Training Module for Health Care Providers to deal with Post COVID Mental Health issues-for doctors & nurses

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RAJESH BHUSHAN, IAS SECRETARY

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Government of India

Department of Health and Family Welfare Ministry of Health and Family Welfare

M E S SA G E

India is in the midst of the second wave of COVID-19 pandemic. The Central Government along with the States is striving hard to roll out vaccination and containment measures to prevent infections; manage acute cases and the post COVID cases through the healthcare delivery system across the country. Historically speaking, mental health issues often arise after disasters of this scale due to various reasons such as deaths in the family, severe sickness, financial crisis, prolonged social distancing measures, restricting activities to online means etc. Therefore, there is a need to address mental health issues on priority.

I am happy that the Director General of Health Services has spearheaded this agenda through the contribution of eminent experts in the field of Psychiatry and Public Health to bring out this module meant for doctors and nurses for all the health care facilities in the country.

I would urge the State Governments to adopt this and roll out training programmes for increasing the State’s capacity to deal with mental health issues adequately.

Date :21stJuly,2021

Place : New Delhi (RAJESH BHUSHAN)

Room No. 156, A-Wing, Nirman Bhawan, New Delhi-110 011

Tele : (0) 011-23061863, 23063221, Fax : 011-23061252, E-mail: secyhfw@nic.in

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Training Module for Health Care Providers to deal with Post COVID Mental Health issues-for doctors & nurses

PROF. (Dr.) SUNIL KUMAR MBBS & MS (AIIMS)

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Government of India

Ministry of Health & Family Welfare Directorate General of Health Services

Message

Having gone through the first wave and being in the middle of the second wave of the COVID-19 pandemic, we have learned many important lessons and we continue to evolve in our public health measures and the care being provided through our country’s healthcare delivery system.

Mental health issues are some challenges which have re-emerged during the COVID and the Post GOVID times due to various factors. While we may not have all the provisions to prevent them happening, we must build the capacity of the healthcare workers particularly the doctors and nurses to be able to recognize and manage them efficiently.

An effort in this direction is this training module for the doctors and nurses.

I congratulate the entire team of experts under the leadership of Professor Rajesh Sagar, Psychiatry Department, AIIMS for their tireless efforts in bringing this module out in record time.

I sincerely urge the states to utilise their relevant faculty members as trainers to train their healthcare workers using this module. Any feedback either on the design of the training module in terms of content or information therein is welcome for future editions.

Room No. 446-A, Nirman Bhawan, New Delhi-110108

Tel: 011-23061063, 23061438 Fax 011-23061924 Email: dghs@nic.in

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Acknowledgement

The COVID-19 pandemic has had a major impact on our lives in terms of morbidity and mortality, chief among them being effects on mental health. The need for capacity building amongst the health care providers to be able to diagnose, treat or refer to appropriate facilities has been felt by many experts.

We wish to thank Dr. Sunil Kumar, DGHS for instilling the thought of addressing the need for training Doctors and Nurses to deal with Post COVID Mental Health issues and giving responsibility to the team to come up with a training module.

Along the journey, the most significant contribution was from the core team led by Dr. Rajesh Sagar (Vice Chairman, Prof., Psychiatry, AIIMS, Delhi) and the members consisting of Dr. C. Naveen Kumar (Prof., Psychiatry, NIMHANS, Bengaluru), Dr. Nand Kumar (Prof., Psychiatry, AIIMS, Delhi), Dr. Vijender Singh (Prof. and Head, Psychiatry, AIIMS, Bhopal), Dr. Ajay Chauhan (MS, Govt. Mental Hospital, Ahmedabad), Dr. Nishant Goyal (AP, Psychiatry, CIP, Ranchi), Dr. Vijay Gogoi (AP, Psychiatry, LGBRIMH, Tezpur), Dr. Rajeev Ranjan (AP, Psychiatry, AIIMS, Patna), Dr. Vandana Choudhary (Clinical Psychologist, AIIMS, Delhi).

I also wish to thank the cooperation and contribution from my colleague Dr. U.B. Das, Senior Chief Medical Officer (EMR), Dr. Pradeep Joshi (NPO, Non-Communicable Diseases, WHO), Dr. Atreyi Ganguly (NPO, Mental Health, WHO), Dr. Shweta Singh (CVH, Consultant-IHCI, WHO), Dr. Abhishek Khanna (CVH, Consultant-IHCI, WHO), Dr. Akash Malik (Senior National Programme Manager- Health Programmes, UNDP), Ms. Akanksha Singh (Partnership Consultant, UNDP) and Dr. Ankita Piplani (Consultant NOHP), and Dr. Prerna Srivastava (Senior Resident, ILBS). Special thanks also go to the CHEB team led by Dr.G. Kausalya, Director (CHEB) for their contributions.

My team members in room no 743 A-wing, Nirman Bhawan had provided all support necessary for making this document see the light of the day in a very short period. I wish to thank all who had been part of this journey.

(Dr. L .Swasticharan) Addl DDG & Director (EMR)

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Training Module for Health Care Providers to deal with Post COVID Mental Health issues-for doctors & nurses

Index

1. Introduction

2. Identifying Symptoms of mental disorders/Psychological Distress

3. Assessment & Screening of Psychological symptoms/Distress

4. Specific vulnerable populations affected due to COVID-19

5. Psychosocial Management

(a) Fostering Resilience & Well-Being

(b) Essential Counselling Skills

(c) Managing Stress

(d) Coping with Grief & Loss

(e) Mental health issues faced by family members/caregivers

(f) Addressing other Psychosocial Issues (stigma, domestic violence & unemployment & financial crisis

6. Self Care Management

7. Psychopharmacological Management

8. Handling Myths & Misconceptions on COVID-19

9. Referral guide & linkages

Sl. No.

