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| PERSPECTIVE/VIEWPOINT |
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| Year : 2021 | Volume
: 3
| Issue : 3 | Page : 131-136 |
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Lessons from COVID-19 Pandemic and Social Psychiatry
R Srinivasa Murthy
Project ENRICH, Mental Health Advisor, The Association for the Mentally Challenged, Bangalore, Karnataka, India
| Date of Submission | 14-Nov-2021 |
| Date of Decision | 08-Dec-2021 |
| Date of Acceptance | 12-Dec-2021 |
| Date of Web Publication | 23-Dec-2021 |
Correspondence Address:
Prof. R Srinivasa Murthy
Project ENRICH, Mental Health Advisor, The Association for the Mentally Challenged, Bangalore - 560 025, Karnataka
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/wsp.wsp_53_21
The COVID-19 pandemic of the last 2 years has changed everything about life. There is wide recognition that following the pandemic, the world will be a different place than it was. The social factors have come to the forefront with regard to the vulnerabilities to infection, severity of illness, access to medical care, hospitalization, intensive care unit care, mortality, post-COVID complications, and work and social lives. The pandemic has held a mirror to the social situations of countries and communities. It also provides opportunities for the application of principles and practices of social psychiatry to build resilience of individuals, families, and communities.
Keywords: COVID-19, pandemic, prevention, social determinants, social interventions
How to cite this article:
Murthy R S. Lessons from COVID-19 Pandemic and Social Psychiatry. World Soc Psychiatry 2021;3:131-6 |
“Health crisis has become a social one (crisis).”[1]
“Apply a whole of society approach to promote, protect and care for mental health.”[2]
| Background | |  |
The social dimension of the COVID-19 pandemic was considered about 12 months back.[3] In the last 1 year, the experiences of the countries, rich and poor, developed and developing have provided fresh opportunity to understand the social dimensions of the pandemic. This article examines the new data on prevalence of mental disorders during the pandemic period, the responses of the governments, and people to the wide range of issues such as mask wearing, physical distancing, vaccination, health-care programs in general, mental health interventions in particular, and the lessons for social psychiatry. In a way, the availability of social factors across all of the above aspects provides an opportunity, similar to the work of Emile Durkheim in 1897 on suicide, to rejuvenate social psychiatry.[4] Professionals have voiced the pandemic as an opportunity to redesign mental health care.[5]
Social psychiatry during the last 100 years has seen many ups and downs. The large-scale epidemiological studies of the early part of the 20th century emphasized the role of social factors in the prevalence of mental disorders. In the middle of the 20th century, the heyday of social psychiatry, there was recognition of the importance of social institutions such as family, community, and social cohesion beyond the individual-level characteristics and actions. However, social psychiatry, so apparently promising in the optimistic context of postwar America in the 1950s and 1960s, saw its influence and status decline within American psychiatry in the late 1960s and 1970s.[6]
However, in the last two decades, there is a revival of the understanding of social factors and mental health.
The most recent review of mental health, the Lancet-WPA Future of Psychiatry, summarizes the challenges as follows:
“A large body of evidence shows the importance of social determinants for mental disorders. Societal factors such as social inequality, crime, poverty, poor housing, adverse upbringing conditions, poor education, unemployment, and social isolation are related to increased rates of mental disorders. The relevance of some social determinants varies across the world. Examples are substantial urbanisation in low-and middle-income countries; increasing social isolation in high-income countries; the changing flow of refugees in some regions; and different levels of economic instability, civil unrest, and inequality between rich and poor people. Most of these social determinants influence physical health problems too, but they can be seen as particularly relevant to psychiatry.”[7]
Further, the group recognizes psychiatry in the first quarter of the 21st century to be at the cusp of major changes, as follows:
“Increased emphasis on social interventions and engagement with societal expectations might be an important area for psychiatry's development. This could encompass advocacy for the rights of individuals living with mental illnesses, political involvement concerning the social risk factors for mental illness, and, on a smaller scale, work with families and local social networks and communities. Psychiatrists should therefore possess communication skills and knowledge of the social sciences as well as the basic biological sciences.”[7]
| Recent Developments | | |
During this month, October 2021, as part of the World Mental Health Day 2021 (World Federation for Mental Health-Mental Health in an Inequal World),[8] there have been many important initiatives. Important of these are, the launch of the Countdown 2030 by Global Mental Health Group[9] and the release of the World Mental Health Atlas, 2021, by the World Health Organization (Mental Health for All-Let us Make it a Reality).[10] The October 2021, State of the World's Children 2021 focuses on mental health[11] (we must change the way we view mental health). In the 270-page report, children and young people could feel the impact of COVID-19 on their mental health and well-being for many years to come. It focuses on risks and protective factors at critical moments in life and attempts to shed light on the social factors that shape mental health and well-being. The report recognizes that the pandemic is the “tip of the iceberg” after years of neglecting child mental health.
