From a few cases in Wuhan; to a worldwide pandemic; COVID-19 has wreaked havoc in all realms of life and livelihood. The sudden and drastic changes that have been brought about in the daily life, uncertainty over an unknown novel virus with serious health complications; lead to serious mental health concerns among various cohorts. The abrupt lockdown of 1.3 billion; further left people feeling anxious and overwhelmed; with the lack of basic supplies, amenities, medical needs etc. It opened up grounds for a whole range of concerns for the vulnerable populations; especially the elderly, people with pre-existing physical and mental health concerns. It brought about the worst migrant crisis witnessed in recent history, with thousands of migrants, some on foot returning to their villages; resulting in loss of lives, physical and mental health concerns.

India went through the deadly second wave. It brought about enormous pressure on the already burdened healthcare system in India; leading to loss of countless lives on account of oxygen crisis, lack of beds and other crucial healthcare facilities. With peak of 4 lakh cases in a single day in May, it has also been the deadliest month. Although, vaccine was a ray of sunshine, more virulent mutations, low vaccine availability, rising cases and deaths; the vaccine proved only to be a thin ray of sunshine. With reports of multiple deaths in families, children losing their parents to COVID-19 and cases of fungal infections among patients; further reduced the morale of the country.

1. Impact of COVID-19 on Mental Health in India

One in seven are affected by some form of mental illness in India. 197.3 million people were affected with mental illness, in 2017; with 45.7 million and 44.9 million people affected by depression and anxiety respectively. The contribution of mental illnesses to the disease burden in India, almost doubled from 1990. Contribution to DALYs (disability adjusted life years), which is the number of years in a person’s lifespan lost due to illnesses; was 2.5% in 1990 and by 2017 it almost doubled to 4.7 % (India State level Disease Burden Initiative, 2019). The treatment gap as a result of low mental health professionals, stigma attached to mental illnesses; still remains high, especially in rural India; despite increased awareness efforts by government and NGOs. There are an estimated 0.75 psychiatrists per 100,000 people in India (Garg, Kumar, & Chandra, 2019).

1.1 Impact on general and vulnerable populations

Although at the forefront is the COVID-19 crisis; at the background is the mental health crisis that India is facing. To an already high burden, treatment gap and low availability of mental health professionals; with the pandemic, we see a rise in anxiety, depression, fear and psychological distress (Hazarika, Das, Bhandari, & Sharma, 2021; Srivastava, et al., 2020). Sleep being dependent on anxiety, depression and stress; many reported insomnia and sleep disturbances as well (Kochhar, et al., 2020). Cases of increased health anxiety, presence of chronic illness further heightened the fear of the pandemic. Women showed more fearful responses and more vulnerable to stress (Hazarika, Das, Bhandari, & Sharma, 2021; Srivastava, et al., 2020). Being single, student and people with pre-existing mental illness also showed heightened anxiety and depression. Social support from family and friends were a source of emotional support acting as a buffer against stress; explaining why single people showed higher anxiety and stress (Hazarika, Das, Bhandari, & Sharma, 2021). As social beings, reduced social contact, lack of access to basic amenities in lockdown left a sense of helplessness, depression and the feelings of being confined and fatigued among people (Kochhar, et al., 2020). The length of lockdown was directly proportional to outcomes of mental health. From the economic perspective, lockdown affected a large portion of the population financially; especially migrants losing their jobs overnight. The working population also saw their work and income affected. This socio-economic distress was another stressor contributing to the mental health; leading to anxiety and anger (Kochhar, et al., 2020).

To the already vulnerable populations, current times have been especially burdensome. Apart from the economic impact from lockdown, the migrant workers face increased risk to communicable diseases due to their socio-economic status, unhygienic living conditions, lack of sanitization and malnutrition. Pre-existing mental health conditions are also prevalent; which could increase in severity due to the pandemic, lack of consultation access and migration crisis that ensued after lockdown (Choudhari, 2020).

The elderly on account of their age, have a threefold increased risk of mortality, higher need of hospitalization, poorer prognosis, rapid disease exacerbation, longer recovery duration. With the awareness of their vulnerability, the fear of COVID-19 is heightened. Quarantine can cause chronic stress, loneliness, hopelessness, anxiety and depression (Banerjee, 2020). Especially in the second wave with the low availability of hospital beds, oxygen and ventilators; the mental health concerns can be chronic and increase in severity. With an abundance of information and rumors spreading, there is a chance of increased health anxiety, apprehension and stress as well (Banerjee, 2020).

