Handbook of Mental Health Issues During COVID19 Pandemic

 

Edition 1

  

Department of Psychiatry
Institute of Medical Sciences Banaras Hindu University, Varanasi

  

Copyright

All rights reserved. The concept,the contents, print & publication, in all its formats (hard copy & soft copy version) are copyright properties of Department of Psychiatry

Institute of Medical Sciences

Banaras Hindu University, Varanasi

DISCLAIMER

We have tried our best to ascertain the contents of this book. Kindly excuse if we have failed somewhere unknowingly. Mail us your suggestions & feedback. All the articles and the information published in this book are only those of authors. Readers are requested to refer to professional websites, books and journals to ascertain or access more information.

All rights are reserved.

Edited By- Dr Nitesh Kumar singh

Concept & Compilation- Prof Mona Srivastava Dr Abhinav pandey

PREFACE

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PREFACE
“Desperate times call for desperate measures” (Machiavelli).

The mid of January 2020, the world was confronted with an illness ‘Covid-19’, caused by the novel coronavirus Sars-CoV-2.The contagion started from the Wuhan city of Hubei province in China. It took the world some time to learn about the illness and its characteristics. The world is still in the process of learning. In order to contain the infection, humanity the world over has witnessed unprecedented lockdown, quarantine, physical distancing and various hygiene precautions. The massive containment drives have led to other problems like economic slowdown; massive unemployment; large scale migration of workers; unprecedented academic losses; restructuring of society; overwhelmed medical health systems; glaring unpreparedness of the medical infrastructure; stigma related to frontline workers; and a massive increase related to the mental health issues.

This pandemic needs preparedness and to equip the masses and professionals with a handy book on the most pertinent mental health issues, the department of Psychiatry, Institute of Medical Sciences, BHU has come up with a compact ‘Handbook of Mental Health Issues During Covid-19 Pandemic’. Apart from the academic responsibility the Psychiatry department of IMS, BHU is also on the fore front of providing ‘teleconsultation’ services to the patient population and conducting on line teaching to the residents of the department.

I thank the entire team of the Psychiatry department for the effort and the prompt action to come up with an introductory ‘Handbook’ on the most pertinent mental health issues faced by the general public and some specific groups. The handbook is meant for a ready and simple preliminary reading for common mental health issues during a pandemic and by no means should it be taken as a reference book. At the time of writing of the book our country has nearly one lakh cases and about three thousand deaths. The race to find a cure or develop a vaccine is in full swing.

Dated – 16/05/2020 Varanasi

Dr. Mona Srivastava,
Prof & Head, department of Psychiatry,

IMS,BHU

 

Members of Department of Psychiatry Institute of Medical Science
BHU

(Names In Alphabetical order)

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Third Year Residents
Dr. Amit Singh singhhii87@gmail.com Dr.Brijbhan bbb332821@gmail.com Dr.Malvika Pandey dr.malvikapandey12@gmail.com Dr.Pradeep Kumar Pradeepky136@gmail.com Dr.VinodVerma vinodmbbs10@gmail.com

Second Year Residents Dr.Chandan Kumar Shah cksahjnv13@gmail.com Dr.Dileep kumar Maurya dkm012imsbhu@gmail.com Dr. Jyoti Yadav jy47837@gmail.com

First Year Residents
Dr.Jitesh Kumar Gupta jiteshguptakgmu10@gmail.com Dr. Jyoti Prakash mauryajpgsvm8@gmail.com Dr.Krishna Kumar Singh singhkrishnakumar56@gmail.com Dr.Rajon Jaishy rajonjaishylfc@gmail.com Dr.Udbhav Tewari udtewari@gmail.com

Ph.D Research Scholar Mr.Shiv Prakash Shiv.prakash15@bhu.ac.in Mr.Saurav 561987saurav@gmail.com

Senior Residents

Dr. Abhinav Pandey drabhinavpandey0103@gmail.com Dr.Nitesh Kumar Singh docniteshsingh@gmail.com

Faculty
Dr.Achyut Kumar Pandey Professor achyutpandey575@yahoo.com Dr.Adya Shanker Srivastava Professor adya_shanker@yahoo.com Dr. Jai Singh Yadav Professor jsypsyjai@gmail.com
Dr. Mona Srivastava Professor drmonasrivastava@gmail.com Dr.Pankaj Kumar Gupta Assistant Professor pankajg0891@gmail.com Dr.Panakj Sureka
Associate Professor pankajsureka17@gmail.com Dr. Sanjay Gupta
Professor guptavaranasi@hotmail.com

     

CONTENT

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Chapter 1

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3 4

5 6 7 8 9

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Title

Common mental health problems during COVID 19

Severe mental illness (SMI) & management issues during Lockdown

Child and Adolescent Mental Health during pandemic lockdown

Issues related to Geriatric Mental Health During Pandemic

Substance use/abuse issues during Pandemic Lockdown

Family Dynamics during Lockdown

Domestic Violence and Child Abuse during COVID 19 Lockdown

Academic Issues and Its Impact on Mental Health during COVID 19 Lockdown

Health Care Workers and Mental Health During Hospital Postings

Mental Health Impact of Quarantine and Isolation

Telepsychiatry-boon or bane

Social Media and its Impact on Mental Health

General Principles on Dealing with Mental Health Problems during the Pandemic
Crisis Intervention of Family and Person with COVID Diagnosis

Suicide Risk & It’s Prevention During Quarantine & Lockdown

Authors

Dr Jyoti Prakash (JR-1), Dr Pankaj Gupta ( Asst. Professor)

Dr Jitesh Gupta (JR-1) Dr Pankaj Suekha ( ASSO. Professor)

Dr Jyoti Yadav (JR-2)
Dr Adya Shanker Srivastava (Professor)

Dr Mona Srivastava (Professor & HOD)

Dr Dileep Maurya (JR-2),
Dr Mona Srivastava (Professor & HOD)

Dr Rajon Jaisy (JR-1)
Dr Achyut Pandey (Professor)

Dr Udbhav Tewari (JR-1) Dr Achyut Pandey (Professor)

Dr Krishna Kumar Singh (JR-1) Dr Jai Singh Yadav (Professor)

Dr Amit Singh(JR-3), Dr Brijbhan (JR-3)

Dr Abhinav Pandey (SR)

Dr Pradeep Kumar (JR-3), Dr Malvika Pandey (JR-3)

Dr Nitesh Kumar Singh (SR)

Dr Abhinav Pandey (SR)
Dr Mona Srivastava (Professor & HOD)
Mr Shiv Kumar, Mr Saurabh(PhD Scholar)

Dr Vinod Verma (JR-3), Dr Chandan Kumar Shah

page 1-4

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11-13 14-17

18-22

23-26

27-32

33-36

37-39

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44-49

50-55

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59-63 64-68

  

Common Mental Health Problems During COVID -19 Pandemic

Dr.Jyoti Prakash , Dr. Pankaj Gupta

INTRODUCTION

A new strain of Coronavirus family originated at Wuhan city of China in December 2019.This novel corona virus is highly contagious and in just few months has become a serious threat to human health all over the world 1. The human to human transmission via droplets or direct contact predicted incubation period of 6.4 days and reproduction number of 2.24- 3.58 of COVID19 is probably responsible for its rapid spread 2.The WHO has recently announced COVID 19 as the sixth public health emergency of International concern 3 .It has taken the lives of 288,239 people all over the world till May 12 ,2020.Even developed countries are failing to control the increasing death rate due to COVID 19.The fatality rate of the virus is still under assessment .

People’s anxious reactions trigger public disruptive behaviors as people rush to stores, health centers, and pharmacies and health supply become scarce and the country health care service provision is affected .Evidence also suggests that individuals may experience symptoms of psychosis, anxiety, trauma, suicidal ideation, and panic during outbreaks of communicable diseases . Anxiety is a facilitator of decreased immune response to infection and further increases the severity of the disease4.

Lockdown Effects

The need for social distancing was immense and the various world leaders were quick to pass stringent lockdowns in most parts of the world . India similarly has been in a lockdown since March 25,2020 . Public transport along with closing of various state borders in India have halted the normal movement of patients to various OPDs in the cities. So a chain of continuous medical

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support through follow ups and use of pharmacy have been halted . This has lead to various patients coming to the emergency services due to relapse of their previously stable diseases. This has been mainly seen in the psychiatric emergency services . Various stressors have culminated to breakdown in normal functioning of the individuals . Loss of jobs ,increased financial strain ,rising prices of goods for consumption ,uncertainty regarding academic sessions and the most important that is fear of the disease have all put a person across the limits of his psychological well being . Data from ILO suggests a significant decline in jobs in the year of 2020 ,i.e. around 25 millions .

With heath and financial security playing on our minds, home schooling stress, concerned about the welfare of our family and friends and frustration at being stuck in the house ,it is fair to say most of our tolerance levels are low. With the lack of standard and specific treatment protocol for covid 19 the uncertainty looms large among the kin of the affected individuals. Contrary to other infections covid 19 presents a variable course of illness.

These above factors have increased unprecedented stress among masses.

Problems in people with Mental illness due to Covid 19

1.Anxiety disorders: COVID-19 pandemic and country-wide lockdown are likely to increase the new onset of illness anxiety disorder and to cause exacerbation of symptoms in diagnosed cases. Any simple flu like symptom increases anxiety due to COVID-19. As the symptoms of various flu like disorders overlap among themselves , a slight cough can create a sense of doom among people . The depiction and exaggeration of the current situation in the media has lead to a panic like situation which is doing more harm than good.

2.Obsessive Compulsive Disorders (OCD): Obsessive Compulsive Disorder patients, especially who have checking, hoarding and washing compulsion, are at higher risk. Abnormal becomes the new normal for people who have washing compulsions and fear of contamination.Advice on improving personal hygiene measures might increase the contamination obsessions and washing compulsions.In the face of ongoing lockdown, patients are more likely to resort to panic buying and excessive hoarding of essential items, even though continuous supply of essential items is assured by the states .

3.Depressive Disorders : For recurrent depressive disorder patients, lockdown is a major stress threatening normal daily routine, social rhythm and thereby increasing stress levels, which would further escalate the cortisol level, resulting in a vicious exacerbation of depressive symptoms . Inability to join work, dwindling finances and the long term impact on economy will have its effect on new and preexisting depressive illnesses 7. In a person with a previous psychiatric disorder, all these problems can surface with renewed severity and can lead to PTSD or even suicidal thoughts and attempts.

4.Substance abuse: For substance use disorder patients, this period could be lethal as non- availability of substance or medicines can precipitate severe withdrawal symptoms and medical

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emergencies like delirium or seizures, which can be life-threatening due to inadequate accessibility to dwindling emergency services .

5.Psychosis : Patients with bipolar disorder and schizophrenia are likely to have relapses due to risk in both the availability of regular medication and medication compliance.Anxiety can be so overwhelming, that it can precipitate paranoia and nihilistic delusions.

6.Suicide: Suicide is reportedly the second leading cause of non coronavirus deaths in India during lockdown, according to data compiled by journalist Rachel Chitra . A similar study by a group of researchers found that 168 of 326 non Covid-19 deaths till May 9th 2020 (51%) were by suicide. There have been a staggering number of suicides ,caused by fear of infection,loneliness,lack of freedom of movement ,and alcohol withdrawal during lockdown. Due to substance withdrawal effects seven people have died after consuming after shave and sanitizer lotions which was taken due to the erroneous belief of the presence of consumable alcohol .A large number of migrant laborers stuck in quarantine facilities, away from families, died by suicide fearing infection and sometimes even the stigma attached to the disease .

Coping during the lockdown : Each person has a unique style of coping and adjusting. The emotional impact of an emergency on a person can depend on the person‘s characteristics, resilience and adjustment. Social and economic circumstances of the person and their community compatibility, availability of local resources all determine the amount of adjustment an individual can have. Though it may be an understatement but “The Ant‘s Rule Book Of Life” the resilience and patience of the ant can teach us how to come out of this pandemic.

Fact checks: To realize that there are certain things which we cannot control: 1.Concern and worry are natural but will merely aggravate the situation.

2.The infection is likely to spread through the population in unpredictable ways. There is nothing one can do about this. If one follows precautions one is are less likely to get sick.

3.There is some benefit to planning. One needs to move on and focus on living life rather than worrying about the virus. One can try to control other people‘s reactions by listening and helping people work through the facts concerning the virus.

4.Being in touch with a health care provider if stress reactions interfere with ones daily activities for several days in a row.

Steps To Reduce The Stress And Improve Psychological Well Being

1.Avoid excessive exposure to media coverage of COVID-19.

2.Take breaks from watching, reading, or listening to news stories. It can be upsetting to hear about the crisis and see images repeatedly.

3.Try to do some other activities you enjoy to return to your normal life.

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4.When you do read news, avoid media outlets that build hype or dwell on things that can‘t be controlled.

5.Instead, turn to information sources that provide reliable information about how to protect yourself, such as the MoHFW.

6.Recognize the things you can control. Take care of your body. 7.Take deep breaths, stretch or meditate.

8.Try to eat healthy, well-balanced meals, exercise regularly, get plenty of sleep and avoid alcohol and drugs.

9.Share your concerns and how you are feeling with a friend or family member. 10.Maintain healthy relationships.
11.Maintain a sense of hope and positive thinking.
12.Maintain proper infection control techniques such as hand-washing and social distancing. 13.Check how realistically you are viewing the situation.

References

1. World Health Organization (WHO),2020a,Huang et al., 2020.

2. World Health Organization (WHO),2020b,Lai et al., 2020.

3. World Health Organization (WHO),Guan et al., 2020; Holshue et al., 2020.

4. World Health Organization (WHO), 2020b; Taylor et al., 2008; Tucci et al., 2017.

5. Dong, L., Bouey, J., 2020. Public mental health crisis during COVID-19 pandemic, China.
Emerg. Infect. Dis.(July).

6. The COVID-19 outbreak: crucial role the psychiatrists can play. AsianJ.

Psychiatry(March (20)), 102014.

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Severe Mental Illnesses (SMI) & Management Issues During Lockdown
Dr Jitesh Kumar Gupta , Dr Pankaj Sureka

Introduction

During the month of January, a serious contagious disease had swept across many Asian countries and threatened to become a major health emergency throughout the world.

