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 Table of Contents  
INVITED COMMENTARY
Year : 2020  |  Volume : 36  |  Issue : 5  |  Page : 49-52

Need to move – Discussion to action


Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Institute of National Importance, Bengaluru; President of Telemedicine Society of India, Karnataka, India

Date of Submission13-Aug-2020
Date of Acceptance13-Aug-2020
Date of Web Publication02-Oct-2020

Correspondence Address:
Prof. Suresh Bada Math
Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Institute of National Importance, Bengaluru - 560 029, Karnataka; Telemedicine Society of India, Bengaluru - 560 029, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_269_20

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How to cite this article:
Math SB. Need to move – Discussion to action. Indian J Soc Psychiatry 2020;36, Suppl S1:49-52

How to cite this URL:
Math SB. Need to move – Discussion to action. Indian J Soc Psychiatry [serial online] 2020 [cited 2020 Oct 31];36, Suppl S1:49-52. Available from: https://www.indjsp.org/text.asp?2020/36/5/49/297159



Murthy has depicted the social issues in detail in a biological disaster (pandemic).[1] This is a novel topic that will be of interest and will definitely attract many readers. His write-up attempts a major effort to discuss the social aspects of psychiatry with regard to COVID-19, where he has compared this biological disaster with physical disaster and extrapolated the findings of the physical disaster. Although important questions are raised regarding the biological disaster, it falls short on the review of emotional and mental health morbidity, public health strategies adopted, screening, effectiveness, outcome, and experiences of biological disasters such as severe acute respiratory syndrome, Middle East respiratory syndrome, Ebola, H1N1, Nipah, and so forth.[2],[3],[4],[5],[6],[7]

The author opens the statement of the problem by introducing the concept of “pandemic” and “social” issues to psychiatry. It is also noted that the “virus” and “social” are equally used in the context of the current pandemic, like two sides of a coin.[1] In my opinion, “social distancing” is a misnomer which is to be avoided and the term “physical distancing” should have been advocated, as this has a larger implication in the context of management of mental and emotional health issues in a pandemic. We need to advocate and encourage only “physical distancing” and to keep the “social connectedness” by means of employing information and technology to remain connected.[8] The best example could have been of providing information and education through the virtual media, i.e., “virtual vaccine” rather than “social vaccine;” this can be achieved easily through the implementation and leveraging of “information and technology” This was very well leveraged in India for “awareness” by bringing in a series of “pandemic of virtual information/misinformation” to achieve social mobilization and behavioral measures change in the population through virtual platforms both from mainstream and nonmainstream (social) media. Further, early lockdown in India helped in slowing down the spread of the virus significantly. Disaster health services are based on the principles of “preventive medicine.” This principle of “prevention” has necessitated a paradigm shift from relief centered postdisaster management to a holistic, multidimensional integrated community approach, and this biological disaster was no different.[9] This preventive lockdown played a crucial role, when no one knows about the treatment, cure, and containment of the “COVID-19” pandemic.

The COVID-19 pandemic has left in its wake an unprecedented challenge for mental health services across the world, without any discrimination across caste, creed, religion, race, and gender. With almost all affected, mental health service delivery to address the psychological consequences at the individual level has become a near impossibility.[10] The existing health services and available health resources are at its breaking point to control the spread and reduce the mortality of COVID-19. Policymakers, though aware of the mental health consequences, are prioritizing to control the mortality and not the morbidity; of course, the tough choice is to be done between “death” (mortality) and suffering (mortality). All efforts for capacity building of the health services revolve around the ruthless containment of the spread of infection. Frontline personnel including medical professionals, however, face the daunting task of dealing with the distress and trauma of individuals, families, and communities on a daily basis.[11] The COVID-19 pandemic is likely to put health-care professionals across the world in an unprecedented situation, having to make impossible decisions and work under extreme pressures. These decisions may include how to allocate scant resources to equally needy patients, how to balance their own physical and mental health-care needs with those of patients, how to align their desire and duty to patients with those to family and friends, and how to provide care for all severely unwell patients with constrained or inadequate resources.[12] This may cause some to experience moral injury or mental health problems. In addition, most have to deal with their own emotions and anxieties.[13] It is imperative to mention here that the vast majority of frontline personnel have limited mental health competencies.

Mental health issues noted in biological disaster zones, including COVID-19, can be classified into an acute phase during the outbreak (approximately 2–6 months) and a long-term phase after the control of the outbreak (>6 months).[9],[12] However, combining the various phases of pandemic (biological) and physical disaster, one can make an attempt to understand this pandemic [Figure 1].
Figure 1: The various phases of pandemic and disaster

Click here to view


The World Health Organization pandemic phases [14] are as follows: Phase 1 – no virus in animals, Phase 2 – viruses noted in animals, Phase 3 – viruses have spread from animal to human, Phase 4 – human-to-human transmission occurring in a community, Phase 5 – human-to-human transmission occurring in at least two countries, and Phase 6 – pandemic. Phases of disasters include the following, such as heroic (health-care workers trying to find the cause of infection in human), honeymoon (lockdown), disillusionment phase (pandemic, spread of virus across countries) with increased mental health morbidity, and finally, restoration phases.[9]


  Acute Phase (During the Outbreak) Top


Issues to be dealt with include immediate mental health impacts such as fear, denial, anxiety, insomnia, dissociative symptoms, depressive symptoms, suicidal ideas/attempts, substance withdrawal, and relapse of preexisting mental health problems. Besides, stress-related issues of the health-care providers and frontline personnel need to be addressed.

