A man wearing a protective face mask looks out of the window during a 21-day nationwide lockdown to limit the spreading of coronavirus disease (COVID-19) in Mumbai, India, April 4, 2020. Photo: Reuters/Francis Mascarenhas
Kanupriya Ahlawat*, a 37-year-old homemaker and mother of two, has suffered violence at the hands of her husband several times in the last month; twice in front of her five-year-old son. Her access to the phone and the outside world is controlled even during regular times, but the lockdown has made matters worse.
“The hostility and abuse have been an issue since the beginning [of the lockdown]. The trigger could be an incomplete house-hold chore or my logging on to social media. Earlier, I would live my life when my husband left for work. I would speak to my friends, check Facebook and delete the phone history before he returned. Now, he is aggressive and abusive throughout the day and I have no time for myself. An evening walk on the terrace is the only time when I am alone and I speak to my parents to check on them. Sometimes I also speak with our family counsellor to share what I am going through,” said Ahlawat, speaking to The Wire through her counsellor, who the couple consulted last year when matters at home got worse.
“Until now, women could access their regular coping mechanisms – a family member or third-party help – in most situations. The perpetrators of violence also had other activities that kept them busy and distracted. Now, everybody is together, in close quarters. In addition, financial strains, job insecurity, pressures of childcare have all increased tension, friction, arguments and even violence within families. There is a mental health crisis underway, and it could be short-term or long-term,” said Sreepriya Menon, a psychiatric social worker who is part of a pan-India network of mental health providers addressing mental health concerns during the COVID-19 crisis. They have come together to offer help to many people like Ahlawat, who are struggling to find support during these extremely strenuous times.
Fear, uncertainty and suicidal thoughts
As mental health and support helplines have witnessed a significant spike in distress calls, the unseen casualties of the pandemic and the subsequent nationwide lockdown are emerging. Helplines for the elderly in particular are flooded with requests for care-givers, groceries, medical supplies and medical consultations. Helplines for mental health are receiving calls that express fear, uncertainty and even suicidal thoughts.
The Ministry of Health and Family Welfare launched a mental health helpline – 080-46110007 – on March 29. It received as many as 3,000 calls on a single day post the launch. The 24×7 helpline, on an average, gets around 300 to 350 calls daily, from people suffering from panic and anxiety. Many callers express fear of being infected, especially if they are from groups deemed vulnerable to infections from the coronavirus, such as pregnant women, elderly persons, or those responsible for providing essential services.
“Pandemics come with an associated mental health pandemic, so we know that there will be an impact of the widespread panic, lockdown-associated difficulties and isolation on people’s mental health. The calls reflect uncertainty, helplessness and even suicidal thoughts. We have received at least two such cases, from Bengaluru and Mumbai, in the last few weeks. In both cases, we managed to speak to caregivers and family members, alert the local police and guide them to the nearest mental health institute. So the impact is visible,” said Dr Naveen Kumar, head of the Community Psychiatry Unit at the National Institute of Mental Health and Neuro-Sciences in Bengaluru, who is facilitating the national COVID-19 mental health helpline.
Distress calls on the helplines
Snehi, one of India’s first psycho-social support centres focused on adolescent mental health, started receiving COVID-19-related calls as early as February. Snehi launched a separate COVID-19 helpline (9582208181) with a pan-India network of trained counsellors, psychologists and psychiatrists on March 31, said Abdul Mabood, founder-director of Snehi. A group of 15 counsellors across various cities receive calls between 10 am to 10 pm, seven days a week.
“Before the crisis unfolded, we would usually receive five to ten calls every day, primarily from students or their parents. Now, we are receiving 30 to 40 calls daily from people across age groups and backgrounds. There are days when we get up to 60 calls,” said Mabood, adding that many calls went unanswered due to the limited resources they had. The callers were usually anxious about getting infected and worried about the impact of the lockdown on their work. They found it difficult to manage anxiety and the fear of the unknown. The counsellors help them in mitigating these worries and guide them to professional help, if needed.
Kashmir LifeLine (KLL), a mental health centre that runs various walk-in clinics across Kashmir and a central helpline (18001807020) to assist and counsel anyone with a mental health concern, is now offering on-call counselling and assistance since its clinics are shut due to the lockdown. The centre scrapped the state’s semi-autonomous status on August 5, 2019 and imposed a communications blockade.
The helpline has received 335 calls since March 24. “The people in Kashmir have been in the lockdown for the longest time and our focus right now is on both people with pre-existing psychological conditions, and others,” said Dr Prerna Sud, a psychotherapist and director of KLL. The incidences of anxiety disorders and post-traumatic stress disorder are quite high in Kashmir, she said, adding that anxiety disorders are about feeling a loss of control over the events and the environment around one, and that a pandemic-like situation exacerbates such feelings.
“A lot of calls that we are receiving are about the fear of reporting oneself to authorities in case symptoms arise. People in Kashmir are used to following restrictive orders by the government, but the challenge right now is to make them understand that the restrictions are for a significant purpose and they need to follow it for their own good,” said Dr Sud. As a conflict-torn region, Kashmir has a widespread prevalence of mental health issues. Nearly 1.8 million adults in the Kashmir Valley – 45% of the adult population at the time – showed symptoms of mental distress in a 2015 survey by the humanitarian organisation Médecins Sans Frontières (MSF, or Doctors Without Borders) highlighted.
Non-availability of psychiatric drugs
CareMongers, a Facebook community bringing those who need urgent help and those who can provide a solution together with one platform, has been flooded with requests for procuring psychiatric drugs. In most cases, pharmacies do not have stocks and online pharmacies do not deliver psychiatric medicines due to regulations.
