Covid-19 Related Psychiatric Disorders and the New Psychosocial Rehabilitation

These are early days for psychiatric consequences of the covid-19 infections to manifest. Historically, a number of psychiatric conditions have been attributed to viral infections in the past. The covid-19 viral epidemic is likely to create similar or may be different psychiatric disorders. In the past, there were discussions on the labile or latent forms of viruses which were thought to have an etiological role in causing schizophrenia. Similarly, studies on occurrence of schizophrenia being more in the winter born subjects were thought to be related to outbreaks of a certain type of influenza. Influenza (H1N1) infection during the first trimester of pregnancy was thought to be associated with the development of schizophrenia. Catatonic symptoms were considered to be related to viral infections, including the decline of catatonic states was postulated to be due to decline of the infective processes [1]. Amongst the non-psychotic disorders, chronic fatigue syndrome (CFS) has been linked to viral diseases and considered as a post viral disorder, as some subjects develop chronic fatigue syndrome after having a viral infection. Viruses suspected to be involved in CFS include Epstein-Barr virus, human herpes virus 6 and mouse leukaemia viruses, however, no conclusive link has yet been established. There are neuropsychiatric disorders related to measles, Japanese B encephalitis, dengue, varied influenza and other viral encephalitic conditions or encephalopathies. In addition, there are neuropsychiatric sequalae and complications of the antiviral treatments for these viral infections [2]. These are in addition to the psychological reactions to such virulent pandemics.

Would there be similar psychiatric syndromes related to the covid-19 in future? In these first six months since covid-19 made its appearance, milder psychiatric disorders like anxiety, fear, adjustment disorders have been reported; functional symptoms in the form of fatigue and tiredness, tingling and numbness have also been noted. Health related anxieties have cropped up. Currently, the common mental health problems are related to misconceptions and lack of adequate information, and rumours being floated about the spread of covid-19 infections, its treatment and prevention. Phobia due to the infodemic (the plethora of information), fake news and rumours can perhaps be reduced by a rational lockdown on news, media and social media!

The editorial in the previous issue of the journal was published when the pandemic was setting in, and a lockdown was in its early days [3]. The immediate concerns about the effect of lockdown on psychosocial rehabilitation services were raised. During the lockdown period, mental health care was provided through use of telephones and videos, remotely. People with already existing mental health conditions were affected to a great extent. Some had relapse of symptoms, others stopped medications due to non-availability of medications and consultations. The traditional rehabilitative approaches could not be practiced, causing unbearable stress and burden on families and caregivers [4].

Like the ‘new normal’ for living in day to day life, psychiatric practice would be transformed, and so would psychosocial rehabilitation be forced to have a ‘new normal’. In order to maintain social distancing and avoiding crowds, work from home, study from home, exercise at home, and recreation at home have become the new lifestyle. Similarly, for psychosocial rehabilitation, work and social activities need to be planned within the confines of home safety. Day care services in institutions would become difficult due to risk for the patient and the staff. Day care vocational and social activities would need to be home based with adequate balance of social isolation and social interaction. Social skills will need to be adapted to a distance of one or two metres; hand shakes and body touch during social interactions would need to be replaced by other forms of greetings, and of course, the masked face will communicate feelings only through eyes, or non-verbal body gestures and not smiles! However, there are limited activities which persons with or without mental health problems can engage in at home. The work-from-home has enhanced the use of mobile phones, internet and social media. The ‘new normal’ of work from home is already drawing attention to the benefits and drawbacks of this work culture. Though, work from home has become a practice only for last few weeks, already stress and burnout of work from home is being talked about.

Stigma is an important theme in rehabilitation of any disabling disorder. One of the key objectives of mental health rehabilitation is reducing stigma towards mental illness and those with mental illness. The covid-19 pandemic has caused so much mental tension, anxieties and fears that the role of mental health professionals and interventions has seemingly become more important than the search for cure or treatment of the viral infection. There is also tremendous stigma towards covid-19, people who turned positive on testing, or were at high risk, or primary or secondary contacts. On the positive side, government and public have become well aware of the mental health issues, fears, anxieties and stress related to covid-19 and launched extensive and mental health education on this aspect [5]. Mental health counsellors are being sought after and multiple telephone help-lines have been launched. The counselling for such mental health issues and stigma could mainly be provided through remote methods, like, tele-counselling and chats. Numerous health education materials in the form of pamphlets, videos and use of technology to deal with this stigma have been launched to counter the effect of stigma, negative impact of rumours, and to provide accurate and authentic information [6–8]. Thus, stigma associated with covid-19 pandemic has reduced stigma towards mental health and seeking mental health services and counselling!

So far, minor mental health problems in the form of adjustment disorders, anxiety disorders, depressive disorders, health anxieties and fear have been reported. Tazaki has mentioned ‘corona virus depression—an economic depression due to corona outbreak’ in her commentary in this issue. There are also subjects with corona neurosis seen in clinical practice, where the persons show an abnormal illness behaviour and maladaptive ways of coping with their covid related fears and anxieties. Though there are exacerbations of pre existing psychosis, obsessive compulsive disorders, alcoholism and substance use, and other chronic mental health problems, incidence of fresh severe psychiatric disorders are still unheard of. In future, if there are multiple mental health problems observed, a new fancy branch of Psycho Covidology, or Psycho Coronalogy may emerge. A lot will depend on the course of the pandemic, whether the virulence of covid-19 virus will come down or would it become a super-infection?

The current issue of the journal has a few commentaries from experts from the United States, Canada and Japan sharing their thoughts on the impact of the pandemic. Mary Seeman finds her patients coping well; Tazaki has expressed dismay at the discrimination of persons with mental health problems; Rudnik has emphasised the usefulness of rPSR [remote psychosocial rehabilitation] and dPSR [digital psychosocial rehabilitation], and Corrigan and Nieweglowski discuss the need for peer support and peer-based education.

Besides these commentaries, this issue has an editorial by Jagadisha Thirthalli on innovating ways of replacing expressed emotions with each other; and an article on perception of expressed emotions among persons with mental illness. There are two interesting articles on hospital based parental support management for autistic spectrum disorders and evaluation of a community recovery programme for persons with substance use. An article discusses the non-Cartesian view of suicide and suicide prevention intervention and another on tribal patients with mental illness and their caregivers are refreshing contributions. Couple of articles on persons with intellectual disabilities, and one on Human Rights with emphasis on the Right to equality and freedom among residents of a therapeutic residential service, complete the issue. In future issues of the journal, more covid related research and papers can be expected.