Bengaluru: As the Covid-19 pandemic rages on, shutting economies, preventing families from being together, and making it harder for people to go about their daily lives, another global crisis is following in its wake — a mental health one.
A mental health crisis is where a situation that is not life-threatening triggers intense, confusing, and painful behavioural, emotional, or psychiatric responses, affecting an individual’s well-being. It varies between individuals, and can often be crippling, preventing people from functioning normally.
Mental disorders occur every day, sometimes without any cause but also due to adverse or traumatic events that have taken place — both on an individual and community or global level, such as eco-anxiety. Mental disorders are among the leading causes of non-fatal diseases in India.
Deteriorating mental health comes in various forms, primarily showing up as anxiety and depression. In 2017, 19.73 crore Indians had mental disorders, including 4.57 crore with depression and 4.49 crore with anxiety.
Covid-19, however, is unprecedented in terms of absolute numbers — of people being hospitalised or dying, job losses, economic ruin, worker migration, and the number of people undergoing extreme distress. Even the UN has issued warnings about the increasingly worsening mental health impact of the pandemic.
Dr B.N. Gangadhar, director and vice-chancellor of the National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, said any kind of uncertainty is bound to be a source of concern, whether because of the pandemic or otherwise, but it’s important to remember what we’re seeing now is a normal reaction to an abnormal situation.
“There is a flood of things causing uncertainties: The spreading infection and uncertainty about life and death, treatments, when and where the infection would come from, about vaccines, drugs, and when the pandemic would end, decisions taken by various authorities such as opening schools, allowing travel, and much more. Reactions of anxiety, depression, and other mental health disorders are normal and expected,” Gangadhar said.
“The longer the uncertainties last, the longer the reactions last,” he said, adding that sustained reactions can trigger psychologic events which can even manifest physiologically in some such as through hypertension, diabetes, obesity, and menstrual issues.
Triggers to anxiety and depression
Mental health experts, psychiatrists, and counsellors have seen a sharp spike in the number of patients since the pandemic began.
“There has been a very noticeable increase in the number of people seeking counselling since March and April. The numbers started to spike drastically since May,” said Ruchita Chandrashekhar, a Mumbai-based behavioural health researcher and psychologist.
Chandrashekhar described her patients as exhibiting stress responses like losing appetite and sleep, reporting aches and pains they normally wouldn’t have, carrying productivity guilt, feelings of entrapment and suffocation, sudden migraines, and feelings of hopelessness.
“Everything is atypical now. There is persistent adjustment stress. At this point, everyone in the world is at a baseline stress mode. Personal stressors on top of that make things much worse,” she said.
Baseline mood is the subjective normal mood a person experiences in a stable, calm mental state.
Stressors are manifold — worries about the virus, inability to be with family, job losses and financial insecurity, coping with loss, and even consuming too much news. These effects of stress are different from the more serious ones like schizophrenia or bipolar disorder. They primarily manifest in the form of anxiety and depression, but could also extend to panic attacks, loneliness, eating disorders, inability to sleep, or suicidal thoughts.
Omar Bazza, clinical therapist based in Toronto, said: “People struggle to control their anxiety and depression, which stem from the economic stress of losing a job, not knowing when someone will be able to pay rent, or how they will get food when their money runs out.”
Helplines not addressing root cause
A prime cause of anxiety is uncertainty — about work, relationships, businesses, finances, jobs, vaccines, drugs, deaths, and/or schools.
Many agencies, institutions, and the government have set up helplines for people to obtain counselling in India. Most were inundated in a span of minutes or hours. Callers complained mainly of anxiety caused by job insecurity.
Healthcare workers too have helplines they can call into.
“Nearly one lakh people and 1,500 healthcare workers have sought help from these helplines,” said Gangadhar, whose institution NIMHANS set up numbers with the aid of the health ministry. “When it comes to real-time support, the state governments and other professional bodies have been supportive. Whether it is sufficient aid is a different issue.”
However, experts pointed out that setting up helplines and volunteers, while removing trained mental health professionals and reassigning them to Covid duties, has compounded the crisis. As the virus spreads in India and hospitals run out of space, psychiatric wards and institutions are also being converted to Covid facilities.
Additionally, the reasons for the growing distress are often left unaddressed.
“While it’s important to have helplines, the root cause of developing and worsening mental disorders have to be addressed,” said Dr Soumitra Pathare, psychiatrist and director of the Centre for Mental Health Law and Policy at the Indian Law Society’s (ILS) Law College, Pune.
“People have no money, no food, and no jobs. How can counsellors help when these root causes are not addressed? Most mental health issues arose from job insecurity. Unless that’s addressed, offering counselling is almost moot,” Pathare said.
