Covid has exacted heavy mental health toll. System must be prepared to provide care

Since the Bangalore Circus fire of 1981, disasters in India have been evaluated for their mental health consequences. Earthquakes, the Bhopal Gas tragedy, bomb blasts, and many other tragedies have been studied in detail by mental health professionals. Unfortunately, this has not led to meaningful mental health interventions largely because of poor awareness among administrators, the stigma associated with mental health issues and the lack of professionals.

Can we face the challenge in India? Yes, we can. Should we lament that we do not have enough mental health professionals? No. Mental health intervention is not rocket science. A compassionate ear, support, reassurance, and tools for tackling grief can be taught to mental health soldiers. Working in pairs prevents burnout. Experts can supervise the entire process and are useful during emergencies, to treat disorders and serious illnesses after a catastrophe.

Every disaster may or may not have a pre-impact phase but it always has an impact phase, a post-impact phase, and a late post-impact phase. The pandemic is unique as the impact phase has been in a continuum for 14 months affecting billions across the world. Surveys and studies across the world reveal an increased prevalence of emotional disturbances and mental disorders during this outbreak.

A report released by the Ministry of Health and ICMR in December 2019 just before the pandemic stated that one out of seven Indians is mentally ill, and approximately 20 crore people in India need treatment. A National Crime Records Bureau study of 2019 also mentions that one out of three people who take their own lives are torn apart by family problems. Nearly a fourth of those who lose their lives after inflicting self-damage are daily wage labourers. The relationship between poverty and emotional disturbances is also well known. Mental health is also related to food and nutrition.

Covid-19 has exacerbated such vulnerabilities. Unresolved grief can erupt in the years to come. Six vulnerable groups need immediate mental health intervention. Families who have lost their dear ones to Covid. Those who have the infection or have recovered from it, as well as their families. Healthcare workers and those involved in emergency services. Those who have lost jobs and incurred financial losses. Those with pre-existing mental or physical illnesses. Children, marginalised groups and elders. Many who have been affected by an overdose of negative stories, and exposed to distress also need support.

Governments, both at the state and Centre, fall back on their own institutions for massive programmes. This is not always pragmatic as they need to take care of their own hospital load. More than 80 per cent of mental healthcare in India happens outside these institutions. Altruism and seva are hallmarks of Indian culture. Psychologists, psychiatrists, medical social workers, counsellors, ASHA workers, NGOs and emotional aid workers can be easily enrolled for this humane task. Many are willing but they would require a structured approach to providing grief counselling. The effort should be coordinated by state governments and the module can be adapted to the needs, resources available, and the cultural contexts of a region.

Counselling has to be entirely voluntary, preferably in groups, largely online, and in the local language. Every district can have two coordinators from the mental health field. A protocol can be evolved by a core team — a multidisciplinary mental health taskforce — after detailed discussions. Protocols should include tools for screening, counselling, and an algorithm for referrals. It should also have processes for directing emergency treatment of those with serious symptoms — these interventions should be documented. All teams need to undergo orientation for at least 18 hours initially and periodically for two hours every 15 days so that standardisation in interventions can be assured. There should be scope for individual innovations within this framework. The outcome of the interventions needs to be measurable and built into the treatment process. The intervention period may be six months or as long as required by the pandemic survivor. The process should be secular and free from any religious or political ideology. Monthly meetings of the team leaders are necessary for troubleshooting, course correction, and continuous capacity building. District coordinators need to meet once a week to negotiate difficulties, smoothen rough edges and assist the smooth transaction of the therapeutic process. As the epidemic abates, “live” interventions may also be possible.

After screening, the team will categorise survivors into groups based on requirements — counselling, medication, or both, hospitalisation, simple advice and information. They will be assessed by simple psychological instruments every two weeks. These instruments will be decided during the meetings to finalise the entire protocol. The entire process will be pro bono for the survivor. Similarly, the participation by the mental health professionals from the private sector will also be voluntary and pro bono.

In certain areas, physical access may be the only method to provide such treatment. Adequate safety measures need to be taken during such visits.

It’s often said that time is the best healer. That unfortunately is not always so. Mental health intervention completes the rehabilitation cycle and makes it robust and holistic.

This column first appeared in the print edition on August 16, 2021 under the title ‘Treating the invisible pandemic’. The writer is a Mumbai-based psychiatrist