|SPECIAL INVITED REVIEW
|Year : 2020 | Volume
| Issue : 5 | Page : 24-42
COVID-19 pandemic and emotional health: Social psychiatry perspective
R Srinivasa Murthy
Professor of Psychiatry (Retired) Formerly, Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
|Date of Submission||27-Aug-2020|
|Date of Acceptance||17-Sep-2020|
|Date of Web Publication||02-Oct-2020|
Dr. R Srinivasa Murthy
553,16th Cross, J.P.Nagar 6rth Phase, Bangalore-560078, Karnataka
Source of Support: None, Conflict of Interest: None
The COVID-19 pandemic is a challenge to humanity. It is not only a health crisis but also a social crisis. As in the case of past pandemics, life, as we know, is unlikely to be the same after we come out of the pandemic. There will be changes at the level of individuals, families, communities, states, nations, international relationships, and the way all of us will deal with a range of human and environmental situations. Disasters are always associated with increased rates of emotional health needs from distress to specific disorders, such as posttraumatic stress disorder, and the vulnerabilities are associated with the way society is organized. Past experiences have shown psychosocial interventions, ranging from self-care, psychological first aid, school interventions, counseling, social support and formal psychiatric care can minimize the emotional health impact of disasters. These activities can be initiated by individuals, paraprofessionals, and professionals. In addition, there is an important role for social–economic interventions such as provision of food, healthcare, shelter, protection from harm, and relocation/rehabilitation. Spiritual resources are an important part of coping with the pandemic. An emerging area of disaster psychiatry is the possibility of posttraumatic growth and facilitating of community resilience. There is sufficient evidence, from the past, of major societal level changes, following pandemics, in healthcare, education, welfare, governance, and citizen–government relationships along with relationships across countries. The psychosocial interventions, with survivors of disasters, should be to promote mental health and prevent mental disorders and care of persons with mental disorders involving the individuals, families, communities, and the government. The pandemic also offers opportunities for understanding and addressing of the risk factors for mental health and factors contributing to resilience of individuals and communities. The current pandemic presents challenges and opportunities for the Indian Association for Social Psychiatry.
Keywords: Community resilience, disaster, posttraumatic stress disorder, research, self-care, social psychiatry, spirituality
|How to cite this article:|
Murthy R S. COVID-19 pandemic and emotional health: Social psychiatry perspective. Indian J Soc Psychiatry 2020;36, Suppl S1:24-42
|How to cite this URL:|
Murthy R S. COVID-19 pandemic and emotional health: Social psychiatry perspective. Indian J Soc Psychiatry [serial online] 2020 [cited 2021 Nov 29];36, Suppl S1:24-42. Available from: https://www.indjsp.org/text.asp?2020/36/5/24/297163
“Health crisis has become a social one (crisis)” -BBC News, May 5, 2020.
| Introduction|| |
Social psychiatry is the essence of psychiatric practice but has often not received due recognition by the psychiatrists in the background of a more glamorous biological psychiatry. In the modern-day world with advancing technologies, changing societal norms, and intermingling of cultures, social psychiatry holds even more importance than before. This is how Prof. N. N. Wig introduced the recent book on Social Psychiatry. Similar views have been expressed by others:
“Psychiatry has not been as individualistically oriented as it is now. Indeed, from the 1950s until the 1970s, social psychiatry (i.e., the study of the mental health of communities and of social correlates of mental health and mental illness) existed as a recognizable subfield within the psychiatric literature.”
The last 8 months has been the most traumatic period for humanity. The world, as we all know, has been turned upside down. Social structures and their functioning are under strain. Emotional health of the population is an important casualty of the current pandemic. There is fear of death and anxiety about the future among all individuals everywhere in the world.,,,,, Medical care services are stretched and the health work force are at risk of severe illnesses. The oft expressed opinion is that the world will not be the same as it was before COVID-19.
The current pandemic differs from everything that has happened in the world in the last century, in terms of the suddenness, the rapid spread, the involvement of the total world, and the severe disruptions in all aspects of life. Unlike other disasters where the events were limited to an area/region and the noninvolved people/communities/countries could reach out to help the affected population, in the current pandemic, everyone is involved. In some areas currently, instead of cooperation, there is competition across individuals, families, communities, and countries for resources and interventions.
The current article presents five aspects of the current COVID-19 pandemic. First, it examines the international social determinants of disaster mental health. Second, it reviews evidence of the social determinants of mental health. Third, it considers the social dimensions of the pandemic. Fourth, it covers the mental health aspects of disasters with a focus on the experiences of India during the last four decades. Fifth, the initiatives in the area of mental health during the last 5 months, both in India and the rest of the world, to specially focus on the sociocultural dimensions of the pandemic are reviewed. Finally, based on the above five aspects of the pandemic, an agenda for action is considered against the discipline of social psychiatry as an essential component of the total response of the country to the COVID-19 pandemic.
| International Experiences of Social Dimensions of Disasters|| |
At the international level, there are a large number of studies to support the importance of social factors that illustrate the social dimension of health, in general, and emotional health, in particular, during adverse situations. Three examples are considered in detail because of their significance and depth of understanding of the social issues in society.
Markel et al. studied the role of nonpharmaceutical interventions implemented by the US Cities during the 1918–1919 Influenza Pandemic. They studied 43 cities in the continental United States from September 8, 1918, through February 22, 1919. The focus of the study was the city-to-city variations in mortality and association with the timing, duration, and combination of nonpharmaceutical interventions. Nonpharmaceutical interventions were grouped into three major categories: school closure; cancellation of public gatherings; and isolation and quarantine. There were 115,340 excess pneumonia and influenza deaths in the 43 cities during the 24 weeks so analyzed. Every city adopted at least one of the three major categories of nonpharmaceutical interventions. School closure and public gathering bans concurrently activated represented the most common combination implemented in 34 cities (79%). The cities that implemented nonpharmaceutical interventions earlier had greater delays in reaching peak mortality, lower peak mortality rates, and lower total mortality. There was a statistically significant association between increased duration of nonpharmaceutical interventions and reduced total mortality burden. Authors concluded that, “in planning for future severe influenza pandemics, nonpharmaceutical interventions should be considered for inclusion as companion measures to developing effective vaccines and medications for prophylaxis and treatment.”
Klinenberg in his book, “Palace for the people,” presented the value of social infrastructure in a disaster. During the week July 14 to July 20, 1995, 739 people in excess of the norm died in Chicago during the “heat wave.” He reported that social isolation increased the risk; living alone was particularly dangerous. Close connection to another person, even to a pet, was protective. Having an air-conditioner reduced death by 80%. There was a strong correlation of “social infrastructure” (the physical spaces and organizations that shape the way people interact) and deaths. Women fared better than men. There was strong correlation with segregation and inequality.
In a recent book, “Together,” Murthy, former Surgeon General of the USA, presents powerful data to make the point, “the healing power of human connection in a somewhat lonely world.” The book covers the origin of loneliness, the importance of the culture of connection, and the origins of the “loneliness epidemic” in the modern world. The book presents a number of well-established interventions toward building a more connected life, through relating inside out, building circles of connection, and moving toward a family of families. The numerous evidence-based examples presented demonstrate how important the “social infrastructure” is to the well-being of human beings.
