Background

The novel coronavirus which originated in Wuhan, China, resulted in a cluster of unexplained pneumonia cases. It subsequently spread to several countries. The World Health Organization (WHO) declared it as an emergency of international concern in January 2020. Officially designated as COVID-19 by the WHO, this crisis generated unprecedented global action. As COVID-19 spread, updates on information and recommendations were continuously put out by epidemiologists, virologists, global media, international health organizations, and opinion makers [1]. Data on the route of transmission of the virus and the incubation period, symptoms, clinical outcomes, and survival rates of the disease was collected and shared in real time [2].

Following WHO’s recognition of COVID-19 as a pandemic, governments all around the world responded by enforcing measures like social distancing and quarantine. Social distancing and lockdown were first carried out in China and then in many European countries including Italy and Spain [3]. Stringent public health measures were implemented to contain the pandemic [4]. Although necessary, these measures had a major impact on the psychological state of the people. The modern world, in which individuals are able to travel frequently and communicate in person, was forcefully restricted leading to feelings of frustration and uncertainty.

The prohibition of almost all non-essential individual movements led not only to a socioeconomic crisis but also to severe psychological distress. Fear, anxiety, anger, and sadness were some of the psychological consequences of isolation. Being far away from school, work, and peers, adjusting to new ways of learning and dealing with job uncertainty and loss of a steady income to support the family resulted in lifestyle changes. Individuals were emotionally unprepared to deal with the COVID-19 pandemic. Psychological reactions such as fear and anxiety were accentuated due to inaccurate, anxiety-provoking information provided by the media [5]. It should be noted that before the pandemic, between 1990 and 2017, one in every seven persons in India had experienced psychological maladjustment which varied from sadness and nervousness to extreme conditions such as schizophrenia. COVID-19 exacerbated the situation. Today, the nation appears to be in a mental health crisis [6].

Due to the burden of infection and other challenges posed by the pandemic, the mental well-being of patients, healthcare professionals, and frontline workers was neglected [2]. With COVID-19 spreading rapidly, nations worldwide were forced to implement emergency protocols as local hospitals began to receive thousands of critically ill COVID-19 patients. This resulted in psychological distress which varied from panic attacks and collective hysteria to pervasive feelings of hopelessness and desperation including suicidal behavior [7,8,9,10,11].

A high prevalence of psychological symptoms, including depression, mood swings, irritability, insomnia, post-traumatic stress, anger, and emotional exhaustion, was reported in those who had been quarantined. Long-term behavioral changes like vigilant handwashing and avoidance of crowds as well as a delayed return to normality even after several months of quarantine have been reported [12]. Quarantine seems to have important dysfunctional psychological consequences on the individual’s mental health not only in the short term but also in the long term. Symptoms of hysteria, depression, and self-reported stress are common psychological reactions to COVID-19. It is important to generate awareness and address the need for psychological interventions.

Approach

The authors of this chapter aim to understand the shift in perceptions of the psychological state in India during the COVID-19 pandemic. The authors have explored the factors within the pandemic scenario that facilitated this process. The chapter begins by providing a general perspective on the psychological state during the COVID-19 pandemic. The concept of the psychological state is enunciated. The discussions focus on why attention should be paid to mental (ill) health and which groups are at greater risk. Finally, a general intervention framework for successfully managing psychological problems during and after the pandemic is presented.

A review of the literature on mental health during the COVID-19 pandemic was undertaken. In addition, a review of the electronic database and newspaper articles searching the terms novel coronavirus, nCov, mental health, anxiety, depression, stress, stigma, transformation, violence, and lifestyle relevant to mental health was done. The literature review included articles related to editorials and commentaries on mental health and COVID-19. Observational and cross-sectional narrative reviews were used to summarize the salient themes. This chapter includes an extensive review of observational studies on mental health during the COVID-19 pandemic, articles addressing the psychological impact of COVID-19, and the impact of COVID-19 on the general population including men, women, children, vulnerable groups, and healthcare workers. While most of the literature was sourced from India, studies from countries like United States, UK, China, Iran, Japan, and Singapore were also reviewed to provide a larger context.