The launch of the “Mentally Healthy Nation” by the American Psychiatric Association (APA) is another important event.[12] The goal of the APA initiative is significant for the scope of the activity to reach the general public [Table 1].
| COVID-19 and Social Determinants | | |
The most recent study aimed to quantify the impact of the COVID-19 pandemic on the prevalence and burden of major depressive disorder and anxiety disorders globally in 2020.[13] The study reported nearly 30% increase in both the disorders. Further, increases in the prevalence of major depressive disorder and anxiety disorders during 2020 were both associated with increasing severe acute respiratory syndrome coronavirus 2 infection rates and decreasing human mobility. We estimated that countries hit hardest by the pandemic during 2020 had the greatest increases in prevalence of these disorders. There was greater increase in disorder prevalence among females than among males. Other groups adversely affected are the elder age group and the young people. They should consider public health messaging about the mental health impacts of COVID-19, how individuals can best manage their mental health, and well-defined pathways to assessment and service access. Authors conclude, “no action is not an option” and mitigation strategies should promote mental well-being and target determinants of poor mental health exacerbated by the pandemic, as well as interventions to treat those who develop a mental disorder.
In another longitudinal study of a nationally representative group of U. S. adults aged 18 years and older surveyed in March 2020 and April 2021, the “COVID-19 and Life Stressors Impact on Mental Health and Well-being,” the prevalence of elevated depressive symptoms persisted from 27.8% in 2020 to 32.8% in 2021. Importantly, the central drivers of depressive symptoms were low household income, not being married, and experiencing multiple stressors during the COVID-19 pandemic. The odds ratio of elevated depressive symptoms for low-income relative to high-income persons increased from 2.3 in 2020 to 7.0 in 2021. The odds ratio of elevated depressive symptoms associated with 4 or more stressors relative to 1 stressor or less increased from 1.9 in 2020 to 5.4 in 2021. Mental health gaps grew between populations with different assets and stressor experiences during the COVID-19 pandemic.[14]
There is growing evidence of racial and ethnic minority groups being disproportionately affected by COVID-19. In a recent cross-sectional analysis, American Indian or Alaska Native, Latino, Black, and Asian or Pacific Islander persons were more likely than White persons to have a COVID-19-associated hospitalization, intensive care unit admission, or inhospital death during the 1st year of the US COVID-19 pandemic. Authors call for equitable access to COVID-19 preventive measures, including vaccination to minimize the gap in racial and ethnic disparities of severe COVID-19.[15]
The association of “stresses” as a risk factor for mental health has come in a number of reports. A study on health-care workers (HCWs) from nine eastern Mediterranean regional countries, working with the pandemic, found that 57.5% had depression, 42.0% had stress, and 59.1% had anxiety.[16] Considering the severity, 19.2%, 16.1%, and 26.6% of patients had severe-to-extremely severe depression, stress, and anxiety, respectively. Depression, stress, anxiety, and distress scores were significantly associated with participants' residency, having children, preexisting psychiatric illness, and being isolated for COVID-19. In addition, females, those working in a teaching hospital, and specialists had significantly higher depression and stress scores. Married status, current smoking, diabetes mellitus, having a friend who died with COVID-19, and high COVID-19 worry scores were significantly associated with higher distress scores. These findings emphasize the importance of social determinants of mental health. Authors urge for immediate implementation of “special interventions to promote mental well-being among HCWs responding to COVID-19”.
