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Tuesday, August 11, 2020

The Sandip Roy Show

What makes people tick? What are the stories they carry with them? In a world of shouting heads, veteran journalist, radio commentator and novelist Sandip Roy sits down to have real conversations about the fascinating world around us and the people who shape it. Catch these engaging interviews every other Sunday

Episode 49 May 3, 2020

The lockdown’s toll on mental health, with Dr Pratima Murthy

During the lockdown, the question on everyone’s mind is what will happen next? When will India open up again? There are debates about the economic cost of keeping a country of 1.2 billion locked down. But what about the mental cost? In this episode, Sandip talks to Dr Pratima Murthy, Head of the Psychiatric Department at the National Institute of Mental Health and Neurosciences (NIMHANS), about how mental health is suffering during this time. From the toll that the lockdown has taken on people suffering from alcohol addiction and severe mental illness like schizophrenia to the problems being faced by the elderly and the stigma associated with the disease.
Transcript:
Sandip Roy

Hello and welcome to the Sandip Roy Show on Express Audio.

[Music]

In lockdown India, the question on everyone’s mind is what will happen next? When will the lockdown end? When will India open up again? And how normal of a life will we be able to lead even if the lockdown ends? There are debates about the economic cost of keeping a country of 1.2 billion locked down. But what about the mental cost? Are you one of those who feels more anxious than usual? Worrying as you scroll through doom and gloom news. Or are you just baking up a frenzy and shaming everyone on Instagram with your charts and cakes and sourdough bread? For some, lockdown days are a time to reconnect with family through old games of Ludo and Carrom. Others are stressing out about being trapped with family or perhaps halfway across the world from family. And as the lockdown drags on, all of this casts a larger and larger shadow over our lives.

This week on the show we talk to Dr Pratima Murthy, Head of the Psychiatric Department at the National Institute of Mental Health and Neurosciences or NIMHANS. NIMHANS has launched a COVID psychosocial helpline with a toll free number – 08046110007. We reach Dr Murthy on her own phone in her office.

[Music]

Dr Pratima Murthy, welcome to the show.

Dr Pratima Murthy
Thank you, Sandip.

Sandip Roy
So, are we at a point where we can make any kind of assessment right now about the impact the lockdown is having on mental health in this country?

Dr Pratima Murthy
I think one knows very well that lockdown can have a fairly significant mental health impact on people. One thing, of course, is that it’s quite an unprecedented situation. We’ve never been forced to be at home for such a long time. And therefore it means that each of us has to make several adjustments. One of the adjustments is simply spending a lot of time at home. With several people around the house.

Normally, not everybody stays at home, people go out to work. So there’s a limited amount of time that you spend with family. These moments can initially be very exciting because there is the excitement of reconnecting with family and so on. And some people who are well adjusted have found it quite easy to adapt. But for several others, it has been quite a moment of great tension to be able, number one, to be able to work from home. I know a lot of people in software companies and even doctors, for example, who are doing a lot of webinars from their home. It’s not as if it’s very easy to completely do this tension free. I mean, you know, you need a quiet place, you need good connectivity, you need to sometimes do meetings back to back. But I think the biggest toll is on the elderly who because of health risks are mostly confined to their homes. I think for them, even outside of lockdown, there are issues of loneliness and emptiness and not being able to connect to people. And this can be particularly challenging for the elderly.

Sandip Roy
You mention the toll on the elderly, but could this now be having a counter effect in terms of loneliness? Where actually elderly people have a lot more family around than they are used to normally.

Dr Pratima Murthy
I mean, while that is true, there is also a worry that a lot of young adults have about, especially young adults who are working outside, that they might bring the infection back to the old folk at home. I know for certain, especially among doctors who work in risky situations, about coming back and exposing the elderly to such kinds of infections.

The second thing is reading about certain very distressing news items. For example, some countries are, you know, deciding that if the elderly got very ill that they would switch off life support, for example, or not offer them life support. And in a country where, you know, where you value the elderly, this can be extremely distressful. And of course you’re right, in places where family members do stay with the elderly, they might be a possibility to connect. It doesn’t mean that if you’re sharing the same physical space that you’re necessarily connected. If you’re working all the time from home and you resent any interruptions, there need not necessarily be quality time with the elderly and that can also be distressing.

Sandip Roy
You all launched the COVID-19 pan India helpline on March 28. Was there any particular other incident that triggered it? Because we don’t always think about the mental health impact on things in advance as it were.

Dr Pratima Murthy
I think what has happened is that the pandemic, you know, ever since it started late last year, has given us various opportunities to anticipate mental health problems. NIMHANS has always been working in various issues where there were psychosocial disasters, you know. When there were floods, when there was a tsunami and so on. So I think we had an idea that situations like this can set off a lot of mental health problems. And in addition, this time, we’ve been aware that there have been lockdowns in different countries and unique thing about this situation are the mental health effects of lockdown. And we initiated the national mental health and psychosocial helpline and it caters to different kinds of service seekers. To the gender adults to children and adolescence to the elderly, as well as women facing domestic violence.

And today, more than 16,000 calls have been received from all over the country and more than 300 mental health professionals have been handling these services. In addition to this helpline, we also have what is called a tele-follow up service for our registered patients. As you know, during lockdown, outpatients had to be closed down and we had a large number of patients who would have gone and had a relapse if they had not continued their medication. So we connected with the district mental health programme, with the Bangalore Corporation, the BBMP. We’ve made sure medications for people with chronic psychiatric illness have been available at both the district as well as the BBMP.

