A Canadian Perspective on the Biomedical and Psychosocial Impacts of the COVID-19 Pandemic on Children and Families

Eliot Sorel, MD
Editor-in-Chief
Editorial Board
MansoorMalik,MDMBA
Senior Editor
GlobalMentalHealth&PsychiatryReview,Vol.1No.2,Spring/Summer2020
ZONAL EDITORS:
AFRICA:
Prof. David M. Ndetei, Kenya
Prof Bonginkosi Chiliza, South Africa
Victoria Mutiso, PhD, Kenya
ASIA/PACIFIC:
Prof. Yueqin Huang, China
Prof. Roy Kallivayalil, India
THE AMERICAS:
Prof. Fernando Lolas, Chile
Prof. Vincenzo Di Nicola, Canada
EUROPE:
Prof. Gabriel Ivbijaro, United Kingdom
Dr. Mariana Pinto da Costa, Portugal
ASSOCIATE EDITORS:
Miguel Alampay, MD
John Chaves, MD
Kyle Gray, MD, MA
Madeline Teisberg, DO, MS
G M H P
REVIEW

Eliot Sorel, MD
Editor-in-Chief
MansoorMalik,MDMBA
Senior Editor
Volume I, No.2
Spring/Summer 2020
Eliot Sorel, MD, Editor-in-Chief
ZONAL EDITORS:
AFRICA:
Prof. David M. Ndetei, Kenya
Prof Bonginkosi Chiliza, South Africa
Victoria Mutiso, PhD, Kenya
ASIA/PACIFIC:
Prof. Yueqin Huang, China
Prof. Roy Kallivayalil, India
THE AMERICAS:
Prof. Fernando Lolas, Chile
Prof. Vincenzo Di Nicola, Canada
EUROPE:
Prof. Gabriel Ivbijaro, United Kingdom
Dr. Mariana Pinto da Costa, Portugal
ASSOCIATE EDITORS:
Miguel Alampay, MD
John Chaves, MD
Kyle Gray, MD, MA
Madeline Teisberg, DO, MS
Engaging Early Career Health/Mental Health Professionals Locally, Nationally and Globally
Colleagues and Friends,
Welcome to Volume 1, Number 2 of the Global Mental Health and Psychiatry Review!
We are pleased to also welcome Prof. Bonginkosi Chiliza of South Africa and Dr. Victoria
Mutiso of Kenya as our newest editorial board members.
We dedicate this issue to and in solidarity with all frontline health workers, inclusive
of workers across all domains who have and are continuing to serve our communities
during this unprecedented global public health emergency, the CVD-19 pandemic. We
focus the entire issue on the mental health consequences of this public health challenge
and possible solutions to it.
We also express our gratitude and admiration for the outstanding stewardship
demonstrated by several female world leaders who managed remarkably well this huge
global public health challenge. They understood very well the intrinsic value of public
health and its value added for their nations’ economies and for their people’s wellbeing.
They are: Taiwan President, Tsui-Ing-Wen, New Zealand Prime Minister Jacinda Ardern,
Germany’s Chancellor, Angela Merkel, Denmark’s Prime Minister Mette Frederiksen,
Iceland Prime Minister, Katrin Jakobsdottir, Finland’s Prime Minister, Sanna Marin, and
Norway’s Prime Minister, Erna Solberg. Last but not least a hearty congratulation to
Health Minister KK Shailaja, of Kerala State, India for her and her team’s extraordinary
accomplishments, in the exemplary public health management of the pandemic in her
country. In Minister KK Shailaja’s own words, “…the secret is no secret, Proper Planning”.
Such proper planning by all of the above described leaders, included, integrating superb
leadership, empathy, scientiﬁc evidence and proven public health practices resulting in
remarkable outcomes.
Stay well, be safe…!
Eliot SOREL, MD
G M H P
REVIEW
COVID-19

TABLE OF CONTENTS
The Global Mental Health and
Psychiatry Review (GMHPR)
is a multidisciplinary
publication serving the Global
Mental Health Community. It
welcomes scholarly
contributions that focus on
research, health systems and
services, professional education
and training, health policy, and
advocacy. It is published three
times a year in January, May,
and September of each year.
GLOBAL MENTAL HEALTH & PSYCHIATRY REVIEW:
Introduction ..............................................................................................................1
AFRICA ZONE:
Mental Health During Covid-19 And Lessons For The Future
Beyond Covid-19 ......................................................................................................3
Prof. David M. Ndetei and Dr. Victoria Mutiso
the AMERICAS ZONE:
Pandemics And Mental Health: Priority-Setting As Challenge For Bioethical
Decision-Making .....................................................................................................................4
Prof. Fernando Lolas
Leading as Psychiatrists during Anxious Times......................................................5
Dr. John Chaves and Dr. Kyle Gray
A Canadian Perspective on the Biomedical and Psychosocial Impacts of the
COVID-19 Pandemic on Children and Families ....................................................6
Prof. Vincenzo Di Nicola
Addressing Mental Health Needs of Healthcare Workers During COVID 19...........8
Dr. Mansoor Malik
ASIA/PACIFIC ZONE:
China: Anxiety and Panic During The Pandemic of COVID-19 ....................9
Prof. Yueqin Huang, MD, MPH, PhD
The Covid-19 & Global Mental Health.....................................................................10
Prof. Roy Abraham Kallivayalil, MD
EUROPE ZONE:
Coronavirus And Care Workers: UK – Mental Health Matters .................11
Prof. Gabriel Ivbijaro, MBE, JP
Early Career Psychiatrists Joining Forces During A Pandemic ......................12
Dr. Mariana Pinto da Costa
Telepsychiatry During The COVID-19 Pandemic............................................13
Dr. Davor Mucic
Volume 1, No Spring/Summer 2020
Engaging Early Career Health/Mental Health Professionals Locally, Nationally and Globally
G M H P
REVIEW