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1. Introduction

As COVID-19 continued escalating at an alarming rate across the globe, it was soon declared to the worst hit Pandemic by World Health Organisation (WHO). It unfolded severe pathophysiological impact in millions of people each day and it was soon realised that the impact is not limited to health of people and is multi-dimensional. The COVID-19 pandemic and its associated factors such as strict lockdown policies, physical distancing norms, sudden transition to online communication, immense grief in the families, and financial crisis proliferated stress situations among people exponentially. This resulted in upsurge of adverse mental health issues in many people. Increasing attempts have been made each day to combat the impact of stress. Though many do realise the need for seeking mental health interventions, competing priorities may often prevent them from obtaining required help. With a pre-existing wide gap between doctor-patient ratio in psychiatry, the need for capacity building was soon realised to be one of the most urgent and feasible solution to the issue.

Doctors and nurses are one of the immediate health care professionals with whom people often connect for seeking treatment of immediate health issues. Hence, equipping our doctors and nurses with appropriate skill and training appears to be one of the significant ways in which mental health needs of the masses can be catered for. Present training module presents coagulative efforts from eminent mental health experts of the country to screen, identify people at risk, provide psychosocial support and referral services for post-COVID-19 survivors in addition to enabling heath care workers to optimise their own self-care. Through this orientation manual, we sincerely hope to align with WHO’s vision for capacity building by empowering existing health care system in providing holistic treatment to COVID-19 survivors and their family members.

The module has the following objectives:

1. Awareness related to mental health problems in COVID-19 survivors.

2. Learning about the common mental health problems and their solutions

3. Assessment and Screening of common mental health problems

4. Extending basic mental health services to the COVID-19 survivor and others.

5. Referral to the nearest mental health facility

The content of the module is developed by eminent experts engaged in mental health care across the country. We have attempted to keep our focus on relevant post COVID-19 mental health problems and their solution in best possible way.

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Training Module for Health Care Providers to deal with Post COVID Mental Health issues-for doctors & nurses

2. Identifying Symptoms of mental disorders/Psychological Distress

Psychological distress is defined as the deviation from some objectively healthy state of being. It implies maladaptive patterns of coping often expressed in various forms such as negative feelings of restlessness, depression, anger, anxiety, loneliness, isolation and problematic interpersonal relationships. Let us understand some of the commonly manifested signs and symptoms of psychological distress:

• Physical Symptoms: deceased energy, sleep disturbances, reduced appetite and unexplained physical symptoms such as pain

• Mood Changes: rapid changes in mood, experiencing sadness, anxiety, fear, irritability, crying spells, helplessness or emotional exhaustion

• Behavioural Changes: restlessness, drowsiness, reduced work efficiency, isolation, absenteeism, excessive use of drugs, sleep disturbances and decreased appetite

• Impact on Ways of Thinking: negative thoughts about self, others and the world; Persistent preoccupation with illness worries; or suicidal thoughts

Though many of the above-mentioned symptoms sometimes resolve on its own with adequate coping, however, when such symptoms persist for longer, and significantly disrupts day to day functioning of any person, it becomes clinically relevant and must be taken care of immediately.

COVID-19 and mental health

Population Affected

 General Population

 Persons in isolation and quarantine

 Family members of patients

 COVID-19 patient (during & post infection)

Special Population

 Health care worker

 Other frontline workers  Vulnerable population

Common Mental Health symptoms (post-COVID-19)

 Anxiety, stress, fear

 Low mood

 Sleep and appetite disturbance

 Headache & other bodily complaints  Fatigue, generalized weakness

 Cognitive symptoms

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Depression

Mania/ Hypomania

Bipolar Affective Disorder (BPAD)

• Low mood, decrease interest in previously pleasurable activities, increased fatigability

• Reduced concentration and attention

• Reduced self-esteem and self-confidence

• Feeling guilty and unworthy of anything

• Negative views about the future

• Self-harm or suicide thoughts or attempts

• Sleep disturbances decreased appetite.

• Elevated mood-more than usual enthusiasm, associated with increased self esteem

• Increased speed and amount of physical and mental activity

• Increased sociability, sexual activity, speech output, overfamiliarity, appetite

• Decreased concentration, sleep

• Intensity and duration

of symptoms required to distinguish between mania and hypomania

• At least one episode each of depression and mania/hypomania

Panic Disorder

Generalized Anxiety Disorder (GAD)

Obsessive Compulsive Disorder (OCD)

• Attacks of severe anxiety not limited to a specific circumstance

• Sudden onset of palpitations, chest pain, choking sensations, dizziness, and feelings of unreality

• Fear of death, being out of control or going mad

• Restlessness, heart beating, excessive worrying not restricted to any specific event or person

• Nervousness, trembling, muscular tension, sweating, light-headedness, palpitations, dizziness, epigastric discomfort

• Obsessions- Repetitive thoughts, ideas or images which are unpleasant or distressing but cannot be resisted

• Compulsions- Stereotypical acts or rituals, not enjoyable, but believed to be required to prevent any harm in response to obsessions

Common Psychiatric Disorders (post-COVID-19)

 Anxiety disorders

 Depressive Disorder

 Post-Traumatic Stress Disorder & other stress related conditions  Psychosis

Starting points in identification:

