When will the pandemic end?

The once in a century coronavirus disease 2019 (COVID-19) pandemic, is an ongoing global pandemic of COVID-19, caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2).[1] The first outbreak of COVID-19 was identified in December 2019 in Wuhan, China.[2] The outbreak was declared a Public Health Emergency of International Concern by the World Health Organization (WHO) on January 30, 2020, and further the COVID-19 outbreak was declared a pandemic on March 11, 2020.[3,4] As per the Johns Hopkins University's statistics, there were more than 21,026,758 reported cases of COVID-19 in nearly 188 countries and territories, resulting in more than 755,786 deaths as of August 15, 2020, making the global death-to-case ratio of about 3.7%.[5]

In low- and middle-income countries, health-care capacity is limited, which has made the prompt implementation of nonpharmaceutical interventions even more critical.[6] As a nonpharmaceutical intervention, on March 24, 2020, the Government of India enforced a nationwide lockdown for 3 weeks, that affected the entire 1.3 billion population. On April 14, 2020, the lockdown was extended till May 3, 2020, which was followed by subsequent 2-week extensions starting May 3 and 17, 2020, with substantial relaxations. From June 11, 2020, the government started “unlocking” the country (barring “containment zones”) in three unlock phases.[7,8,9,10]

The United Nations and the WHO called India's response to the pandemic as “comprehensive and robust,” while addressing the lockdown restrictions as “aggressive but vital” for containing the spread of COVID-19 and building necessary health-care infrastructure. The Oxford COVID-19 Government Response Tracker assessed the government's prompt and stringent actions, emergency policy-making, emergency investment in health care, fiscal stimulus, investment in vaccine and drug R&D. India received a score of 100 for the strict response.[11,12]

Like many other countries in the world, the viruses of starvation, unemployment, poverty, and economic recession brought India down to its knees; hence, the government decided to open the economy. The government asked people to be “Atma Nirbhar” - “self-reliant” and declared the so-called (Political) end of COVID-19.[13]

After more than 2 months of COVID-19-induced lockdown, Unlock 1.0 was announced at around the same time when India became the fourth-worst COVID-19 affected country in the world and cases inched closer to the 3-lakh mark.[5] This reflects that the decision to unlock was based on economic and political reasons and not on medical and public health data.

India currently has the largest number of confirmed COVID-19 cases in Asia, and the third-highest number of confirmed cases in the world after the United States and Brazil, with the total number of confirmed cases in India breaching the 2.5 million mark on August 15, 2020.[5]

People of India strictly observed lockdown and social distancing for about 2 months. However, the increasing number of COVOD 19-infected cases during and exponentially after the lockdown has started resulting in anxiety, fear, uncertainty, and frustration in the population at large. Like other parts of the globe, the prevalence of mental disorder and poor mental wellbeing in India has increased due to the contradictory and uncertain public health situation. As a result, a pandemic of fear is increasing along with the pandemic of COVID-19 in India.

IMPACT OF MENTAL DISORDERS ON PUBLIC HEALTH

Mental disorders are responsible for at least 16% of the disease burden in India and 20% globally.[14] Most mental disorders arise before adulthood, therefore have high prevalence rates. They have a broad range of impacts across health (including higher rates of physical ill-health and are associated with 7–25 years of reduced life expectancy), education, employment, social interaction, stigma, and crime.[16] The National Mental Health Survey in 2016 conducted by the National Institute of Mental Health and Neurosciences estimated the lifetime prevalence of mental illness in India to be 13.7%, and 10.6% of these persons require immediate treatment.[17] However, the budget allocated for mental health is 0.05% of the total health-care budget of the country, resulting in poor implementation of effective Public Mental Health interventions.[18] The matter of grave concern is that like India even globally, only a minority of those with a mental disorder receive any treatment. Coverage of interventions to prevent mental illness-associated impacts is much less while coverage of interventions to prevent mental illness or promote mental wellbeing is negligible.[19]

CORONAVIRUS DISEASE 2019 PANDEMIC AND MENTAL HEALTH CONSEQUENCES

COVID-19 is a beta coronavirus[20] and knowledge from other outbreaks with viruses from the coronavirus family, like SARS-CoV-1,[21] can now be useful, despite differences between the viruses. Psychiatric symptoms including posttraumatic stress symptoms (PTSS)/posttraumatic stress disorder, anxiety, and depression among patients with SARS-CoV-1 have been reported during the SARS epidemic and after 1 month,[22,23]1 year,[24] and 30 months and longer.[25]

