Parallel Pandemic of 2020

Parallel Pandemic of 2020

Dr Arabinda Brahma Dr George V Reddy Dr Sujit Sarkhel

Editors

Dr Arabinda Brahma Dr George V Reddy Dr Sujit Sarkhel

Publication Committee Indian Psychiatric Society

Parallel Pandemic of 2020

(A Publication by Publication Committee, Indian Psychiatric Society)

Editors

Dr Arabinda Brahma Dr George V Reddy Dr Sujit Sarkhel

First Edition: November 2021 @ Indian Psychiatric Society

Published by

Publication Committee

Indian Psychiatric Society Headquarter: Plot 43, Sector 55 Gurugram, Haryana, India, Pin – 122003 http://www.indianpsychiatricsociety.org

ISBN: 9798772377505

All rights reserved. No part of this publication may be reproduced, stored in a

retrieval system, stored in a database and /or published in any form or by any

means, electronic, mechanical, photocopying, recording or otherwise, without the

prior written permission of the publisher.

Acknowledgement

It was indeed a pleasant moment when I was selected as the Chairman of the Publication Sub Committee of Indian Psychiatric Society in this year. I took the charge when the second wave of Covid pandemic was hitting our country. The task was really challenging as this pandemic was considered as the most crucial global health calamity of the century.

I would like to thank the entire executive committee of Indian Psychiatric Society, specially Dr Gautam Saha, Dr NN Raju, Dr TSS Rao, Dr KK Mishra and Dr OP Singh for their support and encouragement at each and every step.

I would also like to thank all the contributors, who have patiently cooperated out of commitment for the subject to make this book possible in a record time.

I would also like to thank the members of Publication Sub Committee and the active and untiring support of the editorial team viz. Dr George V Reddy and Dr Sujit Sarkhel for their support.

The book would not be here without the active support of Research & Publication Consultant team. I acknowledge their commitment and services.

Long Live Indian Psychiatric Society! Jai Hind!

Dr. Arabinda Brahma Chairman Publication Sub Committee, IPS

Indian Psychiatric Society Office Bearers 2021-22

President

Dr. Gautam Saha

Vice President

Dr. N.N. Raju

Hon. General Secretary

Dr. T.S.S. Rao

Hon. Treasurer

Dr. Kshirod K Mishra

Hon. Editor

Dr. Om Prakash Singh

Imm. Past President

Dr. P.K. Dalal

Imm. Past Hon. General Secretary

Dr. Vinay Kumar

Imm. Past Hon. Treasurer

Dr. Mukesh P. Jagiwala

Direct Council Members

Dr. Adarsh Tripathi

Dr. Alka Subramanyam

Dr. Amrit Pattojoshi

Dr. Bhaveshkumar Lakdawala

Dr. Jaisukh M. Parmar

Dr. Kaushik Chatterjee Dr. Ranjan Bhattacharyya Dr. Ruma Bhattacharya Dr. Sandeep Grover

Zonal Representatives Central Zone

Dr. Rajni Chatterji Dr. Sanjay Gupta

Eastern Zone

Dr. Samrat Kar Dr. Sujit Sarkhel

Northern Zone

Dr. Shekhawat B.S.

Dr. Garg P.D.

Southern Zone

Dr. Sureshkumar G. Dr. Vishal Indla

Western Zone

Dr. Parag S. Shah Dr. Sudhir Bhave

Long live IPS!

Parallel Pandemic of 2020

Message

Dear Friends

As the President of the Indian Psychiatric Society, I feel really proud to announce the release of the long awaited book on the mental health aspects of Covid 19: Parallel Pandemic of 2020. This book covers all the essential areas in relation to mental health and Covid 19 and has been enriched by contributions from academicians from all across the country. I wish the entire Publication Committee led by Dr Arabinda Brahma, Dr George V Reddy, Dr Naren Rao and guided by Dr Vinay Kumar and Dr PK Singh all the best for the success of this endeavour.

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Dr. Gautam Saha President , IPS

Dr. Gautam Saha President, IPS

Parallel Pandemic of 2020

Message

It gives me immense pleasure to know that the Publication Committee of Indian Psychiatric Society is bringing out many useful books every year and it is so pertinent that an innovative edition Parallel Pandemic is thought of. We have all witnessed a devastating wave of COVID in 2020 and the immediate and long term impact is immense. The mental health issues of the pandemic have become more burdensome to the humanity which needs more attention and scientific evaluation. I am happy that the subcommittee identified its significance and aptly chosen to bring out a book on such an important are which would be valuable not only to the psychiatrists but also to all those health professionals who work in that area.

The authors must have toiled hard to bring out the latest developments as such a pandemic was not experienced in the recent past. The long COVID is a completely an unknown entity more so when the patho-physiological findings are not so clear- cut. The understanding of the viral pathology is still wrapped in mystery and its long term neuropsychiatric manifestations continue to be enigma. The entire medical fraternity is looking forward to the details in the pages to be uncovered.

I am sure the publication subcommittee under the chairmanship of Dr. Arabinda Brahma is leaving no stone unturned with able assistance from the co Chair Dr. George Reddy and Convener Dr. Naren P Rao under the guidance of an experienced academician Dr. P. K. Singh and resourceful EC Coordinator Dr. Vinay Kumar.

I congratulate all members of the Publication Committee and authors who must have burnt lot of midnight oil for bringing out such a wonderful publication.

Long live Indian Psychiatric Society!

Visakhapatnam

— Dr. N. N. Raju

viii

Dr. N. N. Raju, MD Professor of Psychiatry President Elect, IPS Visakhapatanm

Dear friends,

Long live IPS!

Parallel Pandemic of 2020

Message

I am really happy to know that the Publication Committee of the Indian Psychiatric Society is bringing out the book titled: Parallel Pandemic of 2020. It is indeed a timely initiative and I am sure that the readers will find this collection of articles from reputed authors quite useful. I wish the entire Publication Committee under the leadership of Dr Arabinda Brahma all the best for this and future endeavours.

ix

Dr. TSS Rao Hony General Secretary Indian Psychiatric Society

Dr. TSS Rao Hony General Secretary, IPS

Jai hind! Jai IPS!

Parallel Pandemic of 2020

Message

I am happy to Note that IPS publication ‘Parallel Pandemic of 2020’ is ready for release soon under the able leadership of Dr Arabinda Brahma as chairperson of the publication committee of IPS and Dr George V Reddy and Dr Sujit Sarkhel as co- editors. This valuable piece will soon on the hand of IPS Members and clarify the several mental health issues following the most devastating pandemic of the century. I wish all the members a happy reading.

x

Dr. Kshirod K Mishra Hon Treasurer IPS 2020-22

Dr. Kshirod K Mishra Hon Treasurer IPS

Dear Members

Parallel Pandemic of 2020

Message

I am happy to see that the Publication Committee of the Indian Psychiatric Society is bringing out the book entitled, “Parallel Pandemic of 2020” which is a collection of various articles on the mental health aspects of Covid 19. With each passing day we are becoming aware of the tremendous mental health impact of the Covid pandemic. Hence, this book is expected to meet an urgent need of various health professionals to make themselves aware of the extent to which the entire world has been shaken by the pandemic- both physically and psychologically.

I congratulate the entire Publication Committee of the IPS for such a concerted effort and I wish them all the best!

Om Prakash Singh Hony Editor, Indian Journal of Psychiatry

xi

Dr. OP Singh

Hony Editor Indian Journal of Psychiatry

Parallel Pandemic of 2020

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Parallel Pandemic of 2020

Preface

The COVID pandemic has poured havoc on the entire world. Since March 2020, a series of nationwide lockdowns has brought our society to a halt. With schools, colleges, community centers, places of worship, and recreation shut, people are stuck inside their homes deprived of social exposure causing them to feel loneliness and isolation in addition to the difficulties in carrying out day to day life.

People above 60 years of age and over, and those with any underlying medical problems like high blood pressure, heart and lung problems, diabetes, obesity or cancer, were sad to be at higher risk of developing serious illness. However, anyone can get sick with COVID-19 and become seriously ill or die at any age.

The result is a surge in the number of individuals suffering from mental illnesses. Anxiety and depression are most common among these conditions and are just as disabling as a physical ailment. On one hand, there is a rise in the demand for mental health services, and on the other side due to lockdown restrictions worldwide, disruptions are being experienced by all those trying to reach out for mental health services.

Fact is that all are affected by the COVID pandemic in different way and we can identify different met or unmet needs of different group (e.g. children, adults, elderly, women, migrants, etc.) and also the kind of care, services and mental health treatment they need.

This book is collection of 12 chapters on different population groups as stated in the above paragraph; 10th chapter is on covid-19 pandemic and mental health research; 11th chapter by Prof. Chowdhury et. al. is on impact of COVID-19 pandemic on environment and climate change based on an eco-psychiatric prospective.

Hope this will be a good comprehensive reference book on mental health impact of COVID-19 which can be considered a “Parallel Pandemic” during the COVID-19 pandemic.

— Dr Arabinda Brahma Dr George V Reddy Dr Sujit Sarkhel

Various research studies found an elevated global prevalence

of these mental health issues during COVID-19 and there was a wide variance in

each at the region- and country-level.

xiii

Dr. Amit Singh

Assistant Professor

Department of Psychiatry

King George’s Medical University Lucknow

Dr. Anirban Ray

Department of Psychiatry IOP-COE, IPGME & R

Founder & Child & Adolescent Psychiatrist, Mind Mentors, Kolkata

Dr. Arabinda Brahma

Director, G. S. Clinic

Indian Psychoanalytical Society Kolkata

Dr. Arabinda N Chowdhury

Consultant Psychiatrist Leicestershire Partnership HS Trust, UK

Dr. Avinash De Sousa

Research Associate & Consultant Psychiatrist Lokmanya Tilak Municipal Medical College, Mumbai

Dr. Dhrubajyoti Bhuyan

Associate Professor Department of Psychiatry Assam Medical College Dibrugarh

Dr. E. Mohandas

Senior Consultant Psychiatrist Sun Medical & research Centre Thrissur, Kerala

Dr. G. Prasad Rao

Dr. Gurvinder Pal Singh

Associate Professor

Department of Psychiatry

Govt. Medical College & Hospital Chandigarh, India

Dr. Kamlesh Kumar Sahu

Associate Professor

Department of Psychiatry

Govt. Medical College & Hospital Chandigarh, India

Dr. Karishma Rupani

Assistant professor Department of Psychiatry G.S.Medical College and KEM Hospital, Mumbai, India

Dr. Minhajzafar Nasirabadi

Professor and Head of Department, Deccan college of Medical Sciences, Hyderabad

Parallel Pandemic of 2020

Contributors

Director, Schizophrenia &

Psychopharmacology Div.

Asha Hospital, Hyderabad

Dr. Chytanya Deepak Ponangi

Director, Acute Services

xiv

Dr. Madhiha

Asha Hospital Hyderabad

Junior Resident

Asha Hospital, Hyderabad

Dr. Mrugesh Vaishnav

Contributors

Dr. Shubhangi R. Parkar

Professor Emeritus

Former Professor & Head Department of Psychiatry Former Chief, Bombay Drug Deaddiction Center

G. S. Medical College and KEM Hospital, Parel, Mumbai

Dr. Soumitra Ghosh

Professor & Head

Department of Psychiatry Tezpur Medical College, Tezpur

Dr. Suchismita Roy

Assistant Professor

Visiting Faculty, Indian Institute of Technology Jammu

Dr. Swapnajeet Sahoo

Assistant Professor Department of Psychiatry

Chandigarh

Dr. V. George Reddy

Consultant Psychiatrist

Healthy Brain Clinic & Hospital Alwal,Trimulgherry Secunderabad, Telangana

Dr.Vishal Akula

Associate Professor of Psychiatry Osmania Medical College Hyderabad

Director, Samvedana Psychiatric &

Sex Therapy Hospital

Institute of Psychological and

Sexual Research, Ahmedabad

Dr. N. Chandresh

Junior Resident, Asha Hospital

Hyderabad

Dr. Nilesh Shah

Professor and Head Department of Psychiatry Lokmanya Tilak Municipal Medical College, Mumbai

Dr. Omkar Mahadik

Research Assistant

Desousa Foundation, Mumbai

Dr. P K Dalal

Professor and Head (former), Department of Psychiatry

King George’s Medical University Lucknow, Uttar Pradesh, India

Dr. Sandeep Grover

Professor, Department of Psychiatry, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh

Dr. Savita Malhotra

Former Dean, Professor and Head Department of Psychiatry PGIMER, Chandigarh

Dr. Seujee Goswami

Resident Physician, Department of Psychiatry Assam Medical College Dibrugarh

Parallel Pandemic of 2020

Dr. Sriramya Vemulakonda

Research Assistant

Asha Hospital, Hyderabad

Postgraduate Institute of Medical

Education and Research (PGIMER)

xv

Parallel Pandemic of 2020

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Parallel Pandemic of 2020

Content

COVID-19 and Global Mental Health 1

Sandeep Grover, E. Mohandas

COVID-19 and Mental Health Impact in India – An overview 15 Mrugesh Vaishnav

COVID-19 and Disruption of Mental Health Services 35 Omkar Mahadik, Nilesh Shah, Avinash De Sousa

Undergraduate and Postgraduate Medical Teaching during Covid 46 19 Pandemic.

Soumitra Ghosh, Dhrubajyoti Bhuyan, Seujee Goswami

COVID – 19 Pandemic and Telemedicine Practice in India 56 Minhajzafar Nasirabadi, V.George Reddy, Vishal Akula

Impact of COVID – 19 Pandemic on Women’s Health and 71 Domestic Violence

Shubhangi R. Parkar, Karishma Rupani

Impact of COVID – 19 Pandemic on Child Mental Health 84 Anirban Ray, Savita Malhotra

Geriatric Mental Health during the Covid 19 Pandemic 103 G. Prasad Rao, Chytanya Deepak Ponangi, N. Chandresh, Madhiha,

Sriramya Vemulakonda

Impact of COVID-19 on Substance and Screen Use 115 P K Dalal, Amit Singh

COVID-19 Pandemic and Mental Health Research 126 Sandeep Grover, Swapnajeet Sahoo

Ecopsychiatry and COVID – 19 Global Pandemic: Impact on 147 Environment, Mental Health and Climate Change

Arabinda N Chowdhury, Suchismita Roy, Arabinda Brahma

Mental Health Impact of COVID – 19 Pandemic on Internal 166 Migrant Workers

Gurvinder Pal Singh, Kamlesh Kumar Sahu

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Parallel Pandemic of 2020

xviii

1. COVID-19 and Global Mental Health

Sandeep Grover1, E. Mohandas2

Abstract

The COVID-19 pandemic started from the city of Wuhan in China in November 2019 and, over the period of few months, spread across the globe, affecting almost all the countries. The World Health Organization

(WHO) declared the same as a pandemic on 11th March 2020. The pandemic has led to significant negative mental health consequences in general public at large, persons with suspected COVID-19 infection and in quarantine, patients with COVID-19 infection, patients recovered from COVID-19 infection, family members of persons with COVID-19 infection and the health care workers. The various mental health outcomes have been evaluated in the form of depression, anxiety, post-traumatic stress disorder, insomnia, loneliness, and social isolation. Additionally health care workers have been shown to have high prevalence of burnout. The health care services have also been impacted significantly with restrictions in the hospitalization, and closure of outpatient services. However, during the pandemic the telepsychiatry services have expanded across the globe, more so in the developed countries. The pandemic has caught the governments across the globe unprepared and this has contributed to significant mortality. There is an urgent need to improve the health care infrastructure, across the globe, to tackle the ongoing pandemic.

Keywords: COVID-19, Pandemic, Mental morbidity, Impact

Introduction

The novel corona virus-19 (COVID-19) emerged from the city of Wuhan in China in November 2019 and, over the period of few months, spread across the globe, affecting almost all the countries. The World Health Organization (WHO) declared the same as a pandemic on 11th March 2020. The pandemic brought the world to a standstill. Many countries

1Department of Psychiatry, PGIMER, Chandigarh Email: drsandeepg2002@yahoo.com

2Senior Consultant Psychiatrist, Sun Medical & research Centre, Thrissur, Kerala Email: emohandas53@gmail.com

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Grover & Mohandas: COVID-19 & Global Mental Health

declared nationwide lockdown. The lockdown led to restriction in the movement of people from one place to another, closure of business establishments and offices, schools and colleges, etc., The pandemic necessitated measures like maintaining social distancing, hand hygiene measures, using masks and the use of personal protective equipment (PPEs) for the health care workers, staying away from the family while performing duties in the COVID wards and intensive care units (ICUs). Over the last one and a half years or so, the pandemic has evolved, with many countries facing the second wave and having varying degrees of lockdown.

The pandemic has brought along with it a fear of developing an infection, a fear of dying, losing close relatives, an actual loss of family members, and associated grief. Additionally, the pandemic has adversely affected people’s livelihood and led to the loss of jobs and adverse financial drift with many people moving from middle socio-economic class to lower socio-economic status and resultant poverty. The pandemic is not yet over, and it is uncertain how long the pandemic will continue. Hence, it is predicted that the pandemic will bring in more negative social and mental health outcomes.

This chapter outlines the impact of the COVID-19 pandemic in general and on mental health and mental health services. Based on the available evidence, an attempt has been made to propose a plan to address the mental health issues.

Social Consequences of the Pandemic

As the pandemic unfolded and continues to extend, it has led to prolonged periods of lockdown, restriction in movement, loss of livelihood for people, loss of job, and salary cut. The pandemic has also led to closure of religious places, movie halls, and eating points. It has also led

to significant social interaction difficulties, lack of availability of alcohol

and other licit substances. The need for various commodities and manufactured products has decreased.[1] Many of the business enterprises have closed down or are on the verge of closure. All these suggest that pandemic has brought along poverty for a significant proportion of the world population. Combined with the poverty, the pandemic resulted in health risks even in health care workers (HCWs) and significant stigma for people in quarantine.

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Grover & Mohandas: COVID-19 & Global Mental Health

Impact of the Pandemic on Mental Health Services

The negative effect of pandemic on health care system and workers is reflected in the survey by the World Health Organization (WHO) that covered 130 countries, from August 2020 to August 2020.Multifaceted disruption of mental health care services could be seen: vulnerable group of persons (60% of countries), for children and adolescents (72% of countries), elderly (70% of countries), and women requiring perinatal care (61% of countries, counseling and psychotherapy services (67%), critical harm reduction services (65%), opioid substitution treatment for persons with opioid dependence (45%), emergency intervention services

(33%). The mental health services at the school (78%) and workplace (75%) were also disrupted in the majority of the countries. However, the pandemic has led to the expansion of telepsychiatry services in different countries, with use of the telepsychiatry services in 80% of the high- income countries and less than 50% of low-income countries (World Health Organization, 2020).[2] Another important finding of the survey was that although 89% of the countries reported that mental health and psychosocial support was included in the national plan of the COVID-19 response plan, in only 17% of the countries, additional funding was provided for the mental health services.[2] There is data from different parts of the world that the psychiatry inpatient units were converted to COVID wards.[3] Studies from India also suggest that mental health services were severely impaired during the pandemic, both in the teaching institutes and private practice. The data from India also suggests that almost all kinds of mental health services have been disrupted except for expansion of telepsychiatry services. The surveys also suggested that at many places, especially in institutional settings, mental health professionals were involved in the care of patients with COVID-19.[4,5]

Impact of the Pandemic on Mental Health: General Public

The mental health of the general public has been adversely affected by

the pandemic irrespective of the person suffering from COVID-19 infection, due to a multitude of reasons. A systematic review and metanalysis of data from 62 studies, involving 162,639 participants, spread across 17 countries reported a pooled prevalence of depression to be 28% (23%-32%) and that of anxiety to be 33% (95% confidence interval: 28%-38%) in the general population. There was a lack of significant difference in depression (55%; CI: 48-62%), and anxiety (56%; CI: 39%-73%) in the general public and health care workers (HCWs). Further, the highest prevalence of depression and anxiety was

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Grover & Mohandas: COVID-19 & Global Mental Health

seen among those with pre-existing illnesses. The risk factors which were noted to be associated with the development of depression and anxiety included being women, belonging to the nursing profession, having lower socioeconomic status, having high risks of contracting COVID-19, and social isolation. The factors which were found to be protective against developing mental illnesses include having sufficient medical resources, having correct and up-to-date information, and taking precautionary measures.[6] Besides depression and anxiety studies have also reported a higher prevalence of sleep disorder in the general public (18%).[7] Other adverse mental health outcomes noted in the general public in different studies include loneliness, stress, distress, social isolation, etc in the

general public, people in quarantine, and the HCWs.[8-11] Additionally, HCWs are also facing significant burnout.[12]

The COVID-19 pandemic has forced people to work from home. Available data suggest that work from home has led to an increase in sedentary life,[13] and reduction in mental and physical well-being.[14]

Studies of parents and children suggest psychological distress in a significant proportion of the children, with a higher proportion of those in high school compared to those in primary schools.[15] Other studies suggest that lockdown has led to a significant increase in the prevalence of severe anxiety, sleep-related impairments,[16] increase in screen time,[17] and depression[18] in children and adolescents. Data from different countries also suggest increase in the prevalence of domestic violence against women.[19]

Impact of the Pandemic on Persons in Quarantine

Remaining in quarantine involves staying in isolation. Across the world, the government opened various quarantine facilities and asked people with possible infection or those exposed to persons with COVID-19

infection to isolate themselves for varying duration of time. At places the

red zones were created and the persons were forced to stay indoors in the containment zones. Remaining in quarantine can be very distressing, depending on the place of quarantine, and the level of exposure to the person(s) with COVID-19 infection. A review of data for people in quarantine suggest that people have significant anxiety, depression, sleep disturbances, fear, stigma, PTSD, low self-esteem and a lack of self- control.[11] The various factors which have been shown to be associated with poor mental health outcomes included boredom, frustration,

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Grover & Mohandas: COVID-19 & Global Mental Health

concerns related to infection, longer duration of quarantine, poor information, financial loss, and possible stigma.[20]

Mental Health Issues in Persons with COVID-19 Infection

Suffering from COVID-19 infection leads to remaining in isolation at home, or getting admitted to a health care facility. Some of the patients, who are admitted to the hospital also require a stay in the ICU.The initial reaction to the diagnosis of COVID-19 infection involves shock, disbelief, sadness, anxiety, and panic.[21] A review, which included data from 65 studies of persons who had suffered from severe acute respiratory

syndrome (SARS) in 2002, Middle East respiratory syndrome (MERS) epidemic and COVID-19 infection suggested that during the acute phase of SARS and MERS, a significant proportion of patients developed confusion, depressed mood, anxiety, insomnia, and poor memory. A small proportion of the patients also developed medication-related side effects like steroid-induced mania.[22] Data for patients with COVID-19 infection also suggest that a significant proportion of patients with COVID-19 infection during the acute phase develop delirium.[22] A study from the United Kingdom during the initial phase of the COVID-19 pandemic suggested a high prevalence of delirium (31%), and some of the persons developing new-onset psychosis.[23] Other studies which have focused on patients close to discharge suggest a high prevalence of depression, anxiety, and anticipatory stigma.[21]

Mental Health Issues after Recovery from COVID-19 Infection

It is now well known that the negative mental health consequences of COVID-19 infection persist even after recovery. The systematic review involving patients with SARS, and MERS suggests that during the post- illness phase a significant proportion of patients develop depression, insomnia, irritability, post-traumatic stress disorder (PTSD), anxiety

disorder, cognitive impairment, and fatigue.[22] Data emerging from

COVID-19 patients suggest significant psychiatric morbidity during the immediate post-recovery phase. A large sample size study from the United States involved data of 62354 patients diagnosed with COVID-19 showed an increase in the incidence of first psychiatric diagnosis, during the 14 to 90 days of being diagnosed with COVID-19 that was significantly higher, compared to that among those with other physical illnesses. The hazard ratios, compared to other health conditions were the highest for anxiety disorders, followed by insomnia and dementia. The incidence for any psychiatric diagnosis was 18.1% with the incidence of

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Grover & Mohandas: COVID-19 & Global Mental Health

psychiatric diagnosis for the first time is 5.8%. Based on their findings the authors concluded that the survivors have an increased risk of developing psychiatric syndromes.[24] Some of the studies which have focused on long-COVID also suggest that persons who have developed COVID-19 have a high prevalence of sleep disorders, fatigue and PTSD during the follow-up period.[25]

Impact of the Pandemic on Persons with Acute and Chronic Physical Illnesses

COVID-19 has brought the health care services to a standstill. Due to the

on-going pandemic, routine outpatient services have been disrupted. Similarly, routine surgeries are also being rescheduled or cancelled. This has also led to significant distress among the sufferers as this can lead to progression of disease and death in those requiring proper medical care. One of the studies estimated that 12 weeks of peak COVID-19 disruption could have led to the cancellation of 29,404,603 surgeries across 190 countries.[26] A review of data suggested that delay in surgical procedures involving organ transplantation (60.8%), surgery (21.6%) or cancer care (13.7%) led to significant anxiety and depression among the patients and their caregivers. This has also led to poor quality of life among the patients. The negative mental health consequences were higher for those who had higher waiting times. Other factors which have been identified to be associated with poor mental health consequences include being women, new immigrant, younger age, belonging to low socioeconomic status, and those have lower positive coping skills.[27] These findings suggest that the pandemic has also led to significant collateral damage among people suffering from other physical ailments.

Mental Health Issues among the Family Members who have lost their Relatives due to COVID-19 Infection

As COVID-19 has led to the loss of life of a large proportion of people, it

has left the relatives of these peoples in a state of shock and turmoil,

feelings of guilt and rumination, having a bitter farewell for their loved

ones, and lack of fulfilment of religious rituals. Additionally, the untimely

deaths have to lead to worries related to the future in the form of

stigmatization, consequences in social interaction, financial difficulties,

and issues related to instability of family and job

.[28]

Other studies

suggest an increase in psychological distress, especially in people with

mental disorders

.[29]

The pandemic has left some of the children and

adolescents parentless and abandoned

.[30]

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Grover & Mohandas: COVID-19 & Global Mental Health

Impact of the Pandemic on Persons with Mental Illnesses

The COVID-19 pandemic has severely hit mental health care and little is being understood about the consequences of the pandemic on persons with pre-existing mental disorders. Studies from different parts of the world suggest that a significant proportion of persons with mental illness lack knowledge about COVID-19 and the precautions to be taken and were experiencing relapse of symptoms.[31] The emerging data suggest that persons with mental disorders have a higher risk of developing severe COVID-19 infection, requiring mechanical ventilation, ICU admission, and have a higher risk of mortality due to COVID-19.[32] One

of the studies involving 538 inpatients suggested worsening of symptoms in more than half of the participants with 40% reporting increased need of therapeutic support. The symptom deterioration was seen for depressive symptoms, anxiety symptoms, and sleeping behaviour.[33]

Impact of the Pandemic on Mental Health of Health Care Workers and other Frontline Workers

Studies from different countries suggest that the pandemic has adversely affected the mental health of the HCWs, with significantly high proportion of them reporting high level of stress, psychological distress, depression, anxiety, sleep disorder and burnout.[34-36] The HCWs are also faced with the fear of getting infected and carrying the infecting their family members. Additionally the HCWs are put into tight spot to make difficult decisions with respect to providing care to critically ill patients, resource allocation, and work pressures.[37-39] Besides the negative impact on health care workers, studies involving police personnel’s also, suggest a high level of psychological distress in the form of depression and anxiety.[39]

What can be done to Address the Mental Health Issues

The pandemic is going to continue for some time now and its consequences are going to be seen in the decades to come. Hence, efforts must be made to prevent the development of adverse mental health outcomes, and providing good care to those requiring mental health care.

As the pandemic has exposed the huge gaps in the mental health services across the globe and this call for prioritizing mental health at the earliest, so that everyone on this earth is able to access mental health services and is able to receive quality mental health care (Impact of COVID-19 on Global Mental Health- A Brief). The prevention of adverse mental health

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Grover & Mohandas: COVID-19 & Global Mental Health

outcomes requires formulating strategies to ensure financial stability to people at large. Addressing the psychosocial issues require multi-pronged strategies, starting at the level of governments, employers, non- governmental organizations, etc (Table-1). The governments all across the globe, especially in the developed countries like United States and United Kingdom have come-up with huge financial relief plans for the public.[1] The government of India has also started some of the similar plans, but this requires further expansion.

At the level of healthcare sector different institutions, professional organizations, and private practitioners should make efforts to expand the mental health care services to cater to the mental health care needs of people in distress.

Table-1: Things to be done

Things to be done at the level of the Government

 Policy for retention of jobs, creation of new employment opportunities

 Financial package and schemes to address the issues of different

sectors

 Food security for everyone

 Unemployment allowance/compensation

 Scheme to delay the repayment of loans

 Providing loans at 0% interest rates to start new business ventures

 Tax reliefs

 Provision for free treatment for all

 Supporting orphan children and adolescents

 Supporting the families who have lost their earning members

 Filling up of all government jobs

 Increasing the funding for mental health services

 Increasing the budget for healthcare

 Proper implementation of existing laws and enacting new laws to

provide proper protection to HCWs

 Supporting all health care expenditures

 Insurance coverage for all kind of mental health treatments

 Spending on mental health research

 Awareness campaigns for mental health

 Addressing stigma

 Mass vaccination

 Awareness programs to address the vaccination hesitancy

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Grover & Mohandas: COVID-19 & Global Mental Health

Employers

 Not to remove the employees

 Pay protection for the existing employees

 New recruitments to be done, and at the appropriate salary

Non-governmental Organizations

 Increasing expenditure in health sector

 Creating job opportunities

 Supporting the needy in healthcare expenditures

Health Sector

 Increasing investment in the mental health sector

 Increasing the training opportunities in the mental health sector

 Expansion of tele-mental health services to reduce the mental health

gap and reaching the unreached at places where the mental health

professionals cannot reach

 Expansion of consultation liaison psychiatry services to address the

mental health issues of HCWs, patients with COIVD-19 infection and

those with post-COVID mental health problems

 Expansion of community mental health services

 The mental health services should be able to address the issues

related to grief, burnout, depression, anxiety, etc.

Addressing the issues of HCWs

 Listening to the issues of the HCWs

 Providing adequate infrastructure and working environment to ensure

safety

 Reducing the workload of HCWs by adjusting their work shifts

 Reducing job-related stressors

 Ensuring a healthy working environment to prevent and reduce

burnout

 Increasing the awareness about the negative mental health consequences due to the pandemic

 Screening for mental health issues

 Creating crisis helplines for persons in distress

 Providing mental health care to all the HCWs

Role of Media

 Sensitive reporting of news related to COVID-19

Parallel Pandemic of 2020 9

Grover & Mohandas: COVID-19 & Global Mental Health

Conclusion

A miniscule overview about Covid 19 and Global Mental Health is outlined. We take actions when a pandemic occurs. Instead, preparedness and preventive strategies have to be adopted to counter the pandemic as a whole. For this to happen, an action plan to improve environmental hygiene(waste disposal system, adequate drainage, protection of trees etc),personal hygiene, vaccination strategies, better medical and mental health related infrastructure, alternative health and training modules, better financial planning and educational(awareness) materials with periodic monitoring and transparent accountability, has to be evolved and

implemented in the days to come.