– Identify any stressor in the last few days other than COVID-19

– A general picture from their informant about their pre-morbid personality (how they

were in pre-COVID-19 times)

– History of any psychiatric illness

a. Clinical features of mood related disorders

b. Clinical features of anxiety related disorders

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Training Module for Health Care Providers to deal with Post COVID Mental Health issues-for doctors & nurses

c. Clinical Features of stress related disorders

Acute Stress Reaction

Post-Traumatic Stress Disorder (PTSD)

Adjustment Disorder

• Sudden onset

• Significantly severe

reaction due to a very severe physical or mental stress or (catastrophe, accident, assault) as a victim or carer

• Lasts for hours to days

• Daze followed by a change

in consciousness, reduced attention, comprehension difficulty

• Could lead to other disorders

• Delayed reaction to a stressful event

• Usually following a traumatic or catastrophic event

• Reliving it in flashbacks

or dreams, emotionally unresponsive, decreased interest in anything pleasurable

• Hypervigilance, startled responses, panic, aggression

• Lasts from few weeks to months

• Distress following a stressful event in the last one month

• Dramatic or violent behaviour

• Inability to cope, plan ahead

• Lasts from a few weeks up to 6

months

d. Clinical features of psychosis

 Social withdrawal

 Abnormal or disorganized behaviour

 Unusual or strange appearance

 Unable to understandable talk/non-sensible speech

 False beliefs (e.g. “family members are planning to kill me’’)

 False perception (e.g. hearing voices of people not around)

 Neglect of usual responsibilities related to work/school/domestic chores

 Restless and wandering around

 Talking to self

 Violent/aggressive behaviour

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3. Assessment and Screening of Psychological Symptoms/Distress

Presented here are some of the broad ways in which doctors and nurses can make specific investigations into identifying psychological symptoms and distress.

General Principles in Assessment

• Communication should be clear, empathic, and sensitive to age, gender, culture and language differences.

• Respond to the disclosure of private and traumatic information sensitively.

• Use easy words, drawing flow charts, providing video suggestions, or reading material

• Check what and how the person understood about their health from the discussion.

Assessment

• Take a medical history, history of the chief complaint(s) in their words, past history and family history, as relevant.

• Perform a general physical assessment.

• Assess, manage, or refer, as appropriate, for any concurrent medical conditions.

• Assess for psychosocial problems, noting the past and ongoing social and relationship

issues, living and financial circumstances, and any other ongoing stressful life events.

Steps of History Taking

Step 1: Initiating Rapport Building- Inform them about the confidentiality of information Step 2: Socio-demographic Details

Step 3: History of Present Illness- Chief complaints, associated factors, functionality Step 4: Family history- Genogram, family structure, family history of psychiatric illness Step 5: Personal history- Developmental, education, occupation, sexual, menstrual

Step 6: Past Psychiatric and medical history

Mental Status Examination

• Appearance and behavior

• Mood

• Speech

• Thought form and content

• Perceptual disturbances

• Higher mental functions/Sensorium & cognition

• Judgment & insight

Screening questions of common mental disorders

Begin by asking about general questions such as if sleep and appetite have been normal or disturbed in the last 2 weeks. Then begin specific questions on signs of common mental disorders such as:

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Training Module for Health Care Providers to deal with Post COVID Mental Health issues-for doctors & nurses

Depression

– Do you feel sad most of the time in the last few weeks?

– Have you lost interest in regular daily activities in the last few weeks? – Do you feel tired all the time in the last few weeks?

Suicidal Warning Signs

– Does he/she have been lately talking about no meaning in living or death as the solution to problems?

– Does he/she have been lately talking about feeling helpless, hopeless and burden to other?

– Does he/she show inconsolable signs of sadness and irritability

– Has he/she tried searching for ways to kill self or attempted to do so?

– Has he/she been calling people to say final goodbye?

Anxiety

– Do you get anxious or tensed for trivial reasons in the last few weeks?

– Have you not been able to stop or control worrying in the last few weeks?

Substance Use Patterns

– If you have been using tobacco, has its use increased in the last 3 months (cigarettes, bidis, chewing tobacco, etc.)?

– If you have ever using alcohol, has its use increased in the last 3 months (beer, brandy, whisky, toddy etc.)

Severe Mental Illness

– Does he/she have poor self-care/wandering behavior in the last few weeks?

– Does he/she talk excessively/sleep less/ been more active than usual in the last few weeks? – Does he/she have suspiciousness/make big claims in the last few weeks?

– Does he/she have suicidal, self-harm or aggressive behavior in the last few weeks?

It is important to make note of the chief issues identified in a screening interview along with noting the impact of each of these on their lives, if they are able to deal with the issues and lastly have they sought any treatment for the problems described.

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4. Specific Vulnerable Population affected due to COVID-19

a. Children & Adolescents

How has COVID-19 affected the mental health of children and adolescents?

• Behavioural- Irritability, temper tantrums, dissociative spells, verbal and physical aggression, increased use of technology, high risk behaviour

• Emotional-Anxiety, crying spells, low mood, low frustration tolerance

• Cognitive- Excessive worry about future, family, health and safety, difficulty concentrating,

reassurance seeking, negative thoughts about self, others and future

• Physical- Sleep disturbances, nutritional deficiencies, change in appetite, lack of physical

activity, significant weight change

• Developmental- Decreased environmental stimulation, set back in learnt academic and

non-academic skills

Management strategies

• Cognitive-Discuss the pandemic

• Play- Games or activities they enjoy, preferably together

• Social- Connecting with others virtually, through groups, assignments, classes

• Physical- Exercising, dancing, stretching

• Internal- Mindfulness, gratitude, reflection

• Down time- Letting your thoughts wander, relaxation

• Sleep/Resting- Fixing the timings, no stimulating activities before it, sleep hygiene

b. Elderly population

How has COVID-19 affected the mental health of the elderly?