A recent review of “Screening and Interventions for Social Risk Factors” by the US Preventive Services Task Force,[17] noted that of the interventions studied, 73 addressed multiple social risk domains. The most frequently addressed domains were food insecurity, financial strain, and housing instability. Authors concluded that there is need for more randomized clinical trials that report health outcomes from social risk screening and interventions.
In a recent paper,[18] the complex interaction of factors such as religiosity and lower socioeconomic status (SES) was brought out. In this study using three databases, authors examined the relationship between nationalities and religiosity and the psychological burden of poverty. They report an interesting finding of psychological burden of lower SES, being greater in developed nations than in developing ones. That evidence suggests that economic development is no cure for the psychological burden of lower SES. National religiosity is particularly low in developed nations and can account for the greater burden of lower SES in developed nations. Drawing on three different data sets covering 92 nations, the study shows that low levels of national religiosity can account for the greater burden of lower SES in developed nations. This finding suggests that, as national religiosity continues to decline, lower SES will become increasingly harmful for psychological well-being. There is an interesting observation in the paper: “the challenge will be to find alternatives to national religiosity to curb these harmful effects. Such alternatives will not be easily found because national religiosity exerts particularly powerful effects.”
It is significant that on October 14–15, the APA[19] focused on social determinants of mental health. Some of key observations have direct relevance to social psychiatry [Table 2].
| Common Themes | | |
About a year back, Srinivasa Murthy and Gupta[3] had pointed to the need for “social vaccine” as follows: (i) success of mastering the pandemic will depend not only on the social action but also on the public health and medical interventions as well; (ii) there is a need to build social cohesion through every means available so that the response is harmonized and maximized; (iii) professionals such as psychiatrists, clinical psychologists, psychiatric social workers, and psychiatric nurses should work together, as well as work with other disciplines (especially from the domain of public health, community medicine, and epidemiology) and with groups such as community leaders and religious leaders to maximize the interventions; (iv) there is need to understand the “local” strengths and needs and utilize them to maximum extent; and (v) there is greater recognition and need for the professionals to continuously study the “social dimensions” of mental health and develop medical, public health, and social interventions to mitigate the effects of disasters/pandemics.
The following are some of the common themes emerging from the country's experiences of the pandemic of the last 12 months, relevant to social psychiatry.
Community resilience is central to “master” the pandemic. Countries such as South Korea, Vietnam, Hong Kong, and Taiwan were better prepared because of their past experiences with the epidemics. They had systems ready to respond (systems of screening, contact tracing, isolation, etc.) to the current pandemic as well as the populations were cooperative to the public health measures. In the postpandemic period, there will be greater focus on community resilience.[20],[21]
The biggest universal observation of the pandemic, in countries rich and poor, is the vulnerabilities of population groups such as elderly, poor, homeless, people with comorbidities, and marginalized groups. There is need to address these inequities to prevent their greater vulnerabilities to infection, severe disease, and deaths.
The response to the pandemic is not simply a health-care issue. There is need for actions at the level of individuals (masking, physical distancing, handwashing, and accepting vaccination), families (minimize violence at home and mental health of children), and communities (trust, cohesion, and mutual support).[20],[21]
Professional leadership is to bring the scientific knowledge to each and everyone in the community and to policymakers so that response is based on science rather than ideology.
Interestingly, spirituality is an important community resource to master the stress and recovery and to make sense of the challenges to living.