In March 2020, WHO made the assessment that COVID-19 can be characterized as a pandemic. In this state of emergency, adults, adolescents and children are often exposed to potentially traumatic events. Such events trigger a wide range of emotional, cognitive, behavioral and somatic reactions. Although most reactions are self-limiting and do not become a mental disorder, people with severe reactions are likely to present to health facilities for help.

Treatment of psychiatric illnesses like schizophrenia, bipolar disorder is not merely marked by the decrease in clinical symptoms but rather it involves comprehensive management of the patient‘s wellbeing including relapse prevention through continuity of care .Already burdened mental health care system due to ever-growing mental disabilities ,the pandemic and the precedence given to it can have serious consequences . It is very important to ensure that the maintenance treatment is not discontinued for pre-existing severe mental illnesses .Prioritizing treatment and alleviation of urgent mental health and neurological complaints (e.g. delirium, psychosis, severe anxiety or depression) within emergency or general healthcare facilities.

Severe Mental Illness (SMI) patients during acute episode finds it difficult to maintain precautions needed to prevent spread of COVID-19. Special precaution need to be taken in low immunity cases like anemia, elderly, using steroid inhaler like asthma cases.

   

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Impact of pandemic on major psychiatric illness-

1. Acute stress-

In this emergency, adults, adolescents and children are often exposed to potentially traumatic events. Such events trigger a wide range of emotional, cognitive, behavioral and somatic reactions. People with severe reactions are likely to present to health facilities for help.

Focus should be made on:

  Listening carefully. DO NOT pressure the person to talk.

  Ask the person about his/her needs and concerns.

  Help the person to address basic needs, access services and connect with family and other social supports.

  Protect the person from (further) harm.

  Family members should stay in contact with SMI patients who stay alone.

  If SMI patient is feeling too anxious should contact some trusted person.

  Identify issues which lead to irritability and anger. Try to maintain patience.
2. Psychosis-
During humanitarian emergencies, extreme stress and fear, breakdown of social supports and disruption of health-care services and medication supply can occur. These changes can lead to acute psychosis or can exacerbate existing symptoms of psychosis. During emergencies, people with psychosis are extremely vulnerable to various human rights violations such as neglect, abandonment, homelessness, abuse and social stigma.
Typical presenting complaints of psychosis-
a) Abnormal behavior (e.g. strange appearance, self-neglect, incoherent speech, wandering aimlessly, mumbling or laughing to self).
b) Strange beliefs
c) Hearing voices or seeing things that are not there.
d) Extreme suspicion.
e) Lack of desire to be with or talk with others; lack of motivation to do daily chores and work.

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3. Depression-
Moderate-severe depressive disorder may develop in adults, adolescents and children who

have not been exposed to any particular stressor.
In any community there will be people suffering from moderate-severe depressive disorder.

However, the significant losses and stress experienced during humanitarian emergencies may result in grief, fear, guilt, shame and hopelessness, increasing the risk of developing moderate- severe depressive disorder.

SYMPTOMS-

●  Low energy, fatigue, sleep problems.

●  Multiple persistent physical symptoms with no clear cause (e.g. aches and pains).

●  Persistent sadness or depressed mood, anxiety.

●  Little interest in or pleasure from activities.
4. Epilepsy/Seizures-
The supply of antiepileptic medications is often disrupted during humanitarian emergencies. Without continuous access to these medications, people with epilepsy may begin experiencing seizures again, which can be life-threatening.
Management issues of Mental Disorders at the wake of the Pandemic-
This pandemic has squeezed the health resources of most of the developed countries and India is starting to feel the heat in the recent weeks. The existing health resources are prioritized to handle the pandemic. The worst hit among all are the Mental Health services ,who need long term ,continued medical management and depend on the government services .
Several mental health professionals are catering services in various isolation wards and many mental health facilities have been converted into temporary quarantine units. Disruption to absence of access to care can have serious negatives consequences in patients with severe mental health illnesses.
Though prioritizing the fight towards the pandemic is of utmost necessity but the long term treatment of chronic psychiatric patients should also be kept into mind while considering a broad approach to tackle the pandemic. Any change in behavior or thinking pattern of SMI patient should be immediately brought in knowledge of psychiatrist.
A strategy based on Triage to classify different patients into treatment groups can render the patient with adequate care.

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. a)  Patients requiring medications only.

. b)  Patients who need frequent visits to an OPD setting to continue treatment .

. c)  Patients who require hospitalization.

For the patients classified under the group

(a) A comprehensive strategy which involves district mental health program along with the associated NGOs can be applied and provisions to distribute door to door medication supply can be ensured .

(b) Telemedicine services can replace the previously available general OPD services. The telemedicine services should inculcate a well devised Audio-Visual establishment services.

Where possible use telemedicine service instead of physically going to hospital. For counseling also online services can be approached.

(c) and the most vulnerable group, patients can be provided due services after taking utmost universal aseptic precautions .The patients should be compulsory tested for Covid19 and thereafter necessary intervention should be taken depending on the result. Physical and chemical restraining should be duly considered for agitated patients to avoid unnecessary breach in social distancing protocols .Early discharge should be initiated to avoid crowding and decrease the pressure on already crippled health system. It should be emphasized to patient that there is no evidence that recovering from COVID 19 makes person immune from re-infection. All precautions against reacquiring infection should be taken. Patients should not consider experimental procedures like ̳plasma therapy‘ as definitive treatment against COVID 19. Only treatment as per Governmental guidelines should be relied on.

Role of ECT may be considered in highly distressed individuals(suicidal, violent ,resistant to conventional therapies)but the inevitable risks acquired during giving general anesthesia should be bore in mind .

Pharmacological treatment and related issues during a Pandemic:

1.Clinicians should consider long acting medications during this period because of the risks of withdrawal symptoms in drugs specially Benzodiazepines ,antidepressants and anti epileptics .

Similarly, previously routine purchase of medications have been hampered by lockdown due to decreased mobility in roads . So , in diseases like psychosis ,long acting injectables can provide

the patients with adequate steady state levels of drug and prevent relapse.

2. In a special case of Lithium , withholding or decreasing the dose should be considered because recent studies have found Covid 19 to have a deleterious effect on the renal system. So clinicians in telemedicine services should always inquire about possible side effects of lithium.

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Sociological issues relevant to current scenario:

. 1)  ExtensivemediacoverageofissuesrelatedtoCovid19generateslotofanxietyandpanic. One should limit time spent in accumulating and reading Covid 19 related news, watch others topics also. Available free time can be used in productive activities like taking up new hobbies, improving fitness, reading, yoga, aerobic exercise etc. Keep mind diverted and prevent negative thoughts coming in mind.

. 2)  Unemployment: Current job loss, business closure, financial losses or salary reduction can increase risk of developing SMI.

. 3)  Being stranded outside usual place of residence or work: Many people especially tourist and migrant workers got stranded in outdoor settings. Living in camps can be stress and lead to adjustment disorder.

. 4)  Marital and family conflict: Multiple cases of spouse or family members blaming one other for infecting them with corona.

. 5)  Student distress: Postponing of various exams or their results has caused stress in many students due to uncertainty about future.

. 6)  Disruption of sleep wake cycle: Absence of usual work habits sometimes manifest in disruption of sleep wake cycle. One should sleep adequately and try to maintain regular sleeping and waking time.

. 7)  Avoid over eating or high calorie fatty food intake.

CONCLUSIONS –

Psychiatric patients tend to be socially isolated with cognitive deficits .Still many are homeless and neglected by the society. So in these patients awareness of the ongoing pandemic is not easily dissipated .Moreover ,they will also have difficulty in following lockdown measures due to their psychiatric illness . They have risk of contracting the disease. Special attention should be given to them and their treatment should be highly individualized . Even drugs for Covid 19 should be prudently used in mentally ill patients. General precautions like not spitting in public places, use of mask, hand washing, avoiding touching of face is as relevant in SMI cases as in general population.

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References-

1. MhGAP Humanitarian intervention guide (mhGAP-HIG)-WHO-2015.

2. Ritchie EC, Ehret M, Peake NW, Richter KE (2019). When a disaster disrupts access to psychiatric medications: Advance planning can help minimize the risks of withdrawal, other consequences .Current Psychiatry, 18(5):22-7.

3. Brown AS, Meyer U (2018). Maternal Immune Activation and Neuropsychiatric Illness: A Translational Research Perspective. American Journal of Psychiatry, 175(11):1073–1083.

4. Bogaczewicz J, Sobo ́w T, Bogaczewicz A, et al (2014). Exacerbations of bipolar disorder triggered by chloroquine in systemic lupus erythematosus – a case report. Lupus; 23: 188–193

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Child And Adolescent Mental Health

During The Pandemic Lockdown

Dr. Jyoti Yadav, Prof. (Dr) Adya Shanker Srivastava

Introduction: The Pandemic lockdown has brought us all into a very crucial time. It is not only affecting adults and older people but has also left children and adolescents worrisome. It is affecting them physically and mentally which makes them vulnerable to various problems. Parents play a vital role in helping children and adolescents during this tough time. Be patient, empathic, non- judgmental, supportive and make them cope up with this time with ease.

Due to the nationwide lockdown, all the schools and institutions have been closed. There is a sudden change in the environment of the children who are staying with their parents or any caregiver as their outdoor activities and social interaction with friends have been restricted. Some have been separated from their caregivers due to being infected or suspected from the virus. Whereas, some of them are under the care of charity groups whose caregivers are infected or have died.

Children are most susceptible to various mental health problems. Due to this lockdown many children are suffering, and so significant changes occurring in a child‘s routine life and social infrastructure can be seen.(1)

Mental health problems can broadly be fear of infection, irritability , boredom, anxiety, stress, depression, unhealthy sleeping and eating habits, difficulty in attention and concentration.(2). An undue indulgence with the social media is also being noticed. According to Sprang and Silman, ―The mean post-traumatic stress scores were four times higher in children who had been quarantined than in those who were not.‖ (3)

WHAT CAN BE DONE TO HELP THE CHILDREN? (4, 5, 6)
1. Provide your child with clear information about the pandemic in order to reduce

anxiety and fear, but limit the use of social media and news. 2. Be supportive and empathic to the child.

   

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3. Engage them in activities like crafts from waste papers, dancing, singing, board games and others to make them calm and relieved.

4. Make a daily time-table and ask the child to follow it regularly. Schedule the study hours, if preferable, during their school timings.

5. Engage your child in some physical activities and exercises with the help of some online videos at home to improve sleeping and eating habits.

6. Ensure to provide online content of courses but not to overburden your child with the classes.

7. Keep children close to their parents or caregivers. If there is a need to be separated (suspected or positive case); make sure to have a regular communication through phones, video calls or any means of social media.

8. If the child comes to know about any upsetting news, reassure them and try to keep them away from such things.

9. Encourage your child to learn some new activity daily.

10. For a child already on psychotropic medications, do not abruptly stop the medications. Continue the medications and reach out your doctor through telemedicine or attend emergency incase of any sudden need.

11. Family time should be given. Manage some family interacting activities like playing indoor games and spending some hours chatting with one another.

12. Involve them in household chores like cooking, cleaning, gardening, watering plants, serving food, cleaning utensils and others.

13. Allow them to be in touch with friends or classmates through phone or online media.

14. Help them to find ways to a bright future.

15. Teach them social distancing, hand and self-hygiene practices.

ADOLESCENTS: they can also suffer from the above problems along with involvement in substance use or frustration arising from the lack of substance availability for the addict ones.

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WHAT CAN BE DONE TO HELP THE ADOLESCENTS? (5, 6)
The above mentioned measures can also be applied for adolescents along with the following:

1. Parents or caregivers play a very vital role in helping adolescents during these difficult times. Be patient, listen to them, and understand their problems related to studies, friends, loneliness, substance or disease, without judging them. Try to give them a valid solution and reassure them about the situation.

2. Involve them in non media activities as this is a time when adolescents run towards social media. Use of internet should be restricted.

3. For adolescents living away from their homes, be in touch virtually every day and whenever in need.

CONCLUSION:

During this crucial time, it is necessary for all of us to be calm and supportive for those suffering in this lockdown phase. Be it our family or our friends, we should spread awareness and try to make the situation lighter for them, instead of just stressing them out or leaving them alone.

REFERENCES:

. 1)  Liu JJ, Bao Y, Huang X, Shi J, Lu L. Mental health considerations for children quarantined because of COVID-19. The Lancet Child & Adolescent Health. 2020 May 1;4(5):347-9.

. 2)  Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, Rubin GJ. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. The Lancet. 2020 Feb 26.

. 3)  Sprang G, Silman M. Posttraumatic stress disorder in parents and youth after healthrelated disasters. Disaster Med Public Health Prep 2013; 7: 105–10.

. 4)  Dalton L, Rapa E, Stein A. Protecting the psychological health of children through effective communication about COVID-19. The Lancet Child & Adolescent Health. 2020 May 1;4(5):346-7.

. 5)  World Health Organization. Mental health and psychosocial considerations during the COVID-19 outbreak, 18 March 2020. World Health Organization; 2020.

. 6)  http://nimhans.ac.in/wp content/uploads/2020/04/MentalHealthIssuesCOVID- 19NIMHANS.pdf

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Issues Related To Geriatric Mental Health During COVID 19 Pandemic

Prof. (Dr) Mona Srivastava

Background:

The crisis of the COVID-19 pandemic has created anxiety and panic all over the world. The infection can occur to all age group but elderly are at a higher risk. In this population loneliness, isolation, is already prevailing. The mental health problem may increase in elderly due to social isolation and various medical issues, quarantine and loss of follow up for mental illness. Pandemic may cause increase of existing or relapse of fears/phobias, anxiety disorders, obsessive-compulsive disorder, may lead to posttraumatic stress disorder. Providing physical and social safety, hope, connectedness and calming may be effective in preventing mental illness. It is important that health professionals should be aware of these problems and be proactive in providing measures to reduce the adverse effects of pandemic in elderly.

Introduction:

The crisis of the COVID-19 pandemic has spread throughout the world. Most nations have done quarantine, lockdown and curfew to contain the community transmission. People are forced to stay at home and maintain social distancing. Older age group are the most vulnerable group, they have to take extra precautions for extended period. The severity and fatality of COVID-19 has been directly related to age and immune-compromised states, as 15 percent of the first wave of deaths in China were aged above 60 years. According to Chinese Centre for Disease Control and Prevention, the mortality rate in age group 60-69 years is 3.6 percent which can reach up to 18 percent at 80 years and above (1). World Health Organization in its guidelines has recommended strict social isolation in the geriatric population to control the deaths in heavily affected countries. Visiting community meetings, parks, neighbourhood, places of worship is prohibited as these are the various ways of socialization for most of the elderly. With lockdown or quarantine these are now not possible. The elderly also run the risk of getting neglected even when they are with their families. This leads to social and psychological isolation, which may be a contributor for poor mental health and many psychological problems.