“Anyone with an existing psychological issue is dependent on regular medication to lead a normal life. Under the newly implemented telemedicine guideline, e-consultations are to be considered official and legal. However, the pharmacists are not accepting the e-prescriptions. They are asking for hard copies. If a medicine is not available and the doctor prescribes a substitute via a text message, it must be accepted and fulfilled,” said Dr Harish Shetty, a leading psychiatrist in Mumbai who has been advocating the cause of psychiatric patients and the availability of psychiatric drugs during the lockdown.
People with mental health issues rely on long-term care. Discontinued counselling sessions and not being able to meet the doctor or the counsellor can be unnerving for many, said Vijay Nallawala, a person with a bipolar disorder who has been running and managing the Bipolar India support group since 2013. “We are closely connected with more than 400 members on Telegram. We know that in chronic cases, telephonic counselling or consultation is not effective. Many people in our group are extremely restless and troubled due to this. We try to help them and provide support. We are also organising an online peer support meetup to escalate help during the current crisis,” said Nallawala.
In rural areas, help could be even more scarce. Migrant workers returning home are facing ostracisation and stigma. For everyone, livelihood is at stake. The Centre for Mental Health Law and Policy (CMHLP) is running a community-led mental health and social care project in Mehsana district in Gujarat and the Ahmednagar district in Maharashtra. The trained volunteers are providing what they call ‘mental health first aid’.
“Rural communities have their own mental health issues. Social determinants like education, livelihood, or family structure play a role and social barriers like caste, class or gender can restrict access to mental health. The volunteers are providing counselling and support to people in-home or centre-based quarantine. They are also reaching out to people in the villages to disseminate the right information. The idea is to offer peer-to-peer support, talk to people who have lost livelihood or are facing domestic violence, stigma or financial instability,” said Jasmine Kalha, an anthropologist who is co-leading the initiative known as Atmiyata. “Any wide-scale crisis has an immediate reaction and a long-term impact. What we are seeing right now are immediate concerns, but there will be a second phase of long-term issues which will be much more serious and disturbing,” said Dr Kaushtub Joag, a psychiatrist associated with the project.
Stigma and suicide prevention
The stigma around COVID-19 and the burden of the pandemic have allegedly resulted in suicides across New Delhi, Telangana and Chhattisgarh. The World Health Organisation has issued a set of guidelines for communication and messaging around COVID-19. Among the various points, there is an added emphasis on not attaching a person’s ethnicity or identity to the disease. “It is important to separate a person from having an identity defined by COVID-19, to reduce stigma,” the guideline highlighted. On the ground, the realities could be different.
Mohammed Dilshad, a 37-year-old, died by suicide on April 5, leaving behind a note that read- ‘I am no-one’s enemy’. The incident occurred after people from Bangarh village in Himachal Pradesh’s Una district grew suspicious about him being infected with the coronavirus and called the police.
“He had met two Tabhligi Jamaat members who had returned from Delhi. When villagers got to know, they were paranoid and started accusing him. Dilshad agreed to the test and co-operated with the police. His test report was also negative, but everyone in the village became hostile towards him and the family. On the evening before he hanged himself, I spoke to him for more than an hour and he was extremely distressed by what everyone was saying. I told him to ignore the public and face this bravely. The next day I realised the humiliation was hurting him much more than I could gauge,” said Dilawar Khan, Dilshad’s paternal uncle who stays with the family.
Dr Soumitra Pathare, a consulting psychiatrist and director of CMHLP in Pune, is documenting COVID-19-related suicides in India with the help of his team. “According to the media reports we have tracked and verified till date, there have been at least 153 reported cases out of which 134 are alleged suicides and the rest are attempted suicides. Fear, ostracisation and alcohol withdrawal probably account for the largest number of these cases,” said Pathare, adding that these people may or may not have a mental health problem.
Experts believe that a suicide prevention effort on a wider scale is the only way forward. Using a three-fold mechanism the authorities could either make efforts to target and assist everyone during times of distress or they could undertake selective prevention, i.e. focus on the high-risk groups – recently unemployed, distressed migrant workers, farmers, women experiencing domestic abuse or men with a history of alcoholism.
The third could be focusing on the indicated groups, i.e. people with an existing mental health issue who could be moved to counselling and suicide prevention programmes, they believe. “These interventions can be active or passive. The helpline is a passive way of intervention as the person in need must come to the helpline to ask for help. An active intervention would be reaching out to the needy and susceptible, to teach them how to cope with stress,” said Pathare, adding that waiting for people to approach the authorities does not work very well in issues related to mental health.
In India, suicide and suicidal ideation is a pressing public health concern. One in 20 people in India suffers from depression, according to the National Mental Health survey for the year 2015-16. The availability of psychiatrists per lakh population is as low as 0.05 in states like Madhya Pradesh and 1.2 in Kerala, a state which has the most robust primary health care system.
The survey highlighted the importance of non-specialist professionals such as the ASHA/USHA workers and ANMs the grassroots health workers in delivering mental health care in a resource-starved set-up. The Great Depression of the 1930s saw a significant spike in cases of suicide. In a crisis like COVID-19, outreach efforts are one of the most effective ways of mitigating a wide-scale mental health crisis.
Note: Names have been changed to protect their identities.
Parul Agrawal is an independent journalist from Bengaluru. She writes on issues related to health, gender and technology. She is a journalist fellow with the Reuters institute of journalism at Oxford University.
If you know someone – friend or family member – at risk of suicide, please reach out to them. The Suicide Prevention India Foundation maintains a list of telephone numbers (www.spif.in/seek-help/) they can call to speak in confidence. You could also appear them to the nearest hospital.