|FROM THE EDITORíS DESK
|Year : 2020 | Volume
| Issue : 5 | Page : 1-5
From “normal” to “new normal” and from “social isolation” to “social bubbles”: The impact of COVID-19
Gupta Mind Healing and Counselling Centre, Chandigarh, India
|Date of Submission||25-Sep-2020|
|Date of Acceptance||28-Sep-2020|
|Date of Web Publication||02-Oct-2020|
Dr. Nitin Gupta
Gupta Mind Healing and Counselling Centre, Chandigarh - 160 009
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Gupta N. From “normal” to “new normal” and from “social isolation” to “social bubbles”: The impact of COVID-19. Indian J Soc Psychiatry 2020;36, Suppl S1:1-5
|How to cite this URL:|
Gupta N. From “normal” to “new normal” and from “social isolation” to “social bubbles”: The impact of COVID-19. Indian J Soc Psychiatry [serial online] 2020 [cited 2020 Dec 1];36, Suppl S1:1-5. Available from: https://www.indjsp.org/text.asp?2020/36/5/1/297174
“Everyone knows that pestilences have a way of recurring in the world; yet somehow we find it hard to believe in ones that crash down on our heads from a blue sky. There have been as many plagues as wars in history; yet always plagues and wars take people equally by surprise.”
Albert Camus, The Plague, 1947,
| Prologue|| |
As I sit down to pen my thoughts regarding this Editorial, I can still vividly recall the news trickling in (in the form of “Chinese whispers,” pun intended) regarding the Wuhan scare, when I had attended the 72nd Annual National Conference of the Indian Psychiatric Society from January 22 to 25, 2020, at Kolkata, with advisories being put and screening procedures conducted at the Kolkata airport.
Cometh early February 2020 and I had to travel to and from “Down Under” (Sydney) where a more stringent thermal screening was being conducted while transiting via Singapore. I returned to Chandigarh on February 16, 2020, and got busy in the mundane routine of life, not anticipating what was to unfold.
March 11, 2020, was the fateful day when the World Health Organization (WHO) made the assessment that COVID-19 could be characterized as a pandemic due to the alarming levels of spread and severity.
| Prelude|| |
It was exactly March 23, 2020, when I received an e-mail from Prof. R. Srinivasamurthy, and I quote, “We are experiencing a once in life time pandemic in the world……. It can be safely said that there will be impact on mental health of everyone, at varying levels from distress to disorders…… I am writing to you to consider bringing out on a priority, a special issue of Indian Journal of Social Psychiatry related to the epidemic…. Please do consider this and make SOCIAL PSYCHIATRY relevant and responsive to the current world situation….” The seed was sown, so as to speak!
From March 25, 2020 onward, the country went into the throes of a series of four lockdowns (March 25–May 31, 2020) followed by a series of four unlockdowns (1 June 1–September 30, 2020; ongoing). It may be pertinent to add here that as per the latest analysis, this lockdown imposed in India ranks as the 12th strictest in the World as per the Government Stringency Index (which is based on the following nine metrics: school closures; workplace closures; cancellation of public events; restrictions on public gatherings; closures of public transport; stay-at-home requirements; public information campaigns; restrictions on internal movements; and international travel controls). What this has helped achieve is a moot point, and this is not the focus of my write-up. The lockdown helped in giving ample time for the mind to reflect and, in a manner of speaking, ponder and pontificate. In addition, it led onto the onset of another phenomena which, not unsurprisingly, caught a majority of the population on the back foot  – the phenomena of social isolation and quarantine. However, more about this later!
The above-mentioned e-mail from Prof. Murthy acted as a stimulus in initiating my discussion with the esteemed Office Bearers of the Indian Association for Social Psychiatry (IASP), who very swiftly concurred with the proposal for this special theme issue on “Psychosocial and Emotional Aspects Related to COVID-19” on April 12, 2020. A series of helpful suggestions were received from them, and we were on our way!
| This “special Issue”|| |
The Editorial Team set upon the onerous task of developing the contents of this Issue, with the vision of fast-track publication in maximum of 2 months. In hindsight, this target did seem absurd, but at least, it helped in building an impetus and giving us an objective while we were struggling with the “social isolation” due to the state (government)-imposed lockdown.