Aggressive strategies to be adopted during the acute phase in case finding

There are possibly three streams for case detection/identification of mental health issues that need to be focused in the acute phase of COVID-19

  1. Case identification by frontline medical and nonmedical personnel (including police officers, members of local self-government, and community/health workers)


    • Points of entry into the country/state – airport/railway station/state borders, etc.
    • Home quarantine visits
    • Other medical emergencies.


  2. Case identification by health-care professionals (nonpsychiatric)


    • Hospital quarantine/isolation
    • Routine outpatient assessment for other illnesses.


  3. Self-referral/walk-ins to mental health professionals
  4. Identification of frontline medical and nonmedical personnel in need of help/support for stress management or burnout
  5. Screening of the high-risk (vulnerable) population once community transmission is established.[12]


The strategy of tracing, tracking, and treating do have an important role in public health, but these tools do have serious consequences on the individual mental health issues of the survivors if not employed in a proper sensitive manner, without violating the rights of the individuals. Although containment is the need of the hour, at the same time, the least restrictive measures to be employed and access to virtual network platform (information and technology) is a must for social connectedness.


  Long-Term Phase (After the Control of the Outbreak) Top


Issues commonly presenting include grief, survivors' guilt, depression, substance use, relapses of preexisting mental illness, posttraumatic stress disorder, and somatization disorders. The major stressor during this period will be the direct and the indirect socioeconomic impact of COVID-19. The full effects of COVID-19 are yet to be seen, while the disease begins to spread across the most fragile settings, economic downtrodden ones, orphan survivors, conflict zones, slums, disabled population, rural population custodial settings, and refugee camps. As the global economy plunges deeper into an economic crisis and government bailout programs continue to prioritize industry, scarce resources and funding allocation decisions must aim to reduce inequities rather than exacerbate them.[15] This long-term consequence of pandemic will have serious consequences on the mental health of the population across the globe. Along with the diagnosable mental health issues, the affected community also harbors a large number of the worried well. Mental health professionals should be aware of this phenomenon and restrain themselves from labeling this population with mental disorders and treating them aggressively with medications. In addition, all health-care and frontline personnel should be aware that mental health issues post-COVID-19 (or any disaster) represent the emotional reactions of normal people in abnormal situations, and for a majority, these symptoms are self-limiting. This approach and sensitivity will reduce overdiagnosis, stigma, discrimination, and unnecessary medication of the survivors. The assessment of mental health issues in the vulnerable population (children, senior citizens, pregnant women, persons with disability, homeless individuals, those with poor social support, internally displaced workers population and of lower economic status, marginalized communities, life-threatening chronic medical conditions such as cancer, chronic renal failure, liver diseases, asthma/chronic obstructive pulmonary disease, immunocompromised patients, and people with preexisting severe mental illness and wandering mentally ill) should be the priority.[16] This population should be the focus of providing any social welfare measures and emotional issues need to be addressed on a priority basis.[17],[18] The plight of homeless persons with mental illness during the lockdown, aftermath, and postpandemic needs more focus as these are highly vulnerable population with poor comprehension on the seriousness of COVID-19, need for physical distancing, and handwashing.


  Human Resource Development Top


The COVID-19 outbreak threatens to weaken the already fragile mental health human resources across the country. Considering the mammoth nature of the pandemic and available meager resources, there is an immediate need to address a mental health gap in trained personnel who will be able to make simple mental health assessments. Mental health workshops need to be held online for elected representatives of local self-government, nurses, auxiliary staff, district mental health program (DMHP) team members, physicians, school and college teachers, ASHA workers, and lay-volunteers in early identification and referral.[8] Strengthening and involving existing community resources will not only help in capacity building but also ensure greater community participation. This pandemic is demanding the “out of box” solutions such as to de-professionalize the service delivery and focus on capacity building of the local community. By de-professionalizing, immediate task shifting can be considered and this gives us an opportunity to train the volunteer survivors, lay-public, local administration, community leaders, nongovernmental organizations, faith healers, religious leaders, community level workers, and significant others in providing care to the needy.[9] There is also a need to protect the health-care workers; this necessitated the Government of India to notify the “Telemedicine Practice Guidelines-2020” on March 25, 2020,[19] later AYUSH on April 7, 2020[20] and Homeopathy on April 10, 2020[21] also notified the Telemedicine Practice Guidelines for their system of practice. Further, innovations such as “Aarogya Setu” have been used by at least 120 million people till date for self-monitoring, to break the chain of transmission, to provide authentic information, as an advisory to people, with contact numbers, and for medical help.

