Covid-19: Mind at unrest

A young woman in sunny yellow trousers and a black top, her hair in a careless bun, walks into a building with two small paper bags in hand. Her neighbours are lined up on either side of the entrance. One blows a conch shell, another beats a copper plate. The rest simply cheer her on.

Sumiti Singh, 34, the second person infected by the novel coronavirus in Ahmedabad, was returning home. But this was not the reception she’d expected. “I was worried people would be scared,” says the businesswoman, on the phone from Ahmedabad.

Tough ride: Covid -19 isn’t just physically debilitating; it exacts a psychological toll as well, one that requires care beyond the hospital bed

Covid-19 isn’t just physically debilitating, it exacts a psychological toll as well; one that requires tending beyond the hospital bed. And Singh knows that well.

The past fortnight had been a nightmare for her. A much-desired trip to see the Northern Lights in Finland had ended in infection. When she moved into the isolation ward of Ahmedabad’s SVP Hospital, she was worried about her family, her sister and elderly parents, who were all in quarantine but being inundated by phone calls.

“There was a palpable fear among my neighbours,” says Singh, now free of the infection and under home quarantine.

At the hospital, she watched as patients broke down on receiving their test results. One had a panic attack and needed to be given oxygen. Singh decided to take things head on. The doctors would take care of the virus, and she would deal with her own mental stress.

She chalked out a few rules to abide by. “I decided not to read stories about death. Instead, I read accounts of recovery.” The family was never far as they met — virtually — every day.

But Singh was also the owner of a store and a web of rumours and half-truths was taking over the outside world. Before she and her illness became the subject of feverish WhatsApp forwards, she decided to open up on Facebook about her illness. That changed the tide — accusations and apprehension gave way to empathy. People wrote in to wish her a speedy recovery.

“People who were anxious about Covid-19 called up. Maybe because I was Covid-19 positive, they felt comfortable talking to me. Mothers awaiting test results of their children called. They were all anxious and needed reassurance,” Singh says. She responded to as many as she could from the hospital bed.

If the illness taught her something, it was the need for support. “Most people need somebody to talk to. If you know any Covid-19 infected person, reach out; don’t let them feel alone.” As she noted in a Facebook post: “The fear is real, the shock is real, the paranoia is real, the WhatsApp forwards with no privacy for patients and their names & work, is real (sic).” Her FB posts, she feels, were behind her neighbours’ warm welcome when she returned from the hospital. The video of the homecoming was shared widely on social media.

A microscopic germ on a rampage across the world has snuffed out over 80,000 lives so far. Few other phenomena in recent times have thrown humans off the grid as Covid-19 has, leaving people with two overarching emotions — fear and worry.

“An individual may be worried about the growing number of Covid-19 infected persons or the rising death toll, the possibility of getting infected or the indications to look out for,” stresses Dr Deepak Jayarajan, associate professor, psychiatric rehabilitation, National Institute of Mental Health and Neurosciences (Nimhans). “The worry can be about the financial implications of the lockdown or the social stigma associated with the illness — doctors have been picked on. All this leads to stress.”

The physiological havoc the virus wreaks is evident, but not so much the psychological scars. How does the virus with an ability to sneak in anywhere impact one mentally? How does it psychologically affect the infected and the quarantined, the front-line workers and the vulnerable? And how has the lockdown in India, a measure that has thrown habits and livelihoods out of gear, fused physical confinement with psychological uncertainties?

Singh tries to cope by reaching out to people in a similar situation. The illness, she knows, is unlike any other battle. “To call my Covid-19 days a difficult phase will be an understatement. Those 14 days seemed like 20 years to me.”

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How do pandemics affect the mind? Psychiatry of Pandemics: A Mental Health Response to Infection Outbreak (2019) , written by eight New York-based psychiatrists and edited by Damir Huremovic, is a rare exploration of what goes on in the mind the mental condition in the event of a contagion. While the Spanish flu of 1918 was the last pandemic in human history, recent outbreaks of SARS, H1N1 , Ebola and Zika created new anxieties about infectious diseases.

“We observed in awe how the public would react to an impending outbreak in their midst and how those public fears would emerge and spread like, well, an epidemic,” notes Huremovic in the preface. While the contagion and the fear both tend to swell and abate, the aftermath of an outbreak, Huremovic asserts, is of “serious consequences” as it is about “newly acquired knowledge and immunity”. “The aftermath of an emotional outbreak”, on the other hand, he asserts, “would bequeath to us mostly oblivion”. As a crisis blows over, the individual and the community exhibit a desire to “return to their daily routines and banish the plague from their conscious thoughts”.

