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\begin{document}


\def\RunningAuthor{Arpit Gupta}
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\title{Mental Effect of Covid-19 Pandemic on Affected, Non Affected and Families of the Affected}
\author{Arpit~Gupta\textsuperscript{*}~\\[5pt]{Department of Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India}}

\begin{abstract}
The pandemic of covid 19, which has taken the entire world by storm has not only tested our physical health but also impacted our mental health in ways no one had envisaged! It has lead to a situation of socioeconomic crisis and mental anguish among the general population. The outbreak of a novel virus unknown to the medical fraternity and its explosive spread every day, conflicting messages from the government, lack of infrastructure for treatment, the spread of misinformation on media platforms and an incessant quarantine has to lead to a sense of fear, apprehension, stress, desolation, weariness, frustration and depression among the masses. The imposition of lockdown in the nation not only undermined personal freedom, but it also leads to huge financial losses, unemployment, work and school closure, uncertainty, boredom, stigma which have been major stressors leading to widespread emotional affliction and an increased risk of developing psychiatric illness during the time of the pandemic. People who were already suffering from some form of the psychiatric disorder have been prone to exacerbations due to the pandemic. Individuals living with confirmed or suspected covid 19 cases, frontline workers, unemployed people and people in quarantine are at a higher risk of developing some form of mental illness such as anxiety, insomnia and depression. Resilience and good social support are protective factors against this mental health epidemic that is about to begin. In this article, we reflect upon the impact of covid 19 pandemic and lockdown on the mental health of people in India. 
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Covid-19,\newline mental health,\newline emotional health,\newline stress,\newline frustration
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\section{ Introduction}
 The year 2020 was not easy on the mental health of people in India. We all were submerged under the sea of Covid-19 or precise the impacts and the decisions taken during the covid 19 pandemic. During September 2020, telemedicine app Practo announced that mental health related queries have increased by 665\% since the past year, 60\% of which were from Indians aged 21to 30 years, followed by 30\% from 31 to 60 age group and 10\% from 60 above age group. This itself reflects the extent to which covid 19 has impacted our mental health.

One of the major burdens on the mental health of people was the decision to lockdown by the government of India. Though an essential precaution, it has impacted the psychology of people in ways unforeseen.

All of this started from the date of 21st March 2020 when India noticed its very first spike of covid 19 cases that was 470 in number. As a result, the government of India announced a nationwide Janta Curfew of 14 hours (7 A.M. TO 9 P.M.) to be followed on 22nd march 2020 as a respectful gesture towards all the frontline workers such as medical and paramedical staff, police officers, firefighters, in short, all those who were involved in providing the essential services to the people of the nation. Following Janta Curfew, a very bold step of nationwide lockdown was taken starting from 24th march 2020 till 14th April 2020 which was further extended as pandemic remained out of control. As per rules, no one was allowed to leave except for those involved in essential services \unskip~\citep{1001590:21389992}. The very first lockdown started to build pressure on the mental health of people. Initially, it was not thought that the situation would worsen to such an extent that the lockdown would be extended to 2 more months. When the news of the lockdown extension was announced, there was silent chaos among everyone. A feeling of loneliness and hopelessness started to dwell upon individuals residing far from home and couldn't go back due to travel restrictions. Sense of fear about the newly emerged virus and its impact on loved ones instantly became the major concern. 

Although work from home and online educational activities became the new normal, it had repercussions as the facilities weren't readily available to the lower strata and remote areas. 

In a country like India where most of the population fill their stomach with their day to day earnings and hardly any savings, people started becoming increasingly anxious about how will they feed their families and make both ends meet. In India, there is around 23 percent of daily wage workers. On hearing the news of lockdown, most of them were taken down from their work. No work meant no food and no place to live. Frustration, irritability and hopelessness surrounded them and with no other option available, they tried to travel back to their home villages. Due to strict restrictions of lockdown and lack of public transportation, most of them travelled by foot or on cycles. Many of them lost their lives in this process. Soon this news spread across the nation like a wildfire and had a major impact on the mental health of the people. This uncontrolled migration of people not only worsened the pandemic but also created a state of panic and stress among the masses.

Further, many big multinational companies had to shut down and those which were still operational had to cut down the cost by taking away the jobs of people. Even Companies which had its roots in India ( like Parle G) had to take part in the process of cost cutting. Unemployment has created a financial crises in the life of many people which has negatively impacted their mental health, leading to frustration and anxiety \unskip~\citep{1001590:21389983}.

Front line workers including doctors, nurses, community health workers, police officers, etc had to work under extreme pressures with minimal resources available, stay away from their families for their safety to fulfil their moral responsibilities. They also had to undergo harassment by the house owners and neighbourhood people due to the stigma surrounding the disease. This also increased the risk of developing depression, post traumatic stress disorder and suicidal tendencies.