The other thing is, of course, we’ve been helping the migrant population. The government of Karnataka requested us to provide them psychosocial support. Similarly, in the Centre for Addiction Medicine, we have followed up several thousands of patients who are in contact with us. Made sure that their withdrawals were handled, that they didn’t have a relapse. I think we’ve sent out messages to almost 5000 patients with substance use problems, made calls to more than 3000, addressed the problems of incoming calls from but thousand 400 patients, issued e-prescriptions.

Sandip Roy
And let me unpack some of this stuff because there’s a lot in what you were talking about. If you divide it by age, for example, do you have a sense yet, from the questions that you’re getting on the helpline, about what issues seem to worry each age group the most?

Dr Pratima Murthy
I’d start off with pregnant mothers because there’s an expecting child. So with pregnant mothers, it is about getting antenatal services. They worry about going to hospitals in case they contract infections, there are concerns about the unborn child. So we have a helpline for women who are in the perinatal period, so that they can get counselling over the phone.

You spoke about children. So with young children, I think the biggest problem is engagement and boredom. Because earlier we used to talk about not giving young children access to things like mobile phones and televisions screens and so on, because we recognise the risk of getting addicted to that. But now, we have to rely on technology in some ways to, especially for pre primary children. The other thing is, of course, to really go back and rediscover old games that we used to play as families. And I know people are playing Carrom at home, they’re playing chess with the children, they’re playing all kinds of other board games to keep children occupied. The third thing with children is physical activity. Kids are restless by nature and can’t sit at a time doing things. So they need a little bit of, you know, discharge of energy for these things. And that can be very confining if you’re in a small home. Kids are also very scared because they see adults glued to TV listening to issue two news about death.

Sandip Roy
As you mentioned, right now kids are accessing technology because they’re doing online classes. And at one time, we were worried about our kids being addicted to online activities. Now that even school is online, what do you think is going to be the impact of that?

Dr Pratima Murthy
I mean, it’s the way you look at. It probably gives children a way of looking at constructive ways of using the internet rather than only for entertainment or for distraction. So it is challenging to keep kids doing assignments online and therefore teachers will probably have to rediscover ways of engaging kids online. You know, chunking assignments into little bits or even their classes into much shorter modules. But I think it’s very important to have kids engaged in this manner to complete their assignments. And I think especially slightly older kids are actually very worried about how their syllabus is going to be completed, how prepared they are going to be for their examinations..

Sandip Roy
Now in terms of, you know, psychiatric issues we often hear about things like ‘Fight or Flight’, so Dr Murthy what is actually happening in our brain when we are faced with such kind of pandemic anxiety and panic?

Dr Pratima Murthy
So one is, it’s almost like a global panic. Because everybody everywhere is affected with it in one way or the other. So a lot of the psychological symptoms are about worry. And worry can be sometimes realistic, but sometimes worry can be overwhelming and out of proportion to the probability of actually contracting the infection. The reality is that 80-85% of people will have a flu like illness and get better. But then that reality is often countered by the very distressful things that you read about or watch on social media or television where you see people in great amounts of distress going on the ventilator and so on.

The second thing is that we need to worry about things that we can control and really try and give up worrying about things that are not under control. When lockdown will lift is not under our control, so it’s no point moping about that. But for some others, apart from worry they can become extremely anxious. So anxiety is characterised by what we call autonomic symptoms – the heart beating fast, feeling very sweaty, trembling, a sense of wanting to go to the loo very often. Psychological symptoms feeling that I’m going to get into, I’m going to be choking, I think I’m going to die. These kinds of symptoms are all classical of what we call panic attacks, which can be a part of anxiety.

It’s more likely to occur in people who are generally sensitive or had these problems before but in overwhelming situations somebody who’s been well before can also experience anxiety and panic. Just a little bit of moodiness now and then or, you know, feeling bored and moody, it might be part of the lockdown experience but then if it persists for a very long time and for days continuously one is feeling low in mood, not sleeping very well, not having an appetite and not enjoying the things that they normally do, in terms of talking to others or watching their favourite serials, and then having feelings of helplessness and hopelessness, this is what we’d identify as depression. And sometimes when depression gets severe, you can have a lot of negative thoughts. Negative thoughts about oneself, about the future and so on.

It’s important to recognise this because number one, it’s treatable. Number two, if it becomes very severe, the person can have a lot of negative feelings about themselves and get suicidal. And I think these warning signs need to be recognised by people, they need to reach out. And two kinds of help are available for people with depression depending upon the severity of the depression and the underlying circumstances. One is, of course, that if it’s very severe they may need to go on antidepressant medication. If it is mild or moderate, they can be helped through psychotherapy. So in fact, my colleagues in psychology are also offering online psychological interventions.

One of the other things is the stigma around COVID and the distress that it causes. For a lot of people, I mean, they just get COVID positive because they’ve contracted a viral infection like anybody else. If you took all the right kind of protection, and I think that’s the bottom line, social distancing, protection by wearing masks, not allowing yourself to touch contaminated surfaces, if one is careful about all, the stigma can reduce.

Sandip Roy
I’m not trying to encourage smoking at all, but given what you were talking about all this anxiety and stress that this is inducing, does it make sense, for example, to deprive smokers of cigarettes for such a long period when they anyway stressed out?

Dr Pratima Murthy
Okay, that’s a very interesting question and a lot of people ask this. You know, that when you’re stressed out and have nothing else to do, smoking was what was relieving stress. But we also know how dangerous smoking can be particularly in the times of COVID. We know for example, that smokers, tobacco chewers are more likely to be touching their hands to their lips, to their mouth, and therefore more likely to spread infection to themselves.