Over the next 3–4 weeks, as the pandemic evolved and spread across the world, on similar lines, the list of topics and the contributors also gradually evolved. From a meager 11 titles, this issue expanded to the current list of 43 titles.
This issue titled “Psychosocial and Emotional Aspects Related to COVID-19” is purported not to focus on, and capture, the clinical and/or medical aspects. The collection of articles is variegated, yet comprehensive in coverage and written by invited experts in the field of Social Psychiatry from India (including the Office Bearers of IASP).
Section A, termed as “Editorial Reflections,” comprises independent write-ups based on thoughts coupled with experiences of individual members of the Editorial Team (including this Editorial). It may be helpful to mention here that none from the Editorial Team has any Conflicts of Interest to declare, apart from being willingly and rivetingly involved in the whole process of bringing out this Special issue!
The tone to this Issue is set by a separate Section B containing a personalized viewpoint from the President, IASP. This is followed by Section C which contains a Special Invited Review by Murthy  on the theme of the Issue followed by a series of seven commentaries, critically covering and analyzing various facets presented by Murthy. Section D is on the similar pattern to the previous section, containing a Special Debate by Khandelwal, followed by a series of five conceptual commentaries on the same. Section E is the backbone of this “Special Issue” comprising 16 contributions in the form of Commentaries/Viewpoints/Perspectives/Reviews, aptly being labeled as “Melange.” Numerous key conceptual issues related to the pandemic are addressed followed by the assessment of its impact. A major chunk of this section is devoted toward “interventional” aspects across various fronts; an attempt has been made to keep these as pragmatic and experience based as possible. Interest in books on pandemics (or with a story in the setting of epidemic/pandemic) for voracious readers has arisen during the time of the COVID-19 pandemic. As a reflection of this, Section F has been kept in the end. Two excellent books are reviewed–one on the concept of “social loneliness,” and the other on the Spanish Flu pandemic of 1918.
It may be pertinent now to take up the topic of “social isolation” and discuss its related concepts.
| Interrelated Concepts of Loneliness, Social Isolation, and Social Distancing|| |
”Man is a Social Animal,” and having social networks is important. Living in a society is one of the basic ingredients that help us ensure our optimal functioning. Being social and able to mingle with other people to different degrees does not make us realize probably as to how important this aspect is. However, if we get devoid of this, it is then that the impact makes us realize the same. It will be helpful to briefly touch upon some interrelated concepts to develop a better understanding.
Loneliness is a subjective feeling that one is lacking the social connections that are needed. It makes the person feel that one is abandoned or cut off from the people with whom they belong to despite having them around; the feeling of closeness, trust, and genuine affection is missing. Social isolation, on the other hand, is an objective physical state of being alone and out of touch with other people. This can lead onto “loneliness” as one is more likely to feel lonely if one rarely interacts with others. Voluntary isolation, or peaceful aloneness, is known as Solitude in which a person can indulge in self-reflection and can connect with oneself without distraction or disturbance. However, in Quarantine, people are separated and restricted regarding their movement because they potentially have been exposed to a contagious disease. This is done to reduce their risk of infecting others and also whether they are becoming further unwell.
As can be seen from the above definitions, “quarantine” is different from other concepts as being willfully imposed by an external agency for public health interests. However, it can lead onto “social isolation,” which can induce feelings of “loneliness.” To help the reader understand these concepts better, an illustrative example can be my own individual situation (as mentioned earlier under Prologue and Prelude) wherein I was leading a “normal social life” during early part of 2020 (1 January-24 March 2020) following which I was put under “quarantine (lockdown)” from 25 March- 31 May 2020 leading onto “social isolation”. The “quarantine” gave me ample opportunity to indulge in “solitude” apart from spending time with my family. Thereafter, I have undergone through a series of four unlockdowns (June 1–September 30, 2020; ongoing) where I have continued to experience “social isolation” due to various reasons (restrictions in place in the unlockdowns, continuation of the COVID-19 pandemic, etc.) along with the implementation of the key safety measures of “social distancing.”
