COVID19: ‘Those In Isolation Need Support To Deal With Stress, Guilt, Fear And Stigma’

Pathanamthitta: Anxiety brought on by the fear of infection; guilt, shame and feelings of abandonment during isolation and uncertainty about the future--the COVID-19 pandemic is reported to have affected the mental health of many. It has allegedly resulted in suicides across New Delhi, Telangana and Chhattisgarh. In Kerala, a man who had recently recovered from the disease was turned away by his family because of the fear and stigma surrounding the infection, said Kerala chief minister Pinarayi Vijayan.

With an increasing number of people going into isolation to battle the contagion, it is vital to ensure psycho-social intervention for those in distress, said Sukesh G, a psychiatrist at the district hospital in Kozhencherry in south-eastern Kerala’s Pathanamthitta. The district had the highest number of COVID-19 cases in Kerala until March 18, 2020 and had over 7,200 people in home isolation (as on March 31, 2020). 

Since March 8, 2020, when the first positive case in Pathanamthitta came to light, Sukesh and his 50-member team of doctors, psychologists, and counsellors have been calling and visiting those in need of mental health support, especially those in 14- to 28-day isolation advised to the vulnerable. 

Sukesh is a part of the state's District Mental Health Programme (DMHP), and the Pariraksha initiative that was introduced after the 2018 floods to provide mental health support and counselling. There was realisation after the floods that not having such support “will affect the overall well-being in the long-term”. As a part of DMHP, he has attended workshops in post-disaster mental health psychosocial support, and was part of the team that conducted field visits and community interventions immediately after the floods.

Edited excerpts from the interview:

Why did the state government feel the need for a network offering mental health support during large-scale crises such as this outbreak?

There was a need for psycho-social intervention after the 2018 floods and we had not undertaken such interventions till then. It was decided that we [need] a long-term plan. The government introduced the Pariraksha programme, with one counselor on a one-year contract for each panchayat in Kerala. Before this, we had psychiatry units attached to hospitals [in the district] and each district had a DMHP. Pariraksha includes psychiatrists, psychologists, psychiatric social workers, and nurses and pharmacists. This was inadequate for a large-scale intervention, which is why counsellors were introduced in flood-affected regions.

What kind of mental health support do most people fighting the infection seek?

One of the difficulties is the 14- to 28-day hospital or home isolation. [During this period], the freedom of those in isolation is curtailed, there is boredom, and they worry or feel guilty about spreading the infection among family and friends. Stigma is another major problem. This affects hospital staff in isolation too. Your close family may not break off all communication, but others may. The severity of it may vary, but those in isolation have started experiencing stigma at different levels.

Often, we have noticed, anxiety is the reason why people call us. Asymptomatic persons in quarantine are not routinely tested for COVID-19, hence requests for testing are not entertained. This leads to the worry that they may transmit the disease to their family. This also leads to sleep-related issues. Secondly, others in the community talk [gossip] about an isolated family, which may lead to people avoiding them or their being denied provisions at a shop. This causes huge distress.

Do you find low acceptance of mental health problems in our society?

Yes, mental health issues are given less importance than physical ailments. Several factors including ignorance and stigma contribute to this. The larger realisation [about mental health] came after the [2018] flood. We realised that it affects our overall well-being in the long-term.

How is your team offering support?

Our team calls and checks if those in isolation have any mental health issues. Even if they say they do not, we give them our personal numbers and the government [health] helpline number [DISHA] for future use. Then we call again after 3-4 days. In addition, the team also checks adherence to quarantine [read our story here] when we call those in home and hospital isolation. Psychiatrists also give COVID-19 patients in the hospital personal consultation, if required.

How often have you had to get involved as a psychiatrist?

We make calls everyday. I have made more than 100 calls [since March 8, 2020, after positive cases were first found in Pathanamthitta]. There are three psychiatrists who are currently making these calls in addition to the counsellors [22 from the DMHP and 26 from Integrated Child Development Services]. We speak, on average, for 15 to 20 minutes. 

Of course, there is a difference between making a call and doing face-to-face counselling. The comfort we can offer in case of the latter is more and our ability to convince them is comparatively better.

How are you handling the pandemic, an altogether new crisis?

Immediately after the floods in 2018, we had a number of state-level workshops [related to mental health]. These workshops discussed the types of mental health problems and the intervention for each, although it was mostly focused on flood-related matters. We looked at managing and assessing symptoms related to such problems--sleep, substance abuse, anxiety, suicidality, among others. So we now have broad guidelines for psycho-social intervention which helps in dealing with large-scale disasters. 