1. Consider themselves at the end of their own life

2. Dependent on their caregivers/ helpers/ paid carers

3. Feelings of loneliness, depression, and isolation

4. Reflecting on the life they have lived and come away with either a sense of fulfilment from

a life well lived or a sense of regret and despair over a life

Management strategies

• Normalizing their reaction to the uncertain conditions

• Psychological debriefing-Emotional and psychological support

• Reminiscing-Listening to their narrative and experiences

• Limiting COVID-19 related news, audio, video content (30 mins/day)

• Gratitude-Taking time to expressing what one is grateful for Spiritual routines

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Training Module for Health Care Providers to deal with Post COVID Mental Health issues-for doctors & nurses

5. Psychosocial management

a. Fostering Resilience & Well-Being

WHO defines mental health as “a state of well-being in which each individual realizes his or her own potential, can cope with the normal stresses of life, and is able to make a contribution to his or her community” The definition emphasizes that the mere absence of mental illness is not mental health. Thus, both positive emotions (joy, gratitude, interest, hope etc.) and negative emotions (anger, sadness, fear, frustration, etc.) are natural to human beings. While one should always try to manage negative emotions, they should also strive for achieving resilience and well-being. Resilience is defined as the ability of people to bounce back after adversities and well-being. In simple words it is the presence of positive emotions, absence of negative emotions, satisfaction with life, and a sense of fulfilment. Ways of achieving this are as follows:

Develop Positive Emotions

■ Cultivate emotions of gratitude and forgiveness for the past.

■ Practice mindfulness by slowing down, connecting with your immediate surroundings,

refocusing, and engaging with the present. Use your five senses to experience the moment that you are in now. Listen to the sounds of nature, observe your surroundings, feel the touch. It can be practiced anywhere and anytime.

■ Build hope and optimism for the future.

Engagement in Activities

■ Identify and make a list of your character strengths/values. Examples of strengths are kindness, bravery, help, curiosity, hardworking, etc. These are not talents like being able to play a musical instrument.

■ Use these strengths in new ways and develop that strength by setting a specific, measurable goal and a plan to achieve that goal.

■ Involve in activities where you lose a sense of time (e.g., gardening, reading, playing music, etc.)

Building Relationships

■ Engage with your close relatives actively and listen to what they have to say in an active constructive manner. E.g., instead of simply saying congratulations on their success, you can highlight specific projects which made are all impact and thus lead to success.

■ Get in touch with people you have not seen in a while.

Having a Purpose in Life

■ Having a purpose helps the individual focus on what is essential in times of adversity.

■ Engage in acts of kindness for others.

■ Get involved in serving something more significant than self (e.g., religious institutions,

social causes, organizations, etc.)

Physical Activity

■ Make time for your physical activity without hampering your commitments. ■ Choose the appropriate activity for you based on your health and preference.

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■ Set achievable goals for measuring your progress and start slow.

■ Practice Yoga, aerobics, muscle-building exercises; play a sport or game.

Maintain Sleep Hygiene and Balanced Nutrition

■ Maintain a good sleep routine, even during weekends.

■ Use the bed only for sleep.

■ Avoid large meals, caffeinated drinks, alcohol, and screen use before bedtime.

■ Eat a balanced diet comprising of fruits, vegetables, protein depending on your health

condition.

b. Essential Counselling Skills

Though the content of psychosocial counselling may vary with each patient, it is more likely that a strong therapeutic relationship forms the foundation of bringing out effective changes in the lives of people. This section thus outlines some of the key ethical principles guiding counselling sessions along with brief introduction to the core skills of an effective help provider

Ethical principles are the rules or standards governing the conduct of the counselling process. These are as follows:

1. Do Good & Don’t Cause Harm

2. Respect & Accept their Treatment Choices

3. Maintain Privacy of Identify & Information

4. Respect for the Rights and Dignity of the Patient 5. Be Trustworthy & Fair to Everyone

Core Counselling Skills

1. Built Trustworthy Therapeutic Relationship

2. Actively listen to their concerns and convey understanding, validation, and acceptance of

their distress

3. Keeping empathy towards understanding patient’s completely from their point of views 4. Being genuine, honest, non-defensive, non-role playing, and unpretentious

5. Having a non-judgmental approach

6. Using simple language than medical jargons

7. Being flexible to adapt counseling as per each patient’s needs

8. Allowing silence and time for patients to speak up

9. Always respecting patient’s needs and consent

10. Sensitiveness to patient’s cultural background

c. Managing Stress

Feeling overwhelmed during such a pandemic is a natural and expected response. Some of the ways in which doctors and nurses can suggest people to manage stress are as follows: Acknowledge and Normalize distress

Help people gain perspective that its normal to feel overwhelmed during times of stress.

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Training Module for Health Care Providers to deal with Post COVID Mental Health issues-for doctors & nurses

Discourage any attempt to suppress emotions or distract from them as ignoring distress escalates it in the long run. Acknowledge and validate all their concerns.

Encourage Ventilation of Emotions

Encourage persons to reconnect with their existing support network (family members and friends) and regularly express to them about all their emotions and thoughts. Maintaining a daily journal also allows one to engage in this process regularly.