© GLOBAL MENTAL HEALTH & PSYCHIATRY REVIEW, Vol. 1 No. 2, Spring/Summer 2020 3
AFRICA
MENTAL HEALTH
DURING COVID-19 AND
LESSONS FORTHE FUTURE
BEYOND COVID-19
Prof. David M. Ndetei, DSc 1,2
Victoria Mutiso, PhD2
1
University of Nairobi
2
Africa Mental Health Research and Training Foundation, Kenya
David M. Ndetei
Victoria Mutiso
The Coronavirus disease (COVID-19) has hit the globe with un-
preceded psychosocial needs and challenges that touch on every
aspect of life, including all aspects of the life cycle.
Children are no longer going to school; universities are closed;
people have to learn to adapt technology as a way of doing
things. People have to learn on the critical roles of simple proce-
dures on sanitations and observing social distances. All of these,
and many new innovations will outlast this pandemic.
Mental health has not been left behind and in many ways it is at
the frontline addressing the emotional and social aspects of this
scourge. These includes fear of the unknown and the emerging
and re-emerging infections (1). There is also the realization that
for every known case, there could be many more who are un-
known simply because they are asymptomatic and yet still po-
tentially infectious, hence the need for social distancing that is
being practiced all over the world. Human race is reduced to
the same level of survival instincts. However, we cannot ignore
that different countries have different resources, and the details
in the response in different countries will be determined by
these differences in resources. This is particularly so far Africa.
We all appreciate the critical role of correct information and in-
formed awareness as critical aspects in mitigating the impact
of this crisis as effective preventive measures. The amount of
resourceful information flowing from WHO (2) and other bod-
ies specializing in mental health, including World Psychiatric
Association has emphasized on the mental health aspect of
this scourge, in those who did not have any prior mental prob-
lems and also the increased vulnerability of those who already
have pre-existing mental disabilities. These include anxiety and
depression amongst many others. It has emphasized on the
mental health needs of the caregivers, be they doctors, nurses,
psychologist, family members etc. Indeed, every member of the
community has a role to play. Without even thinking about it we
are all together in this and playing our roles without passing the
buck to others. There could not up to this point been a better
example of a global mental health initiative, not just that it in-
volves many countries, but because we are all collectively play-
ing our roles regardless of our stations in life, professions, etc,.
This is happening despite and in spite of the resources that are at
our disposal. We are learning to do at least something with what-
ever is in our hands. I suspect this approach will survive this
scourge and feed into an inclusive approach to mental health. It
will not have been totally in vain. Remember the history full of
epidemics in which thousands upon thousands of people died of
strange diseases e.g. the Spanish Flu of 1918-1920 that infected
500 million people (a quarter of the world population then) and
killed 50 million people and the much earlier Black Death in Eu-
rope that killed millions of people.
There is a silver lining in every cloud.
REFERENCES
1. Cheng VCC, Lau SKP, Woo PCY, Kwok YY. Severe acute
respiratory syndrome coronavirus as an agent of emerging
and reemerging infection. Clin Microbiol Rev. 2007 Oct
1;20(4):660–94.
2. WHO. Mental health and psychosocial considerations
during the COVID-19 outbreak [Internet]. 2020 [cited
2020 Mar 30]. Available from: https://www.who.int/publi-
cations-detail/mental-health-and-psychosocial-consider-
ations-during-the-covid-19-outbreak

© GLOBAL MENTAL HEALTH & PSYCHIATRY REVIEW, Vol. 1 No. 2, Spring/Summer 20204
the AMERICAS
Fernando Lolas
PANDEMICS AND
MENTALHEALTH: PRIORITY-SETTING
AS CHALLENGE FOR
BIOETHICAL DECISION-MAKING
Both consultation-liaison psychiatry and disaster psychiatry
are involved in the response of the mental health community to
an infectious outbreak. Irrespective of the importance or extent of
the threat, psychiatry deals with the fact that emotions and fears
can be as contagious as germs in the social sphere. It may be said
that psychiatric disorders are communicable disorders, both in the
symptomatology and in the effects on relatives and peers.
Anxiety and paranoid delusions accompany every infectious
outbreak recorded in history. The search for culprits and com-
plaints against authorities and governments usually appear.
At the community level, the essential point is to make decisions
on how to prioritize. Thus, priority-setting strategies related to the
availability and use of resources are necessary and they should be
known by people.
Priority-setting means that scarce resources have to be allocat-
ed based on public and accepted reasons.
Two basic ways of prioritizing health matters are available.
They can be termed evidence-based and value-based.
The first refers to the use of information sufficiently support-
ed by the scientific community, published and replicated inde-
pendently by accredited sources. However, caution is advised since
many pieces of information published are not always reliable and
individual experience needs to be constantly reappraised.
The notion of a value-based prioritization contains at least two
dimensions. One refers to value as cost. In this case, decisions have
to be taken based on the appropriate use of scarce resources and
their just distribution.
The main connotation of value-based prioritization is, how-
ever, a moral one. It refers to those ethical justifications that make
technical decisions acceptable in addition to their appropriateness
in a given situation.
Value-based considerations are rooted in the cultural tradi-
tions of a society and are part of the armamentarium of bioethics,
conceived of as the use of dialogue for formulating and resolving
moral dilemmas derived from the use of technological wisdom to
human affairs. Since diverse schools of thought provide differently,
and sometimes antagonistic, procedures for arriving at moral certi-
tudes, traditional philosophical ethics rarely suffice for an informed
decision-making.
Priority setting based on moral values demands a careful analy-
sis of custom, tradition, and use to be effective. The procedure may
involve the perusal of emotions, attitudes, past experiences, and
feasibility. Any decision, however well-founded on the scientific
facts, needs to be accepted by those affected by it. The plurality of
voices of contemporary societies needs to be acknowledged and
considered. Priority-setting in times of distress needs “ortobioeth-
ical thinking”, this meaning the correct appraisal of all the factors
involved.
Pandemics are complex webs of influences, effects, and causes.
They are the syncretic expression of many social and biological
forces operating in the community. A true prioritization of resourc-
es, demands, and measures, when value-based, should be multidi-
mensional in outlook and integral in its application.
There are two major dimensions along which it is desirable to
construct acceptable values.
One is the traditional tension between the two streams of
Western thought regarding the source of justifications for moral
action: Deontology, or the theory of duties, leading to ethics of
convictions (or Gesinnungsethik, as Max Weber expressed) and
Teleology, or a reflection on the consequences of actions, which
demands responsibility (Verantwortungsethik, in Weber´s termi-
nology). Decisions are usually based on a mixture of both types
of arguments; policymakers and authorities responsible for the
health of populations, irrespective of their personal beliefs, may
need to consider the wider consequences or effects of their actions.
Utilitarianism, seeking the best possible good for the maximum
number of persons, is typical of some decisions in the public health
sector.
The other important dimension to consider is the tension be-
tween individual welfare and the common good of the community.
Sometimes, what is good for individuals may endanger the group.
On occasion, decisions taken giving priority to the group (as in
totalitarian states) may affect individual rights or preferences.
In search for a “correct” (“orto”) bioethical thinking aimed at
a sound priority-setting perspective, these two dimensions need
to be considered. Pandemics and mental health is a challenge for
redefining what is “excellent”, what is “good” and what is “fair”.
The crucial element in designing strategies is that the dialogical
principle be respected: all and every voice in the community should
be heard. Legitimacy arises from an informed exchange of perspec-
tives, views, and beliefs.
REFERENCES
1. Huremovic, D. (editor) Psychiatry of Pandemics. Springer
Nature Switzerland, 2019 (https://doi.org/10.1007/978-3-030-
15346-5)
2. Lolas, F., Martin, D.K., Quezada, A. (editors) Prioridades en
salud y salud intercultural (Health priorities and intercultural
health), CIEB, Universidad de Chile, 2007.
Prof. Fernando Lolas, MD
University of Chile and Central University of Chile

