Jaipur: Suraj Mahawar received a call from the Sawai Man Singh mortuary on June 19, 2020, four days after his father, Navratan Mahawar, 49, was admitted to the Rajasthan University of Health Sciences (RUHS), the largest government COVID-19 dedicated facility in Jaipur.

Lack of information from hospital authorities led the 28-year-old plumber to conclude that his father had died by suicide following his COVID-19 diagnosis. "We had not spoken to him after June 17," Mahawar told IndiaSpend. "We had no idea whether he was being treated or if his health was changing."

RUHS denied that Navratan had died by suicide. "The patient died because of COVID-19," said Sudhanshu Kakkar, principal and controller of RUHS. "He was breathless and was admitted to the intensive care unit for two days. He had given an incorrect number and address during his admission and we were unable to contact the family."

This was little consolation for Mahawar and his family, who say that they had given the correct details when the ambulance came to pick his father up from their home. "My father passed away without us being able to speak to him," said Mahawar. "The hospital should ensure that the family is able to talk to the patient daily."

Even though RUHS said that Navratan did not die by suicide, "two patients did die by suicide at the facility in July", said Kakkar. Following these deaths, RUHS brought in four psychiatrists, including a visiting psychiatrist, to counsel patients and instituted a help desk to provide information to families of COVID-19 patients to help alleviate stress, said Kakkar.

Although there is no comprehensive data on the mental health impacts or suicides related to the COVID-19 pandemic, deaths by suicide due to COVID-19 have been reported from elsewhere in the country too. Patients and doctors in several cities including Patna, Delhi, Surat and Mysore have died by suicide because of COVID-19 or a fear of the infectious disease that has now recorded over 3.75 million cases in India.

Past pandemics led to worsening mental health issues and an increase in suicides, according to studies. For instance, the influenza epidemic in 1918 increased suicide rates in the United States; suicides of those aged 65 and above in Hong Kong increased during the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003.

People in China and the US have said that the COVID-19 crisis has had psychological impacts such as anxiety, depression, worry and stress, according to multiple surveys. Studies in China have also found reduced sleep quality and an increase in the expressions of anxiety, depression and anger on social media.

"The psychological sequelae [a pathological condition resulting from a disease, injury, therapy, or other trauma] of the pandemic will probably persist for months and years to come," wrote Leo Sher, the New York-based author of a study on the impact of the COVID-19 pandemic on suicide rates, which was published in June.

Six months into the biggest health crisis in memory, that has brought untold physical, social and mental distress, India's healthcare system remains unprepared to tackle the mental consequences of the disease, the lockdown and financial crisis, mental health professionals, stakeholders and observers say. They had cautioned about the mental health impacts of COVID-19, as IndiaSpend had reported in April.

The focus thus far has been on boosting COVID-19-related infrastructure, in terms of beds, isolation wards, and so on. But mental health problems also need to be focussed on, said Ananya Dhar, assistant professor in the department of psychiatry at the Byramjee Jeejeebhoy Government Medical College and Sassoon General Hospitals (BJ medical college) in Pune.

Our healthcare system is driven by tertiary care, which means that, in most places, especially in rural areas, the only place for mental healthcare is a district hospital, said Soumitra Pathare, psychiatrist and director of the Centre for Mental Health Law and Policy (CMHLP) at Pune-based ILS Law College.

"Below this, everything is missing, be it grassroots workers or primary healthcare," he said. "The COVID-19 crisis has made it apparent that the mental health system does not have the capacity to manage widespread mental health problems."

The Central government needs to launch a mental health-focussed national public health awareness campaign, just as it did when it sought to eradicate polio or to fight the scourge of HIV/AIDS, said Nelson Vinod Moses, founder of Bengaluru-based Suicide Prevention India Foundation (SPIF).

COVID-19 and suicides

Stress, anxiety and sleeplessness are making many people reach out to doctors, counsellors, psychiatrists and helplines, according to healthcare professionals and stakeholders that IndiaSpend spoke to in five cities.

In many cases, the stress stems from a COVID-19 diagnosis, financial distress arising out of COVID-19 circumstances, an existing mental health problem that has been re-triggered or exacerbated, a lack of human interaction or a fear of infection, professionals and stakeholders told us.