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Parallel Pandemic of 2020 14

Covid 19 and Mental Health Impact In India – An Overview

Mrugesh Vaishnav1

Abstract

India is one of the countries badly affected by Covid 19 with over 34 million confirmed cases and 0.45 million deaths. During the last 21 months of COVID 19 pandemic, common men of this developing country have faced torment and devastation. The uncertainty of an impending third wave is even more stressful. The pre-COVID-19 scenario for mental health in India was grim. One in seven Indians had mental disorders of varying severity in 2017, and Indians accounted for 26·6% of the global suicide deaths in 2016. However, the budget allocated for mental health is 0.05 per cent of the total healthcare budget of the country resulting in poor implementation of effective Public Mental Health (PMH) interventions.

giving rise to new challenges and aggravating pre- existing issues. Several online surveys and meta-analyses report 25% to 35% rise in psychiatric and neuropsychiatric illnesses like anxiety, depression, insomnia, PTSD etc. This review article addresses the extent of Covid19 outbreak, impact on mental health of general populations and vulnerable groups, risk factors for the mental illness and intervention strategies for mental wellbeing.

Keyword: COVID-19, depression, anxiety, insomnia, traumatic stress, intervention strategies

Introduction

Overview of COVID 19 Infection Outbreak in India

The existence of human civilization is being challenged and it is passing through a critical juncture because of the ongoing global pandemic

people in India,

The COVID-19 pandemic has impacted the mental health of

1Director, Samvedana Psychiatric and Sex Therapy Hospital, Institute of Psychological

and Sexual Research, Ahmedabad, Gujarat, India. Ex-President Indian Psychiatric

Society (2019-20) Email: mrugeshvaishnav@gmail.com

Parallel Pandemic of 2020 15

Vaishnav: Covid 19 & Mental Health Impact in India

of Coronavirus disease 2019 (COVID-19), caused by severe acute

respiratory syndrome coronavirus 2 (SARS-CoV-2).[1]

The outbreak was first identified in December 2019 inWuhan,

China.[2] The World Health Organization declared the outbreak as a Public

Health Emergency of International Concern on 30th January 2020 and a

pandemic on 11th March, 2020.[3][4]

The first confirmed case of COVID-19 in India was reported on 30

January, 2020 in Trissur, Kerala, in a medical student who had returned

from Wuhan, the epicentre of the pandemic.[5] After almost 1 year and

nine months, as of 17th October 2021, there are 240,615,743 confirmed

cases worldwide and 4,897,386 deaths while 6,613,894,434 people have

been

vaccinated. In India there has been 34,067,719 total confirmed cases and 4,52,124 deaths while 917,873,889 persons have been vaccinated till date.[6]

As part of a strategy to fight COVID-19, many countries implemented lockdown and other public health measures like social distancing, screening, and compulsory use of masks were implemented by most nations.[7]

As a non-pharmacological intervention, on March 24, 2020, the

Government of India enforced a nationwide lockdown for 3 weeks that

affected the entire 1.3 billion population. On April 14, 2020, the lockdown

was extended till May 3, 2020, which was followed by subsequent 2-week

extensions starting May 3rd and 17th, 2020, with substantial relaxations.

From June 11, 2020, the government started “unlocking” the country

(barring “containment zones”) in three unlock phases.[8]

The United Nations (UN) and the World Health Organization (WHO) have

praised India’s response to the pandemic as ‘comprehensive and robust,’

terming the lockdown restrictions as ‘aggressive but vital’ for containing

the spread and building necessary healthcare infrastructure. The Oxford

COVID-19 Government Response Tracker (OxCGRT) noted the

government’s swift and stringent actions, emergency policy-making,

emergency investment in health care, fiscal stimulus, investment in

vaccine and drug R&D. It gave India a score of 100 for the strict response.[9,10]

Unfortunately, starvation, unemployment, poverty & economic recession brought India down to its knees, hence the country decided to reopen the economy. The Government asked people to be “AtmaNirbhar” “self-

Parallel Pandemic of 2020 16

.[19]

to

Vaishnav: Covid 19 & Mental Health Impact in India

reliant” and declared the so-called (Political)end of COVID19.

and not on medical and public

health data.

In September 2020, India was confirmingnearly 100,000 new coronavirus cases per day.

became the fourth-worst Covid19 affected country in the world and cases

inched closer to the three-lakh mark,[8] Hence the decision to unlock was

When Unlock

1.0 was announced after more than two months of lockdown, India

based on economical & political reasons

By February 2021, daily cases declined

9,000 per-day.[11] However, by early-April 2021, a

dramatically

major second wave of infections took hold in the country with destructive

consequences;[12] By late April, India passed 2.5 million active cases and

was reporting an average of 300,000 new cases and 2,000 deaths per-

day. [13] On 30 April, India reported over 400,000 new cases and over

3,500 deaths in one day.[14]

were proposed, like highly-infectious variants of concern such as Lineage

B.1.617,[15] a lack of preparations as temporary hospitals were often

dismantled after cases started to decline, and new facilities were not

built,[16] and health and safety precautions being poorly-implemented or

enforced during weddings,[17] festivals, sporting events,[18] state and local

elections

Various reasons for the sudden spike in cases

Currently, the country’s Covid cases are declining again as of October

2021, and there is uncertainty about the threat of a third wave of Covid

19 infection, while the vaccination drive has led to almost 100 crores

doses being administered.[6]

[Figure 1]

Facts about Mental Health and its priority in Indian Health care system

One in seven Indians had mental disorders of varying severity in 2017,and Indians accounted for 26·6% of the global deaths by suicide in 2016.The proportional contribution of mental disorders to the total disease burden in India is estimated to have almost doubled between 1990 and 2017. The pre-COVID-19 scenario for mental health in India was grim. Mental disorder is responsible for at least 16% of disease burden in India and 20% globally.[20] Most mental disorders arise before adulthood and have a broad range of impacts across health (including higher rates of physical ill-health and reduced life expectancy), education, employment, social interaction, stigma and crime.[21,22]

in

Health and Neurosciences (NIMHANS) revealed that 13.7% of

Mental Health Survey

2016 conducted by the National Institute of

Mental

Parallel Pandemic of 2020 17

The National

Vaishnav: Covid 19 & Mental Health Impact in India

Figure 1: Extent of COVID-19 infection in India

Parallel Pandemic of 2020 18

Vaishnav: Covid 19 & Mental Health Impact in India

India’s population is suffering from a variety of mental illnesses and 10.6% of these persons require immediate treatment.[23] However, the budget allocated for mental health is 0.05 per cent of the total healthcare budget of the country resulting in poor implementation of effective Public Mental Health (PMH) interventions.[24] Of serious concern is the fact that even globally, only a minority of those with mental disorder receive any treatment, coverage of interventions to prevent associated impacts is much less while coverage of interventions to prevent mental disorder or promote mental wellbeing is negligible.[25] Like elsewhere, the variety and extent of the implications of the COVID-19 pandemic for mental health are yet to be fully understood in India.[26]

Impact of COVID-19 on Mental Health in India

giving rise to new challenges and aggravating pre- existing issues.[27,28] Surveys carried out across the globe during the first

wave of the pandemic

suggested increase in prevalence of various psychiatric disorders like depression, anxiety disorders, and insomnia in general population, patients with acute COVID

infection and in the post Covid infection patients.[29, 30]

A meta-analysis of 5 studies which included data of 9074 persons reported prevalence of stress to be 29.6% (CI: 24.3-35.4%). The same meta-analysis reported prevalence of anxiety as 31.9% (95% CI: 27.5-36.7) and that of depression as 33.7%(95% CI: 27.5-40.6).[31] A recent meta-analysis which pooled data from 65 studies involving 97,333 health care workers from 21countries reported the pooled prevalence of depression as 21.7%

Another study analysed the data using the Global Burden of Disease Study (GBD) model. The COVID-19 Mental Disorders Collaborators[33] provide global insight into the burden of depression and anxiety disorders during the pandemic to date. The authors estimated a significant increase in the prevalence of both major depressive disorder (with an estimated additional 53·2 million [95% uncertainty interval 44·8–62·9] cases worldwide i.e. a 27·6% [25·1–30·3] increase) and anxiety disorders (76·2 million [64·3–90·6] additional cases i.e. a 25·6% [23·2–28·0] increase) when compared to data before the pandemic. Increased prevalence was

The COVID-19 pandemic has impacted the mental health of people

around the world,

in different population groups, including healthcare

workers, patients and quarantined individuals

traumatic Stress Disorder (PTSD) as 21.5% (95% CI, 10.5 34.9%). In terms of

(95% CI,

18.3%-25.2%), anxiety as 22.1% (95% CI, 18.2%-26.3%), and that of Post-

countries, the prevalence rates for depression and anxiety were reported to be

highest in studies from Middle-Eastern countries.[32]

Parallel Pandemic of 2020 19

Vaishnav: Covid 19 & Mental Health Impact in India

seen for both males and females across the lifespan. These findings are of concern because depressive and anxiety disorders were already leading causes of disability worldwide.[34]

In one online survey from India with 1685 valid responses, about two-

fifth (38.2%) had anxiety and 10.5% of the participants had depression.

Overall, 40.5% of the participants had either anxiety or depression.

Moderate level of stress was reported by about three-fourth (74.1%) of

the participants and 71.7% reported poor well-being.[35] Another online

survey reported that COVID-19 lockdown was associated with poor sleep

quality, shift in sleep cycle to delayed phase, sleep-deprivation based on

night-time sleep, and depressive symptoms in a sizable number of

population.[36]

A study examined the psychological impact of COVID-19 and recruited 1106 subjects in a cross-sectional study from 64 cities in India. The mean age of the participants was 41.82 ± 13.85 years and 22% of participants were health-care professionals. One-third of participants had a significant psychological impact based on the Impact of Event-revised (IES-R) score. Higher psychological impact was found in the younger group, females and those with comorbid physical illness, especially liver disease. Regarding psychological impact, most of the participants had minimal (66.8%) or mild (15%) severity (IES-R score 24–32) of impact. Few participants reported moderate (5.5%) (IES-R score 33–36) to severe (12.7%) symptoms (IES-R score >36). The need for tailored mental health interventions were stressed on by the authors.[37]

A study attempted to validate COVID-19-related anxiety scale (CAS) in 307 subjects. According to their study, CAS determined a two-component structure such as: “fear of social interaction” and “illness anxiety.” The final scale with seven items showed good internal consistency and reliability (Cronbach’s alpha = 0.736) along with moderately negative

correlation (Pearson’s r = −0.417) with self-rated mental health.

Interestingly, the results found significantly higher anxiety scores in the lower educational qualification group. The authors stressed that CAS is a rapid, valid, and reliable test, which might be a useful tool to assess the psychological impact of the pandemic in the Indian population.[38]

A hospital-based study evaluated the impact of covid 19 lockdown in India on alcohol dependence. Delirium tremens, with or without seizures, was the most common presentation (80%), followed by withdrawal seizures (17%) and withdrawal hallucinosis (12%). Three-fourth (76%) belonged

Parallel Pandemic of 2020 20

Vaishnav: Covid 19 & Mental Health Impact in India

to below the poverty level. All subjects reported heavy alcohol use as per standard use on a daily basis. Majority (95%) subjects reported COVID- 19-related lockdown cause for the sudden cessation of alcohol use. This was one of the first Indian studies to explore substance abuse complications as a result of the sudden national lockdown.[39]

Another cross-sectional study aimed to know about the gaming behavior of 393 college students during the lockdown period. This study was carried out through social media contact, namely E-mail and WhatsApp messenger using PHQ-9, GAD-7, Diagnostic and Statistical Manual-IV (to assess depression), and Internet Gaming Disorder Short form-9. About

half (50.8%) of the participants reported an increase in gaming behavior during the lockdown period. Further analysis indicated that hours of gaming per day increased due to the stress of examination and the participants’ belief that gaming helps in stress management. Social isolation and lack of family activities were added factors. The authors suggested “gaming” as a two-edged sword during the lockdown period.[40]

The exacerbated psychosocial effects of alcohol use due to the pandemic situation were highlighted in another study of 73 males with alcohol use disorder.[41] Although the sale was restricted during the lockdown, 20% of subjects continued procuring alcohol. Two-third (62.5%) of the participants obtained alcohol at higher prices from illicit sources. In addition, about one-fifth of these patients, were at risk of consuming adulterated alcohol. A small proportion (6.6%) participants reported experience of alcohol withdrawal during the starting of lockdown. Only one subject experienced withdrawal seizures. Majority of the subjects could not access health-care facilities to manage their withdrawals.

In a regional survey which evaluated 507 subjects in West Bengal, India, a 38-item questionnaire was circulated through WhatsApp. 71.8% and 24.7% showed increased worries and depressive symptoms during the

pandemic. About half (52.1%) of the participants were preoccupied with

the idea of contracting COVID-19 and 21.1% wanted testing irrespective of symptoms. About 69.6% were worried of financial loss during the period of lockdown. Slightly less than one-third (30.8%) of the participants perceived health anxiety to be significantly increased and feared that it might not normalize even post lockdown. This study especially showed the importance of uncertainty and panic as factors influencing psychological health.[42]

Parallel Pandemic of 2020 21

Vaishnav: Covid 19 & Mental Health Impact in India

In an online survey to assess Sexual functioning during the lockdown period in India, the participants reported that lockdown led to reduction in the frequency of sexual intercourse and also touching the partner (fondling, caressing, touching, or kissing) when not indulging in sexual intercourse. Majority of the participants reported improvement in the overall relationship, communication with the partner, and interpersonal conflicts. About two-fifths of the participants reported engaging in sexual intercourse more than twice a week or more. About one-fifth screened positive for psychiatric morbidity, 14.2% screened positive for anxiety, 14.8% screened positive for depression and 8.7% screened positive for both. In both genders, presence of depression and anxiety were

associated with lower sexual functioning in all the domains.[43] Figigure 2: Mental Health Issues due to COVID-19

Neurocogn itive Disorders

OCD

Depression

Personality Disorder

Insomnia

Somatic Symptoms

Addiction

PTSD

Psychosis

COVID-19

Anxiety, Fear & Anger

Sexual Disorder

Trauma & Stress

Intimate Partner violence

Loneliness

Parallel Pandemic of 2020 22

Vaishnav: Covid 19 & Mental Health Impact in India

It has been postulated by earlier researchers that at the rise of an epidemic, generally, people with pre-existing mental illness are among the most affected. The reasons include social stigmatization, risk of infection, low priority to mental health etc. These coupled with cognitive impairment, little awareness of risk and diminished efforts regarding personal protection inpatients, as well as confined conditions in psychiatric wards could add to the vulnerability of individuals with mental disorders.[44]

The lockdown has led to difficulties in terms of medication availability, access to health care, issues with transportation, and panic, adding to the number of relapses, especially in severe mental disorders like severe depression, schizophrenia, obsessive–compulsive spectrum disorders, and bi-polar disorders.[45] Alcohol withdrawal disorders, including delirium tremens, have been on the rise after the initiation of the sudden lockdown [46}.Similarly, methanol poisoning and suicides are increasingly being reported in various parts of India due to lack of abused substances, fear and apprehension, stigma, and competition for health care.[47] There has also been pervasive fear and uncertainty related to the pandemic among masses that has given rise to health anxiety, xenophobia, unnecessary hoarding of medical equipment, self-medication, and mass hysteria, all of which can have adverse health consequences.[48]

Protecting the Vulnerable population

Health care and other frontline workers

Healthcare workers including doctors, nurses, ward boys, cleaning staff, community health workers and other frontline workers like sanitation workers, policemen, government officials, journalists, and other volunteers across the world in general and in India in particular have to work under stressful conditions with paucity of resources and are under extreme pressure. Their personal and family life is badly affected, they also face risk to health in daily work which causes mental health problems, including depression, post-traumatic stress disorder, and even suicidal ideation.[48-51] In an online survey from India, the study sample comprised 303 participants with a mean age of 41.2 (standard deviation: 11.1) years. The majority of them were male (69%) and married (79.9%). Nearly half (46.2%) of the participants had either anxiety disorder or depression or both and 12.9% of HCWs had suicidal behavior. Higher level of anxiety and depression scores were associated with being female, having undergone quarantine, being directly involved in the care

Parallel Pandemic of 2020 23

Vaishnav: Covid 19 & Mental Health Impact in India

of COVID-19 patients, and younger age (<30 years). Higher prevalence of depression and anxiety disorder was seen in younger (<30 years) age group, being a doctor (compared to paramedics). In addition, higher prevalence of depression was seen in those who were directly involved in the care of patients with COVID-19 infection.[52]

Figure 3 Risk Factors for Mental Health Impact of Covid-19

Psychosocial & Organizational Factors

1. Perceived lack of organizational support.

2. Shortage of essential resources.

3. Constant media bombarding about Pandemic.

4. Social-media rumours.

Medical Illness related Risk factors

1. Pre-existing Medical Illness.

2. Lack of access to routine healthcare.

Psychological Risk Factors

1. Poor Access to Mental HealthCare

2. Pre-existing Psychiatric illness.

3. Pre-existing Personality Disorders.

4. Fear of contracting Covid-19. 5. Uncertainity about Covid-19 6. Loneliness.

Risk Factors for Mental Health Impact of Covid-19

Economic Risk Factors

1. Economic hardships. 2. Insecurity/Loss of Job. 3. Unemployment.

4. Economic Recession

Covid-19 infection related Risk Factors

1. Covid-19 infection. 2. Hospitalization.

3. Quarantine.

4. Lock-down.

5. Social distancing. 6. Physical distancing. 7. Witnessing Covid-19.

Factors related to Prevention of Covid-19

1. Online Education/Home Schooling.

2. Work from Home. 3. Physical Inactivity.

4. Observing Covid appropriate behaviour.

5. Diminished Personal freedom.

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Vaishnav: Covid 19 & Mental Health Impact in India

A study cross-sectionally assessed the knowledge, attitude, and behavior (KAB) of 152 doctors regarding the pandemic and the influence of depression, anxiety, and stress. KAB of the participants was obtained through semi-structured proforma, and psychiatric morbidity was measured by the Depression, Anxiety, and Stress Scale-21 (DASS-21). Among the participants, 34.9%, 39.5%, and 32.9% were depressed, anxious, and stressed, respectively. Significant predictors of psychological burden were job in the health sector, duty hours, lack of protective measures, and altruistic coping. Stigma and discrimination against the frontline workers were identified as important factors contributing to their

stress.[53]

Another online survey assessed the psychological impact of COVID-19 between two groups of respondents, namely Practicing Ophthalmologists and trainee Ophthalmologists. The survey included 2,355 participants with mean age of 42.5 ± 12.05 years. Of these, 56.7% were male, 20.2% were still not in practice, 15.5% were single. Nearly half (52.8%) of the participants felt that training or professional work was impaired due to COVID-19, while 37% encountered difficulties to meet living expenses. The mean Patient Health Questionnaire-9 (PHQ-9) score was 3.98 ± 4.65. One-third (32.6%) of the participants had depressive symptoms, mostly of mild (21.4%) severity, followed by moderate (6.9%) and severe (4.3%) symptoms. Subsequent analysis revealed that the significant predictors of depression were age (younger age), gender, marital status, practicing status, type of service, concerns about the profession, and inability to incur expenses.[54]

Children and Older People

The sudden and drastic changes in the day- to- day routine can be extremely confusing and difficult to cope with for children, geriatric, and quarantined individuals. Closure of schools and recreational outdoor activities, not meeting their peers could take a toll on the mental health of the children. COVID-19 and Mental Health: A Study of its Impact on Students in Maharashtra, India identifies and analyses the personal, social and psychological impact of COVID -19 on the mental health of 351 students of age group 16 to 25years.The results showed that female students are more concerned about health, and future, and are more prone to psychological issues like feelings of uncertainty, helplessness and outbursts than male students. Urban student population was more mentally affected than their rural counterparts. An increase was seen in need for solitude, being withdrawn and self-harm in male students. A shift

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Vaishnav: Covid 19 & Mental Health Impact in India

in perception from seeing family as a source of support to that of a restriction is indicated, although the benefits of a collectivistic society are undisputed.[55]

The geriatric population in India has been identified as a vulnerable group to COVID- 19. Over 50% of those more than 60 years have at least one comorbidity putting them at a much higher risk. The psychological impacts in these populations can include anxiety, stress or anger. Mental health impact can be particularly difficult to assess for older people who are already experiencing cognitive decline, dementia, social isolation, and loneliness. Also, the progression of the disease tends to be more severe in the elderly resulting in higher mortality.[56]

Migrant Labourers, Slum Dwellers, Uneducated and Vulnerable Groups

The battle against COVID-19 would be totally incomplete without the nation taking care of its vulnerable population. The millions of homeless and migrants that make up a considerable population of this country are “socially” outcast and much more susceptible to the outbreak. Taking care of their overall well-being, arranging shelters and food and basic living amenities, enabling them to reach their families, and most importantly testing and helping them to get quarantined with the necessary precautions is vital for their good and for the greater good.[57] Protecting their rights, dignity, and self-respect has become all the more important during COVID 19 pandemic.

Persons with Disability

Since persons with disability are more vulnerable there is a need to understand the effect of the COVID-19 pandemic on their care and support systems, nutrition, livelihoods, social participation, mental health and access to health and education services.

A study adopted cross sectional, mixed-methods approach, using a

purposive snowballing technique and data was collected from across the

country using tools like telephonic semi structured interviews and focused

group discussions facilitated through the network of NGO partners

providing care and support for Persons with disability. Persons with

disabilities, NGO leadership, government programme officers and

caregivers of Persons with disability were included. A sample of 403

respondents were included in the study, from 14 states. The median age

of Persons with disability who responded was 28 years with an

Parallel Pandemic of 2020 26

Vaishnav: Covid 19 & Mental Health Impact in India

interquartile range (19, 36.5 years) and 60% were males. 51.6% had

physical impairments, 16.1% had visual impairments, 10.9% had

intellectual impairments and 9.2% had speech and hearing impairment.

The important psychological reactions to COVID-19 pandemic varied from

fear and anxiety, panic, feelings of hopelessness to depression. Fear of

getting infected with novel coronavirus and loss of income were affecting

persons with disabilities the most. 81.6% reported experiencing moderate

to high levels of stress. This shows that there is an urgent need to ramp

up mental health support services for persons with disabilities.[58]

Figure 4: Vulnerable Population for Mental Health Impact of COVID-19

HealthCare/Other Frontline Workers. Persons with Physical Disability Persons with Mental Illness Migrant Labourers

Slum Dwellers Adolesents

Children

Elderly

Uneducated

Intervention Strategies for Mental Wellbeing during COVID-19

Specific intervention and preventive strategies at the community level should be outlined like implementing effective communication and providing adequate psychological services in order to attenuate the psychological and psychosocial impact of COVID-19 outbreak. Availability and accessibility of mental healthcare resources is the need of the hour.

Psycho Education & Health education needs to be enhanced using online platforms, print media and electronic media. Nationwide strategy planning for psychological first aid during COVID19 is well organized in India but requires further innovations.

Social fear related to COVID-19 needs to be properly addressed while stigma and discrimination of psychiatric illness and COVID 19 need to be

Parallel Pandemic of 2020 27

Vaishnav: Covid 19 & Mental Health Impact in India

recognized and dealt with massive mental health education drive. The major challenge currently is to overcome the feelings of uncertainty in a period of COVID 19 crisis. Hospital protocols linked to the early and effective management of health emergency need to be implemented while healthcare professionals need to be supplied by adequate protective facilities, teaching and training program. The scientific community should provide appropriate information

to attenuate the impact of anxiety, frustration, and all the negative emotions which represent important barriers to the correct management of social crisis and psychological consequences related to the pandemic.

Figure 5 Intervention Strategies for Mental Wellbeing during COVID-19

Furthermore, telephonic helplines, various social media platforms and dedicated blogs and forums should be utilized intensively in order to reduce social isolation and loneliness.

Vulnerable populations such as elderly individuals or those with psychological problems should be able to actively consult with clinical psychologist/psychiatrist to rapidly detect warning signs. Finally, telemedicine should be implemented especially in areas where mental

Parallel Pandemic of 2020 28

Vaishnav: Covid 19 & Mental Health Impact in India

health services are poorly represented or severely impaired by the rapid spread of pandemic and lockdown restrictions.

Special packages for mental wellbeing of health care workers and other frontline workers are overlooked and should be declared and executed at earliest.

International organizations including WHO, CDC & other NGO, Central and state government, medical colleges, mental health establishments, educational institutes and healthcare professionals in private sector should work in collaboration. Forming self-help groups is a way to combat this COVID 19 pandemic. [Figure 5]

Conclusion

Implementing community-based strategies for psychological first aid and easy access to mental healthcare services for psychologically vulnerable individuals during the COVID-19 pandemic is essential for developing countries like India. The psychological impact of fear and anxiety induced by the rapid spread of pandemic needs to be clearly recognized as a public health priority for both authorities and policy makers who should adopt clear behavioural strategies to reduce the burden of disease and the grave mental health consequences of COVID 19 pandemic and issues of long COVID. .

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3. COVID-19 and Disruption of Mental Health Services

Omkar Mahadik1, Nilesh Shah2, Avinash De Sousa3

Abstract

The COVID-19 pandemic has disrupted mental health services worldwide. All forms of mental health services have been disrupted. Outpatient, inpatient, rehabilitation and therapy services have been disrupted. The chapter entails various facets of mental health services disruptions and the factors that have led to the same. The chapter looks at the various subsets of mental health service interruptions seen during the pandemic.

Keywords: mental health, services, COVID-19, disruption Introduction

The COVID pandemic has rained havoc on the entire world. Since March 2020, a series of nationwide lockdowns has brought our society to a halt. With schools, colleges, community centres, places of worship, and recreation shut, people are stuck inside their homes deprived of social exposure causing them to feel loneliness and isolation. The result is a surge in the number of individuals suffering from mental illnesses.[1] Anxiety and depression are most common among these conditions and are just as disabling as a physical ailment. On one hand, there is a rise in the demand for mental health services, and on the other side due to lockdown restrictions worldwide, disruptions are being experienced by all those trying to reach out for mental health services. The pandemic has affected three groups of patients, viz. those with pre-existing psychiatric illness, those with psychiatric illness and not taking treatment and new

1Research Assistant, Desousa Foundation, Mumbai

2Professor and Head, Department of Psychiatry, Lokmanya Tilak Municipal Medical

College, Mumbai

3Research Associate and Consultant Psychiatrist, Lokmanya Tilak Municipal Medical College, Mumbai

Address for correspondence: Dr. Avinash De Sousa, Carmel, 18, St. Francis Road, off SV Road, Santacruz West, Mumbai 400054. Email: avinashdes888@gmail.com

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Mahadik, Shah & De Sousa: Covid 19 & Disruption of Mental Health Services

cases of psychiatric illness that have arisen in the aftermath of the pandemic, the pandemic has also affected the caregivers of these three groups of patients.[2] There have been huge healthcare and psychiatric service challenges for low and middle income countries and these have included the running of regular psychiatric services, the onset of telepsychiatry, the availability of treatment facilities and the manpower to run these treatment facilities.[3] The current chapter presents an overview of the disruption of mental health services during COVID and their implications.

Mental Health Services in India and the COVID-19 Pandemic

According to a report released by WHO in October 2020, 93% of the countries worldwide are experiencing disruptions or halt in critical mental health services. The data was collected from 130 countries. The primary reason for these disruptions is the lack of funding. Before the pandemic, there was already an underfunding of mental health. Countries assign merely 2% of the national health budget to mental health care. Now with an added burden brought by the pandemic and slowed down economies, the budget for mental health has been cut down to a minuscule amount.[5] This shortage of budget has added to the monetary causes of disruptions in mental health services. In the initial months after the lockdown was imposed, visits paid to the mental health services came to a stop which caused a fall in revenue. After a first few months of complete shut down the mental health services were resumed but over the internet and via telephones. Transitioning to teletherapy required an additional expenditure for setting up the hardware causing the cost of running a mental health service to rise.[6] The disruption in mental health service delivery has happened at all levels i.e. outpatient clinics, inpatient admission, ECT services, long term rehabilitation and care of special populations. We shall now look at specific aspects of mental health service disruptions.

Countries have reported widespread disruption of many kinds of critical mental health services as per a WHO survey:

 Over 60% reported disruptions to mental health services for vulnerable people, including children and adolescents (72%), older adults (70%), and women requiring antenatal or postnatal services (61%).

 67% saw disruptions to counselling and psychotherapy; 65% to critical harm reduction services; and 45% to opioid agonist maintenance treatment for opioid dependence.

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Mahadik, Shah & De Sousa: Covid 19 & Disruption of Mental Health Services

 More than a third (35%) reported disruptions to emergency interventions, including those for people experiencing prolonged seizures; severe substance use withdrawal syndromes; and delirium, often a sign of a serious underlying medical condition.

 30% reported disruptions to access for medications for mental, neurological and substance use disorders.