For those battling pre-existing mental health conditions; the pandemic, lockdown and quarantine can exacerbate their symptoms and lead to relapse. People with anxiety and generalized anxiety disorder can have excessive apprehension of the worst, health anxiety etc. Patients with Obsessive Compulsive Disorder can have their washing, checking rituals increased due to the nature of the pandemic. Depression patients can have exacerbation of their symptoms and hallucinations, delusions related to paranoia can persist among schizophrenia patients. There is also a high risk of suicide and relapse. Treatment stopping due to non-availability of medicines is another risk observed (Chatterjee, Malathesh, & Mukherjee, 2020)

1.2 Impact on children and adolescents

With the closure of schools, decreased social contact and having to be confined at home for longer periods than ever before, have with no surprises had a huge mental health impact. Adjustment difficulties, anxiety, inattention, irritability have been observed in children. This is especially difficult for children with pre-existing mental health illness and for children with single parents (Parekh & Dalwai, 2020). In the event of the single parent going under quarantine, extended separation can have a psychological impact on children, leading to separation anxiety and distress. Children and adolescents who had to go under quarantine themselves, showed greater psychological distress, helplessness, fear and worry (Saurabh & Ranjan, 2020).

Anxiety and depression were also observed among adolescents; over the fear of COVID-19, fear of transmitting COVID to loved ones and their health. Experiences of hopelessness, sudden crying outbursts, inability to find happiness in hobbies, insomnia, fear over future employment opportunities and feeling detached from friends were also observed (Suhail, Iqbal, & Smith, 2020). Although some useful coping strategies to deal with the pandemic and social isolation by creating new hobbies, healthy lifestyle with exercise, healthy diet and keeping in touch as much as possible with family and friends through technology were observed (Suhail, Iqbal, & Smith, 2020).

1.3 Impact on Students

The demographic aspect of being a student came as a risk factor for developing anxiety, depression, stress, disturbed sleeping patterns etc. (Hazarika, Das, Bhandari, & Sharma, 2021). With the fear of the ongoing situation, coupled with disturbed routines (closure of educational institutions) and sudden change in the mode of education, served as factors for the development of mental health concerns. The sudden change in the mode of education; created its own challenges for both teachers and students. The challenge of effective digital skills and infrastructure were present on both sides. Insufficient time to prepare for the change also led to poor satisfaction levels among students with online classes (Chaturvedi, Vishwakarma, & Singh, 2021). As we have seen earlier, the lack of access to smartphones among the poorer sections of society paved the way for student suicides. Coming to the social aspect, the lack of peer interactions and its importance in building social skills and motivation were also affected. Many also used social media platforms as stress buster and used them to stay connected. Most used social media were Instagram, YouTube, WhatsApp etc. To combat the stress, other stress busting activities such as listening to music, web series, gaming, reading, meditation, sleeping etc were mostly used (Chaturvedi, Vishwakarma, & Singh, 2021).

1.4 Impact on Healthcare Workers

The pandemic has had adverse effects on healthcare and frontline workers, with toll on both their physical and mental health. Working on the frontlines of the pandemic; with continuous exposure to patients and higher virus load, India has lost a lot of doctors to the pandemic in both the waves. Catering to a continuous and heavy influx of patients, long work hours and witnessing death and distress had led to mental health concerns like anxiety, depression, stress, burnout, insomnia and Post Traumatic Stress Disorder. Concerns over acquiring the infection, ill-equipped healthcare system and fear of not being able to curb the spread and work-related stress all contributed to their mental health concerns (Gupta, et al., 2020). With a higher exposure duration nurses experienced higher anxiety and distress levels. Demographic risk factors such as younger age (20-35), female gender, occupation (nurses), marital status (single) and educational qualification (lower educational qualification) all contributed to higher levels of anxiety and depression. Being a well experienced doctor was the only protective factor (Gupta, et al., 2020). Those who contacted the illness showed low mood throughout the illness, expressed fear of severe illness, death and re-infection after re- joining (Bajaj & Solanki, 2020). Families of healthcare workers who witnessed death of their loved ones due to the pandemic; have witnessed post traumatic stress disorder, prolonged grief disorder and other mental health issues. The constant fear of contacting the infection, losing their loved ones and inability to say their last goodbyes could lead to all the above mental health concerns (Das, Singh, Varma, & Arya, 2021).