Teach Simple Relaxation Skills

Following 2 major types of simple breathing exercise can be explained to patients:

Deep Breathing

1. Sit in an interruption-free place in a comfortable position on the chair.

2. Breathe in through your nose quietly for four seconds

3. Now hold your breath for count of seven

4. Exhale completely through your mouth, making a whoosh sound to a count of eight. 5. Now inhale again and repeat the cycle three more times for a total of four breaths.

Diaphragmatic Breathing

1. Sit in an interruption-free place in a comfortable position on the chair.

2. Close the eyes and keep the hands on the belly

3. Taking a long deep breath in through the nose and letting belly push to hand out.

4. Breathing out through pursed lips as if someone is whistling. Feeling the hand on the belly

go in and using it to push all the air out.

5. Doing this breathing for 5 to 10 times.

Encourage Positive Self-Talk

Replace negative self-statements (“I will never be okay”; “Nothing good ever will happen to me”) with positive and self-compassionate self-statements (“I will do the best I can”; “Given the reality of COVID-19, this was all that I could have done to manage the situation”). Encourage Engaging in Self-Soothing Activities Daily

Encourage people to relieve stress by doing something self-soothing each day, even if for a short-while. For example, reading a motivating book, singing, cooking or gardening.

d. Coping with Grief & Loss

COVID-19 has claimed many lives so far, many of which happens suddenly, unexpectedly, and sometimes in a traumatic manner. This leaves people with deep grief which are at times too hard to handle. For example, continuing thought pattern about not having done enough, avoiding, or changing grief, imagining alternate scenarios where the loss did not happen and intrusive thoughts about how it is unfair. Some other helpful thinking patterns include remaining angry and bitter about the loss, undermining the ability to face the future after the loss, excessive dwelling on or avoiding any reminders of the loss, refusing support from others and prominent

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guilt of having survived beyond the deceased. The quality or intensity of grief changes over time and not every grieving person requires therapy or psychological help. It is not a mental disorder. Mourning aids those grieving in adapting to the loss and over time integrating it into daily living. However, some of the key things doctors or nurses can emphasise when someone reports grief is to help them to adaptively process it which are as follows:

1. Actively and empathetically listening to the bereaving family members. Allow them to ventilate their emotions and validate their expressed emotions. Provide unconditional acceptance and support.

2. Help them understand that grieving is a process which is very subjective to each person. There is no right and wrong way of grieving. Grief takes times for its processing and that people should allow themselves this time to process grief.

3. Help them understand that running away from reminders of the person, suppressing their feelings for them, or distracting from the memories never helps in dealing with grief. Rather, acknowledging, processing, and expressing helps to gradually mourn.

4. Encourage people to actively seek social support and express their feelings to their loved ones.

5. Help them to identify what gives them hope and courage. Encourage them to keep practicing those to gain strength on daily basis.

6. Help them reconnect with their lives in the meaningful ways again.

7. At the end of such session, do let them know that it’s okay if they are not being able to handle it now. Encourage them to try. However, do spread awareness that sometimes a psychotherapist can also help them in assisting through the process of mourning. Provide

few local services available and encourage them to seek help when required.

e. Mental Health issues faced by family members/caregivers

The family members and the care givers may suffer severe anxiety pertaining to self-infection and passing the infection to friends, families, and their other close contacts. Such constant fears of getting the infection and uncertainties prevailing around, can lead to the development of mental stress. Also, people with an already existing mental health condition may feel even more distressed, and there can be an increase in their problems.

The main source of stress especially for the family member or caregiver is day-to-day responsibility stress, due to a sick person. As a caregiver, they may feel responsible for safety and care of affected family member. Sometimes they may witness or even directly experience terrible things, such as death, severe illness and suffering, social stigma, and discrimination.

The family members, due to Covid -19, could not conduct the normal rituals and processes that help them grieve and say final goodbye to their loved ones or family members, due to risk of spread of infection. Any loss of family member, relative or friend can be devastating and agonising to a person. It can have feeling of anger and frustration that they are not able to remember and honour them the way they want.

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Training Module for Health Care Providers to deal with Post COVID Mental Health issues-for doctors & nurses

The family members/caregivers may suffer various mental health symptoms and disorders as described in section-2

The management principles and strategies are essentially the same as mentioned in this document

f. Addressing other Psychosocial Issues

The psychosocial impact of COVID-19 has been profound. The three major core issues which have been voiced by many people recovering from COVID-19 has been discussed below along with eluding the ways to identify and manage it.

Stigma & Discrimination

Stigma is broadly defined as a negative attitude or a strong feeling of disapproval about certain individual based on some distinguishing characteristics such as having a specific disease like COVID-19. While discrimination is defined as a behaviour where someone with stigma treats another person as inferior. Some of the ways of identifying stigma and discrimination are as follows:

1. Labelling other with derogatory names such as “Corona waali family”, “Corona waali gali”, “Super spreaders”, “Corona carriers” and “COVID-19 patients”

2. Blaming the person of malicious intent of either hiding the testing or diagnosis status of COVID-19

3. Carrying Misconceptions around various facts associated with COVID-19

4. Overgeneralized conclusions. For example, saying that “all those diagnosed with

COVID-19 in the past will always carry a risk of infection”.

5. Discriminatory behavioural acts, such as, denying essential services (like housing, taxi,

education),

Ways of extending psycho-social support to people experiencing stigma and discrimination are as follows:

1. Using non-stigmatising language to address people with COVID-19 or their concerns.

2. Clarifying misconceptions and staying informed about COVID-19 facts. Hence, encourage

people to obtain and forward information from credible source of information like the address/speech by experts of the disease, or obtaining authentic information available on the website of the Ministry of Health and Family Welfare, Govt. of India (https:// http://www.mohfw.gov.in/), World Health Organisation (WHO) and Indian Council of Medical Research (ICMR).

