern communications technologies.”[29] The pandemic has underlined the established economic and societal inequalities which are at the root of human trafficking. Further in time, the UNODC is predicting the risks of forced migration too.

”The Outlook India” reports that one of the largest pornography sites showed an increased “content” and increased access to the “content” to the extent of 20-time jump in India, from 0.9% on February 24% to 18.1% as on March 16. It is assumed by the report that a large segment of this “content” includes trafficked children who are exploited to create pornographic material.[30] The government recently underlined this increased risk of human trafficking by bringing out an advisory to states to open more Anti-Human Trafficking Units.[31]

”India spend” cites National Commission for Women and NGOs like “Breakthrough” and “Jagori” to warn about increased incidence of gender-based violence in the home setting.[32] The number is likely to surpass the earlier National Family Health Survey 2015-2016 data of nearly 30% women reporting the experiences of violence in households. The Hindu reported that the number of complaints of domestic violence in the lockdown period were at a 10 year high. The writers further added that this was “a tip of the iceberg” phenomenon as nearly 86% women do not report domestic violence in India.[33]

This increase in mental health problems and psychosocial impact will have a bi-directional impact on the growth of the epidemic, as there will be decreased compliance of the containment and treatment processes for COVID-19.

In the longer term, the disability related to mental health problems is likely to grow. Suicide and self-harm are also likely to increase.[34] Anecdotal reports of increased suicides are already being reported.[35]

There is also likely to be a characterological impact of trauma. Disasters impact the way we think in the long term.[36] There is an increase in mistrust, negative self-appraisal, impulsiveness, and decreased sense of belonging to a community. All these factors will have a cumulative socioeconomic impact.


  Rethinking Mental Health and Psychosocial Interventions in Times of COVID-19 Top


There is an urgent need to develop community based and community led mental health and psychosocial services to address the current disaster situation in India.[37],[38],[39]

Given the current scenario, the service delivery model has to necessarily include online services with adequate use of technology.[40],[41] However, it is important to quickly move to a hybrid model, as there is a significant digital divide and this is likely to rise as the disaster progresses [Figure 3].
Figure 3: Online service delivery model

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The following principles need to be the basis of mental health and psychosocial interventions:

Mental health interventions and psychosocial support needs to be interlinked and diverse

The interventions need to include biological treatments for psychiatric disorders at one end and measures to address protection and safety issues for children at another end. Psychosocial interventions for community resurgence and resilience like those for livelihoods cannot be divorced from those instituted to address the issues of identity and self-worth.

Mental health and psychosocial interventions need to be integrated with all the relief and recovery efforts [Figure 4]
Figure 4: Integrated responses

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Vertical “Stand Alone Programme” on mental health/psychosocial interventions does not help and an integrated approach in the community is required. Stand Alone Program adds to the stigma and further isolation of those who need most help.

Mental health interventions have to be multi-tiered

These interventions need to have a three-tiered process:

The solutions have to focus on the healing of the community, and not just healing the individual. The response should be three-tiered [Figure 5].[42]
Figure 5: COVID-19 an aware mental health and psychosocial response

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At the primary level

Psychological recovery and sensitivity need to be intertwined with all relief and recovery processes to focus on the communities' resilience. The emphasis of mental health response should be on “enabling and enhancing skills for coping.” Parallel to psychological support and skills, people are likely to benefit from information about supportive resources and safety nets. People also need to feel safe from other risks that they may face and need help for the same. Uncertainty creates helplessness. Therefore, the interventions have to be both psychological and social, and these need to be integrated.

Primary response should include:

  • Empathetic relationships within a framework of dignity and participation
  • Equitable access to resources and information
  • Informed safety nets for protection
  • Expeditious yet safe return to education and work
  • Early recognition of mental health and psychosocial problems and referral for the same
  • Ongoing support for those living with pre-existing mental health problems.


In the present context, mental health interventions are not limited to early diagnosis or treatment of mental illness or even psychological support but sensitizing the care, tracing, containment, and recovery processes to ensure that people's dignity is protected is the key mental health intervention.

At the secondary level

It may be useful to start a network of helplines focussed on psychosocial support and building resilience, run by community mental health volunteers in each state. This will make the response more contextualized and appropriate. These helplines could then refer those people who have significant distress and dysfunction to the national helpline run by mental health professionals.

The activities for this tier should include the following:

  • Dissemination of information about mental health
  • Facilitation of online mental health services to support individuals who are showing early signs of problems
  • Guided self-help programs through webinars and “Online Learning Platforms
  • Tele-psychiatry and tele-therapy
  • Specific support for health-care providers
  • Specific mental health services linked to children and survivors of violence.
  • Mental health/psychosocial mobile teams to reach out to those who are more vulnerable and homebound
  • Supervision of the primary level teams.


