Indian Journal of Social Psychiatry

PERSPECTIVE/VIEWPOINT
Year
: 2021  |  Volume : 37  |  Issue : 1  |  Page : 30--36

Addressing psycho-social and behavioral responses toward the COVID-19 pandemic in an Indian model


Ananta Manna1, Amitava Dan2,  
1 Department of Psychiatry, Calcutta National Medical College, Kolkata, West Bengal, India
2 Department of Psychiatry, Burdwan Medical College, Bardhaman (East), West Bengal, India

Correspondence Address:
Dr. Amitava Dan
Tejganj, Mahanbag (East), P.O. Sripally, Bardhaman (East) - 713 103, West Bengal
India

Abstract

Infectious diseases have plagued humankind since its antiquity. On the way of modern civilization of the species, in the realm of agrarian, industrial, or technological revolution, humankind experienced several such devastating waves in the form of Plague, Cholera, Spanish Flu, H1N1 Influenza, and many more. Every time the whole ecosystem was not at all prepared to combat against these unprecedented happenings, resulting in extreme human suffering with substantial death tolls. Like physical distress, human mind also responded to these cataclysmic events in a vulnerable way. Affliction of a deep emotional impact was inevitable especially to the people of the countries with limited resources including India. To manage these crises in an integrated and optimal way, these diathetic social and behavioral responses of the people should be addressed essentially. This is to supplement the physical intervention as a part of a multidisciplinary approach, to have a favorable outcome.



How to cite this article:
Manna A, Dan A. Addressing psycho-social and behavioral responses toward the COVID-19 pandemic in an Indian model.Indian J Soc Psychiatry 2021;37:30-36


How to cite this URL:
Manna A, Dan A. Addressing psycho-social and behavioral responses toward the COVID-19 pandemic in an Indian model. Indian J Soc Psychiatry [serial online] 2021 [cited 2021 Oct 28 ];37:30-36
Available from: https://www.indjsp.org/text.asp?2021/37/1/30/312882


Full Text



 Introduction



The world is now in front of a great existential crisis in the name of the COVID-19 pandemic. The COVID-19 is the novel coronavirus responsible for viral pneumonia and severe acute respiratory syndrome (SARS-CoV-2).[1],[2],[3] It is a single-stranded RNA virus with a lipid layer envelope and spikes made of Glycoprotein-S.[4],[5] The study indicates that it might be transmitted to humans from bats and pangolins.[6],[7] The first case was reported in Wuhan, China, on December 31, 2019. On January 30, 2020, the WHO declared the outbreak as a public health emergency of international concern. Subsequently on March 11, 2020, it was declared as a global pandemic.[8] Globally, as on 10:00 am CEST, April 22, 2020, there have been 2,471,136 confirmed cases of COVID-19, including 169,006 deaths reported to WHO over 210 countries and territories.[9] The WHO has estimated a mortality rate of 3.4% as on March 3.[10] The fatalities were recorded higher among the elderly and persons with comorbidities. The cases are dying out of SARS due to inappropriate immune response and cytokine storm, resulting in acute respiratory distress syndrome and multiorgan failure.[2],[11]

India recorded its first case of COVID-19 on January 30, 2020, in the state of Kerala, followed by a steep rise in number.[12] Owing to the emerging threat, the Government of India has implemented “lockdown” and “social distancing” of the entire country as a part of the preventive measure from March 23, 2020.[13],[14] As on April 22, 2020, there have been 19,984 confirmed cases of COVID-19, with 610 deaths.[9] To combat this pandemic, the WHO, Centers for Disease Control and Prevention, Food and Drug Administration, and ICMR are playing leading roles by planning and formulating strategies for prevention, promotion, and therapeutic measures. Studies reveal that simple steps of handwashing with soap water and social distancing are the crucial valid measures to check the spread of the virus in the community.[15] Isolation, quarantine, case detection through strong suspicion, and lab diagnosis are also noted as standard procedure to stop the spread.[15],[16] Complete lockdown is found to be the most effective action to contain the virus that too implemented in several nations, including India, following a successful model by China.[17],[18]

The devastations of COVID-19 among the countries with advanced medical facilities despite adequate measures pose a big challenge for the less prepared countries, including India. The population dynamics, weaker economy, poor public health support, political and communal issues all are major deterrents in India's move toward a robust implementation of strategies. At this critical time, the media plays a double-edged role in information and broadcasting. Underexpression may be a threat, whereas overexpression may lead to information overload, anxiety, panic, or depression of the mass population.

