|Year : 2020 | Volume
| Issue : 1 | Page : 133-139
Mental health perspectives of COVID-19 and the emerging role of digital mental health and telepsychiatry
Pragya Lodha, Avinash De Sousa
Desousa Foundation, Mumbai, Mahrashtra, India
|Date of Submission||02-May-2020|
|Date of Decision||14-May-2020|
|Date of Acceptance||15-May-2020|
|Date of Web Publication||20-Jun-2020|
Dr. Avinash De Sousa
Carmel, 18, St. Francis Road, Santacruz West, Mumbai - 400 054, Maharashtra
Source of Support: None, Conflict of Interest: None
The 2019 coronavirus pandemic started in December and has now spread worldwide. This pandemic has huge mental health implications with immense psychological morbidity among the common man, patients with preexisting psychiatric diagnoses causing many relapses and exacerbations after it has ensued. Many guidelines have been put forward by various agencies to address the issue of combating mental health challenges that have arisen as a result of this pandemic. This review paper looks at the role of psychiatry and psychiatrists and the mental health challenges faced by us during this pandemic. The role of mental health interventions, the issues faced and the emerging role of telepsychiatry with its ethical and clinical dilemmas are discussed.
Keywords: Coronavirus disease 2019, interventions, mental health, pandemic, psychiatry, psychological, telepsychiatry
|How to cite this article:|
Lodha P, De Sousa A. Mental health perspectives of COVID-19 and the emerging role of digital mental health and telepsychiatry. Arch Med Health Sci 2020;8:133-9
|How to cite this URL:|
Lodha P, De Sousa A. Mental health perspectives of COVID-19 and the emerging role of digital mental health and telepsychiatry. Arch Med Health Sci [serial online] 2020 [cited 2020 Dec 4];8:133-9. Available from: https://www.amhsjournal.org/text.asp?2020/8/1/133/287370
| Introduction|| |
Corona virus disease 2019, or coronavirus disease 2019 (COVID-19) is a novel virus that belongs to a family of viruses with other viruses as Middle East Respiratory Syndrome coronavirus and Severe Acute Respiratory Syndrome (SARS-CoV). These viruses cause illnesses ranging from the common cold to more severe diseases such as pneumonia, SARS, kidney failure, and sometimes death (in 3%–5% cases). The outbreak began in December 2019, in the city of Wuhan, in China. The global population affected by the COVID-19 pandemic account for about 3 million people (as of April 27, 2020) being affected and >2,00,000 have succumbed to death because of this disease. Developed and developing countries have seen similar effects of COVID-19 with fairly similar ramifications on the mental health of its people as well. Early Chinese studies have reported some aspects of the initial mental health issues that have emerged during the pandemic. This review looks at the various mental health and psychiatric issues related to COVID-19 and also discusses the emerging role of telepsychiatry and digital mental health as a result of this pandemic.
| Mental Health Implications of Coronavirus Disease 2019|| |
Corona-anxiety, coronavirus disease anxiety, and panic attacks
Initially, the outbreak of COVID-19 induced and accelerated anxiety and panic attacks among people as everyone was mopped with the fear of developing the infection. Although an anxiety-laden response may be normatively expected in a situation of an illness outbreak, many people who had pre-existing anxiety-related disorders, experienced worsened symptoms. In general, it invoked a health-anxiety response among people where individuals became extremely cautious of contacting anything possible that could cause them to be infected, and had a hypochondriacal response to common cold symptoms. This was usually aggravated due to misinformation and rumors spreading like wild-fire in such sensitive times. In addition, many people also reported having novel experience of panic attacks and the ones with a preexisting panic disorder or panic attacks, reported experiencing worser ones, with greater intensity. There were some people who also relapsed with a panic attack after the outbreak news. Apart from the panic experience, many people reported fresh episodes of feeling depressed and anxious, experiencing disturbed sleep and overwhelming emotional experiences (personal clinical experience, AD and PL).