 

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Social isolation and loneliness are problems in old age due to functional limitations, inactivity, repeated exposure to disturbing news related to the pandemic, the interactional problem within family members, and they might not able to share their worries . Prolonged lockdown and social distancing, loneliness may lead to hopelessness and discouragement, which may lead to depressive disorders and sometimes self-harming acts. Pandemic creates issues such as: fear of contracting the infection (for self and family members), fear of quarantine or hospitalization, death (of oneself or family members), anxiety related to day to day activity, regular health check up visits and worries about family members living far away. It may aggravate fears and precipitate anxiety disorders, phobic syndromes , painful memories , leading to distress. It may exacerbate behavioural styles and symptoms of conditions such as obsessive compulsive disorder (e.g. washing hands repeatedly, sanitizing the household articles). Sleep and appetite problems may become more pronounced in the absence of physical inactivity during the lockdown. Separation from loved ones, the loss of freedom, uncertainty over disease status, create more disturbance .

New onset symptoms

* Fear of contracting infection (self and/or family) * Fear of death (self and/or family)
* Fear of separation from family
* Insomnia

* Nightmares
* Generalized anxiety symptoms
* Depressive symptoms
* Compulsive hand washing,
* Compulsive sanitizing household articles
* Post-traumatic stress symptoms
* Increased substance use (smoking, alcohol) Worsening of existing conditions– *Depressive disorder
*Anxiety disorder
*Obsessive compulsive disorder *Post-traumatic stress disorder

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*Substance abuse/dependence.
Mitigating adverse effects on elderly during pandemic

There are various ways to support older adults during the social isolation period during the pandemic:

1. It is important to ensure that daily needs such as groceries and medications are delivered regularly, and urgent action is needed to address the mental and physical health consequences of pandemic.

2.Minimize watching, reading or listening to news about COVID-19 that leads to feelings of anxiety and distress. Information should be taken only from trusted sources and practical steps need to be taken. Most of messages on social media may be anxiety provoking and may lead to misinformation. the need of the hour is to be away from the rumours and misinformation

3.Presentation of positive and hopeful stories and positive images of local people who have experienced COVID-19. For example, stories of people who have recovered. Sharing of simple facts and day to day updates in simple language so that older people can understand. Instructions need to be communicated in a clear, concise, respectful and patient way. It may also be helpful for information to be displayed in writing or pictures.

4.Engaging family members and other support networks .Keeping social contacts to provide with assistance and how to get practical help if needed, like calling a taxi, having food delivered and requesting medical care reduces uncertainty. Adequate access to any medications that are currently being used and regular medicines that may be required.

Thematic analysis done by Gardiner et al identified six categories of interventions based on their purpose, their mechanisms of action and their intended outcomes(2). The categories were social facilitation interventions, psychological therapies, health and social care provision, befriending interventions, pet therapy, and leisure/skill development.

Tsai et al evaluated a video conference program which aimed to facilitate contact between an older person and their family (3 ). Creating a sense of companionship and keeping them occupied were found to be effective in dealing with loneliness in older people. Befriending interventions are defined as a form of social facilitation with the aim of formulating new friendships, generating a sense of belonging and having a feeling of ̳knowing that there is a friend out there(4)‘. Leisure activities and/or skill development included gardening programs, computer/internet use, voluntary work, holidays and sports(5). Higher use of the internet may give higher levels of social support and decreased loneliness.

5.Cognitive behavioural therapies could be delivered online to decrease loneliness and improve mental wellbeing. Use of digital platforms such as telepsychiatry by video conferencing can be used effectively to deliver services while maintaining social distancing. Non pharmacological methods like yoga, relaxation, and other therapies may give some relief.

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Conclusion: Elderly population are at higher risk to physical ,mental stress, which can aggravates the pre-existing physical and mental problems .Proper preventive steps should be taken during pandemic. Proper care ,communication, access to information and due respect should be given. Quick seeking of available health care facility should be taken before any problems arise.

References

1Meo, S. A., et al. “Novel coronavirus 2019-nCoV: prevalence, biological and clinical characteristics comparison with SARS-CoV and MERS-CoV.” European Review for Medical and Pharmacological Sciences 24.4 (2020):

2. Gardiner C, Geldenhuys G, Gott M. Interventions to reduce social isolation and loneliness among older people: an integrative review. Health & social care in the community. 2018 Mar;26(2):147-57.

3. Tsai HH, Tsai YF, Wang HH, Chang YC, Chu HH. Videoconference program enhances social support, loneliness, and depressive status of elderly nursing home residents. Aging and Mental Health. 2010 Nov 1;14(8):947- 54.

4. Tse T, Linsey H. Adult day groups: Addressing older people’s needs for activity and companionship. Australasian Journal on Ageing. 2005 Sep;24(3):134-40.

5. Cattan M, Kime N, Bagnall AM. The use of telephone befriending in low level support for socially isolated older people–an evaluation. Health & social care in the community. 2011 Mar

17

Substance Use And Mental Health Issues In COVID 19

Dr Dileep Kumar Maurya, Prof.( Dr) Mona Srivastava

Introduction

As humanity across the world are faced with coronavirus disease 2019 (COVID-19), the researchers across nations should be alert to the probability that it could affect some populations with substance use disorders (SUDs) in an adverse way. As the virus is known to attack the lungs, it can be an especially serious threat to those who smoke tobacco or marijuana . People with opioid use disorder (OUD) and its analogues may also be vulnerable due to the drugs‘ effect on respiratory and pulmonary health. added to the direct effect, individuals with a SUD are more likely to experience homelessness and abandonment more than the general population. All these possibilities should be a focus of active understanding of the disease interaction with the intake of substances.

Tobacco

According to a case series published in JAMA which derived data from Chinese CDC, the fatality rate of people with respiratory ailment 6.3 % in contrast to 2.3% in general population. Evidence suggests that exposure to aerosols from cigarettes harms the cells of the lung and diminishes the ability to respond to infection.

Opioids

People who use opioids at high doses medically or who have OUD face separate challenges since opioids act in the brainstem to slow breathing, their use not only puts the user at risk of life-threatening or fatal overdose, it may also cause a harmful decrease in oxygen in the blood and thus people taking opioids who have diminished lung capacity from COVID-19 could be in danger. The prospect of self-quarantine and other public health measures may also disrupt

   

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access to syringe services, medications, and other support needed by people with OUD. We must also ensure that patients with substance use disorders are not discriminated against.

Alcohol

AUD (alcohol use disorder) are among the most prevalent mental disorders globally, they are also among the most stigmatized. People with an alcohol use disorder are at greater risk of COVID-19 not only because of the impact of alcohol on their health but also because they are more likely to experience homelessness or incarceration than other members of the population. AUD places an individual at risk by its consumption as well as the erroneous consumption of spurious substances based on anecdotal reports and mistaken belief that they will somehow offer protection against the virus. Alcohol has effects, both short-term and long-term, on almost every single organ of the body. Overall, the evidence suggests that there is no ―safe limit‖. Alcohol use, especially heavy use, weakens the immune system and thus reduces the ability to cope with infectious diseases. Alcohol alters thoughts, judgement, decision-making and behaviour. Alcohol increases the risk, frequency and severity of perpetration of interpersonal violence such as intimate partner violence, sexual violence, youth violence, elder abuse, and violence against children. Heavy use of alcohol increases the risk of acute respiratory distress syndrome (ARDS), one of the most severe complications of COVID-19. In many individuals with heavy daily use of alcohol, a sudden reduction or cessation of alcohol use can lead to the precipitation of alcohol withdrawal syndrome (AWS). It is important to note a history of alcohol intake in people infected with Covid 19 ,if they experience restlessness, delirium and in extreme case seizures. Usually the withdrawal is mild but in certain cases there may be development of life-threatening complications such as seizures and delirium. Popularly one can think of alcohol helping them to cope with stress, but it is known to increase the symptoms of panic and anxiety disorders, depression and other mental disorders, and the risk of family and domestic violence. It is therefore essential, under the current conditions, that people who need help because of their alcohol use get all the support they need.

Social Risk factors Related To SUD

Other risks for people with substance use disorders include decreased access to health care, housing insecurity, and greater likelihood for incarceration. Limited access to health care places people with addiction at greater risk for many illnesses, but if hospitals and clinics are pushed to their capacity, it could be that people with addiction—who are already stigmatized and underserved by the healthcare system—will experience even greater barriers to treatment for COVID-19. Homelessness or incarceration can expose people to environments where they are in close contact with others who might also be at higher risk for infections.

Self help Guide for SUD

Instead of consuming alcohol to pass your time at home, try an indoor workout. Physical activity strengthens the immune system and overall and is a highly beneficial way of spending a period of quarantine. Disinfectant alcohol can easily become accessible for consumption purposes in

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home isolation. It is important, therefore, to keep such products out of the reach of children and underage drinkers and others who may misuse them. Alcohol use can increase during self- isolation and both, isolation and drinking, may also increase the risk of suicide, so reducing the alcohol consumption is very important. If there are suicidal thoughts one should seek appropriate help. If a person has problems in relation to alcohol use, there can be a change of perspective, the present situation is a unique opportunity to quit drinking or decrease it substantially because various social cues and peer pressure situations are avoidable. Online interventions for alcohol use disorders by professionals and mutual help groups can be less stigmatizing as they offer greater anonymity and privacy. Create a buddy and self-support system with someone you trust and reach out for extra help if needed, such as online counseling, interventions and support groups. Practice physical distancing but not social isolation. Make a call, text and/or write to friends, colleagues and relatives. Avoid alcohol cues and triggers on TV and media where there is pervasive marketing and promotion of alcohol. Try to maintain a daily routine as much as possible, focus on things that can be controlled e.g. daily workout, hobbies or mind relaxation techniques. If you become infected, discuss with health personnel your alcohol consumption so that they can make the most appropriate decisions with respect to your overall health condition.

Management: Can best be summarized and simplified under 5As

Step I: Ask

The idea is to ask the individual about the problem and a motivational interviewing or in mild cases motivation enhancement is a typical example of a brief intervention for alcohol use. Brief interventions can be provided in 5-15 minutes over 1-4 sessions and have proven effectiveness for reduction of alcohol use.

Step II: Advice- As a doctor, give clear advice to reduce drinking and other drug use. Ask your patient to make a balance sheet. Make them weigh pros and cons of drinking. Clarification of doubts the patient may have about stopping substances. Sobriety can make a person remain vigilant, act quickly and make decisions with a clear head, for self, family and community. It should be noted that people tend to smoke, or smoke more, if they use other substances and smoking is associated with more complicated and dangerous progression of COVID-19. Also it is necessary to emphasize that consumption of substances should be with caution if a person is on some medication e.g. pain killers, sleeping tablets, anti-depressants, etc, as these addictive substances interfere with the liver function and cause liver failure or other serious problems.

Step III : Assess- If there is a pattern of daily drinking particularly with early morning drinking, the treating professional needs to assess for signs and symptoms of alcohol withdrawal. Signs and Symptoms which emerge within 6 to 12 hours after last drink and reduce by 7 to 10 days are usually:

· Increased pulse rate and blood pressure, sweating · Tremors (depend on the severity of withdrawal)

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· Insomnia
· Nausea or vomiting · restlessness
· Anxiety

Step IV: Assist – Recognize and avoid trigger situations like hunger, anger, tiredness, loneliness, peer pressure, Learning to cope with everyday problems that encourage drinking or use of the substance. Finding alternate sources of enjoyment. Tackling stress, anxiety and mood symptoms. It is to be noted that the AUD subjects should not be belittled or criticized. It has to be acknowledge that substance dependence is a problem that is difficult to overcome and needs some effort and help.

Step V: Arrange for follow up and develop self-efficacy- Encourage patient to be optimistic and to bring about the changes in drinking/substance use behaviour

Specific Treatments: Uncomplicated alcohol withdrawal

Evaluate by history of alcohol use, pattern of intake,use and last use of alcohol; ask for symptoms of alcohol withdrawal and coexisting medical problems like head trauma, gastro- intestinal bleed and hepatic disease ,focal neurological deficits; investigate if needed by base line biochemical parameters (CBC,RBS,LFT,ECG ,and chest X-ray); treatment history. AWS is easily treatable and can be managed by physicians from different settings. Treatment of choice for the management of AWS is a benzodiazepine especially Lorazepam in adequate doses. Multivitamin supplementation in appropriate doses is mandatory for all cases of AWS to reduce

the risk of neurological complications. Referral to emergency needs to be considered when there is inadequate control and resolution of symptoms or there are uncontrolled medical co- morbidities.

SUD and home isolation or quarantine To limit the spread of COVID-19, countries have progressively introduced community-wide lockdowns and periods of quarantine . This means that an unprecedented number of people are now staying in their homes. It is important to understand that substances pose risks to the health and safety and should therefore be avoided during periods of home isolation or quarantine. Substances are not a necessary part of the diet and should not be a priority . Stockpiling of substances should be discouraged as it will potentially increase consumption. Time, money and other resources should be invested in buying healthy and nutritious food that will maintain good health and enhance the immune system response.

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References

1. How to stay physically active during COVID-19 self-quarantine. Copenhagen: WHO Regional Office for Europe; 2020 (http://www.euro.who.int/en/health-topics/health- emergencies/coronavirus-covid-19/novel-coronavirus-2019-ncov-technical-guidance/ stay- physically-active-during-self-quarantine).

2. Coronavirus disease (COVID-19) outbreak [online information portal]. Copenhagen: WHO Regional Office for Europe; 2020. (http://www.euro.who.int/en/health-topics/health- emergencies/coronavirus-covid-19).

3.Murthy P, Mahadevan J, and Chand PK. Substance Use Disorders: A Physician’s Guide. (In) Karnataka Medical Council Practitioner’s Guide Series – VI; 2017. ISBN: 978-8192847986

4.Murthy P, Bala Shanthi Nikketha S (2006-7). Psychosocial Interventions for Persons with Substance Abuse: Theory and Practice, NIMHANS, Bengaluru.

