“The Locked Minds” during the COVID-19 Pandemic: Burden of the Global Lockdown, A Psychosocial perspective

1 Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India

2 Consultant Clinical Psychologist, Abhaya Hospital, Bengaluru, India

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Coronavirus disease 2019 (COVID-19) and Lockdown: The Problem Statement
The world has witnessed several ‘plagues’ throughout history and each time the effects have been global and devastating. From the infamous Bubonic Plague to the Spanish Flu, Asiatic Cholera and recently the Severe Acute Respiratory Syndrome (SARS): pandemics are not just biological phenomena. They affect society at large, with widespread psycho-socio- economic impact.[2] The modern day is facing yet another such global public health threat: The Coronavirus disease 2019 (COVID-19), caused by the novel Coronavirus SARS-CoV-2, is highly contagious with a fast human-human transmission. Originating as ‘unidentified pneumonia cases’ in Wuhan, China towards end of last year, it emerged into a ‘public health emergency of international concern’ within a month (World Health Organization, WHO), which then developed into a pandemic in less than two months’ time.[3] As international borders have shut down, economies slashed, travel restricted, and billions quarantined at their homes in an effort to contain the virus, the daily ‘living structure’ has collapsed for humankind with unprecedented consequences. The world took just three months to come down to its ‘knees’, courtesy a microscopic virus. Human civilization has been accustomed to many threats since its origin, and as it has evolved, the resilience has improved parallel to its globalization. However, ‘uncertainty’ is a factor that has always created panic, anxiety and fear in human minds as cognitively we tend to attribute reasons or causes for the directed flow of events or behavior. Theories like learned helplessness, attribution models and approach-avoidant conflict state how thinking becomes chaotic and negative during situations with an unknown course.[4] Insights from health psychology research has shown aggression, violence, chaos, panic, and irrational behavior to be common during disasters.[5] In similar lines, during the present COVID-19 crisis, the widespread misinformation has led to flurry of faulty treatments, conspiracy theories, stigma and ‘othering’, non-compliance to precautionary measures, competition for health access and public agitation.[6] Added to that is the mass lockdown imposed in an order to curtail the outbreak that cuts into the autonomy, freedom, structure and interactions of human life. In both the ways, COVID-19 has brought upon an unprecedented sense of ‘uncertainty’ and panic,that might have detrimental consequences outlasting the infection itself.

All over the world, various countries have taken different measures to fight the infection. Nationwide lockdown is the commonest among them. Such historical lockdowns have restricted any gatherings, group rituals and travel based on the principle of social distancing as recommended by the World Health Organization (WHO).[7] This has been the prime strategy against the pandemic, in the absence of a ‘medical cure’ so far. The virus, however, has affected much beyond just public health. In today’s digitalized world, COVID-19 is literally an ‘infodemic’ as every single conversation, debate or media-feed is bombarded with data and statistics related to it. Ironically, the virus has hijacked our daily life-threads much more than the respiratory system. This further tends to be become a problem during the prolonged quarantine, where families spend more ‘digital screen time’, which further adds to the emotional isolation and loneliness.[8] Adults find working from home as a new challenge, children are deprived of friends and outdoor play, elderly are segregated and vulnerable, as the most important aspect of human life, ‘a daily structure’ has been fundamentally disrupted. This very isolation can have dual effects: it can either segregate couples and families leading to emotional distancing and problems with psychosexual health, at the same time it can also lead to entrapment of family members for prolonged periods of time like never before, which has made domestic abuse and intimate partner violence common during the pandemics.[9] This tends to be more in those with pre-existing history of discord, aggression or substance abuse.

Studies are increasing on the psychosocial effect of COVID-19. People with psychiatric disorders like depression, generalized anxiety disorder, obsessive compulsive disorder, insomnia, schizophrenia are having exacerbations due to lack of health care access and adequate review. Apparently healthy individuals are also having health anxiety, somatic complaints, non-specific panic, unhealthy use of technology, sub-syndromal depressive symptoms and sleep disturbances.[10,11] During the first wave of infection in Wuhan, China it has been shown that prolonged lockdown can compound the anxiety, increase social disconnectedness, worsen depression and lead to suicidality, especially in the vulnerable sections.[12]Quarantined individuals can suffer from loneliness, an independent risk factor for depression and many other mental disorders. This loneliness can also stem from the existential fact that humankind has perhaps lost the essence of experiencing solitude, and is literally being coerced to spend time with themselves and families, which is otherwise desirable.[13] Research in earlier Influenza epidemics has mentioned long quarantine to cause negative effect on mental wellbeing, concentration, occupational health and post-infection

coping. As our country enters the fourth phase of lockdown, economy has had major fallout and multiple small-scale industries involving travel, entertainment, food and tourism have shut down. Unemployment itself can have significant toll on quality of life. This is more crucial for daily wage workers, migrants and paid laborers who are fighting for survival, stranded on the streets and stations.[15] Miles away from home and families, overcrowded and impoverished shelters as well as hunger are worse threats than the virus. India is still the early clutches of the pandemic; the upcoming months will probably project the true psychosocial burden that this crisis and consequent lockdown would have had. Psychological preparedness and public health resourcing are the two important pillars of targeting community wellbeing at such times.