Psychological effects of quarantine and lockdown
The situation worsened with quarantining practices levied for prolonged periods which was deemed to contain the rapid spread of COVID-19. A wide range of psychological symptoms was noted as a result of the quarantine, some of them being, psychological distress, and disorder, including low mood, insomnia, stress, anxiety, anger, irritability, emotional exhaustion, depression, and posttraumatic stress symptoms. In severe cases, suicide has also been reported due to the fear of developing the disease. The COVID-19 pandemic has resulted in a nationwide lockdown that has lasted for over a month. National and international travel was affected and people were ordered to stay indoors while moving out sparingly for essentials only. The lockdown is a unique phenomenon on its own. This is very different from quarantine where the patient is isolated at home or in a quarantine facility and does not get to meet his family members.
The lockdown would have psychosocial and financial implications as well. The lockdown would affect daily wage earners and those that have businesses and establishments that earn on a daily basis. The longer the duration of lockdown, the greater the financial strain. This correlation directs an arrow toward exacerbated experiences of depression, anxiety, uncertainty about the future and days ahead which would cause panic and further anxiousness resulting due to financial insecurities. The person with financial liabilities would succumb more to the same during the lockdown period and this would lead increased severity of depressive symptoms and an increased frequency of panic attacks.
Patients with severe mental illness and coronavirus disease 2019
Patients with severe mental illness may also be at an increased risk of contracting COVID-19 infection. Homelessness and disorganization along with residences in slums may thwart the social distancing protocols in these groups. Lower rates of literacy have been correlated with little access to COVID-19-related educational material and may throw caution to the wind. Many patients with severe mental illness may delay diagnosis and coming to a hospital and may thus not receive mental health care. They may also delay seeking help if having COVID-19 and may unintentionally infect others around them. Even if treated they may not comply with medical care. It is also prudent to understand that sometimes people with mental illness may be turned away from COVID facilities in view of the inability of health-care staff to deal with their needs and there is a need for a psychiatrist as a part of the COVID treating team in these cases.
There have also been challenges for children with special needs such as children with autism spectrum disorders who find it difficult to adapt to changed routines. Children with other preexisting behavioral and emotional concerns have also faced challenges amidst the lockdown. Lack of special schooling, routines, absence of regular occupational, and physiotherapy have led to a deterioration in their mental and physical condition. It is also distressful for parents of special children to manage this population the whole day at home.
Lack of access to proper mental health care
Lack of access to proper mental health care facilities is one of the principal challenges amidst quarantine, causing double-edged distress for people suffering from mental health problems. Most psychiatric facilities and outpatient departments will be nonfunctional (since a major load of work-force has gone and the curtailment of transport during “lockdown” adds to the misery of patients with severe mental illnesses. Patients with severe mental illness are often at home while their caregivers keep outdoors for occupational chores. Patients and caregivers are now having to stay together due to the enforced lockdown and this lack of movement and freedom has brought to the surface irritability and upsetness in many patients. There are increased chances of relapse of illness and/or exacerbation of the symptoms during this period.
Many patients suffering from schizophrenia have reported relapse of delusions and hallucinations and additionally, has also generated new delusions around the themes of the current pandemic (personal experience, AD). There is also proposed increase in aggressive and violent behaviors with patients reporting a considerable rise in paranoia and suspicious thoughts. Some patients with preexisting diagnosis of obsessive–compulsive disorder have also shown a relapse of symptoms, with exacerbated obsessions relating to the current sanitization and cleanliness drive and compulsions in the form of repeated hand washing and cleanliness. Depressive symptoms have worsened while some patients have also developed suicidal thoughts and feelings. There have been reported cases of suicide attempt as a result of the fear of COVID-19 or having known that their family members got diagnosed with the same (anecdotal record reported in regional newspapers). Withdrawal symptoms have been seen in patients with substance abuse to alcohol and drugs.
Relapse of patients with preexisting diagnosis of mental illness
Another vital issue is with patients who have a preexisting psychiatric diagnosis. The availability of psychiatric medications may be difficult in a lockdown due to short supply and there may relapses due to a lack of compliance with medication in many cases due to this reason. We may see acute exacerbations and relapses that may need admissions as well as revised medication schedules which may not be possible in the current scenario. It has been noted that even when these patients visit medical and emergency services with genuine physical and medical symptoms they may be shunned away as the label of psychiatric diagnosis may make health-care personnel assume that all their problems are psychiatric in nature. The caregiver burden of these patients shall also increase due to the lockdown.
