Mental health in the time of Covid-19: An interview

[ Nellie N Manpoong ]

The 21-day nationwide lockdown has not only affected the physical health of people but has also taken a toll on the mental health of many. While some may have strategized ways to cope with the lockdown, others still struggle to come to terms with this temporary yet new way of living.
Senior psychiatrist at TRIHMS, Dr T Kena, addresses some queries and shares ways to deal with the lockdown.

The Arunachal Times (AT): What behavioural changes can we expect in the people during the 21-day lockdown?
Dr Kena: Fear, anxiety and denial. Acknowledging that feeling fearful and anxious at a time such as this is not only normal but appropriate. Given the nature of the threat we are facing, fear and anxiety are adaptive responses as they alert us to the fact that we need to be taking appropriate action to keep ourselves and others as safe and healthy as possible.
It’s also important to recognize that fear and anxiety can quickly escalate and reach a tipping point, beyond which they are no longer helpful and can affect us in negative ways. When the acute stress response, otherwise known as the ‘fight or flight’ response, kicks in, we’re not as able to think clearly or make good decisions; we become more reactive and less responsive, and our thinking can quickly spiral, becoming increasingly negative and difficult to unhook from.
We can get into different mood swings of anger, frustration, dysphoria (sense of sadness), helplessness and easy irritability, losing patience, a sense of urgency, difficulty sleeping, inability to focus, catastrophic thinking, ruminating, eating or drinking more than usual.
As reality sets in, people tend to become more fearful; fearful of self and near ones, which turns into fight-or-flight response. As our body becomes tense (with regard to the lockdown) with a sense of helplessness, one tends to get multiple physical aches and pain.
There can be sleep deprivation due to underlying stress and physical pain. Sleep disturbance is heightened by excessive use of social media, mobile usage, and continuous flow of information/visual images (many of them fake ones) related to Covid-19.
There will be change in the normal circadian rhythm in sleep pattern, wherein one sleeps most of the day and stays awake till early morning. This will give rise to change in food habits, either increase or decrease in consumption, not to mention of unavailability of fruits and fresh vegetables, which is essential in this hour of crisis.
Given the vulnerability of our physical health from this lockdown, alcohol, cigarette and drug intake can further deteriorate our mental and physical wellbeing. Stress and anxiety can increase substance intake, which in turn can disturb the physical and psychological wellbeing of a person, which is a vicious cycle.
This can lead to depression, panic disorder and psychotic breakdown for people who are already vulnerable in the long run.

AT: Some say that introverts are better prepared for a lockdown such as this, but are they truly? How will people who live alone handle the solitude?
Dr Kena: Many people may view the lockdown period as a boon for introverts. However, introverts tend to remain alone and value their ‘alone time’ more than anything else, and for some people, it’s the air they breathe.
The lockdown period was supposed to be the moment for introverts as they are experts at voluntary self-isolation. But the reality is that introverts don’t want to be alone all the time. They might feel an additional layer of stress after the initial euphoria to remain indoors.
Staying at home with other people places a burden on introverts as they are not used to full-time interaction. Besides, they enjoy the freedom to go out for a coffee or shopping.
It can also be a challenging task for people who live alone. The only social interaction at workplace or social gathering is taken away from them during the lockdown. One may tend to start creating socialization within the four walls through social networking or phone calls. However, they will start to miss the human touch, face-to-face interactions and physical closeness, which are very essential for those living alone, especially those who are extroverts and get energized from socializing.

AT: How do you think this is affecting or will affect those providing essential services, such as those in the health, security and administrative sectors? How can their families and friends provide support?
Dr Kena: There is tremendous pressure on all essential service providers. Many would tend to experience bouts of anxiety, sense of helplessness, sleep disturbance, and later may be prone to panic disorder or post-traumatic stress disorder.
For every healthcare worker, there are 10 other family members mumbling and grunting for them to stay away from the war zone as much as possible, for obvious reasons.
This could put a tremendous ethical dilemma on the frontline workers with the background fear of the ‘real danger’ they face on a daily basis. We have to consider the reality of meagre salary they are paid for risking their lives (although this was not an issue pre-Covid-19).
Families and friends are the main pillars of support for the frontline workers. Families need to be positive towards these people and help them recuperate at home and provide adequate basic needs.
Allow them to ventilate their fears and anxiety and help in problem solving and not add to their anxiety by criticizing or avoiding them. Basic needs like sleep and food need to be provided in time.
Social ostracization needs to be condemned. They should be made to feel proud for the work they are undertaking, as the very fact that they are stepping out for work itself should speak volumes about their dedication. Positive feedback should be given from time to time, and the person should not be made to feel different or made conscious all the time.
Supporting the people who are fighting this illness is the need of the hour for all general public.

AT: What would be the status of patients with previous mental health issues, and how can they get through this?
Dr Kena: Persons who had previous mental health issues may face newer challenges during self-isolation or Covid-19 infection. The stress generated from this lockdown is enormous on them. They would also have the same fears and stress as others, which may worsen their previous mental health condition.
Social isolation may make them more withdrawn, moody and irritable. They may also not seek/get easy access to medicines and counselling.
Those who are diagnosed and come off medications are at a high risk of relapse or depression, panic disorder or psychotic illness. They need to be watched for early warning signs and given immediate treatment if signs and symptoms are present (like change in behaviour, anxious mood, irritability, decreased sleep or suspiciousness or referential thinking).
Those who are on medication are also not immune to a relapse. The medication dosing may need to be increased or adjusted according to the presentation of symptoms and signs. Getting medicines is also becoming difficult due to restriction on movement, especially from the districts and remote villages.
Moreover, the supply of medicines from Assam has been stopped since the lockdown. Hence, the supply of medicines for regular patients also would be a challenge if the lockdown continues, and there is a chance of relapses of major mental illness which will be a huge burden to the family and careers.
The burden on family with mental illness could become more pronounced in this lockdown period due to the constant sharing of space and risk of physical and psychological trauma they have to go through in everyday life. The few hours of respite they availed have also been curtailed in this period. This will bring out lot and entity called ‘expressed emotions (EE)’, wherein the family/caregivers become ‘hostile, critical and emotionally over involved’ with the patient.
This high EE can lead to relapse of mental illness, and the lockdown period tends to be a high breeding ground for high EE.