If it is a family, we can counsel them together since they all [may] usually have the same concerns. It helps to be together from the mental health perspective. Though patients are provided books and newspapers for recreation, they feel a sense of boredom. But when all of them are together it is a relief [for them].

Are you extending this intervention to frontline healthcare workers too?

Stigma stems from ignorance and lack of information. It is possible that within a hospital those who work in the isolation ward are stigmatised. There have been cases where doctors were locked in their homes or male nurses were asked to leave their accommodation because they work in an isolation ward. The underlying factor is fear. Stigma, particularly against an illness without a specific treatment, can be managed through proper awareness and information programmes for the public.

Do those offering counselling need personal protective equipment (PPE) too?

We were trained to wear the PPE [to deal with COVID-19 patients]. It is uncomfortable, makes it difficult to breathe, and the person [being counselled] cannot hear what we are saying clearly. It is difficult to speak even for 10 minutes because we have to be loud to make ourselves heard. But people are glad that we approach them and it calms them when we ask about their problems. It shows them that they are not abandoned. 

There was a report of a suicide in New Delhi likely related to COVID-19. Have you observed anyone in extreme distress?

These thoughts can stem from fear--‘What would happen to me if this became severe or I test positive?’ or ‘Will I infect my family? Will they have to take care of me?’ So before anything happens, they would rather take this [extreme] step. But we have not come across many such cases. Usually it is fear, not necessarily suicidality, anxiety or depression. Psychiatrists handle such cases; counsellors offer basic counselling support for tension or minor sleep-related problems. 

We have had to start medication for a few people who had anxiety despite counselling. If they are isolated in the hospital, we provide medicine here, or the DMHP team delivers medicines to the primary health centre in the panchayat, which delivers them further. 

What sort of support do you see in the post-discharge phase?

Stigma-related support will be required. But if there is a widespread community transmission, there is no question of stigma. It will reduce with time and communities will move on. We need to inform people through the media that those in hospital or home quarantine are doing it for the larger community, including those without symptoms. Their freedom has been curtailed for us. We need to communicate this positive message. It is understable you cannot meet them in quarantine, but why should people not call and enquire about their well-being?

We are communicating this message through the media and television debates. For now, the focus is on the increasing cases, but our phone numbers are available to those who have been discharged. 

(Paliath is an analyst at IndiaSpend.)

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.

Pathanamthitta: Anxiety brought on by the fear of infection; guilt, shame and feelings of abandonment during isolation and uncertainty about the future--the COVID-19 pandemic is reported to have affected the mental health of many. It has allegedly resulted in suicides across New Delhi, Telangana and Chhattisgarh. In Kerala, a man who had recently recovered from the disease was turned away by his family because of the fear and stigma surrounding the infection, said Kerala chief minister Pinarayi Vijayan.

With an increasing number of people going into isolation to battle the contagion, it is vital to ensure psycho-social intervention for those in distress, said Sukesh G, a psychiatrist at the district hospital in Kozhencherry in south-eastern Kerala’s Pathanamthitta. The district had the highest number of COVID-19 cases in Kerala until March 18, 2020 and had over 7,200 people in home isolation (as on March 31, 2020). 

Since March 8, 2020, when the first positive case in Pathanamthitta came to light, Sukesh and his 50-member team of doctors, psychologists, and counsellors have been calling and visiting those in need of mental health support, especially those in 14- to 28-day isolation advised to the vulnerable. 

Sukesh is a part of the state's District Mental Health Programme (DMHP), and the Pariraksha initiative that was introduced after the 2018 floods to provide mental health support and counselling. There was realisation after the floods that not having such support “will affect the overall well-being in the long-term”. As a part of DMHP, he has attended workshops in post-disaster mental health psychosocial support, and was part of the team that conducted field visits and community interventions immediately after the floods.

Edited excerpts from the interview:

Why did the state government feel the need for a network offering mental health support during large-scale crises such as this outbreak?

There was a need for psycho-social intervention after the 2018 floods and we had not undertaken such interventions till then. It was decided that we [need] a long-term plan. The government introduced the Pariraksha programme, with one counselor on a one-year contract for each panchayat in Kerala. Before this, we had psychiatry units attached to hospitals [in the district] and each district had a DMHP. Pariraksha includes psychiatrists, psychologists, psychiatric social workers, and nurses and pharmacists. This was inadequate for a large-scale intervention, which is why counsellors were introduced in flood-affected regions.

What kind of mental health support do most people fighting the infection seek?