Factors Impacting Mental Health

The psychological wellness of individuals was influenced unfavorably due to lifestyle changes caused by the pandemic that included isolation, limited mobility, and ever-spreading gossip on web-based media. Tension among the people resulted in frenzy purchasing, impediments in daily exercise, changes in dietary habits, and restricted socialization. There is clearly a need to manage problems affecting psychological wellness [13]. In India, every section of the population was impacted at various levels. Mental health problems resulted in a lifestyle disorder that spared nobody. A discussion of mental health problems in various population groups is provided here under.

Impact on Frontline Workers and Vulnerable Groups

Social stigma in COVID-19 has become ‘normal’ as is the case with leprosy, HIV/AIDS, and other communicable diseases [14]. This stigma is felt, not just toward the individuals who have recuperated from COVID-19, but also toward those who are undergoing treatment and/or have been potentially exposed to the infection. Populations whose mental health is severely threatened include daily-wage laborers, clinical professionals, medical caretakers, and the police. Many of them have been driven away from their neighborhoods, denied admittance to their homes, and their families have been compromised. Their tireless efforts in trying to fight the infection have been overlooked [14]. In battling the COVID-19 pandemic, healthcare workers have been at significant risk of adverse mental health outcomes.

Dong and Bouey point out that the spread of COVID-19 could lead to a mental health crisis, especially in countries with high caseloads which require large-scale psychological crisis interventions. This is the case in India, a country that has one of the highest recorded cases of COVID-19. Anxiety is the most common health symptom faced by individuals. Anxiety is associated with impaired sleep [15]. Studies show that populations having symptoms of COVID-19 have high rates of anxiety and depression. In August 2020, Wang et al. conducted an online survey using the depression, anxiety, and stress scale (DASS-21) and reported that approximately 16.5%, 28.8%, and 8.1% of individuals exposed to infection faced moderate to severe depression, anxiety, and stress symptoms, respectively [16]. A cross-sectional, self-related survey was conducted by Li et al. through the Chinese version of the Vicarious Traumatization Scale using a mobile application. The survey showed that traumatization was higher in the general public than in non-frontline nurses and frontline nurses. And it was higher in non-frontline nurses than in frontline nurses [17]. To examine the impact of COVID-19 on the mental health of individuals in self-isolation for 14 days, Xiao et al. designed a cross-sectional, self-rated questionnaire by using the Self-rating Anxiety Scale (SAS), Stanford Acute Stress Reaction (SASR) questionnaire, Pittsburgh Sleep Quality Index (PSQI), and the Personal Social Capital Scale (PSCS-16). The respondents to the questionnaire reported that: (1) sleep quality was positively correlated with social capital and negatively correlated with anxiety; (2) anxiety was positively correlated with stress and negatively with sleep quality and social capital [18].

Kang et al. showed that working hours, risk of infection, shortages of protective equipment, loneliness, physical fatigue, and separation from families were the main reasons that affected the mental well-being of people in Wuhan, China [19]. According to Chen et al., another significant factor was the gap between planned services at hospitals and the actual needs of healthcare workers. There is a need to set up an intervention team which would design online materials, provide psychological assistance, hotlines, and group activities for stress reduction [20]. Liu et al. point out that mental health professionals need to work especially closely with those working in critical care units to minimize stress levels and reduce the risk of depression [21]. Kang et al. observed that there was a positive impact of telephone helplines that specifically addressed the mental health problems of healthcare workers [19].

Impacts on the General Population

The general population in India has witnessed a health emergency as well as a lingering socioeconomic crisis resulting in dysfunctional processes and maladaptive lifestyle changes [22]. A study by Zandifar and Badrfam in Iran highlights that the COVID-19 pandemic, which is characterized by unpredictability, uncertainty, misinformation, and social isolation, contributes to stress. There is a need to strengthen mental health services and social capital, particularly for vulnerable populations, to reduce the adverse psychological impacts of COVID-19 [23]. Bao et al. highlight that the services provided in China included strategies for the general public to minimize outbreak-related stress. The strategies included: (1) assessment of the accuracy of information; (2) enhancing social support; (3) reducing the stigma associated with the disease; (4) maintaining as normal is a life as feasible while adhering to safety measures; and (5) using available psychosocial services, particularly those online, when needed [24]. As anxiety is the dominant emotional response to an outbreak, Lima et al. describe the need for adequate training of healthcare professionals and the optimal use of technological advances to deliver mental health care. Anxiety that arises from misinterpretation of perceived bodily sensations can be addressed in a non-pandemic period [25]. However, during an outbreak of an infectious disease, with a flood of inaccurate or exaggerated information from the media, health anxiety can become extreme. This manifests as maladaptive behaviors at an individual level and can lead to mistrust of public authorities and scapegoating of particular population groups at a broader societal level.

