How COVID-19 is overwhelming our mental health

[Updated on 22 March 2020 with the correct number of deaths and infected]

“Do you know what it feels like?”

“What, like it’s Godzilla, King Kong, alien attack: all in one!”

“Kind of.. feels like our world is never going to be the same…”

This exchange from Steven Soderbergh’s movie Contagion (2011) sounds uncannily real now in a world gripped with COVID-19. The movie depicts the breaking down of government and public health systems in the face of a new and deadly pandemic, while the US Centre for Disease Control (CDC) struggles to find a cure.

Roughly a decade after the film’s release, the theatrics of the silver screen are mirrored in our daily lives as the novel coronavirus SARS-Cov-2 makes inroads into newer territories every day. Small wonder that along with Outbreak , another 1995 movie in the same league, Contagion is highly popular right now on online streaming platforms. This fear of a pandemic of unknown origin is not new though. Humankind has witnessed worse fatalities during the Great Plague of Marseille (1719), the Asian Cholera Pandemic (1822) and the Spanish flu (1920), just to name a few.

Affecting around 266073 people globally and claiming 11,184 lives as of date (updated 22 March 2020), the virus has hijacked the very rhythm of our daily lives, besides taking a huge toll on public health. COVID-19 originated in Wuhan, China towards the end of 2019 but took just two months to become an integral and alarming part of our daily conversations, debates and social media communication.

As it hits 158 countries besides China, large scale socio-politico-economic impacts are already evident in stock market bloodbaths, a fractured global economy and unprecedented foreign policy measures. China, Iran, Italy, South Korea and Spain are among the worst hit, forced to shut borders and alter immigration policies. The pandemic is slowly clawing on India too with 126 affected so far and many states imposing mass-closures and shutdowns. Fear and chaos are on the rise. Agitation brews over quarantine, isolation and travel restrictions. Face masks and hand sanitisers have become rare, hoard-worthy commodities. Around the world, researchers are racing to decode the viral genome enigma and develop vaccines and antivirals.

Amidst global panic, COVID-19 has come to occupy the deepest corners of our minds and life in general.

The psychological toll of pandemics

Pandemics are far from being just medical phenomena. They disrupt personal and professional lives severely and affect people and societies on several levels. The key strategies promoted for containment of an outbreak of this nature are isolation and physical distancing – both can have significant impacts on our life and relationships.

Like any other fast spreading infection, COVID-19 comes with an exponentially increasing barrage of misinformation constantly thrown at us via social media, fuelling stress and mass hysteria. In addition, the 'fear of transmission' begets stigma, marginalisation and xenophobia, kicking in the 'fear of fellow humans'.

The health machinery of some countries such as Italy is creaking . Healthcare workers are burnt out (and at maximum risk of infection), and medical supplies are depleted. In spite of well-formed protocols, hospitals are flooded with requests for testing and treatment while people fiercely compete for basic health amenities. Faulty treatments claiming cure and prevention are booming, leading to adverse health consequences. Health anxiety, sleep disturbances, panic attacks, depression and loneliness are the other known mental health fallouts of living through a pandemic. All these affect the entire ‘basis of life’ question for many.

But sadly the focus of assessing impact of the COVID-19 pandemic is almost entirely biased towards ‘deaths’, while mental well-being, one of the most common indicators of public health, unfortunately takes a backseat.

It’s, therefore, important to take note of these different ways in which the COVID-19 pandemic may be impacting people’s mental health:

1. The fear of reliving a pandemic if you have lived through another infectious disease pandemic/epidemic in your lifetime (such as Nipah, Ebola or SARS).

2. Fear of losing livelihood due to isolation or marked limitation of travel and social behaviour (applies to those in small scale industries in the travel, fitness, food or tourism sectors).

3. A constant sense of insecurity for oneself and loved ones.

4. Anxiety of social/physical distancing resulting in lack of contact with family or friends who may be living far away. For some it’s the other way round: getting huddled for the first time with a large family resulting in mixed emotions.

5. The phobia of going out of home.

6. Stigma towards people with symptoms such as cold, cough or sneezing, which might just be a simple flu.

7. The compulsive need to hoard food, essentials or medical supplies such as antibiotics, analgesics, anti-allergic medicines, face masks, sanitisers.

8. Psychological stress over the growing panic, which compounds daily, many times due to reinforced messaging in all forms of media.

9. In healthcare workers, paramedics, volunteers, virologists or media persons at the frontline of the COVID-19 control or coverage: fatigue, burnout, frustration or the fear of contracting or guilt of transmitting infection.

One of the key lessons learnt from the SARS and MERS epidemics was the need for early sensitisation of public health experts to the psychological effects of a pandemic and to cater to the mental health needs of those quarantined¹. The World Health Organisation’s mental health and substance abuse department has emphasised the importance of a mental health response to the growing COVID-19 situation. Chinese researchers have recently explored the effects of online counselling sessions for healthcare staff as well as those in isolation during the initial COVID-19 outbreak in China². Even though anger and resentment towards the government was the initial response, most of them reported better work environment and emotional satisfaction with basic psychological support despite the worsening situation in China.