At the tertiary level

Tertiary level should not necessarily be based in large institutions which are a legacy of the custodial hospital-based mental health systems in India. The tertiary level too needs to be located in the community. It should have three roles:

  1. Providing biological, psychological, and social interventions for those with ongoing mental health problems and those with high-support needs
  2. Knowledge management and creation of tools and processes for the implementation of services at the primary and the secondary. These resources should be dynamic be informed by the changing needs of the community and situation on the ground
  3. Influencing policy through evidence-based initiatives



  Rethinking Development of the Human Resource Top


Given the present treatment and human resource gap in the country and if the looming mental health crisis has to be acknowledged and addressed in right earnest, we have to rethink the current “traditional” methodology of developing human resource. Current strategies are in no way going to be ready in weeks and months. The current strategies will continue to focus on the development of institutional care focussed professionals who have virtually no exposure to the realities faced by the communities. The District Mental Health Program (DMHP) in India forms the mainstay of access to mental health care in India and access to mental health is also guaranteed as a right in Mental Health Care Act 2017. However, the Mental Health Care Systems are poorly resourced, and there is a risk that DMHP like before ends up functioning as an outreach unit of the institutional care being provided by the Medical Colleges or Centers of Excellence in tertiary care institutions.

The multi-tiered community mental health services should have a multi-tiered workforce [Figure 6].
Figure 6: Refocusing human resource

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Three proposed tiers would include:

  • Mental Health Associates
  • Mental Health Practitioners
  • Mental Health Specialists.


Mental Health Associates could be primary level workers for mental health interventions.

It is proposed that a new cader of frontline community mental health workers is required. This could be done by repurposing the present “Asha Worker,” “First Response Community Development Worker,” or the “Women's Self Help Groups.” The “Employment Guarantee Schemes” in both rural and urban areas could include community mental first aid as one of the activities which could meet the definition of the “work” provided by such schemes.

Associates would need to have the following competencies:

  • Form empathetic relationships
  • Support people in decision-making
  • Work with an individual or a group of individuals under supervision
  • Support implementation of specific tasks such as care planning, gathering information and providing information and linking to “Crisis Intervention” and secondary and tertiary mental health services.


These skills could be acquired over a period of time and the initial training could be scenario based using online role plays and games.

The “Mental Health Practitioners” would form the spine of the service delivery and would be graduates with specific training in Community Mental Health. Their competencies would include:

  • Supporting adaptive coping programs, supporting access to online behavioral and cognitive interventions
  • Supporting care and protection processes in residential and community settings
  • Supporting informed choices, independence, safety, dignity, privacy, and participation in everyday life
  • Activities of independent living
  • Recreational activities
  • Start conversations about mental health in the community to challenge stigma.


The mental health specialists would include the current workforce and would strategically allow post graduates in psychology and social work to upgrade their skills through an Advanced Diploma in Community Mental Health.

Development of human resource for the mental health should be in a mission mode with the help of a “National Alliance” for psychosocial response to COVID-19 using on line learning and role plays. The focus should be on:

  • Developing online capacity building programs for mental health “First Aid”
  • Developing online capacity building programs for psychosocial interventions in times of COVID-19
  • Developing online capacity building programs which, not only include modules on mental health and mental ill health but focus on psychosocial impact of vulnerabilities such as discrimination due to disability, gender, risks and adversity faced by children and young people, human trafficking, violence, socio-economic impact of disaster on minds of people. Such online capacity building should be available across development sectors for policy makers, program and project managers, and service providers
  • Developing a supervision process for mental health workforce
  • Developing a national group of “Supervisors”
  • Capacity building of existing clinicians to be “Supervisors”
  • Developing a “Code of Conduct” for helplines. The roles of the tertiary level specialists should also include the following
  • Facilitate the development of a Network of Helplines in India
  • Supporting the development of a “plug and play” platform for starting a helpline with both technology and mental health technical assistance
  • Identify partners and collaborate
  • Modify standard operating procedures (SOPs) with the support of partners
  • Develop mental health awareness content in multiple languages
  • Develop mental health self-help content in multiple languages. The capacity building and SOPs for primary and secondary level should include
  • Guidelines for helplines
  • Integrate mental health, psycho-social support with safety nets for protection
  • Evidence based influencing for capacity building of “Safety Nets”
  • Capacity Building of ASHA workers to identify mental health problems
  • Guidelines for COVID containment for those organizations providing institutional care
  • Guidelines for mental health for organizations providing institutional care for children, women, and those who are in conflict with law
  • Developing online capacity building programs to build human resource for mental health interventions with “Health Sector Skills Development Council”
  • Developing online capacity building programs with “Disability Sector Skills Development Council”
  • Influence State Mental Health Authorities to increase the reach and access of DMHPs.


For too long, we have been accepting the legacy of an institutional care mechanisms and limitations of the human resource planning related to it. The current pandemic is the moment of change and needs to be used to not only mitigate the present psycho-social impact but also to lay the foundation for a more comprehensive network of mental health services in India.


  Conclusion Top


As the world fights back the COVID-19 pandemic there is an emerging mental health impact which by itself is a complex humanitarian crisis. The pandemic is not only affecting the individuals directly as evident through increasing reports of anxiety, depression and suicide but also indirectly through magnifying the psycho-social adversities in the community. There is a rising trend of unemployment and there is food, financial and health insecurities. Violence, discrimination, unsafe migration, and human trafficking are putting millions of people at risk. These changes could be long term and could challenge the already poorly resourced mental health systems. There is an urgent need in India to use technology and develop multi-tiered, inter-sectoral human resources which can address the looming mental health “epidemic” in India.

Acknowledgments

The authors would like to thank Saarthak for the illustration in the article.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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