IMPACT OF COVID19 IN MENTAL HEALTH

Impact of COVID-19 pandemic on
mental health
Dr Binoy D Raj
Post Graduate student
Dept of Psychiatry
Dr SMCSI Medical college Hospital

Through slides…………
• Psychological impact on public through quarantine
• Impact oh health care professionals
• Impact on children/adolescence
• Impact on pre-existing mental health problem
• Impact on elderly mental health

introduction
• The world has faced a global threat in last two months from the Corona virus
disease 2019
• (COVID-19), caused by the SARS-CoV-2.
• Starting in the Wuhan region of China, it hardly took a month for it to emerge into
a pandemic.
• Affecting around 4,442,163globally and claiming the lives of around 3,02,418
COVID-19 has affected the very basis of living, leading to mass panic and hysteria
• SOURCE-Mohfw india
.

Psychological impact on healthcare
professionals
• . In the early rapid expansion phase of the SARS outbreak, similar to the
current course of COVID-19 pandemic, healthcare professionals reported
feelings of extreme vulnerability, uncertainty and threat to life, alongside
somatic and cognitive symptoms of anxiety .

• Decisions have to be made fast, ranging from efficiently triaging and isolating
patients with suspicion of infection, to deciding whether to shut down
departments and operating theatres when a patient or staff test positive.
• All these whilst being on limited resources.
professionals

The pressure to act timely and to successfully diagnose, isolate and treat has
been overwhelming, especially amid intense public and media scrutiny.
Psychological impact on healthcare professionals

• Due to the increased risk of exposure to the virus, our frontline doctors,
nurses and healthcare workers fear that they may contract COVID-19
themselves.
• They worry about bringing the virus home and passing it on to loved ones
and family members - elderly parents, newborns and immuno
compromised relatives.
professionals

• Healthcare staff report increased stress levels when dealing with patients
unwilling to cooperate or not adhering to safety instructions
• Feelings of helplessness when dealing with critically ill patients, in the
context of limited intensive care beds and resources.
professionals
How often must i
have told you to wear
that mask?

• The use of protective equipment for long periods causes difficulties in
breathing and limited access to toilet and water, resulting in subsequent
physical and mental fatigue.
professionals

• A very recent study among healthcare professionals in a tertiary infectious
disease hospital for COVID-19 in China, revealed a high incidence of anxiety
and stress disorders among frontline medical staff , with nurses having a higher
incidence of anxiety than doctors.
• Willingness of staff to work has not been really affected, in line with reports
from previous pandemics
professionals
Nice to stand
like this. Who
will take care of
my anxiety?

• Healthcare workers from 5 major hospitals, involved in the care for COVID-19
patients, in Singapore and India were invited to participate in a study by
performing a self-administered questionnaire within the period of February 19
to April 17, 2020.
• This questionnaire collected information on demographics, medical history,
symptom prevalence in the past month, Depression Anxiety Stress Scales
(DASS-21) and the Impact of Events Scale-Revised (IES-R) instrument.
professionals

• Out of the 906 healthcare workers who participated in the survey, 48 (5.3%)
screened positive for moderate to very-severe depression, 79 (8.7%) for
moderate to extremely-severe anxiety , and 34 (3.8%) for moderate to severe
levels of psychological distress.
• The commonest reported symptom was headache (32.3%), with a large
number of participants (33.4%) reporting more than four symptoms.
• Participants who had experienced symptoms were more likely to be older,
have pre-existing co morbidities and a positive screen for depression.
• Nicholas W.S. Chew, et al., Brain, Behavior, and Immunity, https://doi.org/10.1016/j.bbi.2020.04.049
professionals

professionals
professionals

professionals

Impact on children/adolescent
• Schools have been suspended nationwide in 188 countries, according to
UNESCO.
• Over 90% of enrolled learners (1·5 billion young people)worldwide are now
out of education.
• The UNESCO Director-General Audrey Azoulay warned that “the global scale
and speed of the current educational disruption is unparalleled”.