Lockdown has also lead to a record surge in the cases of domestic violence as the victim can no longer move away from a violent situation by staying elsewhere. Thousands of women and children have been psychologically and emotionally impacted due to lack of personal space. It has to lead to nightmares, social dysfunction, eating disorders and suicidal tendency amongst women.

The geriatric age group which is the most vulnerable to covid 19 have been confined to their homes which has become a major cause of loneliness as they cannot travel to be with their kids and are not even comfortable with smartphones. The media created hysteria also negatively impacts their mental health leading to anxiety disorders \unskip~\citep{1001590:21389985}.

People already suffering from mental health disorders have become more vulnerable to exacerbation during this crisis. Their cognitive disability makes it difficult to explain to them the precautions needed to be followed. Social isolation and discrimination further add to their emotional vulnerability.

Covid 19 may not be life threatening for children, but it sure has had a lasting impact on the mental health of children and adolescents. Increased incidences of acute and chronic stress due to disruption of daily routines, increased family violence, lack of personal space and boredom have been reported. Due to online classes, the uncontrolled access to the internet has led to psychological symptoms like self harm.

The concept of mental health was not of much importance before the year 2020. People considered mental health as a stereotype and used to ignore discussion on such a topic. But after this unfortunate year, mental health became a primary concern for a lot of people. Many celebrities and general public committed suicide amidst this pandemic. The very thought of null year has created a huge burden on the mental aspect of people, be it a mediocre or a millionaire.
    
\section{\textbf{Effects of Pandemic on Mental Health}}
\textbf{Fear}

Fear is an unpleasant emotion in the presence of danger, but when the threat is uncertain and prolonged such as the covid 19 pandemic, it becomes chronic and burdensome. Excessive fear can be damaging to the health of people leading to anxiety, phobias and panic attacks. Contrastingly lack of fear may lead to defiance of safety precautions. As far as the pandemic is considered, the major reason for fear amongst people includes concern for the health of loved ones, especially people in vulnerable groups. Being far away from the families and unable to help them due to lockdown has to lead to a further increase in the fear levels. Post covid complications, poor health care facilities, drooping economy, losing jobs, shortage of food supplies, mutating virus, the possibility of spreading the virus to others, mass panic and fake news have been other reasons for developing fear \unskip~\citep{1001590:21389986}.

\textbf{Anxiety}

Anxiety is an emotion characterized by tension, worried thoughts and physical changes like increased blood pressure. It is an emotion necessary for survival - to prepare a human for fight or flight response, but when the duration or severity of this emotion blows out of proportion, it may interfere with the daily functioning of the individual leading to recurrent intrusive thoughts termed as an Anxiety disorder.

Uncertainty with regards to lockdown, employment and health; boredom and loneliness, lack of personal space have all triggered anger, frustration and anxiety issues. People suffering from the disease have to self isolate themselves and lack the comfort, care and support that a sick person deserves in a country like ours where the family is the biggest strength, not able to see our loved ones due to isolation further increases feelings of hopelessness and anxiety in both the patient and family members. Surveys have shown the expectant mothers feel even more anxious due to covid 19 negatively impacting their health and the health of their unborn child.

\textbf{Stress}

A build up of fear and anxiety amongst individuals leads to the development of stress. Common man, with his limited amount of savings spent in the initial days of lockdown now struggling to make both ends meet suppressed under financial burden, suffers from financial stress. Front line workers in the process of trying to protect their families haven't met them for months, living alone in makeshift places working for day long shifts in the hospital experience fatigue and loneliness leading to emotional stress. Adolescents confined to their homes with little or no access to their peers or physical activity already going through an emotional turmoil due to the hormonal changes topped up with parental anxiety suffer from acute and chronic stress. Covid survivors with death experience and many people who have lost their loved ones due to the pandemic are at higher risk of developing post traumatic stress disorder \unskip~\citep{1001590:21389984}.

\textbf{Loneliness}

Even though we are well equipped with technology and smartphones and social media to keep loneliness at bay, at some point or the other during the pandemic we have been surrounded by boredom, desolation and hopelessness as our usual ways of seeing friends and family have been put on a pause. The elderly and people living alone are more susceptible to feeling weary and deserted. The experience of loneliness has 5 dimensions which include emotional distress, social inadequacy and alienation, interpersonal alienation, self alienation and growth and discovery. It is important to understand that being alone is not the same as loneliness as the latter is a psychological illness which can lead to depression, anxiety and suicide attempts.

\textbf{Sleep Disorders}

It is said that sleep is the best meditation and can cure almost anything, but this pandemic has been harsh on our sleeping patterns too. Some people are sleeping less, whereas some are sleeping more than usual. This can be attributed to the loss of our daily routine due to quarantine \unskip~\citep{1001590:21389988}. Daytime napping may also be an important contributor. High anxiety levels lead to unusual sleeping schedules and fragmented sleep. It may also lead to nightmares. Increased stress levels release neurotransmitters such as cortisol which disturb the sleep-wake cycle leading to insomnia. Increased exposure to blue light due to more screen time disrupts melatonin production again affecting our sleep.