Finally, research should be an important part of both understanding the impact of the pandemic as well as the interventions. The pandemic is a challenge to humanity, but it can also be an opportunity to the society to examine and correct societal factors that increase vulnerabilities.
| Lessons Learned | | |
In 1897, Emile Durkheim, based on the church records, brought a new understanding to the problem of suicide,[4] and for this reason, he is considered the father of modern sociology. The current pandemic offers all of us a unique opportunity to understand mental health against the background of social determinants and utilize social interventions to address the harmful effects of the pandemic [Table 3].
| Conclusion | | |
It is good to look at the bigger picture. There is growing recognition among public health professionals and mental health professionals about the often pointlessness of measuring of morbidity, intervening to address the devastations of mass scale stresses like conflict situation,[22],[23] and the current pandemic. There have been some serious professional attempts to address the issue of prevention of conflicts. The American Public Health Association, in its position paper,[24] addressed the role of public health practitioners, academics, and advocates in response to war and armed conflict. The position paper “provides the scientific basis and justification for an acknowledgment that war has been among the most important public health problems of the last 100 years, and there is little evidence its importance is waning. We who have committed our careers to promoting public health need to change our framework to encompass war as 1 of the most significant threats to the health of people in every demographic group and in every country. Practitioners, educators, and other workers in public health can play powerful roles in preventing war itself, as well as mitigating the public health consequences of war. The public health consequences of war are massive and leave few if any areas of public health practice untouched. Thus, war is one of the greatest obstacles to realizing APHA's vision of “a healthy global society” (emphasis added).
The above paper recognizes that public health practitioners, academics, and advocates have an essential role to play in preventing war and this position applies to the current pandemic. The position paper calls on public health professionals and international and domestic organizations to (i) recognize the prevention of war as a local, national, and global public health priority; (ii) educate public health professionals, policymakers, and the public about the anticipated consequences of war and advocate for alternative resolutions to conflict; (iii) encourage and support research and advocacy relating to the structural causes of conflict, trends in risk to civilians from state and nonstate actors, assessment of impacts anticipated from wars that have not yet started, comprehensive monitoring and surveillance of public health impacts in conflict zones, factors in successful settlement, the rapid rebuilding of health systems infrastructure as part of postconflict reconstruction, and identifying ways to prevent war and to mitigate its health consequences; (iv) foster dialog on the issue of war and build partnerships with international public health stakeholders; and (v) improve the competency of the global public health workforce to prevent and mitigate the impacts of war.
These observations apply to the many social determinants of mental health reviewed in this article (emphasis added).
Reviewing the limited progress,Wiist et al.[23] make an important observation applicable to mental health professionals, “public health has been more focused on the effects of war than working towards the prevention of the fundamental causes of war….public health practitioners and academics have an obligation to take a lead role in the prevention of war by addressing the fundamental causes in society that lead to war.”
As a psychiatrist, working with populations affected by disasters, since 1984, and people living in conflict situations, the predominant feeling I carry with me is one of extreme helplessness. In disasters and conflicts, we confront disintegration of individuals, families, and communities with limited scope for interventions. The interventions are most often inadequate and the populations continue to suffer in silence for decades at many levels. The most recent example is that of Afghanistan. My feelings are in line with that of Gall,[25] a reporter who has worked in Afghanistan, “Over twelve years, I lost friends and acquaintances in suicide bombings and shootings, and saw other close to me savagely maimed. I do not pretend to be objective in this war. I am on the side of the victims. The human suffering has been far too great, and we have a duty to ponder for the reasons for such a calamity.”