Influences of Media and Virtual Dependency

During a pandemic, media can add to anxiety which impacts the psychology of people. The swine flu pandemic of 2009–2010, which brought about high mortality, received worldwide media attention and evoked anxiety among the public [13]. This trend was also noticed with the COVID-19 pandemic in India. A recent online survey conducted in India showed that 28% of the population had sleeping difficulties. More than 66% said that they were stressed when they saw posts on the COVID-19 pandemic on different web-based media. Forty-six percent identified stress with conversations on the COVID-19 pandemic in news channels and print media. The study concluded that a critical number of survey respondents did not have sufficient information about the spread of the infection [26].

A survey conducted by Mavericks in India found that 61% of the people experienced mental health issues due to the lockdown because of the uncertainty of the crisis [27]. By restricting individuals within four walls, COVID-19 has prompted new ways of survival. Social distancing has pushed individuals to be able to stay connected with the outside world using digital platforms and relying on social media and video conferencing [28]. Dependence on traditional news formats including newspapers has declined. The need for instant and accurate news and the ease of accessing information online have increased reliance on online media platforms. A joint study by the Broadcast Audience Research Council of India (BARC) and Nielsen India shows a 41% rise in the time spent on news apps during the lockdown [29]. Seventy percent of respondents chose online Web sites and news aggregator apps as their sources of information. This rise was noticeable across all age groups. Google trends data showed more than a 200% rise in online searches for news during the lockdown period [30]. The impact of expanded indoor and screen time hours on mental health is, however, an under‐researched area [28].

Influence of Changes in Working Environment

A large section of the population was forced to reinvent its workplace often in unfavorable environments, resulting in a deep sense of unease. In a situation entirely driven by compulsion and not by choice, working from home did not appear to be favorable to most people, and even more so to the millennials. The lockdown due to the pandemic forced all industries to get their workforce to operate remotely and to explore innovative ways to do so. In a recent survey, corporate executives indicated that working remotely will be the most significant change in the post-COVID world. Given the success of the forced experiment, many organizations are exploring options to get their workforce to work from home even after the pandemic. On the other hand, 75% of Indians find working from home very challenging and want to get back to working from the office. Most homes do not have a dedicated study room or a distraction-free area that guarantees maximum productivity. People are thus unable to chalk out ‘me time,’ a designated hour carved perhaps in their commute to the office. Extended work hours and blurred lines between working and not working at home have led to a desire to return to the office as soon as possible. A survey by the Indian Psychiatric Society showed that because of uncertainties relating to issues such as finances, work pressure, job retainment, and stress in relationships, there has been a 20% rise in cases of mental illness. The number of suicides has also increased [30].

In 2013, the latest available statistics, 270 US officegoers committed suicide at work which was a 12% increase in comparison with 2012. As indicated by a stress pulse overview, unnecessary remaining tasks at hand (46%) and relationship issues (28%) are the main causes of stress at work. Most individuals who attempted suicide or succumbed to suicide had mental health problems that had not been attended to. When compared to females, male employees are many times more likely to commit suicides due to problems in the working environment [31].

While lockdown has affected numerous individuals, more than 75% of the twenty to thirty-year-olds surveyed were idealistic about getting back to work within three to four months. People above 30, however, disagreed. People who started working recently were interested to return to work. The expectation of recent college graduates to return to business is good news for the markets as they constitute the biggest shopper and spender base [30]. However, this is subject to the supposition that they have not been laid off.