Against the background of the recognition of the importance of the “social factors” from the past experiences and current awareness, the last 8 months of the pandemic has provided a rich opportunity to understand the social aspects of the pandemic as well as to recognize the need for social-level interventions.
The United Nations called for action for mental health , and identified a need to “apply a whole-of-society approach to promote, protect, and care for mental health” as the first of the three recommendations for action. The WHO  has given priority to mental health interventions along with other health interventions. Lancet has set up an International Commission on COVID and Health  and focused on a number of areas that need to be addressed.,
A number of mental health professional organizations have taken up this area as a priority area for their activities. Leaders in World Psychiatry identified three levels of mental health intervention – promotion of mental health, prevention of mental disorders, and clinical care., The World Economic Forum has identified addressing social inequalities as an area for action. The American Psychiatric Association (APA), recognizing increased mental health risks to the population, presented to the United States House Committee the urgent need for mental health of the population during the pandemic. Epidemiological studies have been reported from China, and Canada, highlighting the increased rates of mental health needs in the general population, as well as in the survivors and healthcare personnel. Another area of importance is the maternal mental health due to the special risks to pregnant women and the new-born child. Posttraumatic stress disorder (PTSD) is an important area of focus. More and more reports are appearing in scientific and lay press about increasing suicides and domestic violence. The emerging aspects of neurological problems are receiving greater attention., There is a wide recognition of the importance of the mental health dimension of the pandemic and the need to “rethink” mental healthcare in the post-COVID era.,,,, An important part of the pandemic is the lockdown. There are challenges to understand the implications of the pandemic , and the needed reorganization of the services at many levels.,
Another very important area has been the growing recognition of the “social dimension” of the pandemic. This pandemic has thrown a search light such as focus on the social disparities and associated health vulnerabilities in the communities. Besides, the general risk factors, racial differences in mortality,,,, vulnerability of the poor, the role of preexisting inequalities in the society, unemployment, and the poor health infrastructure in low- and middle-income countries, both across countries and within countries, have been reported. Loneliness is a very important factor, especially in the elderly. Of the vulnerable groups of population, the mental health needs of the health work force have become a top priority.
The subject of community resilience at many levels is receiving greater attention in the field disaster care., It can be expected that this area will be dominant in the post-COVID world.,, A very new initiative is the study of areas of vulnerability at the national level, and an initial attempt at identifying indicators of this vulnerability has been initiated.,
Going by the past major disasters and epidemics such as Ebola, the Fukushima earthquake, and the Bhopal disaster, it is expected that the “mental health pandemic” is on the horizon and the effects of the pandemic will be seen over years and decades to come. The need for research to understand the various aspects of mental health aspects of this pandemic has been flagged by researchers.,,, There is also recognition of the opportunity at a large-scale understanding of factors contributing to vulnerability and resilience. There is also attention on the need for mental healthcare and how the post-COVID world would need to reorganize mental healthcare including the utilization of digital mental health as an emerging solution.,
| Social Determinants of Mental/emotional Health|| |
The social determinants of mental health have been recognized over many decades., 3, ,, There are many dimensions to the social variables and mental health from individual level such as child trauma and loneliness to the larger social factors such as inequality to globalization. As noted in the earlier section relating to the international experiences of the pandemic, the social determinants are a vital part toward the contribution to the pandemic, morbidity, mortality, and response to the interventions, as well as the areas that need attention in the post-COVID period.
The most recent review of mental health, the Lancet-WPA Future of Psychiatry, summarizes the challenges as follows:
“A large body of evidence shows the importance of social determinants for mental disorders. Societal factors such as social inequality, crime, poverty, poor housing, adverse upbringing conditions, poor education, unemployment, and social isolation are related to increased rates of mental disorders. The relevance of some social determinants varies across the world. Examples are substantial urbanization in LMICs; increasing social isolation in high-income countries; the changing flow of refugees in some regions; and different levels of economic instability, civil unrest, and inequality between rich and poor people. Most of these social determinants influence physical health problems too, but they can be seen as particularly relevant to psychiatry.”
The following is a summary of the literature of this field.
A large body of evidence has demonstrated that exposure to childhood maltreatment at any stage of development can have long-lasting consequences. It is associated with a marked increase in risk for psychiatric and medical disorders. Adverse conditions in the early life are associated with a higher risk of mental disorders. The evidence of the long-lasting effects of “child neglect and abuse” is in the form of an increased rate of mental disorders. Physically abused, emotionally abused, and neglected individuals have a higher risk, two to three times, of developing depressive disorders than nonabused individuals. Children with a history of bullying, 40–50 years later, had an increased risk for depression and suicidal thoughts and were likely to have lack of social relationships, likely to have lower educational levels, and also more likely to be unemployed and earning less. Other significant associations between childhood adversities are occurrence of first-onset and recurrent mania, fatigue syndromes, adult violent offending, and criminality. There is growing evidence of the mediation of the effects of child neglect and abuse being biologically based with associated changes at the level of stress response and changes in brain structures, inflammatory responses, and neurocognitive functions. Child trauma has a special relevance to the current pandemic, due to the large-scale disruption of the lives of migrants and their families.
Inequality and mental health
Wilkinson and Pickett , have been examining this area. Their 2017 review points out that for the last 40 years, research evidence has been accumulating that societies with larger income differences between the rich and poor tend to have worse health and higher homicide rates. They conclude in the understanding of the epidemiological criteria for causality, “… mental illness is the most recent addition to this list of effects of greater inequality.”
The vulnerability of people living in urban slums such as Dharavi in Mumbai and their health implications during the times of COVID-19 are the news of the pandemic. During the last century, the migration of the populations living in urban areas has shown a massive shift. This is not only in terms of numbers but significantly populations are moving from integrated and supportive communities to anonymous social units, with significant mental health effects. In most developing countries, over 10% of the population living in urban areas lives in slums. The mental health impact of living in slums is getting greater attention. Urbanization affects mental health through the influence of increased stressors and factors, such as an overcrowded and polluted environment, high levels of violence, access to illicit drugs, and reduced social support. For example, low-paid urban workers often live in crowded spaces with poor basic sanitation, food supplies, and shelter, as well as few – if any – basic governmental and social support services.
Loneliness is gaining attention as an important factor for mental ill health. A number of longitudinal studies indicate that loneliness precedes depression, sleep difficulties, high blood pressure, physical inactivity, functional decline, cognitive impairment, and increased mortality. Physical and mental health components of quality of life were significantly reduced by loneliness. Severe loneliness was associated with reduced patient satisfaction. Loneliness as a part of social distancing and vulnerability of the elderly is a matter of special significance during the pandemic.