the AMERICAS
No discussion of COVID19 should begin without acknowl-
edgement of the lives lost or altered by the illness, and the
privileges that allow us the disposition to reflect. We both live
in relatively less affected regions of the United States and our
jobs are stable and allow us to contribute to a comorbid epi-
demic: anxiety. Whether consciously or unconsciously, the fear
that accompanies the pandemic permeates the lives of many
and has varying and dynamic effects of its own. For some, it is a
healthy motivator; for others, it induces panic.
Psychiatrists must accept this increased underlying fear
and our duty to help others manage it. We all learned how to
listen attentively and nonjudgmentally as patients talk about
their worries, woes, and perceived inadequacies. We learn how
and when to offer clinically appropriate interventions; when to
give validation and reassurance, when to challenge cognitions,
and when to support underlying strengths. Professionally, re-
sponding to our patients is our forte and our first responsibility
in this global crisis.
Our second responsibility is responding to those who do
NOT expect our care. One of us, Dr. Chaves, has noticed in
himself and his coworkers in the multidisciplinary environ-
ment, that fear crops up in unexpected ways. Tempers flare,
communication lapses, roles blur, email chains erupt in vitriol.
It’s hard to remember that maintaining positive regard and
respect, and opening your ears and eyes the way we do with
our patients is leadership and social glue that many of us need.
This type of work also highlights the type of fallout that failures
in risk communication can have on organizations. Psychia-
trists would do well to step into advisory roles when it comes
to communicating risk about the virus to our communities.
Adhering to the principles of risk communication expert Peter
Sandman is a good start (Sandman, 2020).
Others may find such micro-level leadership opportunities
less available and may seek to actively search for ways to apply
their skills during this crisis. Via the APA’s Caucus on Climate
Change and Mental Health listserv, Dr. Gray learned about
the Physician Support Line, a free and confidential telephone
support service available to U.S. physicians on the frontlines of
COVID-19. Founded by Drs Mona Masood and Ben Pu Cheng,
the group has recruited over 400 psychiatrist volunteers to
provide peer support, utilizing supportive therapy and other
skillsets. Dr. Gray has found this volunteer effort to be an effec-
tive means of sublimation. It has enriched her perspective on
the effects of this pandemic, despite her rather remote distance
from the fight. Interested psychiatrists can find more informa-
tion at www.physiciansupportline.com.
The pandemic and the international response have empha-
sized existing cracks in societies, economies, and healthcare
systems the world over. A recently published article highlight-
ed the need to be vigilant and innovative as COVID-19 and
downstream effects exacerbate suicide risk factors—our need
for psychiatrist clinicians is unlikely to decrease (Reger, et al.,
2020). We also need psychiatrists to lead and to address the
accompanying uncertainty that marks this time.
REFERENCES
1. Reger MA, Stanley IH, Joiner TE. Suicide Mortality and
Coronavirus Disease 2019—A Perfect Storm? JAMA Psy-
chiatry. Published online April 10, 2020. doi:10.1001/
jamapsychiatry.2020.1060
2. Sandman PM. (2020, April 13). Talking to Frightened (or Mis-
erable People about COVID-19. The Peter M. Sandman Risk
Communication website. Retrieved from URL: http://www.
psandman.com/col/Corona15.htm.
John Chaves, M.D.
CPT, Medical Corps, United States Army
Staff Psychiatrist, Blanchfield Army Community Hospital
Fort Campbell, KY
Kyle Gray, M.D.
LT, Medical Corps, United States Navy
Leading as Psychiatrists during
Anxious Times
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John Chaves Kyle Gray