It is of importance to clarify to the reader another new term, viz., “social distancing.” Social distancing is a key nonpharmacological intervention that aims to reduce the spread of COVID-19 by maintaining physical distance and reducing social interactions. This helps in flattening the curve of the infection. Among the numerous social distancing measures, key ones include travel and movement restrictions and limiting physical interactions.
On the odd occasion, I have experienced “loneliness,” but it is the “new normal” that has been the biggest challenge for me, in my opinion. Nevertheless, a single individual experience may have relevance at a qualitative level, but it needs to be backed up by evidence-based data. Hence, let us examine some of the available data related to these aspects to further understand the impact of loneliness, social isolation, and quarantine.
Brooks et al. conducted a rapid systematic review in February 2020 on the psychological impact of quarantine using three electronic databases and included 24/3166 papers which focused on studies across ten countries and included people with SARS (11 studies), Ebola (5 studies), the 2009 and 2010 H1N1 influenza pandemic (3 studies), Middle East respiratory syndrome (2 studies), and equine influenza (1 study); one of these studies related to both H1N1 and SARS. This was done to urgently inform policy-makers regarding evidence so as to produce guidance for the public based on the best available evidence. The negative psychological effects include posttraumatic stress symptoms, confusion, and anger. Stressors include longer quarantine duration, infection fears, frustration, boredom, inadequate supplies, inadequate information, financial loss, and stigma, with possible long-lasting effects. Killgore et al. conducted a series of studies from the USA assessing the impact of social isolation due to lockdown restrictions in place during/from April till June 2020.,, High rates of social isolation and loneliness, especially for those who were sheltering-in-place, were seen,, along with nearly twice greater presence of moderate-to-severe suicidal thinking in such individuals. Another US-based online survey found association of symptoms of depression, generalized anxiety disorder, intrusive thoughts, insomnia, and acute stress with stay-at-home order status and personal distancing. From the UK, a qualitative focus group study during the early stages of the social distancing measures (5–12 days postlockdown) showed how isolation resulted in significant negative impact on mental health and well-being (demotivation, loss of meaning, and decreased self-worth).
About two-fifths of the general public respondents (N = 1685) were experiencing common mental disorders (anxiety and depression), and nearly three-fourth had moderate level of stress and poor well-being within 2 weeks of the lockdown. Another national study approximately 4 weeks into the lockdown showed 28.4% prevalence of posttraumatic stress disorder with majority experiencing sleep disturbances and ruminations. Specifically from Delhi, within 1-week postlockdown, predominant respondents reported sleep troubles, variations in eating patterns, inadequate basic supplies, with affected work and income, and feeling helpless and depressed.
To summarise, there is reasonable evidence to show that the concepts of quarantine (lockdowns), social isolation, social distancing, and loneliness (by themselves or in tandem) are leading to considerable psychosocial distress and disruption of functioning of the common human.
| Where We Stand and the Way Forward?|| |
As early as March 18, 2020, the WHO had issued technical guidance which had outlined messages, albeit in brief, for people in isolation. Nevertheless, this was a useful start as worldwide lockdowns/quarantines and stringent “social distancing” measures had not yet come into place, and the world was still learning about how to manage COVID-19.
Subsequently, a lot of information has been made available on managing various facets of this pandemic; however, surprisingly, the management of consequences of “social isolation” is reasonably limited.