Migrants and refugees
One of the most distressing aspects of the lockdown is the millions of people migrating from one part of the country to their homes. There are tragic reports of death, such as the train running over sleeping migrants. Migration of population has been a part of human history. However, in recent times, especially in the last few years, these migrations are occurring in response to conflicts, political instability, economic crisis, and the populations, so moving is treated as “unwelcome” in most countries. That the mental health of refugees is compromised is well documented. The stresses of forced emigration – physical, social, and psychological – have taxed all societal systems. These stresses stem not only from factors directly related to migration or living in refugee camps but also from living under the authority of individuals having more likely than not a different culture, language, and traditions. Refugees are at excess risk of psychiatric morbidity because of forced migration, traumatic events, and resettlement in unfamiliar environments. Being a refugee and asylum seeker, both directly and indirectly, can be stressful and disturbing, and such experiences are closely related to suicide and self-harm. The prevalence of suicidal behavior among refugees reported a range of 3.4%–34%. Another aspect of migration is the separation of children from parents, which impacts the mental health of children.,,
The current pandemic is strongly linked with climate changes. Climate change and its impact on population are a part of everyday news. It is significant that the health concerns are reflected by a number of professional groups.,, The American College of Physicians, the American Academy of Pediatrics, and nine other medical societies have joined forces to raise public awareness and action against the harmful effects of climate change on the health of Americans. The report, Medical Alert! Climate Change Is Harming Our Health, outlines three specific types of harms from climate change: (i) direct harms, such as injuries and deaths due to increasingly violent weather, (ii) asthma, and other lung diseases that are exacerbated by extremely hot weather, wildfires, and longer allergy seasons; (iii) the spread of disease through insects that carry infections such as Lyme disease, Zika virus, or West Nile virus and through contaminated food and water. There are effects on mental health, resulting from the damage climate change can do to society, such as increasing depression and anxiety. In a new Position Statement, the APA focuses on the profound impact of climate change on mental health, which may include the development or exacerbation of mental illnesses, such as anxiety, depression, PTSD, or substance abuse. “Those with mental health disorders are disproportionately impacted by the consequences of climate change. APA recognizes and commits to support and collaborate with patients, communities, and other healthcare organizations engaged in efforts to mitigate the adverse health and mental health effects of climate change,” the APA statement said. As part of the future mental health scenarios, climate change as a cause and an area for intervention will be in focus of a wide range of professionals and policy-makers.
There is vast amount of literature that relates a large number of other social factors to health.,,,],, A recent study reporting the vulnerability index of the different states of India and the association with the COVID-19 infection rates presents a novel way of both understanding and offering areas for intervening in the future.,
In the current situation of the pandemic, factors such as isolation and the current social distancing add to the increased need for emotional healthcare. In case of the COVID-19, there is an additional dimension of stigma for the persons diagnosed to be ill and the care providers such as the medical workforce. In a situation like the current pandemic where the frontline workers (medical, police, support services, etc.) are themselves at risk of illness and death, their emotional health needs special attention. Another important dimension of the pandemic is the growing domestic violence.
A common thread linking all of these factors is the importance of governance and the way society is organized in terms of income distribution, equity of services, tolerance of different groups of population, gender equality for opportunities for growth, adequate health, education, shelter and welfare supports for the vulnerable groups, justice for all, and opportunities for democratic participation. All these social determinants need to be studied more extensively  and should be reflected in the future reorganization of mental health care.
| Social Psychiatry Aspects of COVID-19 Pandemic|| |
How does the pandemic relate to social psychiatry? It is significant that in the current pandemic, the word “social” (social distancing, social vaccine, social inequality, what is more important – lives or livelihood, etc.) is voiced as often, as the medical cause (s) of the pandemic, namely the “virus.” Before addressing the social dimension of the pandemic, it is important to recall that social interventions are a recognized part of 21st Century Psychiatry. For example, the Mental Health Group of Future of Psychiatry, recognizing that psychiatry in the first quarter of the 21st century is at the cusp of major changes, identifies the scope as follows: “Increased emphasis on social interventions and engagement with societal expectations might be an important area for psychiatry's development. This could encompass advocacy for the rights of individuals living with mental illnesses, political involvement concerning the social risk factors for mental illness, and on a smaller scale, work with families and local social networks and communities. Psychiatrists should therefore possess communication skills and knowledge of the social sciences as well as the basic biological sciences.”
Similarly, studies in fields as diverse as genetics, psychology, political science, architecture, and human ecology show that resilience depends just as much on the culturally relevant resources available to stressed individuals in their social, built, and natural environments as it does on individual thoughts, feelings, and behaviors.
| Social Issues of the Current Pandemic in India|| |
There are many voices reflecting the importance of social factors as part of the COVID-19 pandemic. It is important to note that the “virus” and “social” are equally used in the context of the current pandemic, like two sides of a coin. Social context is referred at many levels from the special social groups who are vulnerable, the value of isolation/distancing, the need for mitigating impact by social/economic supports, and most importantly the likelihood of long-term changes in the society. The following are a few of them. India with its varied social, economic, infra-structural differences offers a natural opportunity to understand these issues and develop social interventions, along with medical interventions.
Beginning with a positive note about the success of Kerala in effectively addressing the pandemic, Heller  identified four important characteristics of Kerala's response, namely, (i) state response team; (ii) a broad and dense healthcare system; (iii) an already highly activated mobilized civil society; and (iv) the capacity of state actors and civil society partners to coordinate their efforts at the level of panchayats, districts, and municipalities. Tharayan and John  recognized the need for a strategic plan of action to mitigate suffering and to stimulate economic recovery and they called for “using lessons learnt, from polio vaccination, and control of HIV” that a social vaccine (emphasis added) can build societal immunity. In their view, a social vaccine also requires people to hold leaders accountable. They concluded their analysis with the observation, “A social vaccine can build societal immunity to the devastating effects of future pandemics by the lessons learned about addressing the root causes, and our responses to the current one.” Rao, former Health Secretary of Government of India, recognizes that only a measured public health approach with community participation will help the government in ensuring a sustained response to stem its tide. Chidambaram and Chakravarthy  call for a blueprint to revive the economy. Andrade  presents the disruption of the livelihoods due to the lockdown and its impact on the vulnerable groups. Similar views of the challenge of harmonizing the focus on lives and livelihoods is reflected by others.,, The above representative voices all speak the principles of social psychiatry in terms of focusing not only on the individual but also on the families, communities, and the social infrastructure. The different dimensions of the COVID-19 pandemic, including the importance of the community, trust, and transparency, are the keys to controlling the pandemic in countries.,
| Disasters and Mental Health|| |
The emotional health of populations exposed to disasters is a well-recognized public health priority.,,,,,,,,,, The country experiences and that of the World Bank, different disasters  such as war, Sri Lanka, international experiences,,, including the special needs of developing countries,, have been reviewed.