Outpatient Clinics

The pandemic and the lockdown saw the shutting down of outpatient clinics in both the private and public sector healthcare. Many public hospitals were converted to COVID hospitals and these resulted in the shutting down of outpatient departments. Many patients had no access to healthcare and transport as a result of this and thus were forced to stop being compliant with mental health treatments and follow ups.[7] Mental health already had a shortage of manpower and concerns about being exposed to COVID-19 resulted in significant stress among mental health care providers. Many patients were not used to being at home and the lockdown with lack of access to mental healthcare services added to their woes. To add to this there were periods where due to stoppage of transport facilities, there was a paucity of medical drugs and psychopharmacological agents that resulted in doctors being forced to tweak and change treatment regimens, though the patient was stable to allow the patient to attain medications that were easily available. This also caused some jitters to stable psychiatric patients that were maintained on medication.[8]

The Advent of Telepsychiatry and Tele-mental Health Services

In India, there has always been an emphasis on visiting the doctor, being examined and receiving treatment. Seeing the doctor in person has always been paramount for recovery. The advent of telepsychiatry was not received well by patients and caregivers alike as many of them preferred to visit the doctor in person. Patients often were not adept at using digital media and thus we’re not be able to connect well on a video call. They would want to see their doctor clearly and the feeling of remoteness exists and has been expressed by many patients when a tele- consult happens. Even mental health professionals need time to adapt to telepsychiatry as a modality of treatment delivery. There was a need for psychiatrists to be trained in telepsychiatry while more importantly patients needed to be trained in using the right media and right devices so that theygot the most of their telepsychiatry consultation and more so because they were actually paying for the service. It is only now that

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Mahadik, Shah & De Sousa: Covid 19 & Disruption of Mental Health Services

people have become slightly comfortable with the treatment modality. There is a need for establishment of full time telepsychiatry units in the current scenario in various medical colleges and hospitals to cater to the needs of varied populations.[9-10]

Inpatient Service Disruptions

Many inpatient units in tertiary general hospitals and private centres were closed due to the pandemic and the wards were converted into covid wards. There were no centres available for the admission of psychiatric patients and there were no centres available for the admission of psychiatric patients that were covid positive as they would have been a special vulnerable group that needed more help now than ever.[11]Apart from outpatients, inpatients also experienced disruptions in mental health care. As the number of covid-19 cases rose,patients that were already admitted had to be discharged as most centres were taken over by the government as covid centres. Places such as rehabilitation centres, elderly care centres and centres for the mentally and physically disabled were required to send many of their patients back home to maintain the new social distancing and isolation norms. Discharge from the mental health care institutions put these patients in unfamiliar social environments which further negatively affected their condition. Most institutions with inpatients for mental health conditions have reduced their number of admitted patients and provide a visit for others as outpatients once in about 2 weeks.[12]

The patients sent home after discharge often experienced isolation, anxiety, and depression. The ones that stayed back in the institution also experienced negative consequences. Due to covid-19 restrictions, visits from family members were terminated. This caused a significant amount of stress among inpatients. Previously there were visits from family members at least once a week or two but now they are barely once in two months.[13]Shortage of visiting mental health professionals in these centres also caused disruption of treatment processes.[13]

Disruption of ECT Services

Electroconvulsive therapy (ECT) has been the gold standard treatment for patients with psychiatric disorders who have failed to respond to pharmacological therapy or those who are non-compliant with medication and/or suicidal.[14] The COVID-19 pandemic disrupted mental health care all over the world since January 2020 and it also affected the practice of ECT with guidelines being developed for the ECT procedure, ECT

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anaesthesia and ECT administration. There has also been a reluctance to proceed with non-emergency ECT during the pandemic when it is otherwise indicated and a number of patients in the middle of ECT courses were disrupted due to the onset of the pandemic.[15] There was been a concern about the potential risk to patients from cross contamination within ECT departments, risk to staff from aerosol generating procedures during ECT and the redeployment of ECT teams, all contribute to limiting patient’s access to treatment.ECT is a safe and effective treatment and must be administered with due precautions when needed to patients even in situations like the lockdown and pandemic facing us. There have been effective procedures for same that have been established and can be followed.[16] There have been reports of successful running of ECT units during the entire pandemic with due precautions and no mortalities.[17]

Disruption of Long-term Rehabilitation Care

Patients from a study conducted by WHO on mental institutions in Croatia showed how difficult it was for the service user as they were detached from the outside world. Institutions have now switched to taking in only the emergency cases that could be dangerous for themselves or others. Another hurdle that has come in the way of providing care to inpatients in mental care institutions is infections.[18] Especially in institutions providing care to the geriatric the infections have spread like wildfire causing chaos and putting a strain on mental health workers. Being occupied with curbing the spread of infection in the institution the mental health workers at times have needed to put mental health needs aside which has adverse effects on the service user’s mental health.[19]There have been also been instances where there has been shortage of staff in these centres where it became very difficult to manage patients in a centre. Many centres stopped admissions to new patients and there have been instances where caregivers have had to manage disorganized and violent patients at home and there has been no place for admission.[20]

Disruption of Geriatric Mental Health Care and Dementia Care Services

The COVID-19 pandemic has affected the elderly and patients inflicted with dementia as well. The elderly had been alone and had less access to healthcare and have also borne the brunt of the lockdown. Telepsychiatry is a treatment modality that was difficult for older adults that were not technologically friendly and there have been disruptions in their mental health care as well.[21] Patients with dementia have been left alone with

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caregivers and many of their regular caregivers and therapists had stopped intervention due to the pandemic. Many elder adults and patients with dementia had children abroad and there have been instance where elders were not sure whether they would ever meet their next of kin.[22] Long term dementia care centres have also sent back the elderly home and this has disrupted the home ecosystem of many families. There have been disruptions in their routine healthcare as well and many patients with dementia and elder adults have shown a deterioration in their physical health and aggravation of medical problems have ensued.[23]

Disruption of Substance Abuse Treatments

The ongoing pandemic had caused stress and anxiety among the population at large leading to increased demand for mental health workers. Along with it demand and cases of substance use went up radically. Isolation with itself brought up the tendency to undertake substance use. With the rehabilitation centres shut, the provision of care for substance abusers had also come to a halt. Many patients with psychiatric disorders began to use substances as a coping mechanism. The amount of substance use in quantity and tolerance as well as dependence levels increased. Experimental substance and recreational substance use leading to full blown substance was seen in many cases. Smoking in general also increased in many patients and there was also an increase in drug use like cannabis.[24-25] Many patients that were sober also relapsed during this period but had no place for rehabilitation and the intensity of their substance use and abuse increased markedly. Telehealth services are being provided to curb the crisis but that it is at times inefficient in case of substance use cases. A major issue is the absence of any restrictions on access to the substance. Along with that, it is difficult to issue frequent urine toxicology screenings which would gauge the patient’s progress. Keeping a track of “use” is essential in treating a substance abuser.[26]

Telepsychiatry and the Challenges Causing Disruptions

Social distancing norms have made it mandatory to carry out treatment sessions via the internet or telephone. Relying on technology gives us an upper hand in terms of convenience but at the same time has a risk of untimely failure. Treatment of a mentally troubled patient could be disrupted for extended periods due to technical difficulties. These can be on either ends of the caregivers or the patients. Disruption in such a course of treatment can result in an even stronger experience of

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loneliness, isolation, and helplessness as fixing technical issues in these times is difficult. Failure of technology can prevent the patient from receiving e-prescriptions or online prescriptions. Disruptions in a patient’s course of medicine can have serious implications as they will cause elevated stress, anxiety, and depression due to the current outside scenario.[27-28]

The difficulty of delivering teletherapy is not just the technical issues but also the unavailability of hardware overall. Online delivery of therapy requires a computer with a webcam, electricity, and a steady internet connection which is not available to all. Hence leading to the potential exclusion of vulnerable and disadvantaged groups. These are primarily members of the lower socio-economic strata. This is a group that has had to bear the consequences of covid-19 causing a lockdown and they are also the ones who are excluded when it comes to delivery of mental healthcare.[28] If at all access to resources needed is gained from the internet and a computer, it would probably be through internet cafes and libraries. These cafes are not a safe space for the patients to express their thoughts and feelings and they are also closed due to the lockdown. A way around this issue has been therapy over telephones and mobile phones. Through phone verbal messages can be expressed but there is a fall in the quality of the therapy as many problems might remain untouched. One reason for this could be the lack of space.[29]

An absence of space can also bring in disruptions in the delivery of telehealth via the internet. Lockdown has required all to stay home which means all the family members are always home. This takes away the opportunity of having a private space in which the client can sit for their therapy. Environmental disturbances during the delivery of therapy negatively affect the quality and effectiveness of the therapy session. Apart from privacy at home, privacy over the internet is also a major concern. Social isolation and loneliness are major risk factors for the elderly that can have a long-lasting impact on the mental health of the older population. The unfamiliarity of elderly people with technology can be of disadvantage for them during the era of distant therapy. There are advantages to treatment over the telephone or via the internet. Since the shift to telehealth more and more people have been able to access mental health care. As we speak through telehealth mental healthcare has been able to reach rural places where previously it would have been very demanding to reach physically.[30-31]

In rural areas previously healthcare of all sorts was provided with satellite clinics. Through these clinics, a psychiatrist or psychologist would provide

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healthcare monthly or bimonthly in rural regions. These outpatient services of satellite clinics are provided by a local community health centre or drugstore for a small consultation charge. Due to high healthcare costs, loss of infrastructure, and other monetary reasons these satellite clinics have been shut down as a result of the pandemic and lockdown. The delivery of treatment is now being undertaken through telepsychiatry but at many places, there are no set standards for the delivery of treatment online which can affect the effectiveness of the therapy.[32]

A form of psychotherapy in which one or more therapists work with a group of people at the same time is known as group therapy. It aids in multiple instances such as dealing with suicidal patients, substance abusers, depressed individuals, and others. These groups can also act as support groups for people, one example would be gender-affirming groups. As a result of lockdown, the group therapy sessions are being conducted online. In an online setting, it can be difficult for individuals to open up in front of a group of strangers whom they have not met before. The reluctance can disrupt the flow of an otherwise smooth group therapy session. These sessions are of great help to substance abusers when in rehabilitation but with rehabilitation centres shut and group therapies moved to online settings it can be tough to continue with the treatment.[33]

Impact of the Pandemic on Mental Health Professionals

The pandemic has resulted in it taking a toll on mental health professionals as well. There have been mental health professionals that developed COVID and were hospitalised themselves and this also added to the paucity of mental health professionals. There have also been deaths of psychiatrists, senior and junior due to COVID and this has resulted in other mental health professionals feeling scared and anxious as well. It is essential to realise that one cannot serve from an empty cup and hence it is essential that we take care of our mental health as professionals as well.[34]

Conclusion

The COVID-19 pandemic has disrupted or halted critical mental health services in 93% of countries worldwide while the demand for mental health is increasing, according to a new WHO survey.Good mental health is absolutely fundamental to overall health and well-being,” said Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health

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Mahadik, Shah & De Sousa: Covid 19 & Disruption of Mental Health Services

Organization. “COVID-19 has interrupted essential mental health services around the world just when they’re needed most. World leaders must move fast and decisively to invest more in life-saving mental health programmes ̶ during the pandemic and beyond.”

References

1. PfefferbaumB,NorthCS.MentalhealthandtheCovid-19pandemic. New Engl J Med 2020;383(6):510-2.

2. Lodha P, De Sousa A. Mental health perspectives of COVID-19 and the emerging role of digital mental health and telepsychiatry. Arch Med Health Sci 2020;8(1):133-9.

3. De Sousa A, Mohandas E, Javed A. Psychological interventions during COVID-19: challenges for low and middle income countries. Asian J Psychiatry 2020;51:102128.

4. Grover S, Mehra A, Sahoo S, Avasthi A, Tripathi A, De Sousa A, Saha G, Jagadhisha A, Gowda M, Vaishnav M, Singh O. Impact of COVID-19 pandemic and lockdown on the state of mental health services in the private sector in India. Indian J Psychiatry 2020;62(5):488-93.

5. Guan I, Kirwan N, Beder M, Levy M, Law S. Adaptations and innovations to minimize service disruption for patients with severe mental illness during COVID-19: Perspectives and reflections from an assertive community psychiatry program. CommunMent Health J 2021;57(1):10-7.

6. Grover S, Sahoo S, Mehra A. How to organize mental health services in the era of unlockdown. Indian J Psychol Med 2020;42(5):473-7.

7. Amsalem D, Dixon LB, Neria Y. The coronavirus disease 2019 (COVID-19) outbreak and mental health: current risks and recommended actions. JAMA Psychiatry 2021;78(1):9-10.

8. Naqvi HA. Mental health in the aftermath of COVID-19: A new normal. J Pak Med Assoc 2020;70(5 Suppl 3):S141-4.

9. De Sousa A, Shrivastava A, Shah B. Telepsychiatry and Telepsychotherapy: Critical Issues Faced by Indian Patients and Psychiatrists. Indian J Psychol Med 2020;42(Suppl 5):S74-80.

10.De Sousa A, Karia S. Telepsychiatry during COVID-19: Some clinical, public health, and ethical dilemmas. Indian J Pub Health 2020;64(6):245-6.

11. Grover S, Mehra A, Sahoo S, Avasthi A, Tripathi A, D’Souza A, Saha G, Jagadhisha A, Gowda M, Vaishnav M, Singh O. State of mental health services in various training centers in India during the

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lockdown and COVID-19 pandemic. Indian J Psychiatry

2020;62(4):363-9.

12.Sood M, Patra BN, Deep R, Kalyansundaram L, Dua S, Vijay S.

Organizing inpatient services in a general hospital in times of

COVID-19. Indian J Soc Psychiatry 2020;36(5):154-61.

13.Selvaraj S, Reddy PV, Muralidharan K, Gangadhar BN. Impact of COVID-19 on mental health: A watershed moment in tertiary care

service provision in India?. Asian J Psychiatry 2020;54:102229. 14.Payne NA, Prudic J. Electroconvulsive therapy Part I: a perspective on the evolution and current practice of ECT. J Psychiatr Pract

2009;15(5):346-68.

15.Bryson EO, Aloysi AS. A strategy for management of ECT patients

during the COVID-19 pandemic. J ECT 2020;36(3):149-51.

16.Tor PC, Phu AHH, Koh DSH, Mok YM. Electroconvulsive therapy in

the time of coronavirus disease. J ECT 2020;36(2):80-5.

17.Yeole S, Kapri P, Karia S, Merchant H, Shah N, De Sousa A. Electroconvulsive Therapy Administered During the COVID-19

Pandemic. J ECT 2021;37(1):e2-3.

18.Cook JA, Jonikas JA. The Importance of psychiatric rehabilitation

services during and after the COVID-19 pandemic. Psychiatr Serv

2020;71(9):883-4.

19.Parry SJ, Chamorro V, Mohan R. Responding to COVID-19 in

Psychiatric Rehabilitation: Collaboration Is Vital. J Psychosoc Rehabil

Ment Health 2020;7(3):209-10.

20.Dasgupta A, Kalhan A, Kalra S. Long term complications and

rehabilitation of COVID-19 patients. J Pak Med Assoc

2020;70(5):S131-5.

21.Mukhtar S. Psychosocial impact of COVID-19 on older adults: a

cultural geriatric mental health-care perspective. J Gerontol Soc

Work 2020;63(6-7):665-7.

22.Vahia IV, Blazer DG, Smith GS, Karp JF, Steffens DC, Forester BP,

Tampi R, Agronin M, Jeste DV, Reynolds III CF. COVID-19, mental health and aging: A need for new knowledge to bridge science and service. Am J Geriatr Psychiatry 2020;28(7):695-7.

23.Cohen G, Russo MJ, Campos JA, Allegri RF. Living with dementia: increased level of caregiver stress in times of COVID-19. Int Psychogeriatr 2020;32(11):1377-81.

24.Baillargeon J, Polychronopoulou E, Kuo YF, Raji MA. The impact of substance use disorder on COVID-19 outcomes. Psychiatr Serv 2021;72(5):578-81.

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25.Melamed OC, Hauck TS, Buckley L, Selby P, Mulsant BH. COVID-19 and persons with substance use disorders: Inequities and mitigation strategies. Subs Abuse 2020;41(3):286-91.

26.Jemberie WB, Williams JS, Eriksson M, Grönlund AS, Ng N, Nilsson MB, Padyab M, Priest KC, Sandlund M, Snellman F, McCarty D. Substance use disorders and COVID-19: multi-faceted problems which require multi-pronged solutions. Front Psychiatry 2020;11:714. doi: 10.3389/fpsyt.2020.00714

27.Stoll J, Sadler JZ, Trachsel M. The ethical use of telepsychiatry in the Covid-19 pandemic. Front Psychiatry 2020;11:665.

28. Perera SR, Gambheera H, Williams SS. Telepsychiatry in the time of COVID-19: Overcoming the challenges. Indian J Psychiatry 2020;62(Suppl 3):S391-4.

29.Ramalho R, Adiukwu F, Bytyçi DG, El Hayek S, Gonzalez-Diaz JM, Larnaout A, Grandinetti P, Kundadak GK, Nofal M, Pereira-Sanchez V, da Costa MP. Telepsychiatry and healthcare access inequities during the COVID-19 pandemic. Asian J Psychiatry 2020;53:102234.

30. Johnson CC, Aldea MA. Ethical Considerations for Telepsychotherapy and the Management of High-Risk Patients During Coronavirus 2019 (COVID-19): Challenges and Practice Considerations. Ethics Behav 2021;31(3):193-204.

31. Javadi SM, Nateghi N. COVID-19 and its psychological effects on the elderly population. Disaster Med Pub Health Prepared 2020;14(3):e40-1.

32.Choudhari R. COVID 19 pandemic: mental health challenges of internal migrant workers of India. Asian J Psychiatry 2020;54:102254.

33.Weinberg H. Online group psychotherapy: Challenges and possibilities during COVID-19—A practice review. Group Dynamics: Theory, Res Pract 2020;24(3):201-11.

34. Fiorillo A, Gorwood P. The consequences of the COVID-19 pandemic on mental health and implications for clinical practice. Eur Psychiatry 2020;63(1): e32. doi: 10.1192/j.eurpsy.2020.35

Acknowledgements: Nil Conflict of Interest: Nil Funding: Nil

Parallel Pandemic of 2020 45

4. Undergraduate and Postgraduate Medical Teaching During Covid 19 Pandemic

Soumitra Ghosh1, Dhrubajyoti Bhuyan2, Seujee Goswami3

Introduction

The Corona virus Disease 2019 (COVID-19), declared a pandemic by the World Health Organization (W.H.O.) in March 2020, has resulted in a devastating impact on the health care and education systems all over the world.[1] Medical colleges worldwide have been abruptly compelled to adopt the various methods of remote learning using various online platforms going to various lockdown restrictions in the face of this all- pervasive disease. Consequently, most of the undergraduate students of medical colleges have been shifted back home from the institutions. This has deprived the students and trainees from didactic lectures, practical classes, group discussions , and demonstrations as well as from clinical exposure to patients in ward, outpatient department(OPD) and operation theatre(OT) postings which were earlier the cornerstones of medical education.[2,3] Furthermore, the raised numbers of patients with COVID- 19 have resulted in diversion of trainees from non critical care departments to work in dedicated COVID ICUs and wards in a previously unthought-of manner, leaving a deep impact on the academic growth of the medical trainees.[4]

In this review we aim to highlight the effect of the ongoing COVID -19 pandemic on under graduate and postgraduate medical training as well as discuss the strategies that might be utilized to mitigate the far reaching effects of this pandemic on the training of medical professionals.

Major Challenges Faced in Undergraduate and Postgraduate Medical Teaching and Their Probable Solutions

The Medical Council of India earlier and the National Medical Commission now are the leading regulators for medical learning in India responsible

1Professor & Head, Department of Psychiatry, Tezpur Medical College, Tezpur 2Associate Professor, Department of Psychiatry, Assam Medical College, Dibrugarh 3Resident Physician, Department of Psychiatry, Assam Medical College, Dibrugarh

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for designing the online medical learning programs and classrooms. For making use of the electronic media in the learning process, the students and faculty members of the institutions need to follow the guidelines and overcome the challenges posed due to the reason that concept of the e- learning seems to be an innovative expansion seen due to the pandemic circumstances.

Even prior to the occurrence of the pandemic, owing to their hectic schedules, educators of the medical field had been striving a lot for managing the time to deliver the information effectively as per the curriculum.[5] The sudden transition that took place from the traditional learning method to online learning needed a lot of time and skills from the educators involved in the medical institutions. The educator needs to allocate the time to enhance their technical skill of using the electronic media for education and rewrite content that was not appropriate for clinical practice to discover the online method of delivery, overcome clinical issues and find engaging ways to interact with the students. To solve this problem, time management skills could be inculcated in the educators and students alike by various skill enhancement programs. Timetables for the classes should be planned in time and information regarding the class schedules should be disseminated among the students in a systematic manner.[6,7]

The major barriers for medical online learning are the time constraints, inadequate technical knowledge and skills, lack of institutional strategies along with the negative view point towards great transformation in the learning process and methods adopted.[8]

The lack of technical skills was found to be to a major challenge in the online mode of medical education.[9] Inadequate accessibility to electronic devices or the internet, compounded by deficient technical skills has been seen to aggravate the negative attitude of the professionals toward the new method of learning, impacting the delivery of online learning in a harmful manner.[10] It is also been observed that students may not able to develop the required clinical skills adequately via online education that leads to exacerbation of their academic burden. However, these challenges can be minimized with proper planning by the institutions for provision of the requisite resources for e-learning. The educators as well as the students should be familiarized with appropriate usage of the electronic media and the various online platforms for education. They should also be engaged in an interactive process for facilitating the effective communication needed for learning of the concepts in the new

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mode of e-learning.[11,12] Medical students also have been seen to have difficulties in staying motivated and maintaining concentration in the virtual classes because of the lack of direct supervision of the educators, and may get distracted easily by the external environment, which could prove an impediment to their learning.[7] To keep the students actively engaged interactive session should be planned along with regular assessments and post-test quizzes that would help them to self-evaluate their understanding of the lessons and concepts taught as well.[13,14]

Medical institutions have mostly suspended the clinical placement and observation in community settings and hospitals during the pandemic. Such actions could lead to a decline in the clinical knowledge and competence of students, due to the lack of direct access to the patients for learning and observation.[15] Consequently, the student would need costly and time-intensive training on return to the clinical environment so as to meet the desired level of competency in the clinical skills. Furthermore, most of the students involved in the clinical stage of medical education are not being able to be involved in various presentations and research owing to the fear of transmission of COVID-19.[16]

These challenges and issues faced due to the pandemic could, however, also provide the impetus for the students to explore and understand innovative learning strategies as well as exponentially enhance their self- learning skills. The medical school educators are needed to actively motivate their students to remain resilient and be adaptable in the pandemic so as to instill these much-needed qualities among them, quintessential for their professional life later on. The acquisition of these attributes would enable the students to handle the uncertainties associated with their field of work and cultivate the habit of proactive self- learning even in the midst of their busy professional lives. It is advisable for the medical institutions organize regular virtual communications with personal educators which would boost the confidence of the students while presenting their views and thoughts in a professional manner.[17,18] The postponement of the direct consultation techniques can be improvised by facilitating the medical student to make use of the virtual consultation with patients organized in a small peer groups in a supervised manner.[19-21] That could greatly help them to build up their skills required for evaluation, diagnosis and management of patients presenting to them with various clinical conditions in their professional lives. Consequent to the fact that medical students have been withdrawn from the clinical placements, there would be a chance for reduction in the clinical skill proficiency because of the restricted practice. However, this

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could be compensated for by designing project-based learning or using simulated patients which would require the students to proactively participate in the task and communicate with the peer group.[22,23]

The written along with the practical assessment have been considerably influenced by the pandemic to a great extent. Mostly, institutions worldwide have transformed the written examination to the open-book examinations mode of examinations that enhances the probable concern of the examination to be an insufficient measure of the student’s theoretical knowledge and practical skills Traditionally, the assessment of theoretical knowledge of students in medical colleges have been done through various types of questions like short answer questions (SAQs) ,long answer questions (LQAs), multiple choice question (MCQ), case vignette based questions, etc.[24] In the light of the ongoing pandemic, online instruments for evaluation of the students such as Quizlet Live, Kahoot, Nearpod, Google quizzes through Google forms may be utilized.[25] Several methods are available to carry out summative assessment of the students that include open-book exams, essays on relevant academic topics, as well as projects and assignments.[26] The usage of the online proctored examinations using artificial intelligence combined with human proctors to ensure adequate vigilance on the examinees has been seen to have increased greatly in the academic world as a consequence to the COVID -19 pandemic. It appears to have certain benefits over the open-book examination. The availability of the online proctor stimulates the conventional testing environment which students have been accustomed to. However, unlike the open book system of examination, here, the student doesn’t have access to resources, which necessitates a thorough preparation of the theoretical content.[27,28] This system of online proctored examinations could be utilized widely in the medical field also for conducting the theory examinations in the face of the COVID- 19 pandemic. Before the COVID-19 pandemic, the assessment of clinical skills of diagnosis and treatment were carried out via allotment of long and short cases as well as viva of the examinees. For years now, across the globe, the evaluation of clinical and practical proficiency of medical students has been carried out using formats like the Objective Structured Clinical/Practical Examination (OSCE/ PE) and Direct Observation of Procedural skills (DOPS).[24] The ways and means to overcome the interference to these practical assessments in the aftermath of the pandemic remain to be explored. Evaluation of the psychomotor skills of the students poses the greatest challenges in the field of online learning. To solve this dilemma, online versions of objective structured clinical examinations with virtual or simulated

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patients could be used for evaluation of the clinical skills.[28] However, it is pertinent to note here that the abrupt transition of the examinations, both theory and practical , from the traditional offline to be online mode may lead to uncertainty and confusion amongst the student community, as well as confer an unjust disadvantage towards their performance due to their unfamiliarity with the virtual mode of examination. As such, these modifications in the attributes and norms of the examination system of need to be implemented in a well planned manner, taking into consideration the various needs and technical skills of the students as well as the educators in order to ensure the success of the virtual system of evaluation of medical students.

Advantages and Disadvantages of Online Medical Teaching

Thus, we can say online mode of education has come to play a very significant role in the medical field during the COVID 19 pandemic .The various advantages and disadvantages of this mode of e-learning in the training and assessment of medical students can be summarized below in a table (Table 1) for a quick overview.

Table 1: Advantages and Disadvantages of Online Medical Teaching

Advantages Disadvantages

1. It helps to overcome the interruption to medical education caused by lock down restrictions in the face of the COVID 19 pandemic.

2. It can reach out to larger number of students at a time.

3. It can overcome the geographical barriers.

4. It can provide flexible timings for convenience

of teachers and students.

5. It can help to develop self study skills in the

students.

6. It helps the students to learn at their own pace.

7. If planned and implemented properly, can help

to develop the skills of interaction and communication in the students.

1. Problem of time management for teachers and students.

2. Lack of technical skills can impede the teaching and learning processes

3. Inadequate availability of electronic devices and internet services could hamper learning.

4. Difficulty of maintaining motivation and concentration in the classes in the absence of direct supervision of the educators

5. Problems in the acquisition of practical and clinical skills due to lack of direct exposure to patients.

6. Challenges faced in conducting assessments of students in the virtual mode.

Medical Students as Frontline Covid Workers

There are conflicting views globally regarding the role of the medical student in the pandemics. The medical students, mainly in the final year of undergraduate medical education, as well as the medical interns, have been faced with the challenge of active participation as frontline workers,

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in order to meet the increased demand for health care professionals during the pandemic.[29] Moreover, the post graduate trainees of non critical departments have also been seen to be delegated to work in designated COVIDICUs and wards going to the shortage of manpower in the face of the devastating pandemic.[30,31] Medical students have been found to be quite eager to take active participation in this battle against COVID -19. Apart from the indispensable role played by the post graduate trainees in the diagnosis and management of COVID- 19 cases in wards as well as in ICUs, the undergraduate students have managed various tasks such as managing COVID help lines for patients and their attendants, handling the paperwork and logistics of COVID management,

spreading information and awareness regarding the pandemic among general public, and so on.[32,33] The medical students thus introduced into the workforce could consider this volunteerism as an effective opportunity for self-directed clinical learning. It is advisable that before undertaking the role as the frontline workers, steps should be taken to understand their willingness, motivation and competence in relation to the assigned roles and duties. Care should also be taken to make the utilization of their services in a well planned and judicious manner in order to avoid burn out another adverse effects on the physical and mental health and well being of the students.[19]

Thus, we can say that although the involvement of medical students working as the frontline workers has not been globally agreed on, it could provide a great opportunity for the students to receive hands on experience during such pandemics and learn innovations and skills that could help them in their further academic and professional career.

Institutional Adaptations and Innovations

The need for the online medical learning during the COVID-19 pandemics necessitates the exploration and integration of the innovative ideas into

the medical curriculum all across the globe. It would include institutional

programs for the orientation of medical educators towards technological concepts of e-learning along with familiarization with novel methods of teaching and assessment of the students using the various virtual platforms.[34] This would facilitate the medical educator to have improved interaction with the students why are the online mode of learning. Furthermore, the designing of various tools and virtual applications specifically for medical learning should also be encouraged. Proper testing and implementation of innovative methods of learning such as the social media, virtual clinics, virtual models for clinical learning and evaluation,

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remote consultation with the patients including use of the patient simulators and so on can go a long way meeting the various challenges posed to the medical education system by the COVID-19 pandemic.[35]

Development Needed in Online Medical Education

As the development of online education system is a relatively novel concept in the field of medical education in India, there is a scope for a lot of improvement in this regard. After each session of the online learning, the feedback from both the students and the educators could be taken in the online mode.[36] It can be expected that timely feedback and

suggestions from both the educators and medical students would significantly help in understanding the pitfalls of as well as enhancing the effectiveness of the online teaching programs. The difficulties caused by the shift of learning methods from the real to virtual mode could be minimized by proper planning and coordination in the medical institutions.

Conclusion

The outbreak of the COVID-19 pandemic and the consequent measures of social distancing enforced for its containment have left a deep impact on the undergraduate and postgraduate medical teaching. The quick transition from the conventional to the virtual method of medical teaching and assessment has been seen to pose several challenges to the educators as well as the students and trainees of the medical field. The engagement of medical students and trainees in as COVID frontline workers has also been observed worldwide. Proper planning and implementation of innovative strategies of teaching as well as assessing the theoretical and practical skills of medical students via are the virtual mode appears to be the need of the hour. Future studies could be planned to examine the long lasting effects of COVID-19 pandemic on medical education and training in a systematic manner.

Take Home Points

1. COVID 19 has left a deep impact on the undergraduate and post graduate medical teaching

2. There has been an abrupt transition from the traditional classroom and clinics based hands on

training to the virtual mode of education.

3. Medical students have also been engaged as frontline warriors in the pandemic

4. These sudden changes have posed great challenges to the educators and students alike.

5. Capacity building for both educators and students in the field of technical skills and time

management as well as proper planning and implementation of innovative methods of virtual learning and evaluation are the need of the hour.

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Ghosh, Bhuyan & Goswami: UG & PG Medical Teaching during Covid 19 References

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Effect of the COVID-19 pandemic on medical student career perceptions: A national survey study. Med Educ Online 2020; 25(1):1798088. doi:10.1080/10872981.2020.1798088

3. Rose S. Medical student education in the time of COVID-19. JAMA 2020; 323(21):2131–2.

4. Miller DG, Pierson L, Doernberg S. The role of medical students

during the COVID-19 pandemic. Ann Intern Med 2020;173(2):145-6.

5. Costello E, Corcoran M, Barnett J, et al. Information and communication technology to facilitate learning for students in the health professions: current uses, gaps and future directions. Online Learn 2014;18(4). Available from: http://olj.onlinelearning consortium.org/index.php/jaln/article/view/ 512/118

6. Dyrbye L, Cumyn A, Day H, Heflin M. A qualitative study of Physicians’ experiences with online learning in a masters degree program: benefits, challenges, and proposed solutions. Med Teach2009;31(2):e40–6.

7. DelRioC,MalaniPN.2019NovelCoronavirus-importantinformation

for clinicians. JAMA 2020;323(11):1039-40. doi:10.1001/jama.2020.1490

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9. O’Doherty D, Dromey M, Lougheed J, Hannigan A, Last J, McGrath D. Barriers and solutions to online learning in medical education – an integrative review. BMC Med Educ 2018;18(1):130. doi: 10.1186/s12909-018-1240-0

10. Barteit S, Guzek D, Jahn A, Bärnighausen T, Jorge MM, Neuhann F.

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instructional design, 5th edition. Perform Improv. 2005;44(2):44–6.

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13.Goh P-S, Sandars J. A vision of the use of technology in medicaleducation after the COVID-19 pandemic. Med Ed Publish 2020;9(1).

