Letter to editor: Re: "Primary care physician's approach for mental health impact of COVID-19": Case of migrant workers mental health.

Dear Editor,

We read the article by Rohilla[1] with great interest where the authors have described that how our primary care physician colleagues can share the responsibility and can manage the psychological burden of the COVID-19 pandemic. In addition to the many special groups identified by authors,[1] we would like to highlight the psychological issues related to needs of a very important subgroup, that is, “Migrant workers.”[23] The migrant population is already very vulnerable and in addition to the recent outbreak of COVID-19 has brought tremendous challenges for this population.[4] Migration is a process in which people move to another place with the hope of making their lives better. Unskilled and uneducated people lacking job opportunities in local areas often migrate temporary from remote places to larger cities in India. Nationwide lockdown and travel restrictions placed in order of containing virus spread resulted in unbearable social stigma, isolation, income loss, fear and risk for mental health concerns, including suicide.[56] Recently, an editorial “Mental health of migrant laborers in COVID-19 pandemic and lockdown: Challenges ahead” and another article “COVID-19 pandemic: Mental health challenges of internal migrant workers (IMW) of India” draws timely attention to the increased risk and rates of mental health problems among IMWs in India.[37] Mental health problems can have biological, social, and environmental influences in etiopathogenesis and all these are at heightened interplay during the COVID-19 pandemic for IMWs.[8]

The attempts of virus containment affected all components of the social system and thus mental health of internal migrant workers globally but particularly in India. The present COVID-19 pandemic has created extremely challenging social situations. It resulted into more significant social exclusion and risk for mental health problems. Due to inherent vulnerability, migrant workers are at higher risk.[9] Four components of the social-ecological model, individual (intrapersonal), interpersonal relationships, community, and societal policies influence the mental health of an individual.[10] It is essential to recognize that the risk of increased mental health issues that have mainly originated due to social factors and distress should be handled in the context of social-ecological approaches of mental health intervention.[11] The need for mental health care has been sensed by the providers and government officials in several countries, including India. To address the present epidemic related challenges, as an alternative to the face-to-face, mental health services, interventions are being planned and need to be offered in an online mode [Table 1]. In the setting of online mode, psychiatric services offered by trained mental health professionals can be considered the main component to overcome the mental health-related problems.

Table 1

Suggestions for addressing concurrent mental health issues of migrants in social ecological health care framework

Social-ecological factor	Interconnectedness	COVID-19 effect	Long term need	Suggested actions
Individual (Intrapersonal)	Individual’s attitude, knowledge, belief, and personal history affects the mental health of the person	IMWs have lower education, awareness, and lower self-esteem due to their social position. These factors make them more vulnerable and susceptible to mental health problems. During the lockdown, these people were considered the primary vehicle for spreading the virus. Sudden restrictions imposed on them for travel not only affected their survival as well as impacted their self-esteem, which resulted in an increased risk for mental health problems.	Disturbance at any level in the social-ecological framework can lead to mental health issues in a person. The IMWs were affected at all levels of the system. Medical intervention may not undo the effect of the negative impact that resulted due to the flipped role of the system at every level. Mental health professionals and policymakers need to be cognizant of the circumstances of the people they have undergone. More services basing on the social-ecological framework should be planned in the long-term alleviating effect of mental health for this population.	More information related to COVID-19 spread should be provided.
Interpersonal relationships	People in the immediate network including family, partners, relatives, peers, and friend	Because IMWs stay far from their immediate network for employment reasons, so they already lack this support system. During the lockdown, travel restrictions compounded their stress. Many people thought they would die before seeing their loved ones. In this crisis where the immediate network would have been a support for migrant workers turned out to be the biggest worry for them.		Assurance for keeping them and their families safe in this crisis should be offered.
Community	Institutions in the network that provides support and a variety of services	In the case of IMWs, institutions in their support network such as job providing organizations, public and private transportations become dysfunctional for this population. Employing bodies moved away from their responsibilities, which resulted in income loss for this vulnerable population.		Employing organizations should try to compensate for the financial loss to the workers.
Societal Policies	Social and cultural policies and norms play an essential role in our society for ensuring support for the people.	Lockdown policy with punitive actions and a negative image attached to the IMWs		More support through social workers should be offered. More jobs should be created in local settings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.