The World Health Report, 2001 noted:
“Conflicts, including wars and civil strife, and disasters affect a large number of people and result in mental problems. It is estimated that globally about 50 million people are refugees or are internally displaced. In addition, millions are affected by natural disasters including earthquakes, floods, typhoons, hurricanes and similar large-scale calamities. Such situations take a heavy toll on the mental health of the people involved, most of whom live in developing countries, where capacity to take care of these problems is extremely limited. Between a third and half of all the affected persons suffer from mental distress (emphasis added). The most frequent diagnosis made is posttraumatic stress disorder (PTSD), often along with depressive or anxiety disorders. In addition, most individuals report psychological symptoms that do not amount to disorders. PTSD arises after a stressful event of an exceptionally threatening or catastrophic nature and is characterized by intrusive memories, avoidance of circumstances associated with the stressor, sleep disturbances, irritability and anger, lack of concentration, and excessive vigilance. …Studies on victims of natural disasters have also shown a high rate of mental disorders.”
Equally important is the mitigation of the negative impact of the disasters on mental health by building community resilience. This aspect is well recognized:
“Disaster resilience is everyone's business and is a shared responsibility among citizens, the private sector, and government. Increasing resilience to disasters requires bold decisions and actions that may pit short-term interests against longer-term goals. As a nation, we have two choices. We can maintain the status quo and move along as we have for decades – addressing important, immediate issues such as the solvency of the National Flood Insurance Program, the most effective ways to discourage development in high-risk areas, and how to improve the speed and effectiveness of disaster response. Or, we can embark on a new path – one that also recognizes and rewards the values of resilience to the individual, household, community, and nation (emphasis added). Such a path requires commitment to a new vision that includes shared responsibility for resilience and one that puts resilience in the forefront of many of our public policies that have both direct and indirect effects on enhancing resilience.”
This recognition of the importance of the psychosocial dimension of disasters is recognized by the “National Disaster Management Authority” which, during the last decade, has developed detailed guidelines for psychosocial care.
Disaster mental health care in India
It was a little over 40 years back, when the Andhra Cyclone resulted in the first examination of the emotional impact of the disaster. This was followed in 1980, by the study of the Circus Tragedy, by Prof. H. S. Narayan of the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, that laid the foundation for understanding the emotional aspects of disasters and community-level interventions. Narayan identified five action points that are relevant to date. First, the majority of survivors of disasters have multiple psychosocial needs, which continue for many months. Second, the reactions of survivors are a reflection of social, cultural, and personal factors. Third, the majority of survivors are reluctant to seek professional help in psychiatric settings. Fourth, home-based help utilizing community resources is feasible and effective. Finally, it is important to provide psychosocial support as an essential part of postdisaster support to all the survivors.
However, it was the 1984 Bhopal disaster that took disaster mental health to a public health priority. Since that horrific disaster, India has experienced a large number of disasters such as the Latur earthquake of 1993, the Bhuj earthquake of 2001, Gujarat riots of 2002, Tsunami of 2004, floods in Gujarat and Maharashtra in 2005, floods in Bihar in 2007, cloudburst in Uttarakhand in 2013, Kashmir floods in 2014, and forest fires in Uttarakhand in 2018. The most recent is the Kerala Floods of August 2018. A vast amount of literature on disasters and mental health in India covering a number of innovative ways of addressing mental healthcare is available.,,,,,,,
The lessons learned from meeting the needs of mental health of survivors of disasters, during the last four decades, in India are: disasters/emergencies affect the emotional health of all of the population to varying degrees. The impact on individuals is not uniform; every person perceives/reacts to the disaster/emergencies depending on his/her life situation. There are vulnerable groups such as the very young, older group, and disadvantaged persons (socially, economically, health, etc.). In general, women are affected to a greater extent than men.
The range of emotional needs of survivors of disasters is presented in [Box 1].
Interventions shown to be beneficial are at the level of individuals, families, communities, and state (government) levels. The central goal is to help people to not decompensate and to find meaning out of the experience, often referred to as posttraumatic growth. Effort should be to move individuals to think of the disaster situation as “transition” rather than “loss.” Psychosocial interventions directed at all the above four levels are shown to be effective in minimizing the long-term impact on emotional health.
The total population-level interventions are toward “emotional strengthening” by a number of measures at the immediate, short-term, and long-term measures. During the acute phase, the following five measures can promote emotional health, namely, daily 30 min of exercise, 8 h of sleep, yoga/meditation, eating healthy food, and spirituality.
The second group of people who need help are those with “distress” symptoms, such as fear, anxiety, irritability, fatigue, feeling of uncertainty, and fear of death. The interventions to address “distress” should be of higher level than the first, to maximize the coping capacity. Measures known to address this are teaching individual to reach out for help, the availability and full utilization of supports, sharing of emotions, writing down feelings and thoughts, art/music and daily pleasurable activities, and spirituality or finding a meaning for life from the event.
The next important set of emotional health issue is the “behavior changes.” Of this group, three of them are vital – excessive use of medical care/medicines, domestic violence, and substance abuse. High rates of these behavioral changes are reported both in developed and developing countries. The interventions are more complex as they require individual-, family-, and community-level changes and involvement of both professionals and paraprofessionals.
The final group of interventions is for those already under psychiatric care. Here, the challenges are at many levels. Accessibility of services is a challenge. Supply of medicines is vital. Relapse/worsening is another challenge, especially among the substance use group and those on long-term maintenance such as persons with a diagnosis of schizophrenia and bipolar disorders. There is another special group, i.e., the homeless, single, institutional psychiatric patients. One other group needing emotional support are the caregivers – family members, community leaders, and medical and welfare personnel.
Disasters provide an opportunity to “rebuild the community” and enhance community resilience. There is need for addressing the social–economic factors such as the existing inequalities in the community, gender inequalities, intolerance, discrimination, adequacy of healthcare/mental healthcare infrastructure, and welfare support to the vulnerable groups. Spirituality has an all-encompassing role for making sense of the disaster/emergencies and finding a meaning/purpose of life. India, with its rich spiritual roots, can mobilize this resource and offer the importance of this approach to address some of the impacts of the pandemic.
Some other general interventions are valuable during disasters. It is also well established that the following actions help in recovery: Providing essential needs such as food, shelter, and healthcare is vital. There is need for Recognition of the “distress” of the population as “genuine” and not simply as an attention seeking effort. There is an urgent need to communicate with the population and disseminate correct information. A situation of mutual trust between the population and state is very important. Keeping the family members and community units together as much as possible during relocation minimizes distress. Creating opportunities, culturally rooted, to share feelings of loss by the adults; opportunities to share the loss through play and games by children; promoting family level sharing of experiences and common activities within the family; and involvement of the community and individuals in decision-making about rehabilitation are helpful.
In a disaster-like situation like the current pandemic, it is best to avoid using diagnostic labels such as anxiety, depression, and PTSD, except in clinically well-established situations. The focus should be on emotional support to make sense of the loss, to find reasons to go on with life, and to find a new purpose for life. In these efforts, use of social, cultural, religious practices related to loss, as part of the recovery programs, is most appropriate. Creating common spaces for rebuilding of caring and cohesive communities through providing common places for getting together (religious places, community halls, and celebrations) is important. Another vital action is to involve the community in decisions relating to the relief, rehabilitation, and reconstruction.