The word ‘contagion’, the authors point out, comes from the Latin word for ‘touch’. Little wonder that much of the angst around Covid-19 has manifested in the repeated rinsing of hands.

Once again: Much of the angst around Covid-19 has manifested in the repeated rinsing of hands

Sameena* (name changed) has been washing her hands over and over again. The Kozhikode homemaker, in her 60s, was undergoing treatment for depression and the defiant virus upped her anxiety in no small measure. She washed her hands, rinsed them again and repeated the process all through the day, and insisted that everyone around her did the same.

Then, worried that she wasn’t following social distancing norms, she went into the bedroom, separated the twin beds — placing them a metre apart — the prescribed social distance. The family had to schedule another meeting with her psychiatrist.

“Stress precipitates psychiatric illnesses,” says her doctor PN Suresh Kumar, professor of psychiatry at KMCT Medical College, Kozhikode.

For people with underlying psychiatric conditions, crises such as a pandemic, coupled with a lockdown, can be exacerbating, points out Dr Kumar.

There are cases of patients undergoing treatment for obsessive compulsive disorder (OCD) who refuse to take off their masks, or who keep washing their hands. Some patients find it tough to control their anxiety about illnesses and those with post traumatic stress disorder (PTSD) are fighting a relapse, he says.

The pandemic and the ensuing lockdown are unpredictable events which have no clear end in sight — an uncertainty that adds to the stress. “Stress, in itself, is not a severe condition, but becomes one when it morphs into depression or takes other forms,” says Dr Kumar, who is the convenor of the Indian Medical Association’s Kerala state mental health committee.

Dr Jai Ranjan Ram, consultant psychiatrist at Apollo Gleneagles Hospital, Kolkata, has noted a steady increase in patients dialling in for help. “Situations such as these can give rise to a spectrum of psychological problems,” he points out.

The most vulnerable segment — apart from people with pre-existing psychiatric conditions — are the elderly, he adds. Senior citizens are at the highest risk of contracting Covid-19 and this susceptibility has kept a whole section of the population on guard.

“They need a steady supply of medicines and are usually dependent on carers. All of that is affected by a lockdown,” Dr Ram points out, while Dr Kumar notes senior citizens have few avenues where they can voice their worries.

The lockdown, more than the pandemic, has been cataclysmic for women, especially those trapped in bad marriages or have suffered sexual abuse.

“Being physically confined takes women back to a dark space. I try to reassure them that they have survived worse situations, so they will tide over this, too. But they certainly are in distress as past traumas are recreated,” says Dr Ram.

The lockdown has bared the fissures in intimate relationships. News reports highlight the surge in domestic abuse world over since the pandemic. In India, the National Commission for Women reportedly received 58 complaints from March 23–30, the first week of the lockdown.

Many have called helplines, and not just for answers to queries on Covid-19. The Kolkata-based Indian Psychoanalytical Society (IPS) launched a helpline soon after the lockdown. “We received over 70 calls in a matter of four days. And they came not just from Kolkata, but also Delhi and other states,” says IPS president Pushpa Misra.

The century-old society has trained over 20 counsellors to specifically be a part of the helpline and has psychiatrists on board.

“While the psychiatrists received calls from existing and new patients with queries on Covid-19, the calls received by our counsellors are different in nature,” Misra says. The calls, largely from people in the 25-45 age group, span a slew of latent problems.

“The lockdown has confined people within the four walls of a house. Long-running personal problems, which otherwise had an outlet, no more have one,” Misra says.

People dialled in to share divorce proceedings and break-up issues. Youngsters stranded in the city, cut off from family and friends, called seeking support. Many were concerned about their non-existent social life. “Going to work and stepping out are a mechanism to cope for many,” notes Misra. The lockdown, more than the virus, brought them face-to-face with their deep-seated anxieties.

Bharti Jain, a psychoanalyst with IPS, has been helming the orientation classes for counsellors, who are all qualified therapists and psychologists. ”In dire situations such as these we seek to provide immediate relief,” Jain says. The counsellors are given instruction — mainly to listen patiently and wholeheartedly.