the AMERICAS
As of this date – April 15, 2020 – almost 1,200 people
have died in Canada from the COVID-19 pandemic. The total
number of confirmed cases is just over 30,000 with Quebec
reporting the most infections at 14,248, almost half of the na-
tional burden with a only quarter of the population, and a third
of the deaths from COVID-19 at 360. With half of all Canadian
cases now in Quebec, more than half again of those are here in
the city of Montreal where almost 50% of the population of the
province lives.
Data about children are limited everywhere, including in
Canada. Here is what we know: in Wuhan, under 10 and those
10-19 years old each represent 1% of the total of over 72,000
cases of COVID-19. By contrast, in Korea the proportion of
cases 0-19 is 4.8%, while in the USA it is 5%. The severity and
mortality among children and youth is lower than in adults.
Various factors have been hypothesized including lung matu-
rity; what is known is that co-existing conditions increase risks
dramatically, apparently at all ages (see Canadian Pediatric
Society web page on epidemiology). This refers to the narrowly
medical aspects; yet co-existing mental health problems, which
often have their roots in childhood and youth, will amplify the
impact of this virus on current and future mental health (Gol-
berstein, et al., 2020).
This COVID-19 pandemic which is global by definition
is also a naturally-occurring biomedical and psychosocial
experiment of massive proportions. Some countries have opted
for early detection, containment and prevention with vary-
ing degrees of governmental commitment and populational
adherence, while others have chosen to rely on herd immunity.
Neither the epidemiology nor the virology of this disease is
secure enough to pronounce on the wisdom of those choices
but all jurisdictions in Canada have opted for prudence and
the prevention of further community spread of COVID-19 as
we are well beyond controlling the entry of the virus into our
borders via international travel.
The medical profession is working closely with authorities
at all levels of government and we have seen sure and deci-
sive leadership in Quebec with our recently-elected Premier
François Legault among whose key cabinet members is Dr.
Lionel Carmant, a leading pediatrician, in the Health and
Social Services ministry. Premier Legault is showing the kind
of compassionate and informed leadership that such a crisis
demands.
This highlights critically important issues: the need for wise
and informed leadership on policy making, the urgent neces-
sity for the medical profession to inform and collaborate with
the leadership, and the value of a system of universal health
care. The language here is instructive – while Americans call
it a “single payor” approach or “socialized medicine” (mostly
as a snarky criticism), Canadians call it “universal health care”
(rather than a “National Health Service” as in the UK).
The comparative values of the two societies are now on
full display. In one society, public services are reduced to “the
bottom line” (it’s not just a folk club in The Village in NYC). In
another, it’s about coverage of the whole population which is so
self-evidently a right for Canadians that it is taken for grant-
ed. As we see with the difficulties in providing screening tests
for COVID-19 and personal protective equipment (PPE), you
cannot run public services on a for-profit basis and make them
responsive to the needs of the society. In the US and elsewhere,
we hear that private hospitals and private clinics may go bank-
rupt. Whatever other problems we have with waiting lists, for
example, the vast majority of health care services in Quebec
and the rest of Canada are publicly funded including physician
services in private practice.
Nonetheless, the social and mental health impacts of the
virus and of the confinement are disquieting:
reflects a steep social gradient as many parents are now out
of work.
are being asked to replace nurses and orderlies in long-term
care facilities in Quebec which have become epicenters for
contagion and high levels of mortality; families cannot see
their loved ones in these facilities and children are separat-
ed from their grandparents.
adequate PPE, screening tests, and coherent province-wide
policies and procedures; the failure to do so is triggering
high levels of anxiety and stress among all health and social
care workers.
A Canadian Perspective on the
Biomedical and Psychosocial
Impacts of the COVID-19
Pandemicon Childrenand Families
Vincenzo Di Nicola
Vincenzo Di Nicola, MPhil, MD, PhD, FRCPC, DFAPA
Professor of Psychiatry, University of Montreal
President, Canadian Association of Social Psychiatry
President-Elect, World Association of Social Psychiatry

the AMERICAS
Lastly, the psychosocial impacts are complex and must be seen
as heterogeneous, affecting age groups, genders, family configu-
rations, social class, and culture differentially. While it is a shared
natural occurrence, it is not experienced in the same way. Fur-
thermore, is not a unitary, one-time experience but a varied and
cumulative set of psychosocial impacts. I will highlight just three key
features here in what I see as a cascade of consequences:
Social distancing – the impact on the development of pro-
social skills in young children and maintaining and expanding
such skills in youth is being critically impeded by the impact of
social distancing and home confinement.
Confinement – there is a great difference between choosing
a limited social lifestyle and having it imposed on individuals,
families and entire communities. It’s impact on families varies
on family unity and level of functioning along with social values
and cultural differences. Many parents are reporting that their
children are spending even more time in their rooms, stuck to
their screens, and addicted to video games.
Adverse Child Events (ACE) – “The longest shadow” – the
pioneering ACE Study (see ACE Study/CDC) clearly demon-
strates a linear gradient between adverse events in childhood
with poorer lifelong health, mental health, and social outcomes
in what I call “the longest shadow.” Whether children and youth
themselves fall sick or not, through their families, friends, and
neighbors, they will all be exposed to a series of adverse events
so that the COVID-19 pandemic will cast a dark shadow over
their lives for a long time to come.
REFERENCES
1. ACE Study at the Centers for Disease Control and Prevention
(CDC):
https://www.cdc.gov/violenceprevention/childabuseandneglect/ace-
study/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.
gov%2Fviolenceprevention%2Facestudy%2Findex.html
2. Current Epidemiology and Guidance for COVID-19 in Children
and Youth:
https://www.cps.ca/en/documents/position/current-epidemiolo-
gy-and-guidance-for-covid-19-march-2020#ref1
3. Golberstein E, Wen H, Miller BF. Coronavirus Disease 2019
(COVID-19) and Mental Health for Children and Adolescents.
JAMA Pediatr. Published online April 14, 2020. doi:10.1001/jama-
pediatrics.2020.1456
4. COVID-19 Resources for Pediatric Care and Mental Health
5. American Academy of Child & Adolescent Psychiatry:
https://www.aacap.org/AACAP/Families_and_Youth/Resource_Li-
braries/covid-19/resources_helping_kids_parents_cope.aspx?utm_
source=Informz&utm_medium=email&utm_campaign=Annu-
al%20Meeting
6. Canadian Pediatric Society:
https://www.cps.ca/en/tools-outils/covid-19-information-and-re-
sources-for-paediatricians
7. Canadian Psychiatric Association:
https://www.cpa-apc.org/covid-19/
A Canadian Perspective on the
Biomedical and Psychosocial
Impacts of the COVID-19
Pandemicon Childrenand Families
(Continued)