Economic Insecurity and Increased Risk of Suicides and Crime

Nearly 800,000 individuals die by suicide every year globally. According to the WHO, for every suicide there are 20 suicide attempts. These numbers are bound to increase during the COVID-19 pandemic. Data from the monetary emergency of 2008 indicates that increase in suicides is related to joblessness [32]. The downsizing of the economy due to the COVID-19 pandemic has resulted in long-haul issues especially for the vulnerable at the edges of the society. It is important to set up hotlines and mental health support groups to address mental health problems. Increasing joblessness and financial misfortunes brought about by the COVID-19 pandemic have further compounded the problem [33]. As one study suggests, job losses due to COVID-19 could result in up to 9,570 more suicides globally than in a normal year [34]. Suicide rates are expected to increase after financial downturns. The US joblessness rate remains at around 14.7%. It could be nearer to 20% which means that a stunning 20.5 million individuals were jobless in April 2020. This is the largest work market decrease ever. Some financial experts caution that monetary recuperation will probably be moderate and uneven [35]. Most adults in an American Psychiatric Association study conducted in March 2020 were concerned that the pandemic would have a genuine negative effect on their funds. Sixty-six percent dreaded that the pandemic would have a significant effect on the economy [36].

The International Labor Organization (ILO) gauges that worldwide joblessness could increase from 4.9 to 5.6%. Suicides increased by 9,570 annually before the pandemic but would increase by an additional 2,135 during the pandemic [34]. Suicides are higher among individuals who have encountered brutality, harassment, and violence. Sentiments of disconnect, sadness, stress, and other monetary burdens are known to increase the danger of self-destruction and suicide. Individuals are bound to encounter these sentiments during an emergency like a pandemic. Be that as it may, there are approaches to prevent self-destructive considerations and practices. For instance, support from the family and network and face-to-face or virtual connection can help [37]. People with substance abuse are more likely to commit suicides than the people who do not use drugs. According to an alarming report from the Centers for Disease Control and Prevention, the US suicide rates are the highest since World War II [31].

Lack of adequate and accessible support services is not the only factor that has resulted in the looming mental health crisis which remains unaddressed. Its psychological impacts are also significantly tied to the economic instabilities brought about by COVID-19 [38]. According to Shigemura et al. from Japan, the economic impact of COVID-19 influenced mental well-being, sometimes leading to high levels of fear and panic [39]. Disruptions in basic livelihoods have threatened food security and shelter, pushing people toward socially undesirable and illegal activities. In contrast, the lockdown and the restrictions imposed by the pandemic that impeded everyday actions like shopping, vacations, and gatherings resulted in fewer habitual offenders like thieves and pickpockets. A study in Sweden found that pocket-picking diminished by 61% in Stockholm during the COVID-19 period when restrictions on gatherings and crowds were imposed [40].

A survey in late March 2020 found that 90% of Americans, including basic laborers, ‘remained at home as much as they could reasonably be expected to [41]’. ‘Stay at home’ commands caused maladjustment in the lives of billions of individuals. In the United States and around the globe, a positive side effect was a sensational drop in crime [40]. Economies around the globe were hit by lockdowns because of which financial experts anticipate an economic downturn. Joblessness will probably increase, and individuals will have less dispensable incomes to handle emergencies. Previous experience has shown that crime increases in emergency situations.

Specialists have indicated that there a rise in cybercrime since the beginning of the pandemic. For example, police authorities in Maharashtra caught 400 individuals for cybercrime. Officials also say that an increasing number of people are complaining of being cheated through online transactions [42]. The Indian government has urged citizens to be careful about phony messages and to report instances of online misrepresentation.

The Gender Factor

Due to the pandemic and the consequent lockdowns, women in India are struggling more than men as their workload has increased significantly. Women are carrying multiple responsibilities without any assistance from domestic helpers [27]. Several workers have left, and low-cost part-time help is no longer available to women. Women are reluctant to take on full-time help because it is more costly. Consequently, demand has increased for home appliances like dishwashers, vacuum cleaners, and fully programmed washing machines.

According to one survey, men experienced a greater social disconnect than women owing to forced confinement during the lockdown. However, the adverse impact on their mental health was less when compared with women because women had to cope with the additional workload at home. Women faced the possibility of higher rates of mental health problems [30].

Household stress has increased intimate partner violence [43]. The disruption of social and protective networks due to the lockdown has meant less support and protection from violence. Violence against women and girls, a human rights issue, has exacerbated during the pandemic. According to UN Women, one in every three women experience physical or sexual violence by an intimate partner worldwide. Emerging data and reports on COVID-19 have shown that all types of violence against women, particularly domestic violence, intensified. Women are placed under the increased strain of responsibilities in confined living conditions. Government authorities, women’s rights activists, and civil society partners across the world are calling for help against domestic violence [44]. In China, police reports show that domestic violence tripled during the pandemic. Organizations that prevent domestic violence have observed increased household tension and domestic violence due to forced co-existence, economic stress, and fears about the virus. However, there are also examples of innovative practices to support survivors.