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15.Ama-assn.org. Protecting underrepresented students and residents during COVID-19 [Internet]. American Medical Association [cited 2021 June 7]. Available from: https://www.ama-assn.org/delivering -care/public-health/protecting-underrepresented-students-and- residents-during-covid-19.

16.Lcme.org. COVID-19 updates and resources. Liaison Committee on

Medical Education [Internet]. [Updated 2020 March 25, cited 2021

June 7]. Available from: https://lcme.org/covid-19/

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and academic performance. Sleep Med Rev 2006;10:323–37. 19.Kalet AL, Jotterand F, Muntz M, Thapa B, Campbell B. Hearing the call of duty: what we must do to allow medical students to respond

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transition course in preparing medical students for internship. Acad Med 2011;86(7):860-5.

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5. Covid 19 Pandemic and Telemedicine Practice in India

Minhajzafar Nasirabadi1, V. George Reddy2, Vishal Akula3

Introduction

The Novel Coronavirus-19, emerged from Wuhan, China and spread throughout the world.[1] WHO declared it as a ‘Public Health Emergency of International Concern’ on 30th January 2020.[2] The COVID-19 virus pandemic and the resulting lockdown globally, has had a severe impact on multiple facets of day to day life, functioning and mental health.[2][3]

India being the second most populous country in the world, the number of doctors to serve this large population is in incongruence with the population load.[4]

The World Health Organization recommends a doctor–

population ratio of 1:1000[5]while in India, the current doctor population

ratio is only 0.62:1000.[6] Adding to it, India has 0.75 Psychiatrists per

100,000 populations, while the desirable number is above 3 Psychiatrists

per 100,000.[7][8] Moreover, 68.84% of Indian population resides in

rural/remote[9] areas with deficient health care facilities.

The Covid-19 pandemic has added unprecedented burden on an already

burdened health-care system in a country like ours.[4]

Thus, Telemedicine is an important tool that can combat this mismatch

and improve the delivery of health-care services.

Definitions

Telemedicine: World Health Organization defines telemedicine as, “The delivery of health-care services, where distance is a critical factor, by all health-care professionals using information and communications technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and the continuing education of health-care workers, with the aim of advancing the health of individuals and communities.”[10]

1 Professor & Head of Department, Deccan College of Medical Sciences, Hyderabad 2Consultant Psychiatrist, Healthy Brain Clinic and Hospital, Alwal, Trimulgherry, Secunderabad, Telangana

3 Associate Professor of Psychiatry, Osmania Medical College, Hyderabad

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Nasirabadi, Reddy & Akula: Covid 19 & Telemedicine in India

Telepsychiatry: Telepsychiatry is the application of telemedicine to the

specialty field of psychiatry. The term typically describes the delivery

of psychiatric assessment and care through telecommunications

technology, usually videoconferencing.[11]

History of Telemedicine

Globally: “Telemedicine is the natural evolution of health care in the

digital world.”[12] Earliest published record of telemedicine is in the first

half of the 20th century when ECG was transmitted over telephone lines.

[13] Telemedicine played an important role in disaster management during

the 1985 Mexico City earthquake when NASA first used telemedicine

services [14]

Mental health care seems especially well suited for telemedicine since most diagnostic and treatment information is gathered audio-visually.[15] Most early telemedicine applications were psychiatric in nature. The first reported use of telemedicine, took place during the 1950s and 1960s at the Nebraska Psychiatric Institute, which initially used closed circuit television for medical education purposes, followed by group psychotherapy, consultation, assessment, collaboration and teaching. The phrase tele-psychiatry was subsequently coined in the early 1970s with Dwyer’s description of the Massachusetts General Hospital project, in which psychiatrists at the hospital consulted via closed circuit television with patients at a medical station located at the airport.[15]

In India: The activities related to telemedicine started in 1999 in India.

Indian Space Research Organization (ISRO) was the pioneer of

telemedicine in India with a Telemedicine Pilot Project in 2001, linking

Chennai’s Apollo Hospital with the Apollo Rural Hospital at Aragonda

village in the Chittoor district of Andhra Pradesh[16]. Initiatives taken by

ISRO, Department of Information Technology (DIT), Ministry of External

Affairs, Ministry of Health and Family Welfare and the state governments

played a vital role in the development of telemedicine services in India. In

the recent years, the Ministry of Health in the Government of India has

taken up projects like Integrated Disease Surveillance Project, National

Cancer Network (ONCONET), National Rural Telemedicine Network,

National Medical College Network, and the Digital Medical Library

Network.[17]

Telemedicine practices in India have slowly and steadily gained foothold

and the 2020 Covid-19 pandemic provided the nation’s health systems an

opportunity to make a concerted effort to increase access and coverage.[4]

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practice of telemedicine.

Nasirabadi, Reddy & Akula: Covid 19 & Telemedicine in India

Many private corporates and start-ups have started their own platforms to

cater to the need in telemedicine. Some of them range from very basic

consultations to super speciality consultations and diagnostics, covering

rural to urban populations.

In India, till now, there was no legislation or

guidelines on the practice of telemedicine and the gaps in legislation and

the uncertainty of rules posed a risk for both the doctors and their

patients.[10]

However, there has been concern on the

Realizing its potential in health-care delivery, on March 25, 2020, the

Ministry of Health and Family Welfare, India, had released the

“Telemedicine Practice Guidelines” for allopathic registered medical

practitioners (RMPs). This guideline is prepared by the Board of

Governors, Medical Council of India. This would be included in the

Appendix V of 2002 Regulations on “Professional Conduct and Ethics”

under the Indian Medical Council Act, 1956.[10]

Advantages of Telemedicine

a) Telemedicine: An Enabler of Healthcare Access and Affordability

 In India, providing in-person healthcare is challenging, particularly given the large geographical distances and limited resources.

 One of the major advantages of telemedicine is that it can be used for providing timely and faster health care access.

 It would reduce financial costs associated with travel.

 Reduce the inconvenience/impact to family and caregivers and

social factors.

b) Telemedicine in Providing Protection to Patients and Health Care Workers during Outbreaks/Natural Disasters

 Disasters and pandemics pose unique challenges to providing health care. A telemedicine visit can be conducted without exposing staff to viruses/infections in the times of such outbreaks.

 Telemedicine practice can prevent the transmission of infectious diseases reducing the risks to both health care workers and patients, as patients can be screened remotely.

c) Telemedicine in Reducing the Burden

 Makes available extra working hands to provide physical care at the respective health institutions

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Nasirabadi, Reddy & Akula: Covid 19 & Telemedicine in India

d) Telemedicine in Managing the Treatment Regimens

 There are a number of technologies that can be used in telemedicine, which can help patients adhere better to their medication regimens and manage their diseases better.

e) Telemedicine in Providing Legal Protection

 With telemedicine, there is higher likelihood of maintenance of records and documentation hence minimalizes the likelihood of missing out advice from the doctor and other health care staff.

 Written documentation increases the legal protection of both parties.

f) Telemedicine: Equality to all

 Digital health is a critical enabler for the overall transformation of the health system. Hence, mainstreaming telemedicine in health systems will minimize inequity and barriers to access.

Disadvantages of Telemedicine

Telemedicine has its own disadvantages like:

     

Features of “Telemedicine Practice Guidelines”: MCI 2020

Miscommunication of symptoms by patients

Misinterpretation of symptoms by physicians

Misdiagnosis

Not suitable for emergency situations

Difficulty to apply for medical procedures

Network issues, app usage and familiarity issues by technologically

challenged people and cyber threats

A) Scope

These guidelines are meant for a Registered Medical Practitioner(RMP)

who is enrolled in the State Medical Register/the Indian Medical Register under the Indian Medical Council Act 1956. The guidelines cover norms and standards of the RMP to consult patients via telemedicine.

B) Important exclusions in the guidelines

 Digital technology should not be used to conduct surgical or invasive procedures.

 There is no provision for consultations outside the jurisdiction of India.

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Nasirabadi, Reddy & Akula: Covid 19 & Telemedicine in India

C)Training for telemedicine practice

To enable the RMPs to get familiar with these guidelines as well as with the process and limitations of telemedicine practice:

 An online program will be developed and made available by the board of Governors in supersession of MCI.

 All currently registered medical practitioners need to complete a mandatory online course within 3 years of notification.

 Thereafter, undergoing and qualifying such a course, as prescribed, will be essential prior to registration of a medical practitioner.

D)Telemedicine applications

Telemedicine applications can be classified into four basic types:

 Mode of communication (audio/video/text/internet applications, etc)

 Timing of the information transmitted

 Purpose of the consultation

 Interaction between the individuals involved: RMP-to-patient/

caregiver or RMP to RMP

E) Elements for telemedicine in India: seven elements.

1. Context: appropriate and adequate as per context.

2. Identification of both parties: The name, E-mail ids, and address

should be known to each other for the sake of transparency.

3. Mode of Communication: The strength and weakness of audio, video, text, etc., should be weighed as per context.

4. Consent: Consent can be ‘Implied’ in case of mentally sound adult who initiates consultation. It can be ‘Explicit’ when the consultation

is initiated by a health worker or caregiver. For an explicit content,

patient can send an E-mail, text, or audio/video message stating his/her intent to the RMP.

5. Type of Consultation:

First consult: When the patient is consulting the RMP for the first time for the current health condition or has consulted more than 6 months ago for the same health condition or the patient has consulted with the RMP earlier, but for a different health condition.

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6.

Follow up consult: When the patient consults the same RMP within 6 months of previous in-person consultation and is for the same health condition.

Patient Evaluation: Proper care must be taken by RMPs to collect all medical information about patient’s condition before making any professional judgment.

7. Patient Management: If the condition is manageable via tele- medicine, a professional judgment to provide health education and counselling and to prescribe medicines through a properly signed e-

prescription can be given by the RMP.

F) Specific Restrictions

List O: Safe to be prescribed through any mode of teleconsultation. They would comprise of ‘over the counter’ medicines.

Medicines that can be prescribed via teleconsultation will be as per the

notification in consultation with the Central Government from time to

time.

The categories of medicines that can be prescribed are:

List A: Relatively safe medications which can be prescribed during the first consult and are being re-prescribed for refill, in case of follow-up.

List B: Medication which RMP can prescribe to a patient who is undergoing follow-up consultation in addition to those which have been prescribed during the previous in-person consult for the same medical condition.

Prohibited list: These medicines have a high potential of abuse. These include medicines listed in Schedule X of Drug and Cosmetic Act and

Rules or any Narcotic and Psychotropic substance listed in the Narcotic

Drugs and Psychotropic Substance.

G) Maintaining digital trail/documentation of consultation

H) Fee for telemedicine consultation can be levied, and a receipt/invoice may be given to the patient

I) For emergency situations, the goal should be to provide in person care at the earliest.

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Telepsychiatry Practice Guidelines in India Telepsychiatry Operational Guideline 2020:

 It is a roadmap to practice psychiatry online with taking in account of Telemedicine practice guidelines and MHCA 2017.

 Prepared by NIMHANS Banglore, in association with Telemedicine Society of India & Indian Psychiatric Society.

 This guideline has 8 chapters.

CHAPTER 1

Legality of Telepsychiatry Practice

 Should be used in conjunction with other national clinical standards, policies, protocols, laws & Telemedicine practice guidelines 2020.

 Psychiatrist should observe the laws of the country in practicing

tele-psychiatry.

 Law applicable for in person consult is also applicable for tele-

psychiatry.

CHAPTER 2

Advertisement and Telepsychiatry

 IMC-Ethics regulation 2002: 6.1.1 states that soliciting of patients directly or indirectly, by a physician, by a group of physicians or by institutions or organization is unethical.

 A medical practitioner is however permitted to make a formal announcement in press regarding the following:

(1) On starting practice

(2) On change of type of practice

(3) On changing address

(4) On temporary absence from duty

(5) On resumption of another practice

(6) On succeeding to another practice and (7) Public declaration of charges

 There is thin line between informing & advertisement.

 Rule of thumb is to avoid advertisement on social media or internet

to solicit patients.

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 Social & professional boundaries:

– Maintaining separate professional/personal social media accounts. – Dedicated office mobile number, email & social media account.

– Directing patients to professional social media account.

 Not to share patient’s data on social media: Psychiatrist should refrain circulating patient’s data on any social media, without proper written irrevocable informed consent.

 Comments on Colleagues in Social Media: be watchful of behaviour online.

 Avoid endorsement of patients: rating/voting CHAPTER 3

Technology Requirement of Telepsychiatry

 Dedicated office mobile/landline number & Email ID.

 Telemedicine consultation hardware/software should be simple &

economical- any common man can afford.

 Internet connection:

At least 2 internet service provider. Wired connection internet.

At least 512kbps

Wi-Fi: 2.4/5 GHz band router.

 Hardware:

Video: Good HD camera

Camera to be placed at eye level.

Audio: to avoid background noise, headsets to be used.

Lighting: Sufficient light, recommended is warm, white LED

light [3200k-4000 kelvin)

Non reflective surfaces in background

Tele-psychiatry Chamber: should be sound proof, closer to in person OPD, aesthetically similar to in-person consult chamber.

CHAPTER 4

Electronic Health Record/ Electronic Medical Records

 Maintaining EHR/EMR are not mandatory.

 Notes can be put in patient’s physical record directly, keeping the

copy of prescription.

 Complying with MHCA 2017, section 25, which is about the need to

maintain basic medical record.

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Access to basic medical records:

 Requires written authorisation from the patient as per MHCA,2017,section 25.

 Patient’s record shall be made available to patient only. Securing the devices:

 Devices must be in possession of psychiatrist/authorised person.

 Unauthorised access should be prohibited

 Securing, disabling/wiping the tele-psychiatry devices in event of

theft or loss.

Audio/Video recording:

 Explicit consent.

 Covert recording, without knowledge of patient are illegal.

CHAPTER 5

Stepwise Teleconsultation: Pre, During, Post Consultation A) Pre-consultation:

 Consultation should be planned on appointment basis.

 Alternate contact details to be provided for both sides.

 Patients to be explained about emergency consultation before in

hand.

 Soft copy of telemedicine guidelines can be made available.

 Consent form can be sent.

 Optional telemedicine pro-forma can be sent, not mandatory.

 Patient & psychiatrist has right to choose in person consultation

anytime/any stage.

 Doctor has professional discretion to choose the mode of

consultation any time any stage.

 Identity of patient/id card.

 Presence of patient is essential during the first consultation.

Follow up consultation:

 Pro-forma can be sent [not mandatory)

 Demographic details, ID verification, last in person consult,

improvement, previous prescription, side effects to be enquired.  Any legal/pending legal inquiry.

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B) During consultation:

Internet connectivity problems: stop the session, plan for new

session.

C) After session:

 Prescription, in telemedicine practice guidelines 2020 to be sent.

 Explaining about medication intake.

 Lifestyle changes advice to be provided.

 Feedback pro-forma (optional) can be taken.

 Online investigations can be raised, and directly sent to patient.

 If required patient can be referred for general physical examination.

 Clinical practice guidelines to be followed.

 Emergency Situation: first aid, counselling and patient must be advised for an in-person interaction with RMP at the earliest.

 Odd hour consultation: doctor can choose either to attend call or not.

CHAPTER 6 Telepsychiatry Practice

a) First Consultation: First time/ > 6months back/ different health condition.

b) Follow up consultation: within 6 months of consultation with same health condition

 At least once in 6 months patient is required to come for in person consultation for tele follow ups.

 Proxy tele-psychiatry consultation:

Authorised letter from patient should be available.

If patient is minor (<16years) caregiver on behalf of child can take tele- psychiatry consultation.

 Proxy Prescription not to be given without authorisation letter, Id proof,established relationship to patient.

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 Parentral Injections can only be given if consultation is between RMP with other health care worker.

 Health care worker/RMP can go to patient’s resident to initiate tele- psychiatry.

CHAPTER 7

Prescribing Medications Online

Prescribing list:

List O: over the counter. (Paracetamol/antacid/syrups/vitamins) List A: Essential drugs

 Relatively safe medicines with low potential for abuse in first video consultation/re fill /follow up

 First video consultation is must to prescribe list A drugs: Anti-depressants

1. Imipramine

2. Escitalopram

3. Fluoxetine

Mood stabilizers

1. Lithium carbonate

2. Carabamazepine

3. Sodium Valproate

Oral Antipsychotics

1. Haloperidol

2. Risperidone

3. Olanzapine

Anti-cholinergic drugs

1. Trihexyphenidyl

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Anti-epileptics

Nasirabadi, Reddy & Akula: Covid 19 & Telemedicine in India

1. Phenobarbitone

2. Diphenylhydantoin

Sedative- Hypnotics /Benzodiazepines

1. Clonazepam

2. Clobazam

(appendix 6,MCI amendment dated 6/04/2020)

Injectables: Online Prescription shall be given by a Psychiatrist to a Healthcare worker only through collaborative tele-video consultation

1. Inj Fluphenazine

2. Inj Haloperidol

3. Inj Promethazine

Zolpidem, lorazepam not to be prescribed online

Injection risperidone/injection olanzapine to be given under supervision of psychiatrist.

LIST B: Add on medications.

List-B is exhaustive, not restrictive:

Antipsychotics: Aripiprazole, Quetiapine, Clozapine, Lurasidone, Ziprasidone,

Chlorpromazine, Paliperidone, iloperidone, Amisulpiride, Asenapine, Zuclopenthixol,

Flupentixol, Thioridazine, Droperidol, Pimozide, Trifluoperazine, Loxapine, and other antipsychotics

Anti-depressants: Sertraline, Paroxetine, Desvenlafaxine, Mirtazapine, Citalopram,Vortioxetine, Vilazodone, Duloxetine, Venlafaxine, Doxepine, Clomipramine, Nortriptyline, Bupropion, Trazodone, Nefazodone, Amitriptyline, Fluvoxamine, Reboxetine, Milnacipran, Protriptyline, Maprotiline, Amoxapine, Moclobemide and other antidepressants.

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Anti-cravings and Aversive drugs: Disulfiram, Topiramate, Baclofen, Naltrexone & Acamprosate and other anti-craving agents.

Anti-Dementia drugs: Donepezil, Rivastigmine, Memantine, Galantamine and other drugs used in the treatment of Dementia.

Anti-ADHD drugs: Atomoxetine, Clonidine, Modafinil and other drugs Mood Stabilizers: Oxcarbamazepine, Lamotrigine, Divalproex sodium

and other drugs

Beta-blocker: Propranolol

Anti-anxiety drugs: Buspirone & Pregabalin

Injectables: – Online Prescription shall be given by a Psychiatrist to a Healthcare worker after collaborative telemedicine consultation – Zuclopenthixol, Flupentixol, Paliperidone and Aripiprazole

List C: Prohibited list

a) Schedule X of Drug and Cosmetic Act, 1940 and Rules, 1945 (Amphetamine, methamphetamine, dexamphetamine, phencyclidine, methylphenidate).

b) Narcotic and Psychotropic substance listed in the Narcotic Drugs and Psychotropic

Substances, Act, 1985

[Such as:- Methylphenidate, Methadone, Buprenorphine, Ketamine, Morphine, Tramadol, Codeine, Benzodiazepines, Zolpidem and so forth)

CHAPTER 8 Telepsychotherapy

 Can be done concurrently or sequentially.

 To check for suitability of patient for psychotherapy.

 Explicit consent to be taken.

 To maintain basic medical records.

 Session notes should be available for patient.

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Take Home Points

 Telemedicine will continue to grow and be adopted by more healthcare practitioners and patients in a wide variety of forms, and these practice guidelines will be a key enabler in fostering its growth.

 While, telemedicine cannot replace the traditional medical consultations and hospital visits for emergency conditions and medical procedures, it will certainly reduce the pressure on the healthcare system in a vast and populous country like India with disproportionate healthcare facilities.

 With development of regulations & practice guidelines for telemedicine we can definitely improvise the existing health infrastructure.

 With the help of telemedicine timely and accessible health care can reach to remote and rural areas of India, thus providing Health For All.

References

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Holshue ML, DeBolt C, Lindquist S, Lofy KH, Wiesman J, Bruce H,

Spitters C, Ericson K, Wilkerson S, Tural A, Diaz G. First case of

2019 novel coronavirus in the United States.

2020;382:929-6 doi:10.1056/NEJMoa2001191.

2. WHO. Pneumonia of Unknown Cause – China. 2020,

https://www.who.int/emergencies/disease-outbreak-

news/item/2020-DON229. Accessed 21 Nov 2021.

3. Siddiquie S, Ali M, Ali KM, Atif KS, Nasirabadi MZ. Fear of COVID-

19: A cross-sectional study among general population in Telangana

during lockdown. Telangana J Psychiatry 2020;6(2):170-5.

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WHO. Telemedicine-Opportunities and Developments in Member

States. 2nd ed. Geneva, Switzerland: WHO Press; 2010.

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Baby steps forward, but a long way to go. Indian J Psychiatry

2019;61 (1):104-5. doi:10.4103/psychiatry.IndianJPsychiatry_7_18

8.World Health Organization. Mental Health Atlas2014.Geneva:

WHO; 2015.

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results/paper2/data_files/india/Rural_urban_2011.pdf

Nasirabadi, Reddy & Akula: Covid 19 & Telemedicine in India

10.Telemedicine Practice Guidelines – Enabling Registered Medical Practitioners to Provide Healthcare Using Telemedicine. Appendix 5 of the Indian Medical Council [Professional Conduct, Etiquette and Ethics Regulation) 2002.

11. American Psychiatric Association. Telepsychiatry. Psychiatry.Org,

2021. Available from: https://www.psychiatry.org/psychiatrists/

practice/telepsychiatry. 12.

13. WHO. Telemedicine-Opportunities and Developments in Member States. 2nd ed. Geneva, Switzerland: WHO Press; 2010.

14.A Brief History of NASA’s Contributions to Telemedicine. https://wwwnasagov/content/a-brief-history-of-nasa-s- contributions-to-telemedicine/ .

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from: http://americantelemedorg

Simpson AT, Doarn CR, Garber SJ. A brief history of NASA’s

contributions to telemedicine.

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history-of-nasa-s-contributions-totelemedicine/#. VUZm_qw8-M8

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mental health. London: Royal Society of Medicine Press; 2003.

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Acknowledgement: We thank Dr. Shadma Siddiquie (PG, DCMS, Hyderabad) for her extensive help.

NASA. 2013. [Last accessed on 2020

J Family Med Prim Care. 2019;8(6):1872–6. doi: 10.4103/jfmpc.jfmpc_264_19

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6. Impact of Covid19 Pandemic on Women’s Health and Domestic Violence

Shubhangi R. Parkar1, Karishma Rupani2

Introduction

The SARS COV-2 Virus has held the world to ransom. Desperate times call for desperate measures and efforts to contain the virus have included self-isolation of the infected, quarantine, travel restrictions, lockdown including closure of schools, colleges and religious places. As a result, mental health issues resulting from isolation, financial problems and uncertainty have been on the rise. Research on mental health crises suggests that COVID-19 and its mitigation measures will have an impact on mental health that will far outlast this contagion control period alone. These conclusions have been drawn based on several research groups who started investigating the psychological effects of the pandemic on the general population and found that; 28.8% reported moderate to severe anxiety symptoms, 16.5% reported moderate to severe depressive symptoms, and 8.1% reported moderate to severe stress levels.[1,2,3] Another cross-sectional study by Liu et.al (2020) concluded that the prevalence of posttraumatic stress symptoms after the outbreak was 7% and particularly higher in women and those with pre-existing psychiatric disorders.[2] Posts from a social media platform found that negative emotions [e.g., anxiety, depression, indignation] increased after the announcement of the lockdown which was a mitigating strategy for COVID 19 contagion, while positive emotions and life satisfaction decreased.[3]

1Professor Emeritus, Former Professor and Head, Department of Psychiatry, Former Chief: Bombay Drug Deaddiction Center, G.S.Medical College and KEM Hospital, Parel, Mumbai India

2Assistant professor, Department of Psychiatry, G.S.Medical College and KEM Hospital, Parel, Mumbai India

Depressive[4] and posttraumatic stress[5] symptoms have emerged among

people affected by COVID-19, compounded by the additional fear of the

disease’s consequences, fostering stigma, loneliness and anger.[6,7]

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Available research showed that as far as sex disintegrated data was concerned there were higher numbers of COVID-19 cases in women compared to men, with higher mortality rates in men [Global Health. COVID-19].

Thereafter, Lai et al.[9] conducted a cross sectional research on sex disintegrated data for emotional disturbances to find that more than 71.5% women reported psychological distress. Of these, 50.4%, 44.6%, 34.0% women reported symptoms of depression, anxiety, and insomnia respectively. In fact, female gender was significantly associated with experiencing more severe depression,

anxiety, distress and psychiatric morbidity.[9]

Women’s Life in the Pandemic

Current ongoing pandemic calamity is already contributing to health, wellbeing, and economy, social and mental crisis globally. Pandemic history over the years affected women more than men; hence it becomes a significant concern for public health so as to understand this disparity and respond to it in a gender sensitive way. Since the beginning of the current pandemic, many studies have recognised the impact of the pandemic on women. There are various reports stating the changes in menstrual periods of women while suffering from infection and even after recovery. Women with long Covid also had changes in menstrual periods which were more debilitating. Though mortality in men was more due to viral infection, women suffered major psychological and social consequences. They were exploited at all levels as 24/7 unpaid caregivers, for their kith and kins. With closure of school and child care surviving shutdown, dealing with vigorous child care services, working in jobs without social protection, losing those jobs with startling fraction and abused by domestic violence (DV) behind closed doors during pandemic surge, previously existing gender inequalities have intensified further. One of the important focus in Women’s Mental Health by WHO is to enhance the competence of primary health care providers to recognize and treat mental health consequences of DV, sexual abuse, and acute and chronic stress in women. Lockdowns associated with quarantine measures have contributed to a rise in DV against women, as well as inability of victims to access timely help and support. In addition access to sexual and reproductive healthcare is limited in the pandemic. Continuation of lockdown worldwide further deteriorated the bleak situation for women.

However, there is dearth of data on the psychological

consequences of the pandemic on various different sections of society, as

a result of which some vulnerable sections of the society are not identified

and left to fend for themselves.[8]

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Global records are suggestive of day to day incidences of DV against girl child is an unique phenomenon in spite of tight international legal provision to protect girl child. Forced Child Marriage, female Genital Mutilation, and sexual exploitation of girl child is seen globally on day to day basis for centuries. In pandemic, economic recession combined with lockdown, women are imprisoned with their abusers. Many of the hotlines and online resources from Europe to other western world countries were alarmed with a 25 t0 50 percent increase in demand for their services.

Internationally and within the European Union,[10] there have been calls

for gender-sensitive emergency and long-term responses.

Along with the pandemic there is worsening of gender inequality leading to increased incidences of DV as well as sexual exploitation of women and children when they are involved in procurement of firewood water and food. Research also documented widespread gender based violence in the HIV hyper endemic countries as well as in India. As per a report,[2] women do not exert right over their sexual choice, they experience sexual violence and also are at risk of exposure to viral contagion through male career. Also wearing a way of social norms and the breakdown in law during pandemic leads to lack of adequate social and legal support to victims and perpetrators escape from control of law.[11] Sikira and Urassa[12] observed an increase in wife battering in HIV pandemic due to suspicion of extramarital affairs. There were increased DV cases and a demand for emergency accommodation in Canada, Germany, Spain, the UK and the USA.[10] At least 26 women and girls were killed in alleged domestic homicides during this period. Within the first month, 16 of them were murdered, which was three times more than the number of women killed under similar circumstances in the same period in 2019.[13] Besides many poor countries have diverted their medical resources to combat Covid 19 crisis, as a result women are not able to get support from other resources like sexual and reproductive health provisions. This is leading to

unintended pregnancies, unsafe abortions, miscarriage, premature labour,

maternal deaths and sexually transmitted diseases. Socially events of child, early and forced marriages are happening globally and in India too. Several antisocial movements against safety of women are taking advantage of pandemic crisis and exploiting the unfortunate situation further by creating barriers and hindrance to safe abortions.

As per UN women [2020] the global cost of violence against women and girls including public, private and social is estimated at approximately 2% of global gross domestic product [GDP], which is roughly US $1.5 trillion. With the rise of the spike of DV cases in ongoing Covid 19 crisis, it’s easy

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to expect that the global cost is consequently going to go up at present and will persist in the post pandemic period [UN Women, 2020].Women are inexplicably located in insecure, underpaid, part-time and informal employment sector with financial crisis. Even a gender gap is identified in vaccination programs. Earlier pregnant women did not get vaccination due to their vulnerability and unclear guidelines about even breastfeeding mothers leading to many pregnant women and new mothers not receiving vaccination and being exposed to increased risk for infection.

Since Gender based violence (GBV) and intimate partner violence(IPV) is on critical rise globally it is important that the voice of the woman should

be included in Covid related, economical and health policies of nations. As per a report by CARE, till date 54 % of countries have not taken action against GBV and 33% have not addressed sexual and reproductive health.[14] In keeping with the above mentioned picture of gender roles, available data shows that women contribute to 71% of the global hours of informal care,[15] during this lock down. As a result of the lockdown, work and life balance has been significantly affected for women. With the closing of schools and childcare centres, compounded by confinement, they have to take on more domestic care. We can therefore understand that the pandemic has accentuated gender roles by imposing greater responsibility on women for informal care.[16]

Pandemics in past often lead to breakdowns of social infrastructures and norms thus compounding the already existing inequalities and conflicts.[17] Even under normal circumstances: low income, unemployment, economic stress, depression, emotional insecurity and social isolation are all risk factors for DV. Many of these factors have worsened in the context of COVID-19 as an increase in social isolation is used by the perpetrators of violence to exert power and control, especially on women as they have less chance to reach out to co-workers or extended family members[18, 19]. Echoing this, personnel in charge of law and order in countries hard hit by COVID-19 began raising alarm bells about an increase in the reports of DV. France saw a 36% increase in the number of reported DV cases and China reported a two-fold increase in DV cases in one month following movement restrictions.[20,21]

There are multiple psychological theories explaining DV, one of them is the traumatic bonding theory in which; when the abuse is intermittent, the attachment [during periods of absence of violence between the partners is strengthened through a negative reinforcement mechanism, that is, by, the removal of battering.[22] The term ‘intimate terrorism’

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refers to violence, by male coercion emerging from the need to exert control over the partner. It is therefore evident that the pre-existing societal norms are imperative to understand and recognize DV in a particular society.

What is Domestic Violence and Intimate Partner Violence?