A mental health institute at the Second Xiangya Hospital in Hunan, China followed a protocol for ensuring the quality of life of those in isolation. The steps were simple – daily digital communication with their closed ones, group counselling, catering to individual dietary needs, comfort and leisure, continuation of job-related activities and updates on the outbreak condition. Weekly supportive psychotherapy sessions and periodic hygienic measures were ensured for healthy living. These helped preserve the dignity of those in isolation and their compliance to restrictive protocols. In the absence of such care giving, we often see people defy isolation or abscond for the fear of getting ‘stranded’, which is a larger menace to public health.

Protecting the most vulnerable

Social (or physical) distancing and the risk of losing livelihoods to a pervasive ‘macro-stress’ puts a burden on vulnerable populations. Many small scale businesses or set-ups are going bankrupt and government policies to help them appear far-fetched. In line with the measures taken in China during the SARS outbreak⁴, insurance and support grants should be prioritised for these set-ups. Legal provisions for war time and natural calamities must be enforced for pandemic situations too to protect and nurture the most vulnerable sections of the society.

Populations in need of social or financial support or those with infected or dead family members in long-term isolation, and people from lower socio-economic backgrounds with increased risk of being misinformed, need special care. They also need to be made aware that help is available.

Though scores of hotlines dishing out COVID-19 help are active, they tend to pollute information with precautionary messages against the infection. There’s rarely a ‘voice’ that caters to those in panic. Central institutes like National Institute of Mental Health and Neurosciences (NIMHANS) and All India Institute of Medical Sciences (AIIMS) are working with community healthcare teams to provide ongoing mental health care support at various levels.

Existential questions

An ongoing qualitative study at the Department of Psychiatry and Department of Community Health of Christian Medical College in Vellore shows that ‘existential’ questions of survival and death mainly rise out of ‘fear of uncertainty’ and are compounded by various sources of misinformation. An active role, primarily of researchers, healthcare professionals and the media, is necessary to disseminate facts at the grassroot levels and prevent ‘medical mistrust’, which has further adverse consequences.

Debunking misinformation in this digital age is a collective responsibility and authentication of facts is a necessity. Even one senselessly forwarded message can snowball panic.

Healthcare workers are at the highest risk and need peer support sessions, adequate work breaks, shifts and organisation of leave structure as well as scope for catharsis.

People also report emotional distancing with family members for the guilt of transmitting infection. Experience at NIMHANS shows that something as simple as a telephone conversation with family members addressing their unmet needs makes a huge difference.

The impact of an unknown infection is much beyond its symptoms, or mortality. It becomes a part of our existence, threatening our very ways of living.

There's life after outbreak

Pandemics are eventually transient. As hundreds of researchers across the world unravel the many mysteries around the virus, drugs are made and countries mount their emergency responses, there's hope that life, economy and work will ultimately take their own course. However, what will really immortalise this microscopic virus in human history is its ability to bring together the entire world as a unified family with a common suffering and a common goal of eradication, irrespective of geo-political differences.

Prioritising public health and aggressive restrictive measures early on are always the key measures for containment of a pandemic. Social media is perhaps going to be implicated as the most vulnerable vector for the spread of COVID-19 in our minds. Misinfodemics (spread of an epidemic through misinformation) has been rampant since the first case of COVID-19 and this distinctly makes it different from its earlier congeners like SARS or MERS, which came when telephones were still the dominant mode of communication.

As the whole world hopes to get a hold on this ongoing threat, we will surely remember this disease as one that made us revisit Russian writer Leo Tolstoy’s words: “We are divided by borders, but united by the world.”

(* Debanjan Banerjee is a psychiatrist at the National Institute of Mental Health and Neurological Sciences, Bengaluru. He can be contacted at dr.djan88@gmail.com.)

[Nature India's latest coverage on the novel coronavirus and COVID-19 pandemic here . More updates on the global crisis here .]

References

1. Chan, S. S. et al. Improving older adults’ knowledge and practice of preventive measures through a telephone health education during the SARS epidemic in Hong Kong: A pilot study. Int. J. Nurs. Stud. 44, 1120-1127 (2007)

2. Liu, S. et al. Online mental health services in China during the COVID-19 outbreak. Lancet Psychiat. (2020)

3. Chen, Q. et al. Mental health care for medical staff in China during the COVID-19 outbreak. Lancet Psychiat. (2020)

4. Wu, P. et al. The psychological impact of the SARS epidemic on hospital employees in China: exposure, risk perception, and altruistic acceptance of risk. Can. J. Psychiat. 54, 302-311 (2009)