5.World Health Organization (2017). “Mhgap Intervention Guide For Mental, Neurological And Substance Use Disorders In Non-Specialized Health Settings”. World Health Organization.

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Family Dynamics During Lockdown

Dr Rajon Jaishy, Prof. ( Dr) Achyut Kumar Pandey

In the wake of the covid19 pandemic a need has arisen to decipher the underlying impact of lockdown and isolation on the functioning of a family.

Family simply defined as a basic unit in society traditionally consisting of two parents rearing their children. It performs a variety of functions in human society. The interactions among the family members, and its role in the development of modern human society has been immense. The new world order created by the pandemic has threatened to disrupt the well maintained social fabric and family unit as a whole.

Family dynamics are the pattern of relating, or interactions between family members. Each family system and its dynamics are unique, although there are some common patterns. Having a close-knit and supportive family provides emotional support, economic wellbeing, and increases overall health. This unprecedented event of lockdown has extended for a prolonged period of time. People who were never accustomed to spending much time in home now are forced to stay in self isolation or quarantine for their own safety and greater cause to flatten the pandemic curve.

Before understanding the impact of lockdown and isolation on family functioning, there is an urgent need to inculcate the basic functions which make a family important and a basic social unit.

Social psychologists like Maclver have included three functions of a family as follows: 1. Stable satisfaction of sexual needs.

Family has been performing this function since the inception of human civilization. It is the primary duty of a family to satisfy the sexual urge of its members in a stable and desirable way.

2. Procreation and rearing of children.
Family provides the basis for production of children. It institutionalizes the process of

procreation.
3. Provision of home.

   

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Other important functions of a healthy family include socialization, economic interdependency, education, cultural and health related functions.

This inevitably has led to people juggling home schooling their kids while working from home, spending more time in the company of one‘s partners than ever before, or feeling cooped up in a house full of impatient family members who are desperate for their own space.

Or perhaps they are living with extended family for the first time or have moved back to the home where they grew up in to care for older relatives or escape the city.The lockdown due to corona virus has bought a host of new pressures and challenges to our everyday family life. The Covid -19 crisis means many people are feeling overwhelmed. Excessive levels of familial conflicts and reports of domestic violence and child abuse has grown manifold.

Pandemics are a form of external stress for couples and families specially for those who are more severely affected (e.g. those who develop the disease, become unemployed, experience major financial losses).Although we know little about how pandemics might shape longer terms of outcomes such as rates of divorce, marriage, birth, research on the effects of disasters which are similar in some respects to epidemics, suggests that the nature of a disaster may determine how it effects marriage related demographics. After hurricane Hugo, for example, divorce, marriage and birth rates increased in the following year in the areas most affected by the hurricane.

But not everything is gloomy. The increased time and involvement of the family members in day to day activities has given a new found living experience for the children of this age .Mothers teaching their children to cook ,fathers taking their children for a hike was the sort of things people in urban India would rarely experience .Communication among family members has grown with the rise of multimedia technology like video calling apps .

Some of the steps that can be taken by family members to maintain happy family relationships during lockdown

A. Good communication skills among family members

Families that practice positive communication express appreciation and gratitude for one another. They are able to compromise ,and to have fun and laugh with one another .

B. Practicing the virtue of pardoning oneself and others

In this unprecedented times ,there is no right or wrong way to be. Don‘t expect perfectness from yourself or from others.

C. Try to find out precipitating factors leading to problems in family interaction

Common triggers include: 1.Invasion of private personal space

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2.Unfair division in family chores
Family members should agree to ease off one another . D. Try to maintain a productive routine

In this time of social distancing and isolation , one may slip into not getting properly dressed ,not having meals on time ,disturbances in sleeping pattern .These factors lead to stressful personal conditions eventually leading to difficulties in the family setting. So a defined morning routine ,taking meals on time, exercises ,meditation ,end point to a day‘s activity may be precisely devised .

E. Identifying unhealthy behaviors of family members

Common unhealthy behaviors include: 1.Lack of empathy
2.Drug or alcohol abuse
3. Using intimidation to get their way 4. Overdependence

Reach out to your kith and kin if any deviant behavior is noticeable and a sitting down and talking approach should be adopted . Finding out problem solving strategies to ameliorate unhealthy behaviors can lead to a fruitful time in the house.

F. Effective strategies to counter conflicts in the family

1. Always use the ̳I‘ word rather than using ̳You‘. For e.g. ̳I am feeling tired because of the yelling in the house‘ should replace sentences like ―Your yelling has made my headache unbearable‖ .The ̳you‘ word may instantly put the person why am I being blamed .

2. Avoid finger pointing at each other .
3. Taking responsibility that you may have negatively contributed to the conflict . G. Seek out help from Professionals

There is always a need for assistance when personal capabilities have been squeezed out. Asking help from mental health professionals and psychiatrist may help in dire situations and help fulfill a person‘s role in a family .

Finally we all should acknowledge that we are stuck. Lockdown is an opportunity to do something differently .Everyone is sequestered together at home and this tends to put a spotlight on what is, and isn‘t, working with in your relationship and family dynamics .

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References

1.Coronavirus lockdown: How to maintain happy family relationships in difficult circumstances ,an article by Louis Tyler adopted from official website of British association of counseling and psychotherapy.

2.7 ways to deal with toxic family members family members during self quarantine, an online article adopted from ̳Hotel California by the sea‘website .

3.APS Backgrounder Series :Psychological Science and COVID-19; Pandemic Effects on Marriage and Relationships

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Domestic Violence During COVID 19 Lockdown

Dr Udbhav Tewari, Prof. ( Dr) Achyut Kumar Pandey

The term domestic violence was first used in an address to the parliament of the United Kingdom by Jack Ashley in 1973. Domestic violence is an indoor crime which usually happens in an intimate relationship such as dating, marriage, cohabitation or a familial relationship and hence it is also termed as intimate partner violence. In India, 70% of women are victims of domestic violence.

The protection of women from domestic violence act 2005

It was enacted by parliament of India to protect women from domestic violence. It came into force from October 26, 2006. This definition is broad and inclusive and included within its ambit not only physical violence but also other forms of violence such as emotional, verbal, sexual and economic abuse.

Domestic violence is defined by section 3 of the act as ―any act, omission or commission or conduct of the respondent shall constitute domestic violence in-case it;

1. Harms or injuries or endangers the health, safety, limb or well being, whether mental of physical of the aggrieved person or tends to do so and includes causing physical abuse, sexual abuse, verbal and emotional abuse and economic abuse.‖

2. Harasses, harms, injures, and endangers the aggrieved person to coerce her or any other person related to her to meet any unlawful demand for any dowry or other property or valuable security.

3. Has the effect of threatening the aggrieved person or any person related to her by any conduct mentioned in clause (a) or clause (b).

4. Otherwise injuries or causes harm, whether physical or mental to the aggrieved person.

 

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Impact of lockdown on domestic violence

To put a check on the spread of corona virus a step of lockdown was enforced throughout the world.

This initiative taken by the governments of several countries has proved to be quite successful in slowing down the spread of this deadly and highly contagious virus. But like a coin it also has two sides to it i.e. with its merits, its demerits tag along. And among its many demerits are the increase in domestic violence and child abuse.

Marianne Hester, a Bristol university sociologist studies abusive relationships found that domestic violence rise every time the family spends more and more time with each other such as Christmas and summer-winter vacations.

Domestic violence a global crisis

Now that the movement restrictions have been imposed throughout the world hotlines across the world are flooding with reports of domestic violence.

In Spain, emergency number for domestic violence received 18% more calls in the first two weeks of lockdown. And since the launch of a WhatsApp service for women trapped at home there had been an tremendous increase of 270% in consultations since lockdown began. ——Reuters

The French police reported about 30% rise in domestic violence.
Calls to a national domestic abuse helpline rose by 49% and killings doubled weeks after

lockdown in United Kingdom. — BBC news

The catastrophe of domestic violence or ―intimate terrorism‖ was so grave that UN Secretary General Antonio Guterres wrote in twitter ―I urge all governments to put women‘s safety first as they respond to the pandemic.‖

The governments of several countries imposed the lockdown without making sufficient provisions for domestic abuse victims, 10 days later the distress call spike which sets off a public outcry.

Governments had to come up with new schemes as shelters refused to take the victims due to risk of infection. So the governments devised a new and improved strategy to acquire local hotel rooms where the victim could quarantine safely.

Lockdown & domestic violence: India

Lockdown in India has been no different; India‘s national commission for women on Friday said it registered 587 complaints of domestic violence from March 23 to April 16 which was a significant more than the 396 complaints received in the previous 25 days.

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One in six new complaints of domestic violence was made over a re-launched WhatsApp number. The commission then publicized the email address of its members and began receiving complaints on social media and through its online portal.

—– Aljazeera.

But in a country like India where population is large and illiteracy creeps through every nook and corner reporting of domestic violence is very less. It is only like the tip of the iceberg, where only a handful of cases get reported for every thousands of the cases occurring throughout India. The reasons for this low reporting are:

Illiteracy; which has lead to a state of unawareness, women are not aware of their civil right that our constitution provides them and the actions they can take against it.

Stigma; socio-cultural stigma and superstitions that run throughout the country are immense and prevent the reporting of domestic violence.

Lack of resources; it is one of the foremost reasons less reporting of domestic abuse cases, one- third of the women in India have no access to internet so they can‘t report their complaints.

Lack of moral and social support; another big reason for less reporting, a domestic violence victim needs support in these desperate times but due to the stigma of shame and guilt that prevails in our society even the family members of the victim are often found to be not supportive.

Psychiatry, domestic violence and child abuse

Judith Lewis Herman, a renowned trauma expert at Harvard University Medical School found that the coercive methods that domestic abusers use to control their partners and children bear an uncanny resemblance to those kidnappers use to control their hostages and repressive regimes use to break the will of political prisoner. ―The methods which enable one human being to control another are remarkably consistent. While perpetrators of organizes political or sexual exploitation may instruct each other in coercive methods, perpetrators of domestic abuse appear to reinvent them.‖

In addition to physical violence, which is not present in every abusive relationship, common tools of abuse include isolation from friends, family and employment, constant surveillance, strict details rules for behavior and restrictions on access to such basic necessities as food, clothing and sanitary facilities.

Why domestic violence increased during covid19 pandemic?

The main reason here was the state of lockdown which lead to crisis in many sectors of life leading to increased irritability.

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1. Financial crisis: the state of lockdown has put financial burden of most people in the country. As most of the citizen earn their share of daily bread by working daily and get paid for it on a daily basis.

e.g. in New Delhi a woman rushed to her mother‘s place just before the lockdown was imposed to save herself from physical and verbal of her spouse. She felt she could remain safe and at peace for some days, but her hopes were short lived. With the lockdown preventing her from returning to her husband‘s house and slide in income with no job, tension was rising in the lower-middle class family. As income was squeezed, her brother was apparently feeling that she was an additional burden. One day, the brother severely beat her up. Somehow the woman managed to call a helpline to seek help – —– Deccan Herald.

2. Difficulty in accessing the substance had lead to the rise in irritability among the perpetrators.

3. Confinement into small space has also lead to invasion of personal space which has lead to continuous locking into the argument.

4. Reduced job opportunities have further lead to increased irritability among perpetrators. 5. Difficulty in seeking help against violence.
6. Lack of provisions and services for violence during the pandemic such as shelters. Domestic violence: SOLUTION

The problem of domestic abuse has its roots deep within our country. To uproot this tree of abuse measures have to be taken at both organization level and individual level.

At organization level:

1. Increase awareness; inform women about their rights.

2. Increase support; for women who have lack of support.

3. Increase employment and create opportunities for victims.

4. Create awareness against stigma and shame.

5. Increase resources and make them accessible.

At individual level:

1. Identify people with sense of control and try to avoid them.

2. Understanding manipulative behavior; abuser‘s apology in between episodes of abuse can make it difficult for the victim to get out of an abusive relationship.

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3. Build self esteem; as it is often found that low self esteem is the reason for victim to be stranded in an abusive relationship.

4. Don‘t be isolated from the society and family as lack of support also lingers on the abusive relationship.

5. Identify your rights.

6. Do not cave into the pressure of the society, have your own opinion of right or wrong.

Whilst at home during lockdown simple steps to be taken to avoid it:

1. Do not involve yourself in an argument.

2. Division of household chores among all family members.

3. Follow a routine; include physical exercise, hobbies, play indoor games with children, etc are often seen to reduce the chances of conflicts.

4. Give yourself enough time, because invasion of personal space gives rise to conflicts. 5. Involve yourself in family activities and play indoor games as a family.
6. Manage your finances wisely so as to avoid financial burden.
7. Lowering of expectations has shown to decrease familial conflicts.

8. Avoid topics that lead to conflicts.

9. Don‘t extend the conversation on small issues as it might lead to an unnecessary argument.

10. Inform the authorities or contact the helpline if act of violence happens.

How can it be done?

In case of violence contact nearby police helpline 1091 or On National Commission Women domestic violence helpline – 07217735372

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References

1. Domestic violence amid lockdown: The shadow pandemic, published in website of IndiaLegal(stories that count) by Dr. Vidyottma jha on May 7, 2020.

2. Corona virus crisis: No lockdown for domestic violence, published in website of Deccan Herald.By Shemin joy, DHNS, NEW DELHI on April 26, 2020.

3.http://www.nytimes.com/2020/04/06/world/coronavirus-domestic-violence.html.

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Impact of Mental Health On Academic

Performance Of Students, During COVID19

Lockdown

Dr Krishna Kumar Singh , Prof. (Dr) Jai Singh Yadav

―The roots of education are bitter but the fruits are sweet.‖ (Aristotle)

Education has been defined as a process of including ―progressive or desirable change in a person as a results of teaching and study‖( English and English 1958) and ― systematic instruction, schooling or training given to the young (and by extension to the adults ) in preparation for the work of life‖ (Oxford univ. dictionary 1955).

Academic performance issue

Academic performance is the extent to which a student, teacher or institution has attained their short or long term educational goals. Academic achievement commonly measured through examination and assessments.
Factors affecting academic performance

Personal factor: These factors are sensation and perception, fatigue and boredom, age and maturation, emotional condition, needs, interests, motivation, attention, intelligence, aptitude, attitude etc.