Like SARS-Cov-1, pandemics such as COVID-19 are associated with increased prevalence of mental disorder and poor mental wellbeing. This is likely mediated through effects on different risk factors including socioeconomic inequalities, poverty, unemployment, debt, recession, food insecurity, childhood adversity, violence, work-related stress, social isolation, physical illness, reduced access to health care, physical inactivity, and other health risk behavior. Persons with mental illness are likely to be at higher risk of COVID-19 infection and mortality, given their higher rates of health risk behavior and physical ill-health. Groups whose mental health is disproportionately affected by pandemics include those with an existing mental disorder, health professionals and carers, children and families, particular ethnic groups, people infected with COVID-19, migrants, and elderly.[16,26]

There are increasing data across the globe on the effect of COVID-19 infection and the effect of nonpharmaceutical measures to contain the spread of COVID-19, on mental health. The data indicate increased levels of PTSS and depression following the COVID-19 infection. Regarding the indirect effects of COVID-19 on general mental health, there seems to be evidence of an increase in depressive and anxiety symptoms along with a negative impact on general mental health, particularly among health-care workers (HCWs).[27]

In an online survey from India with 1685 valid responses, 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. The moderate level of stress was reported by about three-fourth (74.1%) of the participants, and 71.7% reported poor wellbeing.[28] Another online survey with 958 valid responses found that COVID-19 lockdown was associated with poor sleep quality, a shift in sleep cycle to delayed phase, sleep-deprivation based on night-time sleep, and depressive symptoms in a sizable number of the population.[29]

A systematic review and meta-analysis found COVID-19 was associated with a prevalence for depression of 33% (95% confidence interval [CI] 28–38) and for anxiety of 28% (95% CI 23–32) which was similar for health-care workers and the general population.[30] The prevalence of anxiety and depression was highest among those with preexisting health conditions (56%: 95% CI 39–73) and COVID-19 infection (55%: 95% CI 48–62). Studies from China, Italy, Turkey, Spain, and Iran reported higher prevalence among health-care workers and the general public. Risk factors included being female, nursing occupation, lower socioeconomic status, being at higher risk of contracting COVID-19 and social isolation. Protective factors included sufficient medical resources, up-to-date and accurate information, and taking precautionary measures.[16,26]

MENTAL HEALTH AND PSYCHOSOCIAL CONSIDERATIONS DURING CORONAVIRUS DISEASE 2019 GUIDANCE ISSUED BY WORLD HEALTH ORGANIZATION[31]

This WHO guidance[31] recommended actions for health-care workers, people in isolation, children, people with underlying health conditions, people with intellectual/cognitive/psychosocial disabilities, and older adults and their caregivers.

The guidance document further outlined ways to prevent associated stress and mental disorder in the general population which suggested:

• To empathize with persons with COVID-19

• To minimize watching, reading, or listening to news about COVID-19

• To protect oneself and at the same time, support those in need

• To look for opportunities to promote positive and hopeful stories and positive images from the local community who have experienced COVID-19.

INDIAN PSYCHIATRIC SOCIETY'S ACTION REPORT

The Indian Psychiatric Society (IPS) is playing a proactive role in the management of mental health issues of the Indian population through various activities. IPS is at the forefront of dealing with the psychological impact on the populace, supporting its fellow members and liaising with the government, other professional medical organizations, and nongovernmental organizations (NGOs) for improving situations related to mental health in our country.

IPS has developed advisories for the Government of India, its fellow members and the general public regarding appropriate steps to be taken for mental health wellbeing during this pandemic. These were appropriately circulated and put on the official website of IPS for wider perusal. IPS is conducting nationwide online surveys for the mental health impact of COVID-19 pandemic on health-care professionals as well as on the general public. Various branches and subcommittees of IPS are also holding several webinars and using different social media platforms for HCWs, mental health professionals (MHPs) and general public enabling them to readjust to the new realities arising out of this worldwide crisis.

MHPs across the country have come together to provide free voluntary online, tele-psychiatry services for all in collaboration with NGOs and Government of India. As of now, 656 MHPs have been offering their services for this activity.

The MHPs in different parts of the country have quickly reorganized their services. Outpatients and inpatient services are being provided while following new norms of social distancing, respiratory hygiene and cough etiquettes. Deaddiction services have changed the dispensing patterns for opioid de-addiction services, intravenous drug use and methadone maintenance clients. They are now being given a week's supply of buprenorphine and methadone as take-away, respectively. Many institutions are running mobile units for dispensing psychotropic medications and providing consultations.

IPS is playing an active role in the training of HCWs who are working in the care of COVID-19 patients. Training on stress management, support, and counseling is being provided to the HCWs in need during posting in COVID-19 wards as well as during their quarantine and isolation period. MHPs are also taking an active part in the preparation of additional workforce during COVID-19 like training of the National Cadet Corp volunteers and veterinary doctors. IPS members are providing resources and consultation to print and electronic media with reliable mental health information in the context of situations such as lockdown, domestic violence, and substance-use-related problems.