The second thing is that smokers, especially chronic smokers, are already likely to have some degree of impairment in their lung capacity. So I think it is a very good time for smokers to understand that they definitely need help to reduce their anxiety. They definitely need help to reduce the reasons for their smoking, and therefore they can get help now. The Government of India has a national health portal and there is a number that they can call which is 01122901701. They can actually get help to learn how to deal with their craving, how to manage their mood, while giving up tobacco at this time.

There is also what is called the mobile session where you can actually speak to a counsellor in your own language anywhere you are in the country and get help to stay quit. And that number is one 800112536. I didn’t mention spitting and its consequences. In fact, the government is planning to have a law against spitting because spitting is one of the easiest ways to actually spread droplet infection, and smoking and tobacco use is invariably associated with more spitting. So you’ll see that there are a variety of reasons why smokers and tobacco users should consider this as a golden opportunity to learn how to deal with anxiety.

Sandip Roy
What kind of stories have you heard about addicts and the withdrawals that they might be experiencing right now because they’re not able to get their fix in a way that they were used to?

Dr Pratima Murthy
Yeah, I start out with alcohol withdrawal, and I think for a lot of people, this has been one of the biggest problems. In the first two weeks of lockdown, we had several patients with severe alcohol use who came into us with a condition called delirium tremens, where they get confused, where they get disorientated, they can be highly hallucinating, they’re also at risk to develop seizures. And therefore we provided treatment in our emergency to these patients. We got a huge number of calls from patients with alcohol dependence to help them to deal with their withdrawal.

Similarly, there are patients who are dependent on opioids, who are on treatment with what is called opioid substitution therapy. The National AIDS control organisation has actually made sure that particularly in districts and in places where they have their counselling centre, that the medication, the OSD medications, are made available. But I completely acknowledge that these can be very difficult times for people with addictions, particularly during lockdown. And I think we need to spread awareness of how they can get help and where.

Sandip Roy
And you mentioned, people with pre-existing conditions like anxiety disorders and things like that. I interestingly heard therapists say that strangely … that some people with anxiety attack problems are actually coping with the lockdown a little better than they expected because everybody around them is having an anxiety attack.

Dr Pratima Murthy
Ya, I know Sandeep, I think it works both ways. So as you said, I mean, you know, sometimes when you’re anxious, when you have an anxiety problem, and everybody around you is calm, you feel very isolated. Now, with everybody experiencing various kinds of anxiety, you might understand this as a universalisation of the symptoms that you’re experiencing. And that might give you some sense that you’re not alone in this kind of situation. For example, if people have what is called social anxiety – anxiety that is much more when they go out in different situations, when there is a lot of pressure on them – perhaps the pressure may ease when they are at home. But it’s generally true that for many people, especially if they were getting help earlier and that help is deprived, they may have an exacerbation of this anxiety.

Our greatest concern at NIMHANS is for people with severe mental illnesses, what we call schizophrenia, bipolar mood disorder and so on; people with chronic schizophrenia, for example, we recommend socialisation. You know, for them to go out to mingle more, to get over what we call a-socialisation, their anhedonia. They need to go out more and interact more … and now, lockdown. It prevents that kind of thing from happening. So families who have patients with severe mental illness need to find innovative ways of keeping them engaged. Maybe this is a good time for them to learn home chores – how to, you know, how to clean, how to cook, and learn how to use technology.

Sandip Roy
What kind of stories and calls that you get in relation to people facing issues with being around family all the time. I mean, this is a time where somebody who undergoes domestic abuse is trapped at home with the abuser.

Dr Pratima Murthy
I don’t think It’s appropriate to kind of generalise that, you know, this will happen in families or that will happen with families, and some families, these are opportunities to get connected, to stay connected, things that you couldn’t do earlier. But if you have strained interpersonal relationships, these can be very difficult times. In fact, I think the National Commission for Women has actually registered a growing amount of domestic violence in families, you know, where there have been troubled relationships. So child abuse, domestic abuse – these are things that are increasingly being recognised in families where, you know, this kind of intimacy can actually be problems. And I think everybody needs to be aware that these are criminal acts, if domestic violence occurs, and that these are reportable acts.

Sandip Roy
Let me, we talked about children and we talked about elders. Let me talk a little bit about the working population, you know, this whole working from home and the challenges that it is bringing and the kind of questions you’re getting on your helpline. I mean, at one level, there is the challenge of working from home, but there’s also a performance anxiety that I see around me of trying to use this period to somehow be extra productive. For example, I’m a writer and you know, I keep constantly being asked, so are you writing a lot? Are you writing that next novel, and it actually induces more anxiety in me.

Dr Pratima Murthy
I think the initial phases, you know, you were able to relax a bit and thought you could be more productive. As you said, for writers for researchers, this is seen as a time where you can get your maximum number of papers or articles, etc. written. But then you know, the mind doesn’t flow as easily as the pen or indeed the typewriter keys. So it requires a lot of adaptation, a lot of focusing of your mind. But the second thing is, of course, the pressures to deliver may actually increase when you’re at home. Very often you’re on back to back online meetings, there are deadlines. It’s very difficult to really balance what is home-based activity and workplace activity when you’re working from home.

Sandip Roy
I was reading a story in the newspaper about a man in Kolkata who had a jewellery shop. And now, because of this thing, the lockdown, the shop is shut. He has a lot of debt. So he is selling fruit on the street, and he says his family’s quite ashamed about it, and the only silver lining of all of this is, he says he can wear a mask. And so people in his neighbourhood don’t recognise him very easily.