About 68% of 159 mental health professionals interviewed between April 24 and May 28 by SPIF said that more people had been reaching out for help since the COVID-19 outbreak, SPIF's Noor Malik told IndiaSpend. The survey was looking at the impact of the first lockdown, announced on March 24. Nearly 58% mental health professionals told SPIF that patients making a recovery or those who had recovered had had a relapse even as about 29% mental health professionals said that suicide ideation had increased among patients they counselled, said Malik.

In May, researchers also established a link between COVID-19, unemployment and suicide through a modelling study, which predicted an increase of about 2,135 suicides if the worldwide unemployment rate increased from 4.93% to 5.088% due to COVID-19.

COVID-19-related suicides have already been reported from the United States, the United Kingdom, Italy, Germany, Bangladesh and India.

The first known COVID-19 suicide in India, as reported by the media, came in February. A 50-year-old man from Chittoor district in Andhra Pradesh had contracted a viral illness and incorrectly believed it to be COVID-19, the Hindustan Times had reported. He was stressed after watching videos of COVID-19 in China and eventually quarantined himself. He did not allow his family members near him because he was afraid that they would contract the disease from him. At the time, there was no known COVID-19 outbreak or cases in Andhra Pradesh.

Subsequently, in the three months following the COVID-19-induced nationwide lockdown, the police reported an increase in deaths by suicide in the state of Jharkhand and in the cities of Bhubaneshwar in Odisha and Ludhiana in Punjab--and fewer such cases in Pune in Maharashtra--between April and June.

India reported 139,123 deaths by suicide in 2019, according to the latest available data as per the National Crime Records Bureau; this is about 381 deaths by suicide per day on average.

"It is not possible to know how this number [of deaths by suicide] has been impacted by COVID-19 owing to multiple reasons, including a lack of data and that only a small proportion of suidice deaths are reported in the media," said Pathare of CMHLP.

One analysis of media reports found that 72 people died by suicide for reasons related to the pandemic in India; the analysis, by researchers at the Manipal College of Health Professions in Karnataka and at Jahangirnagar University in Bangladesh, looked at deaths by suicide as reported in seven English language newspapers from March 24 to May 24, i.e. the two-month nationwide lockdown period.

Of the 72 deaths, 21 died by suicide because of a fear of COVID-19 infection, 15 because of a financial crisis, seven were COVID-19 positive and three were stressed because their work was related to COVID-19. The remaining 26 either suffered from loneliness or depression in the lockdown or in quarantine and because of an unavailability of alcohol.

Data are needed to understand who has been impacted, said Pathare. "Are they the elderly or the children, which socio-economic or professional group do they come from and if they are in rural or urban parts of the country," he said. "We can then plan intervention on the basis of the data."

Distressed COVID-19 patients need support

The central government issued a guide in April for general medical and specialised mental healthcare settings to be followed during the COVID-19 pandemic. The document offers guidance for mental health in different situations such as for COVID-19 patients, for those in quarantine, for children, etc.

It states that policy makers should be "mindful" about the health of the community, there should be "psychological crisis interventions for the high-risk population and mental health education for the general population" and that the "management and treatment of severe mental disorders should not be interrupted as far as possible".

Administrative and medical authorities involved in COVID-19 care do not always realise that they need to be 'mindful' about the community. Researcher Dimple D'souza had been home-quarantined during the early days of the pandemic following international travel to return home. She received calls from different government authorities such as the police and the health department, all of whom questioned her about maintaining isolation and details of her travel, she said.

"They are doing their job but this [constant questioning] can be scary for a person in isolation," D'souza told IndiaSpend. "Instead it might be helpful to those who are quarantined or for COVID-19 patients if these officials also asked how the person was and whether he/she needs any help."

COVID-19 patients are feeling that they are not being heard, which can build up anxiety, anger and stress. "When we speak to COVID-19 patients, there is a lot of anger… they say their questions are not being answered and they do not know what is happening," said Akanksha Chandele, a psychologist, who also works with a helpline that provides assistance to Delhi's COVID-19 patients during and post-recovery and for plasma donation.