Mental health crises are even manifesting in children, due to extreme uncertainty about school reopening and exams across different boards and states.
“The government and education boards announce postponement of openings or exams for a span of just weeks or a couple of months,” explained Pathare. “This causes extreme uncertainty, which worsens mental distress.”
Pathare invoked the example of Kenya, which has decided to nationally scrap one full academic year, to maintain a level playing field for all students.
“There should have been a policy decision about when classes would resume, even if it is after six months or a year. Even if the certainty is not ideal, having a timeline to work with enables people to plan their lives better with a little bit more stability,” he said.
Frontline healthcare workers — doctors, nurses, ambulance drivers, ASHA workers, mortuary workers — face the disease and its misery every day, and are also being impacted mentally, especially from post-traumatic stress disorders (PTSD) and burnout, worsened by children or elderly at home or infected family members, and mainly by low income.
“Many frontline workers have been fighting the virus for months now, getting sick, losing their colleagues, and not being able to process these emotions because they have to get back to work and continue fighting this pandemic,” explained Bazza. “The fact that PPE was not available for so long was an extreme stressor.”
The elderly too face increasing stress, as do those with substance/alcohol abuse issues. However, there isn’t enough data yet.
Pre-existing mental issues
Many people who already suffered from disorders before the pandemic are reportedly seeing their condition worsen.
“A lot of new symptoms are manifesting, like people with manageable OCD being triggered by contamination anxiety, an additional distress they have to manage in crisis mode,” explained Chandrashekhar.
Being in close quarters with families, abusive spouses, or having to study at home under parental pressure, have all exacerbated existing conditions and feelings of hopelessness, worthlessness, and physiological disorders.
Existing patients faced an unprecedented problem when lockdowns were imposed, explained Arpitha Jacob, who studies bipolar disorder and schizophrenia at NIMHANS.
“All systems shut down except for emergencies,” she said. “Once out-patient departments (OPD) closed, it became extremely difficult to access prescription medications,” Jacob said.
Psychiatric medications are prescribed typically for three months.
Institutes like NIMHANS eventually set up telephonic consultations for existing patients, but many belong to low-income groups and did not have access to or awareness of this.
Low-income groups also face very different problems from city dwellers. The urban population struggles with isolation caused by physical distancing measures, while the rest of India has to deal with overcrowding, which results in high-strung emotions, fights, physiological changes, and anxiety about Covid.
Existing patterns in deaths by suicide are also thought to have changed. While absolute numbers get attention, profiles of individuals can indicate shifts in triggers. Pathare thinks there might have been a drastic drop in suicides among younger people following exams, but a spike among older people due to financial insecurity. The National Crime Records Bureau (NCRB), which obtains data about deaths by suicide from police departments, is under increasing pressure to release data in a timely manner instead of years down the line.
Inaction despite knowledge
The looming and growing mental health crisis was very much predicted, by both practicing experts as well as scientific evidence.
“Despite established evidence that mental health crises definitely set in after other kinds of crises, there is a lack of a properly concerted, coordinated response for different sectors with only ad hoc decision making,” said Pathare.
Experts have instead started recommending self-care, primarily meditation, and urging people to identify triggers that heighten emotional responses.
“Common indicators of deteriorating mental health to watch out for are loss of sleep or appetite, constant worrying rumination, and sometimes excessively consuming content just to avoid thinking,” explained Jacob.
Other symptoms include feelings of despair, loss of interest in work, irritability, and changes in behaviour — both excessive and restrictive.
“We get conditioned to set unrealistic expectations from ourselves and when we don’t meet them, we think we failed,” explained Chandrashekhar. “Instead, we must accept that our body and mind are struggling, and start taking better care of ourselves.”
Setting a strict daily routine — especially when working from home— and exercising are very helpful, said Pathare. Staying in touch with family and friends, and periodically taking time away from spouses or other family members we live with, are also advised.
Pathare added that just like washing hands and wearing masks are systemically promoted, so should self-care.
“People in general have reacted remarkably in a responsible way in the face of an unknown disease and that’s commendable,” said Gangadhar, referring to the near-widespread adoption of masking and general isolating in India. “There now needs to be education and awareness, both in terms of clear communication of facts about the disease, as well as about managing sustained stress well,” he added.
“This is going to be the biggest mental health crisis we are going to feel worldwide. From people getting sick, or losing their loved ones, to losing jobs, all the uncertainty is enough to precipitate anxiety and depression to unprecedented levels. Some of this crisis has already started but this will continue for a long time,” warned Bazza.