 Psycho-Social Issues for the Vulnerable Population



The phenomenon of psycho-social issues reflects only the tip of the iceberg. The entire community is at risk arising out of the pandemic, news about pandemic, deaths, and the restrictive lockdown strategy. Lockdown forces people to isolate from others, stay at home, either stopping their earning or working from home, leave their leisure, bear with family disturbances, and closure of nonessential services. Majority of people are staying 24/7 with mobile, internet, social media, or online videos and busying with gossiping about one another, but corona must be the general topic.[19] Population in general faces health issues on account of unavailability of routine hospital services, closure of emergency hospital services,[20] lack of transportation, and closure of most private clinics. People are sometimes puzzled for loss of freedom and autonomy, instructions, or advisory from the authorities or different dos and don'ts. People are in a panic related to insecurity of job, family, and future.[21] Some might have ideas of suicide and other impulsive behaviors. This psychological unrest is often amplified by not getting access of the usual social buffers. People have lost their social life for the caution of coronavirus prevention by following social distancing,[15],[16] banning of social and religious gatherings, and lack of environment to express or ventilate their emotions. The migratory population, inter-state labors, or homeless people are grossly victimized by social distancing and state emergency.[22] The stigma of spreading infection makes their life miserable.[23] Deaths due to malnutrition and hunger in the country are on the rise and underreported.[24] Domestic violence starts prevailing where women and children are the principal victims.[25],[26] Cases of alcohol and nicotine abuse to get relief from tension and anxiety are increasing.[27] Overall, general people are fighting with an extreme level of stress at their individual or social levels.

The elderly are the primary victims of this pandemic.[28],[29] Psychological health of the elderly has become fragile not only for COVID-19 infection, but also for parallel stresses such as elderly isolation and neglect. Often they have lost their priorities in the family in the current time. In our social structure, where the economy of a family is broken, the older adults become victims of domestic violence. Further, presence physical comorbidities such as coronary artery disease, chronic kidney disease, COPD, and diabetes make them more vulnerable to extreme physical and mental distress. Children are the other side of vulnerability of this pandemic. Suddenly their world becomes so restricted. Other than frequent reinforcing comments from everywhere for maintaining general corona precautions, one cannot go outside home, even for play with friends, papa is at home all-time, schools are off, teachers are now online, ordering food is stopped, any request is going to be rejected by parents. At their level, it is hard to convince them about these abrupt and conflicting changes in the environment. These may lead to aberrant reaction, violence, self-isolation, fear, overall improper upbringing, and pose a threat to the child psyche.[30],[31] Children may develop bad manners like disobeying seniors and harmful daily routines such as late wake-up and late-night watching videos. Excessive use of mobile phones, playing games may lead to an increase in internet gaming disorder. Pregnancy and childbirth at this time is a mental agony. There may be failure of routine care of pregnancy, ailments in pregnancy may exacerbate due to lack of caretakers and separation from a beloved one. Pregnant women may worry about getting an infection, the impact of the coronavirus on their unborn babies. They may be confused whether repeated use of hand sanitizer is safe or not, should they get tested or not.[32] Childbirth may be traumatized, and the outcome may worsen for lack of transport system in rural India, where midwives may be the only hope.

Continuous care for the people with severe mental illness is challenging at this high time of pandemic. The episodes of depression, obsessive-compulsive disorder (OCD), schizophrenia, epilepsy may recur on account of unfavorable situation and unavailability of mental health services.[33] Cases of suicidality may increase in such an atmosphere. Caregivers are at definite stress in handling patients with mental illness, losing of caregiver's dedication may be a common issue. OCD patients with washing habits are at an increased risk of worsening of symptoms due to the practice of handwashing to prevent COVID-19 infection. Persons with disabilities may face unprecedented challenges.