To conclude, the medical, social, and psychological issues following the pandemic are likely to be common and at times devastating in certain sets of population. To provide care for a large number of population, there is an urgent need to think innovatively and leverage IT technology to provide care and reach out to people.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Murthy RS. COVID-19 pandemic and emotional health-social psychiatry perspective. Indian J Soc Psychiatry 2020;36 (Suppl):S24-S42.  Back to cited text no. 1
    
2.
Wong J, Zheng Y. The SARS Epidemic: Challenges to China's Crisis Management. Singapore: World Scientific Publishing Company; 2004.  Back to cited text no. 2
    
3.
Mehta K, Vasoo S, Tiong TN. New challenges for social work and social development: SARS and community well-being. Asia Pac Soc Work Develop 2004;14:1-5.  Back to cited text no. 3
    
4.
Peeri NC, Shrestha N, Rahman MS, Zaki R, Tan Z, Bibi S, et al. The SARS, MERS and novel coronavirus (COVID-19) epidemics, the newest and biggest global health threats: What lessons have we learned? Int J Epidemiol 2020;49:717-26.  Back to cited text no. 4
    
5.
Ding H, Li X, Haigler AC. Access, oppression, and social (in) justice in epidemic control: Race, profession, and communication in SARS Outbreaks in Canada and Singapore. Connexions: Int Profess Commun J 2015;4:21-55.  Back to cited text no. 5
    
6.
Aguanno R, ElIdrissi A, Elkholy AA, Embarek PB, Gardner E, Grant R, et al. MERS: Progress on the global response, remaining challenges and the way forward. Antiviral Res 2018;159:35-44.  Back to cited text no. 6
    
7.
Ajith Kumar AK, Anoop Kumar AS. Deadly Nipah Outbreak in Kerala: Lessons Learned for the Future. Indian J Crit Care Med 2018;22:475-6.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
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;180:817-818.  Back to cited text no. 8
    
9.
Math SB, Nirmala MC, Moirangthem S, Kumar NC. Disaster management: Mental health perspective. Indian J Psychol Med 2015;37:261-71.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Ji Y, Ma Z, Peppelenbosch MP, Pan Q. Potential association between COVID-19 mortality and health-care resource availability. Lancet Glob Health 2020;8:e480.  Back to cited text no. 10
    
11.
Lancet T. COVID-19 and China: Lessons and the way forward. Lancet 2020;396:213.  Back to cited text no. 11
    
12.
Mental Health in the Times of COVID-19. Pandemic Guidance for General Medical and Specialised Mental Health Care Settings. Eds Janardhan Reddy YC & Jaisoorya TS. Pub: NIMHANS, Bengaluru (2020). Available from: http://nimhans.ac.in/wp-content/uploads/2020/04/MentalHealthIssuesCOVID-19NIMHANS. Pdf. [Last acessed on 2020 Jun 09].  Back to cited text no. 12
    
13.
Greenberg N, Docherty M, Gnanapragasam S, Wessely S. Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ 2020;368:m1211.  Back to cited text no. 13
    
14.
Pandemic Influenza Preparedness and Response: A WHO Guidance Document. Geneva: World Health Organization; 2009.  Back to cited text no. 14
    
15.
Ahmed F, Ahmed N, Pissarides C, Stiglitz J. Why Inequality Could Spread COVID-19. Lancet Public Health 2020;5:e240.  Back to cited text no. 15
    
16.
Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet 2020;395:1054-62.  Back to cited text no. 16
    
17.
World Health Organization. Preparedness, Prevention and Control of Coronavirus Disease (COVID-19) for Refugees and Migrants in Non-Camp Settings: Interim guidance, 17 April 2020. World Health Organization; 2020.  Back to cited text no. 17
    
18.
World Health Organization. Mental Health and Psychosocial Considerations During the COVID-19 Outbreak; 18 March 2020. World Health Organization; 2020.  Back to cited text no. 18
    
19.
Telemedicine Practice guidelines-2020. Available from: https://mciindia.org/MCIRest/open/getDocument? Path=/Documents/Public/Portal/LatestNews/Telemedicine%20140520.pdf. [Last accessed on 2020 Jun 09].  Back to cited text no. 19
    
20.
Telemedicine Practice Guidelines for AYUSH. Available from: https://www.ayush.gov. in/docs/CCIM_Telemedicine_Guidelines. Pdf. [Last accessed on 2020 Jun 09].  Back to cited text no. 20
    
21.
Telemedicine Practice Guidelines for Homeopathy. Available from: https://www. ayush.gov.in/docs/126.pdf. [Last accessed on 2020 Jun 09].  Back to cited text no. 21
    


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