Domestic violence is a pattern of coercive behaviour which involves physical, psychological, mental, economic and emotional abuse committed by one individual against another near individual with the purpose of gaining and retaining power and control. The term ‘DV’ is used when there is a close relationship and a power gap between the offender and the victim, when the victim is dependent on the offender.[23] Intimate Partner Violence [IPV] includes physical, sexual, and psychological abuse by a past or current intimate partner. CEDAW [Committee on Elimination of Discrimination Against Women] has defined gender-based violence as a form of violence that disproportionately affects women. Some common forms of gender-based violence include intimate partner violence [IPV], sexual violence, and violence against women. There are a number of reasons for such across-the-board increase in gender violence cases. During quarantine, as more women were in informal jobs and got laid off and this led to a greater impact of abuse as they then became economically dependent on their male counterparts.[24]

Lessons from the Past

Sikira and Urassa[12] reported an increase in wife battering during the HIV pandemic due to suspicion of extramarital affairs. Recent outbreaks such as Ebola, Cholera, Zika, and Nipah also led to an increase in the cases of DV.[25] Pandemics like influenza, swine flu, and SARS have been found to result in psychological issues such as anxiety, substance abuse, PTSD, and sleep disturbances that often tend to continue even after the pandemic.[25] According to Campbell,[26] IPV is associated with PTSD, depression, chronic pain, and sexually transmitted diseases. Walker[27] reported that victims of DV experience anxiety, depression, avoidance, re- experiencing traumatic events, and hyper-arousal. Domestic violence is a correlate of posttraumatic stress disorder and major depression in pregnancy and of adverse pregnancy outcomes including preterm birth.

Psychiatric Implications of Intimate Partner Violence

Most research addressing the consequences of IPV has focused on acts of physical aggression, and significantly less attention has been accorded to

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psychological abuse[28-30] This is a apologetic state of affairs, given that battered women frequently identify psychological abuse as inflicting greater distress compared to physical acts of violence [29,30]. Mental health effects of violence against women include behavioural problems, sleeping and eating disorders, depression, anxiety, posttraumatic stress disorder [PTSD], self-harm and suicide attempts, poor self-esteem, harmful alcohol, and substance use. There is growing evidence on mental health consequences of DV globally.[31] However, there still is limited region-specific reliable data which are essential for planning meaningful intervention strategies.[32,33] Sackett and Saunders assessed depression, self-esteem, and fear and found that psychological abuse contributed uniquely as a predictor of all the above-mentioned three outcomes, with the most robust effects of psychological abuse identified on outcomes assessing fear and self-esteem.[34] More women who reported the experience of IPV in the past 1 year have had an unhealthy mental status [28.2%], and suicidal thoughts [63.2% each].[35] In in-depth interviews, women reported mental effects such as suicidal thoughts/attempts, depression, forgetfulness, and sadness as evident from their verbatim. Loss of confidence/decision-making capacity was another consequence of violence. It can be concluded that DV not only affects the mental well- being of women but also erodes their self-confidence.[36]

The mental health consequences of IPV have been well documented, with PTSD (31%to 84%) and depression (48%) as the most commonly identified disorders (38, 40). These rates are considerably higher than PTSD rates found among general community samples of women, ranging from 1% to 12%.[37] Using a sub-sample of female participants completing a telephone survey, Basile and colleagues found that physical violence, psychological violence and stalking were associated with PTSD symptoms [38]. Notably, depression among battered women has been found to be chronic and persistent with symptoms continuing to exist over time for some battered women, even in the absence of recent revictimization. In terms of symptom severity, the majority of the sample reported moderate to severe [45%] and severe [31%] PTSD. Mild and moderate symptoms were seen in 5.9% and 17.9% of the sample, respectively. Depressive symptoms yielded a similar pattern of results. Moderate and severe symptoms were endorsed by 31.8% and 39.6% of the sample, respectively.[39]

The impact of IPV affects survivors differently. Some may exhibit adaptive and resilient responses to abuse, while others may develop psychiatric symptoms. Survivors often internalize verbal abuse from their partner.

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They may blame themselves for their situation, experience fear, as well as anger and resentment towards themselves. Chronic abuse may result in compulsive and obsessive behaviours and lead to self-destruction or suicide. IPV-associated abuse may affect emotional regulation, facial interpretation, and reading of social cues.[38]

In the Indian context, Varma et al. reported that depression, somatic, and PTSD symptoms were higher in those with a history of abuse or sexual coercion, and life satisfaction was poorer in those with any form of violence.[39] Another study in India reported that DV in the past 12 months is inversely related to rural women’s mental health.[40] A study from Kerala found DV to be an independent risk factor for attempted suicide [OR 3.79, 95% CI = 1.35–10.62].[41]

Summary of Risk Factors

1. A study done by Yu et.al found that men with depressive disorder, anxiety disorder, alcohol use disorder, drug use disorder, attention deficit hyperactivity disorder, and personality disorders had a higher risk of inflicting IPV against women than their unaffected siblings. The results indicate that most of the studied mental disorders are associated with an increased risk of perpetrating IPV towards women, and that substance use disorders have proved to be the highest absolute and relative risk factors for DV. The findings support the development of IPV risk identification and prevention services among men with substance use disorders as an approach to reduce the prevalence of IPV.[42]

2. Economic insecurity has been found to be linked to adopting poor coping strategies that are inclusive of substance abuse. These, in turn, have been found to be associated with various forms of gender based violence.[43]

3. It is reported that increase in male unemployment was associated with increase in IPV against women where an increase in women unemployment was associated with a decrease in violence against them.[44] According to Schneider et al.,[45] such an outcome could be because of male backlash resulting from feelings of emasculation and inadequacy at not being able to serve the role of a breadwinner of the family.

4. Mandated reporters, such as teachers, child care providers, and clinicians, also have fewer interactions with children and families

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and fewer opportunities to assess, recognize, and report signs of abuse than they did before the pandemic due to contagion measures taken.

5. Economic strain, substance abuse, and isolation all tend to increase the risk of DV.[46] It is evident that understanding of gender violence is a key priority in order to achieve gender equality globally.

Evaluation

The evaluation should start with a detailed history and complete physical

examination. Clinicians should screen all females for DV. This includes

females who do not have signs or symptoms of abuse. All healthcare

facilities should have a plan in place that provides for assessing,

screening, and referring patients for IPV. Protocols should include referral,

documentation, and follow-up. Screening can be either an interview by

the medical personnel or a questionnaire filled by the patient. Some of the

common questionnaires/tools for screening are as follows: [a] The HITS

screen involves a four-item scale [hurt, insult, threaten, and scream] and

has a Likert scoring system ranging from 1–5.[47] [b] STaT screen

[slapped, threatened, and throw] is a highly sensitive tool to screen IPV.[48]

Typical domestic injury patterns include contusions to the head, face, neck, breast, chest, abdomen, and musculoskeletal injuries. Accidental injuries more commonly involve the extremities of the body. Abuse victims tend to have multiple injuries in various stages of healing, from acute to chronic. Complaints may include backaches, stomach aches, headaches, fatigue, restlessness, decreased appetite, and insomnia. Women are more likely to experience asthma, irritable bowel syndrome, and diabetes.

Implications

● There is enough data to hypothesize that the pandemic will cause distress to women to a greater extent.

● Gender-sensitive interventions during the pandemic should be considered, given this situation, public policies should promote equity in care and strengthen those research programs that include a gender perspective. Globally, this is the moment to invest in women’s mental health.

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● Moreover, continuous and rigorous efforts are required to put an

end to the stigma associated with gender-based violence.

● Clinicians can also educate themselves about available community resources. If abuse is disclosed, the clinician and patient can establish signals to identify the presence of an abusive partner during telemedicine appointments.

● Health professionals and administrators should be aware of challenges such as barriers to screening for DV: lack of training, time constraints, the sensitive nature of issues, and a lack of privacy to address the issues are all barriers.

● Governing bodies should consider social determinants of health when developing crisis standards of care. Privilege, finances, and access to resources all affect the impact of IPV on patients.

Take Home Points

In the current pandemic, it is imperative that sex-disaggregated data are collected and effectively analyzed from the outset such that policies can be structured to mitigate DV. There is Shadow pandemic of violence especially domestic violence (DV) against women, girls is spreading globally along with current health crisis which needs to be controlled at earliest.(UN WOMEN).The pandemic has highlighted how much work needs to be done to ensure that people who experience abuse can continue to obtain access to support, refuge, and medical care when another public health disaster hits.

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42.Schneider D, Harknett K, McLanahan S. Intimate partner violence in the great recession. Demography 2016;53:471–505. doi: 10.1007/s13524-0160462-1

43.Richards L. DASH: Domestic Abuse, Stalking and Harassment and HonourBased Violence Risk Identification and Assessment and Management Model. DASHRiskChecklist [2009, April 12]. Available from: http://www.dashriskchecklist. co.uk

44.Canterino JC, VanHorn LG, Harrigan JT, Ananth CV, Vintzileos AM. Domestic abuse in pregnancy: A comparison of a self-completed domestic abuse questionnaire with a directed interview. Am J Obstet Gynecol 1999;181:1049–51.

Bhalotra S, Kambhampati U, Rawlings S, Siddique Z. Intimate

partner violence: The influence of job opportunities for men and

World Bank Econ Rev doi: 10.1093/wber/lhz030

women.

2021;35(2):461-79.

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Impact of Covid 19 Pandemic on Child Mental Health

Anirban Ray1, Savita Malhotra2

Introduction

Covid 19 pandemic has had an impact on the whole world, after starting from Wuhan China.[1] The year 2020 had seen most of the world shifting to indoors due to lockdowns. Most of us have seen a pandemic first time in our lives. The world has also heard the new word ‘lockdown’ and experienced it.

The whole society is tottering with problems. Actual ill-health, deaths, dearth of medical facilities are reality. It has increased the fear of death of oneself and relatives. Economic slow-down, loss of jobs, also has deteriorated the financial health of the families. These issues also tell upon the psychological well-being of the person.[2] Directly Covid virus- related neuropsychiatric manifestations are also important areas of concern.[3]

Children comprise28% of the world’s population and they have virtually been put indoors.[4] Where the schools are not completely closed, they have a lot of restrictions and Covid has snatched the childhood of crores children of 216 countries of the world.[5] Hence the mental health impact on the children is a burning issue to ponder over for child mental health professionals.

Experience of Previous Pandemics

Previous epidemics like SARS, MERS, Ebola, etc have found that children are one of the worst affected psychologically. 15% of children and adolescents have psychiatric morbidity and 50% of psychiatric disorders start before 14 years of age.[5] It was also found out that, coronavirus infections can have a direct impact on a patient’s neural system and can have neuropsychiatric manifestations.

1 Associate Professor, Department of Psychiatry, IOP-COE, IPGME & R; Founder & Child & Adolescent Psychiatrist, Mind Mentors, Kolkata Email: drani_r@yahoo.co.uk

2Former Dean. Professor and Head Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh

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Experience from Current Pandemic

Mental health problems can happen in Covid-19 infected children:

Children have less incidence of the disease. Also, they are having a milder variety with less hospitalization and mortality.[6] Children also present with skin rashes.[7] But they can have other classical covid symptoms also,[8] and recently a treatment guideline has been published by the government of India for the paediatric population.[9] Warning signs of the onset of mental health problems among these children are as below:

 Abnormalities in daily tasks (sleep, appetite, and behavioural issues)

 Mood swings (aggression and anxiety)

 Abnormal behaviours (self-harm etc.)

 Psychosis-like symptoms

 Somatic symptoms[10]

Mental health problems can happen in Covid-19 affected children (indirect effect):

Multiple studies from across the world have found out the presence of anxiety, depression, and other PTSD-like symptoms, [11,12] sleep disturbances,[13] and social isolation[14] in children. A study from India also depicted worry, hopelessness, and fear in a survey among 121 quarantined 9-18 years old children along with their parents.[15]

There are a lot of studies from around the world. Naturally, all of them are online studies done cross-sectionally. Several studies from China have unanimously shown an increase in psychiatric morbidity especially an increase in anxiety and depression[16-25] Most of the studies were done among adolescents. Some of them even taken children from early or middle school years, from 6 to 12 years of age. One study among the youth population of medical college students had shown urban residence or staying with family can be protective factors, whereas a quarantined family member is a risk factor for psychiatric morbidity. Similarly, European studies from Italy and Spain have found an increase in psychological morbidity, boredom, irritability, etc.[26,27] One of them also observed more screen time, sleeping, and less physical exercise in kids.[27] One Norwegian study[28] shown less life satisfaction during the pandemic. Similarly American studies from the USA[29] and Canada[30] shown anxiety, depression, loneliness in adolescents. In a similar tune even a study from Australia[31] also shown anxiety, depression is more

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and life satisfaction is less among adolescents during the pandemic. It has also shown, it is more prominent in girls. Abiding by the social distancing and other safety norms was associated with a less psychiatric problem, and conflict with parents was associated with more psychiatric issues.

Many studies and reviews about child and adolescent mental health have observed children and their family members are overburdened with information about the disease on social media. This ‘infodemic’ negatively affects the behaviours and psychological well-being of the family.[32-33] Studies also observed that job loss and loss of daily routines add to the increased family stress. Domestic violence and child abuse have increased. It can also impact the mental health of the children negatively[34] Children, who already suffer from psychiatric morbidity or are at risk of it, are more vulnerable.[4,34]

All families are not affected similarly. Those from the low socioeconomic background, migrated origin, limited living space,[35] where parents are covid front-liner, or lost a job during the lockdown, or suffering from covid, are worst hit.[5]

María Luisa Zagalaz-Sanchez et al have shown that daily activities in the lockdown depend on place and type of residence. Where rural children are more engaged in reading and physical activity. Urban children are more adherent to gadgets. Residents of small flats are engaged more to screen, where as a house with a garden seems to urge them for free play activity.[36]

Increased pornography watching and cyberb ullying and cybercrimes are already being reported during the lockdown phase.[4,37] Unfortunately, as the schools and other protective services are not functioning optimally, it is difficult to report abuse for a child.

Adolescents are more prone to self-harm and adolescent turmoil is more prominent during the lockdown. Hence adolescent suicide is a logical concern during this pandemic.[37] Though at least studies from Japan have observed no increase in adolescent suicide during this pandemic.[38,39] Further studies need to be done.

Oosterhoff et al. studied the association between adolescent mental health and motivation to comply with preventive measures like social distancing. They observed that social responsibility and subjective anxiety positively correlated with the motivation of social distancing. Interestingly, in this study, a subset of youth (25%) reported that they

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were social distancing because they would prefer to stay home regardless of social distancing recommendation enforcement status. (29). A subset of children who have some social skill deficit or are bullied in school perform better in home-schooling as the main source of daily irritation have gone. On the contrary, hyperactive and externalizing children have found it more difficult to stay at home for a prolonged period. Currently in India due to 2nd wave of upsurge, it is more than a year the schools are closed, and the children are at home.[40]

Some families also have done well during this period. More family time allowed, more spouse time, and more parent-child time. That can improve family bonding and family members get to know better about each other. Where government support systems are in place, material support to the families did have a positive impact on both family and child functioning. Where a family is conversant about the digital world, they could function better.[34]

Closure of Schools and Online Classes

In March 2020, 188 countries closed down schools (40) and 91% of the world population (1.6 billion) missed the opportunity for physical schooling.[4,41]

School is not only an institution that teaches course curriculum to the children. It hasa significant developmental role in any child’s life. It is the place of peer interaction and process-based social skill training that prepares a child for future life. Adolescent peer interaction cannot be over-emphasized.[42] Still, adolescents have an opportunity for social media and the digital world to resort to. But younger children do not have that benefit also. School routines are crucial for young persons. Especially those with mental health challenges and special education needs are at high risk.[43]

Children are feeling bored, depressed. Their hyperactivity increased. While parents are working from home, they lost jobs, faced financial constraints. Managing children entirely at home is a stress for them. It results in child abuse and an increase in domestic violence. A school is a place of a lot of social security schemes of government to children. Those are halted too.[44]

Considering these, Viner RM et al. in their two articles argued for the earliest reopening of schools, taking adequate social distancing measures.[44,45] They have reviewed 16 such studies in previous

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pandemics to show that physical school continuation could not increase the chance of transmission while social distancing methods are in place. Iwata et al. observed similar things through epidemiological data modelling in covid 19 pandemics.[46] Silverman et al also had a similar opinion. They observed the school closure decision was based on the influenza pandemic experience. In influenza, children are more vulnerable but in Covid 19, it is not so.[47]

On the other hand, Klimek-Tulwin & Tulwin opined school closures can potentially reduce transmission during the pandemic.[48] A study from Israel has observed sudden local spread on school reopening.[49] A USA- based study shown sports activity in school increased the transmission.[50]

Though some other studies opined against school closure as a useful strategy fora reduction of transmission.[51,52] Lordan et al in editorial observed a balanced view.[53] Honein et al also had a balanced viewpoint where it was stressed vaccination as a prerequisite of opening school.[5]

Because of the severity of the pandemic, and the possibility that children can serve the asymptomatic carrier as adults.[55,56] despite opposing views about the reopening of schools, schools of a lot of countries of the world including India are closed for more than a year now. Till Feb-March 2021, half of the world’s student population (more than 800 million learners) is still affected by full or partial school closures. In 29 countries, schools remain fully closed.[41] 2nd wave of Covid doing havoc across India now. Hence reopening of schools seem to be a far-off possibility as of now.

Older students are also stressed as their examinations are getting postponed and carrier options are unsettled[57] due to covid lockdowns. Authorities need to be sensitive to students’ stresses.

Online education: challenges and consequences like behavioural addictions:

Online education was in vogue in graduate and adult learning fora long time. It has its share of strengths and difficulties. On one side, it’s flexible, affordable, and less restrictive. On the other hand, it needs high digital expertise for both teachers and students, specialized teaching skills, and independent student learning or student motivation, along with uninterrupted connectivity. Hence, it’s a great mode of learning when it is elective.[58,59] But during Covid 19 it has become a compulsion and many countries had to resort to it without prior preparation.[60] In countries like India, where a large part of the diverse population has no access to digital

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media and internet and necessary gadgets and technology,[61] compulsive online teaching may classify students as privileged and underprivileged. Older students are better learners in this mode.[62] But covid compulsions made the younger children also to resort to this mode of education, even as small as nursery students. While normal attention span for children increases at the rate of 2-5 mins/ year. A 3-year-old can concentrate 9- 15 min at a stretch. American Academy of Paediatrics in 2016 suggested no screen time below 1.5 years, between1.5 – 2 years only supervised viewing of high-quality, slow content for the minimum duration. In 2-5 years of age, 1-hour screen-time is the maximum that is allowed throughout the day.[63] Whenever we expose a child with materials of distraction like the internet, with his low attention span, and low educational motivation, he tends to deviate more easily to more appealing content and develop behavioural addiction. The only solution may be supervised shadow teaching. But that is also difficult for busy parents and most of the families don’t have that social support system. But completely avoiding the school time and curriculum can lead to deskilling and loss of structure or routine in a student’s life. That can also be a deleterious effect on a child’s development. Hence to avoid the online mode completely may not be rational. Limiting online time, parental awareness, and engagement may be the only way out in the current scenario.

Hence along with boredom and gadget availability, the long duration of online classes can also be a cause for behavioural addiction like screen addiction which sored high during this time.[64-67] In addition to that, eyesight issues, attention, and learning issues can also affect as per expert opinions.[68] Guidelines for parents have been suggested by different organizations and groups to minimize these problems.[69]

Children with Special Needs

Children with developmental disorders like autism spectrum disorder

(ASD) or attention deficit and hyperactivity disorders (ADHD) or

intellectual deficiency disorder (IDD) or pre-existing psychiatric disorders

like anxiety, depression, or obsession (OCD) have more difficulty. Their

regular therapies were stopped or difficult to access. Environmental

changes and alteration of routine are more difficult for them to handle.[13,14,70]

There are very few studies on the impact of Covid 19 on children with developmental disorders. In a Uganda-based qualitative study, Mbazzi observed they are equally disturbed as their neurotypical peers as they

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missed peers and schools. Parents felt that this is hampering their development.[71] Asbury et al observed that in the UK both parents and children appear to be experiencing loss, worry, and changes in mood and behaviour.[72] Tremmel shared a success story from the USA where online training, community participation, and long-standing relation with students clinched the goal for the commerce school district in Texas.[73]

Governments have the responsibility to support children with special needs in countries where social security is better or parents are more comfortable in digital media use.[74] In 3rd world counties like India, a large number of students don’t have access to digital media, and also children with special needs have difficulty in understanding instructions on the online platform due to their cognitive and behavioural problems. The learning curve of the children with special needs deteriorated due to the prolonged closure of special schools.[75] One size does not fit all, especially from a special education perspective. In-person consultations can be an option when possible.[76] There are concerns, those children with special needs may not use musk for their sensory, cognitive, and behavioural issues. Authority needs to device something different like a face shield or shielded cubicle to do the functions without compromising safety.[74] According to the experience of one of the authors, shadow teaching by parents through digital platforms is a useful technique to tide over these difficult times. It can also empower the family in a better way to deal with the child’s problem in long run. A small proportion of students where they are bullied in school or parents can give more parental quality time during lockdown and pandemic, which can improve significantly as observed by Asbury et al.[72] The families who are members of large parents’ groups, those who are more active in social digital platforms, have done well during the pandemic.

Child Mental Health Service Delivery System

Due to restrictions of physical visits in covid lockdown, the health and service delivery system, especially in non-emergency care, has suffered a lot. More difficult is the mental health delivery system, as sometimes it is difficult for patients to maintain safety precautions given their cognitive and behavioural challenges. Also wearing musk deter the understanding of emotional expression, which is an integral part of the assessment in psychiatry. Longer duration face-to-face interaction is needed sometimes to have a proper assessment of the behavioural issues of the patients, which is also not recommended in this pandemic situation.

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The medical system has found its alternative in the online mode of consultation. In mental health clinics, online consultations increased drastically during the covid pandemic.[77] An expert group of research and opinion in China suggested online consultation mode also along with the establishment of service and care system network involving multiple organizations and stakeholders in child mental health. The need for high- quality training in child psychiatry was emphasized.[10]

In India, the Ministry of Health and Family Welfare made a timely step to permit online mode of consultation permitting even text messages as a prescription from doctors.[78] That can cater to a lot of needy people across the country. NIMHANS came up with telepsychiatry guidelines immediately following that.[79] Psychotherapy had been permitted to be done online before.[80,81] In this pandemic, psychotherapists become accustomed and comfortable with the mode of service delivery. Not only that, the speech therapy association came up with an online mode of service delivery system too.[82] Occupational therapists[83] and special educators[84] also have implemented local service delivery protocols for different organizations.

These are immense positives from this difficult scenario. These forced training for the professionals will help service delivery even after the pandemic is over, in different corners of the country where transportation is difficult, costly, and time-consuming.

Child in Need of Care and Protection

The Deputy Director of ‘CHILDLINE 1098’ India, announced that India saw a 50 percent increase in the calls received on the helpline for children when the lockdown began. This rate increase is alarming and has made an increasing number of children, victims in their own homes.[4] Poverty will sweep the lower socioeconomic strata for a long duration even after the pandemic is over, due to a slowdown of the economy. As a result, child labour, both physical and sexual child abuse, child marriage, child sex work, and trafficking have a strong possibility of reaching a higher proportion. Our response system needs to gear up to counter those.[85] While 2nd wave of Covid is sweeping across India with a high toll of mortality and morbidity, parental loss due to death for children is a reality. Hence Covid Orphans are proposed to be taken care of by the government in India.[86,87]

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Ray & Malhotra: Impact of Covid 19 on Child Mental Health Future Research in Child and Adolescent Mental Health

According to expert groups all over the world, the following are the proposed areas of future research in this child and adolescent mental health-related to COVID-19.

1. Documenting impacts: risk & protective factors (epidemiology, biomarker, neuroscience, service system surveillance), mental health, cognitive development, children at risk, resilience, clinical service areas /equity, and outcomes.

2. Developing and testing intervention (prevention, services)[34] a. Clinical and community intervention

b. Services and system intervention

c. School intervention

3.Empirical work on clinical service delivery or educational initiatives[88]

Conclusion

Though life-threatening infection from Covid 19 is rare in children, they are no less affected by this pandemic. Rather this impact may last beyond the pandemic years. As a generation is robbed of their vital developmental years along with financial burden in family, even loss of family support permanently in varied extent. Experience from the previous pandemic showed play therapy, yoga, community, and social intervention were effective[89] along with nurse-led psycho-social even psychopharmacological support in non-specialist settings.[90] We need more such intervention-based studies in this Covid-19 scenario. This can help the children in a better way in this difficult time.

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Take Home Points

1. Covid 19 infection is less in frequency and severity in children. But they can be asymptomatic carriers. Those who are infected can have neuro-psychiatric manifestation also. It is direct or indirect result of the virus that is yet to be determined.

2. Both typically developing and children with special needs can have anxiety, depression, behavioral problems, and behavioral addiction in this Covid 19 pandemic situation, secondary to the stress.

3. Some children and families may do well also

4. While school closure is not good for child’s overall development, the widespread

pandemic situation and possible asymptomatic carrier state of children in children may

make the decision to open the school, tricky from government’s perspective

5. While online classes are good for older adolescents and adults, may not be as useful for

the kids. But may be the only option left;

6. Atrocity and abuse against children may increase during and post pandemic. Hence, we

must be ready to address that issue.

7. Online and teleconsultation for all the child mental health and allied professionals has

expedited due to the pandemic. That may be beneficial for the future also

8. More research on impact, intervention and service delivery systems are needed.

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Geriatric Mental Health during the Covid 19 Pandemic

Introduction

In terms of mental health, they often present with conditions warranting treatment but often not satisfying diagnostic criteria and at times with evolving and fluctuating symptoms involving multiple systems. This is associated with intake of drugs for a number of comorbid illnesses and the drug interactions further complicate the picture.

The social factors which can inhibit the reach of mental health providers include:

1) Physical obstacles – rural geriatric populations, loss of ambulation, distance from family members.

2) Cultural obstacles – myths around ageing, expectation of functional decline in elderly, social withdrawal, expectation and normalisation of memory loss, cognitive decline, disability, attributing comorbidities to “natural” causes. “Ageism” leads to increasing stigma and secondarily neglect.

3) Economic obstacles – loss of income and dependence on immediate family members, difficulties with enrolment in health insurance policies/ higher premiums[1]

1Director, Schizophrenia & Psychopharmacology 2Director, Acute Services, 3Junior Resident, 4Junior Resident, 5Research Assistant,

Asha Hospital, Hyderabad

Address for correspondence:

G. Prasad Rao1, Chytanya Deepak Ponangi2, N. Chandresh3, Madhiha4,

Sriramya Vemulakonda5

India is home to 1.31 billion people, second to China on lists of most

populous countries of which the geriatric population stands at nearly 100

million. This number is predicted to rise to 324 million–nearly 20% of its

total population, by 2050.

Dr. G. Prasad Rao, Director, Schizophrenia & Psychopharmacology Dn. Asha Hospital,

Road No. 14, Banjara hills, Hyderabad – 500034

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Rao et al: Geriatric Mental Health during Covid

Adding to the above, the Covid 19 pandemic has been ravaging populations and fundamentally altering the way people interact with the world at large, their local communities and family members.

Risingcost of healthcare during the pandemic in a population prone to financial insecurity, loss of a spouse, lockdowns leading to distancing from family members, at times abandonment, loss of support from domestic helpers, further restrictions at an age of limited freedom, all further add to increasing risks of inducing an adverse mental health event.[2]

Actual risk and fear of being infected during consultations further impedes management of both physical and mental health disorders.

Compared to COVID-19 induced pneumonia among the young, in elderly age groups, it is found that progression of illness and risk of death is three times higher. There are higher chances of bad outcomes due to increased frequency of mechanical ventilation, higherlung-lobe involvement, and more blood-gas diffusion abnormalities.[3]

Social distancing especially in old-age homes can increase loneliness which is a risk factor for depression, anxiety disorders, and suicide.[4]

An inverse relationship between psychological stress and parameters of the immune system makes the elderly more susceptible to viral infections.[5]

New onset of mental health events, though not meeting diagnostic criteria, still cause distress to the individuals. Such sub threshold symptoms of anxiety and depression may be treated using brief psychosocial interventions, which involves educating them and their caregivers about the stresses associated with the pandemic and methods to cope with them, sticking to

.[6]

.[7]

a daily routine, nutritious diet, physical

exercise, mindfulness exercises, and taking an active role in household

activities

In elderly with a pre existing mental health illness, the various factors

mentioned previously can lead to drop in follow up with the psychiatrist,

discontinuation of medicines, at times self-medication and restarting

medicines at inappropriate doses from past prescriptions leading to

adverse events

Patients with cognitive decline may also fail to adhere to infection

prevention measures, and their reduced activity due to negative

Parallel Pandemic of 2020 104

symptoms or fear of infection can further impair their physical health and

.[8]

Rao et al: Geriatric Mental Health during Covid

immunity

Nearly 66% of those over 60 years of age are currently married, 32% are

.[1]

widowed and nearly 3% are separated or divorced

A meta-analytic study in which majority (80%) of the articles used

Geriatric Depression Scale,34.4% of elderly population living in India was

found to suffer from depression of which the estimate among the female

population is higher

.[9]

It has been reported that a geriatric individual takes an average of six

prescription drugs concurrently and often suffers from adverse drug

.[10]

Focus on a few Mental Health Disorders Generalised Anxiety Disorder (GAD)

reactions

It is one of the commonest forms of anxiety disorders seen among the

elderly in India with an overall prevalence of 10.7%. Increasing COVID-19

cases with significant mortality in elderly, social isolation, family members

being stuck at disease cluster zones, worry about children and

grandchildren contracting the illness, and apprehension about institutional

quarantine, admissions and Intensive Care Unit (ICU) stay cause anxiety

in elderly.

Benzodiazepine receptor occupancy of 20% causes anxiolysis, occupancy of 30% to 50% causes sedation, and 60% causes hypnosis[12] Benzodiazepines produce dose-dependent respiratory depression. In healthy patients, respiratory depression is moderate, but depression is enhanced in patients with chronic respiratory disease, and synergistic depressant effects occur when benzodiazepines are combined with opioids.

A study in Ontario, Canada[11] showed benzodiazepine users were found to have a 45% increased risk of respiratory exacerbations in outpatient setting and 92% increased risk of emergency room visits for COPD or pneumonia. Increased risks of adverse respiratory outcomes were found inpatients on short/intermediate- and long-acting benzodiazepines,[12]

Benzodiazepine use has been associated with increased influenza-related mortality.[13]

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Rao et al: Geriatric Mental Health during Covid

This population may present with vaguesomatic complaints due to the

underlying anxiety – body pains, sleep disturbances, inability to relax and

consultations with multiple doctors of various specialities. Breathlessness,

palpitations due to anxiety may be confused with cardiovascular or

respiratory causes, with normal oxygen saturation levels and ECG.

Gastro-oesophageal Reflux Disease with dysgeusia and dyspepsia may

improve with management of underlying anxiety.

Generalized Anxiety disorder can be treated with psychopharmacotherapy

and/or psychotherapy. Cognitive Behavioural Therapy would be useful in

patients without neurocognitive disorders.