Galea et al. have emphasized the use of digital technologies to bridge the social distance and provide social support; develop mechanisms for surveillance, reporting, and intervention, particularly related to domestic violence and child abuse; and adopt a stepped-care approach and bolster the mental health system. A similar call has been made by Grover et al. where they have suggested a need for expanding mental health services to everyone in the society, during this pandemic situation.
Apart from looking at the care systems and service delivery, the impact on individuals needs to be ameliorated. In the absence of a vaccine against COVID-19, governments and organizations faced considerable economic and social pressures to gradually and safely open up societies, allowing people to interact while keeping the curve “as flat as possible.” However, they did not have enough scientific evidence on how to do this. The concept of “social bubbles” was introduced which involves behavioral network-based strategies for selective contact reduction that every individual and organization can easily understand, control, and adopt. Simply speaking, a “social (or support) bubble” is defined as a group of people with whom you have close physical contact. People in each bubble can stay in each other's homes and do not have to socially distance. However, support bubbles must be “exclusive.” Once in one, you cannot switch and start another with a different household. The idea was first introduced in New Zealand  and is being used extensively in various sports, especially cricket (by the concept of bio-secure bubbles). However, this concept of “social bubbles” is not that simplistic as it has been developed by simulating stochastic infection curves incorporating core elements from infection models, ideal-type social network models, and statistical relational event models. Although these “social bubbles” will help and empower individuals and organizations to adopt safer contact patterns across multiple domains by enabling individuals to differentiate between high- and low-impact contacts, without the need for complete isolation, yet the biggest limitation is that they have not been put to rigorous testing. As per the available information, SAGE, an independent advisory group, is examining if when and how people might safely be allowed to expand their bubbles.
It was heartening to read that Parliamentary Standing Committee for Home Affairs, Government of India, has started examining the impact of multiple stages of lockdown on mental health of the individual and collective public. Interestingly, the term “new normal” was also mentioned in the news brief.
I had used this term earlier during the write-up, and this is an oft-used term in my conversations with numerous colleagues, peers, and seniors. What is the “new normal”? I would refer the reader to the article by Killgore et al. where this is beautifully elaborated and elucidated. Very aptly, it is pointed out that despite re-opening and the so-called normalization, the typical social interactions remain profoundly altered where people refrain from handshakes and hugs, and masks hide subtle facial expressions of emotion and muffle vocal intonations. Due to this, there is a presence of social awkwardness, despite the presence of (familiar) others. Moreover, this “new normal” is here to stay as is evident from the increasing trend of COVID-19 cases across nearly all of the various regions of the world, which require the need to continue with the practice of maintaining a physical distance of at least 1 m  and wearing of face masks.
Killgore et al. have already reported that loneliness is also elevated even among those who report that they are no longer under restrictions or sheltering-in-place due to this “new normal” as it is not normal. This is of concern as loneliness has been linked with a wide range of mental health problems, interpersonal issues, cognitive decline, substance use, physical morbidity, and significantly elevated mortality. In fact, Murthy has mentioned that loneliness is a great masquerade and can appear as anger, alienation, sadness, and a host of distressing emotional states.
| To Conclude….|| |
The word ' pandemic' means ' all people. The need to reach services to all people, has resulted in a number of innovations, in health care, like telemedicine. The current situation also offers a unique opportunity to empower individuals, families and communities towards their emotional health. There is enough knowledge in this area waiting to be applied, but had not received as much attention as clinical services. Again, the compulsions of the pandemic provides an unique opportunity to move emotional health from the clinics, to communities/ families / individuals. This shift could be as important as the move from institutional care to community care that occurred during the last century. This could be an another gain from the pandemic.
Hence, it is imperative that mental health professional work on recognizing these subtle, yet the key determinants of social aspects related to our mental health. In my personal opinion, we should additionally focus on these aspects in our clinical assessments and incorporate into our formulations, rather than restricting ourselves to the more easily discernible clinical syndromes and symptoms. Probably that is where COVID-19 has imperceptibly crept into both our individual lives and the societal fabric, and left a significant impact overall. It is up to Social Psychiatry (and the people who are associated with it) to recognize these facets and tackle this pandemic to minimize its current impact and the aftermath!