Owing to media propaganda, confirmed and suspected cases are facing stigma and rejection from the society. Practices like biting, derogatory leaving from residence, cutoff of standard facilities in a community are seen as a reaction of the society. A situation of panic is created around the people who are on quarantine. Mental health issues are health-related anxiety, depression, nervousness, anger, substance withdrawal, end-of-life crisis, etc.[34],[35] Doctors and other health care professionals in the frontline are facing extreme stress and burnout.[36] They are facing troubles from multiple sources such as administrators, relatives of patients and media personnel. Pressure of duty, risk of contracting the disease to self and family, apprehension of staying away from the home or family, deprivation of family, lack of adequate equipment for personal protection, financial stress, administrative force all these are bringing uncertainty in their life. At the same time, they are facing public attack and rejection. Anxiety, depression, and a feeling of learned helplessness are the collective psyche of the health care professionals. Administrators, police, banking staff, media personnel, and others involved in emergency services are also feeling the burden of duty, risk of public hazards, risk of contracting the disease, and so on.

 Behavioral Manifestations



Despite repeated reinforcement of safety protocols, campaign for the lockdown, stay home-stay safe policy and even penal action, a substantial proportion of people are not following these norms. People are going out of home despite listening to the threats. In some cases, there are genuine reasons, but some are utterly erratic in behavior. Multiple reasons are interacting here. Ignorance is reflecting in action; people are going out for some very trivial reasons. Indeed, it is a matter of excuse only. Some energetic young people are going out thinking that they can save the world. Thus they are breaking the rules of social distancing. Denial or suppression of facts like travel history or any contact history has also been very common to get rid of isolation and quarantine protocol. People are thus unknowingly spreading the infection. There are instances of panic buying of grocery items. All these are due to a lack of understanding of social responsibilities.[37] Some of the related behavior can be explained by the “mob psychology”[38] in real social situations or in the context of social media, where the decision of a group of persons collectively influenced by multiple forwarded messages to their individual or group account.

 Biological Underpinnings



Direct research evidence on the biological effect of COVID-19 on the human mind is not yet apparent in literature. Based on existing the literature, we can predict, how COVID-19 can alter our biological system, especially immune and neuroendocrine system.[39] Other than the direct effects of the viral components on the human body, current environmental stress can overwhelm the immune system to increase the susceptibility of contacting the infection. Further stress activates the cascade of neuro-endocrine events, for example, a state of hypercortisolemia[40],[41] associated with an increased level of pro-inflammatory cytokines, interleukin (IL)-1, IL-6, tumor necrosis factor-alpha that in turn increases the risk of infection susceptibility and psychological vulnerability.[42] On the contrary, the evidence of secondary neuropsychiatric damage is lacking. Although a case report of COVID-19 associated acute necrotizing hemorrhagic encephalopathy is found.[43] We are also getting other significant findings emerged in literature, for example, the crucial role of IL-6 in cytokine release syndrome, and presence of methemoglobinemia in the pathogenesis of COVID-19 disease.[44] However, bio-psycho-social implications of the findings will be apparent in future researches.

Stress-diathesis model

Several predisposing factors contribute to the prevailing significant stress on a person or community and make them vulnerable to certain biological, psychological and behavioral phenomena, which are especially implicated for COVID-19 pandemic.[45],[46],[47],[48] An integrated Stress-Diathesis Model in reference to the COVID-19 pandemic is shown in [Figure 1].{Figure 1}

 Intervention Strategies Against Psychological and Behavioral Manifestations



Intervention is a part of the multidisciplinary approach. The goal is to achieve psychological well-being of the individual and to enhance the behavior in compliance with different preventive and therapeutic measures which are essential for the containment of the ongoing pandemic. We should take care of an individual's psychological well-being and thus empower his or her capacity to withstand trauma and stress (e.g., psychological immunity)[49],[50] which will supplement the process of managing this critical situation with a better outcome. With a constraint of resources in the country like India, to implement various strategies of psychological interventions, we should follow the disaster management protocol, that starts from primary health-care level with a preventive approach.[51] The modalities can be applied in an individual or group level. It can be done by conventional procedure with safety measures such as masks, gloves and personal protective equipment whenever applicable or in telepsychiatric version, which is a more compatible and approved method in the current situation.[52],[53] Intervention procedure has two components: assessment and intervention.