As social psychiatrists, with our recognition that mental health of individuals is largely social in origin, we are eminently placed to contribute to the future mental health of humanity by focusing on social issues and societal-level interventions. There is growing recognition of the challenges of the pandemic and the opportunities[5],[26] to rethink mental health of the community.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | BBC News. 'Health Crisis Has Become a Social One (crisis). BBC News; 05 May, 2020.  |
| 2. | United Nations. Policy Brief: COVID-19 and the Need for Action on Mental Health. New York: United Nations; 2020. |
| 3. | Srinivasa Murthy R, Gupta N. Social vaccine for the ongoing COVID19 pandemic! Indian J Soc Psychiatry 2020;36:S107-11. |
| 4. | Durkheim E. Suicide. London: Routledge; 1951. |
| 5. | Dandona R, Sagar R. COVID-19 offers an opportunity to reform mental health in India. Lancet Psychiatry 2021;8:9-11. |
| 6. | Blazer GD, Kinghorn W. Positive social psychiatry. In: Jeste DV, Palmer BW, editors. Positive Psychiatry – A Clinical Handbook. Washington: APA Press; 2015. p. 71-90. |
| 7. | Bhugra D, Tasman A, Pathare S, Priebe S, Smith S, Torous J, et al. The WPA-lancet psychiatry commission on the future of psychiatry. Lancet Psychiatry 2017;4:775-818. |
| 8. | World Mental Health Day, October 10, 2021. World Federation of Mental Health, Virginia, 2021. |
| 9. | Countdown Global Mental Health 2030: Using Data to Inform Action. United for Global Mental Health, Harvard, 2021. |
| 10. | World Health Organisation. Mental Health1 Atlas, 2021. Geneva: WHO; 2021. |
| 11. | United Nations Children's Emergency Fund. The State of the World's Children, 2021, On My Mind: Promoting, Protecting and Caring. New York: UNICEF; 2021. |
| 12. | American Psychiatric Association (APA). Mentally Healthy Nation. Washington: APA; 2021. |
| 13. | COVID-19 Mental Disorders Collaborators. Global prevalence and burden of depressive and anxiety disorders in 204 countries and territories in 2020 due to the COVID-19 pandemic. Lancet 2021;398:1700-12. |
| 14. | Ettman CK, Cohen GH, Abdalla SM, Sampson L, Trinquart L, Castrucci BC, et al. Persistent depressive symptoms during COVID-19: A national, population-representative, longitudinal study of U.S. adults. Lancet Reg Health Am 2021;100091. doi: https://doi.org/10.1016/j.lana.2021. 100091 |
| 15. | Acosta AM, Garg S, Pham H, Whitaker M, Anglin O, O'Halloran A, et al. Racial and ethnic disparities in rates of COVID-19-associated hospitalization, Intensive Care Unit admission, and in-hospital death in the United States from March 2020 to February 2021. JAMA Netw Open 2021;4:e2130479. |
| 16. | Ghaleb Y, Lami F, Al Nsour M, Rashak HA, Samy S, Khader YS, et al. Mental health impacts of COVID-19 on healthcare workers in the Eastern Mediterranean Region: A multi-country study. J Public Health (Oxf) 2021;1-9. doi: https://doi.org/10.1093/pubmed/fdab321. |
| 17. | Eder M, Henninger M, Durbin S, Iacocca MO, Martin A, Gottlieb LM, et al. Screening and interventions for social risk factors: Technical Brief to Support the US Preventive Services Task Force. JAMA 2021;326:1416-28. |
| 18. | Berkessel JB, Gebauer JE, Joshanloo M, Bleidorn W, Rentfrow PJ, Potter J, et al. National religiosity eases the psychological burden of poverty. Proc Natl Acad Sci U S A 2021;118:e2103913118. |
| 19. | American Psychiatric Association (APA). Plenary Speakers at APA's Fall Conference Focus on Social Determinants of Mental Health, October 14-15, 2021. APA; 2021. |
| 20. | National Academy of Medicine*(NASEM). Disaster Resilience: A National Imperative 2012. Washington: National Academies Press; 2021. |
| 21. | National Academy of Medicine*(NASEM). Enhancing Community Resilience through Social Capital and Connectedness: Stronger Together! Washington: National Academies Press; 2021. |
| 22. | Horgan J. The End of War, McSweeny's Books. San Francisco: McSweeney's; 2011. |
| 23. | Wiist WH, Barker K, Arya N, Rohde J, Donohoe M, White S, et al. The role of public health in the prevention of war: Rationale and competencies. Am J Public Health 2014;104:e34-47. |
| 24. | |
| 25. | Gall C. In The Wrong Enemy-America in Afghanistan, 2001-2014. New York: Penguin; 2014. |
| 26. | Srinivasa Murthy R. COVID-19 pandemic and emotional health: Social psychiatry perspective. Indian J Soc Psychiatry 2020;36:S24-42. |
[Table 1], [Table 2], [Table 3]
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