Mental health and special populations during coronavirus disease 2019
It has been a challenging situation for many people who find themselves stuck at home when the home environment is negative, hostile, and abusive/violent. There has been a surge in calls were received in 11 days of initiating a helpline for reporting domestic violence in Mumbai and Paris reported a rise in domestic violence cases by 36% during the lockdown phase. Along with incidences of domestic violence, incidences of child sexual abuse, sexual and emotional abuse with or without physical abuse have seen a spike for women and children. Unfortunately, accessing protection and help becomes more challenging in such times; and even more for children in case the perpetrator may be from home.
There are a large number of elders in the community and a further number of elders in old age homes. The effects of COVID-19 vary between these populations. The people in an old age may be secure as protection may be implemented but also old age home staff may reduce in the wake of the lockdown and their care may get compromised. Their families who would visit them weekly or fortnightly shall cease to do so and the uncertainty on when the lockdown ends shall add to their trials. For those living alone in the community will have to step out of their houses for essentials as they have no one to get chores done for them while the lack of transport will make their commute tedious and the absence of maids shall make chores seem onerous. They shall thus have to exert more than they did before with their bodies which are already reeling under the weight of their existing medical and physical ailments.
Many children and adolescents with preexisting behavioral and emotional issues have a possibility to experience worsened symptom and there may be exacerbation of attentional and basic disciplining issues. Lack of medication may worsen these issues. The present situation entitles schools as stakeholders to take the initiative and carry out positive mental health interventions using digital media for children and adolescents who may be worried about multiple issues and they can be addressed in simple and lucid language for them to understand. Educators are expected to play the role of “educarers” where the issue of concerns rise beyond those of academics.
Another vulnerable population is the LGBTQ + group who has had to face hostility and loneliness along with the similar mental health challenges as many others such as frustration, emotional exhaustion, panic attacks, anxiety pangs, low moods, and anger. A large number of members of this populations have found it difficult because they have had to move back to staying indoors in negative household environments and homophobic unsupportive family members. Having the status of belonging to the Black, Asian and Minority Ethnic (BAME) population and homelessness have increased the isolation rates and greater risks for embalming in the pandemic. At home, where they are not understood and supported, ill-treatment and discrimination have been double edged. This increases their risk for mental health burden by two-fold.
Mental health implications among frontline workers
Frontline workers are usually the medical health and para-health professionals who work with the pandemic victims directly. However, during COVID-19, several others have also served as the frontline workers who have enabled services and security being ensured. The other frontline workers are police personnel, cleaners and sweepers, delivery personnel, pilot and flight attendants, grocers, pharmacies, scientists and researchers, IT professionals, farmers and food providers as well as Non Governmental Organizations (NGOs), Accredited Social Health Activist (ASHA) workers, Anganwadi workers, and public health caregivers. All these people have been ensuring the safety, security, and administrative needs during the time of lockdown by delivering required respective services. However, a neglected area among these frontline workers is that of their mental health. It is disappointing to learn that noncooperation with and physical injuries inflicted on the police personnel and the doctors amidst this lockdown has added to greater mental health burden as well. In a country like India where cultural factors aggravate the stigma attached to talking about mental health, several frontline workers are left to suffer the grind of mental health turmoil while they continue to be at work. Some immediate mental health challenges that our frontline working medical health and paramedics are currently facing include emotional strain and physical exhaustion, co-workers falling ill, shortage of staff creating burden on existing working staff, a looming fear of carrying back the infection to their families, taxed with unfamiliar, new duties in times of crises, increased workload means extra and long working hours with bare minimum sleep and essentials and the loss of patients in pandemic situations it can be overwhelming and beyond compassion fatigue to deal with excessive numbers of death.
Continuing mental health care in coronavirus disease 2019
The biggest problem during COVID-19 would be availability of proper mental health care. In addition of facing crises with aggravated symptoms, people with preexisting mental health illnesses have also had to struggle with inaccessibility to mental health professionals, online consultations and online therapy sessions (which may not be as adequate as face-to-face consultation for many) and lack of availability of medication. Patients would not be able to reach a mental health professional and a majority of consultations would happen over the phone and in India, telepsychiatry as a modality is yet to kick off in a big way. The psychiatric examination and mental status examination are best done in person and a teleconference video call may not suffice for the same. Many agencies have started telepsychiatry services offering free mental health services during the COVID-19 lockdown. Thus, while services are available, there is no stringent body that would monitor the quality of these services and whether ethical standards are adhered to. It is important that professionals and agencies offering telepsychiatry services have professionals who are qualified and trained in this regard to some extent. This is just one of the few issues that concern mental health during the lockdown but plays an important role as delivery of care is solely based on online platforms in periods of logistical curtailments of the lockdown.