Dr Pratima Murthy
There’s no doubt that the economic fallout of these events are going to be enormous and people are very, very frightened, and realistically, so. Especially people with small businesses who’ve had to shut business for a whole month. You know, it can be extremely traumatic. So I think we need to get people to be proud of the fact, this gentleman for example, that he was innovative in actually being able to do something and be productive rather than waste this time and not have any income at all, and I wish his family would actually be proud of him.

In fact, on the contrary, you also read news of somebody whose onion business was deteriorating. She posted a video on WhatsApp. And immediately, the district administration got in touch with her and made sure her onions were sold. And I think what we need to do, whether it’s about COVID recovery, or employment, etc., we need to put out a lot of positive stories there. So that people feel encouraged to look at ways and means of coming out of this. Otherwise, I think, if the stress is overwhelming, and people lose hope, and you know, the anticipation of things turning around, that can be disastrous in terms of consequences. Because we know that when these stressful times occur, and when people are not supported, rates of suicide, for example, increase.

Sandip Roy
Do we, in fact, know whether suicide rates have increased during the lockdown?

Dr Pratima Murthy
You do read anecdotal reports of suicides, but I don’t think one has still done a meaningful analysis of this. You do read again, not … not only India, but you read, I mean, just yesterday, there was a physician who … who died, who killed herself. So I think people are going through stress in unimaginable ways. And some of it, particularly the economic part of it, the lack of support, and that’s why I want to emphasise that people should feel supported.

Sandip Roy
You mentioned that you are also working with migrants. We’ve all seen the images of the migrants trying to go home and the panic that the lockdown initially caused. What do you think is going to be the mental health impact of all that?

Dr Pratima Murthy
I think we’ve known several kinds of impacts from this. And I think the economic impact, you know, the distress associated with it, separation from families, the kind of condition that you’re exposed to, the lack of support. These are things that determine the outcome from this, but I think if this is reasonably tided over and people are reasonably resilient, we should be able to come out of this. But I think the newer problems will arise, post the lockdown, where people, if they’re out of jobs, particularly daily wage workers, particularly people who don’t have stable sources of income, you know, to be able to make sure that their livelihoods are taken care of is going to be the biggest challenge. It’s not just economic. It’s also the emotional disconnect that you might have from your sources of support, that can be a source of huge distress.

Sandip Roy
And the fact that things like isolation and social distancing are such alien concepts to us, especially in a country like India, built as it is on social connections. What do you think can be the mental health impact of all of this, that now suddenly, the fact that many of us live in close proximity with grandparents can actually become an issue?

Dr Pratima Murthy
Absolutely right. I think, one of, especially for grandparents who live with grandchildren, and both connected to the grandchildren, the concept of physical distancing means, you know, reduction of proximity. And that can be pretty challenging. So ways of getting about it is really not to refer to it as social distancing, but to refer to it as physical distancing. I just saw a thing in Kerala where they’re holding umbrellas to indicate the distance that they must keep between themselves.

I mean, I think people should not, while people should not be overly anxious, people should not become very complacent that they are not at risk. I think it’s very important for people to be careful, whether it’s using masks, whether it’s continuing to use hand hygiene.

The other thing is overcrowding. And I think the biggest problem in our country, particularly in the low socioeconomic strata, is even when you look at houses, there are sometimes eight to ten people living there. When people are working, especially the migrant population, they’re living in extremely crowded circumstances. And these can be hotspots where, you know, where the problem can increase, and it can be extremely difficult in such situations.

Sandip Roy
Do you think it would help in terms of what you were just talking about, for us to get into a mind-frame, especially after the lockdown is lifted, whenever it’s lifted, of living with the virus around us rather than the messaging being all about defeating the virus and kicking it out of India.

Dr Pratima Murthy
Absolutely, I think anybody will tell you that in these flu like epidemics, there is a huge kind of wave of the flu, and then it kind of lingers on for years together. So I think we need to adjust to a life where we manage ourselves in a sensible manner but we go about our work. And one of the things, you know, one of my colleagues told me is as a civilization, we actually wash quite a bit. We wash our hands before lunch, we wash our hands before we accept anything from somebody, but I think that needs to translate into making sure we don’t touch unfamiliar surfaces, that we don’t spit in public. And I think if one lesson can occur from this pandemic, it is to make sure that as a civilization, as a society, we stop spitting.

Sandip Roy
The Prime Minister, you know, when he announced that lockdown, he called for Sainyam and Sankalp, restraint and resolve, but what followed was panic. Whether it was migrants trying to go home or the upper middle class rushing to supermarkets. As this sort of lockdown keeps getting extended, how will we cope with that psychologically?

Dr Pratima Murthy
And panic is not just migrants. Panic is not just about buying. There is panic everywhere. I can tell you, I work in a hospital, our doctors are constantly in a panic as well because they’re worried about their health, about taking infection home to their families. So I think generally, I mean, I think the word PANdemic is a very appropriate thing because it also causes PANic. When you look at societies and groups of these collectives, you know, getting into a panic, I think the only way is to have good communication, is to offer them support, is to tell them exactly the rationale for various things that are being done, is to have a sense of preparedness. And when I say preparedness, for example, I think people should have been told when the lockdown occurred and let’s say alcohol outlets were being closed, I think we should have communicated to people that they can take help from healthcare settings. I think that’s a very important lesson for us in terms of preventing panic. Whether it’s food supply, whether it’s information giving, whether it’s health related facilities being set up, I think we need to do all that to prevent this.