An assessment should be in an empathetic manner, and the examiner should try to bring the subject in a position of ease by reducing the apprehension. In the initial part, information about the individual's COVID-19-related status (e.g., travel/contact history, presumptive/symptomatic/confirmed case, physical comorbidities, status of other family members, current staying environment etc.) is essential to understand the psycho-social issues and to intervene them safely. We should find out any behavioral shortfalls which are going against the compliance to current restrictive policy for containment of the ongoing pandemic, for example, lockdown strategy, social distancing, isolation, quarantine, panic buying etc., The next focus should be on any specific area of apprehension of the individual, for example, apprehension of being COVID-19 positive or death of self or loved one, any bodily symptoms (mis) interpreted as COVID-19 symptoms, future occupational and financial drifts etc., other (non-COVID) areas of stress should be identified and intervened. Any specific symptom of depression, anxiety, posttraumatic stress disorder, death wishes/suicidal behavior or other psychological disturbances with disturbances of bio functions and current social functioning should be assessed. Substance history with current substance use and past psychiatric history are also contextually important. We should assess another related constructs, psychological resilience and psychological immunity, which is relevant in this assessment. Psychological immunity is a multidimensional construct containing cognitive, motivational and behavioral components, to combat psychological trauma and stress.[52.53] Although assessment is a continuous process, it should end at a point of triage for effective intervention in the situation of the pandemic.

Intervention should target at a different level with a graded manner. Normal subjects with worried behavior should focus on education about facts and reassurance. The facts about infectivity, fatality, mode of spread made to be clear with scientific evidence as per the educational status of the subjects. Side by side, it should address any myths or misconception related to COVID-19.[54] It should make them understand to avoid reading and posting of sensational and unauthenticated information from the media and social media. The learning should include how to the use social media at a scheduled time and why to follow the restrictive policies and precautionary measures (e.g., isolation, quarantine, social distancing and lockdown) against COVID-19.[34]

People should follow some general psychological measures in addition to education and reassurance on COVID-19. It also includes activity scheduling. The purpose of activity scheduling is to build up a holistic wellness schedule by the engaging mind in a positive way so that the receptivity of the mind focuses on the areas of good emotions. One can discover hobbies and incorporate them in the schedule. Other components are, spending quality time with the family, communication with near and dear ones, taking care of elderly members, involvement in social services by helping neighbors in need, relaxation exercises, and sound sleep. Thus it can distract the mind from stressful news and vulnerable thoughts. Activity schedule should be maintained regularly without any procrastination. Behavior and cognition related to COVID-19 and related areas should be optimized by creating self-awareness. Emphasis should be on the positive side of the news, forwarding those to others, engagement in activities that are within self-control. Any bodily symptom should not be (mis) attributed rather consult with doctors timely and follow the advice. One should balance between the social and medical rules, e.g., everyone should maintain the “physical distancing” but not “social or emotional” and a person should be judged not by the status of COVID-19 but by standard social norms. Spiritual practice in culturally accepted norms may also help to reflect on the inner self and tide over such difficult situation by achieving mental peace. The practice of “Yoga” and “Meditation” are also effective in maintaining health and wellness.[55],[56]

Subjects with serious psychological symptoms or alarming signs should be treated with active interventions as per individual assessment. It may require pharmacotherapy (antidepressant, BZD, etc.), behavioral management to improve any specific behavioral deficit, cognitive behavioral therapy, specific intervention for children and elderly, and optimization of ongoing treatment for preexisting psychiatric illness if any. A working model for COVID-19 related psycho-social intervention is depicted in [Figure 2].{Figure 2}

 Current and Future Research



The interaction between psychiatry and pandemic is a prospective area of research that can reveal the immediate, short-term and long-term effect of the pandemic on mental health. Whether or not COVID-19 has the potential to increase the risk of specific psychiatric disorders such as schizophrenia,[57] autism, depression and several other illnesses through genomic modifications are central questions to solve. Overall, it is a highly challenging question concerning safety and ethics. However, technology may bridge the gap to some extent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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