Mitigating the psychosocial effects of the Lockdown
Keeping this is in background, we put together few strategies to glide through this crisis time, making the most out of the quarantine. These factors if delivered using the Mental Health Education (MHE) model, can help sensitize the mental wellbeing of the masses.

  1. Discipline and Communication: These are the key elements to cope with the social isolation. Though sounding old-school, having an indoor structure to the day provides adequate balance to the activities of daily living (ADL) and work, as well as recreational activities. How the day starts, and ends can affect the subsequent routine, circadian rhythm, and hence sleep. Excessive procrastination during the morning and pandemic related discussion at night might lead to anxious ruminations amidst lockdown, that can hamper mental wellbeing and sleep. The children need to be integrated into this routine. Working hours from home need to be regulated and consistent. Too much freedom in this regard has a risk to disrupt the work-life balance. The second aspect is communication. Sharing distress and direct channels of interpersonal discussion between the family members helps dealing with the stress ‘together’. Those staying alone can virtually connect regularly with their loved ones. This helps to fight loneliness, boredom and
  2. Working from Home and Working for Home: These two aspects need a crucial balance for some. Prioritizing work and personal needs, having a separate and organized work- place and preventing extension of work into odd hours of night help creating a ‘work-friendly’ mentality which can be difficult in the comfort of

Though apparently lucrative, working from home can be a real challenge especially for those doing it for the first time. Interpersonal difficulties can arise, with gender bias and misperception by family members about work. Domestic and emotional abuse is on the rise during lockdown which further make work from home difficult for some.

  1. Staying away from the Media: To quote Taleb (2012) “The difference between technology and slavery is that slaves are fully aware that they are not free”.[16] The continuous and relentless use of technology, especially social media can snowball panic and have detrimental effects during this crisis. With the plethora of information going viral about COVID-19 each day, misinformation creeps in too. This contributes to mass hysteria, fear and apprehension adding to the already prevalent public chaos.[8] Unnecessary arguments about the disease can harm mental peace. Many have been browsing through internet late night for COVID-19 news, hampering their sleep and rest. The usage of social media has tripled in India alone, for the past two months. This is also an unwanted offshoot of online classes and work during these lockdown times.[17]While it is important to have relevant updates about the pandemic situation, it is always better to keep it brief and time limited. Bulk of numbers makes no sense to the masses, rather than adding to anxiety! ‘Digital distancing’ helps reduce panic and uncertainty, and at the same time adds to the time for interpersonal bonds and social
  2. Social Integration and Connectedness: The quarantine is unwarranted, but it has given a chance for certain things. What about using this time to have more personalized touch with our families, having fruitful ‘me’ time and engaging in family rituals like games and prayers. Has not all of these been long due! The ‘locked-down’ time can be used to revive lost hobbies, nurture forgotten skills and mend strained relationships. Integrating the people associated with our lives like the security personnel, the vendors, the domestic helpers and the workers, and catering to their well-being can make us feel that ‘we are not alone in this’. Social distancing is essentially a misnomer, which actually means ‘physical separation’. This generates hope, a powerful weapon during such times.[13]A casual greeting from the balcony or conversations with random people can mitigate loneliness during these distressing times. Few beneficial attitudes developed during the lockdown can help generate positivism and personal growth for much
  1. Modifying ‘thoughts’ to cope with the crisis: This is perhaps one of the most important principles used in psychotherapeutic techniques like cognitive behavioral therapies.[18] However, here we will discuss only about the thought-processes during a crisis and certain ways of dealing with it. Thoughts related to the duration, uncertainty and aftermath of COVID-19 have often bothered us during the lockdown. It generates anxiety, panic and bodily symptoms and the automatic focus tends to be on them, rather than the thoughts that have caused these. The estimation of a ‘threat’ which in this case is the pandemic-crisis, can lead to an anxious thought process that triggers physical panic, and thus gives further rise to threat which turns this into a vicious cycle.[18] Understanding and identifying negative thoughts like “COVID-19 will kill me”, “This situation will never end” or “I will lose everything during lockdown” will help in appreciating the ‘overestimation of threat’ and the resultant anxious behavior can be warded off. Definitely, in extreme cases this might not be possible and professional help is warranted. But during the daily threat-provoking thoughts of the lockdown, attempting to modify them are worth
  2. Boosting the Immunity: This is vital especially against an infectious outbreak. Daily indoor exercises like Yoga, or a brisk walk in the immediate proximity (definitely with adequate precautions), healthy diet and sound sleep all contribute to the generic boosting of immunity. Chronic stress during such times can have harmful effects on our immune system leading to fatigue, insomnia, mood changes, irritability and depression.[19] Taking care of physical and mental well-being are essential to counter it. Simple techniques like deep breathing, Pranayama and relaxation exercises help to relax both the body and
  3. Taking care of the vulnerable: Children need age-appropriate understanding of the ongoing scenario and its quite usual for them to get restless. This energy can be channelized for something productive academically or through board games. Incorporating them into the family times and structuring their day, prevents too much indulgence in online games, which can be a potentially harmful addiction even beyond the pandemic. On the other spectrum, the elderly are often stigmatized and isolated. Ageism has emerged as a marked polarizing factor, as the seniors are susceptible both to the health and psychosocial issues related to COVID- 19.[20]Isolation increases the risk of severe depression and self-harm in the older adults, more so in those with cognitive and sensory deficits. Those who are institutionalized and living alone, face problems in daily life due to the absence of