1.5 Suicides during COVID-19

The first COVID-19 fear suicide was reported in Hindustan Times, where a 50-year-old man, from Andhra Pradesh committed suicide by hanging from a tree due to the fear that he had contacted COVID-19 mistakenly after he contacted a viral infection (Dsouzaa, Quadrosa, Hyderabadwalaa, & Mamun, 2020). Quarantine also caused substantial psychological distress. Feelings of loneliness, boredom, anxiety, depression, along with financial loss could lead to suicidality especially among people with pre-existing mental health conditions. The most common causative factors were the fear of contacting COVID-19 infection, financial crisis, pressure to quarantine, testing positive for COVID-19, unable to return home due to lockdown, loneliness and work-related stress (Dsouzaa, Quadrosa, Hyderabadwalaa, & Mamun, 2020). The second wave has been more devastating to mental health, with rise in cases of anxiety, depression, suicidal tendencies and fear. A rise in cases of suicides was seen with COVID-19 affected patients committing suicides in hospitals, doctors and nurses, families who’ve lost their loved ones to coronavirus etc. Some cities like Jamshedpur, have seen a spike in suicides cases as the second wave started, with suicides almost doubling each month (Times of India, 2021).

Another cohort that has been affected are students. The online mode of education has brought about many problems for students who belonged to the poorer sections of society. Many took to suicide, because of their lack of access to smartphones, unable to pay school fees; as their parents lost their jobs during lockdown. Multiple states such as Kerala, Tamil Nadu, Karnataka, West Bengal etc. have recorded such cases (Agoramoorthy, 2021).

2. Mental Health care and the Future

Mental health care is of paramount significant in times like these. Hence, it is important to be aware of mental health challenges faced by different cohorts. So that, as mental health professionals we can provide the best possible care for each of the cohorts based on empirically reliable knowledge; as the challenges faced by cohorts is caused by different and multiple factors specific to their age, stage in life and circumstances. Although there are mental health helplines and professionals working to help people with mental health concerns; the increased need for such services has still left huge treatment gap. Many mental health services like, Electroconvulsive therapy, inpatient and outpatient services, brain simulations and psychotherapy services were stopped (Grover, et al., 2020). A huge shift was seen towards online counselling and telepsychiatric services. Although there are some cons involved in online counselling with connectivity issues, mid conversation call dropping etc., thanks to technology, it has helped people in general, people in quarantine and those affected by COVID-19 get the care they greatly needed. There should be mental health screening services at all levels of care and must be referred to mental health professionals for appropriate treatment if needed. Vulnerable populations must be provided access to care and treatments. Mental Health professionals must be stationed in hospitals; for doctors to refer and provide holistic care of both physical and mental health. This can greatly reduce suicides as well. Families who have been affected by COVID-19 must also be given mandatory counselling. Many have also faced grief; especially during the second wave; which is another area where mental health services are needed.

Awareness must be raised both by the government and mental health professionals among the general public, country wide on mental health needs and concerns that arise out of such crises and coping strategies that can be used to deal with them for all ages. Coping mechanisms like staying digitally connected, being behaviorally active and scheduled engaging in relaxing and recreational activities, with adequate sleep can bring back a routine and structure for children and elderly (Samantaray, Pattanaik, Srivastava, & Singh, 2020).

The hidden mental health crisis is going to have an effect and stay; long after the pandemic is controlled. Hence, the importance of mental health is deepened and so is the importance of creating awareness, helplines, screening tests, access to services and medications. Awareness of coping strategies, helplines, normalization and reducing stigma, can help people in providing support or suggest seeking help among their friends and loved ones; creating social support systems that go a long way in the collective healing process.

3. How to Cope with Covid-19?

Stress, fear, health anxiety, depression and insomnia are exacerbated and increasingly being observed among the general population, children and adolescents, health care workers and the elderly. There is a mental health crisis and pandemic going on along with COVID-19. Mandatory isolation, being confined to home, financial concerns, decreased social contact, abrupt changes in daily routines and work schedules; has created additional stressors. And change in mode of education and being confined to home for longer periods than ever has been difficult to adjust for children, led to irritability, inattention etc. Hence, adaptive coping becomes especially important.

3.1 General Coping Strategies

People in different ages, in different life stages have their own circumstances that might be causing them different stressors. One way doesn’t fit all, but there are some common ones that help everybody get through these troubling times. Normalization of stress, anxiety and fear is the first step. This step is important in giving some comfort, realizing that one is not alone in going through these emotions. Next step is to deal with it. As there is reduced social contact, it is important to digitally maintain touch with friends and family. Having social support systems is a stress buster. It is also essential to be behaviorally active with scheduling your recreational activities and physical exercise. They could be board games, outdoor games etc., which could help in creating some quality family time as well. It is also important to keep away from maladaptive coping strategies like substance abuse.