Psychosocial factors

Arises from cultural environment, community, family, organization, society, media, technology, religion, ideology, language, and communication which influence the individual to think and act in a certain way.

Environmental Factors

Family is primary and most significant environment in which a student is exposed. Family plays a important role in students academic performance. Family cultural resources and environment determines child‘s academic performances. Participation of parents in education and learning behaviors and achievements affect the academic performance. Socio-demography of a family can

   

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affect the academic performances. Change in family circumstance, conflicts, stress load, substance abuse by any family member, lack trust can affect the academic performance.

Teaching and school environment:

Play an important role in shaping the behavior of students. The way they manage and teach produces effects on academic performances in natural surroundings.

  

Personal factor sensation perception,fatigue and boredom, age and maturation, emotional condition, needs, interests, motivation , attention, intelligence, aptitude, and attitude

psychosocial factor

community, organization, society, government, state , media, technology, religion, ideology, language, and communication

Academic Performance

Environmental

factors Home and school, environment,

financial position of their families, provision of tuitions and assistance at home

Figure 1. Shows: The effects of various indicators like psychosocial, environmental and personal on academic performance of students.

Impact of lockdown on academics

Since the time, most of board examinations were postponed. Therefore biggest challenge to the students is the dilemma about future in terms of their, promotion to next class/ courses and academic future.

Since 25th march 2020, 150 countries have closed schools and educational institutions nationwide, resulted over 80% of the world‘s student population affected by closure of their

 

schools, colleges, universities and other educational institutions in many countries.

Although many schools, colleges and institutions started e learning, but major questions arises for those students who do not have laptops and internet facilities at home. Apart of that some courses, such as labs, fine arts, clerkship, dance, art, and music, cannot be taught online. India being a primarily rural country faces issues of internet facility and accessibility. Further the worldwide rapid increase of infected cases has created a sense of uncertainty about future and has lead to an anxiety about the end result about the outcome. It has also caused significant increases in stress, anxiety, emotional breakdown and internet addiction among the school/ college and university students. These can lead to unfavorable effects on the learning and psychological health of students1. Students are also noticed to be spending undue time on the

social media and electronic gadgets.

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The COVID-19 pandemic has forced us to address three emergencies at the same time: health, social and economic emergencies2. Definitely these emergencies will further exacerbate the academic problem in students, therefore we have to improve in strategies of study according to the following flow chart.

Academic performance

Lockdown

Adjusted in Social,family,teaching and schools enviroment for optimum support

Average variation of stress, anxiety, depression, metabolic disorder,weight gain, poor socialization,Financial and schooling

physical and psychological adjustment

Resilience, e learnig, family guidance are not enough to overcome the problems,to be successful, we need a joint approach

After effects;singificant increase findings of stress, anxiety, depression, metabolic disorder,weight gain, poor socialization,Financial and schooling problems in many studies

Emotional adjustment , counseling, , assurance

Goal

uncertainty leads to

Decomposition of physical and mental health dilemma about future in terms of their, up gradation to next class/ courses and academic future

 

Figure 2. Shows the changes of various indicators related to academic performance and

Emotional, physical adjustment during COVID-19 lockdown.

Prevention and resilience: Persons who are practicing social distancing and sanitization will not

get COVID-19; though among those who do get infected, the majority will not need hospital

level care; and the majority of those who are hospitalized will survive. Physical exercise, taking

balanced diet and good sleep are important factors for self-care because poor quality of sleep is

predictor of emotional distress. In research, it has been found simply helping individuals to sleep

properly is proving to be as effective as treatment for depression as antidepressant3.

Regarding care of students and their academic performance special attention is needed in the

form of life skills education, e-learning, families, social supports, strengthen emotional health by

(exercise, sleep, relaxation, healthy eating), motivation sharing of feelings, writing, music, tele-

counseling by specialist health workers.

35

References

1. An online cross-sectional study to assess the prevalence of stress and internet addiction among students living at their home during the period of lockdown due COVID-19. Study done in department of psychiatry, between 1st to 2nd week may2020 (unpublished data).

2.

3. Cunningham JEA, Shapiro CM. Cognitive Behavioral Therapy for Insomnia (CBT-I)to treat depression: A systematic review. J Psychosom Res. 2018;106:1-12.

36

F. Etienne. The Director of the Pan American Health Organization, Carissa. Washington

D.C., May 12, 2020.

Health Care Workers And Mental Health During Hospital Postings

Dr. Amit Singh, Dr. Brij Bhan

During crisis , disasters and outbreaks, all individuals including health care workers may be affected emotionally and physically, as is happening during the COVID-19 crisis. Everyone reacts or responds differently to stressful situations. How a person responds to the crisis, or disaster is influenced by individual’s background and psychological adjustments, the differences compared to others, and the community they live in. It is common for individuals to feel stressed, worried and anxious. Fear and anxiety about COVID-19 can be overwhelming and cause strong emotions in an individual.

Facing this critical situation, health care workers on the front line who are directly involved in the diagnosis, treatment, and care of patients with COVID-19 are at risk of developing psychological distress and other mental health symptoms. The ever-increasing number of confirmed and suspected cases, overwhelming workload, depletion of personal protection equipment, widespread media coverage, lack of specific drugs, and feelings of being inadequately supported may all contribute to the mental health burden of these health care workers. Healthcare workers are known for their stamina and emotional resilience in the workplace, however, COVID-19 comes with a new set of standards. The pressure of caring for patients is amplified in the setting of a virus with human-human transmission and no specific lifesaving treatment.

Handling life and death situations while simultaneously putting one’s own life at risk contributes to an actual sense of danger. Other workplace stressors during COVID-19 include:

Extended shifts with increased volume and severity of patients.

Triaging patients while knowing that there are a limited number of ventilators and ICU beds cause emotional and psychological strain.

   

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The emotional trauma endured by physicians is intensive as they witness high volumes of death, including infection and deterioration of coworkers contributing significantly to burnout among healthcare workers. A rapid review of existing evidence found that health care workers who are self-isolating or under quarantine report symptoms of posttraumatic stress disorder, depression, stigmatization and fear of financial loss.(Brooks et.al. 2020) [1].

A cross-sectional survey Conducted by J Lai et.al. 2020 in Wuhan China and enrolled 1257 respondents and revealed a high prevalence of mental health symptoms among health care workers treating patients with COVID-19 in China. Overall, 50.4%, 44.6%, 34.0%, and 71.5%of all participants reported symptoms of depression, anxiety, insomnia, and distress, respectively[ 4].

Among the risk factors for development of psychological stress are :

· Long working hours
· Worry about risk to self and family
· Concerns about inadequate personal protection materials · Separation from family/loved ones [2] .
Steps for prevention:

Self-care, includes those activities to promote our emotional, physical, relational, and spiritual/religious wellness .These include like having a structured routine; ensure breaks and a proper sleep hygiene; keeping in touch with relatives/friends; practicing some activities and hobbies which are relaxing and not related to work; exercise regularly and having a healthy diet; practicing relaxation exercises like yoga; spirituality if one is religiously inclined; self time and self help for one self and family [3] .

Role of Team Leaders:

To reduce the stress of the health care workers, team leaders are encouraged to focus on the long- term outcome, ensure as much as they can offer in training for their staff to fulfill roles, have a judicious mix of workers, ensure that juniors with limited experience work with their senior

colleagues, ensure staff rotation from jobs of higher stress to lower stress and vice-versa, duty/shift breaks/holidays to be agreed within the team and ensured as far as possible, and refer staff members who appear to have uncontrollable distress for assessment and intervention to the nearest specialist [3] .

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Conclusion

Almost all frontline personnel in pandemics like COVID-19 are likely to experience stress to a certain degree. Personnel should practice ‘self-care’. Team leaders should employ steps to minimize mental health difficulties. Administrators should be aware that the mental health support of personnel is an important part of the COVID-19 response. Most importantly, personnel requiring help should be identified and offered appropriate intervention to prevent negative consequences. The community members and media persons should have an attitude of empathy and encouragement for such personnel.

References

1.Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet 2020; 395:912-20.

2.Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Network Open, 3(3).

3.Greenberg, N., Docherty, M, Gnanapragasam S, Wessely S (2020). Managing mental health challenges faced by healthcare workers during COVID-19 pandemic.British Medical Journal, 368.

4.Lai J., Ma S., Wang Y., Cai Z., Hu J., Wei N., Wu J., Du H., Chen T., Li R., Tan H., Kang L., Yao L., Huang M., Wang H., Wang G., Liu Z., & Hu S. (2020).

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Mental Health Impact Of Quarantine And Isolation

Dr. Abhinav Pandey

In December 2019 news about Corona Virus cases in China started coming. Initially people in other countries though fearful, were mostly in denial that it won‘t affect them. With cases increasing and taking the form epidemic and gradually other countries being affected by it, the panic spread and worry among individual person of getting affected by it. When India first announced its lockdown on 23th March, Initial reaction was that it would remain a one day affair, but state government by themselves and later central government on a country level decided to extend it. However, with high infective potential of the virus it soon took the form of a pandemic, a significant public health concern despite various Countries taking many steps in an attempt to curb its spread.

The Corona viruses responsible for this public menace belong to a group of RNA viruses, which causes diseases in mammals and birds. In humans, predominantly it causes mild to lethal respiratory tract infections. Lethal varieties of these viral infections are Sub-acute respiratory Syndrome (SARS), Middle East Respiratory Syndrome (MERS), and Corona Virus Disease 2019 (COVID-19).The history of human coronaviruses began in 1965 when Tyrrell and Bynoe found that they could passage a virus named B814 from human organ culture, isolated from a person having respiratory tract infection. Later with work of Tyrell and other scientists a new group of viruses named coronavirus (corona denoting in Latin a crown-like appearance, of the surface projections) came into being, officially accepted as a new genus of viruses.

This is not the first time world has been affected by epidemics and pandemics. The world over a period of thousands of year has seen many pandemics. During the 18th and 19th century pandemic of Cholera, plague, typhoid, Small pox, HIV AIDS (Ongoing Pandemic) and yellow fever has been seen. Sub-acute Respiratory Syndrome (SARS) epidemic affected many parts of the world during 2002-2004, and then the swine flu epidemic of 2009.

The Spread of COVID-19

With the spread of Covid-19 Government of India has taken several measures to contain it. Isolation, quarantine and lockdown rigorously are the most difficult yet necessary step.

   

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Quarantine and Isolation are methods to stop the spread of an infective illness. Quarantine means separation of an individual from others and community, who has any exposure to known infected person with that infection. The disease may or may not be evident in a quarantined individual. Isolation word although used interchangeably with Quarantine in stricter sense is applied to restriction of movement of Infected person in whom the disease is evident.

Quarantine and Isolation has been used for persons who had travelled internationally recently and for those individuals who had come in contact with persons declared to be COVID 19 positive which includes family members and others who had significant exposure with infected person in last few weeks before their illness was known. Self-deceleration of exposure has been made compulsory under the Epidemic Disease Act 1987 and Epidemic Diseases (Amendment) Ordinance 2020.

While the news of Epidemic spread is a significant Stress for most, for those Individual who have to undergo Quarantine and Isolation the problems are more. Quarantine and Isolation can be of three types- Home based- self quarantine, hospital based quarantine, camp based quarantine. Home based quarantine edges slightly better than others as it may provide the individual the comfort of their homes but at the same time if stringent methods are not followed adequately then the very purpose of quarantine may be defeated. Home based quarantine puts the responsibility entirely on an individual to save themselves, family members and the entire community from spread of the illness. However for those individuals where home isolation is not possible due to lack of space for e.g. slum areas or due lack of knowledge and understanding of the various measures, hospital based quarantine is done providing the individual with their basic needs. Camp based quarantine is also being followed for selected cases like on duty doctors and migrant labourers where large number makes it impossible to provide accommodation in hospitals.

The Mental Health of Persons during Quarantine

Quarantine can be imposing based on current laws or it can be self-motivated by responsible individuals. This Stress of going into Quarantine like other Stresses may present differently in different individuals depending on their coping skills, personality factors and pre morbid functioning. The distress of going into quarantine may lead to acute stress disorder, Adjustment Disorder in some. Quarantined individual may report feeling exhausted, boredom, detached, irritability, anxiety, sleep disturbance, low mood. While for many these symptoms may be short lasting for the period of quarantine for others these may be long lasting and may require follow up care to deal with emerging psychiatric disorders which can be Post traumatic Stress Disorder, Major Depressive Disorder, Anxiety Disorders, Obsessive Compulsive Disorder among others. For many Quarantine period may be impossible to pass and have suicidal ideations which needs special consideration since in discussion on Quarantine this aspect of mental health has largely been explored which can have dangerous implications.

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Factors Leading to Stress and ways to handle them in Quarantine

1. Unplanned Quarantine: Planning decreases half the Stress of almost anything. Making of quarantine checklist by each and every Individual in the community should be encouraged. Community awareness and mental preparedness that any person may have to go to Quarantine any time in this situation is need of hour. A proper checklist should contain all the items that a person may require in isolation. For e.g. Mobile phone, tooth brushes, Chargers, etc.

2. Stigma: Like many other illness being quarantined can also lead to person feeling stigmatised (Perceived Stigma) and actual Stigma from the community after coming out from Quarantine. A simple counselling, providing proper information and public awareness may cater these easily. The quarantine is for infective illness and infective illness carrier state doesn‘t last for more than few weeks in most of the infections.

3. Period of Quarantine: The time one has to live in Quarantine is of utmost importance. While most of the problems listed above are expected to increase as the period of quarantine is more, short duration increases the risk of improper quarantine.

4. Inadequate Information: The person may be ill informed about the infection and its spread in various ways through fake news. Providing correct information circulating helpline numbers may help disseminate anxieties related to these misinformation‘s.

5. Fear of Illness: During the initial stay quarantined person may be harbouring extreme of having the illness and its possible consequences. The tests report should be made available to the individual as early as possible and also the person should be clearly explained that even if tests positive the chances of actual illness is still low and despite having the illness chances of recovery are still high.

6. Boredom during Quarantine: Providing TV, Mobile phones and other entertainment sources as deemed necessary and depending on the individual choices is necessary.

Conclusions

COVID-19 pandemic has led world to a standstill. Quarantine and Isolation are a must to contain the viral spread. This has led to newer challenges for the Psychiatrist and other Mental Health Professionals World Wide. The Quarantine period is extremely critical from a Psychiatric view point as the affected individual may not only be exposed to psychological problems during but also after it. The Psychiatrist must take into the consideration the various psychological morbidities associated with it and should tackle them accordingly to provide effective health care.

