Impact on mental health by "Living in Isolation and Quarantine" during COVID-19 pandemic.

Dear Editor,

We read with great interest the recent article by Rohilla et al. published in your esteemed journal.[1] We would hereby like to add our perspective of mental health issues during COVID-19 era.

The ongoing Coronavirus (COVID-19) pandemic by the novel strain SARS-CoV-2 has dragged the entire world to its feet leaving people scared and anxious. Starting in December 2019 from Wuhan, China, COVID-19 has spread like rapid fire to more than 200 countries.[2] As of July 20, 2020, worldwide there are 14,686,829 confirmed COVID-19 cases and 609,835 deaths.[3] COVID-19 is challenging not just for its medical phenomenon, but also for its capability to affect the financial, mental, emotional wellbeing of the individuals across the globe.[45] National agencies, Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), and many other organizations are promoting to follow non-pharmacological interventions (NPIs) to combat the pandemic.[6] However, amidst the challenges of mitigating COVID-19, little has been known about the mental health impact of NPIs.

There is significant evidence to suggest the importance of socialization and connectivity in maintaining a good mental wellbeing.[7] Social networking, community engagement, and participation have been shown to be associated with both physical and psychological well-being.[78] Detrimental effects on mental health are expected to arise with isolation, neglect, and loneliness. COVID-19 pandemic has multi-dimensional impact on our physical, mental, social, and emotional wellbeing.[89] Similar experience was reported during previous coronavirus pandemics, namely SARS and MERS pandemic.[101112] Mental health issues like anxiety, depression, post-traumatic stress disorder (PTSD) are some of the mental illnesses that are on rise ever since the COVID-19 pandemic started which needs immediate attention.

Usually, people suffering from mental illnesses are advised to socialize as a part of therapy in most of the psychiatric illnesses. However, for containment of the COVID-19 pandemic, almost all countries are endorsing the concept of social distancing, quarantine, and isolation as the most effective strategies.[13] It has been a couple of months since many countries like India, Italy, Spain, France, etc., are on lockdown with citizens sheltering inside their own houses and following the social distancing protocols. With “restriction of movement” and “not socializing with each other” becoming a new normal lifestyle for most of us, mental vulnerability to conditions like anxiety and depression has been increasingly recognized.

During previous outbreaks of severe acute respiratory syndrome (SARS) and the Middle East respiratory syndrome (MERS) outbreak, many studies confirmed that there were worsening mental illness symptoms in an individual with preexisting mental health conditions as well as healthy individuals. For example, in Hong Kong, about 70% of people expressed anxiety about getting SARS and people reported they believed they were more likely to contract SARS than the common cold.[14] Hypervigilance, for example, can arise because of fear and anxiety and, in severe cases, result in post-traumatic stress disorder (PTSD) and/or depression.[15] Another aspect that can complicate mental illness symptoms during such times is discrimination. For example, the 2014 Ebola outbreak was considered an African problem resulting in discrimination against those of African descent.[16] Similarly, the 2009 H1N1 flu outbreak in the USA saw Mexican and migrant workers targeted for discrimination.[17] Since January 2020, the UK and the USA have reported increased reports of violence and hate crimes towards people of Asian descent and an overall rise in Anti-Chinese sentiment because of the spread of COVID-19.[18]

Since isolation and quarantine from the loved ones is the norm of the current world situation, it can often precipitate depression and anxiety and often feel they are being ripped off their purpose of living. Isolation is known to cause a lot of stress which can exacerbate feelings of anxiety and uncertainty.

Post-Traumatic Stress

Having to be isolated from the society being affected with the SARS-CoV-2 virus, and the fear of transmitting it to the loved ones, patients are prone to experience PTSD which could affect the mental wellbeing of an individual in the long run. Psychological trauma can result in mixture of emotional surges like nightmares, self-blame, flashbacks, and experiencing recurrent thoughts of the trauma.[19] This could happen to the patients as well as to the health care providers. Risk factors that makes patients susceptible to PTSD are self-quarantine, self-isolation, fear of death social discrimination, witnessing others becoming sick and dying and so on. Similarly, for health care professionals, COVID-19 has brought innumerous challenges.[6] Witnessing frequent deaths, fear of acquiring the infection, spreading to the other family members, lack of adequate personal protective equipment's etc., can expose them to recurrent mental trauma and to PTSD.[20]

A study was conducted in China on patients who were infected with COVID-19.[21] Online assessment using a 17 item self-reported PTSD checklist (PCL-C) was used. A total of PCL-C score of ≥ 50 is an indication of 'having significant posttraumatic stress symptoms. A total of 730 COVID-19 patients were assigned in the study and the prevalence of significant posttraumatic stress symptoms was 996.2% (95% CI: 94.8% -97.6%).