Post Traumatic Stress Disorder (PTSD)

Critical illness such as covid 19 and associated ICU admissions cause the

patients to be exposed to extremes physiological and psychological stress

and they experience a direct threat to their lifeand also witness life

threatening events in those around them leading to trauma and

precipitation ofpre-existing psychiatric illness. The prevalence of PTSD

following ICU stay is estimated to be up to 75%

Studies have shown that PTSD can result in significant immune

suppression leading to recurrent infections including susceptibility towards

.[15]

Covid 19 and Dementia

.[16]

.[14]

sarscov2

Treatments for PTSD include psychotherapies and pharmacotherapy.

Psychotherapies found to be effective for PTSD include exposure therapy –

prolonged exposure-, a combination of exposure and a cognitive therapy –

trauma-focused cognitive-behavioural therapy, cognitive processing

therapy, eye movement desensitization and reprocessing therapy

Common shared risk factors for both Dementia and COVID 19 are obesity,

hypertension, cardiovascular disorders, diabetes mellitus.

It is seen that the blood brain barrier is weakened in cases of dementia

thus increasing the chances of invasion by pathogens.

Dementia predisposes to an increased risk of COVID 19. In order of

descending risk are vascular dementia, Alzheimer’s disease, senile

dementia, post traumatic dementia. In this population, The 6-month

mortality risk was 20.99% and that of hospitalization was 59.26%

respectively

.[17]

Parallel Pandemic of 2020

106

Long term/ remnant effects of COVID 19 are loss of sense of smell

and/or taste, difficulties with memory and concentration.

Inflammation and strokes observed in COVID patients could increase the

risk of developing Alzheimer’s disease and other types of dementias.

Geriatric Depression

[18] .[19]

.[20]

Rao et al: Geriatric Mental Health during Covid

It has been seen that infections by pathogens such as chlamydia, herpes

virus, and spirochetes may at a later date trigger and/or expediate

neurodegeneration. Whether a similar effect will be seen due to SARS-

COV-2 will be seen in the coming decades.

A study from France revealed that 65% of patients suffering from severe

forms of Covid 19 had acute onset of confusion as a symptom which is a

part of the delirium complex. A single episode of delirium can lead to an

increase in the chance of developing dementia later

and cause further

decline in cognitive abilities in those with dementia

Depression in India has a prevalence of 21%–39%

The severity of

depression is directly proportional to age and number of co-morbidities.

A study on the impact of COVID-19 on mental health of the elderly in

[21]

Spain

showed that those above 60 are less vulnerable to depression

and acute stress, and no difference in anxiety levels during the peak of

the pandemic compared to the group under 60 years of age was seen, but

the long-term prevalence is unknown.

Dementia often presents as depression in the age group of 60–65

[22]

years.

Depression in older adults is mostly associated with organic

lesions such as Alzheimer’s disease or vascular dementia and the

phenomenon of vascular depression has been well studied.

Parallel Pandemic of 2020

107

[23]

Presenting symptoms include insomnia, pseudo dementia, apathy in

personal care, loss of appetite, loss of weight, anger outbursts, increased

substance use, atypically with increased appetite, hypersomnia. As these

may be considered as a normal part of ageing, it is often overlooked and

underdiagnosed.

Depression often goes undiagnosed in primary care and its recognition by

the primary care physician is vital, since they are often the main

providers of health care and educating them on geriatric depression is

important.

other treatment options.

Rao et al: Geriatric Mental Health during Covid

Apart from pharmacotherapy, family therapy is useful in those having

social/ familial risk factors. Teaching relaxation techniques and CBT are

Antidepressant drugs are the mainstay of treatment combined with

psychological interventions. Elderly persons are more prone to side effects

of antidepressant drugs even at lower doses and require careful

monitoring.

Substance Misuse and Abuse

Substance abuse in patients aged 65 years and above is often

underestimated and underdiagnosed. The Family Health Survey of India

(1998–1999) reported that regular consumption of alcohol was 18.6%

prevalent in elderly men and 3.1% prevalent in elderly women.

Separation from their children, death of their spouse, retirement,

restriction to homes during lockdowns without other outlets, may lead to

start of alcohol consumption, even if they have not been an active alcohol

consumer in the past.

Other reasons include financial strains, relocation, troubled sleep, familial

conflicts, and physical or mental health degradation. Alcohol is used as an

escape from negative life events and stressors but can exacerbate mood

and anxiety disorders.

Individuals above age of 65 years have a reduced ability to metabolize

drugs, alcohol, and increased sensitivity.

The concentration of all of these factors during covid 19, prepares the

ground for an increase in substance abuse, with similar rises seen in

[24]

times of natural disasters in the past.

There has been an increase in alcohol consumption in all age groups with

21% increase in the number of people exceeding drinking guidelines and

[25]

a 26% increase in binge drinking

and people with substance use

disorders are both more likely to develop COVID-19 and experience worse

COVID-19 outcomes.

[26]

The prevalence of alcohol consumption among the cohort between the

ages of 60 and 64 years was found to be 25.4%, which declined to 10.5%

[27]

in a cohort of above the age of 75.

Parallel Pandemic of 2020 108

Clinically, not many elderlies opt to get rid of or reduce their dependence

on alcohol or nicotine.

The number of heavy smokers declined from 22.7% between the ages of

60 and 64 years to 8.2% of heavy smokers between the ages of 65 and

[27]

Elder Abuse

Rao et al: Geriatric Mental Health during Covid

75 years.

Elder abuse includes physical, sexual, psychological, emotional, financial,

and material abuse; abandonment; neglect; and serious losses of dignity

and respect. 10 percent of elderly experience abuse.

[30]

[28]

One in five older persons in the study sample of 192

abuse, an increase of 83.6% from pre pandemic prevalence rates. Sense

reported elder

of community was protective factor against elder abuse – individuals

derive strength and confidence when they perceive themselves to be a

[29]

part of a larger network.

Physical distancing was associated with

reduced risk of elder abuse. Financial strain due to economic downturn

has a negative impact on interpersonal relationships, leading to increased

interpersonal violence.

It damages family well-being directly by triggering hostile and disruptive

interactions, or indirectly due to collective concerns about future

economic outlook.

[31]

Victims of abuse have a high rate of depression,

anxiety, feelings of shame and guiltleading to social isolation which

further increases risk of abuse and secondarily to increasedrisk of suicide.

The presenting complaints include chronic pain, gastrointestinal and

neurological complaints, arthritis, and gynaecologicalissues, such as

vaginal bleeding and pelvic pain without a particular diagnosis to explain

them. Abused elders are 300% more likely to die a premature death than

their not abusedcounterparts.

Suicide

The rate of elderly suicide in India is 7/100,000. Moreover, the ratio of

completed suicide to attempted suicide for elderly in India is 1:7, which is

double that of the lower age groups, in whom the ratio is 1:15. Among

the elderly, isolation and loneliness, loss of economic independence,

reduced social activity and presence of a chronic debilitating illness

contributes to negative thought patterns.

[32]

One in four persons in a

sample of terminally ill elderly patients expressed a desire of ending their

Parallel Pandemic of 2020

109

lives. Out of this sample, 25% of them were diagnosed with depression,

71% and 95% of the elderly who completed suicide had been diagnosed

[32]

Medical Illness/Co-morbidities

[33]

Rao et al: Geriatric Mental Health during Covid

with at least one mental disorder.

With increasing prevalence of anxiety and depression during the Covid 19

pandemic, there has been a rise in elderly suicide with notes indicating

fear of corona, lack of familial and economical support.

Physical illnesses in the elderly can often present with psychological

[20]

symptoms or vice versa.

In late life, rehabilitation takes precedence

over cure due to the presence of comorbidity and chronic conditions.

Common medical conditions can present with atypical features and mimic

psychiatric disorders and requires careful investigation for organic causes.

Post covid neurological complications, shortness of breath, angina

associated with rising d-dimer levels often can appear like features of

anxiety. Steroid use in the management and their abrupt discontinuation

present with psychosis. Poor diabetic control may present with delirium.

Liaison between psychiatrists and other medical professionals is essential

to resolve diagnostic confusions and offer good geriatric care. Multiple

medications for several co morbid conditions can be minimised by a good

liaison.

[34]

Polypharmacy

With an increased prevalence of comorbid conditions and their associated

treatment, there is an increased prevalence of polypharmacy in the

[36]

geriatric population.

[36] [37]

Inappropriate polypharmacy ranges at times

upto60%.

This brings with it an increased risk of morbidity and

mortality.

Declining immune system, kidney function, diabetes,

cardiovascular disease, hypertension, along with polypharmacy increase

the risk of morbidity and mortality and added acute infections such as

Covid-19 commonly lead to consequences like multiorgan failure,

respiratory failure and death.

Polypharmacy in critically ill COVID-19 patients may precipitatetorsades

de pointes (tdp) and prolonged QT interval, especially in the setting of

antipsychotics drugs, requiring greater vigilance in monitoring of drug

interactions.

[38]

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Rao et al: Geriatric Mental Health during Covid

To reduce the risk of these adverse drug events, deprescribing – identifying and discontinuing drugs where the risks outweigh the benefits within the context of the patients’ life expectancy, functioning and outcome[39]– may be attempted. Several tools exist to aid in this process Beers criteria,[40] STOPP,[41] Mcleodcriteria.[42]

Developing New Ways to Reach Patients

Asha workers/peripheral health workers /social workers

The screening for psychiatric disorders in geriatric age groups can be

performed by peripheral health workers /social workers trained to make

assessments using scales. Online consults with psychiatrists can be

arranged from old age home. Helpline numbers handledby trained staff

can address mental issues faced by the public during a disaster for aiding

minor mental health issues.

Teleconsultations

Home Visits

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is no suicidal risk, severe agitation, catatonia or delirium.

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9. Impact of COVID-19 on substance and screen use P K Dalal1, Amit Singh2

Introduction

The COVID-19 pandemic has had a devastating impact on human lives. It substantially changed the way people live or interact, who are forced to stay indoors, limit physical interactions, modify the usual recreational habits, and change the way of coping with stress. It is responsible for a significant global disease burden through its direct and indirect contributions to morbidity and mortality worldwide. It adversely impacted the mental health of the public and acutely hit the care and support services. The reduction in income, loss of jobs, and increased expenditure over healthcare and other services during the pandemic led to a financial crisis in many families contributing significantly to the overall stress. During the pandemic, a remarkable increase in substance use and time spent on-screen was also noticed, which may affect the health, productivity, and overall well-being of the individuals. This chapter focuses on the COVID 19 pandemic’s impact on the substance use and screen use of the affected population.

Covid 19 and Substance Use

The multitude of ways the pandemic has influenced substance use and related aspects are described below.

Increase in substance use and related complications

Stress is an established factor responsible for substance use.[1] The “self- medication hypothesis” of substance use implies the use of substance by individuals to ameliorate their symptoms of stress, anxiety, worry, insomnia, and low mood.[2] Besides, under stressful situations, people who have used substances often restart using the substance and even

1Professor and Head (former), Department of Psychiatry, King George’s Medical University, Lucknow, Uttar Pradesh, India; Past President Indian Psychiatric Society

2Assistant Professor, Department of Psychiatry, King George’s Medical University, Lucknow, Uttar Pradesh, India

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increase the amount consumed.[3] The pandemic has led to losses related to health, finances, and jobs, substantially increasing the stress levels of individuals. Besides, the concerns related to the security and well-being of the family and relatives only contributed to this stress. The researchers across globe notice a pattern of increased substance use during the COVID-19 pandemic. A large population used alcohol and other substances to cope with the pandemic-related stress. A study conducted in Canada and the USA reported substance use in over a third of the surveyed population of 1405 individuals to cope with stress. The personal and family stressors were found to be associated with alcohol/substances use during the COVID-19.[4] An association was found between COVID- 19-related worry and substance use. Among those who initiated substance use during the pandemic, the levels of worry and fear were higher compared to pre-pandemic substance users or those who opt to abstain from substance use.[5] An online survey was conducted in France to assess the substance consumption pattern during the containment period of the pandemic. About one-third of the 11391 participants reported an increase in tobacco and cannabis consumption, and about a quarter reported increased alcohol use. Lower well-being and increased stress scores were associated with an increase in addiction-related behaviours.[6] Regarding the factors associated with increased substance use, they found a higher increase in tobacco use among lesser-educated females with no partner and still working at the workplace. Alcohol use was higher in those within the age range 30-49 years, on current psychiatric treatment, and with a high level of education. The increase in cannabis use was associated with intermediate/low levels of education.[6]Individuals with substance use disorder may have symptoms such as insomnia and anxiety exacerbated during stress. A study with the users of medical cannabis as participants reported an increase in the overall use of cannabis owing to COVID-related anxiety (68%), boredom (47%), and an increase in the symptom burden of pre-existing illness (42%).[7] The increase in use may persist for a long. A study found that compared to influenza or other respiratory tract infections, the COVID-19 survivors evaluated beyond six months of infection had significantly higher substance use disorders.[8] An online survey in the US with 5285 participants reported a persistently increased substance use in over 10% of the individuals.[9] The psychosocial interventions targeted at engaging clients in different activities also suffered. The activity schedule of people was disrupted. Stuck in one place, the issues of boredom and high free time compelled people to use substances.

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Social media also plays a major role in enhancing stress. Itdeluges individuals with sensational information, often enhancing their fear and stress. Users’ emotional distress can be exacerbated during disasters and crises as a result of the potential of social media to augment and propagate emotional contagion.[10] Studies have found an association between the use of social media as an information source and higher consumption of substance use and alcohol.[4]

Alcohol and substance use not only increased in the general population but also in special population groups. Increased use was noticed among the healthcare workers as well during the pandemic. However, the healthcare workers consumed alcohol products with comparatively lower alcohol percentages.[11]Among pregnant women, economic strains and symptoms of depression and were associated with more cannabis and/or tobacco use as well as the co-use of substances.[12]

Meanwhile, the p

atients diagnosed with substance use disorder may be at

increased risk for COVID-19 infection. A retrospective case-control study

using health records of 12,030 patients with a diagnosis of COVID-

19reported an adjusted odds ratio of 8.699 (P < 10−30) for COVID infection

among those with a diagnosis of substance use disorder during the past

year. The infection risk was highest for individuals with opioid use

disorder (AOR = 10.244, P < 10−30), followed by tobacco use disorder

(AOR = 8.222, P < 10−30).

[13]

This increased vulnerability may be due to

various factors, including the direct impairment in immunity due to

substance use, engaging in COVID unsafe behaviours, and the presence

of multiple comorbidities among the substance users. Thus,

the COVID-19 and substance use may be a vicious cycle where one increases the risk of the other. While the COVID-related stress symptoms are higher in people who use substances, the disregard for social distancing norms has also

been found to be higher in this population.[14]

The pandemic-related restrictions and lockdowns led to the closure of liquor shops. This resulted in a sudden shortage of alcohol availability to the consumers, resulting in several adverse outcomes, including withdrawal seizures and complicated withdrawals.[15] People started stockpiling alcohol, anticipating its non-availability during COVID restrictions creating a panic-like situation. The prices of alcohol soared, and even cheap quality alcohol was being sold at manifold its usual prices, increasing the financial burden on the user. Black marketing of alcohol begun. Even adulterated alcohol and alcohol not fit for drinking were sold and consumed, resulting in morbidities and deaths.[16] People unable to

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manage craving even consumed sanitizers. In many places, a stock-out situation developed due to panic buying of medicines. Thus, the abstinent patients under SUD treatment relapsed back due to the lack of medicines and non-availability of medical services.[17]

The users’ stockpiling of drugs and alcohol was suggested to be a potential factor for increased intoxication and overdose incidents during the pandemic. A pragmatic explanation is that those with diminished control over their substance use are more likely to consume the stocked substances in higher amounts.[17] Besides, the loss of tolerance to the substances following sudden non-availability made them vulnerable to overdose at the previously consumed amounts. Due to disruptions in the drug distribution networks, the availability of illegal drugs was also not regular. The users resorted to alternative drugs and combinations to manage their discomfort. There were reports of fentanyl use-related overdose and death among the users of opioids.[18,19] Since injecting equipment was harder to get in the first place due to a lack of supplies, the chances of reusing and sharing it increased. Thus, increasing the risk for blood-borne infections, including HIV and Hepatitis, among people who inject drugs.[20]

Change in Substance Use Patterns

The lockdown and government-imposed restrictions have resulted in a change in the alcohol use pattern, with more people using alcohol at home either alone or with their life partners than with friends.[9]During the period of COVID-19 confinement, people switched over to other readily available substances. A study using human hair for substance use profiling reported a substantial reduction in samples

[22]

Increased Morbidity and Mortality

People with SUD were reported to have higher morbidity and mortality due to COVID. They often suffer from various comorbidities, which worsen the outcomes. A retrospective case-control study of electronic health records (EHRs) data reported significantly poorer outcomes in COVID-19 patients with SUD (death: 9.6%, hospitalization: 41.0%) compared to

positive for heroin,

cocaine, cannabis, and MDMA during the lockdown; whereas, the

consumption of benzodiazepines and alcohol increased. After the

confinement was over, the pattern became similar to the pre-lockdown

[21]

levels.

The use of party drugs such as ecstasy and nitrous oxide was

reduced or discontinued during the lockdown because of the lack of

appropriate social occasions.

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general COVID-19 patients (death: 6.6%, hospitalization: 30.1%). The COVID-19 patients with SUD had a higher prevalence of chronic renal, hepatic, pulmonary, diabetes mellitus, obesity, cardiovascular diseases, and cancer.[13]A meta-analysis of 23 studies find increased risk of COVID- 19 related hospitalisation (aOR 1·87 [1·16–3·03]) and mortality (OR =1·76 [1·27–2·44]) among people with SUD.[23]

Reduced Adherence to Treatment and Substance Use Relapse

A halt in public transportation services and lockdowns resulted in patients enrolled in supervised opioid maintenance treatment programs not getting their daily dose of medications. Similarly, the shortage of medications at pharmacies due to disruption in the supply chain and increased demand during the lockdown resulted in a relapse in many people. However, interim guidelines were issued to deal with the situation and healthcare agencies promptly responded by modifying their strategies to mitigate the adverse impacts of COVID lockdown, which includes implementing take- home options of medications provided under the opioid-substitution program in India.[24]

Increased Treatment Needs

The pandemic increased the healthcare burden and treatment needs of people who use alcohol, tobacco, and drugs. An increase in the use of these substances straightforward contributed to the increased treatment needs. Higher instances of withdrawal (including complicated ones), intoxication, and substance use-related complications were also contributory. Worsening of the psychosocial milieu and financial adversities resulted in relapses and improper management of comorbidities. A survey reported that people living with HIV and SUD had an increase in illicit substance use. They came in contact with other substance-using individuals more often, and their confidence to stay abstinent and attend recovery meetings was decreased. More people missed HIV medications and became irregular to follow-ups.[25]The enrolment to opioid agonist treatment centers markedly increased during the pandemic.[26] It even resulted in a situation of impending shortage of opioid substitution treatment medicines at several centers, which was managed through emergency relocation of medicines.[27]The mental health and substance use related visits increased during the pandemic. The role of primary care facilities is augmented due to better access to such centers.[28]

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Covid 19 And Screen Use

The covid-19 pandemic forced people to spend a large amount of time indoors or at home. A large number of day-to-day operations shifted to virtual space. At home or places with limited space for movement, people tend to spend a long time watching television or using digital devices for entertainment. In the current era, with smartphones, tablet computers, and personal computers at their disposal, people resort to these for social interactions and entertainment purposes. Besides, a substantial amount of official work, meetings and reviews, interviews, teaching, and educational activities are being conducted online and accessed through digital media devices. Thus, the young and adults alike spend more time on-screen during the pandemic. An online survey conducted in India to assess the impact pandemic related lockdown, with over 1600 participants, found an increased time spent over watching movies and playing video games in around 57% and 34.5% participants, respectively.[29]Similarly, increased use of screens was reported by 64.6% of 11391 participants in a French survey. The risk factors identified were female gender, age less than 29 years, having no partner, intermediate/high education level, being employed, being locked down with no access to an outdoor space or locked down alone, living in an urban environment, and not working.[6]A survey on 254 Canadian families revealed an increase in screen time in 87% of children, 74% mothers, and 61% fathers during COVID-19.[30]A study on 2427 children and adolescents from China compared physical activity and screen time before and during the COVID pandemic and found around a four-fold increase in screen time, including more than 2.5 times increase in the leisure screen time. Significantly more participants spend longer durations on screen for leisure activities during the pandemic. Besides, there was around five times reduction in time spent on physical activity.[31] Excessive screen use has its own harms, including unhealthy sedentary lifestyle, eye strain, poor sleep, increased risk of non-communicable diseases including obesity and myopia, misinformation about COVID-19, exposure to harmful content (violent or sexual), development of gaming disorder, or engagement in online gambling.[32–34]Besides, it makes children and adolescents vulnerable to cyber bullying. The COVID-19 related increase in screen use duration may relate to poor mental health in individuals.[35] However, some studies suggest mental disorders to be related to covid related distress and not to the increased screen exposure.[36]

Various guidelines have talked about limiting screen time during the pandemic and participating in physical activities, exercise, yoga, or other

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meditation exercises. Those who continued to exercise and limited their screen use were found to highly self-rate their mental and physical health, indicating the beneficial effects of these practices.[37]However, due to myriad factors, people often lose motivation for these activities, which some may find demanding.

Contextual Interventions

The SUD treatment during the COVID-19 pandemic poses unique challenges. This chronic relapsing problem demands good coordination among and within the healthcare sector, social welfare, and human rights sector to mitigate substance use related harms. During the COVID-19 pandemic, when various systems crumbled under pressure, it has been difficult for the service providers to continue their work in the usual manner. The policy and structural changes were made, and newer strategies were adopted to with the demand of the current situation. The glaring issue of continuing SUD services while following the physical distancing norms has been attempted by treatment providers and facilities globally. The service providers and policymakers recognized the role digital health interventions may play during current times and promptly employed telehealth services for the users. Various web-based and mobile applications were developed for the same. The provision of counseling, psychotherapy, and treatment was all made available online.[38] The policy changes include providing take-home opioid agonist medication for opioid use disorder clients, strengthening satellite opioid substitution treatment center strategy, longer inter consultation durations, and medications and accessories dispensed to clients for long durations. Stronger social protection measures; higher integration of primary care, addiction treatment, psychiatric and medical healthcare systems; training

provide safe addiction care

[39]

physicians, nurses, psychologists, and social workers to

identify and

physical, social, and human capital; and, modernizing the substance use

; mobilizing services to enhance

and addiction care system may go a long way towards continued recovery

even during the pandemic times.

Regarding screen use,

the interventions should be aimed at preventing excessive exposure to screen, making people aware of the adverse effects of longer time spent on screen, and improving their health and well-being by encouraging them to live active lifestyles with improved eating habits and healthier

behaviours.[40]

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Conclusion

Dalal & Singh: Impact of COVID-19 on Substance & Screen Use

All populations should be assessed for the use of alcohol and other substances at all points of contact with healthcare. In addition, the public should be made aware of the measures directed at helping them sort out substance use related problems. Providing online healthcare services is a crucial strategy to reach out to large populations and those in remote locations. However, considering the vast differences in the overall infrastructure in different geographies, the comprehensive implementation of this strategy needs a lot more work. Moreover, since the pandemic is continuing, decision-makers should anticipate and plan in advance for unimpeded delivery of healthcare services, especially during the surging phase of the COVID pandemic.

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32. Wang X, Li Y, Fan H. The associations between screen time-based sedentary behavior and depression: a systematic review and meta- analysis. BMC Public Health 2019;19:1524.

33. Susilowati IH, Nugraha S, Alimoeso S, Hasiholan BP. Screen Time for Preschool Children: Learning from Home during the COVID-19 Pandemic. Glob Pediatr Health 2021;8:2333794X211017836.

34. Wong CW, Tsai A, Jonas JB, Ohno-Matsui K, Chen J, Ang M, et al. Digital Screen Time During the COVID-19 Pandemic: Risk for a Further Myopia Boom? Am J Ophthalmol2021;223:333–7.

35. Smith L, Jacob L, Trott M, Yakkundi A, Butler L, Barnett Y, et al. The association between screen time and mental health during COVID-19: A cross sectional study. Psychiatry Res 2020;292:113333.

36. Sewall CJR, Goldstein TR, Rosen D. Objectively measured digital technology use during the COVID-19 pandemic: Impact on depression, anxiety, and suicidal ideation among young adults. J Affect Disord2021;288:145–7.

37. Statistics Canada, Colley RC, Bushnik T, Langlois K. Exercise and screen time during the COVID-19 pandemic. 2020 [cited 2021 Aug 15]; Available from: https://www150.statcan.gc.ca/n1/pub/82-003- x/2020006/article/00001-eng.htm

38. McDonnell A, MacNeill C, Chapman B, Gilbertson N, Reinhardt M, Carreiro S. Leveraging digital tools to support recovery from substance use disorder during the COVID-19 pandemic response. J Subst Abuse Treat 2021;124:108226.

39. Jemberie WB, Stewart Williams J, Eriksson M, Grönlund A-S, Ng N, Blom Nilsson M, et al. Substance Use Disorders and COVID-19: Multi- Faceted Problems Which Require Multi-Pronged Solutions. Front Psychiatry 2020;11:714.

40. Sultana A, Tasnim S, Hossain MM, Bhattacharya S, Purohit N. Digital screen time during the COVID-19 pandemic: a public health concern. F1000Research 2021;10:81.

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10. COVID-19 Pandemic & Mental Health Research

Sandeep Grover1, Swapnajeet Sahoo

Abstract

The COVID-19 pandemic has led to several mental health problems in every strata of population. Ever since the origin of the COVID-19 pandemic, a large amount of research has emerged, which can be broadly divided as impact of Lockdown on the mental health and mental health impact of the COVID-19 infection on the patients or the health care workers (HCWs). With regard to the impact of lockdown on mental health, research suggests significant increase in depressive and anxiety symptoms, fear of getting infected with COVID-19 infection, insomnia, post-traumatic stress disorder (PTSD) related symptoms and suicidal ideations in general public and worsening of mental health conditions in persons with pre-existing mental illnesses. There was a global increase in self-harm and completed suicide. Mental health care was reformed to online and tele-psychiatric services to cater to the needs of the public in most of the countries. Further, a large body of research had been done on the impact of COVID-19 on patients suggesting greater rates of common mental health conditions, PTSD, cognitive deficits, delirium and several neuro-psychiatric manifestations during both acute and recovery period of illness. There has also been significant evidence of prevalence of mental health issues in frontline health care workers.

Keywords : COVID-19; Mental Health; Research; Impact; Pandemic Introduction

The ongoing COVID-19 pandemic can be said to be one of the historical events which had shattered the mankind and it is expected that it has causedsevere consequences in all domains (health, economy, livelihood), which are going to persist for long. It has been now well-known that the COVID-19 infection emerged from Wuhan, China, and later spread to all

1Professor, 2Assistant Professor; Department of Psychiatry, PGIMER, Chandigarh

Address for correspondence: Dr. Sandeep Grover, Professor, Department of Psychiatry, PGIMER, Chandigarh Email: drsandeepg2002@yahoo.com

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over the World. It is caused by the SAR-2-CoV virus and later spread to all over the World. Till date (as of 25.05.2021), COVID-19 pandemic had affected almost all countries of the World, with a cumulative case load of 166 million and 34.59 lakhs deaths.[1]

It is well known that natural calamities, disasters and wars, often lead to a multitude of mental health problems. As compared to the mental health impact of natural calamities and wars, little is known about the mental health impact of pandemics. Over the last century, many pandemics (Spanish Flu, Severe acute respiratory syndrome-SARS, Middle East respiratory syndrome-MERS, Ebola, Swine Flu etc.) has threatened the mankind.[2] However, the ongoing COVID-19 pandemic can be said to be different from the earlier pandemics, as it has affected much largerpopulation across the globe. It has led to a complete lockdown, shut down of services and movements of people in almost every country and has affected the world economy at large.[3] As the existence of humanity is at stake, the COVID-19 pandemic has led to several mental health problems in every strata of population. Ever since the origin of the COVID-19 pandemic, a large amount of research has emerged. The existing literature in this area is growing exponentially every day.

Mental health research and COVID-19

Impact of lockdown

Public

Persons with mental illness

Persons with substance use disorders

Impact of COVID-19

Patients with COVID-19

HCWs-Frontline

Special population

1. Children/adolescents 2. Elderly

3. Migrants

Mental health service delivery

Self-harm and suicide

Figure 1 Different domains of mental health research done during the ongoing COVID-19 pandemic

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In this book chapter, we try to discuss the various aspects of mental health research conducted so far in different parts of the world.The research can be broadly divided into two main areas (1) Impact of Lockdown on the mental health and (2) mental health impact of the COVID-19 infection on the patients or the health care workers (HCWs).

Research related to the impact of lockdown subsequent to declaration of COVID-19 pandemic

The initial phase of research on mental health was related to the effects of lockdown on different strata of the society. While lockdown was essential to stop the rapid spread of the infection, it has several consequences on the mental health of general public at large. Lockdown implied sudden closure of all public places, schools, colleges, restriction of movements of people and travel, and people had to be home-bound and work from home.

In this regard, the research can be further sub-divided into mental health impact of lockdown on public, persons with mental illness, persons with substance use disorders, self-harm and suicide and how the mental health delivery system was affected (Box-1).