• Children have been reported to be less susceptible to COVID-19 infection.
• Psychological implications- the shutting down of schools and playgrounds, the
restriction of outdoor activities , parents' fears of contamination have been
triggering manifestations of anxiety, such as panic attacks and psychosomatic
symptoms.

• School routines are important coping mechanisms for young people with
mental health issues.
• When schools are closed, they lose an anchor in life and their symptoms
could relapse. Some lock themselves up inside their rooms for weeks , refusing
to take showers, eat, or leave their beds.” (Hong Kong)

• In a survey by the mental health charity Young Minds, which included 2111
participants up to age 25 years with a mental illness history in the UK, 83%
said the pandemic had made their conditions worse.
• 26% said they were unable to access mental health support.
• Peer support groups and face to-face services have been cancelled , and
support by phone or online can be challenging for some young people.

• Children with special education needs- autism spectrum disorder, are also at
risk.
• They can become frustrated and short-tempered when their daily routines are
disrupted, social skills groups suspended.
• With speech therapy sessions and social skills groups suspended children with
special needs might miss their chance to develop essential skills.
• Online speech and social skills training, are needed to make up for the loss.

• Many countries are postponing or cancelling university /board /entrance
exams.
• Uncertainties of whether the exams could be delayed further stressful.
I have a huge wave
of fear that I might
contract the virus
and thus cannot
make it to the
exams

• College and university students are stressed about dormitory evacuation and
cancellation of anticipated events such as exchange studies and graduation
ceremonies.
• Some lost their part-time jobs as local businesses closed.
• The final years are anxious about the job market they are going to enter and
financial burden.
• Study portal,impact of covid 19,,international students perceptions

• Social distancing measures can result in social isolation in an abusive home,
with abuse likely exacerbated during this time of economic uncertainty and
stress.
• Increased rates of child abuse, neglect, and exploitation have also been
reported .→ stress
• Lancet Child Adolesc Health 2020Published OnlineApril 142020https://doi.org/10.1016/S2352-4642(20)30109-7

THE TIMES OF INDIA,APRIL 20
The NGO, All India Council of Human Rights, Liberties
and Social Justice (AICHLS), has claimed that there were
increasing number of domestic violence and child abuse
incidents since the nation was put under lockdown and
sought an urgent intervention by the court.
The April 18 order from Delhi high court, uploaded
Sunday night, came on an NGO's plea seeking measures
to safeguard victims of domestic violence and child
abuse amidst the coronavirus or COVID-19 lockdown.

Impact of COVID-19 pandemic on pre-existing mental
health problems
• Most of the psychiatric disorders have an intricate association with stress
leading to increase in incidence and relapse rates.
• Research is sparse with regards to psychiatric disorders in viral pandemics.
• Most of the studies from this current COVID-19 and previous SARS epidemic in
2003 or corona influenza epidemic in 2009 have shown anxiety, panic,
depression to be the predominant manifestation.
• Asian Journal of Psychiatry 51 (2020) 102071Barikar C Malathesh Department of Psychiatry, NIMHANS,
Bengaluru, India

• COVID-19 pandemic and country-wide lockdown are likely to increase the new
onset of Illness Anxiety Disorder and to cause exacerbation of symptoms in
diagnosed cases.
• Any simple flu like symptom increases anxiety under present circumstances.
• patients are more likely to resort to panic buying and excessive hoarding of
essential items.
health problems
Oh God…! I am
infected….