the AMERICAS
Severe acute respiratory syndrome coronavirus 2 (SARS-
CoV-2) continues to spread internationally, with devastating
social and economic impact. Undoubtedly, health care workers
(HCWs) are essential to overcoming a healthcare crisis of this
global magnitude. Nevertheless, low morale, burnout, ab-
senteeism, and the illness itself threaten our precious HCWs
which could lead to the collapse of our healthcare systems, an
outcome we cannot afford.
Healthcare workers, like the general population, can have
strong psychological reactions of anxiety and fear during a
pandemic, but they are required to continue their work in
uncertain and sometimes dangerous conditions. The impact of
working in this type of environment has been identified by a
number of studies during previous pandemics and disasters.
HCWs not only worry about their own safety, but also fear
bringing disease to their families and communities. Many may
feel guilty about their conflicting feelings about wanting to
help people in need on the one hand and exposing themselves
and their families to health risk on the other. Working with
insufficient protective equipment and long hours can also put
significant strain on HCWs and exposes them to the risk of
infection.
Even after the acute outbreak is over, the effects on health-
care workers can persist for years. In a follow up study 13 to
26 months after the SARS outbreak, Maunder et al found that
Toronto area HCWs reported significantly higher levels of
burnout, psychological distress, and posttraumatic stress. They
were also more likely to have reduced patient contact and work
hours and to report behavioral consequences of stress,such
as depression and anxiety, as well as increased alcohol and
substance use1
.
COVID 19 is likely to have a huge impact on the mental
health of HCWs, both during the outbreak and in its aftermath.
Fortunately there are evidence based strategies that can be used
to mitigate the impact on HCW’s. Fostering self-efficacy and
optimism has been shown to improve coping and efficiency
during disasters. Higher perceived workplace safety is asso-
ciated with lower risk of anxiety, depression and post-trau-
matic stress among HCWs, while lack of social support has
been linked with negative behavioral outcomes . A recent
study found that among Chinese physicians who cared for
COVID-19 victims, greater social support was associated with
better sleep quality, greater self-effectiveness, and less psycho-
logical distress2
. Positive leadership and a professional culture
of trust and openness with unambiguous communication have
been shown to improve engagement of the medical workforce.
It is critical that we advocate for the adoption of these prac-
tices in the workplace. Assessing and addressing mental health
needs of the healthcare workforce is going to be a key factor in
controlling COVID 19, and in healing our communities in its
aftermath.
REFERENCES
1. Maunder RG, Lancee WJ, Balderson KE, et al. Long-term
psychological and occupational effects of providing hos-
pital healthcare during SARS outbreak. Emerg Infect Dis.
2006;12(12):1924–1932. doi:10.3201/eid1212.060584
2. Xiao H, Zhang Y, Kong D, Li S, Yang N. The effects of social
support on sleep quality of medical staff treating patients with
coronavirus disease 2019 (COVID-19) in January and February
2020 in China. Med Sci Monit. 2020;26:e923549.
Mansoor Malik MD, MBA
Johns Hopkins University
School of Medicine
Addressing Mental Health Needs of
Healthcare Workers During COVID 19
Mansoor Malik

ASIA/PACIFIC
When COVID-19 is attacking, natural psychological re-
actions in general population are fear and panic. There is a lot
of news about the epidemic situation on the Internet, which
makes people confused. Due to the need for prevention and
control, people are restricted to work and live at home, lacking
communication and entertainment, resulting in making people
feel lonely and bored. Some people may have emotional reac-
tions such as anxiety, depression, dejection, despair, self-blame
and anger, as well as various physical problems such as flutter,
chest tightness, headache, waist and leg pain, gastrointestinal
reactions, poor sleep quality, and so on.
In fact, anxiety disorder is a common psychological symp-
tom. The first nationwide epidemiological survey of mental
disorders in China showed that the lifetime prevalence of
anxiety disorder in adults was 7.57%, indicating that nearly 8%
of community residents would develop anxiety disorders in
their lifetime. However, if a person does not reach the severity
of diagnostic criteria of anxiety disorder, he is considered to be
suffering from anxiety symptoms. The essence of anxiety symp-
toms is the intolerance of various uncertainties. In this case,
people do not know what COVID-19 is and how to prevent
from infection of it, which has caused widespread anxiety in
general population.
What are the solutions to various psychological problems
that have appeared in different people after the COVID-19 out-
break? First, changing cognition is the most important priority
for relieving anxiety. We should have knowledge of epidemic
infectious diseases first, and further understand the relevant
knowledge of COVID-19. Antiviral medication, symptom-
atic therapy, and supportive therapy can cure most patients
effectively. Avoiding going out, wearing masks, washing hands
frequently, regular ventilation, good nutrition and more rest
can reduce the risk of spreading COVID-19.
Second, accepting reality is a good way to relieve anxiety.
Since the environment is difficult to change, we can only accept
the reality and learn to coexist with anxiety brought by the
epidemic.
Third, we can try to make appropriately emotional expres-
sion to avoid mental and physical discomfort. The emotional
expression can be described as self-expression, telling others,
and delivering to the environment. It also can be sublimated in
a higher realm.
Fourth, catharsis can relieve anxiety. Please try to talk about
your feeling to your family, intimate friends, close classmates
and familiar colleagues. If you want to cry, let it flow with tears.
Furthermore, we should cultivate a sense of humor which could
ease the tension.
Fifth, emotion transference can relieve anxiety. When
anxiety is unbearable, we should take a vacation, read a novel,
watch TV, do interesting housework, organize your room, or go
to open public park, playground or suburb for exercise. Don’t
stare at your phone to read the messages and watch TV for
searching the news all day long.
Sixth, try to give up properly in order to avoid anxiety. It
is now at the stage of epidemic prevention and control, many
plans cannot be completed. Change the goals and rationalize
the consequences of procrastination, so that we can take it easy
and get relax.
Finally, if none of the above approaches work, please go to
see a mental health professional for psychological help.
China: Anxietyand Panic During
The Pandemicof COVID-19
REFERENCES
1 Yueqin Huang, et al. Prevalence of mental disorders
in China: a cross-sectional epidemiological study. The
Lancet Psychiatry, 2019; 6(3): 211-224
2 HUANG Yueqin. Self-relieving for anxiety symptom
during the COVID-19 epidemic Chinse Mental Health
Journal, 2020,(3): 275-277
Prof. Yueqin Huang, MD, MPH, PhD
Beijing, China
Yueqin Huang