It can easily be seen that the vulnerabilities, what helps, who can help, are all the subject of the field of “Social Psychiatry.” Truly, as Emile Durkheim opined about suicide, though suicide as an action is individual, the causes and solutions are social in nature.
| Indian Mental Health Responses to COVID-19|| |
The pandemic has challenged lives of Indians in all aspects of life and administration. The government and the members of civil society have all responded to the challenges. This area as well as the responses of a number of sectors has been comprehensively covered in this issue later by Khandelwal.
The following section covers interventions in the area of mental health.
The striking aspect of the mental health responses to the COVID-19 pandemic in India has been the wide range of responses and the rapidity with which this has occurred during the last 4 months (March 1, 2020, to August 24, 2020). During the last 6 months, initial attempts have been made to understand the impact of the pandemic, in general, and the lockdown, in particular.,,,,,,,,,,,,,,,,,,,,,,,,,,,
First of the studies  addressed the impact of lockdown on the general population. A total of 1685 responses were analyzed. 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. The survey suggests that more than two-fifths of the people are experiencing common mental disorders due to lockdown and the prevailing COVID-19 pandemic. This finding suggests that there is a need for expanding mental health services to everyone in the society, during this pandemic situation. The second study  addressed sleep and reported widespread problems in sleep. In the third study, the focus was on the adequacy of mental health services. It was noted that COVID-19 pandemic and lockdown have led to the collapse of regular mental health services. Further, it was observed that the mental health professionals are playing a significant role in addressing the prevailing psychiatric morbidity, specifically related to the COVID-19–related issues, and taking care of the healthcare workers (HCWs). The fourth study was with a select population of West Bengal. In addition, the mental health and other needs of population,, including vulnerable groups such as migrants, have received attention. Another group receiving attention are the frontline health personnel and their needs., The value of tele-psychiatry to meet the new challenges has been explored. There is recognition for the need to reorient training of doctors in view of the experiences of the current pandemic. That this subject is of priority in the minds of the psychiatrists is reflected in the active discussion of the above issues.,,,
The latest issue of Indian Journal of Psychological Medicine (July 2020) has 11 scientific papers addressing different aspects of the pandemic. The following are the observations from these scientific papers. Every 1 in 5 respondents from Tamil Nadu had some forms of COVID-19–related stress, and 2.7% had severe stress. The 25–34 years of age group, those with an annual income of rupees 2.5–5 lakh, and married were more prone to stress. The COVID-19 pandemic puts frontline healthcare personnel at great risk of psychological stress. The prevalence values of high-level stress, depressive symptoms requiring treatment, and anxiety symptoms requiring further evaluation were 3.7%, 11.4%, and 17.7%, respectively. Similar is the observation in Armed Forces  and in Kashmir  where more stress was experienced by nurses and staff working in swab centers than doctors. There is also discussion about the principles of triage in tertiary care psychiatry practice  and importance of stigma., There is universal recognition of need for mental health support to HCWs and patients/survivors  as well as the ethical aspects of research in this area. There is recognition of the scope for the development of psychological theories of pandemic and resilience., Professionals have identified the needs of vulnerable groups such as young children and adolescents.,
The Ministry of Health and Family Welfare (MOH and FW) included, from the beginning, mental health as a part of the overall health response. It designated the NIMHANS, Bengaluru, as the resource center. A number of educational materials in the form of pamphlets, posters, self-care documents, and brief videos are available on the MOH and FW website and accessible to the professionals and the general public. As per my assessment, the emphasis of the materials has been on “normalizing the emotional reactions,” reassurance, and measures of self-care.
The Indian Psychiatric Society (IPS) has undertaken a number of activities such as a position statement for the government/public, a guidance for professionals, guidelines for the management of opioid dependence, and survey of the general public for emotional responses to the COVID-19 pandemic. Regular webinar training programs have been organized on a wide range of topics to continuously engage the professionals with the issues emerging during the course of the pandemic.
NIMHANS, Bengaluru, set up a cloud-based helpline (080-4611 0007), stretching to over 20 States. As of August 2020, over 400,000 persons have used this service across 21 states and union territories in collaboration with the local administrations. NIMHANS has organized webinar sessions on various aspects of mental healthcare. In addition, NIMHANS has developed and disseminated a 200-page manual of mental healthcare-”COVID-19 Pandemic: Guidelines for general medical and specialised mental health care settings.” Other documents that address tele-counseling by different mental health professionals such as psychiatrists, clinical psychologists,, and psychiatric social workers  have also been developed. There are educational materials for the general public on psychiatric and neurological conditions.,,,, At the time of preparing this write-up, NIMHANS is preparing a national action plan on addressing mental health and psychosocial issues related to COVID-19 and postpandemic issues, and the Union government is likely to announce the action plan shortly.
Similarly, the All India Institute of Medical Sciences (AIIMS), New Delhi, has adopted the WHO Mental Health Resources for use in India, in several Indian languages. The Postgraduate Institute of Medical Education and Research, Chandigarh, as part of the telemedicine initiative of the Institute, had a 90-min webinar for all healthcare professionals on May 1, 2020. The three topics covered were (i) psychological care of patients having COVID-19; (ii) substance abuse and COVID-19; and (iii) coping and stress management for HCWs during COVID-19 outbreak. It was attended by over 60 participants. Institute of Human Behaviour and Allied Sciences (IHBAS), New Delhi, organized a 3½-h Zoom meeting on mental health needs, mental healthcare systems, tele-counseling, and tele-consultation. Over 100 participants from different disciplines and backgrounds participated. The focus was on taking psychiatric care to the general population.
There have been many professional groups providing tele-counseling in individual cities, such as Chennai, Kolkata, and across states. There have also been initiatives by the voluntary organizations such as Kutumbashree in Kerala training counselors and providing services. A group of 15 psychiatrists of Karnataka have been offering free tele-counseling for clinical problems. This group received over 3900 calls, almost all of them a single contact, and reported that majority could be helped by the service, with only about 5% requiring psychiatric referral. Interestingly, the calls were mostly in the first 3 weeks of the lockdown.
A very interesting service is the Alcoholic Anonymous helpline. The Indian Ministry of Social Justice and Empowerment, Government of India, together with National Drug Dependence Treatment Centre at AIIMS, Delhi, has issued a specific “Advisory on Alcohol Withdrawal during Lockdown” on April 11, stating that this lockdown situation, which entails nonavailability of alcohol, “may be a blessing in disguise for some people who may utilize the opportunity to quit drinking altogether.” However, it is also a significant challenge for a certain proportion of people with alcohol dependence, who are at risk of experiencing severe alcohol withdrawal and its consequences. The AA National Help Lines are open 24/7 (+91 9022771011).
There have been a large number of webinar programs addressing specific disorders, such as bipolar disorder, neurological aspects of psychiatric disorders, needs of women, consultation liaison psychiatry, trauma therapy, yoga, and general public education. A large number of professionals have written newspaper articles on a variety of topics. The news media, radio, and television have been another medium of reaching out to the general public and educate the community. Existing online mental health services such as the Mind Specialists, located in New Delhi and Your Dost, located at Bangalore have recognized the new need and developed a wide range of self-care resources for the general population.