Impact of lockdown on Public: Studies from different parts of the world reported significant increase in depressive and anxiety symptoms, fear of getting infected with COVID-19 infection, insomnia, post-traumatic stress disorder (PTSD) related symptoms and suicidal ideations.[4–11] Most of the studies were online/web-based cross-sectional surveys, that used standard questionnaires (such as patient Health Questionnaire-9 [PHQ-9], Generalised Anxiety Disorder-7 Questionnaire [GAD-7], Centre for Epidemiological Studies – Depression scale [CES-D], General Health Questionnaire -12 [GHQ-12], Perceived Stress Scale -10 [PSS-10] etc.). Therefore, these studies provide a rough estimate of the depressive/anxiety/stress symptoms and are not diagnostic for the same. However, despite these limitations, it is clearly evident that across the World (both in developed less/dense populous countries as well as developing densely populated countries), there is an increase in mental health problems in the general public. A few studies, also attempted to assess the contributing factors for the poor mental health and suggest that staying isolated/alone, fear of being infected, staying away from family/near ones, female gender, low education, younger as well as older age groups, people living with young children, being unemployed/having loss of business/livelihood and those with chronic physical health or

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mental health conditions had higher prevalence of adverse mental health outcomes.[4,7,11–13] Some of the studies, especially from India, focused on mental health issues among the migrant populations,[14–16] and highlighted their distress. A few studies have also evaluated the impact of lockdown on the sexual functioning,[17] and domestic violence.[18,19]

Impact of lockdown on persons with mental illnesses: Lockdown adversely affected the mental health of the persons with pre-existing mental illnesses. Only a handful of studies have looked into the impact of lockdown on persons with mental illnesses. In this regard, existing literature suggest as compared to pre-lockdown, patients with mental illnesses had worsening of mental health conditions and experienced relapse of previously stabilised mental illness during the lockdown, many patients reported significant distress due to lockdown/home bound, had disruption of daily routines, concerns about infection with COVID-19, less frequent contacts with family/friends, boredom and reduced access to psychiatric facilities.[20,21] Although there has been reduced visits to the psychiatric emergencies during lockdown period, yet studies had reported significant increase in patients with schizophrenia and affective disorders attending psychiatric emergencies and subsequent requiring acute hospitalization during lockdown period.[22,23] On the contrary, few studies reported decline in the emergency department visits by patients with schizophrenia and mood disorders.[24,25] There has been few reports of new onset brief psychotic disorders in some parts of the world due to intense psychosocial stress due to COVID-19 pandemic and subsequent lockdown.[26,27] Moreover, complete lockdown policy also had several direct and indirect impact on homeless persons with mental illness related to shelter, basic needs and access to health care etc., which not been given due importance.[28] Some of the reports also highlighted the impact of COVID-19 on the psychopathology in patients with severe mental disorders.[29]

Impact of Lockdown on Mental health delivery systems: The complete lockdown resulted in significant disruption of delivery of mental health care services across the globe. Studies from several parts of the world echoed same findings[30–34]. Telepsychiatry and online technology led to reforms in providing psychiatric care in this regard.[35,36] A recent survey by the WHO conducted between June to August 2020 among 130 countries across WHO’s six regions revealed widespread disruption of almost all kinds of critical mental health services (over 60% of countries reported disruptions in providing mental health care to children/adolescents/older adults and women; 67% countries reported

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disruptions to counselling and psychotherapy services; more than 35% of countries had significant disruption to critical/emergency and access to substance use disorders services with 65% reporting difficulty in providing harm reduction services).[37] Further, the survey also reported that although 70% of the countries had adopted telemedicine or tele-therapy to overcome these disruptions, yet there were significant disparities in uptake of these interventions i.e. suggesting several gaps and barriers in service delivery.[37] Some of the studies also described different service models, which linked the telepsychiatry with the emergency care services, and providing mental health care to patients with COVID-19 infection from the remote locations.[38,39]

Impact of lockdown on self-harm/suicide :There have been several reports and studies across the globe about the increase in self-harm attempts and completed suicides during the lockdown[40–43] A study from India based on news and media reports analysis reported 369 cases of suicides and attempted suicide during lockdown period of 24th March to 3rd May 2020 (67% increase as compared to 2019)[43]. The studies from western world (Austria, United Kingdom) also reported significant increase in self-harm attempts and completed suicide rates.[41,42,44]The risk factors which were identified for suicides and self-harm attempts during the lockdown period included loneliness, isolation, older age group, male gender, married, unemployment, those having poor mental and physical health issues, fear and uncertainty, vulnerable groups (migrants), economic fallout, domestic abuse and intimate partner violence.[41,43,45] In this regard, several countries started helpline and tele crisis-intervention programs to help the sufferers.[35,46]

Impact of lockdown on persons with substance use disorders: The sudden imposition of complete lockdown in many countries across the world posed several challenges to persons with substance use disorders (SUD). There have been many surveys in different countries which have tried to explore the substance use patterns during the lockdown period. Few studies have reported reduction in alcohol[47,48], and illicit substance use, while others have reported the reverse i.e. lockdown led to increase in hazardous and heavy drinking behaviour in both gender,[49] overall increase in alcohol consumption (particularly in the 30-39 years age group),[50,51] significant increase in tobacco and cannabis consumption[52], and difficulty in procuring illicit opioids and increase in emergency visits subsequent to opioid withdrawal.[53,54] Risk factors for increase in substance use during lockdown have been found to be joblessness, quarantine, having COVID related worries and economic worries,

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boredom, lack of social contacts, loss of daily structure, younger age, female gender, stress about contracting COVID-19 or becoming ill, stress of getting hospitalized, fear of death due to COVID-19, and having pre- existing anxiety disorder.[50–52] Studies had also reported higher depression and anxiety scores in those having increased use alcohol and tobacco use disorders.[55]Other studies have reported the impact of alcohol based sanitizers on people with alcohol use disorder.[56]

Box 1: Summary of research related to the impact of lockdown

Research had shown that lockdown led to :

1. General public: Significant increase in depressive and anxiety symptoms, fear of getting infected with COVID-19 infection, insomnia, post-traumatic stress disorder (PTSD) related symptoms and suicidal ideations.

2. Persons with mental illnesses: Worsening of mental health conditions and relapse of previously stabilised mental illness during lockdown, increase in distress and reduced access to psychiatric facilities; increase in emergency visits by patients with schizophrenia and affective disorders.

3. Self-harm/Suicide: Global increase in self-harm attempts and completed suicides during the lockdown as compared to pre- lockdown period.

4. Persons with substance use disorders : Increase in hazardous and heavy drinking behaviour, overall increase in alcohol consumption, significant increase in tobacco and cannabis consumption, difficulty in procuring illicit opioids and increase in emergency visits subsequent to opioid withdrawal

5. Mental health service delivery:Significant disruption of delivery of all types of mental health care services across the globe. Mental health care was reformed to online and tele-psychiatric services to cater to the needs of the public in most of the countries.

Research related to impact of COVID-19 infection

The COVID-19 infection is taking a heavy psychological toll on the mental health of patients infected with COVID-19 and their caregivers. Additionally, emerging data suggests that COVID-19 infection has significant impact on patients with mental illnesses and those with SUD when they get infected with COVID-19. COVID-19 has also affected the mental health of the healthcare workers in many aspects (Box 2).

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Impact of COVID-19 on mental health of patients with COVID-19:

Studies had reported widespread fear, anxiety, depressive symptoms, PTSD, insomnia and suicidal ideations in patients admitted to COVID designated hospitals or isolation centres.[57–60] Most of the studies had reported these findings in patients with mild to moderate COVID-19 infection. Additionally the data suggest that adverse mental health outcomes are more commonly seen in people who are isolated, have fear of own death or death of near ones, havelifetime history of psychiatric disorder, female gender, both younger as well as age>50 years and during the early days of hospital stay.[57,58,60,61]Studies which have evaluated the neuro-psychiatric issues in patients with COVID-19 have also found high prevalence of delirium among patients with severe COVID-19 infection.[62,63] Moreover, studies have reported significant prevalence of anxiety and depressive symptoms post-discharge from the hospitals i.e. during the recovery period suggesting persistence of anxiety, perceived stress and depressive symptoms.[64–66] Studies have revealed that stigma of COVID-19 infection (in domains of social rejection, internalised shame and social isolation) was significantly associated with greater prevalence of depression and anxiety in COVID-19 survivors.[67,68] More recently, cognitive deficits and dementia following severe COVID-19 infection and post mechanical ventilation in intensive care unit (ICU) have been reported from several parts of the World demonstrating the direct impact on brain and linked with underlying inflammatory processes.[69,70] Even after 3-4 months after COVID-19 hospital discharge, clinically significant cognitive impairment have been observed in 59 to 65% of the patients and data suggest that the cognitive impairment correlate with d-dimer levels during acute illness and residual pulmonary dysfunction.[71] A large scale cohort study which analysed the electronic health records of 62,354 individuals with COVID- 19 demonstrated that a diagnosis of COVID-19 was associated with increased incidence (18.2%) of a first psychiatric diagnosis in the following 14 to 90 days; hazard ratio being greatest for anxiety disorders, insomnia and dementia.[72] Emerging data (from China and Czech Republic) on the impact of second wave of COVID-19 on patients infected and getting re-infected suggests greater prevalence of symptoms of anxiety, depression and PTSD.[73,74]

Data also suggest that patients with co-morbid psychiatric illness who develop COVID-19 infection face significant problems. There are issues related to drug-drug interactions (between anti-COVID medications and psychotropics),[75,76] lack of knowledge and awareness about COVID appropriate behaviours and difficulty in following the same,[77] greater risk

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of medical complications due to high prevalence of metabolic syndrome, difficulty in keeping them isolated in COVID wards, difficulties in managing agitation, insomnia and somatic symptoms.[78] More recently, a large scale study (n=7348) from New York, revealed that after adjusting for demographic and medical risk factors, having a pre-morbid diagnosis of schizophrenia spectrum disorder was significantly associated with higher mortality in patients with mental disorders (Odds ratio -2.67).[79] All these findings suggest that COVID-19 adversely affects the mental health of infected people in multiple domains and can have long term consequences which may require neuro-psychiatric rehabilitation.

Impact of COVID-19 on mental health of Health-care workers (HCWs)/Front line workers: Abundant literature had been accumulated on the impact of COVID-19 on mental health of HCWs. Most of the studies are web-based cross-sectional surveys, that have used validated questionnaires (PHQ-9, GAD-7, Impact of Event Scale –Revised (IES-R),PSS, Insomnia Severity Index (ISI) and many more). These studies had given wide ranging estimates for the prevalence of depression (30-77%), anxiety (30-50%), PTSD (44-76%) , insomnia (30-50%), somatisation, perceived stress and stigma in HCWs.[2,67,80–83] Systematic reviews and meta-analysis of available literature on this topic suggest a pooled prevalence of 23.2-24.94% for anxiety, 22.8-24.8% for depression and 38% for insomnia.[84,85] Almost all the studies, suggest that female HCWs and nurses have the higher rates of mental health problems and stigma than male HCWs/medical staff.[85,86]

Studies have also recommended interventions for preserving mental resilience, improving safety at workplace, providing psychological first- aid, effective communication(both formally and socially), organisational online mental support services, provision of adequate protective supplies and promotion of coping strategies to improve the mental health of HCWs engaged in COVID-19 duties.[87–89] More robust data in form of longitudinal studies are needed to estimate the long term mental health outcomes of COVID-19 on HCWs as well as to plan structured psychological interventions.

Impact of COVID-19 on mental health of Children/Adolescents:

Closure of schools and educational institutions due to lockdown has posed significant distress among children and adolescents. Systematic review of the surveys conducted on students (adolescents) on several countries report stress, worry, feeling helpless, difficulty in attention, irritability, anxiety, depressive symptoms and behavioural problems.[90,91] Studies

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have reported increase in prevalence of oppositional-defiant behaviours in pre-schoolers and increase in emotional and behavioural problems in adolescents.[92] Higher grade, female gender, low socio-economic status, staying in limited living space and having more worries related to getting infected were some of the risk factors for anxiety and depressive symptoms in children and adolescents during the ongoing pandemic.[93–95] In response to the increasing evidence of mental health issues in children and adolescents and also in children with special needs, there is a need to expand mental health services for providing mental health support and care during the ongoing pandemic.

Impact of COVID-19 on mental health of Elderly: Elderly (adults>65 years of age) are at increased risk of developing severe COVID-19 infection and have about 23 fold greater risk of death. Older individuals have multiple medical co-morbidities and weakened immune responses which lead to fatal outcome.[96] COVID-19 has significantly affected the mental health of elderly across the world. Studies had reported worsening or relapse of previous mental health conditions or onset of new mental health issues in the elderly population due to fear, worries related to infection, staying alone/isolated, increase in loneliness, decrease in outdoor activities and restriction of social activities.[97,98]There were more restrictions in some countries for the elderly citing to protect the “weak and the frail” such as asking them to avoid meeting grandchildren and children, avoid going to shops or walking outdoors etc., which created more psychological distress and stigma for older people.[99] Very few studies have explored the prevalence of psychiatric issues in elderly and had reported that older subjects reported significantly lower percentages of anxiety and depressive disorder or stress/trauma related disorder and lower suicidal ideations than younger age groups, suggesting better emotional regulation and low stress reactivity.[100] However, these findings may not be generalised to the entire world as in many developing countries, there have been reports of issues related to access to psychiatric services by the elderly (being less technology savvy).[101,102]

Impact of COVID-19 on mental health of Women: Many large surveys/studies had reported that women have more PTSD-like symptoms (re-experiencing, negative mood regulation and hyperarousal) than males and are at higher risk of developing psychiatric disorders and loneliness.[103,104] Various studies have also reported more mental health problems (greater psychological distress, depression, anxiety, insomnia) in female HCWs involved in patient care as frontline workers during the pandemic.[80,105] Higher mental health problems have been reported in

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pregnant females, during postpartum or those experiencing intimate partner violence.[106] There have been several reports of increased violence (domestic and intimate partner violence) against women worldwide.[18,19,107–109] However, the available research on women mental health during the ongoing pandemic is relatively scarce and further studies would be required to estimate the impact of pandemic on women mental health.

Box 2: Summary of impact of COVID-19 on mental health

1. Patients with COVID-19 infection :

a. Higher prevalence ofdepression, anxiety,PTSD, insomnia and suicidal ideations in patients admitted to COVID designated hospitals or isolation centres.

b. Persistence of psychological morbidities during the recovery period.

c. Emerging evidence of cognitive deficits and dementia in patients with severe COVID-19 infection and among those who required

mechanical ventilation.

d.Data suggests that patients with COVID-19 had an increased

incidence of a first psychiatric diagnosis in the following 14 to 90 days; hazard ratio being greatest for anxiety disorders, insomnia and dementia.

e.Those with co-morbid psychiatric disorder had greater problems during acute illness and a pre-morbid diagnosis of schizophrenia spectrum has been found to be significantly associated with mortality.

2. Health care workers:A higher prevalence of anxiety, depression, PTSD, insomnia, stigma; more in female HCWs and nurses.

3. Special population

a. Children and adolescents: Increase in emotional and behavioural

problems and subsequent anxiety and depressive symptoms have

been reported.

b. Elderly: Worsening or relapse of previous mental health conditions

or onset of new mental health issues in the elderly population. Lower prevalence of anxiety and depressive symptoms as compared to younger population.

c.Women: A higher prevalence of PTSD like symptoms, more psychological distress and common mental health issues, more mental health issues in pregnant females and postpartum, increased rates of domestic and intimate partner violence.

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Conclusion

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COVID-19 pandemic has brought the world to a standstill. The pandemic has affected the mental health of everyone in the society. A large body of research has emerged, which has demonstrated increase in the prevalence of mental health disorders in the form of depression, anxiety, insomnia, and PTSD. Further, emerging data suggest that the pandemic has affected the sexual life of the general population, has led to increase in the prevalence of intimate partner violence, fear of getting infected, etc. Among the persons who have developed COVID-19 infection, a higher prevalence of common mental disorder has been reported, not only during the acute phase of illness, but also during the post-COVID phase. Available data also suggest that the pandemic has also adversely affected the frontline health care workers. However, most of the available data is in the form of cross-sectional surveys. There is an urgent need to carryout longitudinal studies to understand the long term impact of the pandemic.

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52. Vanderbruggen N, Matthys F, Laere SV, Zeeuws D, Santermans L, Ameele SV den, et al. Self-Reported Alcohol, Tobacco, and Cannabis Use during COVID-19 Lockdown Measures: Results from a Web-Based Survey. EAR 2020;26(6):309–15.

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63. Kennedy M, Helfand BKI, Gou RY, Gartaganis SL, Webb M, Moccia JM, et al. Delirium in Older Patients With COVID-19 Presenting to the Emergency Department. JAMA Netw Open 2020;3(11).

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70. Zhou H, Lu S, Chen J, Wei N, Wang D, Lyu H, et al. The landscape of cognitive function in recovered COVID-19 patients. J Psychiatr Res 2020;129:98–102.

71. Miskowiak K, Johnsen S, Sattler S, Nielsen S, Kunalan K, Rungby J, et al. Cognitive impairments four months after COVID-19 hospital discharge: Pattern, severity and association with illness variables. European Neuropsychopharmacology 2021;46:39–48.

72. Taquet M, Luciano S, Geddes JR, Harrison PJ. Bidirectional associations between COVID-19 and psychiatric disorder: retrospective cohort studies of 62 354 COVID-19 cases in the USA. The Lancet Psychiatry 2021;8(2):130–40.

73. Zhang Z, Feng Y, Song R, Yang D, Duan X. Prevalence of psychiatric diagnosis and related psychopathological symptoms among patients with COVID-19 during the second wave of the pandemic. Globalization and Health 2021;17(1):44.

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74. Winkler P, Mohrova Z, Mlada K, Kuklova M, Kagstrom A, Mohr P, et al. Prevalence of current mental disorders before and during the second wave of COVID-19 pandemic: an analysis of repeated nationwide cross-sectional surveys. J Psychiatric Res 2021 [cited 2021 May 27]; Available from: http://www.sciencedirect.com/ science/article/pii/S0022395621003010

75. Mohebbi N, Talebi A, Moghadamnia M, Nazari Taloki Z, Shakiba A. Drug Interactions of Psychiatric and COVID-19 Medications. Basic Clin Neurosci 2020 ;11(2):185–200.

76. Plasencia-García BO, Rodríguez-Menéndez G, Rico-Rangel MI, Rubio-García A, Torelló-Iserte J, Crespo-Facorro B. Drug-drug interactions between COVID-19 treatments and antipsychotics drugs: integrated evidence from 4 databases and a systematic review. Psychopharmacology (Berl) 2021;238(2):329–40.

77. Muruganandam P, Neelamegam S, Menon V, Alexander J, Chaturvedi SK. COVID-19 and Severe Mental Illness: Impact on patients and its relation with their awareness about COVID-19. Psychiatry Res 2020;291:113265.

78. Xiang Y-T, Zhao Y-J, Liu Z-H, Li X-H, Zhao N, Cheung T, et al. The COVID-19 outbreak and psychiatric hospitals in China: managing challenges through mental health service reform. Int J Biol Sci 2020;16(10):1741–4.

79. Nemani K, Li C, Olfson M, Blessing EM, Razavian N, Chen J, et al. Association of Psychiatric Disorders With Mortality Among Patients With COVID-19. JAMA Psychiatry 2021;78(4):380–6.

80. Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Netw Open 2020;3(3):e203976–e203976.

81. Tan BYQ, Chew NWS, Lee GKH, Jing M, Goh Y, Yeo LLL, et al. Psychological Impact of the COVID-19 Pandemic on Health Care Workers in Singapore. Ann Intern Med [Internet] 2020 [cited 2020

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82. Cabarkapa S, Nadjidai SE, Murgier J, Ng CH. The psychological impact of COVID-19 and other viral epidemics on frontline healthcare workers and ways to address it: A rapid systematic review. Brain Behav Immun Health 2020;8:100144.

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Golitaleb M. The prevalence of anxiety and depression among healthcare workers during the COVID-19 pandemic: An umbrella review of meta-analyses. Prog Neuropsychopharmacol Biol Psychiatry 2021;107:110247.

85. Pappa S, Ntella V, Giannakas T, Giannakoulis VG, Papoutsi E, Katsaounou P. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis. Brain Behav Immun 2020;88:901–7.

86. Zandifar A, Badrfam R, Mohammadian Khonsari N, Mohammadi MR, Asayesh H, Qorbani M. Prevalence and Associated Factors of Posttraumatic Stress Symptoms and Stigma among Health Care Workers in Contact with COVID-19 Patients. Iran J Psychiatry 2020;15(4):340–50.

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88. Giorgi G, Lecca LI, Alessio F, Finstad GL, Bondanini G, Lulli LG, et al. COVID-19-Related Mental Health Effects in the Workplace: A Narrative Review. Int J Environ Res Public Health 2020;17(21).

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11. Ecopsychiatry and Covid 19 Global Pandemic: Impact on Environment, Mental Health and Climate Change

Arabinda N Chowdhury1, Suchismita Roy2, Arabinda Brahma3

Ecopsychiatry is a developing discipline which studies health in general and mental health in particular, interlinking between ecological specificity in a region. The recent global deterioration of the natural landscape associated with climate change makes this study more critical and relevant. A host of the devastating effect of climate change- land erosion, seawater level rise, environmental pollution, wildlife trade and consumption, deforestation, rampant use of highly toxic chemicals, pesticides, and non-biodegradable materials, already caused irreparable damage to many countries and the indigenous population. The list is long, and this is not the place to discuss it in detail. Given the global Covid-19 pandemic, the issue of deforestation and zoonotic diseases came to the forefront. It is noted that the whole world is currently crossing through an unprecedented climate crisis.

On top of that COVID-19 pandemic, it poses a severe threat to the socio- economic and environmental status of human and non-human species. Though global pandemic restrictions and lockdown showed some improvement on the environmental front, there is an undercurrent of many negative impacts. Following is a brief discussion on the positive and negative impacts of the COVID-19 pandemic with a case study of the Sundarban delta, a highly vulnerable landmass already struggling for survival.

COVID19 Pandemic Effects: Positive and Negative Environmental impacts: The extensive global disruption caused by the COVID-19 has brought about several positive and negative effects on human life, livelihood, environment, and climate.[1]

1Consultant Psychiatrist, Leicestershire Partnership NHS Trust, UK

2Assitant Professor, Visiting Faculty, Indian Institute of Techonology, Jammu 3Director, G.S.Clinic, Indian Psychoanalytical Society, Kolkata

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Positive Effects: These are the few notable positive effects of COVID lockdown observed globally. It mainly improves some climatic conditions and forces people to adopt new ways of life and work behaviour.

1. Reduced CO2 emissions: 2.6B metric tons of CO2 never emitted in the atmosphere, which is about 8% of the estimated total for the year, according to the International Energy Agency estimates. [2] It is a world- shaking event from 20th-century history—never such considerable decrease in emissions was recorded.

Ten million metric tons less CO2 emitted from aviation: (Feb. 1-March 19 compared with the same period last year). Aviation activity in Europe has dropped more than 80%. Daily flights between Europe and the U.S. have come down to 90, from 485, and over 16,000 passenger jets have been grounded worldwide. As Work from Home becomes the mandatory option during lockdown periods in major working cities, reducing transportation leads to a 23% reduction in carbon emission.[2]

2. Reduced Global energy demand: It has a fall of 6%, seven times the decline seen after the global financial crisis of 2008. In absolute terms, this drop is equivalent to the one-year total energy demand of India.

3. Reduced Global Traffic congestion: 59% less traffic congestion in Mumbai, India (Thursday, April 23 at midnight compared with 2019 average. 28% less traffic congestion in London, U.K. (Thursday, April 23 at midnight compared with 2019 average.[2]

4. Reduction of air pollution and GHGs emissions: Greenhouse gas emission reduction was significant. Among them, seven global cities- Delhi, Sao Paulo, and New York—experienced a 25% to 60% reduction in the delicate particulate matter known as PM2.5 during the lockdown. 42% reduction of PM2.5 in Mumbai, India (Compared with prior 4–year average). 55% reduction of PM2.5 in Delhi, India (Compared with the previous 4–year average. 51% reduction of PM2.5 in Los Angeles, U.S. (Compared with prior 4–year average. Los Angeles experienced its longest stretch of clean air on record.[2]

5. The lockdowns reduced NO2 levels: NO2 is emitted from the burning of fossil fuels, 80% of which comes from motor vehicle exhaust.

[3]

NO2 causes acid rain and several respiratory diseases in humans (USEPA, 2016).[3] NO2 emission is an important fundamental indicator of global economic activities. The recent shutdown of economic activities

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caused a marked reduction of NO2 emissions in the US, Canada, China, India, Italy, Brazil, etc.[4-7] In China, a nearly 50% reduction of N2O and CO occurred due to the shutdown of heavy industries.[8]

The European Environmental Agency (EEA) predicted that NO2 emissions dropped from 30-60% in major European cities.[9] A 54.3% decrease of NO2 was observed in Sao Paulo, Brazil.[10] NO2 reduction in Ontario (Canada) is from 4.5 ppb to 1 ppb.[11] the levels of NO2 and PM2.5 reduced by almost 70% in Delhi, India.[12]

Negative Effects:

1. Monumental biomedical waste generation: COVID-19 pandemic triggered an enormous amount of medical waste generation globally. Bio-medical waste is a severe threat to public health and the environment.

Some examples: In Ahmadabad city, India, medical waste generation is

increased from 550-600 kg/day to around 1000 kg/day at the first phase

of lockdown.[7] In Wuhan, China produced more than 240 metric tons of

medical wastes every day during the outbreak,[6] which is almost 190 m

tonnes higher than the average time. [13] In Dhaka, the capital of

Bangladesh, around 206 m tonnes of medical waste are generated per day.[14]

Such a sudden stockpiling of huge hazardous waste (e.g., needles, syringes, bandages,mask, gloves, used tissue, discarded medicines etc.) and their methodical management and recycling (to reduce further infection and environmental pollution) has become an enormous challenge to all the national governments.

2. Hazardous disposal of non-recyclable waste and PPE:

Covid 19 pandemic has increased the use of plastic-based PPE (Personal Protection Equipment) and thus increased medical and domestic disposal worldwide.[15] During the COVID-19 pandemic, plastic demand for medical usage has grown considerably in many countries. One estimate in the USA showed that the first six months of the pandemic had generated 7,200 tons of medical waste every day during the pandemic.

According to a study conducted by the Massachusetts Institute of Technology, the effects of the pandemic are estimated to generate up to

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3.

7,200 tons of medical waste every day, much of which are disposable masks (during the first six months of the pandemic- late March to late September 2020) in the United States. These calculations were based on masks used by healthcare workers, not mask used by the general public. Theoretically, if every health care worker in the United States wore a new N95 mask for every patient they encountered, the total number of masks required would be approximately 7.4 billion, at the cost of $6.4 billion. This would lead to 84 million kilograms of waste.[16]

Widespread health illiteracy prone most people to dump these PPE (e.g., face mask, hand gloves, etc.) in open places or with household wastes. [14] Such haphazard dumping creates clogging in waterways and worsens environmental pollution.[13,15] The plastic-based PPEs are a potential source of microplastic fibers in the environment.[17]

Reduction of national recycling programs:

Due to the pandemic, Quarantine policies and social isolation during the COVID10 pandemic increased people’s shopping behavior, and there is a tremendous increase in online shopping observed globally. Effectively, this has increased the amount of household waste.[7,13] However, many national governments stopped recycling.[18] In the USA, 46% of cities restrict recycling programs. [7] UK, Italy, and other European countries also limited waste management and recycling.[15] This disruption of municipal recycling activities causes increased landfilling and environmental pollutants worldwide.

Hazardous wastewater pollution:

Recent use of the heavy amount of disinfectants is applied into roads, commercial, health care facilities, and residential areas, which may destroy non-targeted beneficial species, resulting in ecological imbalance. [19] It is reported from Australia, Sweden, the USA, India, and the Netherlands that municipal wastewaters are infected with COVID 19 patients’ feces.[20-22] So, proper wastewater treatment is becoming important, especially in developing countries like Bangladesh.[23, 24]

Health Care Challenges and COVID19 Emergency:

Experience has shown that our healthcare system was not designed to deal with the COVID19 pandemic crisis in both developed and developing nations. The first few months were utter chaos due to policy paralysis,

4.

5.

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6.

shortage of human resources, and supply of lifesaving measures (respirators, medicine, etc.) and PPEs. There was a long delay in the urgent mobilization of a combative healthcare force and resources to combat the pandemic. The most important reasons for this failure was lack of preparedness for urgent intervention and lack of scientific communication between the medical scientists and national governments. As a result, the COVID19 emergency paralyzes the total health delivery system all over the world with an accumulation of high health care burden, especially regarding the care of the elderly and disabled people, mental health, chronic diseases, cancer treatment, and postponement of emergency operations and procedures, child health and dental health. Hospital beds were reduced, and hospitals were turned into COVID-hospital. This has resulted in a severe vacuum in the care delivery system and worsened the health difficulties of millions of high- risk ill people.

COVID emergency has three significant negative impacts: 1. Worsening out of health infrastructure; 2. Physical and mental burn-out (and death) of frontline health workers; 3. A massive backlog of health care procedures, and 4. Accumulative economic strain and COVID-diversion of funds from other health sectors. 5. The Covid pandemic will also have a longer-term impact on healthcare systems, a new post-covid reality that should be adequately addressed by political bodies, national governments, and healthcare authorities, and the background of a severely resource-constrained economy.

Significant death of health care workers. One WHO estimates, May 2021, that deaths reached 1,15,000.[25] This colossal loss of health care workers created a massive vacuum for the treatment and cared for the COVID -19 and other categories of patients.

Loss of life and emotional, economical family disruption:

Moreover, the Stigma of Covid infection disrupted health care delivery and created severe emotional trauma(isolation and restriction) to both affected and not affected person. The massive number of COVID death in isolated hospital respiratory units made extreme emotional pain and feelings of loss and helplessness among the patients and a longstanding complicated bereavement (near relatives were not allowed to visit or even prevented from attending funerals) among their relatives. National and international travel restrictions many patients died alone without seeing their near and dear ones.

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Increasing Social and Economic inequality: Covid-19 impacted in the following ways: (a). higher-paid workers had options to work from home, but low-paid workers did not have such scope. Many of them lost their jobs like hotels and restaurants while others continued like police, nurses, scavengers, transport workers, etc., making themselves vulnerable to continuing their duties. (b) While more affluent countries provide a social safety net, the poorer countries do not have such policies, and income inequality sharpens. (c) More women, the elderly, the disabled, and members from marginalized ethnicities and religions lost their jobs and became poorer. Contrary to this, 2020 witnessed an increase in numbers of billionaires,

Loss of earning members and jobs during the pandemic is an essential cause of unprecedented economic disaster in all the countries affected by COVID19.

7. The ecosystem at risk: Illegal deforestation, wildlife and the massive surge in bushmeat poaching in African countries:

globally, [26] by decreasing the interest rate of the central banks, soft

from 5.2 million to 56.1 million

government policies, producing vaccines and other durable goods during

the pandemic. With regret, one can note that at least nine new

billionaires were created by utilizing covid 19 vaccine-produced pharma

industries.

Stay home regulation of environmental protection workforces at national parks, land, and marine conservation zones have resulted in less protection and unmonitored free zone for illegal activities. Disruption of surveillance systems during the pandemic enhances illegal activities like extensive deforestation of the Amazon rainforest[27] and increased poaching in Africa. In extreme food shortage, social isolation, and restricted movements, there is a surge of poaching of rhino and ivory in

South Africa. Gabon’s government banned the human consumption of

bats and pangolins from curbing the spread of zoonotic diseases.[28] It is apprehended that the breeding programme of endangered animals (in Myanmar) to facilitate commercial and illegal trade may create a new strain of the COVID-19 virus.[29] The global decline in ecotourism also caused considerable unemployment and enhanced a sharp increase in illegal deforestation, fishing, and wildlife hunting.

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8. COVID19 pandemic disrupted rural-urban and international migration patterns and impacted climate change adaptation strategies and climate finance:

COVID19 lockdown and job loss and return of migrant workforce, both internal and international, is having a severe economic impact on their communities of origin. The pandemic has diminished many migrants’ incomes, reducing the amount of remittance back home and causing severe financial strain on the local communities and intense competition for local resources. According to World Bank’s estimate, a pandemic may reduce international remittance flows to Low and Middle- Income countries by as much as 20 % in 2020 (a total of USD 110 billion).[30]

Countries are also seeing migrants return home in huge numbers, increasing the strain on resources at local and national levels and unemployment rates.With around 28 million people, Nepal expects 400,000 migrants to return from countries such as Malaysia and the Gulf States. India has brought 1.8 million citizens back to the country.[30] Most climate-vulnerable countries face severe economic pressures that will cause severe disruption on climate change governance and adaptation strategies.