ASIA/PACIFIC
As I write this now, Covid 19 is shaking the entire health
establishment of the world. The number of infected people have
reached 1.7 million and more than 100,000 people have lost their
lives. More than 100 doctors and several other health personnel
have lost their lives, while managing Covid 19. The world is look-
ing at a calamity, worse than a world war and with no end in sight.
India with a huge population of 1.38 billion is facing a daunt-
ing task. There is a nation-wide “lock-down” from March 24 to
April 14, 2020 which is likely to be extended. The Union and State
Governments are doing tremendous and co-ordinated work. The
number of infected as of today is 6,761 with 206 deaths. But we
fear, the worst is not over, and hence there is constant vigil. But
the enormity of the country’s size and population is making the
task of the planners and health professionals much harder. The
Dept of Psychiatry at the Pushpagiri Institute of Medical Scienc-
es, Thiruvalla, Kerala, India organised a lecture on ‘ Covid 19 and
its impact on Mental Health’ last week.
Enforced isolation, social rejection, financial crisis can
contribute to depression
Quarantine can cause negative psychological impacts, includ-
ing post-traumatic stress symptoms, confusion, anger and de-
pression, according to Roy Abraham Kallivayalil, secretary general,
World Psychiatric Association. Talking to The Hindu, Kallivayalil
said officials should quarantine individuals for no longer than is
required, chalk out clear rationale for quarantine, provide informa-
tion about protocols, and ensure sufficient supplies for them. He
added that the government decision to quarantine those returning
home from COVID-19-affected countries was a step in the right
direction.
Many people feel distressed at the prospect of being quaran-
tined. One person ran away from the isolation ward at a General
Hospital and was found hiding in his home!. Two American
citizens who fled from Medical College Hospital, Alappuzha,
were tracked down at the Cochin international airport. A post-vi-
ral fatigue, due to consequences of the virus infection on brain
function, and intense bereavement could cause severe depression
among the quarantined people. On April 10, one such ‘guest work-
er’ from Orissa has committed suicide.
WHO guidelines
Enforced isolation in a quarantined environment, that too
in strange places, and social rejection by people who are afraid
of dealing with the cured or suspected patients, and unexpected
financial crisis are the other contributing factors to depression and
suicide thinking in the quarantined people, he said. Dr. Kallivayalil
said the World Health Organization (WHO) had brought out cer-
tain guidelines to minimise the psychological stress in quarantined
and affected people.
Those home quarantined should maintain a healthy life-
style, which includes proper diet, sleep, exercise, and social
contacts over phone.
Only credible info
As per WHO guidelines, quarantined and affected people
should gather only credible information which could help them
assess their risk and take precautions. They should find a trust-
worthy source like WHO website or a State public health agency in
this regard. Quarantined and affected people should avoid media
coverage which is upsetting and seek help from mental health
professionals when needed. Our medical, public health, political,
economic, and educational institutions have to work together to
face this global threat. There were attempts to trivialise this viral
disease, treating it like a ‘flu-like illness’ that was likely to disappear
soon, at the beginning. But, COVID-19 has proved more devastat-
ing to the humanity as a whole.
REFERENCES
1. Chaturvedi, S.K. Covid-19, Coronavirus and Mental
Health Rehabilitation at Times of Crisis. J. Psychosoc.
Rehabil. Ment. Health 7, 1–2 (2020). https://doi.org/
10.1007/s40737-020-00162-z
2. Looking after our mental health. https://www.who.int/
news-room/campaigns/connecting-the-world-to-combat-
coronavirus/healthyathome/healthyathome---
mental-health
Roy Abraham Kallivayalil
Roy Abraham Kallivayalil, M.D.
Professor and Head,Department of Psychiatry
Pushpagiri Institute of Medical Sciences, Thiruvalla, Kerala- 689101, India
Secretary General, World Psychiatric Association
President, World Association of Social Psychiatry (2016-2019)
Photo Caption: Prof Roy Kallivayalil delivering Lecture on mental health of Covid19
at Pushpagiri, Kerala, India. Also seen are Dr Joice Geo, Dr Liza Varghese, Dr Sivin
Sam, Keerty Reji and K Aravind.
The Covid-19 & Global
Mental Health