“People depend on a helpline when they are threatened. That threat can be Covid-19, the lockdown or a personal matter,” says Jain. She guides the counsellors to provide, what she calls, “factual hope” to the callers. “We direct them to the positive aspects in their life which are definitely there. People going through a bleak phase tend to feel that time moves very slowly. But that is not the case,” adds Jain.

For a large section of people, the lockdown has snapped shut avenues for income. Faced with a dire future, migrant workers had set off for home hundreds of kilometres away on foot late last month. Mental health experts point to the widespread anxiety about jobs that has surfaced after the lockdown.

Among the new patients who reached out to Dr Ram in the recent weeks was an IT professional in her 30s. “She was reasonably certain that she would lose her job after the lockdown,” Dr Ram says. The woman’s fears were real; she had dependent parents and was daunted by the possibility of joblessness. “She came to me with a severe panic attack,” he says.

Dr Kumar concurs on the toll these disruptions will take on the working class. “For daily wagers, these transform into days without income. Even if they are compensated it would never be on par with what they would earn in the normal course. The psychological impact of these uncertainties is immense,” he says.

He observes that mental health issues tend to surge in the wake of an infectious outbreak. “This happened in Kerala after the Nipah attack two years ago,” he notes.

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In its short lifespan, Covid-19 has become a logbook for despair and heartbreaks. One image, shared on social media, shows a doctor breaking down as he stands metres away from his small son, unable to give him a hug.

Learn afresh: The lockdown, despite the physical curtailments it bring, may be a good a opportunity to forge a meaningful bond between parents and children

“That boy will think for the longest time that he did something to make his father weep,” observes Nupur Dhingra Paiva, Delhi-based clinical child psychologist. Young children, the psychologist points out, do not have the cognitive capacity to see if there is something else that is troubling the parent. “When the parent is under stress the child sees it as their responsibility to do something about it.”

The virus and the lockdown have immeasurably shrunk a child’s physical world. There are no schools to attend, no play in the park or friends to meet. Despite the curtailments, Paiva considers this an opportunity to build meaningful relationships with children. Unlike for adults, a lockdown need not turn a child’s world upside down.

“Often, physical activity compensates for other things missing in our life. But at a time when that activity is not an option, family relationships take the centre stage,” Paiva says. For that to work, the child psychologist says, it is imperative to move beyond the staple reaction: What does one get a child to do.

“That is a trap. It is as if giving the child something to do will take care of the inner world. It won’t,” she adds.

Children, Paiva observes, should experience boredom and irritation before finding out what they would like to do. A child can cope with restrictions as long as the parents are fine.

“One thing that matters to children is the relationship of the parents,” she says. When the parents are stressed, they tend to pass the tension on to the children in the form of annoyance or a spate of instructions.

“Parents come down with control because they are feeling controlled by the State. Human reaction is to pass that control to someone who is weaker than you. For the child, all this can appear like a long, bad summer holiday.”

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As Covid-19 continues to wreck lives, mental health experts advise curbing the unhindered consumption of news related to the pandemic. Dr Jayarajan from Nimhans says it is best to stick to a schedule — maybe twice a day — to gather news updates. Relentlessly following the death toll and those newly infected will only stoke fear and anxiety. “Transparent channels of information from the administration will help reduce fear. When people know enough, they will act rationally. When they know the measures they are to take in times of crisis, it will help take away fear,” says Dr Jayarajan.

The importance of mental health in a pandemic has not been missed by the Kerala government. It is among the few state administrations to draw up mental health guidelines for each section of the community, including the elderly and the quarantined. There are separate recommendations for healthcare workers. “Availability of basic protective gear will go a long way in assuaging the anxiety of healthcare workers,” Dr Jayarajan adds.

Mental health in the time of pandemic has been flagged by the Supreme Court, too. In a series of recent orders, it has emphasised the need to focus on the mental wellbeing of the migrant workers stranded in camps, as well as juvenile inmates in correction homes and undertrial prisoners during the viral attack.

Some amount of anxiety, notes Dr Jayarajan, is normal in unusual situations such as these. “It becomes dysfunctional when it interferes with the ability to function,” he adds.

Help and support, he observes, can come from diverse avenues: From family and colleagues, a virtual conversation between a quarantined person and the family, in compassion shown to an infected person or in facilitating the supply of medicines to existing mental health patients.

While individuals may learn to cope, it might be a while before they find comfort in community once again.

“It remains to be seen how we will respond if the person next to us in the mall sneezes,” Dr Ram says.

P Anima

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