The emergence of telepsychiatry
Telepsychiatry has helped negotiate the biggest problem faced during the COVID-19 pandemic which is access to proper mental health care. Telepsychiatry is a method where online consultations, e-prescriptions and taking online therapy sessions have been the only alternative one could have headed to. Although guidelines for telepsychiatry and teletherapy are in place, there are also various clinical issues that pose ethical challenges. Intriguingly, with only the online medium being available, various considerations of online counseling and telepsychiatric consultation have had to be tweaked keeping the well-being of patient's paramount.
While mental health services have been provided through a telemedicine format there are many clinical, public health, and ethical dilemmas that have arisen in the practice of telepsychiatry:
- Even though medications have been prescribed and prescriptions sent in a pdf format to patients through E-mail, there have been issues of chemists not honoring the prescription due to the need for an original physical copy of the prescription when it comes to their guidelines. There has also been an acute shortage of many psychiatric medications due to nonavailability and short supply from the drug distributors. Thus, many patients though wanting to be compliant and even after seeking a consultation online or through telephone and after procuring a fresh prescription from their doctor, still have had to face a shortage of medication. Thus, we are an unprecedented rise in relapses of psychiatric illnesses not due to noncompliance but due to a short supply of medication 
- Many people have developed what has been called corona-anxiety with fears that may contract infection and then may later be admitted or quarantined after they may contract the virus. Mild fever, sore throats, and cough may be thought of as COVID when it may just be another viral infection. The need to wear protection and step out of their houses may precipitate anxiety and this shall only exacerbate anxiety further in patients with anxiety disorders and those with anxiety as a personality trait. Excessive protection-related worry and obsessions related to social distancing and protection may develop in people. When these patients may call a telepsychiatry service, there is a huge clinical debate in distinguishing them as having pure psychological issues while also referring them to medically oriented helpline where they may be guided better on COVID. The medical helpline may increase their anxiety and stress if they are told to go in for a check-up and mandatory COVID testing 
- The ethical dilemma that may also arise which is a personal rather than a professional one is whether one must charge for a telephonic consultation or not. Another issue is whether the charges would be same as that for a face-to-face consultation. There has been surge of nongovernmental organizations and voluntary agencies that along with professional medical association that have been offering free telepsychiatry services while the challenge for private practitioners is whether they must charge for telepsychiatry services or not. Many doctors who never charged for telephonic advice would have to charge now as their telephone consultations are the only source of income for them during the current pandemic. Another professional dilemma is whether the charges would be time based and on what guidelines must these charges be based. Many doctors in India have houses to run and families to care for and one would have to maintain a fine balance between the professional aspect of being a doctor, charging fees and being altruistic and maintaining the ethical and social standards of medicine being labeled a noble profession where money though essential is not a priority 
- Telepsychiatry has the dilemma of handling major psychiatric emergencies. How does one handle a patient that is suicidal and about whom we have no details except the number he called from. Suppose, he calls a psychiatrist for a telephonic consultation and expresses suicidal ideation. Then he cuts the call and switches off the mobile phone. We have no clue of what may happen to him. Do we collect names, address details, and details of caregivers with documents for address proofs before a telepsychiatry consultation? This may be prudent and just but may also drive away patients from seeking help who do not wish to inform family members and prefer to maintain anonymity to some extent while seeking telepsychiatry consultations. There is no proper guideline to help us in clinically relevant yet vexing situations like these 
- The same dilemma holds true in cases of domestic violence and child sexual abuse and under the law we are supposed to report such matters to local authorities. There has been surge of such cases during the COVID pandemic. Do we refer such patients to issue specific helplines for these causes or do we take it on ourselves to report such matters in the wake of the already testing nature of an existing pandemic and the fact that law authorities are already grappling other situations to deal with 
- Telepsychiatry has been used for adolescents in juvenile remand homes and school metal health settings, but there has been lack of guidelines assisting the same. There is a need to decide how to continue to provide help to adolescents when and if they choose telepsychiatry over face-to-face consultations and whether this would be an acceptable norm. Another concern has also been to have continued therapy for children below the ages of 16-year-old where their access to therapists have completed been weaned and rather been guided by parents (which may not be as effective for children with existing behavioral and emotional challenges). Lack of guidelines and poor privacy controls on social media platforms being used for telepsychiatric consultations are also challenges in the present form of delivery psychiatric care of patients 
- There is a need to seriously look at telepsychiatry and mobile mental health as a means to reach every corner of India and thus use the full potential of mobile telepsychiatry in India. Telepsychiatry facilities needs to operate round the clock and must look after psychiatric emergencies all over India.