• Obsessive Compulsive Disorder patients, especially who have checking,
hoarding and washing compulsion, are at higher risk.
• Advice on improving personal hygiene measures might increase the
contamination obsessions and washing compulsions.
health problems

• For Recurrent Depressive Disorder patients , GAD , chronic insomnia
lockdown is a major stress jeopardizing normal daily routine, social rhythm
→increasing stress levels-→escalate the Cortisol level-→ vicious
exacerbation of depressive symptoms.
• (Qiu et al., 2020)
health problems

• Inability to join work, dwindling finances and the long term impact on
economy will have its effect on preexisting common mental health disorders.
• (Zandifar and Badrfam, 2020
health problems
No work
No money

• Quarantine can lead to feelings of fear, anger, anxiety and panic about worse
possible outcome, boredom and loneliness and guilt about not being there for
family.
• In a person with a previous psychiatric disorder, all these problems can surface
with renewed severity → PTSD or even suicidal thoughts and attempts.
• Anxiety → canprecipitate paranoia and nihilistic delusions
• . . Brooks, S.K., 2020. The psychological impact of quarantine and how to reduce it: rapid review of the evidence.
Lancet(February 2020.
health problems

• Patients with bipolar disorder and schizophrenia are likely to have relapses due
to jeopardy in both the availability of regular medication and medication
compliance.
• For substance use disorder patients, this period could be lethal -non-
availability of substance or medicines→ severe withdrawal symptoms and
medical emergencies like delirium or seizures, which can be life-threatening.
• Xiang, Y.T., Yang, Y., Li, W., Zhang, L., Zhang, Q., Cheung, T., Ng, C.H., 2020. Timely mental health care for
the 2019 novel coronavirus outbreaks.Lancet Psychiatry 7 (March (3)), 228–229
health problems

• Doctors involved in emergency services must be more aware about
psychiatric emergencies so that appropriate and timely referrals can be done.
• There is need to bring in policy changes which will ensure continuous
availability of healthcare services and essential drugs.
• E-dispensing rules should be relaxed, albeit under close monitoring.
• Telemedicine consultation should be practiced and policymakers should
focus on making doctors more aware and comfortable using tele-
consultation.
health problems

• In the aftermath of COVID-19 outbreak, Medial Council of India has issued
guidelines for practicing telemedicine on 25th March (MCI,2020), which is a
welcome step establishing the basic purpose, guideline and protocol of
telemedicine.
• No mention of psychiatric management and use of psychotropic medications.
• A lot of common psychotropics which are essential, like SSRI's, atypical
antipsychotics , Sodium Valproate can be prescribed without stringent
monitoring and ought to be mentioned in the list ‘A’ and ‘B’ drugs.
• Further study and discussion should be planned on the tele-prescribing
guidelines of other medications like lithium, Clozapine, Benzodiazepines etc.,
which warrant more strict regulation.
Impact of COVID-19 pandemic on pre-existing mental health
problems

• “I am concerned about them because they were in a good place to move to the
next level. But they have discontinued the sessions now,” .
“It is hard to maintain a relationship with your client via online communication
especially .teenagers.
https://economictimes.indiatimes.com/industry/healthcare/biotech/healthcare/how-covid-19-has-
affected-indias-mental-healthcare-support-system
health problems

Impact on elderly mental health
•15 percent of the first wave of deaths in
China were aged above 60 years.
• According to Chinese Centre for Disease
Control and Prevention, the mortality rate
in age group 60-69 years is 3.6 percent
which can reach up to 18 percent at 80
years and above

What makes the elderly at-risk population?
• COVID-19 induced pneumonia and risk of death is three times higher in the
older age-group.
• The number of lung-lobes involved, the need for mechanical ventilation,
chance of blood-gas abnormalities was all higher in the elderly .
• Non-specific organ involvement in the elderly.
• Older people might have cognitive and sensory deficits which make it difficult
for them to comprehend and follow precaution.

• Pandemics have significant psycho-social impact in elderly.
• Social distancing, is also a major cause of loneliness, particularly in settings like
nursing-care or old-age homes →independent risk factor for depression,
anxiety disorders and suicide.
• covid-19 and elderly mental health, Dr. DEBANJAN BANERJEE, Department of Psychiatry, NIMHANS, Bengaluru 560029, India

• Most seniors are not comfortable with smart phones or the media language,
hence the precautions for a pandemic need to be explained to them in their
own simple terms.
• Cognitive impairment, wandering, irritability and psychotic symptoms can
worsen the panic and make it difficult for them to follow the precautions of
distancing and hand hygiene.
Sir,you know
about social
distancing?