Increased violence against women is not only within the home, but also in other spaces. Female health workers and migrant domestic workers have faced violence. Xenophobia-related violence, harassment, and other forms of violence on online platforms have become more prevalent during the pandemic. In Delhi, for example, female students from the northeast were verbally harassed and had objects thrown at their private parts with attackers shouting ‘Aye, coronavirus!’ [45]. According to the survey by UN Women in New South Wales, Australia, 40% of frontline workers including human rights defenders, women in politics, journalists, bloggers, lesbians, transgender, women belonging to ethnic minorities, indigenous women and women with disabilities reported increased requests for help as violence escalated [46]. In China, there have been reports of physical and verbal attacks against frontline healthcare workers. In Italy, the national healthcare workers union has raised concerns about attacks against doctors and nurses as COVID-19 overwhelmed health resources [45].

In Seattle, United States, there have been reports of more coercive and violent behaviors against street-based sex workers since the COVID pandemic began. In Hong Kong, the migrant workers association warned that domestic workers, most of whom are migrant women, are being made to work on their day off [45]. The health system is under an enormous burden of COVID-19. We need a global collective effort to stop the shadow violence pandemic that is growing amidst the COVID-19 crisis. As COVID-19 cases continue to strain health services, essential services such as domestic violence shelters and helplines have reached capacity. There is an urgent need to mitigate the risk of violence against women during the pandemic. The COVID-19 pandemic has also curtailed access to support services for survivors, particularly in the health, police, and justice sectors.

Overwhelming pressure on employees and increased workload and responsibilities have imposed unimaginable lifestyle changes in women. More needs to be done to address these critical concerns. The first step should be to invest in response and recovery efforts by scaling up hotlines, crisis centers, shelters, legal aid, protection, and counseling services.

Concluding Comments

The year 2020 has been surprising in a myriad of ways. The world has lived through a pandemic where travel plans, celebrations, and social events have all been wedged. And, educational institutions, offices, entertainment spaces, and transport facilities have been shut down indefinitely. As stress, anxiety, and depression become a new part of every individual’s life, mental health which were once heavily stigmatized is now recognized as a lifestyle disorder that has affected everyone. No one has been spared. Factors that have affected these changes are a lack of social interactions, changes in living and working environments, a flood of inaccurate and exaggerated information, and insecurities regarding employment and livelihoods. Research shows that mental health problems are very widespread. Mental health problems were on the rise even before the pandemic. In India, for example before the pandemic, one in seven people had experienced a mental health problem. The pandemic, however, has greatly exacerbated mental health problems.

Even though there are robust plans and interventions to strategically respond to the pandemic, there remains a need to include and actively address mental health concerns within a larger framework. In India, the Ministry of Health and Family Welfare has taken numerous steps to address COVID-induced mental health concerns through the development of guidelines prepared in collaboration with National Institute of Mental Health and Neurosciences. These guidelines are aimed at improving the resilience of populations prone to mental health problems. The Ministry of Health and Family Welfare has additionally installed helpline services in collaboration with several institutions to provide counseling, behavioral, and psychosocial assistance. Continued guidance for mental and psychosocial well-being of individuals is of high priority. A lot more needs to be done including the provision of mental health services and large-scale communication campaigns for the public to spread awareness. There is a real need to build community-based capacity to handle local issues even after the pandemic. A team of peer counselors should work with local administrators in different parts of the country to address mental health problems.

The pandemic might be the much-needed wake-up call to make long-term adjustments to India’s health system. It has provided an opportunity for India to take greater cognizance of mental health problems and to include mental health within the primary healthcare system.

Promoting job security, providing employment opportunities and economic compensation, and redressal should be some of the fundamental priorities of the government to mitigate the adverse impact of COVID-19 on the people. Leveraging public–private partnerships through existing systems and promoting cross-sectoral and multi-stakeholder engagement will be important in the COVID-19 response. COVID-19 has provided an opportunity to rethink, reinvent, and collectively readapt. The crisis has affected the very fabric of society and has placed mental health awareness on a higher level than before. As we move forward to promote solidarity and social support, the lessons learned will, no doubt, contribute to the progress of society by providing an opportunity to reflect on the ethos of individual and collective responsibility.