A more focused gaze

While one can view these reactions from a 'general' lens, it is equally important
to consider the impact of the various phases of the pandemic on children, the
elderly and pregnant women. The worries of adults can be transmitted to children
and make them anxious and fearful. They can become very easily bored, angry and
frustrated. Without an opportunity for outdoor play and socialisation, they may
become increasingly engrossed in social media and online entertainment, which can
make them even more socially isolated when they emerge out of this situation.
Parents need to know means of keeping the children engaged, providing an
opportunity to learn new skills at home, as well as encourage children to
participate in activities, get them engaged in �edutainment� and hone their extra-
curricular skills as well. Children with special needs may need innovative
approaches to engage them and keep them active at home. For the elderly, they can
feel further isolated and neglected, become more worried about their families, and
increasingly worried about their health. They may not have the support systems to
care for them, particularly in terms of their medical needs. This can aggravate
into anxiety and depression. Pregnant mothers can have a host of concerns, from
worries about whether or not to go for ante-natal examinations, worries about risks
to the unborn child, worries about their contracting the infection and concerns
about the future. Gender perspectives also need attention as times like this can
amplify an abusive relationship and increase intimate partner violence.
In any of these situations, it is important to anticipate that stress, depression,
and anxiety, if not effectively recognised and handled can transform into more
severe distress, even leading to negative thoughts about the future, helplessness,
hopelessness and suicidal thoughts and feelings.
Stigma

One has never imagined the stigma that might accompany COVID-19. There are several
instances of people at risk, particularly health professionals being evicted from
their premises by anxious landlords, people in quarantine being isolated from
society, and cruel societal responses to people with a diagnosis of COVID-19,
leading to people not disclosing symptoms and not seeking appropriate medical help.
Concerns for persons with mental illness
Persons with pre-existing mental illnesses and substance use are particularly
disadvantaged during the lockdowns. For persons with mental illness or epilepsy,
reduced access to medication can lead to relapse
of symptoms, as can the compounded stress. For persons with substance use
disorders, sudden withdrawal leading to seizures, delirium, agitation, and even
suicide have been described.
Adapting to the changes
At this point, it is also important to emphasize that many people can handle this
situation more constructively- by being calm or learning to stay calm, by busying
themselves with simple daily activities, avoiding depressive or fear-inducing
programmes on television or social media, connecting with others through telephone
or digital means, cultivating or rediscovering old interests and hobbies and of
course. For those employed, learning to work from home is a novel and challenging
task for many. Discovering ways to calm the mind is another helpful strategy. For
students, academic institutions are switching to digital modes of training,
interaction, and assessment.
Anticipating situations of distress
As we advance deeper into the pandemic, mental health professionals also need to
anticipate growing mental health problems. There can be psychological distress
consequent to the diagnosis, guilt, worries about family and others as well as
worries about recovering. For families separated from patients admitted with COVID-
19 complications, the separation can be excruciatingly painful from a psychological
viewpoint leading to worry, helplessness and frank depression. There will be
situations when people have to face the unexpected instance of the death of a
family member or be prepared for negative outcomes.
With the quickly growing knowledge of the impact of COVID-19, there are growing
concerns about the possibility of direct neuropsychiatric consequences of COVID-19
infection, the interactions between psychotropic medications and those used to
treat the infection, as well as drug interactions in patients with multi-morbidity.
The modifications that might be required to deliver ECT and other physical methods
of treatment in acutely symptomatic COVID-19 patients is yet another area that
requires greater understanding.
Minding our own minds
One important group of professionals are health care professionals, who go through
the same worries discussed earlier, but as the pandemic progresses, they will
become more and more engaged in COVID- 19 care. Worries about caring for such
patients, adequacy of protection, taking infections to their families, long working
hours, inadequate access to food, liquids and rest, and separation from families
can lead to severe psychological distress among health professionals. Even for
professionals working in the community, the fears of risk and perceived or actual
community aggression are realities that can cause tremendous anxiety. Listening to
their anxieties, ensuring adequate protection, training health care professionals
to provide appropriate care, supporting them and extending care to their families
are important ways to help health professionals help others.
Adapting to changing knowledge and adopting newer approaches
Thus, we need to constantly update ourselves, as mental health specialists on the
changing information concerning risk prevention, signs and symptoms, criteria and
tests for diagnosis, safe management of the psychiatrically ill patients with
COVID-19 infection, in addition to providing psychological support to persons
affected in a myriad of ways in the present situation.

Indeed COVID-19 has impacted the mental health of the entire community in one or
another manner. This has created an unprecedented mental health challenge in the
face of limited specialist resources. This also means that we need to think beyond
conventional strategies. Frontline personnel need to be trained in simple and
emerging evidence-based strategies of assessment and management. Presently, the
remedial measures suggested for COVID-19 have only empirical evidence. We need to
manage with what is available, but constantly update ourselves, almost daily.
Simultaneously, we need to engage with non-psychiatric medical professionals to
facilitate the psychiatric management of patients with COVID- 19 infection and co-
morbid physical illnesses. Digital-enabled learning and support for mental health
issues need to be considered for all non-psychiatric medical professionals and
frontline personnel. Online learning for are equally useful for regular updates for
psychiatrists as well.
Despite the various disruptions in routine clinical practice, especially the
regular outpatient services, this crisis has thrown up alternative and innovative
approaches to offer psychosocial support and continuous care for patients with
psychiatric problems or psychological distress. Online digital communication
platforms have become a boon for follow-up contact with patients as well as to
disseminate training to professionals working even in remote settings. The
strengthened District Mental Health Program (DMHP) promises to deliver community
care and ensure continuity of medications to prevent relapse. NIMHANS has initiated
a mental health support helpline (08046110007).
Fresher challenges

Continuing challenges include the development of protocols for emergency care for
suspected COVID-19 patients as well as positively diagnosed patients with
appropriate precautions for the safety of the treating psychiatrist and other
health personnel. The kind of modifications that might be required in the rapid
tranquillisation of COVID-19 positive patients, modifications in interventions like
ECT, TMS, tDCS require to be further examined, especially if this pandemic prolongs
or lingers.
This guidance document brought out by the Department of Psychiatry at the National
Institute of Mental Health and Neuro Sciences, India, attempt to address all these
factors with the currently available knowledge to help psychiatrists, other mental
health practitioners, non-psychiatric medical professionals, and other front-line
personnel reach out in new and unconventional ways to provide support to troubled
minds in the time of COVID-19.
References
Armitage R, Nellums LB (2020). COVID-19 and the consequences of isolating the
elderly. The Lancet.
Public Health, 2667(20), 30061.
Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N et al (2020).
The
psychological impact of quarantine and how to reduce it: rapid review of the
evidence. The Lancet, 395: 912�20.
Duan L, Zhu G (2020). Psychological interventions for people affected by the COVID-
19 epidemic.