In addition to the psychological impact, a recent report suggested immune dysregulation in patients suffering from chronic stress secondary to PTSD which might make them prone to opportunistic infections like COVID-19 pneumonia.[22]

Information Adding Anxiety and Fear

In a crisis like this, it's a common interest of people to find out as much information as possible to stay tuned on what is going on around them people are consuming information on every platform available like WhatsApp, Facebook, YouTube, Twitter, and many others, which necessarily does not contain accurate information. Subjects who used updates via phone text messages and used social media for critical updates during the lockdown had higher chances of exposing themselves to false information and stress [Figure 1]. Higher acute stress was seen in heavy social media users in the study. This report highlights the importance of releasing substantive official updates at regular intervals during a crisis event and monitoring social media to reduce exposure to misleading information and distress 36.2% (95% CI: 94.8% -97.6%).[21] Other factors that could contribute to the anxiety and mental unrest are fear of losing job, financial crisis, interruption in studies, physical inactivity, running out of medicines, lack of sleep, social isolation, fear of acquiring infection.[23242526]

Figure 1

Pictorial description of the potential concerns of a person during COVID-19

When we are grappling with this gigantic global crisis humans can get creative with their social interactions and can even have trivia nights with your coworkers or friends or maybe even have a virtual date night. Having this social connection can improve not just your mental health but your physical health as well. These social interactions give us a sense of togetherness as a species in our fight against this virus. Moreover, experts suggest having a daily routine can help fight anxiety during this unprecedented time. Having a routine while maintaining the sleep cycle can have a positive impact.[27]

Emerging Role of Telemedicine in Psychiatry

The impact of isolation can be more severe in individuals with preexisting mental illness, with worsening of anxiety, depression, despair, and feeling of loss of control. Coping with pandemic can get especially difficult when patient's access to its primary source of support and care is restricted. There is a tremendous role of psychotherapy in the treatment of anxiety, depression, and PTSD, and other mental illnesses. Not only do regular visits to the clinic help in getting appropriate therapy and care, but they also add a good working schedule for individuals. Patients suffering with alcoholism and other substance use disorders who are associated with various deaddiction programs might also find it difficult to refill their prescribed medications like methadone, suboxone, etc., Also, it is difficult to continue their engagement with support groups, and programs due to closure of these societies.

However, despite knowing the importance of in person encounter in clinical practice of psychiatry, unfortunately due to the fear of community transmission, cross infections, and other logistic reasons of lockdown, travel restrictions, and limited health care access, health care providers are not able to execute their health services to their patients suffering from various mental health issues.

Telemedicine service has proved itself as an important asset, and a way of effective communication between patients and their physicians.[28] It has especially proven to be of great benefit for patients with mental conditions to receive psychoeducation in a timely fashion via using telemedicine and remote medical care services.[29] This will be of utmost importance especially in patients who are having active psychiatric disease flare up.[2930] Kalin et al. recently share their successful institutional experience with telemedicine in the inpatient setting. They shared their experience based on 110 tele encounters during inpatient psychiatry consults.[31] They could successfully accomplish an effective dialogue exchange and were able to execute supportive psychotherapy during tele encounters. Although, in our opinion a telemedicine is certainly an immediate solution to provide the supportive therapy to patients, it can never replace the impact, and positive outcome of an in-person meeting. Also, it might not be possible to communicate and engage in an effective conversation in patients who are mentally challenged or in children with ADHD, autism, etc., A healthy parenting might help in such scenarios till the regular clinic visits services are resumed.

Conclusion

From the mental health perspective, so far, the COVID-19 pandemic has been extremely challenging. With the uncertainty of the current living situation, people with preexisting mental illnesses like PTSD, anxiety, depression, and severe persistent mental illness are prone to having worsening of their conditions, and studies from the past pandemics reflect the same. Time-bound behavioral therapy should be provided to persons who exhibit signs of mental disorders to reduce the cognitive effects of the pandemic. Psychiatrists and psychotherapists should maximize the use of telemedicine services use to connect to their patients.

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Conflicts of interest

There are no conflicts of interest.