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References:

1. Brooks, S.K, Webster, R.K, Smith, L.E, Woodland, L., Wessely, S., Greenberg, N., Rubin, G.J. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet 2020; 395: 912–20.

2. Jeffrey S.K. &Kenneth, M. History and Recent Advances in Coronavirus Discovery. The Pediatric Infectious Disease Journal 2005; 24(11) – p S223-S227

3. Mental health and psychosocial considerations during the COVID-19 outbreak. WHO Publication 2020

4. Webster R, Brooks S, Smith L, et al. How to improve adherence with quarantine: Rapid review of the evidence. medRxiv. 2020.

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Telepsychiatry- Boon or Bane

Dr.Pradeep Kumar, Dr. Malvika Pandey

Introduction

Advancements in technology has contracted the world to the extent that distances of miles are just a few clicks away. One of the uses of technology in medicine is in distant medical consultations through telemedicine using interactive audio, visual, and data communications. According to the United States Food and Drug Administration, ―Telemedicine refers to consultative services to individual patients and the transmission of information related to care, over distance, using telecommunications technologies. It incorporates direct clinical, preventive, diagnostic and therapeutic services and treatment; consultative and follow‐up services; remote monitoring of patients; rehabilitative services; and patient education.[1] In present scenario of COVID 19 pandemic, telemedicine lies at the forefront of medical care along with ensuring safety of the health care workers and patients. Its goal is not only increased access but also improved quality and effectiveness of healthcare. It also offers promise as an innovative approach to integrate complex health systems by providing consultation‐liaison service in primary healthcare. Indeed, it has implications in both individual wellbeing and public health systems. Its use was far less recognized until the wake of present COVID 19 pandemic which forced the administrations to ensue nationwide lockdown. The most effective way of controlling the COVID 19 spread being social distancing pointed to harnessing the potential of telemedicine.

Telemedicine is being used in all the medical specialties such as radiology, dermatology, pathology, systemic medicine, ophthalmology, and psychiatry. Telepsychiatry emerged as an off shoot of telemedicine in the digitally connected world with ever increasing stress and ailments. In developing countries like India with scarcity of psychiatrists as well as resources for infrastructure for telecommunication, the development of telepsychiatry is a challenge. Psychiatry being unique when compared to other specialties of medicine, as human interaction and client–therapist relations are integral to its practice. Hence, utility of tele-services in mental health care has been highly debated.

Technological models for telepsychiatry practice-

Several models of telemedicine are mentioned in literatures since its inception. Broadly, however, all these models can be classified as either synchronous or asynchronous. Allely et al. (1995) first described two models of delivering telemedicine to the patients.

    

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Synchronous telemedicine-

In synchronous telemedicine there is live, two‐way interactive transmission between patient and provider at distant locations via telephone, online communication (e.g., chat forums) and video‐conferencing.‖

Asynchronous telemedicine-

Whereas in asynchronous telemedicine, medical information is recorded in the form of data, audio, video clips, or recordings and then transmitted via E‐mail or Web applications to be later reviewed by a specialist.

Telepsychiatry in India

Quality health care services in India lag far behind the needs of its 125 billion population. The scarcity of psychiatrists makes the situation even grimmer for mental health care. Estimates indicate that there are two psychiatrist available for every ten lakh population. It is estimated that 7% of the total population suffers from mental illnesses, with close to 90% remaining untreated.[2] The problem is compounded by the equally alarming acute dearth of trained mental health professionals in the fields of psychiatric nursing, psychiatric social work, and clinical psychology. With the increasing competition and demands for increased productivity, people have become more and more vulnerable to mental health issues. However the mental health of an individual is often ignored to the point until which the ailment becomes incapacitating to the individual. Mental health care still seems far from the list of essential health care services for a lot of regions in India. Though the Government has increased emphasis on mental health care with several reforms in the Mental Health Care Act, 2017 the ground reality is less amenable to change until the number of specialists in Psychiatry increase which is thereby dependent on the number of seats for post-graduation in Psychiatry. The gap in mental health services and need can be bridged with effective utilization of Information and communication technology. Telepsychiatry can enable mental health professionals render their expert services to patients in far reach areas, and also provide specialist consultation to the primary care providers in the rural

areas. It can be used for psychiatric consultation, assessment, and diagnosis, medication management and management by individual and group psychotherapy.

The use of telemedicine in India began in 2000 with the initial applications in medical fields that are heavily dependent on image-based diagnoses. Soon, its application spread to other fields alongwith psychiatry. However its enormous potential was under recognized due to the paucity of communication network in a large part of the country. Till date, its use in this field remains in infancy and consequential dearth of available literature regarding the use and impact of telepsychiatry units in India. In addition to video conferencing, telepsychiatry now incorporates telephone, e-mail, and other modes of internet communication to facilitate mental health care. Telepsychiatry can also be used to facilitate home health visits in social work practice, potentially saving a significant amount of time that would otherwise be spent on traveling. SCARF Telepsychiatry in Pudukkottai (STEP) program, launched by the Schizophrenia

 

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Research Foundation of India (SCARF), particularly deserves attention for its multifaceted model of mental health care delivery through telepsychiatry.

Boon

In most situations, telemedicine is beneficial. It gives access to healthcare services in remote areas and to those with mobility issues such as the elderly. Therefore, it has the power to overcome geographical barriers to provide healthcare services. It may provide an opportunity to reduce healthcare spending and save time for the patient and caregiver. With the advent of telemedicine, a medical practitioner or hospital can consult with different specialists, irrespective of their location. Telemedicine helps patients to engage with their healthcare providers more frequently, in a convenient way, which may result in a better doctor–patient relationship. The follow-up of patients is likely to be better, which may improve outcomes. Mental health professionals may use videoconferencing to deliver treatments such as cognitive behavioral therapy and group therapy for mood and anxiety disorders. Crisis interventions for people with suicidal ideations may be conducted through online counseling, instant messaging, and chat groups. It also helps in compiling medical data in an electronic format which may be readily utilized for the purposes of research. As per the Indian telemedicine guidelines, the initiation of communication by the patient is itself regarded as an implied consent. Overall, telemedicine has the potential to provide better healthcare services to the masses. Evidences suggest that telepsychiatric services perform, as well as traditional services in terms of feasibility, effectiveness, quality of care, and user satisfaction. Accordingly, they meet the WHO yardstick for an ideal mental health service including accessibility, comprehensiveness, coordination and continuity of care, effectiveness, equity, autonomy, and empowerment.[3]

Bane

Telemedicine has some downsides because of its virtual nature. It requires infrastructure and technical training. It may reduce direct interaction of patients with doctors because online interactions are impersonal and, to make a complete diagnosis, physical examination needs to be done. There is a lack of a standardized format to the interaction and the absence of a consent form for either opting for or refusing the service. Telemedicine is still not included in the medical curriculum. Besides ambiguity regarding responsibilities in case of negligence, there are concerns about privacy, confidentiality, security of patient information and treatment. There is no clarity with respect to medicolegal issues arising out of telemedicine. Currently, no health insurance policy in India factors in telemedicine.[3]

Medicolegal Issues

Doctor–patient relationship

Patients trust healthcare professionals while seeking treatment and confide in them. The lack of face-to-face contact in some modes of telemedicine is seen as a barrier to adequate development of the doctor–patient relationship. It is essential to maintain the trust of the patient to meet legal requirements. Healthcare providers are obliged to establish good doctor–patient relationships.

Informed consent

 

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Informed consent is an important medicolegal requirement while treating a patient; failure to do so is a tort and crime. Though the initiation of communication by the patient is itself an implied consent, an informed consent should be obtained for transmission of data, monitoring and consultation with other specialists. Further, it is important to clarify whether the medicolegal value of informed consent in telemedicine is the same or different with respect to traditional face-to-face interactions.

Malpractice and liability

Once the doctor–patient relationship is established, it is the responsibility of the doctor to provide due care and treatment, which is expected from the professional in the given circumstances. Can physicians be sued for medical malpractice in telemedicine and virtual consultation and can they be protected by medical indemnity insurance? The following are some important points in this context.

1. The ̳duty of care‘ must be established in all telemedicine encounters to clarify responsibility(s) for the patient/caregiver as well as other involved healthcare providers.
2. Healthcare professionals should clearly define their roles and responsibilities regarding the various aspects and extent of treatment.

Privacy

The right to privacy has been an integral part of medical ethics since the time of Hippocrates and is supported by various codes including the International Code of Medical Ethics. It mandates that the health practitioner must maintain confidentiality regarding personal information of the patient even after his/her death. Every individual has a right to privacy even in telemedicine. There is the potential for leakage of electronic records of a patient. The onus for safeguarding this information has to be on the medical practitioner. Information must be transmitted in a secure way by protecting thee information with password.

Product liability

It is the liability of manufacturers for any harm caused to the patient by a defective product. Thus, it means the duty of care is owned by the manufacturer, which includes the manufacturer of the computer system compatible for telemedicine, manufacturer of compatible software, manufacturer or supplier of various accessories related to telemedicine, network provider, healthcare service provider who is using the technology and the service company responsible for maintenance of the whole telemedicine unit.[3]

Rights of patients

In traditional medical practice, certain rights of patients have been recognized, such as the right to get treatment, choose a doctor freely, change doctor at any stage of treatment, right of compensation, right of confidentiality, right of dignity, right of grievance redressal, right of information and right to refuse treatment. The same applies to the practice of telemedicine and virtual consultation. The patient has a right to receive one‘s medical record in the electronic format, to know standards and safety guidelines. He/she has the right to be informed regarding

   

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authorization or registration status of the service provider and to know the various complaint processes which he/she can use in case he/she suffers any harm during the consultation.[3]

Reimbursement

Currently, there is no provision for reimbursement from medical insurance in telemedicine practice. Whether telemedicine was required or not in the given situation is another condition which should be cleared for reimbursement.

Laws in India applicable to Telemedicine

Information Technology Act, 2000 (IT Act) The Information Technology (IT).[4] Act contains provisions safeguarding the security and privacy of information exchanged using means recognized under the IT Act. All companies registered under technology or providing technology services are governed by the IT Act. Telemedicine involves a constant exchange of information between the patient and the service provider. The patient‘s personal information, such as medical history and physiological conditions, is considered sensitive personal data or information ( ̳SPDI‘ under the Data Protection Rules).[5] When a corporate body collects, stores, transfers or processes such information, certain requirements under the Data Protection Rules are triggered.

Cost‐effectiveness Another major concern is the cost effectiveness of telepsychiatry. The results of cost‐ effectiveness studies are mixed and in developing countries like India cost of any service is the limiting factor for its utility.

Challenges and the future There is much hope for the future of telemedicine. With rapid advances in technology, telemedicine will become easier and more widely accepted in coming years. India took a giant leap in telemedicine during the current COVID 19 pandemic by releasing the telemedicine guidelines. It ensures safety of the doctors as well as patients by contributing to social distancing protocol during lockdown period. For successful integration of telemedicine with the existing health structure, we need to develop policies for its effective operation and optimum utilization, development of dedicated units, training of the personnel, maintenance of confidentiality, periodic checks by a regulatory authority and disputes readdress committee. The use of smartphone-based applications should be developed to avail healthcare services so that a patient can contact a doctor without the need to go for a consultation physically.

Advances in technology and research are expected to overcome many of the current obstacles. Increased awareness and a more realistic appreciation of telepsychiatry‘s potential, as well as limitations may contribute to better acceptance among users. Telepsychiatry has the capability to enhance the overall efficiency of mental health services in developing countries and also the need of the hour for the prevailing COVID 19 pandemic.

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References

1. White LA, Krousel‐Wood MA, Mather F. Technology meets healthcare: Distance learning and telehealth. Ochsner J 2001;3:22‐9.)

2. Government of India Planning Commission. Report of the Working Group on Disease Burden for 12th Five Year Plan: WG 3(2)‐ Non Communicable Diseases Available at :
https://niti.gov.in/planningcommission.gov.in/docs/aboutus/committee/wrkgrp12/health/
WG_3_2non_communicable.pdf (Last accessed on 14 May 2020).

3. Ateriya N, Saraf A, Meshram VP, Setia P. Telemedicine and virtual consultation: The
Indian perspective. The National medical journal of India. 2018 Jul 1;31(4):215.

4. The Information Technology Act; 2000. Available at https://indiacode.nic.in/bitstream/123456789/1999/3/A2000-21.pdf (accessed on 14 May
2020).

5. The Information Technology (Reasonable Security Practices and Procedures and
Sensitive Personal data or Information) Rules; 2011. Available at https://www.wipo.int/edocs/lexdocs/laws/en/in/in098en.pdf (accessed on 14 May 2020).

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Social Media And Its Impact On Mental Health

Dr. Nitesh Kumar Singh

Introduction

Social media refers to ̳websites and applications that enable users to create and share content or to participate in social networking‘. There are about 3.81 billion social media users around the world. More than 63% of eligible population is already on social media, spending on an average, two and half hours using social media each day. Human beings are social creatures. We need social relationship, companionship and validity of others to thrive in life and the strength of our connections has a huge impact on our mental health and happiness. At this time of lockdowns, social distancing and isolation, social media can be an invaluable tool for keeping us in touch with friends, loved ones, and the wider world. Being socially connected to others can ease our distress, boost self- esteem, prevent loneliness and provide comfort and joy. On the flip side, lacking strong social connections can pose a serious threat to our mental and emotional health. It‘s important to remember that social media can never be a replacement for real world human connection, spending too much time engaging with social media can actually make us feel more lonely and isolated and exacerbate mental health problems such as anxiety and depression. We should also be careful about fake news circulating on social media, always check its authenticity before forwarding to someone else. Always check reputable news sources before believing or forwarding any rumors about COVID-19 that may cause panic

Positive aspects of social media

Communication- Social media is an easier and cheaper way to Communicate and stay up to date with family and friends around the world. We not only know about different events happing in

   

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our friend‘s life, we can also express our emotions through social media. It increase the sense of interconnectedness and social closeness.

Networking- Social media help as find new friends and communities and network with other people who share similar interests or ambitions.

Emotional support- At this time of lockdowns, social distancing and isolation, social media can be good medium to seek and provide emotional support. It provide vital social connection to people living in a remote area, for example, or having limited independence, social anxiety, or are part of a marginalized group.