• The substantial stress generated by ‘information overload’ can lead to
paranoia and health-care related mistrust which might lead them to avoid
quarantine.
Thanks for
your
information
sir, But I don’t
want to go in
quarantine

Important components of mental health care in
the elderly
• Regular telephonic counseling sessions
• Healthy contact with family
• Relevant and updated information
• Caring for the general medical and psychological needs
• Respecting their personal space and dignity

The psychological impact of quarantine
• A study of hospital staff who might have come into contact with SARS found
that immediately after the quarantine period (9 days) ended, having been
quarantined was the factor most predictive of symptoms of acute stress
disorder.
• Effect of being quarantined was a predictor of posttraumatic stress
symptoms in hospital employees even 3 years later.
• Dr Samantha K Brooks et.al,The psychological impact of quarantine,www.the lancet.com Vol 395 March 2020

• Report exhaustion, detachment from others , anxiety when dealing with
febrile patients, irritability , insomnia, poor concentration and indecisiveness,
deteriorating work performance

• A study comparing post-traumatic stress symptoms in parents and children
quarantined with those not quarantined found that the -mean post-traumatic
stress scores were four times higher in children who had been quarantined
than in those who were not quarantined.
• Another study19 of hospital staff examined symptoms of depression 3 years
after quarantine and found that 9% (48 of 549) of the whole sample reported
high depressive symptoms

• For health-care workers being quarantined was associated with avoidance
behaviours , such as minimizing direct contact with patients and not reporting
to work.
• SARS affected been quarantined avoided people who were coughing or
sneezing, 26% avoided crowded enclosed places , and 21% avoided all public
spaces in the weeks following the quarantine period.
• A qualitative study reported that several participants described long-term
behavioural changes after the quarantine period, such as
vigilant hand washing and avoidance of crowds and, for some, the return to
normality was delayed by many months.

Stressors during quarantine
• Duration of quarantine
• longer durations of quarantine were associated with poorer mental health ----
post-traumatic stress symptoms, avoidance behaviours , and anger.
• Fears of infection
• fears about their own health or fears of infecting others and were more likely
to fear infecting family members .They also became particularly worried if they
experienced any physical symptoms potentially related to the infection .

• Frustration and boredom
• Confinement, loss of usual routine, and reduced social and physical contact
with others were frequently shown to cause boredom, frustration, and a sense
of isolation from the rest of the world.
• This frustration was exacerbated by not being able to take part in usual day-
to-day activities, such as shopping for basic necessities.

• Inadequate supplies
• Having inadequate basic supplies (eg, food, water, clothes , or accommodation)
during quarantine was a source of frustration and continued to be associated
with anxiety and anger 4–6 months after release.
• Being unable to get regular medical care and prescriptions also appeared to be
a problem for some participants.

• Inadequate information
• poor information from public health authorities as a stressor, reporting
insufficient clear guidelines about actions to take and confusion about the
purpose of quarantine.
• content of various public health messages because of poor coordination
between the multiple jurisdictions and levels of government involved.
• Lack of transparency between health and govt officials --→poor compliance
to quarantine→PTSD

post quarantine stressors
• Finances
• people unable to work and having to interrupt their professional activities
with no advanced planning.
• the financial loss created serious socioeconomic distress and was found to be
a risk factor for symptoms of psychological disorders and both anger and
anxiety several months after quarantine.
• Jeong H, Yim HW, Song Y-J, et al. Mental health status of people isolated due to Middle East respiratory
syndrome. Epidemiol Health2016; 38: e2016048.

