Self-harm and COVID-19 Pandemic: An emerging concern - A report of 2 cases from India.

Introduction

COVID-19 outbreak ever since its onset and subsequent global spread had created several challenges for the general public and the health care workers across the World. COVID-19 pandemic is projected to lead to a significant degree of mental health crisis across the globe and therefore, the World Health Organization (WHO) had published brief messages/notes related to mental health and psychological considerations during COVID-19 outbreak and had highlighted the importance of psychological first aid (World Health Organisation, 2020).

The growing concern of the general public regarding the spread of infection from suspected COVID-19 positive individuals has created a panic mode in the community. While this will help in limiting the growing number of cases of COVID-19, this has also led to significant fear and anxiety related to spread of infection in the general public. Excessive fear and apprehension of spread of infection can lead to acute stress, anxiety, and subsyndromal to syndromal level of depression in vulnerable individuals. The National centre for Suicide Research and Prevention of Mental Ill-health (NASP) is already attempting to increase awareness about the potential increase in suicide and self-harm behavior as a result of the societal impact of the ongoing pandemic (“The Corona Virus, ” n.d.). Possible potential risk factors such as prolonged periods of social isolation, fear of unemployment, economic loss due to lockdown, death of family members and significant others etc. have been proposed to precipitate self-harm behaviors during this pandemic crisis (“The Corona Virus, ” n.d.) There have been reports of suicide due to excessive fear of contracting COVID-19 from India as early as 12th February,2020, even when the infection was not spread across the country (Goyal et al., 2020). Further, there have been isolated reports in the newspapers/bulletin of suicide due to alcohol ban during the lockdown period from different parts of India (M.K, 2020; Pathak, 2020). Here we present two different presentations of self-harm attempts related to apprehension of developing COVID-19, who presented to our emergency medical services.

Case Description: 1

A 52 year old man, who was premorbidly well adjusted with no past and family history of mental illness presented to emergency with a gunshot injury. Exploration of history revealed that patient was doing well 3 weeks back, when he went to a social gathering, where he came in contact and interacted with one of his friend, who had recently returned from abroad. After 3-4 days, patient came to know that his friend had been diagnosed as COVID-19 positive. After learning this, he started worrying, that he might also have been infected and started remaining distressed and preoccupied with the thought of being infected with COVID-19. He was contact-traced by the healthcare authorities of his locality and was asked to be stay in self-isolation. He was asked to inform the health care workers if he develops any symptoms suggestive of COVID-19 infection (which was well-explained to him). He immediately isolated himself, because of fear of spreading the infection to his family members. Over the period next 2 weeks, while in isolation, gradually he developed depressive symptoms in the form of sadness of mood, anhedonia, lethargy, decreased appetite and decreased sleep. He kept on following the news of COVID-19 and learnt that it is leading to painful death. He would remain extremely anxious and would be preoccupied with the thought that he is going to die soon, became hopeless and considered himself to be worthless. He transferred all his property to his family members. After about 10-12 days of onset of the depressive symptoms, he started to have suicidal ideations more often and finally he shot himself with his gun in upper part of his left abdomen thinking that he is going to anyway die due to the COVID-19 infection. He shot himself to avoid painful death due to infection. There was no history of any cough, expectoration, running nose, fever and other depressive symptoms during this time. He was immediately brought to the trauma services of our hospital, operated (had only entry gunshot wound) and medically stabilized. Later he developed delirium due to medico-surgical complications and which was managed with Tab melatonin. He improved with melatonin over the next 24 hours was medically stabilized. A diagnosis of severe depression without psychotic symptoms was considered after clearing of delirium. Later he was planned for starting an antidepressant and supportive psychotherapeutic measures were started and continued.

Case Description: 2

A 40 years old male, was brought to emergency after a suicide attempt by hanging. Exploration of history revealed that around 1st week of March 2020, on one occasion while on his routine morning walk he was asked to take a photograph by a foreign couple. Later, patient came to know about the mode of transmission of COVID-19 infection. As a result, he started to remain distressed and worried that he could have contracted the infection from the foreigners. Following this over the period of next 2 weeks, despite having no respiratory symptoms, he started to remain sad, excessively worried about his health, and would express near his family members that he is going to die soon. He self-isolated himself from rest of his family members, would refuse food, stopped talking to his family members, developed somatic/bodily symptoms in the form of dryness of throat, pain abdomen, fatigue and attribute these symptoms to corona virus/COVID-19 infection. He kept on following the news about COVID-19, initially, learnt that it is associated with high mortality and the death is painful. Later, he started avoiding watching the news, because of increase in anxiety on listening about COVID-19 infection. He was not able to concentrate on his work. Because of fear of developing severe COVID-19 infection, he started to get thoughts that it is better to die by some means rather than waiting for the progression of COVID-19 infection and having a painful death. After about 2 weeks of onset of fear of developing COVID-19 infection, he attempted suicide by hanging himself with a rope. Within minutes of the attempt, he was found by the family members and was rescued, brought to emergency. He was medically stabilized. He was diagnosed with Adjustment Disorder Versus Severe Depressive Episode without psychotic symptoms. He was started on Cap fluoxetine 20 mg/day, which was increased to 40 mg/day after 1 week, along with low dose benzodiazepines (Clonazepam). He was also started on supportive psychotherapy. Within a week of starting of antidepressants and psychotherapeutic interventions he started to show improvement in his symptoms.

Discussion

These cases highlight the fact that how information overload can lead to increase in psychological distress among normal people too. One of the case developed severe anxiety and depression, after learning that the person with whom he came in contact with, was found to be COVID-19 positive and the second case developed anxiety and depressive symptoms, due to apprehension of possible infection, after coming in contact with people with travel history. While the first case had a direct contact with a COVID-19 positive case, the second subject had merely met a foreign couple. In both the cases, the depression and anxiety were fueled by the information overload in the media, with respect to COVID-19. Media reports have been highlighting the possible painful deaths and significant higher mortality with COVID-19 infection. Both the scenarios, depict that both the suicidal attempts could have been prevented, if proper awareness about the infection is done, by providing the necessary information about spread of infection, rather than talking about mortality rates and type of death.

The media (social media platforms, newspapers, radio/telecommunication services) on one hand are providing adequate information about safety measures to control the infection, but on the other hand, excessive description of COVID-19 related news in all social media platforms/ telecommunication platforms is creating a sense of panic among the vulnerable individuals. Therefore, there is a need for the media houses to judiciously transmit the information about the infection, to avoid scare and panic in people. However, this in no way means that they should not increase the awareness about the infection. Mental health professions should also advice people for judicious and cautious use of social media/telecommunication services. Further, in all patients coming to the medical-surgical or psychiatric setting with self-harm, anxiety and fear related to COVID-19 must be routinely enquired.

Declaration of Competing Interest

None.

Financial Disclosure

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