3. Showing trust, compassion, and support for other going through difficult times of the pandemic. Appreciate and show compassion towards Health Care Workers (HCWs) working immensely to combat the impact of COVID-19.

4. Narrating Recovery Stories which are likely to create hope in public that might help individuals come out with their symptoms instead of hiding them

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5. Self-compassion especially when we start criticising ourselves or feel bad about spreading the infection or are unable to help ourselves or the people around us. Reach out and talk to someone you trust in such a situation, ventilate your feelings and receive support.

6. Find your own zone of impact and continue making efforts in overcoming the pandemic

Domestic Violence

Domestic violence is abusive behaviour occurring in a family or a couple relationship that presupposes cohabitation. Domestic violence tends to increase in any emergency situations such as current COVID-19 pandemic as it is associated with increase in economic hardships, disruption of social network with decreases access to protective and support services. Such conditions may stimulate violence in families where it did not exist before and worsen situations in homes where mistreatment and violence has been a problem. Since violence in the home has an overall cost on the society, leading to potentially adverse physical and mental health consequences, it is urgent to identify the various forms of violence, its early warning signs and respond appropriately to deal with it.

Whenever a clinician identifies red flag indicators of domestic violence, first-line psychosocial support should be offered to person’s emotional, physical, safety, and support needs without intruding their privacy. WHO propagates the first line support of domestic violence involving 5 simple tasks, summarized in the form of acronym called as “LIVES” which indicates following:  Listen: Listen to the person closely, with empathy, and without judging.

 Inquire about Needs and Concerns: Assess and respond to their various needs and concerns—emotional, physical, social and practical (e.g. childcare)

 Validate: Show them that you understand and believe. Assure them that they are not to blame.

 Enhance Safety: Discuss a plan to protect them from further harm if violence occurs again.

 Support: Support them by helping them connect to information, services and social support.

Unemployment & Financial Crisis

COVID-19 has been translated from unprecedent health crisis to economic crisis, putting at risk both the income as well as means of earning livelihood for millions of people across globe. Some of the chief ways of supporting other facing financial crisis due to unemployment are as follows:

1. Help them express all their concerns related to their financial crisis to the HCWs. Convey understanding of the distress and validation of their concerns

2. Help them acknowledge that this is an unusual situation of uncertainty. Provide reassurance (in a realistic way) that the situation is transient and will soon resume back as previously

3. Build hope by talking about recovery stories and success of the vaccination drive which

would help in containing the virus and its adverse impact soon 19

Training Module for Health Care Providers to deal with Post COVID Mental Health issues-for doctors & nurses

4. Encouraging self-employment with skills they already have or joining an organisation dedicated at generating employment opportunities relevant in the present scenario like stitching masks etc.

5. Spread awareness on utilising healthier coping mechanisms for stress such as seeking support from others, exercising every day, or practicing activities which provide profound relief in their distress.

6. Collect and provide them with all the necessary information available from central and state government to seek relevant help and support.

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6. Self-Care management

Post COVID-19 recovery period is stressful for both patients, caregivers as well as HCWs. Self-care is thus vital to nurture themselves and ensuring their well-being. Some of the ways of optimising self-care on daily basis are as follows:

1. Maintaining Healthy Lifestyle: This refers to the process of ensuring that the physical

health of a person is well-nourished and fine. This can be done by eating food with balanced and good nutrition every day at regular intervals, having sufficient rest or sleep and involved in necessary exercise or yoga. Attending to signs and symptoms of distress on the body in time with taking care of pre-existing illnesses would also be an essential step towards optimising physical health.

2. Self-Compassion: Be mindful of critical and harsh statements and turn them into compassionate thoughts. Rather than saying “I have failed”, replace it with compassionate thoughts such as “I did everything with limited resource and personnel”. Similarly, rather than saying “I can never do this”, say ‘I need a break and some support before I get back to it”.

3. Stay Connected: Actively seek social support and share stress with loved ones or colleagues going through the similar difficult times. Remind yourself that you are not alone in the journey. Locate a quality time with their family members and other significant others to socially connect.

4. Cognitive Coping: Pay attention to the inner dialogue and do not automatically believe your thoughts. Challenge it if it is fact or just a passing by fleeting thought or opinion. Also ask yourself if that thought is helpful? Acknowledge the distress that the thought brings. Let the thought go and focus on something which is more helpful for you at that moment.

5. Structure Your Routine: As pandemic is associated with much distress related to uncordialities of life and loss of regular living, structuring routine helps in bringing certainties and focus to life each day. Chart out a little routine for yourself and appreciate yourself if you can comply with it. Keep both the regular as well as pleasurable activities in each day to sustain your motivation.

6. Locate and Focus on Your Control Zone: Classify your anxiety as those falling within your control zone and those outside your control. Try not elaborating much on things in out-of-control zone and keep practicing and making a difference where you can. This also helps in attaining self-confidence and keeping motivation through the day alive.

7. Gratitude Journaling: Maintain a gratitude journal where you can acknowledge and write about all the good things in life which you are grateful for. This helps to shift your focus on positive emotions each day.

8. Practice What Already Helps You: Review all the stressful times of the past and some of the key coping skills which have always helped you to overcome it. Use those unique skills to manage your current stress as well.

9. Seek out for specific mental health support whenever required. Reach out to local mental health professions available.