\textbf{Alcohol use disorder}

In a country where 50\% of male drinkers have an alcohol use disorder, sudden abstinence due to nationwide lockdown (except in Punjab where alcohol was considered as an essential item) lead to a rise in cases with alcohol withdrawal symptoms leading to frustration and suicide among the masses \unskip~\citep{1001590:21389990}. This was again detrimental for an already burdened health sector. Cases of black marketing and illicitly brewed liquor were on the rise, which further increased the problem. Further isolation has also increased the risk of relapse and loss of control over the decision to stop drinking due to loneliness, frustration and hopelessness. 

\textbf{Depression}

Employment insecurity, disabling loneliness, fear and apprehension have all lead to an increased risk of landing into depression during the pandemic. Female gender, having a friend or family member with mental illness, self quarantine, recurrently exploring the internet for covid news can be considered as significant predictors for depression.

Overcrowding in houses with no escape into the outside world leads to lack of personal space, which builds up frustration leading to depression.

 \textbf{Preventive Strategies}

In the difficult times of covid 19 pandemics, a lot of attention needs to be paid towards the mental health of people along with the physical well being. People all around the globe have not only dealt with physical stress but to a much more extent dealt with psychological stress. That is why it is really important to deal with the psychosocial aspect of health. The following points are some of the preventive strategies which one could use to cope up with the mental health along with the stigma associated with it,

\textbf{Pause and Analyze}

In this difficult time, we all should act like a semicolon, not like a full stop. This statement has a much greater meaning than it seems. A semicolon is a reflection of a pause and not to stop. It reminds us that at some point of time, we should pause ourselves and analyze what is wrong with our current psychological status. We should explain it to ourselves that's is fine not to be fine sometimes. Around 50 percent of the problem is solved automatically when we realize that there is some problem going with our mental health.

\textbf{Social interaction}

After realizing that we are not fine, it is time to take the next step. Our very next step should be to socially engage ourselves with the surroundings around us. Interaction, in a way, is a solution to our loneliness. Most mental health issues arise from the sensation of being alone \unskip~\citep{1001590:21389991}. By interaction, not only we can have someone to talk to, but we have someone to share about how we feel about ourselves. 

\textbf{Healthy Routine}

Routine is something which keeps all the things going around us in check. It is something which impacts our day to day activities which indirectly soothes our mental health. Health routine includes the sleeping pattern which should be similar each day, personal hygiene such as bathing should be taken care of, dietary meals should be taken on time, dividing our day to various segments can help us regulate our time more effectively as well as effectively, one should allocate time for work as well as leisure and exercise is even an important factor which should be taken into account during our day to day routine \unskip~\citep{1001590:21389989}.

\textbf{Pamper Yourself}

Sometimes we should accept our limits. We should always try to break them but at the same time should not be harsh on ourselves. We should analyze the part that stresses us more and should eliminate it from our routine. Instead of being disappointed by the things we couldn't achieve, we should be happy about the things we have achieved on a day to day basis. Life is just like a river which keeps flowing and sometimes it's totally fine to go with the flow and give the river its course of time instead of being harsh on oneselves.

\textbf{Professional Help}

Sometimes in life, even after adopting certain measures, we cannot cope with the stress around us and it is totally fine if such a thing happens. At that moment, instead of being afraid, we should analyze and realize that it's time to seek some medical help. A person should not hesitate to seek medical help if required. The best safe place to seek medical help is a psychotherapist. A person can open up to them without being vulnerable and can express herself/himself to the best possible limits. The MOHFW-GOI has also issued a toll free helpline number for Behavioral Health. The Psychosocial toll free helpline- 08046110007 can be used by anyone needing help with her/his mental health well being. With time, the mental stress and pressure start reducing and appropriate measures suggested by the medical professional can be taken into account to lead a more peaceful and healthy life.

\textbf{Telemedicine}

In recent times, the importance of medical professions has increased. People realize that seeking medical help is not a stigma but importance in today's time. It is basically for the betterment of our self only. In India, the number of health care workers compared to the vastly big population is less. So to compensate for the difference in the population to the health care professionals, telemedicine is gaining importance \unskip~\citep{1001590:21389987}. 

It can be easily implemented in areas where mental health services are poorly represented or unavailable due to severe lockdown restrictions.
    
\section{Conclusion}
The effects of a pandemic on the mental health of people have been detrimental. The psychological impact of fear, apprehension and depression due to the pandemic needs to be recognized as public health precedence and clear behavioural strategies should be implemented by the government. Education and training regarding mental health should be provided even at the grassroots level. Budget allocation and funding should be increased to prevent the emergence of a mental health epidemic amidst an already going pandemic.

\textbf{Conflict of Interest}

The authors declare that they have no conflict of interest for this study. 

\textbf{Funding Support }

The authors declare that DMIMS Provided funding support for this study. 
    

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