Managing stigma related to a psychiatric diagnosis
In India, psychiatric diagnosis often comes with stigma and this diagnostic label that would often affect the care that the patient would get from other medical specialties. A large number of physical symptoms that the patient experiences will tend be attributed to psychopathological rather than physical cause and they would be labeled as having functional somatic symptoms. There is a need for all medical departments to treat patients with psychiatric diagnosis, open mindedly as these patients are likely to visit emergency medicine departments during the pandemic period. As part of equal practice, it should be ensured that these patients receive the proper and prudent level of care that they may need. All specialties must be welcoming and not turn away patients with a psychiatric diagnosis. There are situations possible where patients with psychiatric illness may require treatment if they suffer from COVID-19 and may not always be cooperative to treatment and care. In such instances, psychiatric facilities that cater to COVID patients must be separate in view of the aggressive and uncooperative behavior that patients may show. They must be attended to and their medical needs must be handled if required with equal care. The print and social media along with cinema and portrayal of mental illness in movies also play a central role in both aggravating and fighting stigma and discrimination. Correct and scientific portrayals of mental health need to replace the negative media stereotypes regarding people with mental illness, their families and mental health-care professionals.
Faith healing and cultural considerations in psychiatric illnesses
To begin with, there are several factors that cause hindrance and delay in getting the first right treatment for psychiatric problems. Some of these factors are sociocultural backgrounds, level/exposure of education, traditionally influenced attitude of family/society toward mental illnesses, (mis) perceptions, myths, misled beliefs and stigmas attached with psychiatric disorder along with the lack of availability/accessibility of psychiatric services, referral patterns, and religious views including approach to faith healers. In India (and several parts of the world), problems of age old cultural myths, demonic and supernatural explanations of psychiatric disorders and the need to visit faith healers and places of worship seeking a cure for mental illness have persisted over hundreds of years. Faith healers are often first care providers for a majority of psychiatric patients and they are rarely referred for psychiatric care thereafter. Although recent instances exist where caregivers and patients might visit faith healers and but also simultaneously seek help from modern and traditional methods of therapy. The reason for the same is magicoreligious model of causation of psychiatric disorders and faith in black magic and exorcism. Many religious leaders (not all) may impart wrong impressions about COVID-19 and offer diverse therapeutic methods, and ignore social distancing. Combating these blind beliefs is another challenge faced during the pandemic is yet another issue for psychiatrists and mental health professionals and social media and print media must be well used in this regard.
Need for proper consultation liaison psychiatry services
Earlier the need for mental health services during the current pandemic was not felt and this made psychiatry appear as a nonessential need during COVID-19. Many hospitals and centers have allowed that their nonessential medical staff to stay home that included basic sciences and psychiatry in many quarters. Psychiatrists and mental health professionals are needed for everyone who may have fear and uncertainty related to the pandemic, even if they are not infected with COVID. These patients may come to emergency departments and may present with psychiatric symptoms, panic attacks, and acute anxiety. They may need acute management and counseling. There may be admitted in-patients who are worried about their existing medical problems worsening and even admitted psychiatric patients may have their treatment half complete as hospitals have been vacated in view of the current pandemic and closure or nonessential medical services. Consultation-liaison psychiatrists will be the mainstay in hospital and multiple specialties systems and will be on the frontline in the COVID pandemic.