domestic aid and basic amenities amidst lockdown. Lack of medication is another concerning issue. While taking care of their physical health, it is also necessary that we respect their autonomy and dignity, involving them in decision making. Daily physical activity is all the more important for them. Many seniors might not be well- versed with technology use and hence might stay unaware of the necessary precautions, which need to be carefully supervised. The less privileged sections of the society need special mention (discussed in the next sections).

  1. Essential services: All throughout lockdown, the Governments have tried their best to ensure that food, medicine and other essential service deliveries remain functional. Various helplines have been arranged for easy delivery of necessities to people living alone or the elderly. These services are however mostly urbanized, and a major section of population remain deprived of these benefits.[21] Community outreach including availability of emergency medications at district and Taluk levels are vital. Care homes, disability residentials and rehabilitation centers should not be deprived of the essential services. The migrants and homeless form an equal part of the society; besides community kitchens, shelters and quarantine measures for them are mandatory. Generating awareness about the pandemic in them and ensuring they follow the necessary precautions will help in the eventual containment of the infection. Medical protective equipment like masks, sanitizers, etc. are to be supplied for people who cannot afford it. It is important to remember that the virus does not discriminate between castes, ethnicity, races or classes and even the society should not.
  2. Integrating public and mental health: Pandemic response is not necessarily biological. When the holistic wellbeing of the community is at threat, the measures also need to be at all levels. As the lockdown creates widespread fear and anxiety about the outbreak and its aftermath, understanding and apprehending the mental health effects are vital which need to be ingrained into the public health response.[22] The primary health care includes general physicians, nurses and community workers (like ASHA, Multipurpose Health Workers, etc.), who can be sensitized to the mental health needs and deliver basic interventions at ground level. The lay counsellors can be trained to deliver supportive care and screen for mental health issues, which need prompt referral. Gatekeeper training for suicidal preventions is to be active during such crisis, when lockdown prevents timely detection and prevention of self-harm attempts. Based on the earlier Zika outbreak, Banerjee and Nair had proposed a

community-based toolkit for the COVID-19 that involves multiple level stakeholders in the psychosocial care, with important collaboration of the media for Information- Education-Communication (IEC) activities.[23]

  1. Hope and Positivism: The pandemic is definitely not going to last forever. Social support, happiness and positive thinking foster personal growth and optimism, which are important factors to look beyond the lockdown and prepare for its aftermath. This psychological preparedness can be hastened by altruism and care towards the underprivileged as well as emotional bonding with families and loved

Conclusion

Frankly, no amount of preparedness can make a nation ready for such a large-scale crisis. Even when the world celebrated 2020 like any other new year, it was totally unaware of the months of isolation that would follow. As WHO mentions that there is “No Health without Mental Health”,[24] the psychosocial wellbeing of people is as important as finding a cure or vaccine for the virus. Even though national and international borders are sealed to segregate masses into ‘isolated’ pockets, humanity is into this together. Collective effort has always been the key to resilience during the past pandemics and is all the more so at present times. It is important to fight the outbreak but more essentially during the lockdown, it is necessary to spend some ‘COVID-free’ time during the day. The pandemic will hopefully eventually resolve, but certain positive habits we inculcate will persist beyond, for the better. Helping others goes a long way for collectivism and ‘holding hands in humanity’ can make us live through this pandemic, stronger and more resilient than ever before. This generates hope and emotional bonding, which are important facets of psychological resilience and coping. True that it is an ‘un-apprehended threat’, but as mentioned in the starting quote by Camus, it is ‘life’ that ultimately triumphs, and life is much beyond just COVID-19!
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