Sandip Roy
Yeah, well, one way I deal with anxiety around this is I try and avoid all COVID News, Whatsapp university or general news, after 8pm. After 8pm no more COVID.

Dr Pratima Murthy
I think if you have a small window, where do you know where to get information and get information from valid sources and then forget about the rest of it. I think that’s very important. We have a world and a life outside of COVID. And we shouldn’t forget that.

Sandip Roy
And the thing that you mentioned about the stigma of acquiring the infection. Do you think this is going to require a cultural response? Like, and I’m thinking about HIV AIDS, I mean the stigma associated with that, and how a lot of the work that was done to address that stigma was actually cultural.

Dr Pratima Murthy
Now, the difference between stigma related to HIV and this is that contracting HIV is from a particular behaviour. In conditions like HIV, the stigma is moralistic. Here the stigma arises directly from fear. And I think stigma around fear is something that can be very, very challenging to deal with. And as you said, as we learn to normalise this as part of our ongoing journey of living with flu, I think the stigma will also reduce.

Sandip Roy
And Dr Murthy, what do you think might be or what do you foresee as the long term mental health implications, if any, of this pandemic even after it dies down? Are there mental health issues that people may still face as a result of going through this period of lockdown and in lockdown extensions?

Dr Pratima Murthy
I’m an eternal optimist. I believe that most people are resilient, they will grumble, they will have some degree of anxiety now, but things will settle down and people will go back to normal. But having said that, there will be people who have undergone intense emotional trauma and we know that when you undergo intense emotional trauma, unless you’re supported following the trauma, there can be what we call Post Traumatic Stress Disorder (PTSD) or worsening of anxiety and depression. In addition, there are families who have family members living in distant locations in different countries and I think there is a lot of stress around that. The other thing, of course, is we know that if emotional stress is chronic and not addressed, it can actually worsen our health outcomes. I remember you mentioned ‘flight or fight’ earlier, you know, even if there is no flight or flight response, if there is chronic psychological stress, it can indeed worsen the outcome or hypertension, diabetes, cancer, what we call the non-communicable diseases as well.

So I think we would do very well to integrate our physical and mental health. Stay physically healthy but as well make ourselves a little more mentally resilient. But I would like to again end on an optimistic note that civilization has seen this before, we will all bounce back.

Sandip Roy
What’s your anxiety coping mechanism?

Dr Pratima Murthy
I have no time (Laughs). So strangely enough everybody says that ‘There’s so much time, what do I do?’ My constant refrain is I have no time to get bored, I have no time to be anxious. So I think keeping yourself busy is extremely important. And I think staying connected with people, using humour as a response, you know, learning to laugh over things that you cannot control, I find that very, very alleviating in terms of allowing me to relax. Staying connected with friends and family members, spending a little time in the evening, you know, cooking, baking something that I wouldn’t normally do, watching the movie, which we all do as a family, I think these are hugely relieving things.

Sandip Roy
Dr Pratima Murthy, well thank you very much for taking the time to join us on the show today.

Dr Pratima Murthy
Thank you, Sandip.

Sandip Roy
Dr Pratima Murthy is the Head of the Psychiatric Department at the National Institute of Mental Health and Neurosciences. Their COVID helpline number is 08046110007.