One of the difficulties is the 14- to 28-day hospital or home isolation. [During this period], the freedom of those in isolation is curtailed, there is boredom, and they worry or feel guilty about spreading the infection among family and friends. Stigma is another major problem. This affects hospital staff in isolation too. Your close family may not break off all communication, but others may. The severity of it may vary, but those in isolation have started experiencing stigma at different levels.

Often, we have noticed, anxiety is the reason why people call us. Asymptomatic persons in quarantine are not routinely tested for COVID-19, hence requests for testing are not entertained. This leads to the worry that they may transmit the disease to their family. This also leads to sleep-related issues. Secondly, others in the community talk [gossip] about an isolated family, which may lead to people avoiding them or their being denied provisions at a shop. This causes huge distress.

Do you find low acceptance of mental health problems in our society?

Yes, mental health issues are given less importance than physical ailments. Several factors including ignorance and stigma contribute to this. The larger realisation [about mental health] came after the [2018] flood. We realised that it affects our overall well-being in the long-term.

How is your team offering support?

Our team calls and checks if those in isolation have any mental health issues. Even if they say they do not, we give them our personal numbers and the government [health] helpline number [DISHA] for future use. Then we call again after 3-4 days. In addition, the team also checks adherence to quarantine [read our story here] when we call those in home and hospital isolation. Psychiatrists also give COVID-19 patients in the hospital personal consultation, if required.

How often have you had to get involved as a psychiatrist?

We make calls everyday. I have made more than 100 calls [since March 8, 2020, after positive cases were first found in Pathanamthitta]. There are three psychiatrists who are currently making these calls in addition to the counsellors [22 from the DMHP and 26 from Integrated Child Development Services]. We speak, on average, for 15 to 20 minutes. 

Of course, there is a difference between making a call and doing face-to-face counselling. The comfort we can offer in case of the latter is more and our ability to convince them is comparatively better.

How are you handling the pandemic, an altogether new crisis?

Immediately after the floods in 2018, we had a number of state-level workshops [related to mental health]. These workshops discussed the types of mental health problems and the intervention for each, although it was mostly focused on flood-related matters. We looked at managing and assessing symptoms related to such problems--sleep, substance abuse, anxiety, suicidality, among others. So we now have broad guidelines for psycho-social intervention which helps in dealing with large-scale disasters. 

If it is a family, we can counsel them together since they all [may] usually have the same concerns. It helps to be together from the mental health perspective. Though patients are provided books and newspapers for recreation, they feel a sense of boredom. But when all of them are together it is a relief [for them].

Are you extending this intervention to frontline healthcare workers too?

Stigma stems from ignorance and lack of information. It is possible that within a hospital those who work in the isolation ward are stigmatised. There have been cases where doctors were locked in their homes or male nurses were asked to leave their accommodation because they work in an isolation ward. The underlying factor is fear. Stigma, particularly against an illness without a specific treatment, can be managed through proper awareness and information programmes for the public.

Do those offering counselling need personal protective equipment (PPE) too?

We were trained to wear the PPE [to deal with COVID-19 patients]. It is uncomfortable, makes it difficult to breathe, and the person [being counselled] cannot hear what we are saying clearly. It is difficult to speak even for 10 minutes because we have to be loud to make ourselves heard. But people are glad that we approach them and it calms them when we ask about their problems. It shows them that they are not abandoned. 

There was a report of a suicide in New Delhi likely related to COVID-19. Have you observed anyone in extreme distress?

These thoughts can stem from fear--‘What would happen to me if this became severe or I test positive?’ or ‘Will I infect my family? Will they have to take care of me?’ So before anything happens, they would rather take this [extreme] step. But we have not come across many such cases. Usually it is fear, not necessarily suicidality, anxiety or depression. Psychiatrists handle such cases; counsellors offer basic counselling support for tension or minor sleep-related problems. 

We have had to start medication for a few people who had anxiety despite counselling. If they are isolated in the hospital, we provide medicine here, or the DMHP team delivers medicines to the primary health centre in the panchayat, which delivers them further. 

What sort of support do you see in the post-discharge phase?

Stigma-related support will be required. But if there is a widespread community transmission, there is no question of stigma. It will reduce with time and communities will move on. We need to inform people through the media that those in hospital or home quarantine are doing it for the larger community, including those without symptoms. Their freedom has been curtailed for us. We need to communicate this positive message. It is understable you cannot meet them in quarantine, but why should people not call and enquire about their well-being?

We are communicating this message through the media and television debates. For now, the focus is on the increasing cases, but our phone numbers are available to those who have been discharged. 

(Paliath is an analyst at IndiaSpend.)

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.


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