Preparing for the mental health epidemic in the wake of the COVID-19 pandemic

How can psychiatrists prepare for the mental health epidemic in the wake of the COVID-19 pandemic? What are the signs to watch out for in prospective patients and prepare families for the same? Dr Ranjan Ghosh, psychiatrist, Good Karma gives some recommendations

We were already in an epidemic of mental health issues prior to the SARS-COV-2 pandemic. As we brace for an unprecedented amount of mental health cases, how should we prepare for it

The Indian Psychiatric Society (IPS) in a recent study found that mental illness had increased by 20 per cent since the lockdown, and that at least one in five Indians were affected.  For a fact, my practice showed a 50 per cent increase in the online portal due to the easy accessibility.  Unprecedented levels of economic hardships, isolation and all the complications will arise in one of the worst mental health crises in India.  IPS has even said it may “substantially increase risk of suicide”.  With the highest suicide in the world from ages 15-29 years old, how much more can we stand to lose?

Stress during an infectious disease outbreak can sometimes cause the following (as per CDC):

• Fear and worry about your own health and the health of your loved ones, your financial situation or job, or loss of support services you rely on.
• Changes in sleep or eating patterns.
• Difficulty sleeping or concentrating.
• Worsening of chronic health problems.
• Worsening of mental health conditions.
• Increased use of tobacco, and/or alcohol and other substances.

What should we look for firstly in ourselves?  If we have loss of interests, low moods, changes in sleep and appetite we should investigate why. In the same regard, if you have an increased restlessness, negative thinking and even recurrent negative thoughts we should assess how to control these. Also, after a significant life stressor sometimes there is difficulty getting back to order mentally. Best examples are breakups, family issues or financial hardships. We need to ensure being transparent even to ourselves. Then assess if we need help as to things happening in our life due to possible poor coping skills. The most common is alcohol, pills or other forms of dependency in food, streaming sites, anything really.

Not all children and teens respond to stress in the same way. Some common changes to watch for include (as per CDC):

• Excessive crying or irritation in younger children.
• Returning to behaviors they have outgrown (for example, toileting accidents or bed-wetting).
• Excessive worry or sadness.
• Unhealthy eating or sleeping habits.
• Irritability and “acting out” behaviors in teens.
• Poor school performance or avoiding school.
• Difficulties with attention and concentration.
• Avoidance of activities enjoyed in the past.
• Unexplained headaches or body pain.
• Use of alcohol, tobacco, or other drugs.

We normally transmit our anxieties and fears to our children.  Please try understanding them and explaining them very calmly in a language appropriate to their level. Do not allow them to watch news or any other criminal investigative shows. Look for the above symptoms and foster an unbiased non-judgmental listening partner for your child in the family.

Now moving on to people with pre-existing mental health conditions and/or substance use disorders what can we expect?  Mental health conditions of depression, anxiety, bipolar disorder, schizophrenia, and somatisation worsen. These individuals’ feelings, thinking, behavior or mood impairing them further in social or occupational/academic functioning.

Obsessive-compulsive disorder- We as practitioners are seeing an increase in compulsive behaviors and an increase in mysophobia (which is a fear in germs or specifically in this virus) and these thoughts become so bad that it makes the compulsions to do whichever ritual even more.

Bipolar disorder- This is the most common thing we need to carefully look for as sometimes when the wrong medication is given, it could worsen the situation. More commonly, only obtaining unipolar history but not further screen for history of mania or hypomania. We commonly see patients have increase in racing thoughts, expansive thought, not needing sleep, impulsivity and reckless behavior. We, as practitioners, see increase rapid cycling from depression to mania as well as psychosis sometimes. Commonly paranoid and/or grandiose delusions and rarely auditory hallucinations. Most dangerous combination is impulsivity, suicidal thoughts and anger.

Major depressive disorder- There is a worsening thought which leads to “what is the point of living thought” to planning ways to enact that thought.  Another thing that may happen is extreme ‘leaden paralysis’ which is early morning inability to get up and initiate your day.

Anxiety/panic disorder- The most common is extreme worsening of negative automatic thoughts which I saw hijack the brain.  This does not allow our rational thoughts come through. So what happens is that the sleeplessness and worrying lead to panic attacks definitely at higher percentages during the pandemic?  Palpitations, dizziness, shortness of breath, dyspepsia (gas formation), tingling numbness, syncope (passing out) and sometimes a fear of dying.

How do we all prepare from practitioners to peers?

There was always a shortage of mental health practitioners and with regard to psychiatrists, especially with child and adolescent, specialty was rare.

• Prevention is key: This is now for all the physicians we need ensure that there is preventative check in with regards to mental health. Even a simple PHQ-9* which a 9 point questionnaire would suffice. We, as a community, must make changes to not be embarrassed to express our feelings and if a doctor asks the question that carries a lot of weight. Normalising such questions and conversations is the key to survival.
• Awareness of the issue from educated to non-educated. Everyone has the right to know what is happening with them and how to make it better. They should be explained that it could further worsen if not taken care of. It has no class, caste, creed, religion, race or color as you know, it can happen to anyone.

1. We need to encourage our families to discuss their feelings. Social emotional learning should be part of the curriculum and more parents should learn it and teach their children about the same.  The tenets being:

• Self-Awareness:

– Identifying and recognising emotions

-Accurate self-perception -Strengths, needs, values

-Self-efficacy

• Relationship Skills:

-Communication

-Social engagement and relationship building

-Working cooperatively

-Negotiation

-Refusal

-Conflict management

-Help seeking

• Responsible-decision making:

-Problem identification and situation analysis

-Problem solving – Evaluation and reflection

-Personal, social, and ethical responsibility (very important)

• Social awareness:

-Perspective taking

-Empathy

-Difference recognition

-Respect for others

• Self-management:

-Impulse control and stress management

-Self-motivation and discipline –

-Goal setting

-Organisational skills

Think about how many of you have these down successfully or actively foster these traits in your children.  I know a lot of parents do some or most, but these will be needed in the modern world.  Big corporations have started administering mindfulness questionnaires as part of their interviews. These skills do not happen overnight but is continuous learning but that does not mean we do not start.

• Stop the stigma, blame and when you see it, speak against it.

 Stigma hurts everyone by creating more fear or anger toward ordinary people instead of focusing on the disease that is causing the problem. Stigma can also make people more likely to hide symptoms or illness, keep them from seeking health care immediately, and prevent individuals from adopting healthy behaviours. This means that stigma can make it more difficult to control the spread of an outbreak.

This is true both with mental health and the coronavirus.  Patients with mental health issues want to blame someone or something or some sort of failure on the spouses or parents. There can be myriad of reasons and one reason does not make someone have clinical symptoms of mood or anxiety. Speak out against someone blaming you for someone else’s ill-health when you, yourself are having difficulties functioning.  You have the right to have your feelings and even tough days.