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The lockdown’s toll on mental health, with Dr Pratima MurthyDuring the lockdown, the question on everyone's mind is what will happen next? When will India open up again? There are debates about the economic cost of keeping a country of 1.2 billion locked down. But what about the mental cost? In this episode, Sandip talks to Dr Pratima Murthy, Head of the Psychiatric Department at the National Institute of Mental Health and Neurosciences (NIMHANS), about how mental health is suffering during this time. From the toll that the lockdown has taken on people suffering from alcohol addiction and severe mental illness like schizophrenia to the problems being faced by the elderly and the stigma associated with the disease. Transcript: Sandip Roy Hello and welcome to the Sandip Roy Show on Express Audio. [Music] In lockdown India, the question on everyone's mind is what will happen next? When will the lockdown end? When will India open up again? And how normal of a life will we be able to lead even if the lockdown ends? There are debates about the economic cost of keeping a country of 1.2 billion locked down. But what about the mental cost? Are you one of those who feels more anxious than usual? Worrying as you scroll through doom and gloom news. Or are you just baking up a frenzy and shaming everyone on Instagram with your charts and cakes and sourdough bread? For some, lockdown days are a time to reconnect with family through old games of Ludo and Carrom. Others are stressing out about being trapped with family or perhaps halfway across the world from family. And as the lockdown drags on, all of this casts a larger and larger shadow over our lives. This week on the show we talk to Dr Pratima Murthy, Head of the Psychiatric Department at the National Institute of Mental Health and Neurosciences or NIMHANS. NIMHANS has launched a COVID psychosocial helpline with a toll free number - 08046110007. We reach Dr Murthy on her own phone in her office. [Music] Dr Pratima Murthy, welcome to the show. Dr Pratima Murthy Thank you, Sandip. Sandip Roy So, are we at a point where we can make any kind of assessment right now about the impact the lockdown is having on mental health in this country? Dr Pratima Murthy I think one knows very well that lockdown can have a fairly significant mental health impact on people. One thing, of course, is that it's quite an unprecedented situation. We've never been forced to be at home for such a long time. And therefore it means that each of us has to make several adjustments. One of the adjustments is simply spending a lot of time at home. With several people around the house. Normally, not everybody stays at home, people go out to work. So there's a limited amount of time that you spend with family. These moments can initially be very exciting because there is the excitement of reconnecting with family and so on. And some people who are well adjusted have found it quite easy to adapt. But for several others, it has been quite a moment of great tension to be able, number one, to be able to work from home. I know a lot of people in software companies and even doctors, for example, who are doing a lot of webinars from their home. It's not as if it's very easy to completely do this tension free. I mean, you know, you need a quiet place, you need good connectivity, you need to sometimes do meetings back to back. But I think the biggest toll is on the elderly who because of health risks are mostly confined to their homes. I think for them, even outside of lockdown, there are issues of loneliness and emptiness and not being able to connect to people. And this can be particularly challenging for the elderly. Sandip Roy You mention the toll on the elderly, but could this now be having a counter effect in terms of loneliness? Where actually elderly people have a lot more family around than they are used to normally. Dr Pratima Murthy I mean, while that is true, there is also a worry that a lot of young adults have about, especially young adults who are working outside, that they might bring the infection back to the old folk at home. I know for certain, especially among doctors who work in risky situations, about coming back and exposing the elderly to such kinds of infections. The second thing is reading about certain very distressing news items. For example, some countries are, you know, deciding that if the elderly got very ill that they would switch off life support, for example, or not offer them life support. And in a country where, you know, where you value the elderly, this can be extremely distressful. And of course you're right, in places where family members do stay with the elderly, they might be a possibility to connect. It doesn't mean that if you're sharing the same physical space that you're necessarily connected. If you're working all the time from home and you resent any interruptions, there need not necessarily be quality time with the elderly and that can also be distressing. Sandip Roy You all launched the COVID-19 pan India helpline on March 28. Was there any particular other incident that triggered it? Because we don't always think about the mental health impact on things in advance as it were. Dr Pratima Murthy I think what has happened is that the pandemic, you know, ever since it started late last year, has given us various opportunities to anticipate mental health problems. NIMHANS has always been working in various issues where there were psychosocial disasters, you know. When there were floods, when there was a tsunami and so on. So I think we had an idea that situations like this can set off a lot of mental health problems. And in addition, this time, we've been aware that there have been lockdowns in different countries and unique thing about this situation are the mental health effects of lockdown. And we initiated the national mental health and psychosocial helpline and it caters to different kinds of service seekers. To the gender adults to children and adolescence to the elderly, as well as women facing domestic violence. And today, more than 16,000 calls have been received from all over the country and more than 300 mental health professionals have been handling these services. In addition to this helpline, we also have what is called a tele-follow up service for our registered patients. As you know, during lockdown, outpatients had to be closed down and we had a large number of patients who would have gone and had a relapse if they had not continued their medication. So we connected with the district mental health programme, with the Bangalore Corporation, the BBMP. We've made sure medications for people with chronic psychiatric illness have been available at both the district as well as the BBMP. The other thing is, of course, we've been helping the migrant population. The government of Karnataka requested us to provide them psychosocial support. Similarly, in the Centre for Addiction Medicine, we have followed up several thousands of patients who are in contact with us. Made sure that their withdrawals were handled, that they didn't have a relapse. I think we've sent out messages to almost 5000 patients with substance use problems, made calls to more than 3000, addressed the problems of incoming calls from but thousand 400 patients, issued e-prescriptions. Sandip Roy And let me unpack some of this stuff because there's a lot in what you were talking about. If you divide it by age, for example, do you have a sense yet, from the questions that you're getting on the helpline, about what issues seem to worry each age group the most? Dr Pratima Murthy I'd start off with pregnant mothers because there's an expecting child. So with pregnant mothers, it is about getting antenatal services. They worry about going to hospitals in case they contract infections, there are concerns about the unborn child. So we have a helpline for women who are in the perinatal period, so that they can get counselling over the phone. You spoke about children. So with young children, I think the biggest problem is engagement and boredom. Because earlier we used to talk about not giving young children access to things like mobile phones and televisions screens and so on, because we recognise the risk of getting addicted to that. But now, we have to rely on technology in some ways to, especially for pre primary children. The other thing is, of