3.2 Coping Strategies for Children

With a sudden loss of routine, a structured schedule that they have been following till now is lost. Although sometime is occupied with online classes, fun ways of fostering academic learning can also be devised etc. A structured schedule of recreational activities that they enjoy, behavioral activation through physical activities, games etc. can be helpful in utilizing their time better and even limit their social media intake and screen time. Since, everybody is at home, some quality bonding time can also be arranged; through fun activities that is enjoyed by all. Keeping children engaged and helping them be in touch with other family and friends digitally can also help. Apart from this it is also extremely important to talk to children about the ongoing situation, in a developmentally appropriate fashion. In a two-way communication method, raise awareness about the pandemic, the safety measures to follow, masking and hygiene such as washing hands (how and how long). Also, listen to the child and help them understand and clarify their doubts about COVID. Check on how they are feeling, reassure and support them if they express fear, anxiety or stress. Let them know that you are there for them; if they want to talk about it and listen to them with the intent to understand their feelings, fears and don't forget to show empathy.

3.3 Coping strategies for adolescents

Adolescents can go through anxiety, fear of COVID-19, concern about their loved one’s health and stress. Due to reduced social contact, they can feel distant from their friends. During adolescence, friendships gain importance. Adolescents look towards friendship for meeting their needs; such as self-esteem, validation, belonging, support etc. Hence, it is important to find a set of activities that keep them engaged socially, personally, and physically. On the social level, although social media helps in connecting with friends and loved ones; it is important to watch screen time. Put some time for connecting with friends and family; but also schedule time for physical and recreational activities. On the personal level, coming up with recreational activities that they would enjoy; like reading a book, catching up on a series, cooking, singing, dancing etc. can help in keeping them engaged and take their mind off things. For relaxation, mindfulness meditation, yoga, would also help. There are also apps now for mindfulness meditation. On the physical level, trying to maintain a healthy diet, setting time for some physical exercise etc. would be very important.

3.4 Coping for elderly

With the awareness of their vulnerability, they may have increased anxiety, worry, depression and fear of severity and death. And the abundant of information hitting them from social media and news may not be very conducive as well. It is important to limit their news intake. The most important is staying connected with family members, digitally. This brings them a sense of belongingness, social support which can go a long way in maintaining mental health. Remaining behaviorally active, with activities they are physically able to do. It can be some indoor games, meditation, breathing exercises and yoga. Some household chores they are able to do and other recreational activities they find relaxing. Other activities such as gratitude journaling etc. can also help. Especially for the elderly helping in decreasing their health anxiety and stress that abundance of information and rumors causes (Banerjee, 2020).

3.5 Coping for Healthcare Workers

Working on the frontlines of the pandemic; they are faced with many concerns from excessive work stress, long work hours, fear of contacting the illness, fear of transmission to their loved ones, fear of severity and death etc. Normalization of stress, anxiety and depression is especially important for healthcare workers. Acceptance can help as well. Being in touch with their loved ones can help them relax. It is also essential for them to have breaks and rest periods during work with enough sleep, to be able to function optimally. Seeking support from mental health professionals can help in the ventilating and normalizing their emotions and mental health concerns. Stress relieving activities with colleagues can be helpful as well. With excessive and long working hours, it is important that healthcare professionals give time for themselves and family, work-life balance strategies can be especially helpful, such as allotting time for family after work, de-stressing activities with family, not taking work related calls, unless its an emergency etc.

3.6 Coping with isolation

In case of isolation, the mental health concerns maybe be heightened with COVID-19 anxiety, fear of contacting the illness, its severity etc. and being confined all day and idleness can be especially damaging for mental health. Having support, help and reassurance from family members can help with stress. To have a sense of purpose and plan for the day can be helpful. It could be meditation, relaxing activities like listening to music, reading a book, some physical activities and breathing exercises, sound sleep and food, journaling, drawing etc. helps in distracting and giving some comfort.

3.7 Coping for Parents

For parents and especially working parents; with children at home, work from home and household chores can all be very difficult to manage. With all the routine changes, lack of social activities and outdoor entertainments closed, it becomes very important to communicate to children as to why this is happening. Since, work and home are in the same space, it is important to set up separate workspaces, set time boundaries for work, household and child care tasks, and it is also important to communicate about these time boundaries with your children and significant other. There may be long working hours, experiences of burn out. And with technology involved in work now; feeling of always working, responding to calls and email may lead to the ‘always-on’ culture. Hence, devising adaptive coping strategies can be very helpful. Follow the link to read more on burnout and work-life balance skills. Burnout and work-life balance.

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