There have been a number of documents to address the specific needs of the general population during the pandemic. Kapur's  book, “It's Okay to Reach Out for Help” is a very valuable contribution. The book deals with several self-care measures that can be employed to help oneself in dealing with this global pandemic, making use of India's own indigenous and time-tested methods with ample illustrations from India cultural traditions and practices. The goal is for counseling to be for the people, by the people, and of the people. A booklet for child care has been published by the Association of Psychiatric Social Workers. The Mariwala Health Initiative has brought out an illustrated self-care book on mental health and migrants in shelters.,
The WHO Guidebook, “Doing What Matters in Times of Stress: An Illustrated Guide,” has been adopted to meet the different linguistic groups of the country. This guide is a stress management guide for coping with adversity. The guide aims to equip people with practical skills to help cope with stress. A few minutes each day is enough to practice the self-help techniques. The guide can be used alone or with the accompanying audio exercises.
However, in all of the above efforts, the focus has been largely on “disorders” and less on the wider psychosocial dimensions of the pandemic. To illustrate my argument, let me share two examples. The Hindu was one of the early news agencies to recognize the wider implications of the pandemic. It had an article and an excellent podcast. However, the booklet it brought out, subsequently, finds no inclusion of this area. Similar is the booklet by Torrent which mentions “psychosocial” in brief and not as an important intervention, similar to physical distancing and hand washing/wearing a mask.
My own understanding of the above efforts of the last few months is as follows:First, there is high awareness of the mental health impact of the COVID-19 pandemic in the general public, professionals and policy-makers. Second, the current focus has been largely on the clinical dimensions and clinical care and not the larger public health needs. Third, the effort has been to reach people with help, rather than sharing of skills and empowerment of the population.
There is a disconnect with what is happening in the community and what the professionals are giving attention to. In spite of the IPS survey showing that nearly 75% are experiencing distress, the focus of the webinar is on disorders. Two specific examples will illustrate this attitude. On July 30, 2020, a webinar was held on “trauma-based therapy,” and on August 1, 2020, another webinar was on nutrition and exercise. In the first webinar, the focus was not on distress of the community but on distress of the syndrome of PTSD and very specialized interventions. What can be offered to the general public to address the fear of illness, fear of death, and stigma of illness was not considered. Similarly, in the second webinar, the focus was role of nutrition and exercise as supplements to treatment rather than their value in prevention of mental disorders, such as depression and promotion of mental health and increase in population immunity. The recently published “Pandemic Management Module UG-Module 7” by the Medical Council of India  is a response to the current pandemic. This 75-page document covers a range of topics including palliative care. However, mental health aspects of pandemic care are significant in its total absence. The only reference I could find was on page 61, “The emotional issues for the relatives and HCWs related to death of a person during epidemics.” This absence of a vital aspect of emotional health as part of pandemic care reflects the lack of awareness of the expert team and the failure of the profession to present the case of including emotional healthcare as an essential aspect of the pandemic response.
There is recognition of the economic dimension of the pandemic and lockdown, but the bigger debate of the linkages to the social aspects of the pandemic in terms of the social origins of the pandemic such as poverty, inequalities in the society, inadequate health infrastructure, rights of vulnerable groups, such as migrants, that contribute to mental health issues, the need for working toward community resilience are yet to find voice in the professional and public spheres.
The following section presents an agenda for such professional and public action.
Looking to the future: Rebuilding of “social infrastructure” for emotional health of the population
From the earlier sections, it is clear that the disasters in general and the current COVID-19 pandemic are a medical challenge as well a social and governance challenge.,,, In fact, it can be said that the medical and social/governance needs of the population are like two sides of the same coin. Along with the enhanced needs of the population, there is also a scope for undoing the harmful realities in the society, such as inequalities and rebuilding of a better society.
One of the striking aspects of the pandemic is the intense examination of what this pandemic means to the larger humanity. It can be recalled that it was the atrocity of the Second World War that brought major advances in human rights. There is an attempt to re-examine the lessons of the 1918 flu pandemic.,, Similarly, a number of thinkers have shared their analysis of the lessons learned from the Second World War and the other pandemics.,, Of these, the “New Humanitarian Analysis” of the disasters of last 25 years is the most useful guide to plan for the future.
The United Nations Secretary General, in July 2020, called attention to global fragility. This pandemic is recognized as a test for all communities.,,, The broader and long-term impact is presented comprehensively by Jeremy Farrar, Director, Wellcome Foundation. He notes that the true impact of the COVID-19 pandemic will be felt beyond its immediate effects. He describes four levels of the COVID-19 effect, such as ripples spreading on throwing a stone into a pond. The innermost circle is the immediate impact of the virus: fear, illness, and death. The second, larger circle describes COVID-19's indirect health effects, including the loss of trust in healthcare systems. The third circle, the social and economic impact of rising joblessness and shrinking economies is larger still, amplifying the existing social fractures and inequalities with political consequences. The fourth and biggest circle of impact is the geopolitics. The international institutions such as the UN, World Bank, and WHO, which were established after the Second World War, were born of a moment of enlightened self-interest by the leading nations.
Other leaders have emphasized the impact on Planet Health., There is an equal effort to understand the political strengths and weaknesses of countries and the value of community participation, with a special focus on countries who are considered leaders in fighting the pandemic, like South Korea. There is growing recognition that community participation holds the promise of reducing immediate damage from the COVID-19 pandemic and crucially of building future resilience. This has been expressed by a number of leaders. It was over 100 years back, during the 1918 Spanish Flu epidemic, Father of the Nation, Mahatma Gandhi observed, “this protracted and first long illness in my life thus afforded me a unique opportunity to examine my principles and to test them.”
It is appropriate to recall at this point, two recent quotes. First is the one that starts the article, namely, “health crisis has become a social one (crisis).” The second is by Ms. Nicole Sturgeon, Prime Minister of Scotland, presenting the range of interventions needed to address the pandemic and specifically looking at the health app for tracking of people, said: “It (Health App) will not provide all the answers. It is not a quick fix or a magical solution. It has to be combined with the continuous physical distancing, regular hygiene and the appropriate face covering. Crucially, it means” you - “the public” knowing, what we are asking you to do, why we are asking you to do, and you being prepared to do it.”
One other aspect of the pandemic is the scope for innovations such as digital health, telemedical care, and mobile care.,, Equally important is the scope of research and better understanding of resilience of individuals and communities.,,, The challenges faced by the frontline workers, especially their mental health needs, have been given prominence., A reflection of the importance of the pandemic is the setting of Lancet Commission  and call for a special fund. A common theme that is seen in the writings of all thinkers, all over the world, about the COVID-19 pandemic, is that “life will no more be the same.”