As Camus said, we have been taken by surprise, but if we can put our heads TOGETHER during this “new normal,” we should be successfully able to tackle the psychosocial ramifications of the COVID-19 pandemic!
I would like to place on record my heartfelt thanks to the following during the process of bringing out this Issue: Core Editorial Team for their full support and involvement. Dr Debasish Basu who continued to be ever available in his role as Advisor with his infinite pieces of wisdom. Dr R Srinivasamurthy for his constant enthusiasm and encouragement to ensure achievement of the goal. Mr Ramakant Bandbe, Production Manager-Wolters Kluwers, and his team who have worked extremely hard and tirelessly behind the scenes.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Camus A. La Peste (French), Paris: Gallimard, 1947. The Plague. Translated in English by Gilbert S, London: Hamish Hamilton, 1948.
Honigsbaum M. The Pandemic Century: A History of Global Contagion from the Spanish Flu to COVID-19. London: Ebury Publishing; 2020.
Murthy RS. COVID-19 pandemic and emotional health-social psychiatry perspective. Indian J Soc Psychiatry 2020;6 (Suppl):S24-S42.
Khandelwal SK. Debating the Process, Impact and Handling of Social and Health Determinants of the COVID-19 Pandemic. Indian J Soc Psychiatry 2020;36 (Suppl):S64-S83.
Aristotle (350 BC). Politics. New York: Dover Publications; 2000.
Murthy VH. Together: The Healing Power of Human Connection in a Sometimes Lonely World. New York: Harper Collins; 2020.
Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al
. The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet 2020;395:912-20.
Block P, Hoffman M, Raabe IJ, Dowd JB, Rahal C, Kashyap R, et al
. Social network-based distancing strategies to flatten the COVID-19 curve in a post-lockdown world. Nat Hum Behav 2020;4:588-96.
Killgore WD, Cloonan SA, Taylor EC, Miller MA, Dailey NS. Three months of loneliness during the COVID-19 lockdown. Psychiatry Res 2020;293:113392.
Killgore WD, Cloonan SA, Taylor EC, Dailey NS. Loneliness: A signature mental health concern in the era of COVID-19. Psychiatry Res 2020;290:113117.
Killgore WD, Cloonan SA, Taylor EC, Allbright MC, Dailey NS. Trends in suicidal ideation over the first three months of COVID-19 lockdowns. Psychiatry Res 2020;293:113390.
Marroquín B, Vine V, Morgan R. Mental health during the COVID-19 pandemic: Effects of stay-at-home policies, social distancing behavior, and social resources. Psychiatry Res 2020;293:113419.
Williams SN, Armitage CJ, Tampe T, Dienes K. Public perceptions and experiences of social distancing and social isolation during the COVID-19 pandemic: A UK-based focus group study. Available from: http://dx.doi.org/10.1136/bmjopen-2020-039334.
[Last accessed on 28 Sep 2020].
Grover S, Sahoo S, Mehra A, Avasthi A, Tripathi A, Subramanyan A, et al
. Psychological impact of COVID-19 lockdown: An online survey from India. Indian J Psychiatry 2020;62:354-62. [Full text]
Kochhar AS, Bhasin R, Kochhar GK, Dadlani H, Mehta VV, Kaur R, et al
. Lockdown of 1.3 billion people in India during COVID-19 pandemic: A survey of its impact on mental T health. Asian J Psychiatry 2020;4:102213.
Galea S, Merchant RM, Lurie N. The mental health consequences of COVID-19 and physical distancing: The need for prevention and early intervention. JAMA Intern Med 2020;180:817-8.
Ingram I, Kelly PJ, Deane FP, Baker AL, Goh MC, Raftery DK, et al
. Loneliness among people with substance use problems: A narrative systematic review. Drug Alcohol Rev 2020;39:447-83.