EUROPE
CORONAVIRUS AND
CARE WORKERS:
UK – MENTAL HEALTH MATTERS
Coronavirus 2019 has laid bare how ill prepared we are glob-
ally and gives us a clear lesson that health and wealth are inter-
linked. It also shows that governments cannot handle a pandem-
ic alone, no matter how rich they are.
As a family doctor working in London, UK I have seen the
direct and indirect consequences of COVID-19. Many of our
friends and colleagues on health’s front lines are trying their
hardest to provide continuous care for the populations that they
serve and the people of the UK are showing their appreciation at
their weekly Thursday 8pm clap – a small gesture that provides
solidarity and show that we are all in it together.
Let me look at it through the eyes of a caring doctor. A friend
of mine called me to tell me that he had developed symptoms
that seemed like COVID-19 and immediately followed the pro-
tocol of self-isolation including canceling his clinics. Within 24
hours he had been admitted to a local general hospital High De-
pendency Unit. As soon as he felt well enough to contact his
first words were that this was a frightening experience for him
– something which many people who have been through this
experience and come out of the other side have said.
When I decided to see what reflections healthcare workers
in China experienced when they first faced COVID-19 I found
they reported generalised distress, fear, panic symptoms, gener-
alised anxiety and sleep difficulties.
The management of psychological difficulties post-expo-
sure to COVID-19 in those who work in caring professions is
very important and we are not yet doing enough to address this
across the whole health and care spectrum.
The leaders of global mental health need to come together to
develop appropriate care pathways and care packages for those
care workers who have experienced the direct or indirect effects
of this global pandemic. Collaboration across sectors and spe-
cialties will be important.
Already UCL Partners in London UK have forged a partner-
ship of the NHS, academia and industry to support London and
surrounding counties that have so far borne the brunt of this
illness and we can learn from what they are doing. Click on the
ten top tips for managing COVID-19 on the frontline https://
uclpartners.com/news-item/london-clinicians-share-top-10-
tips-from-covid-19-frontline/
This pandemic will not be a one off – lets prepare better for
the next time.
REFERENCES
1. Lai J, S Ma, Y Wang, Z Cai, J Hu, N Wei, J Wu, H Du et al. Fac-
tors associated with mental health outcomes among health care
workers exposed to coronavirus disease 2019. JAMA Network
Open. 2020; 3(3):e203976.
2. Bringing together NHS, academia and industry to support the
COVID-19 response. Professor Mike Roberts
3. https://uclpartners.com/blog-post/bringing-together-nhs-aca-
demia-and-industry-to-support-the-covid-19-response/
Prof. Gabriel Ivbijaro MBE, JP
MBBS, MMedSci, MA, PhD, FRCGP, FWACPsych, IDFAPA
Medical Director The Wood Street Medical Centre, London, UK
Professor, NOVA University, Lisbon Portugal
Honorary Visiting Fellow, Faculty of Management, Law and Social Sciences,
University of Bradford UK
President, The World Dignity Project
Gabriel Ivbijaro

EUROPE
The COVID-19 outbreak has brought many challenges to
everyone to live their normal lives as usual and around the world
many concerns in the frontline provision of health care.
Despite these unprecedented moments, new initiatives of
solidarity emerged. Amongst them, has been the strengthening
of collaborations and support among peers in the Early Career
Psychiatrists Section of the World Congress of Psychiatry As-
sociation.
A close connection has been reinforced with WhatsApp
groups, mailing lists and remote online meetings, which have
been a source to many of emotional support and academic op-
portunities.
Among this initiatives, has been the Special Issue Newslet-
ter of the WPA Section of Early Career Psychiatrists, has been
an initiative of our Editor, Tando Melapi, and a collective effort
with contributions of numerous early career psychiatrists from
different corners of the globe, that share how they have been
living in and working on during this pandemic.
https://3ba346de-fde6-473f-b1da-536498661f9c.filesusr.
com/ugd/e172f3_639f16e2573248e8b278d0f428318908.pdf
Another initiative has been the development of a conceptu-
al framework for mental health during the pandemic developed
by 16 early career psychiatrists across the globe, which is freely
available here: Ransing R et al, 2020: https://www.sciencedirect.
com/science/article/pii/S1876201820301969
We are delighted that another publication was recently ac-
cepted in the prestigious Journal The Lancet Psychiatry, which
reports a snapshot by early career psychiatrists from 16 different
countries around the world, in terms of access to Personal Pro-
tective Equipment (PPE), redeployment and Telepsychiatry use
by Pereira-Sanchez et al 2020.
All early career psychiatrists currently working in the front-
line for the mental health care provision of their patients are
heroes, and we invite all to seek peer support locally and across
the world. The companionship, spontaneity and resilience with
which many have joined forces is truly inspirational. We look
forward for the aftermath to be together, to be with our friends
and colleagues again, and to meet again.
REFERENCES
1. Sanchez P, Adiukwu F, El Hayek S, Bytyçi DG, Gonzalez-Diaz
JM, Kudva Kundadak G, Larnaout A, Nofal M, Orsolini L, Ra-
malho R, Ransing R, Shalbafan M, Soler-Vidal J, Zulvia Syarif
Z , Schuh Teixeira AL, Pinto da Costa M. COVID-19 effect on
mental health patients and workforce. The Lancet Psychiatry.
2020
2. Ramdas Ransing, Frances Adiukwu, Victor Pereira-Sanchez,
Rodrigo Ramalho, Laura Orsolini, André Luiz Schuh Teixeira,
Jairo M. Gonzalez-Diaz, Mariana Pinto da Costa, Joan Sol-
er-Vidal, Drita Gashi Bytyçi, Samer El Hayek, Amine Larnaout,
Mohammadreza Shalbafan, Zulvia Syarif, Marwa Nofal,
Ganesh Kudva Kundadak. Early career psychiatrists’ perspec-
tives on the mental health impact and care of the COVID-19
pandemic across the world, Asian Journal of Psychiatry, 2020
EARLY CAREER PSYCHIATRISTS
jOINING FORCES
DURING A PANDEMIC
Dr. Mariana Pinto da Costa
Chair of the Early Career Psychiatrists Section of the World Psychiatric Association
Doctoral Research Fellow, Unit for Social and Community Psychiatry, WHO Collaborating
Centre for Mental Health Services Development, Queen Mary University of London, London, UK
Lecturer, Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
Consultant Psychiatrist, East London NHS Foundation Trust
Mariana Pinto da Costa