Outlet for creativity and self-expression- People are increasingly relying on social media platforms to express themselves positively and accurately. Social media provide an outlet to teenagers to express themselves, which is important because expression is key during teenage years. Lockdown has inspired people to be creative and carry out their hobbies of cooking, singing, gardening etc. social medial has provided them platform to share their creativity.

Promotion and awareness- Social media helps to promote worthwhile causes; raise awareness on important issues like social distancing and use of mask to prevent COVID infection.

Learning- Social media if used carefully can be a sources of valuable information and learning. During lockdowns various school and colleges are teaching and sharing academic materials through social media.

Negative aspects of social media

Promoting Negative emotions- Even if we know that images we are viewing on social media are manipulated, they can still make us feel insecure about how we look or what‘s going on in our own life. Similarly, we‘re all aware that other people tend to share just the highlights of their lives, rarely the low points that everyone experiences. But that doesn‘t lessen those feelings of envy and dissatisfaction when we are scrolling through a friend‘s airbrushed photos of their tropical beach holiday or reading about their exciting new promotion at work. Social media seem to exacerbate feelings that others are having more fun or living better lives than us. Fear of missing out (FOMO) on certain things can impact our self-esteem, trigger anxiety, and fuel even greater social media use. It can compel us to pick up our phone every few minutes to check for

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updates, or compulsively respond to each and every alert even if that means taking risks while we are driving, missing out on sleep at night, or prioritizing social media interaction over real world relationships.

Self-absorption- Sharing endless selfies and all your innermost thoughts on social media can create an unhealthy self-centeredness and distance you from real-life connections.

Cyber bullying and Trolling- Cyber bullying is extremely common these days, many teens report being bullied on social media and many other users are subjected to offensive comments. Social media platforms can be hotspots for spreading hurtful rumors, lies and abuse that can leave lasting emotional scars. Victims of cyber bullying suffer from bouts of depression, anxiety, Suicidal tendencies, low self-esteem, anger and frustration.

Social media addiction- social media addiction is a behavioral addiction characterized by uncontrollable urge to use social media and devoting so much time and effort to social media that it impairs other important life areas. Excessive social media have detrimental effect over mental health and can cause insomnia, memory problem, anxiety and depression.

Impact of Lock downs on Social media use

Lockdown increased Lonliness and boredom

Use of social media has increased many folds during current lockdowns due to various obvious reasons. We should be careful as it can lead to excessive social media use which can create a negativity, self-perpetuating vicious cycle of unhealthy social media use

Figure 1. Unhealthy Social media use cycle

  

worsen symptoms of stress, anxiety & Depression

Negative effect on mood

Using social media more often

Increased FOMO, inadequacy, dissatisfaction

    

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.

Indicators that social media may be adversely affecting your mental health

  Spending more time on social media than with real world friends and family members.

  Comparing yourself unfavorably with others on social media.

  Pressure to post regular content about yourself, get comments or likes on your posts, or
respond quickly and enthusiastically to friends‘ posts.

  Engaging in risky behavior in order to gain likes, shares, or positive reactions on social
media.

  Suffering from sleep problems. Do you check social media last thing at night, first thing
in the morning, or even when you wake up in the night?

  Rather than helping to alleviate negative feelings and boost your mood, you feel more
anxious, depressed, or lonely after using social media.

  Experiencing cyber bullying or you worry that you have no control over the things people
post about you.

  Every spare moment is filled by engaging with social media, leaving you little or no time
for reflecting on who you are, what you think.

  Checking social media while in important meeting or family gatherings.
Steps to modify social media use to improve mental health
1. Limit online time

  Use an app to track how much time you spend on social media each day. Then set a goal for how much you want to reduce it by.

  Turn off your phone at certain times of the day, such as when you‘re driving, in a meeting, having dinner, spending time with offline friends, or playing with your kids.

  Don‘t bring your phone or tablet to bed. Turn devices off and leave them in another room
overnight to charge.

  Disable social media notifications. It‘s hard to resist the constant buzzing, beeping.

  Limit checks. If you compulsively check your phone every few minutes, wean yourself
off by limiting your checks to once every 15 minutes, then once every 30 minutes, then once an hour

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2. Change of focus- Many of us access social media purely out of habit or to mindlessly kill moments of downtime. But by focusing on your motivation for logging on, you can not only reduce the time you spend on social media, you can also improve your experience and avoid many of the negative aspects.

3. Spend more quality time with your family and offline friends 4. Take time for self-reflection

5. Feeling and expressing gratitude about the important things in your life can be a welcome relief to the resentment, animosity, and discontent sometimes generated by social media.

6. Practice mindfulness. Experiencing FOMO and comparing yourself unfavorably to others keeps you dwelling on life‘s disappointments and frustrations. Instead of being fully engaged in the present, you‘re focused on the ―what ifs‖ and the ―if onlys‖ that prevent you from having a life that matches those you see on social media. By practicing mindfulness, you can learn to live more in the present moment, lessen the impact of FOMO, and improve your overall mental wellbeing.

7. Monitor and limit your child’s social media use & teach your child how social media is not an accurate reflection of people’s lives.

Conclusion

Social media if used carefully can help us to stay connected with our friend and family in this time of lockdown. It can be a source of emotional and social support at time of need. If use of social media make us happy, boost our self-esteem it can have positive impact on our mental health but if we have feeling of missing out, self-doubt, and disappointment after using social media we should check our time on social media.

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References

1. Hootsuite & We Are Social (2019), ―Digital 2019 Global Digital Overview,‖ retrieved from https://datareportal.com/reports/digital-2019-global-digital-overview [12/5/2020]

2. Melissa G. Hunt, Rachel Marx, Courtney Lipson, and Jordyn Young (2018). No More FOMO: Limiting Social Media Decreases Loneliness and Depression. Journal of Social and Clinical Psychology: Vol. 37, No. 10, pp. 751-768

3. Lup, K., Trub, L., & Rosenthal, L. (2015). Instagram #Instasad?: Exploring association among Instagram use, depressive symptoms, negative social comparison, and strangers followed. Cyberpsychology, Behavior, and Social Networking,18, 247–252.

4. Rosen, L. D., Whaling, K., Rab, S., Carrier, L. M., & Cheever, N. A. (2013). Is Facebook creating ̳ ̳iDisorders‘‘? The link between clinical symptoms of psychiatric disorders and technology use, attitudes and anxiety. Computers in Human Behavior, 29, 1243–1254.

5. Smith, A., & Anderson, M. (2018). Social media use in 2018. Pew Research Center.

http://www.pewinternet.org/2018/03/01/social-media-use-in-2018/

6. Song, H., Zmyslinski-Seelig, A., Kim, J., Drent, A., Victor, A., Omori, K., & Allen, M. (2014). Does Facebook make you lonely?: A meta-analysis. Computers in Human Behavior, 36, 446–452.

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General Principles On Dealing With Mental Health Problems During The Pandemic

Dr. Abhinav Pandey, Prof. (Dr) Mona Srivastava

For people around the globe these are difficult times. The spread of COVID-19 has brought devastations in economic, social and personal life. In these testing conditions maintaining fitness, both physically and mentally is important and at the same time challenging. In this chapter we would try to cover a few aspects on how to maintain mental fitness and deal with the mental health problems.

Understanding that we are not alone

Yes it is a pandemic. All most all people around the globe have been affected. Fear is the most common reaction emotionally in this pandemic so it should be considered normal and dealt with accordingly. Fear of being affected by the illness and fear of loved ones getting affected. When we are not alone in dealing harbouring in such fear we shouldn‘t try to handle it alone either. Sharing your fear with your family members, friends, relatives if not help remove it can at least help us provide strength to fight it.

Understanding the Government rules and regulation

Government has employed several strategies to counter its spread. Lockdown, quarantine are these among several others. In Lockdown besides essential services everything else had been closed however as the lockdown progressed and as the authorities decided on opening and supply of essential commodities have been maintained. Unnecessary panicking has to be avoided at all cost as it will not impact oneself but also their family members and pushes down the moral of service providers.

Eat well and Drink well

Marinating hydration, taking healthy diet is of utmost importance as this pandemic has hit us in summer time which can be taxing and is responsible for large number of deaths in previous years,

 

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independently let alone this Pandemic. Also Healthy diet is important from boosting immunity point of view as this battle with virus will be ultimately be won when as a community our immunity will be at higher levels. Also, better health will be helpful to overcome infection in case eventuality occurs and if we do get infected

Exercise and Maintaining Daily Routine

Besides boosting immunity, it will also be helpful in reducing the Stress levels if we exercise daily and maintain a daily routine. Also, in lockdown period daily routine can easily be disturbed but it will be detrimental for its negative effect on health and also on work when it eventually returns.

Handling the Isolation

The key word is keeping engaged. If you have a child at home its good time to be engaged in his care. Reading books, music, watching TV for restricted amount of time, being busy doing pending home works, cleaning etc. are various measure. Hobbies can be further explored. If trapped alone, you may schedule video conference regularly might be important.

Rejecting the false news

Be sure before believing any news. Be double sure before spreading it to someone else by checking its source and cross verifying from trusted news sources. Do not keep watching the news all the time as it may be negative impact on oneself.

Managing Health Anxiety Symptoms

Not all common cold are caused by Corona Virus. Infact even if during this pandemic you develop sore throat and runny nose it still has higher chances turning out to be a common cold than COVID-19. In case your symptoms match that of COVID you can inform the authorities about it and get yourself tested for it. There is no need for panic. Deep breathing relaxation exercises may help you get rid of excessive anxiety. You can also consult your family doctor or to telemedicine centre for help.

Help in Reducing Self-stigma and don’t stigmatised others

If you had to face quarantine or have recovered from COVID-19 there is no need for feeling stigma. It is a viral illness and once the infection is over within two weeks person is free of it. There is no need to fear facing people completely recovered from it as they have no risk of spreading the virus.

Be a support to others

Act as a source of support for those who are not able cope with the lockdown. Identify developing mental illness in your near and dear ones. Observe for any change in behaviour, sleep

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patterns, difficulty in concentration, irritability or any other symptoms. Consult your doctor if you see any problem.

How to tackle emotional problems during Lockdown

Simple techniques can be tried like relaxation exercise, distancing from the thoughts provoking anxiety. Try to slow down your mind during the period of intense anxiety. Think of something calm and relaxing time you ever had.

If irritability is an issue you may try to count backwards from 10 to 0 and by distancing from the situation.

If intense anxiety persists you may ask yourself questions step by step

  What are things under my control?

  Am I unnecessarily worrying about the worst thing that can happen?

  When I have been stressed in the past, how have I managed?

  What are the things I can do to help myself and be positive?
If you feel sad stay communicated with others. Call up people whom you haven‘t spoken to and surprise them. Discuss happy events, common interests, exchange cooking tips, share music.
If these problems persist you make seek expert‘s health telephonically. Institute of Medical Sciences, Banaras Hindu University have started telemedicine facility under which services of a Psychiatrist is available the number of which is
Things not to be done during lockdown
Avoid addiction in any form. Not only it will have cost issues as most of the addictives will cost you higher and drain you more economically but it also increases the risk of COVID-19 spread. Any form of addiction like tobacco and alcohol reduces your immunity and increases the risk of infection. It can further worsen your physical and mental health.
Do not spread fake news of any form.
Do not stigmatise medical professionals dealing with COVID cases and patients of this illness. References
1.Minding Our Minds during COVID-19 MoFHW
2.Tips on maintaining mental health during lockdown-The Hindu
3.Mental health and psychosocial considerations during the COVID-19 outbreak-WHO

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Crisis Intervention of Family And Person With COVID Diagnosis

SHIV PRAKASH, SAURAV KUMAR

The world is facing a crisis situation during this time that is known as COVID-19 Disease. The World Health Organization (WHO) has declared COVID-19 as a pandemic on 11th March 2020 (Limcaoco, et al 2020). It is a disease due to corona virus that is related to the RNA virus family. It is pathogenic to all mammals and birds and affects generally the respiratory system in humans. A number of humans have died due to COVID-19 in just 3-5 months after it was first noticed. It is a more dangerous disease because of the absence of effective medicine. Due to this, all the countries have declared a complete lockdown to prevent their citizens from this disease. The people are not only afraid of this disease but they are facing several types of psychosocial problems that may affect their physical and mental health. And the prevalence of psychological disorders may increase in co-morbid conditions all over the world.

A crisis is defined as a perception or experience of an individual in an adverse situation when his or her current resources and coping mechanism are not helpful to get out of the difficulty. Resulting this, the individual can‘t receive the relief and feels severe behavioral, affective, and cognitive malfunctioning (James, 2008). In other words, a crisis is a difficult situation when an individual‘s normal mental state got disturbed and he/she feels incapable to get out of it due to the failure of defense mechanisms and problem-solving abilities. A crisis can be either situational (such as natural disasters, pandemic disease, loss of job and loved ones, etc.) or Maturational (a crisis occurs when an individual is not able to cope with the normal age-related developmental process) or Socio-cultural crisis. Here we can state that COVID-19 is a situational crisis that is being faced by every individual around all over the world. The problems being faced by individuals may be differ due to vividness in the personal abilities among person to person. A normal healthy person may control over situational crisis but it may be more difficult for an individual who has already a mental health-related problem such as, anxiety, obsessive- compulsive disorder, PTSD, depression, bipolar disorder, and schizophrenia, etc. In such cases, the importance of crisis intervention will become more essential.

Crisis intervention can be defined as an organized and systematic application of techniques derived from the principles of crisis theory, by a qualified, trained and experienced person who

   

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assessed individuals and families situations and try to modify their personal abilities, attitude, feelings and behaviors that are diagnosed as a mall adaptation (Ewing, 1978). Crisis intervention is a type of psychotherapy that is developed for the management of psychosocial problems of an individual during and after the crisis. Crisis intervention can be applied in both forms; individual crisis intervention and family crisis intervention. In this chapter, we will discuss about these types of interventions. Because a better result will be obtained only when treatment will be provided in both levels individual and family.

Crisis Intervention with Individual

Individual-based crisis intervention especially deals with all psychosocial problems and maladjustment developed due to crisis. When an individual went through hazardous and very difficult situations that are beyond his coping ability and he/she found himself/herself unable to get out of this situation then he/she may face several types of psychological disturbance which are given below;

• Emotional instability.

