Among COVID-19’s many effects on society, one of the most insidious is the way it has affected global mental health, giving rise to new challenges and aggravating pre-existing issues. In this article, Subhra Sarkar, who is currently pursuing a PhD in psychiatric nursing, discusses the ways in which the pandemic has affected the mental health of a large segment of the Indian population.
COVID-19 has created a global crisis that the world was not prepared for. Lack of known strategies to control this pandemic, lockdowns, loss of work and shelter, sudden overflow of patients in hospitals, closed educational institutions and more such disruptions have led to a huge impact on every aspect of human life around the globe.
Some of these aspects include work and education, physical and mental health conditions, family dynamics, and social relationships. While many of these effects are being discussed on news portals and social media on a daily basis, COVID-19’s impact on mental health remains one of the least recognized and least addressed aspects, especially in India.
As a researcher in the field of mental health, where my work involves attending to patients with mental illness in the inpatient as well as outpatient departments of a specialized mental health institute in India, I find addressing this issue to be of utmost importance at this critical juncture. This conviction is bolstered by my interactions with the community at large.
Lack of recognition and discussion regarding mental health issues is not unique to the COVID-19 situation. Mental health issues have long been equated with psychotic disorders with symptoms like disruptive behaviour, hallucinations etc. Only recently have increased awareness of mental health issues shifted the focus to common but less obvious mental health symptoms. Conversation about other mental health issues, like depression, anxiety, attention-deficit/hyperactivity, and learning disabilities, has finally been stirred.
The pandemic has had a huge impact on people’s mental health, both positive and negative. The lockdowns have given some people an opportunity to work (or study) from home, enabling them to spend more time with their family and build relationships. This, in turn, can enhance psychological wellbeing and a feeling of contentment. But this is the story of only a small section of the population.
The larger population is facing a strong negative impact of COVID-19 on their mental health. For example, COVID-19 positive patients often suffer from depression, anxiety, and post-traumatic stress related to the disease. Frontline workers often face stigma from their community and family and have to deal with the fear of getting infected. They also suffer from burnout, anxiety, and insomnia related to overwhelming workloads.
While the challenges faced by COVID patients and frontline workers are relatively more noticeable, the issues that go unnoticed and unaddressed are that of the general population. Studies reveal that mental health issues like anxiety, depression, stress, psychological distress, loneliness have emerged progressively among the general population during the COVID-19 outbreak. Increased suicidal ideation and suicide, specifically among youth are an important concern during this time, which could be triggered by the isolation during the quarantine during the lockdown period. Clinical observation often shows an increase in alcohol and drug use, as well as severe withdrawal symptoms due to the sudden unavailability of alcohol and other addictive substances during the lockdown.
However, progressively significant work is being done to increase awareness about mental health and to strengthen mental health services in India. For example, the Government of India has initiated programs like the National Mental Health Program (NMHP) and District Mental Health Program (DMHP). During the initial lockdown period, under the mandate of the Ministry of Health and Family Welfare, Govt. of India, the three central mental health institutions, National Institute of Mental Health and Neuro-Sciences (NIMHANS), Lokopriya Gopinath Bordoloi Regional Institute of Mental Health (LGBRIMH), and Central Institute of Psychiatry (CIP) initiated a national helpline to provide support for mental health concerns arising out of COVID-19.
But such mental health services still remain inaccessible to a large population in India. One of the main reasons for this is stigma. My interactions with the community have often revealed that people do not want to consult a psychiatrist or visit a mental health facility because of the social stigma associated with the same. Discussion of mental health issues on news and social media often does not help the majority of the Indian population due to a lack of education as well as language gaps, given that most of such coverage takes place in English. Some other important barriers include uneven distribution of mental services, economic inequality, and lack of enough trained mental health professionals.
While the growing conversation regarding mental health is indeed driving a slow yet significant change, these conversations are driven by and centred around those who already have access to mental health services. This has uncanny parallels with COVID-19: if one doesn’t get tested, one doesn’t get diagnosed. But the lack of diagnosis does not mean the disease doesn’t exist.
Two other reasons why these issues go unaddressed are lack of knowledge, which results in an inability to recognize the symptoms, and limited access to mental health services. For a large fraction of those who are vulnerable, limited education leads to not only a lack of awareness of mental health issues, but also a lack of vocabulary to express those issues. Again, disorders like depression, somatization and hypochondriacal disorder, which are classified as mental and behavioural disorders in ICD-10, may present only with physical symptoms like pain. This often leads individuals with these conditions to bypass mental health facilities and approach general healthcare facilities. Such patients often go undiagnosed. This is also complicated by the lack of skilled mental health personnel and excessive burden of patients in general healthcare facilities.
Mental health issues also go unidentified due to one’s inability to express emotional stress. During clinical practice, it is often seen that men and women with minimal educational exposure and lack of self-awareness find it difficult to identify and express their emotional stress and low mood, eventually resulting in not seeking help and suffering in silence. Due to their cultural beliefs, women often accept stress related to emotional and physical abuse, domestic violence, and repression (occurrences of which, according to studies, have significantly increased during the COVID-19 pandemic) as normal.
Traditional gender roles play an important role in the lack of reporting of men’s mental health issues as well. Studies show that although men are less likely to develop depression than women, they are more likely to die by suicide, indicating that many men may have unidentified and undiagnosed mental health issues. From interactions with people of all genders, we gathered that men find it more difficult than women to seek help due to cultural and social beliefs. These include beliefs related to the ability to control emotions, the need to have a ‘tough’ personality, and other such masculine stereotypes. It is thus understandable how the impact of loss of work and financial constraints during this time might remain unreported or underreported in men.
However, India has long been in a mental health pandemic, which is now being exacerbated by COVID-19. Lack of language on the part of the sufferers, lack of functional knowledge on dealing with mental health issues on the part of their family and friends, and apathy by the rest, has led to this pandemic. The only way forward is a sustained conversation regarding mental health in an understandable language- one that is inclusive. Mental health issues, if experienced by an individual, need to be accepted as normal because they are. The important thing is to take action and reach out for professional help.
Countering this hidden pandemic requires collective effort by various stakeholders, including health professionals, community health workers, persons affected by mental illness, family members, school teachers, workplace managers, police, civil society organizations, community heads, and policymakers. Such concerted effort needs to be directed towards the development of new infrastructure around mental health care that recognizes the crisis as institutional, as well as towards the continuous expansion of existing resources.