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Training Module for Health Care Providers to deal with Post COVID Mental Health issues-for doctors & nurses

7. Psychopharmacological Management

These treatment guidelines are in accordance with the List of Psychotherapeutic drugs/Medicines for Distt. Hospital/CHC/PHC vide MOHFW GOI notification dated 18.05.2018 and the recent tele-psychiatry operational guidelines2020.

General Principles for pharmacological management

• Start low and go slow

• Injectable psychotropic to be used under direct supervision of psychiatrist

• Explain patient and family about common side effects of medication

• In case of serious side effects/toxicity, please contact nearest medical college/tertiary care

centre

Pharmacological Treatment for Psychotic disorders

Drugs

Dosing (Mg/Day)

Side Effects

Special Comments

Olanzapine (Oral)

Starting dose:5 mgUse- 10-20mg/day

Common: Sedation, hypotension, Constipation, dry mouth, dyspepsia, increased appetite, akathisia, and tremor.

Serious: Metabolic syndrome, EPS

Monitor weight, lipid profile, abdominal circumference Monitor Blood sugars and transaminases. ‘List A’**for telepsychiatry prescription.

Risperidone (Oral)

Starting dose: 1-2 mg daily.

Increase to 2- 8 mg daily

Common: sedation, dizziness, orthostatic hypo tension, tachycardia, anxiety, nausea and vomiting

Serious: metabolic effects (elevated lipids, insulin resistance, weight gain), EPS, elevated prolactin, sexual dysfunction, neuroleptic malignant syndrome (NMS)

High incidence of EPS- careful monitoring needed. Monitor for drug interaction with fluoxetine (can increase the blood levels).

‘List A’** for telepsychiatry prescription.

• Action starts in 2-3 weeks, Clinical response in 4-6 weeks & usual course of medication for 6-9 Months

• Initial FU@2-4 Weeks> If improvement, follow the patient monthly> If NO improvement, Refer to Psychiatrist/Medical college/tertiary hospital

*Extra pyramidal Syndrome (EPS):

• Typically, a triad of tremors, rigidity (Cogwheel type) and bradykinesia along with mask

like faces and slowed gait.

• Akathisia: -50% of all the patients presenting with extra pyramidal symptoms.

• Characterized by restlessness, difficulty is sittings till or strong urge to more about.

22

Drugs

Dosing

Side effects

Special comments

Escitalopram (oral)

Starting dose -5 mg Use-15-20 mg/day

Common side effects: Sedation, insomnia, headache, dizziness, gastrointestinal disturbances, changes in appetite, and sexual dysfunction-anorgasmia and delayed ejaculation.

Serious side effects: Serotonin syndrome, bleed in tendencies, Low sodium levels, SIADH

Use with caution in patients with bipolar disorder unless treated with concomitant mood-stabilizing agent

List A*of telepsychiatry prescription

Fluoxetine (Oral) (also, treatment for obsessive compulsive disorder)

Starting dose- 20 mg Use-20-40 mg/day

Common side effects: Sedation, insomnia, headache, dizziness, gastrointestinal disturbances, changes in appetite, and sexual dysfunction-anorgasmia and delayed ejaculation.

Serious side effects: Serotonin syndrome, bleeding tendencies, low sodium levels, SIADH

Starting dose for children- 10mg/day. Avoid with warfarin, NSAIDs and aspirin as may cause bleeding abnormalities List A* of telepsychiatry prescription Monitor

for paradoxical suicidal tendencies

Drugs

Dosing

Side effects

Special comments

Sodium Valproate (Oral)

15 mg/kg/day with maximum of with maximum of 60 mg/kg/day

Use-500-1500 mg/day

Common Side effects: -Nausea, vomiting, diarrhea, sedation, gain, loss of hair.

Serious side effects- Tachycardia

Or bradycardia, hepatotoxicity, pancreatitis, sometimes fatal

Before starting treatment, complete blood counts, coagulation tests, and liver function tests

Avoid in pregnancy & children under 2yearsold, use lower doses in elderly List A*of telepsychiatry prescription

Pharmacological Treatment for Depressive Disorders (also for anxiety disorders)

• Action starts in 2-3 weeks, Clinical response in 4-6 weeks & usual course of medication for 6-9 Months

• Initial FU @ 2-4 Weeks >If improvement, follow the patient monthly>If NO improvement, Refer to Psychiatrist/Medical college/tertiary hospital

Pharmacological Treatment for Bipolar Disorders

23

Training Module for Health Care Providers to deal with Post COVID Mental Health issues-for doctors & nurses

Pharmacological Treatment for Generalized Anxiety and sleep disorders

Drugs

Dosing

Side effects

Special comments

Clonazepam (Oral)

0.5-3 mg

Common side effects-Sedation, fatigue, dizziness, ataxia, slurred speech, weakness, forgetfulness, confusion, hypotension, dry Mouth

Serious side effects-Respiratory depression, hepatotoxicity, ataxia, teratogenicity.

High risk of abuse-Schedule IV drug Strict dose monitoring as tolerance develops over long- term use

Avoid driving and other activities

Requiring high attention.

Avoid use in third trimester-floppy infant syndrome and neonatal withdrawal.

List A*of telepsychiatry prescription

Zolpidem (Oral)

5-10 mg/ day

Common side effects: Dizziness, memory loss, mental/mood/ behavior changes (such as new/ worsening depression, abnormal thoughts) Serious side effects: thoughts of suicide, hallucinations, confusion, agitation,

Aggressive behavior, anxiety.