• Increased level of anxiety.

• Depression and agitation.

• Tension, guilt, fear, and anger.

• Irritation and other‘s blames.

• Panic Attacks.

• Low level of self-esteem and confidence.

• Frustration, confusion, and inability to take a decision.

• Physical illness and incapability.

• Hyperventilation and hypertension.

• Unable to maintain a daily routine.

• Difficulty in communication.

• Difficulty in social relationships.
There are several techniques to crisis intervention to deal with these psychological disturbances. It will be better if a proper assessment of the individual has been done before providing the intervention because it is important to make a management plan and to set the goals of intervention. Generally for the therapist, there are four main goals of crisis intervention; (1) Decrease the level of individual‘s emotional stress, (2) Protect the individual from additional stressors, (3) Providing assistance to the individual in the organization and improve the

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racecourse utilization, and (4) Help the individual to achieve the efficiency as he was prior the crisis or to improve his level of functioning.

Techniques of Crisis Intervention

A therapist generally uses different techniques while providing the intervention to an individual. By understanding these techniques we can know how crisis intervention helps an individual to get out of psychological problems developed by a crisis. Myer and James (2005) techniques for crisis intervention are as follows:

•Creating awareness: With this technique, a therapist attempts to acquaint the individual with the thought, repressed feelings that generate such behavior patterns. With awareness, they see with a new perspective.

•Allowing catharsis: Allowing an individual to vent feelings and thoughts is an important therapeutic strategy. Through emotional ventilation In order to do this crisis intervention therapists need to provide a safe and accepting environment. In doing so you can say that the therapist accepts the client‘s feelings and thoughts. This strategy is most often used with individuals who have struggled to get in touch with their feelings or thoughts.

•Providing support: Sometimes the crisis intervention therapist may be the sole support available to the individual. It can be helpful for the therapist to validate the individual‘s responses as being reasonable given her situation. At times individuals believe they must be crazy and it is helpful to share that many others would act in a similar way given the crisis situation. While supporting the individual, it is not good to give the impression that the therapist is supporting the individual‘s injurious or harmful behaviors.

•Increasing expansion: It means engaging the individual‘s in the activities to expand his/her view of the Situation. Individuals are often unable to see other perceptions and possibilities and tend to focus on one perspective only. By presenting another view of the situation, clients are able to step back, reframe their problems, and gain new perspectives.

•Emphasizing focus: Sometimes the individual is unfocused and talks about numerous issues in his/her lives that are not working. At times some may appear to be out of control. It can be helpful for the therapist to attempt to focus the individual‘s often overwhelming interpretation of the crisis event to more specific, realistic, and manageable options.

•Providing guidance: When an individual is in a crisis he/she often may need guidance and direction. The Individual may not have the knowledge or the resources needed to make good decisions. When crisis intervention therapist provides information, referrals, and direction which assists individual handling specific issues in their life with the application of information earlier they were not aware.

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•Promoting mobilization: It means that Crisis intervention therapist tries to activate and arrange the individual‘s internally available resources and to find and access external support systems which assist in generating better coping mechanism and problem-solving abilities.

•Implementing order: Crisis intervention therapist needs to assist an individual to categorize problems in order to prioritize and systematically deal with the crisis in a rational way.

•Providing protection: Crisis intervention therapist needs to save individuals from engaging in harmful, lethal, detrimental and unsafe feelings, behaviors and thoughts that may be hazardous to themselves or others.

•Other Techniques: Besides the techniques mentioned by Myer and James (2005), there several others techniques or strategies used by the therapist such as improving the self-esteem, self confidence, improving problems solving abilities, teaching about relaxation techniques, reinforcing the positive behaviors, managing the defence mechanism, social skill training if required, and improving the individual functioning.

Crisis Intervention with family

Family crisis intervention is also important as well as the individual based crisis intervention. The family environment is also an important factor that affects the mental state of every individual living the family. Family members also have to suffer due to the crisis not only the individual having a mental illness suffers. Therefore the intervention is also required to provide every individual in the family. It is also important for the treatment of the individual who has gone through the crisis situation (Falloon,2003). Because there are several issues presents at the family level that causes the psychological stressors among the individual having a mental illness, especially severe mental disorders such as severe depression, bipolar disorder, schizophrenia, substance abuse disorders, and other personality-related disorders.

The therapist first educates every family member about the effect of crises and mental illness. This helps to reduce environmental stress and increase the level of social functioning in the family. The therapist tries to reduce the family burden by educating the caregivers about stress management techniques and coping strategies. This may also be helping to improve the family environment and quality of life of family members.

The individual with mental illness requires better support from every family member. The therapist engages every family member in the treatment process. Better family support can be provided by improving the level of social functioning. To improve social functioning the therapist improves the communication skills of each member of the family including the individual having a mental illness.

The therapist also tries to educate the family members about their responsibilities regarding the individual with mental illness. This is important because of the stigmas in the family related to the mental illness and the treatment. Many of the family members don‘t behave in a proper manner with the individual having a mental illness, and they criticize and misbehave the

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individual. Resulting this, most of the patients get relapse and the situation becomes more serious and sometimes leads to suicide.

Conclusion- In conclusion, it can be stated that crisis intervention is more important for the family and the individual having mental. In crisis situations such as COVID-19, every individual in the family faces several types of psychological problems including the patients. Therefore, the patients may relapse and the family members have a chance of getting affected with mental illness. In such cases, crisis intervention is required both level individual-based and family-based crisis intervention.

References:

1. Ewing, C. P. (1978). Crisis intervention as psychotherapy. Oxford University Press.

2. Falloon, I. R. (2003). Family interventions for mental disorders: efficacy and
effectiveness. World Psychiatry, 2(1), 20.

3. James, R. (2008). Crisis intervention strategies – 6 th edition. Belmont, CA: Thomson.

4. Limcaoco, R. S. G., Mateos, E. M., Fernandez, J. M., & Roncero, C. (2020). Anxiety,
worry and perceived stress in the world due to the COVID-19 pandemic, March 2020.
Preliminary results. medRxiv.

5. Myer, R.A. & James, R.K. (2005). Crisis intervention workbook and CD-ROM. Belmont,
CA:Thomson Brooks/Cole.

63

Suicide Risk And It’s Prevention During Quarantine And Lockdown

Dr. Vinod Verma, Dr Chandan Kumar Shah

Introduction

Infectious disease outbreaks such as COVID-19, as well as other public health events, can cause emotional distress and anxiety , especially for individuals who are already at risk e.g. those suffering from depression, anxiety or other common mental disorders (CMD). The realization of the non-availability of vaccine and effective antiviral drug against SARS-CoV-2 virus, and understanding that social distancing and quarantine/self-isolation is the only available remedy to us, forced the governments of most of the countries to declare the nationwide lock down. Some cases have been reported around the world where people out of fear of getting COVID-19 infection, social stigma, isolation, depression, anxiety, emotional imbalance, economic shutdown, lack and improper knowledge, financial and future insecurities took their lives. Secondary consequences of these factors may increase the risk of suicide. People with pre- existing psychological problem, psychiatric illness (previous history of suicidal thoughts, depression, anxiety and alcohol dependence) make the individual more vulnerable to suicide risk.

Economic Stress

There are fears that the combination of cancelled public events, closed businesses, and shelter-in- place strategies will lead to a recession. Economic depressions are usually associated with higher suicide rates compared with periods of relative prosperity. Since the COVID-19 crisis, businesses have faced adversity and laying off employees. The stock market has experienced

 

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historic drops, resulting in significant changes in retirement funds. US already claimed a vast increase in unemployment (4.6 million) during coronavirus emergency and speculated that lockdown will cause more deaths than COVID-19 itself amid the recession [1]. This uncertainty of time for isolation, not only demoralize but also make people feel worthless, hopeless about present and future as exemplified by the suicide of German Hesse state Finance Minister Thomas Schaefer [2].

Social Isolation

Leading theories of suicide put forward the key role that social connections play in suicide prevention. Imposed isolation and quarantine disrupted the normal social life and created a psychological fear and feeling of entrapment, for an indefinite period of time. Suicidal thoughts and behaviors are seen to be associated with social isolation and loneliness. Therefore, from a suicide prevention standpoint, it is concerning that the most critical public health strategy for the COVID-19 crisis is social distancing. Furthermore, family and friends remain isolated from individuals who are hospitalized, even when their deaths are imminent. This has lead to an emotion conflict within the individual, which creates an emotional turmoil which in turn leads to low mood and irritable behavior. The strategies which increase social isolation and loneliness may increase suicidal tendency. The first suicidal case was reported from south India on 12th Feb 2020, where Balakrishna, a 50-year-old man wrongly co-related his normal viral infection to COVID-19[3]. Although out of fear and love for his family, he quarantined himself, but later committed suicide, as he was psychologically disturbed after reading COVID-19 related deaths in the newspaper. In Delhi, India, one COVID-19 suspected man admitted in the isolation ward of the Safdarjung Hospital allegedly committed suicide by jumping off the seventh floor of the hospital building [4].

Suicide is the leading cause for over 300 ―non-coronavirus deaths‖ reported in India due to distress triggered by the nationwide lockdown. The group, comprising public interest technologist Thejesh GN, activist Kanika Sharma an assistant professor of legal practice at Jindal Global School of Law Aman, said 338 deaths have occurred from 19th March till 2nd May and they are related to lockdown.[5]

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Illness and Medical Problems: Exacerbated physical health problems could increase risk for some patients, especially among older adults, in whom health problems are associated with suicide.

Stress, anxiety and pressure in Health Care Professionals are at immense. Medical professionals are constantly in close contact with COVID-19 positive and/or quarantined patients. This has lead to a constant rise in fear of getting infection, which has further lead to an increase in unbearable stress. The helplessness that has crept in because of distress of watching the infected patients die alone, exposure of family members, sick colleagues, shortages of necessary personal protective equipment, overwhelmed facilities, and work stress has also been an addendum in stress.

Social prejudice and boycott: Mamun MA et al., 2020 reported the first COVID-19 suicide case in Bangladesh, where Zahidul Islam, a 36-year-old man committed suicide due to social abhorrence by the neighbors and his moral conscience to ensure not to pass on the virus to his community [6].

Barriers to Mental Health Treatment

Health care facilities are adding COVID-19 screening questions at entry points and at some facilities, children and other family members (without an appointment) are not permitted entry. The state of lockdown that is currently in place has created a regulated flow of patients in the health facilities. In a country like India, mental health issues are considered to be of lesser importance and seen with slight.

Such actions may create barriers to mental health treatment. Information in the media may also imply that mental health services are not prioritized at this time (eg, portrayals of overwhelmed health care settings, canceled elective surgeries). Moreover, overcrowded emergency departments may negatively affect services for survivors of suicide attempts. Reduced access to mental health care could negatively affect patients with suicidal ideation.

Suicide Prevention strategies:
COVID-19 is a global crisis, so collective efforts are required to deal with this global pandemic.

Emotionally distressed people need to first set the limit of COVID-19 related news consumption

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from local, national, international, social and digital platform and the sources must be authentic like Ministry of health and family welfare( mohfw.gov.in), CDC and WHO.

Indirect clues need to be noticed with great care, where people often say ̳I‘m tired of life‘, ̳no one loves me‘, ̳leave me alone‘ and so on. On suspecting such behavior in person, we can pull together the people struggling with suicidal ideation to make them feel loved and protective.

Physical Distance, Not Social Distance Despite its name, social distancing requires physical space between people, not social distance. Efforts can be made to stay connected with loved ones and maintain meaningful relationships by telephone or video, especially among individuals with substantial risk factors for suicide. Social media solutions can be explored to facilitate these goals.

Tele–Mental Health: There is national momentum to increase the use of tele health services in response to COVID-19. Unfortunately, tele-mental health treatments for individuals with suicidal ideation have lagged far behind the tele- health field. Opportunities to increase the use of evidence-based treatments for individuals with suicidal thoughts have been noted for years, especially in rural settings, but fear of adverse events and lawsuits have paralyzed the field. Disparities in computer and high- speed internet access must also be addressed. Research, culture change, and potentially even legislative protections are needed to facilitate delivery of suicide prevention treatments to individuals who will otherwise receive nothing.

Our hospital has been a frontrunner in providing telemedicine services to the people of Purvanchal. A helpline number receiving calls from various parts of India are attained by the distinguished consultants of our Psychiatry department (8887019159).

Increase Access to Mental Health Care: As COVID 19 precautions develop in healthcare settings, it is essential to consider the management of individuals with mental health crises. Screening and prevention procedures for COVID-19 that might reduce access to care (e g, cancelled appointments, sending patients home) could include screening for mental health crises; clinical staff would be needed to some degree in settings that may currently relegate COVID-19 symptom screening to administrative staff. Also, rather than sending a patient with a child home, alter- native treatment settings could be considered (e g, a private space outside).

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Distance-Based Suicide Prevention: There are evidence-based suicide prevention interventions that were designed to be delivered remotely. For example, some brief contact interventions (telephone-based outreach) and the Caring Letters intervention (in which letters are sent through the mail) have reduced suicide rates in randomized clinical trials.

REFERENCE

1.Reger MA, Stanley IH, Joiner TE. Suicide mortality and coronavirus disease 2019- A perfect storm? (2020) JAMA Psychiatry. doi:10.1001/jamapsychiatry.2020.1060

2.https://www.todayonline.com/world/covid-19-german-minister-commits- suicide-after-virus- crisis-worries (Accessed on 8 April 2020)

3.Goyal K, Chauhan P, Chhikara K, Gupta P, Singh MP. Fear of COVID 2019: First suicidal case in India! (2020) Asian Journal of Psychiatry. 49:101989.

4.https://economictimes.indiatimes.com/news/politics-and-nation/mansuspected- of-covid-19- commits-suicide/articleshow/74700431.( Accessed on 9 April 2020)

5.https://economictimes.indiatimes.com/https://economictimes.indiatimes.com/news/politics- andnation/suicide-leading-cause-for-over-300-lockdown-deaths-in-india saysstudy/articleshow/75519279 .( Accessed on 9 April 2020)

6. Mamun MA, Griffths MD. First COVID-19 case in Bangladesh due to fear of COVID-19 and xenophobia: Possible suicide prevention strategies. (2020) Asian Journal of Psychiatry 51 (2020) 102073.

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DEPARTMENT OF PSYCHIATRY, IMS, BHU,VARANASI

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