EUROPE
The COVID-19 pandemic is affecting mental health of both
psychiatric patients and the general public. Social distance, isolation
and loss of work or fear of losing jobs may lead to increased anxiety,
stress,agitation,depressionetc. Mostpsychiatrichospitalsreportlower
occupancy than usual as many patients do not want hospitalization
due to fear of infection. Nevertheless, they still need professional
support and qualified help.
In such a context, telepsychiatry can be an excellent complement
to existing treatment options.
Since 1959. video-conferencing has been used in the assessment
and / or treatment of all mental illnesses, as well as for psycho-
education and supervision. Today, it is just one of many applications
that goes under the common denominator: ”e-Mental Health” [1].
Professionalshaveunfortunatelybeenreluctanttowardstelepsychiatry
primarily due to a lack of general knowledge and clinical experiences
[2]. Patients, on the other hand, have expressed a high degree of
satisfaction and comfort with remote consultations [3,4].
In the current pandemic era, telepsychiatry seems to be most
practicaltouseinassessmentand/ortreatmentofpatientsinisolation.
Suitable patient groups include:
1. children and adolescents
2. elderly with or without multiple chronic diseases
3. persons with limited mobility
4. patients diagnosed with autism
5. individuals with anxiety problems (especially social anxiety,
panic and agoraphobia), depression, PTSD, OCD
6. ethnic minorities with limited language proficiences (when
the therapist ”matches” both linguistically and culturally, so-
called ”cross-cultural telepsychiatry” that eliminates the use of
interpreters)
Immediate benefits of the model are:
1. money and time savings associated with:
(a) no need for transport with associated expenses
(b) no need to wait in frequently crowded waiting rooms
2. no risk of infection
3. the patient is seen in his/her usual surroundings
4. reduced number of cancellations
5. reduced stigma
6. easier to maintain continuity of treatment
A combination of the above results in higher patient satisfaction
and better compliance.
Disadvantages of the home-telepsychiatry model are:
1. limited opportunity for somatic examination
2. limited ability to read the body language
3. the risk of the patient recording the sessions and publishing
them on the Internet
4. electricity power failure or disrupted internet connection are
an unpredictable obstacles
A combination of the above is a possible reason for offering the
service only to previously known patients. Whether it reflects the
professional’s own uncertainty and inexperience with telepsychiatry
cannot be ruled out.
While telepsychiatry is partialy implemented in some countries
(primarily USA, Canada, Australia), the experiences of home
telepsychiatry are limited. In Denmark home telepsychiatry was
introduced in 2016. So far, both patients and therapists are extremely
satisfied with the model. It works so that the patient receives
guidance and log-in information for a software in order to download
it to computer, ipad, or mobile phone. This ensures an encrypted
connection. The meeting takes place in the virtual room ”up in cloud”
where the patient ”meet up” with the therapist after receiving a one-
time code which expires after the end of the conversation.
The current pandemic may be a turning point for the future of
telepsychiatry.
However, the development is partly dependent on the decision-
makers’ insight and willingness to act. Well-functioning service
requires standardized guidance on both equipment selection and
set-up, practical training and theoretical instructions [5]. Further
motivation can be obtained through promoting ”best practice”
examples and research in the field of telepsychiatry. One must not
forget that ”e-mental health”, inclusive telepsychiatry, has not yet
become a mandatory part of neither student teaching nor the special
educationprogram.Home-telepsychiatryisjustoneexampleofawide
range of opportunities that technology offers to those who can think /
step out of the box.
REFERENCES
1. Mucic D, Hilty DM (eds). e-Mental Health. Springer, Cham, 2016.
2. Norris ER. Physicians’ Beliefs, Attitudes, and Use of Telepsychiatry
Services. Jacobs Journal of Psychiatry and Behavioural Science, 2018.
3. Campbell R, O’Gorman J, Cernovsky Z.Z. Reactions of psychiatric
patients to telepsychiatry. Mental Illness 2015; volume 7:6101
4. Mucic D. Transcultural telepsychiatry and its impact on patient satis-
faction. Journal of Telemedicine and Telecare 2010; 16: 237–242
5. Mucic D. Training in Telepsychiatry. In : Edmond H. Pi, Tan Chay Hoon
and Marc H.M. Hermans (Eds). Mental Health and Illness Worldwide.
Education about Mental Health and Illness. Springer 2019: 411-440.
Telepsychiatry During The COVID-19 Pandemic
Davor Mucic, M.D.
Founder of the Telemental Health Section of the
EPA (European Psychiatric Association)
Re-founder and Board Member of the Section on
Informatics of the World Psychiatric Association
Editor-in-chief of Edorium Journal of Psychiatry.
Davor Mucic

SAVE THE DATE!
Mark your calendars for these upcoming events:
MON. - FRI.
JUN. 29 -
JUL. 3, 2020
Royal College of Psychiatry
INTERNATIONAL CONGRESS
JUN. 29 - JUL. 3, 2020
THU. - SUN.
JUL. 2 - 5, 2020
European Federation of
PSYCHIATRIC TRAINEES FORUM
JUL. 2 - 3, 2020
OCT. 14 - 17, 2020
World Psychiatric Association (WPA)
CONGRESS OF PSYCHIATRY
OCT. 14 - 17, 2020
Stay well and
Be Safe
Stay well and
Be Safe

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