course, to really go back and rediscover old games that we used to play as families. And I know people are playing Carrom at home, they're playing chess with the children, they're playing all kinds of other board games to keep children occupied. The third thing with children is physical activity. Kids are restless by nature and can't sit at a time doing things. So they need a little bit of, you know, discharge of energy for these things. And that can be very confining if you're in a small home. Kids are also very scared because they see adults glued to TV listening to issue two news about death. Sandip Roy As you mentioned, right now kids are accessing technology because they're doing online classes. And at one time, we were worried about our kids being addicted to online activities. Now that even school is online, what do you think is going to be the impact of that? Dr Pratima Murthy I mean, it's the way you look at. It probably gives children a way of looking at constructive ways of using the internet rather than only for entertainment or for distraction. So it is challenging to keep kids doing assignments online and therefore teachers will probably have to rediscover ways of engaging kids online. You know, chunking assignments into little bits or even their classes into much shorter modules. But I think it's very important to have kids engaged in this manner to complete their assignments. And I think especially slightly older kids are actually very worried about how their syllabus is going to be completed, how prepared they are going to be for their examinations.. Sandip Roy Now in terms of, you know, psychiatric issues we often hear about things like 'Fight or Flight', so Dr Murthy what is actually happening in our brain when we are faced with such kind of pandemic anxiety and panic? Dr Pratima Murthy So one is, it's almost like a global panic. Because everybody everywhere is affected with it in one way or the other. So a lot of the psychological symptoms are about worry. And worry can be sometimes realistic, but sometimes worry can be overwhelming and out of proportion to the probability of actually contracting the infection. The reality is that 80-85% of people will have a flu like illness and get better. But then that reality is often countered by the very distressful things that you read about or watch on social media or television where you see people in great amounts of distress going on the ventilator and so on. The second thing is that we need to worry about things that we can control and really try and give up worrying about things that are not under control. When lockdown will lift is not under our control, so it's no point moping about that. But for some others, apart from worry they can become extremely anxious. So anxiety is characterised by what we call autonomic symptoms - the heart beating fast, feeling very sweaty, trembling, a sense of wanting to go to the loo very often. Psychological symptoms feeling that I'm going to get into, I'm going to be choking, I think I'm going to die. These kinds of symptoms are all classical of what we call panic attacks, which can be a part of anxiety. It's more likely to occur in people who are generally sensitive or had these problems before but in overwhelming situations somebody who's been well before can also experience anxiety and panic. Just a little bit of moodiness now and then or, you know, feeling bored and moody, it might be part of the lockdown experience but then if it persists for a very long time and for days continuously one is feeling low in mood, not sleeping very well, not having an appetite and not enjoying the things that they normally do, in terms of talking to others or watching their favourite serials, and then having feelings of helplessness and hopelessness, this is what we'd identify as depression. And sometimes when depression gets severe, you can have a lot of negative thoughts. Negative thoughts about oneself, about the future and so on. It's important to recognise this because number one, it's treatable. Number two, if it becomes very severe, the person can have a lot of negative feelings about themselves and get suicidal. And I think these warning signs need to be recognised by people, they need to reach out. And two kinds of help are available for people with depression depending upon the severity of the depression and the underlying circumstances. One is, of course, that if it's very severe they may need to go on antidepressant medication. If it is mild or moderate, they can be helped through psychotherapy. So in fact, my colleagues in psychology are also offering online psychological interventions. One of the other things is the stigma around COVID and the distress that it causes. For a lot of people, I mean, they just get COVID positive because they've contracted a viral infection like anybody else. If you took all the right kind of protection, and I think that's the bottom line, social distancing, protection by wearing masks, not allowing yourself to touch contaminated surfaces, if one is careful about all, the stigma can reduce. Sandip Roy I'm not trying to encourage smoking at all, but given what you were talking about all this anxiety and stress that this is inducing, does it make sense, for example, to deprive smokers of cigarettes for such a long period when they anyway stressed out? Dr Pratima Murthy Okay, that's a very interesting question and a lot of people ask this. You know, that when you're stressed out and have nothing else to do, smoking was what was relieving stress. But we also know how dangerous smoking can be particularly in the times of COVID. We know for example, that smokers, tobacco chewers are more likely to be touching their hands to their lips, to their mouth, and therefore more likely to spread infection to themselves. The second thing is that smokers, especially chronic smokers, are already likely to have some degree of impairment in their lung capacity. So I think it is a very good time for smokers to understand that they definitely need help to reduce their anxiety. They definitely need help to reduce the reasons for their smoking, and therefore they can get help now. The Government of India has a national health portal and there is a number that they can call which is 01122901701. They can actually get help to learn how to deal with their craving, how to manage their mood, while giving up tobacco at this time. There is also what is called the mobile session where you can actually speak to a counsellor in your own language anywhere you are in the country and get help to stay quit. And that number is one 800112536. I didn't mention spitting and its consequences. In fact, the government is planning to have a law against spitting because spitting is one of the easiest ways to actually spread droplet infection, and smoking and tobacco use is invariably associated with more spitting. So you'll see that there are a variety of reasons why smokers and tobacco users should consider this as a golden opportunity to learn how to deal with anxiety. Sandip Roy What kind of stories have you heard about addicts and the withdrawals that they might be experiencing right now because they're not able to get their fix in a way that they were used to? Dr Pratima Murthy Yeah, I start out with alcohol withdrawal, and I think for a lot of people, this has been one of the biggest problems. In the first two weeks of lockdown, we had several patients with severe alcohol use who came into us with a condition called delirium tremens, where they get confused, where they get disorientated, they can be highly hallucinating, they're also at risk to develop seizures. And therefore we provided treatment in our emergency to these patients. We got a huge number of calls from patients with alcohol dependence to help them to deal with their withdrawal. Similarly, there are patients who are dependent on opioids, who are on treatment with what is called opioid substitution therapy. The National AIDS control organisation has actually made sure that particularly in districts and in places where they have their counselling centre, that the medication, the OSD medications, are made available. But I completely acknowledge that these can be very difficult times for people with addictions, particularly during lockdown. And I think we need to spread awareness of how they can get help and where. Sandip Roy And you mentioned, people with pre-existing