Short term use of 4-6 weeks Rare cases of Abuse and dependence reported

Pharmacological Treatment for Extra-pyramidal Symptoms

Drugs Dosing Side effects Special comments

Trihexphenidyl (Oral)

Start-2 mg daily. Maximum-10 mg/day in divided doses

Common Side Effects-Dry mouth, blurred vision, diplopia, Confusion, Constipation, nausea, vomiting Serious Side Effects-Angle-closure glaucoma, Heatstroke, Tachycardia,

cardiac arrhythmias, hypotension, urinary retention, myasthenia gravis and GIT obstruction.

Can exacerbate or unmask tardive dyskinesia

Contraindicated in angle closure glaucoma.

List A*of telepsychiatry prescription

Inj. Promethazine

Use:25-50 mg

Common side effects- epigastric distress, nausea, vomiting, diarrhea, and constipation, dry mouth, urinary retention, blurred vision, and

constipation.

BP monitoring for hypotension.

Do not use in patients with closed angle glaucoma

List A*of telepsychiatry prescription

• Pharmacologic *Telepsychiatry consultation-

• LIST A-Relatively safe medicines with low potential for abuse. These can be prescribed

during first/new teleconsultation.

• LIST B-These are add-on medications used to optimize an existing psychiatric illness.

These can be prescribed in follow-up teleconsultation only.

24

S. No.

Myths & misconceptions

Facts

1

People with mental illness are more likely to get infected with COVID-19.

People with pre-existing mental illnesses as compared to healthy population are vulnerable to acquire infection due to poor immunity, which is same as chronic

Medical illness. Although chances of getting seriously ill are less.

3

COVID-19 Vaccine causes autism and other neurodevelopment disorders in children.

Studies have shown that there is no link between COVID-19 vaccine and autism/ Neurodevelopmental disorders.

5

People suffering from COVID-19 and mental illness can develop black fungus/ Mucormycosis.

This is not true. It can cause infection in any person who has a weak immune system. People suffering from HIV, diabetes and cancer are more at risk.

6.

People who get infected with COVID-19 will die.

It has been seen that 80-90% of the cases are

a symptomatic or have mild symptoms can

be managed at home. Even those who need hospitalization, chances of recovery are good. Survival rates are poor only for patients who are admitted in Intensive Care Units (ICU).

8. Handling Myths & Misconceptions on COVID-19

Below table lists common myths/misconceptions prevalent in our society related to COVID-19 & mental health and related facts.

A Directly affecting mental health

2 COVID-19 vaccine would make individual more prone to psychological symptoms.

4 People with mental illnesses should not get vaccinated.

B Indirectly affecting mental health

7 Catching COVID-19 means you have it for life.

8 The COVID-19 vaccine causes infertility in women/impotency in men.

Only few patientsreported neuropsychiatric manifestation still now.

People with pre-existing mental illness can get vaccinated

In most of the patients test for COVID-19 gets negative within a month.

There is no evidence to suggest it affects fertility.

25

Training Module for Health Care Providers to deal with Post COVID Mental Health issues-for doctors & nurses

9. Referral Guide for Medical Staff

When to Refer

• Refusal of food and medications

• Marked violence and the threat of harm to self or others

• Presence of severe symptoms, poor social support, diagnostic dilemma, and multiple Co-

morbid conditions

• Any disorder with partial / non-response to treatment for four weeks with adequate

doses.

• Moderate to severe risk of Suicide or Deliberate self-harm.

• Complications of Substance withdrawal.

• Severe adverse drug reactions (Fever > 104 F, Lithium toxicity, Idiopathic skin rashes,

hyponatremia)

Principles to Follow

• Gather information about the Telemedicine facilities, National and Local Help line numbers for Psychosocial issues during COVID-19.

• Establish and maintain consultation linkages with tertiary care centers / mental health services.

• Always ensure that the Airway, Breathing, Circulation (ABC) of the patient I maintained and medically stable.

• For acutely violent/aggressive patients, use benzodiazepines or neuroleptics Lorazepam, 2-4 mg, PO or IM–in non-psychosis

• Olanzapine 10mg, PO or IM–inpsychosisHaloperidol,5-10 mg+Promethazine25-50 mg IM

• For all adverse reactions of drugs, stop the offending agents and treat them symptomatically.

• Advise close monitoring of patients by family members who had attempted Suicide Linkages & collaborations

Need for appropriate Linkage with nearby resources such as medical college, mental health institutions, state health services & ongoing National Mental Health Program (NMHP)/District Mental Health Program (DMHP) for the purpose of delivery of clinical care, investigations, referral, Training of Doctors and Nurses in Psychosocial Counselling& mental health care for COVID-19 patients

Helpline contacts

National Mental Health: 08046110007 CHILDLINE: 1098

26

Address:

Address:

Co-Morbid Physical Illness:

Pulse: BP:

Significant Physical Examination Findings

Substance Use History

Reason for Referral

□ Suicidal

□ Threatening of Harm to others/self

□ Refusal of Treatment

□ Children with mentally ill parents

□ Multiple Co-morbidity

□ Poor Response to Treatment

□ Diagnostic Dilemma

□ Others

For Others, please specify there as on for referral

Laboratory results (if any) Treatments Received (if any):

Signature of Doctor (with date)

Referral Form for Physicians

Name of Doctor: Name of Patient:

Registration No. Age:

General Practitioner/ Specialist (tick whichever is Identification Mark: applicable)

Specialty: Guardian Name:

Place of Work:(SC/PHC/CHC/SD H/DH/Others) Relationship with Patient:

Phone No: Phone No:

Gender:

27

NOTES

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