Lack of pandemic preparedness
The limited scientific understanding of the COVID-19 pandemic and the technical “know how” of interventions is coupled with a lacked of disaster preparedness and pandemic preparedness in the medical community. Pandemics are rare occurrences and do not follow similar trends that are identifiable and that one may thus plan in advance. It is humanely not possible for any scientific group to be able to predict how the COVID-19 would affect human health and how it would start, spread, and end. We need a deeper biological and epidemiological understanding to help us in pandemic preparedness. Pandemic preparedness has to be on holistic health level where it is a combination of preparedness from a physical and mental health point of view. Psychiatry and mental health play a role in such pandemics in addressing the challenge of the ensuing stress that pandemics bring, in liaison with policy makers, public health leaders as well as mental health professionals. The COVID-19 pandemic will challenge national authorities to function more efficiently and effectively with limited resources and also to plan mental health interventions in pandemic situations to address the crisis comprehensively.
General tips for managing psychological well-being during coronavirus disease 2019
This section focuses on general tips to manage one's and other's mental health during the COVID pandemic. These include:
- Ensure correct intake of information: Do not only focus on COVID-19 related news 24-h on news or social media as these updates can make you more worried. Set specific times in the day to check news, maybe three to four times in a day
- Get the facts right: Gather high-quality information that will help you to accurately determine your own or other people's risk of contracting coronavirus (COVID-19) so that you can take reasonable precautions. Trust the government and WHO websites only
- Connect with others: Messaging, playing games online together, writing E-mail telegrams and video calls with friends and family can help beat isolation
- Talk or write down your worries: Remember that this is a difficult time for everyone and sharing how you are feeling and the things you are doing to cope with family and friends can help them too. Should you not feel like talking to someone or may not find someone to talk to, take to journaling your thoughts in that moment
- Look after your physical wellbeing: Try to eat healthy, well-balanced meals, drink enough water, exercise inside where possible and outside once a day (keeping the recommended 1.5 m distance from others as part of physical distancing)
- Help and support others, do your bit: Think about how you could help those around you – it could make a big difference to people in need and can make you feel better too. You could be there to listen to someone, donate in cash or kind, spread healthy and correct information to others or even participate in food drives
- Follow a healthy sleep pattern: Try to maintain regular sleeping patterns and keep good sleep hygiene practices– like avoiding screens before bed, cutting back on caffeine, and creating a restful environment. Avoid reading about the pandemic or lockdown 45–60 min before sleep
- Have a lockdown routine: Think about how you can adapt to and create positive new routines – try to engage in useful activities (such as cleaning, cooking, or exercise) or meaningful activities (such as reading or calling a friend). Having a flexible time table for the day and week may help
- Make time to do things you enjoy: Engage in hobbies, try something new, learn or enroll for courses, try bringing back things you did earlier that made you happy and use this time to do all that you wanted to do
- Short-time goal setting: Setting realistic, achievable, and short-term goals gives a sense of control and purpose – think about things you want or need to do that you can still do at home
- Cognitive engagement: Ensure you keep your mind active by either reading, playing games, solving puzzles and sudokus in the newspaper, reading the newspaper, writing or drawing and painting. Find something that you enjoy
- Bring your focus to the here and now: Remember that everyone is going through this and we all are sailing in the same ship. This will pass too, take 1 day at a time. Relaxing techniques, yoga, meditation, breathing, or simply spending some quiet time re things you can do to come back to the here and now
- See if you can get in contact with nature: This could be simply standing at the window and allowing air to brush your face, little exposure to sunlight, catching up with some terrace time, going down in the building compound for a stroll or finding your feet walking/sitting on the grass are things that can help you feel rested and calm. Take time to listen to the birds chirping outside all day, you would probably never get this long a time to hear all the birds, listen to the ruffling leaves, stare into the night sky and observe the butterflies, bees and insects, scrawl over gardens.
| Conclusion|| |
The current review has aimed to present the various facets of mental health issues, mental health interventions and telepsychiatry from a COVID-19 perspective. The review is based on data available till now and we agree that further reviews shall be needed as the pandemic progresses and data-based research papers shall start coming in. There is a huge role of psychiatry, psychiatrists and mental health professionals during this pandemic and there is a need for developing mental health interventions that are needed for psychiatric patients to help them tide over the pandemic. Telepsychiatry has come into vogue and we must exploit the benefits and utility of telepsychiatry to the fullest at this point of time.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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