Case Study

COVID19 pandemic impact on vulnerable population: A case study from Sundarban Delta, India

To understand the lives of Sundarbans (Fig.1), one must acknowledge the interdependence between Society and Environment. Covid induced unemployment, and back-to-back cyclones made Sundarbans more dependent on nature, which was observed after Aila, another significant hurricane. The unique delta landmass in the Bay of Bengal implicates a critical relationship and impact of climate change, recurrent cyclonic disaster, environmental degradation, human-animal conflicts, and extreme poverty.[31] Moreover, gradual land loss due to sea-level rise is a constant threat to the deltaic population.

Following is a snapshot of Sundarbans’ field survey, which describes Sundarbans’ general background from an eco-vulnerability perspective followed by the impact of the Covid-19 pandemic on this delta.

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Fig.1. The Sundarban region (not to scale)

Internal Migration: The story of Sundarbans, the poster child of disaster, is a little different from other places in India. During the cyclone Aila (in 2009), the saline water intrusion in the agricultural fields compelled many farmers/ agricultural labour to leave their land and dispersed all over India to earn their livelihood. After the Covid-19 outbreak in 2020 and sudden lockdown, migrant workers lost their jobs. They returned to their village due to the absence of alternative means of earning in their respective destination and subsequent harassment by the landlords and police. Al over India, one can see migrant workers who do not have any forum or formal organization to raise their voice and demand collectively to fight injustice during this unprecedented event.

Aside from poverty and aspiration, for Sundarbans, climate change and frequent disasters-super-cyclone Amphan (in 2020) and Yaas (in 2021) coincide with the Covid-19 pandemic make the livelihood worse. The

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cumulative impact of eco-specificity of the Sundarban runs in a vicious

cycle.

The last few years witnessed submerging whole or partial islands in the Bay of Bengal; for instance, almost 600 families were displaced from Ghoramara island, once a home for 40000 people, quickly disappearing due to land erosion and sea-level rise. Those who have better options are not only leaving Ghoramara but are also leaving other islands of Sundarban( internal migration).

The islands of Sundarban now have at least one migrant member, almost in every family, who left the land due to frequent disasters and lowered agricultural productivity, and lack of local income opportunities. Due to the exodus of migrants during the lockdown, remittance to home was lost and pressured on scarce family, community, and ecological resources for their survival intensified poverty in micro and macro-structural levels.

Human-animal conflict: Disappearing island, saline water in agricultural land, unemployment, and distress selling of cattle pushed Sundarbans people to enter the forest land and mainly to the restricted land to collect shrimp, crab, honey, forest woods, and fish. Only in 2020, more than two dozen people died in the human-animal conflict as per official record, and unofficially, the number of death is far high. Collecting crab or shrimp requires a particular skill and practice. Migrants who are not practicing this skill for a significant period would be more prone to take a long time and, therefore, more chances to have tiger crocodile and snake attacks. In the last few years, the higher volume of migration reduced entering into restricted areas of forestland, which increased sharply after return migration. Most of the families who lost their beloved one did not get any compensation from Govt. or the forest department as they did not have any valid permission to enter the forest’s core area. [32]

Aquaculture and fragile embankment:

Impacts of the growth of shrimp farms include deterioration of drinking water quality, loss of traditional fishery, loss of

Sensing their endangered

livelihood, the locals have abandoned traditional fishing techniques and

pursued excessive prawn seedling catches and prawn farming,

threatening the delicate ecosystem of Sundarban and resulting in

declining mangrove forests. The more Sundarban faces disaster, the more

agricultural lands become prawn farms where chemicals are used in

abundance to supply national and international markets. National and

international MNCs play significant roles in this shrimp farming which is

fetching dollars.

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land for grazing of livestock, and changes in agricultural cropping patterns, which has particularly affected the landless agricultural labourers. Shrimp farming is also posing a threat to the poor people living close to embankment. Owners of Shrimp farms create holes in mud embankments to ensure water flows from rivers connected to the sea. Holes without planning make the embankments weak and, as a result, easy prey during cyclones and which fail to protect the islands from saline water.[33]

Women, salinity, and marginalization: The poor people of Sundarbans mainly stay in the low lands of the village or near the embankments, and the higher castes and classes occupy higher lands with lower possibilities to be affected by saline water. Saline waters in ponds and agricultural lands are causing distress selling of cattle among the poor. Cyclone Yaas resulted in the intrusion of a large amount of saline water, which destroyed agricultural products, mud houses, land fertility, and contaminated salinity in precious drinking water resources. Women, mostly from low-income families dependent on these natural and community water sources, are disproportionately affected by the crisis as they are the water fetchers of the family and face severe problems with saline water that pose a threat to their reproductive health.

Relief tourism: Many Islands of Sundarban do not have proper medical facilities. Whatever little they have disturbed by the covid related lockdown, most doctors who work in these islands are outsiders. Even after return migration, the Sundarbans somehow managed to restrict the spread of Covid-19 due to its relative geographical inaccessibility and isolation. After cyclones Yaas and Amphan, Sundarbans witnessed the surge of ‘relief tourism’ where people from several districts and towns poured to Sundarbans with relief materials consisting of the plastic water bottle, clothes, and dry foods. These short time reliefs without any sustainable solution increased the possibilities of Covid-19 spread. To prevent the spread of Covid, the local governments of many affected islands barred these voluntary organizations from distributing relief and entering into their islands. Interestingly, many island people rejected the clothes because they were already used and contaminated with the virus. The present author (SR) witnessed heaps of donated clothes thrown at the roadside.

Human Trafficking: Like in every society, marginalized people are mostly affected by disasters.[30] After cyclone Aila, the number of missing girls from the islands increased as per the national crime Record Bureau

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data. When most literature on human Trafficking saw gender relations, exploitation, poverty, cultural practice as the leading causes of Human Trafficking, it largely overlooked climate change as a significant stressor. Disasters due to climate change increased the anxiety and insecurity of the natives of Sundarbans and increased migration, often enhancing human Trafficking. After every disaster, it is observed that there is severe deterioration of the socio-economic landscape, and traffickers utilize this misery for their benefit. For instance, the number of missing girls significantly rose after Cyclone Aila, and it became clear that girls were not running away and kidnapped, but these are cases of human Trafficking. In the face of disasters, girls are the soft targets. In the name

of marriage or promise of jobs, they were taken away from their families and sold, especially in red light areas of big cities. Covid-19 created a peculiar situation by restricting movement. Restriction of transport and lockdown made the situation difficult for traffickers to export girls. Demand for these girls also decreased as Red light areas were not fully functional due to lockdown and fear of Covid spread. Sundarban experienced a rise in child marriages(apparently some are fake marriages) during lockdown when schools closed; surveillance was low as most families could not provide mobile to their children for online classes. Return migration means more pressure on relatively scarce resources left for low-income families to survive. Human traffickers reach faster than police and administration during disasters with their flowery promises and often monitory help. In a few instances, police successfully saved minor girls from Trafficking.

Hopefully, Covid-19 may end after the rapid vaccination drive, but climate change showing its impact on Sundarban, home of a few brick kilns, cannot be accused of carbon emission for climate change. Natural disaster-induced migration, the cycle of debt, unemployment, human- animal conflict, the rise of prawn shrimp farms, and its side effects on the sensitive ecology of Sundarbans is an example of cumulative and cyclical burdens. However, some scientists and researchers suggest that Sundarbans’ only option is “managed retreat”. Those already marginalized who lost their lands to rivers can not afford to leave Sundarban as they do not have the skillset or support to survive in the already overpopulated cities. They were not sure whether they could save whatever they had, or all would be underwater soon. Some of them are also suffering from mental ill-health, and anecdotal observation shows that during the April to June 2021 months, there were at least reported around 90 attempted suicides.

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Covid-19 pandemic intensified anthropogenic socio-environmental challenges and calls for a rapid and sustainable etic approach to mitigate these human sufferings and ecological destruction. National and international agencies should take prompt action by involving local people.

Ecopsychiatric Lessons

There is a misperception that nature is “Getting back” to normalcy during COVID19 pandemic. It is worth remembering that this planet faces a severe climate crisis, and the COVID19 pandemic accelerated this crisis in many ways. The few positive environmental effects will return as soon as the economic activities start functioning globally. The unprecedented lost jobs, millions of internal migration, and severe competition for local resources increased the spread of COVID19 among rural and indigenous people. At the same time, there are reports of increased deforestation in Africa, Asia, and Latin American countries, which exposes remote indigenous people to the strains of the virus. Conservation scientists have shown that there is a link between the destruction of forests and the environment and the virus-related zoonotic disease outbreaks. It is already evident that wildlife species threatened by exploitation or habitat loss and destruction of natural eco landscapes are more likely to cause epidemics of animal-borne illness.

Immediate tasks:

1.Restoration of forests and eco landscapes: One of the primary tasks is slowing down deforestation to maintain a healthy ecosystem.

2. Stopping the illegal and curbing legal wildlife trade and consumption.

3. Priority for National Governments: Immediate socio-economic rebuilding and recovery from the pandemic is the first priority.

Policymakers should provide all possible measures to safeguard the

protected areas and formulate measures to finance sustainable green structural transformation to mitigate biodiversity loss. All possible time- bound programs should be taken to reduce global emissions, viz., the transition from fossil fuels to cleaner energies. Climate and biodiversity should be the top agenda.

4.Corporate responsibility: Multinational and big corporate houses should respond sensibly and responsibly by increasing their investments in conservation of nature, viz., natural climate solutions to restore critical

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ecosystems and climate stability. They should provide economic packages so that people will have access to jobs and income. The nature protection funds will help restore biodiversity loss (help improve resistance to diseases) and job creation. It is calculated that nearly 40 jobs can be created for every $1 million invested in restoration or forest management.

5.Health care policy and investment: This is a challenging area in the post-covid world. The health system should address the following issues on an urgent footing.

a. Investment in overall health prevention.

b. Special policies and procedures should be devised regarding the unmet needs and vulnerable population.

d. Special focus- mental health: Mental health burden has increased many folds during the COVID19 pandemic. Mental healthis projected by WHO to become the leading cause of morbidity and mortality globally by 2030. [34] Several reports indicated that mental health services were severely disrupted during the pandemic. WHO [35] surveyed 130 countries from six WHO regions, showed the devastating impact of COVID-19 on access to mental health services, and highlighted the urgent need for increased funding in mental health care. Following is a summary of significant findings:

 Over 60% reported disruptions to mental health services, including children and adolescents (72%), older adults (70%), and women requiring antenatal or postnatal services (61%).

 67% reported disruptions to counseling and psychotherapy services, 65% to critical harm reduction services, and 45% to opioid agonist maintenance treatment for opioid dependence.

 More than a third (35%) reported disruptions to psychiatric emergency services (in prolonged seizures; severe substance use withdrawal syndromes; and delirium).

 30% reported disruptions to access for medications for mental, neurological and substance use disorders.

 Around three-quarters reported at least partial disruptions to school (78%) and workplace mental health services (75%).

c. Increase ‘drive efficiency’, shifting care from hospital to outpatient and community settings to combat health emergencies.

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Covid-19 pandemic triggered an unmanageable socio-economic crisis with profound psychological distress, especially among frontline professionals and the geriatric population.[36] In addition to that, there was an increased rate of anxiety, depression, suicides, child abuse, substance abuse [37], and domestic violence[38,39] during the pandemic. COVID19 both amplified and introduced a range of domestic violence, both in women and men, and calls for appropriate multidisciplinary mental health interventions to this alarming crisis of a global nature. [40] It is evident that a range of psychosocial morbidity, including unprecedented stress, pervasive anxiety, depression, frustration and boredom, uncontrolled fear about the uncertainty of COVID-19 outbreak and infection, social isolation, and disabling loneliness, increased progressively with the pandemic among all nations.[41]

Some extensive psychological dysfunctions were also noted among the quarantined subjects. [42] Different studies have found a higher prevalence of depression, mood fluctuations and irritability, insomnia, post-traumatic stress disorder, aggression, and extreme exhaustion.[43] and worsening of ADHD symptoms among adolescents.[44] Long-term behavoural abnormality includes vigilant and repeated handwashing,[45] avoidance and isolation, and overwhelming health anxiety and fear about COVID-19 infection and social stigma. [46] Inadequate and often confusing and conflicting information and quarantine rules and contradictory health messages from the public health bodies, and lack of transparency about the real-time information of the outbreak[47] enhance public anxiety during pandemic also.[48]

During and after the pandemic, severe inefficiency of mental health delivery was a global phenomenon. Reorganizing and refunding mental health services is a high-priority agenda globally.[49] New post-COVID reality endorsed the development of care delivery via technology platforms like telemedicine and virtual visits with psychologists and social workers.

6.Climate change should be the top agenda: Climate change imposes compounded stress on the environment and impacts the country’s economic, social, and political systems. It may take any form like heat waves or extreme weather conditions like hurricanes or disasters or droughts- all of which endangered livelihoods with a high risk of food and water crisis, poverty, loss of income, malnutrition, and hunger. Climate change creates refugees

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In 2019 natural disasters affected 95 million people with $103 billion economic losses. Droughts affect around 55 million people every year, with a severe effect on agriculture. Food shortage leads to undernutrition, affecting about 690 million people, i.e., 9% of the global population in 2019. Displacement due to rising sea levels, extreme weather events, and prolonged drought is horrifying. Globally around 9.8 million people become climate refugees by climatic shocks and approximately 50,000 people every day.

WHO[50] provided a very stark estimate of climate change impacts as follows:

 Climate change affects all the necessary social and environmental determinants of health, viz., clean air, safe drinking water, sufficient food, and secure shelter.

 There will be approximately 250 000 additional deaths per year from malnutrition, malaria, diarrhea, and heat stress between 2030-2050

 The direct damage costs to health (excluding agriculture, water & sanitation), is estimated to be between USD 2-4 billion/year by 2030.

 Most developing countries will be affected.

 Significant reduction of greenhouse gases will help to improve health,

mainly through reduced air pollution.

COVID-19 pandemic, in a sense an urgent ecopsychiatric alarm to us that reminds us that enough destruction has been done, and it is the final call to restore the environment to safeguard this civilization, its people, and the planet. The end result of unmitigated climate change is thus aptly described as “existential danger” by Meyer and Araujo.[51]

Conflict of Inteest: None Funding: None References

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Mental Health Impact of COVID-19 Pandemic on Internal Migrant Workers

Gurvinder Pal Singh1, Kamlesh Kumar Sahu1*

Introduction

The terms migrant, migration and reverse migration, displaced population are variably defined by various researchers and health agencies. World Health organization defined the term migration as the movement of a person or a group of persons, either across an international border or within a State. International Organization for Migration (IOM) coined migrant as a person who moves away from his or her place of usual residence, whether within a country or across an international border, temporarily or permanently, and for a variety of reasons. The reverse migration was defined as the movement of people from the place of employment to their native places.[1] The migrants are regarded as transitory populations and faced many psychological issues during the COVID-19 pandemic.

The process of migration and post-migration adjustment can be stressful for individuals and families, with the potential for generating mental health problems. The job loss, uncertainty about the future, high labour intensity, interactions with authorities and employers, language barriers can all lead to an overall increase in mental health conditions, including depression, anxiety, post-traumatic stress disorder, and substance abuse. Thus there is a need for increasing the mental health and psychosocial services for migrants. The migrants keeps the Indian cities running and their existence was hardly recognized in India. This population in India stayed in unauthorized colonies, works in the informal economy, and have negligible registration facilities in their workplace.

There are about 30 million migrants in India and constituted more than a quarter of the workforce in industrial sectors. They are marginalized, underprivileged, and vulnerable to mental health problems such as

1Associate Professor, Department of psychiatry, Govt Medical College and hospital, Chandigarh, India *withkamlesh@gmail.com

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depression, anxiety, and substance abuse. A study from Karnataka conducted in pre-COVID times had reported the prevalence rate of mental health problems as 19%, alcohol current use in 21%, and tobacco in 23% of the migrants.[2] Firdaus analyzed the social environmental issues for the psychological well-being of migrants in an urban centre of India.[3] Some authors reported that migrants had either fewer substance- related problems, including alcohol use, or were similar to the native population. In migrants, a higher prevalence of mental health issues and substance abuse in comparison to the general population has also been reported.[4,5]

In recent times a sudden national lockdown was declared in India, starting on March 25 in the first phase and extending up to May 3, 2020, in the second phase. The government of India planned a lockdown to contain the spread of the Covid 19 in the country. The lockdown was total, and citizens were not even allowed to step out of their houses. The population which was affected the most by the lockdown due to Covid 19 was the migrants. The sudden imposition of lockdown resulted in enormous hardship for migrants.[6] The daily workers who were suddenly rendered jobless had no choice but to return to their native places. On the advice of the Ministry of Home Affairs, Govt of India, each state was asked to look after the migrants so that their basic needs were met out. More than 21,600 shelter/relief camps were set up in our country for migrants.[7] Covid 19 pandemic lockdown has created various problems in subjective well-being for this vulnerable section of the society.

Invisible Mental Health Tsunami among Migrants

COVID 19 pandemic was sudden in onset. Covid-19 pandemic and lockdown on March 25, 2020, was the fertile ground for an increase in psychological stress, severe psychiatric disorders, alcohol dependence, and suicidal tendencies among the migrants. In India, the COVID-19 pandemic brought a mental health crisis for migrants and a novel term for psychological crisis among migrants was described as an invisible mental health tsunami.[8] It was the biggest urban dilemma and spread rapidly throughout India, Suicide-related death was associated with this migrant crisis. This pandemic created a severe crisis for them as a prior public health strategy dealing with mental health issues among migrants was completely missing in India.[9] Severe anxiety, loneliness, panic symptoms, and feelings of isolation was observed among migrants. Lots of migrants died due to avoidable accidents.

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The Magnitude of Problems During the COVID-19 Pandemic

Increased rates of mood disorders, psychotic disorders, and posttraumatic stress disorders are prevalent in migrants during the COVID-19 pandemic.[10-14] The rates of mental disorders were variably in different research works. In some studies, the rates of PTSD and depression were ≤15%. The majority of migrants do not have mental disorders but suffered from the psychological distress during the lockdown. The psychological impact of the COVID-19 pandemic and lockdowns lead to unemployment and misery among migrants. COVID 19 pandemic was sudden in onset. The strict protocol had to be followed by them during the lockdown. Covid 19 Pandemic has induced panic reactions among them and various associated stresses could have additive effects on individuals. Covid 19 Pandemic and conditions of lockdown influenced the subjective well-being of an individual. Subjective well-being was a requisite for migrants regarding positive impact on health and health perception, and problem-solving capacity. Lockdown due to Covid 19 pandemic not only exposed migrant workers to the various extrinsic pressures from their occupation, the economy, and family members, but also induced intrinsic passivity and loneliness without family accompaniment. All of these factors together induced psychological distress in migrants.

Time constraints and healthcare infrastructure were stretched in India during lockdown. Mostly cross-sectional studies were reported in Indian literature among migrants during Covid-19 pandemic.[10-12] In migrants, not all spectrum of psychiatric morbidity could be captured (anxiety, depression, coping, stress, substance use, etc). The migrant population was mobile thus follow-up study would be challenging in this group. In many community surveys, high levels of the negative psychological impact of the Covid-19 pandemic on migrants were reported.[10,11] Marked psychological distress, insomnia, deliberate self-harm, severe depressive symptoms, and significantly multiple mental health issues were found among them. In a multicentric population-based study, at least one psychiatric diagnosis (depressive disorder) was found significantly higher among the displaced migrant working population than the general population.[11] In a cross-sectional survey of 98 migrant workers having a mean age of 32.7 Years (SD 10.1) and were assessed on instruments Patient Health questionnaire-2, Generalized anxiety disorder 2 and Perceived Stress Scale-4. The findings revealed that 73.5% screened positive for depression, 50% screened positive for anxiety and 51% screened positive for both depression and anxiety. Severe anxiety, panic disorder, and a vicious cycle of the susceptibility to Covid-19 active

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infection increased susceptibility to major depressive disorder with psychotic symptoms and suicidal risk among the migrant was observed.[15]

The migrants during this dual crisis of the Covid-19 pandemic and job loss seemed pessimistic towards their life and were more concerned for their families and well-being. Lockdown due to Covid 19 has a huge impact on the psychological stress levels of migrants. Due to lockdown migrants from various states started moving towards their native places on foot and on the way took shelter in various relief camps constituted by the Government of India. State Governments constituted teams of district mental health professionals to address the psychosocial issues of this vulnerable population. Regular counseling services were provided to migrants in these shelter homes. The migrants were provided with basic needs like food, hygiene cleanliness, recreational items, toys to children, and nutritious food, safety masks, sanitizer, and sanitation in these shelter homes. Immediate concerns of migrants were related to fear of getting infected, anxiety, family concerns. The various issues expressed by the migrants were how they will go to their native place, financial needs, future jobs, expenditure to keep their family and children.

Predisposing Factors for Adverse Mental Health of Migrant Workers

1 Susceptibility for new communicable diseases

2 Pre-existing occupational morbidities as a risk factor

3 Absence of family support and caretaker during crisis

Predisposing Factors for Mental Health

of the Internal Migrant Workers

4 Proneness to develop common mental disorders

5 Limitations to follow the rules and regulations of personal Safety

6 Pre-existing mental health issues

7 Social exclusion

8 Peri-traumatic psychological distress during the pandemic

9 Barriers to assess the psychiatric consultation

10 Economic constraints due to loss of work

11 Absence of effective laws for unorganized workers

12 Acute and chronic adverse effects of the SARS- CoV2 on the nervous system and mental health

13 Adverse occupational health scenario during lockdown and post lockdown period

Adopted from Choudhari[16]

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During COVID 19 pandemic in the Indian some of the predisposing factors that might affect adversely to the mental health of the internal migrant workers are mentioned above. “They are predisposed to experience adverse psychological consequences of multiple stresses, generated through interactions of various factors, not limited to chronic poverty, malnutrition, cultural bereavement, loss of religious practices and social protection systems, malalignment with a new culture, coping with language difficulties, changes in identity, substance abuse and poor access to healthcare in addition to the poor living conditions and financial constraints.”[16]

Early Assessment

Migrants keep on moving from one place to another place. They may not perceive or have time to visit health care institutions or psychiatric clinics for mental health and substance use problems. The assessment models need to be developed to cater to their mental health needs. The most important assessment measures include the establishment of rapport with migrants. The migrants could be explained the need to detect mental health issues at an early stage and treat it and also explain the impact of non-treatment of these disorders on individuals and families. Various assessment tools like the Hindi version of General Health Questionnaire- 12 or GHQ-30, Perceived Stress Scale could be helpful in the proper assessment and screening of the migrants.[17]

The other assessment instrument could be the Hindi version of the PRIME-MD assessment instrument and their responses are recorded. The screening tool for substance abuse may also be used to see the pattern of ever use and current use of the substance. Once the assessment is over and the person has been identified with the psychological problem and substance abuse, a severity assessment can be carried to decide about the treatment modality. During the early assessment, it was important to impart education about COVID infection and need to take appropriate precautions to prevent the spread of infection. There was a need to share information with migrants about the magnitude of mental health issues and substance abuse during the COVID-19 pandemic.

Interventions

A multidisciplinary approach for minimizing the psychological impact of the Covid-19 pandemic among the displaced migrant population was attempted at many places in India and reported successful outcomes.[17,18] The periodic screening for common mental disorders and

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psychological stress among migrants was a component of therapeutic intervention for this population. This approach helped in managing their psychosocial issues. The integrated mental health services with trained manpower to handle such crises was the need of the hour in India. Basic mental health care services and telemental health services and e- Sanjivani outdoor services needed to be prioritized at district and primary health centre levels so that migrants could take benefit from these basic mental health care services.[18-20]

As far as possible, non-pharmacological intervention should be used as there might be difficulty to supervise medication as well as the risk of drug misuse. In case of dispense of medications, short-term prescription for more than 2-3 days medicines at a stretch was advisable. Regular follow-up and periodic assessment of migrants is warranted. World Health Organization resources and guidelines have been developed to assist community health workers in the clinical management of mental health problems of migrants. Brief intervention helplines were the key to the success of such a district-level programme for migrants in India. The basic interventions that have worked in this population included information sharing, involving them in decision sharing, relief activities, sharing of grief, losses, mutual support, healthy living. The other interventions were psychological first aid by community-level workers, sensitization of the general health care staff to psychological aspects of migrants, sharing skills of coping with stress among migrants, and professional help from mental health professionals. Some regular registration facilities and mobile apps for migrants could be attempted by policy planners to reach the unreached migrant population. An integrated mental health awareness drive among the migrant population could help them in seeking the various psychosocial and mental health services and social welfare schemes announced for them by Government agencies of India. This migrant population could be incorporated into the mainstream as beneficiaries into the health care system, by providing them social, legal, and occupational security.[21]

Regular registration facilities and mobile apps for migrants could be thought of and planned by policy planners to reach the unreached migrant population. An integrated mental health awareness drive among the migrant population may help them in utilizing various psychosocial and mental health services and social welfare schemes by the Government of India. The awareness drive among migrants about when and how’ of seeking help from mental health professionals is useful. The migrant population can be and should be incorporated into the mainstream of the

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general population by providing them social, legal, health, and occupational security.[14,21] Simple measures such as the visit and intervention by a mental health team to migrant camps are integral factors in management. Empathetic listening and sharing the available facts and listening to their administrative and health concerns, reassurance, and reinforcement had helped the migrants.

There is a need for close collaboration, interaction, and dialogues amongst central and state governments, health organizations, non- governmental organizations, and migrants is required. There is a need to understand the concern of migrants. The holistic services and health and non-health targeted policies are required to address the migrant’s vulnerability to ill-health and substance use. Training of community health workers for providing the first line of treatment to migrants is the primary need at a crucial time. Various psychological stresses and family-related issues faced by migrants during future pandemic situations need to be addressed. Today is an era of technology, a mobile van with facilities of teleconferencing and Tele counseling with migrants can be planned at multiple sites for providing services in such future crises like Covid 19. The policy planners and senior public health administrators should be sensitized to minimize the gap in providing psychosocial services to this vulnerable section of society. Acceptance of the changed situation among migrants, sharing of feelings, journaling, writing down feelings and thoughts are important psychosocial strategies to handle migrants’ mental health issues. Text messages were highly effective in increasing awareness. Decreasing stigma and inducing help-seeking behavior. The focus of psychosocial intervention should be on the self, family, community. A psychoeducation module needs to be prepared for educating the migrants on the consequences of traveling during the Covid-19 pandemic. Police authorities of the local area and nodal officers of shelter homes need sensitization about various services provided in the community and telemental health services at regular intervals.

This Chandigarh model for psychosocial intervention was different from already available disaster models in many ways.[22] The Chandigarh model for psychosocial intervention was based on Maslow’s theory of hierarchy needs. Once the most basic and physiological needs are met, migrant workers could proceed to concerns regarding psychological and higher- ordered needs. Physical survivorship was no longer the goal, but rather emotional and psychological functions, happiness, and physical abilities of the participant should all be considered important needs that can be immediately addressed and incorporated into psychosocial intervention.

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Application of Maslow’s Hierarchy model-based psychosocial intervention would help propel mental health care professionals toward comprehensive care of the whole person, not merely for survival, but toward restoration of all-important function of mind and body disaster models documented in the literature, handling the severe life-threatening stressful situations of the victims was prioritized. In NIMHANS model psychosocial issues of the migrant population were taken which were theoretical.

During a disaster event like earthquake, floods, and tsunami one of the most common and effective informal health community interventions reported in the disaster manual is called Psychological First Aid (PFA). Psychological first-order interventions after a crisis, an emergency, or a disaster are designed to reduce the distress caused by exposure to a traumatic event and to enhance the knowledge of the protective factors that helped the person to survive the event.

Conclusion

In conclusion, the Covid-19 pandemic has had a huge mental health impact on internal migrant workers. Predominantly psychological distress, depressive disorders, anxiety disorders, substance use disorders were reported among migrants during the Covid-19 pandemic. An integrated comprehensive mental health care approach and community outreach services programme for migrants may help in minimizing the psychological impact of the Covid-19 pandemic on migrants. Psychiatric morbidity and substance abuse were highly prevalent as found in cross- sectional studies, multicentric studies. The migrant population needs optimal mental health care to minimize mental health implications. Combined efforts of Mental health professionals, policy planners, industrialists, researchers, a social scientists for psychosocial intervention for mental health care of migrant population is needed.

References

1. Mukhra R, Krishan K, Kanchan T. COVID-19 Sets off Mass Migration in India. Arch Med Res 2020;51:736-8.

2. Rock B, Nisha C, Theres M et al. Alcohol Use and Mental Health among Migrant Workers. Indian Journal of Public Health Research & Development 2016;7:16973. doi: 10.5958/0976-5506.2016.00212.6

3. Firdaus G. Mental well-being of migrants in urban center of India: analyzing the role of social environment, Indian J Psychiatry 2017,59:164-9.

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4. Horyniak D, Melo JS, Farrell RM, Ojeda VD, Strathdee SA. Epidemiology of Substance Use among Forced Migrants: A Global Systematic Review. PLoS One 2016 13;11(7):e0159134.

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11.Kumar K, Mehra A, Sahoo S. Nehra R, Grover S. The psychological impact of Covid-19 pandemic and lockdown on the migrant workers: a cross sectional survey. Asian J Psychiatr 2020;53:102252. doi:10.1016/j.ajp.2020.102252.

12. Chavan BS, Sidana A, Arun P, Rohilla R, Singh GP, Solanki RK, et al. Factors leading to reverse migration among migrant workers during the COVID-19 pandemic: a multicenter study from Northwest India. Prim Care Companion CNS Disord 2021;23:20m02810.

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Editors

Dr Arabinda Brahma is currently the Director and Consultant Psychiatrist of Girindra Sekhar Bose Clinic, Kolkata. He is also Hon. Lecturer of Indian Psycho Analytical Society, Kolkata. He has received many awards of Indian Psychiatric Society & Indian Association of Private Psychiatry including Bhagwat Award, Marfatia Award & RB Davis Oration Award. Currently, Hon. Secretary of Indian

Psychiatric Society, Eastern Zone; Chairman, Publication Subcommittee of Indian Psychiatric Society and Council Member of Rehabilitation Council of India. He has published more than 50 papers in national and international medical journals including 4 Book Chapters.

Dr. George V Reddy is consultant Psychiatrist and Director

of Healthy Brain Clinic and Hospital, Secunderabad, Telangana. He Worked with the editorial board of Telangana Journal of Psychiatry and was the founder and first general secretary of Indian Psychiatric Society, Telangana state.

Dr Sujit Sarkhel is currently working as an Associate Professor of Psychiatry at Institute of Psychiatry, Kolkata. His is the Associate Editor of Indian Journal of Psychiatry and has more than 60 publications in National and International peer reviewed journals.

Publication Committee Indian Psychiatric Society Headquarter: Plot 43, Sector 55 Gurugram, Haryana,

India, Pin – 122003 http://www.indianpsychiatricsociety.org

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