AT: How will people who indulge in substance abuse cope?
Dr Kena: The other group of youngsters coming to the limelight from the lockdown episode comprises those who have been abusing substance, especially opiate (heroin, brown sugar, spasmoproxyvon capsules). Many of them are emerging due to unavailability of substance due to loss of supply chain from forceful social restriction of movement.
We are getting a spurt of youngsters (average age range of 17-30 years) coming for voluntary detoxification from heroin addiction, who normally wouldn’t seek help. There are frequent and constant phone calls from patients, relatives and doctors who are willing to detoxify or go to rehabilitation centres at this current stage. In pre-Covid-19 period, families would have difficulty in getting them to the hospitals, let alone rehabilitation placement.
As of now, home detoxification is being advocated as most hospitals, including TRIHMS, are locked down as we prepare for Covid-19 management. Patients are advised to visit RKM Hospital and other private hospitals.
Alcohol, cannabis and nicotine abuse may also increase during this period. However, not many are coming out in the open or seeking help as of now. The numbers are likely to increase as the lockdown is lifted.
A tele-consultation helpline has also been launched recently by the IMA Arunachal chapter and regular psychiatric consultation/counselling will be provided to the general public at large between 9 am and 5 pm, in addition to the emergency arrangements. The numbers are: 8010340000 and 0360-2292774.
One can also call the national helpline, number, 080-46110007, for counselling on mental health issues.
Dr Kena also advises recognizing mental health problems in those close to us.
“Just as you can recognize your own mental health problems, be sensitive to such problems in your near and dear ones,” he says, while also advising that we look for changes in sleep patterns, difficulty in sleeping and concentrating, worsening of health problems, and increased use of alcohol, tobacco or drugs in those close to us.

Dr Kena suggests ways to handle social isolation:

1. Have a regular schedule for
a. Sleep (sleep by 10 pm, and get at least 7-8 hours of sound sleep).
b. Food (have food together as a family).
2. Help in doing some household work at home (cooking can be therapeutic)
3. Distract yourself from negative emotions by
a. Listening to music, reading.
b. Watching an entertaining programme on television.
4. If you had old hobbies like painting, gardening or stitching, go back to them.
5. Do simple indoor exercises that will keep you fit and feeling fit.
6. Understand if someone around you needs advice, food or other essentials. Be willing to share.
7. Elderly people may feel confused, lost and need help. Offer them help by getting them what they need, their medicines, daily needs, etc.
8. If you have children at home, keep them busy by allowing them to help in the household chores – make them feel responsible and acquire new skills.
9. Spend time together with indoor games.

Handling emotional problems:

1. At times of anxiety, practice breathing slowly for a few minutes. Try and distance the thoughts that are making you anxious. Think of something calm and serene, and slow down your mind.
2. When feeling angry and irritated, calm your mind and/or count back from 100 to 1. Distracting yourself also helps.
3. Even when feeling afraid, deal with it by asking yourself:
a. What is under my control?
b. Am I worrying unnecessarily about the worst thing that could happen?
c. How have I managed when I was stressed in the past?
d. What are the things I can do to help myself and be positive?
4. Feeling lonely or sad is also quite common. Stay connected with others. Communication can help you to connect with family and friends. Call up people whom you haven’t spoken to and surprise them. Discuss happy events, common interests, exchange cooking tips, share music.
5. If any of these emotions persist continuously for several days, despite your trying to get out of it, talk about it with someone. If the feelings worsen, a person may feel helpless, hopeless and feel that life is not worth living. If that happens, call the helpline number (080-46110007)/state tele-consultation helpline (8010340000 and 0360-2292774) for advice from a mental health professional or contact your doctor/mental health professional.

What is not advisable:

1. Avoid tobacco, alcohol and other drugs.
# Use of tobacco or alcohol or other drugs to cope with emotions or boredom can worsen physical, mental health and reduce immunity.
# People who already have a substance use problem may require professional help, especially when they feel low in mood or stressed.
2. Do not shun or judge people with Covid-19 infection.
# While you need to maintain a physical distance and keep yourself safe to prevent such infection, remember they need care and concern.
# If you know someone who might have the infection, tell them about precautions, and how to get medical assistance, if required.
3. If you happen to get infected with corona, remember most people get better. Do not panic. Practice self-isolation and take medications that are advised.

Focus on facts, reject rumours and theories:

1. The more you know about a certain issue, the less fearful you may feel. Make sure to access and believe only the most reliable sources of information for self-protection.
2. Do not follow sensational news or social media posts which may impact your mental state. Do not spread or share any unverified news or information further.
3. Do not keep discussing (all the time) about who got sick and how. Instead, learn about who got well and recovered.
4. Stick to the known advice – hand hygiene and keeping physical distance from others. It is being careful about yourself and also about care for others.
5. A common cold is not a Covid-19 infection. Follow etiquette of sneezing, coughing, and avoid spitting in public places etc.
6. In most people, Covid-19 infection causes mild symptoms and the person only needs to follow social distancing till he/she stops being infective, usually two weeks. Mild infection does not require a person to be admitted in hospital. Only people who have breathing difficulties need to be in hospital. Most people recover.