Those who are diagnosed with COVID-19 should be counselled, given clear information of the prognosis and treatment, along with resources and contact details of those they can reach out to for assistance, said Dhar of BJ medical college in Pune.

This is what happened with Bengaluru residents Jimmy Xavier, 43, and his 62-year-old mother, Anjana. Both were diagnosed with COVID-19 in April and admitted to Victoria Hospital Bangalore for treatment, where all their questions were met with clear responses.

"The ward's health officer was fantastic. She treated us like family and was always there, night and day, if we needed help," Xavier told IndiaSpend. "People need to be made aware of what to expect in the disease… that for most patients, COVID-19 will be a mild disease and that they will not die."

COVID-19 patients fear that their family and children will get the disease, and this creates additional stress, said BN Gangadhar, director of the National Institute of Mental Health and Neurosciences (NIMHANS) in Bengaluru.

"COVID-19 is a viral infection with social consequences," said Gangadhar adding that patients experience a culture shock in COVID-19 wards or in quarantine centres when they share a ward and bathroom with many other patients.

"The disease itself can impact mental health because of how the body biologically responds to the virus," he told IndiaSpend. "Nearly all COVID-19 patients believe that they are [among] the 1-2% who will die of the disease," leading to anxiety.

In addition, "there is a certain amount of stigma associated with COVID-19," said Dhar. "If there is a COVID-19 patient in the household, neighbours might label the house as the one where there is/was a COVID case (woh ghar jaha pe COVID hai)," which can make people anxious and depressed."

About 5-10% of recovered COVID-19 patients are likely to face mental health issues even after their physical recovery, said Pathare, citing evidence from western countries.

Communicating with patients' families

COVID-19 patients experience loneliness in isolation while at the same time their relatives are often unable to communicate with them, and both these situations can cause stress, said Dhar of BJ medical college.

"It is important that patients and family members be able to communicate throughout their treatment," she said. This can be done using phones, videos or even by setting up a room with a glass partition where patients and family members can see one another and talk via a telephone, she said.

"A help desk is extremely important as the family and the patient are often unaware about what is going on, and this can increase stress and anxiety," said Chhaya Pachauli, the director of Chittorgarh-based Prayas Centre for Health Equity, a non-profit health research and advocacy group.

The Central government wrote a letter in end-July to all states asking them to allow mobile phones for COVID-19 patients in hospitals. The Rajasthan government had passed a similar order earlier in July stating that all patients in wards as well as in the intensive care units be allowed to keep their mobile phones and tablets to ensure they are able to communicate with their families.

The Rajasthan government also ordered, on July 25, that CCTV cameras be installed in all COVID-19 facilities for monitoring and that help desks at all hospitals provide information to family members. The order states that every hospital should have a dedicated place on the hospital premises where family members can wait.

Tough on the vulnerable, mental health patients

Apart from COVID-19 patients and their families, others such as the vulnerable and those living with mental health illnesses could be most impacted, say stakeholders. Among them are the ones with a chronic disease who have been unable to easily access hospitals and doctors because of the lockdown, people already on the edge who were 'keeping their head above water' but were pushed because of the pandemic, and women who might be facing domestic violence within the household, said Pathare.

"Often, the most vulnerable and the most affected are the ones who are unable to access help and are out of the conversation on mental health," he said.

People living with mental illnesses have had it particularly tough, said Mumbai-based psychiatrist Avinash Desousa, because restrictions on travel and movement have affected their treatment.

"It [COVID-19 crisis] has also made it challenging for them to access medication, such as anti-anxiety drugs or pills for schizophrenia at local chemists," Desousa told IndiaSpend. "There are times when chemists refuse to recognise prescriptions sent on WhatsApp, and we [psychiatrists such as himself] have to get on a call with them so that they give the patient the medication."

Special psychiatric COVID-19 wards need to be set up for the special care of people living with mental illnesses such as schizophrenia if they contract the infectious disease, he said.

Healthcare workers on centrestage

Healthcare workers are playing a vital role through the COVID-19 crisis, and have to look after not just the well-being of their patients but equally pay attention to their own, stakeholders said.