The Government of India has issued a telemedicine guideline as the patients are unable to visit hospitals and clinics. For improving its practical utility, an official request was made to Government of India by IPS to allow prescription of certain prohibited psychotropic medication such as phenobarbitone, clobazam, and clonazepam through telemedicine to which government agreed. This is expected to help a wide variety of patients.

WHEN WILL THE CORONAVIRUS DISEASE 2019 PANDEMIC END?

MHPs are now facing the question from every individual and all the sections of society that “When will the coronavirus pandemic come to an end?” This single question which has far-reaching consequences on mental wellbeing is on everyone's mind. While astrologers and politicians have answers, scientists, doctors, and psychiatrists have wisely refrained from offering predictions on the same, as the answer involves a complex multifactorial interplay.

Medical historians recognize two types of endings of any pandemic. The medical ending, which occurs when the incidence and death rates plummet; and the social ending, when people have overcome their anxieties and moved on, in other words, when the epidemic of fear about the disease wanes.[32] It would be appropriate to add two other types of ending: an economic ending, when lockdown measures for saving people from the coronavirus are sequentially lifted, and economy gains back its momentum and a political ending when the government claims that as far as it is concerned, the pandemic is over. Any of these four endings could occur first. With unlocking the country government has declared the economic and political end of the pandemic. However, the increasing numbers of infected cases across the globe in general and India, in particular, the uncertainty regarding the end of the pandemic can have even more severe psychological impact and requires assessment.

THE PSYCHOLOGY OF UNCERTAINTY

The psychological wellbeing of the whole world is at stake. Uncertainty can cause most of us tremendous anxiety. Why? Our brain is continuously updating an individual's world. It keeps on making judgments regarding what is safe and what is not. It makes up all sorts of untested theories hundreds of times a day. To the survival brain, uncertainty means danger.

If one's brain does not know what's around the corner, it always assumes the worst, over-personalizes threats and jumps to conclusions. Moreover, we are hardwired to overestimate threats and underestimate your ability to handle them - all in the name of survival. When certainty is questioned, our stress response goes haywire, instantly arousing our fight-or-flight reaction. At times, uncertainty may feel like being tortured by a million tiny cuts. The brain prefers to know a particular outcome rather than anticipation of various unknowns to take the edge off.[33]

Studies show that people are calmer anticipating pain than anticipating uncertainty because pain is certain. Job uncertainty, for example, takes a more significant toll on one's health than actually losing the job. We are more likely to maintain the stamina to continue taking risks after a car crash than after a series of psychological setbacks. Changes at the policy level and broader public education are essential for minimizing the harmful effects caused by stress arising from uncertainty.[34]

Researchers had observed that study participants with knowledge of an inevitable painful electric shock felt calmer and less anxious than participants that were informed they only had a 50% chance of receiving an electric shock.[35]

The COVID-19 pandemic could end socially prior to meeting its medical end. This can be understood in a social-psychological context of exhaustion and frustration. It is possible that before a vaccine or effective treatment is found, the masses growing tired of the safety restrictions may declare that the pandemic is over, even as the virus continues to spread in the population.[36] Further, the conventional way to try to answer the question of “when new Covid-19 cases will start declining?” is to look for an effective vaccine. Once a safe and effective vaccine is invented, undergoes mass manufacturing and universally administered, the community will acquire “herd immunity” against the SARS-CoV-19 virus, and the COVID-19 pandemic will be brought under control. For herd immunity to kick in, 50%–75% of the population needs to attain immunity either through vaccination or infection. Till then, it is advisable to practice the following tips for mental wellbeing.

Do the basics, but do not panic

The risk of COVID-19 infection to the Indian public is relatively low. It is expected that as much as 80% of the population may not require any or only minimal medical care. COVID-19 has a high transmission rate with a low mortality rate. This said, we still need to remain vigilant, calm, and level-headed and follow recommendations from the experts.[37]

Living well

Social interaction while maintaining physical distancing, physical activity promotion including at home, positive psychology interventions such as meditation and mindfulness, financial interventions, neighborhood and housing interventions, access to green space while maintaining physical distancing, arts, creativity, cultural, religious, and spiritual interventions.

Working well

Increased control, flexible working including working from home, training to improve jobs, shared activities including online psychological approaches, and support for people recovering from a mental disorder.

Ageing well

Older people are at higher risk of COVID-19 and are advised to be particularly stringent about physical distancing.

Promote resilience

Resilience involves negotiating, managing and adapting to stress or trauma. Having resilience protects against the onset of mental disorder, poor mental wellbeing and associated impacts. Resilience can be promoted through mindfulness programs, school-based interventions, and work-based interventions aimed at persons with a higher risk of stress.[16,26]

Learn to live with coronavirus disease 2019 pandemic and the new normal

Accept that the world has changed and we have to change our lifestyle in the face of COVID-19.