• Many became dependent on their families to provide for them financially
during quarantine -hard to accept and could cause conflicts in families.
• assistance they received did not cover their ongoing professional expenses

• Stigma
• quarantined participants were significantly more likely to report stigmatisation
and rejection from people in their local neighbour hoods
• Treating them differently , avoiding them, withdrawing social invitations ,
treating them with fear and suspicion, and making critical comments.
• unable to resume their jobs after surveillance ended because their employers
expressed fear of contagion (FIG)

• Surat doctor was physically attacked
and verbally abused by her next-door
neighbour on Sunday. The neighbour
threatened to kick her out of her house
as he believed that the doctor had novel
coronavirus and she would spread it to
the entire building
• INDIA TODAY,April7,20200

What can be done to mitigate the consequences
of quarantine
• Keep it as short as possible
• Restricting the length of quarantine to what is scientifically reasonable given
the known duration of incubation periods.
• For people already in quarantine, an extension, no matter how small, is likely
to exacerbate any sense of frustration or demoralization.

of quarantine
• Give people as much information as possible
• Catastrophic appraisals of any physical symptoms experienced during the
quarantine period → fear exacerbated by the often inadequate information.
• Ensure that those under quarantine have a good understanding of the disease
in question, and the reasons for quarantine ------------should be a priority.

• Provide adequate supplies
• Officials also need to ensure that quarantined households have enough
supplies for their basic needs.
• these must be provided as rapidly as possible
• Coordination for provision of supplies should ideally occur in advance, with
conservation and reallocation plans
of quarantine

• Reduce the boredom and improve the communication
• people who are quarantined should be advised about what they can do to
stave off boredom
• practical advice on coping and stress management techniques.
• Activating social network through mobile phone/wifi.
of quarantine

• Public health officials maintain clear lines of communication with people
quarantined about --what to do if they experience any symptoms.
• This would show they have not been forgotten and that their health needs are
just as important as those of the wider public.
• A support group who had been through the same situation could be a
validating, empowering experience.
of quarantine

………………….....................................................
• Special care to health workers.
• negatively affected by stigmatizing attitudes from others.
• concerned about causing their workplaces to be understaffed
• causing extra work for their colleagues
• colleagues’ perceptions
• Separation from usual working team
• increased awareness of symptoms, taking breaks from work, engaging in self-
care, taking breaks from media ,enhanced peer-support and practical
assistance for healthcare workers who find themselves exhausted, stressed
• QJM: An International Journal of Medicine, 2020, Vol. 0, No. 0
………………….....................................................
of quarantine

• Special care to elderly
• Spending quality time with family and getting involved in family discussion.
• Spend time on recreational activities
• Keep doing some household activities at home daily
• Connect to your loved ones through telephone/video-call to keep stress at bay.
• Make sometime for simple exercises at home
• Cut down listening to news all the time. Seek information from credible sources
only.
• Caring for the general medical and psychological needs
• Respecting their personal space and dignity
• NIMHANS , psychosocial helpline publication
of quarantine

references
• Nicholas W.S. Chew, et al., Brain, Behavior, and Immunity,
https://doi.org/10.1016/j.bbi.2020.04.049
• Jeong H, Yim HW, Song Y-J, et al. Mental health status of people isolated due to Middle
East respiratory syndrome. Epidemiol Health2016; 38: e2016048
• Dr Samantha K Brooks et.al,The psychological impact of quarantine,www.the lancet.com
Vol 395 March 2020
• covid-19 and elderly mental health, Dr. DEBANJAN BANERJEE, Department of Psychiatry,
NIMHANS, Bengaluru 560029, India.
• . Brooks, S.K., 2020. The psychological impact of quarantine and how to reduce it: rapid
review of the evidence. Lancet(February 2020.
• Lancet Child Adolesc Health 2020Published OnlineApril
142020https://doi.org/10.1016/S2352-4642(20)30109-7
• Asian Journal of Psychiatry 51 (2020) 102071Barikar C Malathesh Department of
Psychiatry, NIMHANS, Bengaluru, India

IMPACT OF COVID19 IN MENTAL HEALTH

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