Recently, Ms. Susie Orbach, practicing psychoanalyst, shared a hopeful view in the John Donne lecture at Hertford College, Oxford, which was delivered on April 24, 2020. “We can expect psychological difficulties to follow as we come out of lockdown. But, we have an opportunity to remake our relationship with our bodies, and the social body we belong to.” Further, she comments, “More people are seeing a more nuanced social landscape. The opportunity is here for reframing how we represent the social body. It is of necessity differently hued, and that needs acknowledging, as does the shame of our previous marginalising. COVID-19 is cleaning the lens, so we can see more clearly.”
She identifies the task ahead as follows, “A societal trauma gives opportunities for people to go through things together, rather than suffer alone, as long as we don't bury or make light of what we have experienced and continue to experience. We will have to find new ways to live with our fears and discomforts, to overcome COVID-minted social phobias, with what we project on to other people's bodies and the fears we have about our own vulnerabilities. We will need all the help we can get in reshaping our relationship to our own and each other's bodies, to find a way to build bonds of attachment and respect.” Similar hopeful thoughts have been expressed by other thinkers from different disciplines such as economics, ecology, and political sciences.,,,,,
Indian responses to the pandemic
Similar to the international responses to the pandemic, reviewed above, in India, there is an intense examination of the social, political, economic, and governance aspects of the pandemic. There is a recognition of the similarities to the 1947 partition and the migration of large groups of people, similar to the current migration due to the pandemic. The National Human Rights Commission has set up a special group to understand and recommend the human rights dimension of the pandemic, including the mental health aspects. There is internal examination of the states that have addressed the pandemic relatively better, like Kerala, for lessons learned., A number of think tanks are examining the post-COVID India from the developmental perspective,, law, special needs of women, women with disabilities, and migrants. There is also a relook for resilience sources in the culture, specifically a relook at Shrimad Bhagwat Geeta  for lessons to live with uncertainty. There is also indication of enhanced going back to spiritual resources, as seen in the increase in the purchase of spiritual books  on the country. All in all, every aspect of the society from poverty, inequalities, urbanization, labor laws, health infrastructure, educational policies, and the welfare services is under re-examination.,,
| Social Psychiatry Interventions|| |
As per my understanding, the focus on public knowing (education, sharing of full information) and public being prepared to do what is needed (wearing masks, social distancing, avoiding crowds, supporting each other, etc.,) is the core of “social trust” and building of “community resilience.” Against this background, I want to consider the social psychiatry interventions, by recalling three experiences, from my over four decades of work in the area of disaster mental healthcare, of the social dimension of the disaster survivors.
The first was with the population of Bhopal, who experienced the worst industrial disaster in 1984. I have been associated with the mental health research and care from 1985 to 2017. In 2010, I started working again with the people of Bhopal toward improving their mental health. During one of the conversations, as to what has been the impact of the disaster on the community life, one of the respondents replied, “Before the disaster we were very poor but we were together close as a community. Following the disaster there is a lot of money with all of us, but we have become distant.” He further illustrated, “yesterday, there was a wedding, I went-had a meal and came back; in olden days, we would have celebrated it as a community event.”
The next was in Uttarakhand following the earthquake in the 1990s. I was visiting to the disaster area, to understand the impact, about 6 months following the earthquake. When I asked one of the respondents, what do they miss most. He replied, “We need badly a place of worship, a place where we can all meet and share our experiences. Following the earthquake, we all have become interested only with ourselves.”
The third incident was in Jagatsinghpur, the place of the 1989 supercyclone. We were sitting with a group of villagers, when a group of young women walked past. To my question, how has social life changed in the village, one of the villagers said, “The earthquake changed the gender relationships. Now, women are more confident.” Further, he added, wistfully, “earlier when men used to walk, women used to withdraw into the houses; now, as women go about doing things in the community, they walk in the middle of the road, we men are on the sidelines!” Interestingly, all others in the group agreed.
An agenda for action
Based on the earlier sections, where the social dimension of the epidemic has been presented, the disaster mental health literature has been considered, the social aspects of mental health has been reviewed, the Indian response to organize mental healthcare in India has been considered, and the next step is to consider the required social psychiatry interventions.
There are three levels of mental health interventions [Figure 1].
|Figure 1: Social psychiatry interventions during a pandemic-3 levels: Building community resilience|
Click here to view
First level is the universal interventions, which is considered under the broad heading of “community resilience” and focuses on the whole community and the environment.
The second level is the selective interventions, which focuses on the individuals who are not clinically ill but who are “distressed” and have the potential of becoming ill, if not helped.
This refers to the health promotion through emotional healthcare and specific skills for distress/behavior change management at the individual and family level.
The third is the indicated care or clinical care of persons who become ill because of the pandemic experiences or who are already in mental health care.
As we think of a model to consider for action, the example of vaccination is appropriate. A live vaccine uses a weakened version of a virus to teach the immune system how to respond to the real thing. Long after the vaccine is gone, the body remembers its immuno-playbook and stands prepared to fight a stronger pathogen in the future. For example, South Korea's national immune system was instructed and strengthened by previous epidemics. Although epidemics came and went, they left behind guidance that Koreans recalled and executed when they were suddenly confronted with the current pandemic. South Korea's world-class response to COVID-19 is not the product of religion, or cultural destiny, but rather the result of diseases bested and crises weathered.
Unlike the biological response to a pathogen, public policy is not an automatic response, but a deliberate one. South Korea chose to learn.
What are the avenues for action in India?
The evidence considered in the earlier sections brings out the following four observations that can guide the planning of interventions.
First, the pandemic provides social psychiatrists an opportunity to work toward a better society – A caring and equitable society for all the population.
Second, the core of social psychiatry of recognition of the importance of historical, social, political, economic, religious components of mental health has been brought to the forefront by the pandemic and offers opportunity to develop decentralized local solutions.
Third, the current experience reinforces the need for social psychiatrists to be not only clinicians but also social change agents, who work with the larger society for the common good. I started the article with the thoughts of Prof. N. N. Wig, and it is appropriate to recall his advice to mental health professionals, “mental health is too important to be limited to only mental health professionals.”
Fourth, there is need for caution to recognize the limitations of professional interventions as mental health is dependent on so many other factors.
The following section presents a possible plan of action. However, it is not a prescriptive plan, but an outline for action, to be modified to suit the local conditions and to be revised from time to time. These interventions can be seen within three-time frames – immediate, short term, and long term.
At the immediate level, in the coming weeks, the focus will have to be on the management of the distress. Making psychiatric care accessible, affordable, and acceptable to the population should be the goal. In this phase, the emotional health needs of the frontline personnel (medical, police, support staff, etc.) should be addressed actively. This group will also provide an opportunity to develop, implement, and evaluate the self-care measures, their limits, and the need for the professional services. The urgent need is for clinical care as the opportunity here is to make psychiatric care accessible, affordable, and acceptable to the population.
Innovations such as help lines, tele-counseling, tele-consultation, mobile clinics, supply of medicines for a longer period of time, and involvement of a wider range of professionals in the care programs are in order.
