Nature India | Indigenus

Why mental health discourse must transcend the pandemic

Mental health of societies is justifiably under the spotlight during the COVID-19 pandemic. However, psychiatrist Debanjan Banerjee of the National Institute of Mental Health and Neurosciences (NIMHANS) Bengaluru is sceptical that the important issue may be pushed back into obscurity once the crisis ends.

Debanjan Banerjee

Being a psychiatrist, I have been overwhelmed with the explosion of data, discussion and debate on mental health from even before COVID-19 was declared a pandemic by WHO in March 2020. Surprisingly, a virus has suddenly helped peak interest in an aspect of public health that has long been overshadowed in our societies by stigma and neglect.

In the last six months, there hasn’t been a single day that I haven’t been invited for webinars or media appearances on mental health or read a research paper or article around this. Various online fora discuss the ‘pertinent matter’ daily. I have discussed, debated and advised on topics ranging from psychiatric disorders to psychological effects  of COVID-19 on populations or special groups (based on age, gender or social status), as well as the future implications of the pandemic. Mental health journals are publishing special supplements related to psychiatry or psychological problems of COVID-19. Like many of my peers, the fertile ground created by the virus has resulted in several publications to my credit in these journals.

The rising curve of ‘COVID-19 related mental health’ provides a tough challenge to the slope of the COVID-19 case curve itself. But has it helped our service delivery and in estimating the mental health problem in this crisis? Perhaps not. Mental and psychosexual health has always been important. Did we need a pandemic to open our eyes to that?

“To worry or not to worry”

That is the most common question I face in public online discussions and media interviews. Has the COVID-19 pandemic impacted psychological health, or are we overestimating the threat? –people seem to be quite confused about that.

So here’s a rational approach to unpack this question – unlike other natural or human-made disasters, pandemics are not ‘a one-shot’ events. The mortality and morbidity continue to rise for months to years, and the rippling effects span the socio-economic, political, psychological and psychosocial dimensions.

COVID-19 related fear, health, anxiety, stigma, stress and sleep disturbances have affected the world’s population. Added to that are financial constraints, disruption of social structure, the effects of physical distancing, lockdowns and the ‘misinfodemic’ (misinformation epidemic).

Population-based research in India, China, UK, USA, Brazil and Italy has established the worsening of psychological status due to the pandemic. Though limited data exists on people already suffering from mental disorders before COVID-19, hypothetically they might be more vulnerable to the effects of chronic stress and trauma. Besides, many of them might lack access to mental healthcare and medications due to travel restrictions. The other vulnerable groups are the frontline workers, the students, the children, elderly and socio-economically impoverished groups, including the migrants.

Interestingly, even though generic measures of ‘stress’ and ‘quality of life’ get reflected in classical quantitative research, the needs for mental wellbeing are mostly similar across the world.

One size does not fit all

I read somewhere that “COVID-19 is a great equalizer”. Of course, it is not.

The needs of a migrant labourer stranded in an overcrowded railway platform are far different from a rural healthcare worker with no access to personal protective equipment (PPE). The factors governing resilience vary widely between someone trapped with an abusive partner and suffering violence during the lockdown and an adolescent deprived of intimacy with his/her partner for months together. In short, COVID-19 has ironically highlighted the crevices in our understanding of what mental health constitutes, the same understanding that has surreptitiously governed the attitudes of the general population and physicians alike for a long time. Beyond the rigid diagnostic criteria of psychiatric disorders and the ‘medicalization’ of mental health, the pandemic displays that psychological wellbeing is as abstract as the ‘mind’ itself and also highly individualized.

It is natural to be worried or anxious during a pandemic. Anxiety is the natural defence to deal with the crisis, and being ‘perfectly composed’ is a myth. The grey but vital line of what constitutes ‘acceptable stress’ and what needs professional help can be markedly polymorphic, again depending on personal and social circumstances.

Contrary to common advocacy recommendations, no one suit fits all. When the socially unprivileged are deprived of basic amenities like food, water, shelter and security, these needs seek much urgent attention than anything else. Mental health is intricately linked with physical, sexual and social health. Divorcing these contexts and giving it a purely ‘psychological’ shape is an injustice to the human mind itself.

Mental health: A piece of the pie

Feeding off the confusion and anxiety around COVID-19 is an alarming new brigade of life-coaches, happiness experts, faith-healers, counsellors, motivators, speakers and theorists – each claiming that they are the best ‘distress-relievers’. This is of grave concern.

Some of these healing methods and their purveyors have been controversial and merit scientific scrutiny. Psychological health, seen as an accommodative arena, has traditionally been an attractive breeding ground for numerous such ‘professional experts’ in mental health. Improvement in any medical disorder (including psychiatric disorders) depends largely on the patient’s trust in the therapist or the doctor-patient relationship, and this factor is exploited many times in advertisements and endorsements about such professions.

Faulty advice can harm patients of psychological distress and disorders. The underlying societal stigma and marginalization against the mentally ill have only helped putting them “away from the society” for ages. The same stigma is prevalent against those testing COVID-19 positive or those working on the frontline exposed to viral risk. Stigma and prejudice are an integral part of the ‘collective mental health’ and are often under-detected, as they cannot be categorized as ‘disorders’.

Social problems that affect mental health – poverty, homelessness, gender-based discrimination, ageism, domestic violence, deprivation of human rights and social injustice – are often politicized or discussed for academic obligations but rarely addressed with sincerity, either at an individual or administrative level. These lacunae get unmasked during a biopsychosocial threat like COVID-19, further re-enforced by the socially-dissociated storm of sudden mental health promotion and awareness.

It is important to realise that mental health can only be conceptualized as holistic psychosocial and psychosexual health. A number of factors are involved in the genesis of stress and trauma during a crisis. That necessitates an assumption and bias-free approach, sensitivity, empathy towards the underprivileged, administrative enthusiasm and collective understanding of the importance of mental health irrespective of the pandemic.

Will it fizzle out?

Mental health, unlike many other disciplines, is quickly capitalised and politicised for short-term gains. My scepticism is that, like any other piece of popular news, the relevance of this ‘hot and in-demand topic’ will fizzle out soon after it has served its purpose.

The most recent example of such event-driven concern is that of a Bollywood film star’s death by suicide, which gave way to the usual conspiracy theories alongside online awareness drives around depression and suicide prevention. I received numerous calls with inquiries on the ‘psychological premise’ of suicide and how it can be prevented.

What we fail to understand is that like diabetes, hypertension, strokes or heart attack, psychiatric problems are also better prevented. The approach of prevention starts right when a child is born, or a family is started. Environmental influences, parenting, education, upbringing and social interactions have as much a role to play in the genesis of mental health problems as genetics. But unlike genetic influence, the other factors can be modified, which gives us a wider angle of interventions. It is rather pointless discussing and criticising suicides with hypotheses about how they could have occurred, as one can’t second guess or retrospectively prevent the premature ending of a life.

The debate around psychological wellbeing during the pandemic will continue enriching our academic and professional lives.  However, whether the numerous webinars, articles, guidelines, Ted talks and public lectures will penetrate the concrete social shell to destigmatize mental health is doubtful.

When the pandemic ebbs, this heightened sensitivity about psychological concerns should not. That might help global mental health and sharpen our preparedness for such crises in future.

Nature India’s latest coverage on the novel coronavirus and COVID-19 pandemic here. More updates on the global crisis here.

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