"The mental health of people who manage COVID-19-related operations is just as important," said Chandele, pointing out that the 80-100 counsellors at the helpline she works with have supervisors, i.e. a person with more counselling experience. Once every week, all the helpline's 80-100 counsellors meet the 10 supervisors in groups to relieve anxiety and feelings of stress. "They are going through this as much as anyone else and along with it providing care to others."

To ensure their staff is in healthy spirits, Pune's BJ medical college has hosted three workshops for nurses and other healthcare workers who are stressed and have been away from their families. The workshop teaches participants how to relieve stress, its causes and management and a demonstration of how guided imagery, deep breathing and muscle relaxation can be used to deal with it.

NIMHANS in Bengaluru also started a separate helpline for healthcare staff after the COVID-19 outbreak, according to Gangadhar.

Hospitals and quarantine centres can put institutional mechanisms in place to ease stress and anxiety of COVID-19 patients, say healthcare professionals. COVID-19 wards in hospitals can make available flyers and posters about relaxation techniques, play yoga videos and relaxation music on speakers to help make patients feel at ease, they say.

Communication with patients is key, and healthcare staff must be trained in the art of listening as they are the only ones in touch with patients, said Chandele.

Healthcare workers should speak distinctly or loudly when communicating through their personal protective equipment, suggested Dhar. "They can use a photo or a name tag to introduce themselves so that patients can identify them. They should listen to the patients and ask if they need help."

Gaps in the system and fixes

The pandemic has reduced the stigma attached to mental health issues and brought it out of the closet. People are now more open to therapy and counselling, said Desousa, the Mumbai-based psychiatrist.

It is necessary that families and healthcare professionals be aware that COVID-19 can have mental health impacts even post recovery, and patients should be directed to seek the right help, said Pathare.

Gangadhar of NIMHANS said that given the limited government resources, the resources are deployed to reach as many people as possible. For instance, he cited the example of an anti-anxiety medication that was approved especially during the pandemic for prescription over telemedicine because of the lockdown and issues of accessibility. "This is not a situation we were prepared for. The government has done what was possible at their level."

India has 50-odd government-run or funded hospitals that provide mental health services, said SPIF founder Moses. "We need more than 200 hospitals, and have them evenly distributed across geographies so that regions like Kashmir and the northeast are serviced," he said.

Remedying the lack of mental health care requires intervention at multiple levels, according to mental healthcare professionals and stakeholders. For starters, the government could publicise where mental health medication is easily available so that patients do not find it difficult to access drugs, said Shalini Quadros, co-author of the study on COVID-19 related deaths by suicide as reported in the media.

"This will encourage the community to seek help and treatment," she told IndiaSpend. "The community should also be made aware of the income tax benefits that they can opt for if a family member is suffering from a mental illness which might encourage them to seek care," added Quadros.

Social media platforms, news platforms and videos can help spread awareness about stress relaxation techniques, and also work as easily accessible mental health resources, said Quadros. Employers can also publicise such platforms and videos and encourage their employees to rely on such resources, added D'souza, her co-author on the study.

Doctors and those in authority can employ a trauma-informed lens as everyone is being impacted by the pandemic, said Chandele. "For instance, if school teachers are trauma-informed, they can identify what might trigger a student," she said.

The mental health effects of an economic crisis (such as that created by the pandemic) can be offset by social welfare and other policy measures, according to a 2011 World Health Organization report on the mental health effects of economic crises. For example, active labour market programmes aimed at helping people retain or regain jobs, family support programmes, debt relief programmes and responsive primary care services support people at risk and prevent mental health effects, the report said.

"Overall, the government needs an agency, a team of public health professionals, disaster experts, psychiatrists, so we can plan for this sort of a situation, including providing mental health support, in advance," said Desousa. "We were not prepared for this pandemic and the lockdown, but now that COVID-19 is here, public health and mental health can be thought of as part of disaster management plans."

(Khaitan is a writer/editor with IndiaSpend. Editing by Marisha Karwa.)

Additional info:

Those who are seeking help can reach the following helplines:

National helpline: 080 46110007

Samvaad helpline, Pune: 020-261 27331

Delhi State Coronavirus Mental Health Helpline: 1800 111 647

National tollfree helpline: 18005990019

Other helplines here

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