There are two components, namely strengthening of emotions by evidence-based activities such as daily exercise, 8 h of sleep, daily practice of yoga/medication, eating fruits, and vegetables and spirituality as an essential part of life. All of these interventions, when they become a part of routine life, have potential for better quality of life and decreased incidence of different forms of mental disorders. The other component is especially relevant during the current pandemic, where the restrictions such as lockdown, need for physical distancing, wearing of masks, washing of hands, concerns about the safety of the daily members, and presence of “fear,” “anxiety,” and “depression” have potential for negative emotional health effects. Everyone who is experiencing these either for short periods or long periods can reach professionals, and further, they do not necessarily need to see a professional as the first step. People with subclinical “distress” can benefit from making the family the unit of responding to the pandemic; specifically by sharing of emotions; fully utilizing the social supports to decrease the acute burden of stress; “journaling” or writing down of thoughts and emotions; use of art, especially music; and finding meaning of the situation for personal growth, similar to what Mahatma Gandhi did with his 1918 flu experience. Spirituality helps understand the linkage to the God/nature/universal force beyond the self. India is rich with examples in its religious scriptures and spiritual leaders. What is required is to adapt these to meet the current pandemic situation. If this is done successfully, this could become the important contribution of India to rest of the world.
In the short term, over the next 1 year, strengthening of the general medical services by training of the professionals and paraprofessionals in essentials of mental healthcare, along with making psychiatric care accessible through innovative measures such as tele-psychiatry, is needed. Another group that needs urgent addressing to is the victims of domestic violence and substance abusers and children traumatized by migration and other deprivations. Based on disaster literature, both these will increase. To address these, the approach will have to be one of the promoting emotional health and strengthening of societal networks and norms of behavior along with local/community-level stress supports. For children, life skills; education programs in schools would be the best way to enhance their resilience.
In the above interventions, the challenge is to develop culturally relevant interventions and present them to the community not as prescription to be taken but as skills to empower individuals, families, and communities. The WHO Guide  shows the way to address this effort.
For the long-term actions, the need is to provide psychiatric care for the expected 30% with long-term effects such as PTSD. Simultaneously, we should be addressing the governance issues. It should be noted that all the social factors that both predispose and perpetuate emotional health issues and those with universal benefits are the following: inequalities in the society; health literacy; gender relationships; local governments and local leaderships; tolerance of differences; limiting childhood trauma; limited use of substance abuse; respect for elders; recognition of the vulnerability of the children, in general, and persons with disability, in particular; social supports for migrants, lonely individuals, community spaces for interaction, and greenery in the environment; and climate change. Mental health professional should lead these changes in the society.
Research should be an integral part of the above three levels of social psychiatry interventions for the purposes of understanding the needs: identifying the vulnerable groups, identifying the strengths of the community, and identifying the development of innovations and the evaluation of their effectiveness by using simple assessment tools. This area has been extensively developed by a recent expert group. Documenting the experiential (narratives) and measurable aspects (using standardized tools) of emotional health should be part of all the three phases. I read with special interest the following innovative way of looking at the current pandemic. “In the classic hero's journey – the archetypal plot structure of myths and movies – the protagonist reluctantly departs from normal life, enters the unknown, endures successive trials, and eventually returns home, having been transformed. If such a character exists in the coronavirus story, it is not an individual, but the entire modern world (emphasis added). The end of its journey and the nature of its final transformation will arise from our collective imagination and action. Moreover, they, like so much else about this moment, are still uncertain.”
In a different context of reviewing the developments of the last two centuries, Pankaj Misra's recent book, “Age of Anger,” makes two important points to describe the current social situation and individuals. He places the current situation against the developments after enlightenment and the failed goal of equality. He makes two important observations relevant to social psychiatry – amoral individualism and re-sentiment. He summarizes the current social situation of individualism and impact on the individual as follows: “Many of these shocks of modernity were once absorbed by inherited social structures of family and community, and the state's welfare cushions. Today's individuals are directly exposed to them in an age of accelerating competition on uneven playing fields, when it is easy to feel that there is no such thing as either society or state, and that there is only a war of all against all.” He ends the book with a conclusion of being in a period of endless transition. He calls for, “the need for some truly transformative thinking, about the self and the world.”
This review has taken a positivistic approach. However, it is important to share a word of caution. Blazer and Kinghorn, in their book chapter on Positive Social Psychiatry, share words of caution to not to overreach: “However, it is also important to make certain that this turn to community and social flourishing does not cause positive psychiatry, like social psychiatry and positive psychology before it, to lapse into forms of utopianism that will eventually undermine its credibility…. If positive psychiatry were to ignore these concrete, particular challenges in the pursuit of some ideal of perfect mental health or perfect flourishing, it would soon lapse into unsustainable utopianism. However, it were to fix resolutely on how individuals and communities thrive within these particular contexts, it could be both robustly 'positive' and unquestionably and faithfully “psychiatry.”
Against the broad panorama of the pandemic, there is special place for each of us, whether it is at the level of individual mental health professionals in a clinic, or the departments of psychiatry training of mental health professionals or for inter-sectoral activities (involvement and integration of public health, medicine, and mental health) and the Indian Association of Social Psychiatry. The common themes to adopt in responding to the pandemic are to recognize the uniqueness of the pandemic and document all the experiences of presentation of needs, interventions that have worked, and disseminating emotional self-care skills to all contacts in the clinic and the community. Each one of us can make a difference to the population and also create new knowledge about the social psychiatric interventions in pandemic situations. It would be appropriate to add that, India, with its rich tradition and philosophical understanding of adverse life experiences, can make singular contributions in this pandemic situation.
| Conclusions|| |
Two quotations from the most recent commentary on the pandemic highlight the needs for social interventions. Deshpande and Ramachandran, referring to the social inequalities, observe, “Early impacts of the pandemic-induced lockdown indicate that the resultant economic distress is exacerbating preexisting structures of disadvantage based on social identity, and investments in education and health that close gaps between social groups would be essential to build resilience in the face of future shocks.” At the international context, The Lancet Position Paper  concludes, “The interconnectedness of the world made society vulnerable to this infection, but it also provides the infrastructure to address previous system failings by disseminating good practices that can result in sustained, efficient, and equitable delivery of mental healthcare delivery. Thus, the COVID-19 pandemic could be an opportunity to improve mental health services.”
The word “Pandemic” comes from the two words meaning, “All People.” A way of summarizing all that is written so far would be to recognize for the mental health of all, “Everyone have to be for each other.” Here lies the challenges and opportunities arising from the pandemic, for the society, in general, and Social Psychiatry, in particular.
I want to thank Dr. Usha Ramanathan, Chandigarh, for her critical observations and insights into the socioeconomic and political dimensions of the pandemic. My sincere thanks and appreciation to Dr. Nitin Gupta, Former Professor of Psychiatry, Chandigarh, and Editor of Indian Journal of Social Psychiatry (IndJSP), for his vision, perseverance, and most importantly patience in supporting me and offering valuable suggestions to write this article. However, for his efforts, this article would not have been a reality.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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