conditions like anxiety disorders and things like that. I interestingly heard therapists say that strangely ... that some people with anxiety attack problems are actually coping with the lockdown a little better than they expected because everybody around them is having an anxiety attack. Dr Pratima Murthy Ya, I know Sandeep, I think it works both ways. So as you said, I mean, you know, sometimes when you're anxious, when you have an anxiety problem, and everybody around you is calm, you feel very isolated. Now, with everybody experiencing various kinds of anxiety, you might understand this as a universalisation of the symptoms that you're experiencing. And that might give you some sense that you're not alone in this kind of situation. For example, if people have what is called social anxiety – anxiety that is much more when they go out in different situations, when there is a lot of pressure on them – perhaps the pressure may ease when they are at home. But it's generally true that for many people, especially if they were getting help earlier and that help is deprived, they may have an exacerbation of this anxiety. Our greatest concern at NIMHANS is for people with severe mental illnesses, what we call schizophrenia, bipolar mood disorder and so on; people with chronic schizophrenia, for example, we recommend socialisation. You know, for them to go out to mingle more, to get over what we call a-socialisation, their anhedonia. They need to go out more and interact more ... and now, lockdown. It prevents that kind of thing from happening. So families who have patients with severe mental illness need to find innovative ways of keeping them engaged. Maybe this is a good time for them to learn home chores – how to, you know, how to clean, how to cook, and learn how to use technology. Sandip Roy What kind of stories and calls that you get in relation to people facing issues with being around family all the time. I mean, this is a time where somebody who undergoes domestic abuse is trapped at home with the abuser. Dr Pratima Murthy I don't think It's appropriate to kind of generalise that, you know, this will happen in families or that will happen with families, and some families, these are opportunities to get connected, to stay connected, things that you couldn't do earlier. But if you have strained interpersonal relationships, these can be very difficult times. In fact, I think the National Commission for Women has actually registered a growing amount of domestic violence in families, you know, where there have been troubled relationships. So child abuse, domestic abuse – these are things that are increasingly being recognised in families where, you know, this kind of intimacy can actually be problems. And I think everybody needs to be aware that these are criminal acts, if domestic violence occurs, and that these are reportable acts. Sandip Roy Let me, we talked about children and we talked about elders. Let me talk a little bit about the working population, you know, this whole working from home and the challenges that it is bringing and the kind of questions you're getting on your helpline. I mean, at one level, there is the challenge of working from home, but there's also a performance anxiety that I see around me of trying to use this period to somehow be extra productive. For example, I'm a writer and you know, I keep constantly being asked, so are you writing a lot? Are you writing that next novel, and it actually induces more anxiety in me. Dr Pratima Murthy I think the initial phases, you know, you were able to relax a bit and thought you could be more productive. As you said, for writers for researchers, this is seen as a time where you can get your maximum number of papers or articles, etc. written. But then you know, the mind doesn't flow as easily as the pen or indeed the typewriter keys. So it requires a lot of adaptation, a lot of focusing of your mind. But the second thing is, of course, the pressures to deliver may actually increase when you're at home. Very often you're on back to back online meetings, there are deadlines. It's very difficult to really balance what is home-based activity and workplace activity when you're working from home. Sandip Roy I was reading a story in the newspaper about a man in Kolkata who had a jewellery shop. And now, because of this thing, the lockdown, the shop is shut. He has a lot of debt. So he is selling fruit on the street, and he says his family's quite ashamed about it, and the only silver lining of all of this is, he says he can wear a mask. And so people in his neighbourhood don't recognise him very easily. Dr Pratima Murthy There's no doubt that the economic fallout of these events are going to be enormous and people are very, very frightened, and realistically, so. Especially people with small businesses who've had to shut business for a whole month. You know, it can be extremely traumatic. So I think we need to get people to be proud of the fact, this gentleman for example, that he was innovative in actually being able to do something and be productive rather than waste this time and not have any income at all, and I wish his family would actually be proud of him. In fact, on the contrary, you also read news of somebody whose onion business was deteriorating. She posted a video on WhatsApp. And immediately, the district administration got in touch with her and made sure her onions were sold. And I think what we need to do, whether it's about COVID recovery, or employment, etc., we need to put out a lot of positive stories there. So that people feel encouraged to look at ways and means of coming out of this. Otherwise, I think, if the stress is overwhelming, and people lose hope, and you know, the anticipation of things turning around, that can be disastrous in terms of consequences. Because we know that when these stressful times occur, and when people are not supported, rates of suicide, for example, increase. Sandip Roy Do we, in fact, know whether suicide rates have increased during the lockdown? Dr Pratima Murthy You do read anecdotal reports of suicides, but I don't think one has still done a meaningful analysis of this. You do read again, not ... not only India, but you read, I mean, just yesterday, there was a physician who ... who died, who killed herself. So I think people are going through stress in unimaginable ways. And some of it, particularly the economic part of it, the lack of support, and that's why I want to emphasise that people should feel supported. Sandip Roy You mentioned that you are also working with migrants. We've all seen the images of the migrants trying to go home and the panic that the lockdown initially caused. What do you think is going to be the mental health impact of all that? Dr Pratima Murthy I think we've known several kinds of impacts from this. And I think the economic impact, you know, the distress associated with it, separation from families, the kind of condition that you're exposed to, the lack of support. These are things that determine the outcome from this, but I think if this is reasonably tided over and people are reasonably resilient, we should be able to come out of this. But I think the newer problems will arise, post the lockdown, where people, if they're out of jobs, particularly daily wage workers, particularly people who don't have stable sources of income, you know, to be able to make sure that their livelihoods are taken care of is going to be the biggest challenge. It's not just economic. It's also the emotional disconnect that you might have from your sources of support, that can be a source of huge distress. Sandip Roy And the fact that things like isolation and social distancing are such alien concepts to us, especially in a country like India, built as it is on social connections. What do you think can be the mental health impact of all of this, that now suddenly, the fact that many of us live in close proximity with grandparents can actually become an issue? Dr Pratima Murthy Absolutely right. I think, one of, especially for grandparents who live with grandchildren, and both connected to the grandchildren, the concept of physical distancing means, you know, reduction of proximity. And that can be pretty challenging. So ways of getting about it is really not to refer to it as social distancing, but to refer to it as physical distancing. I just saw a thing in Kerala where they're holding umbrellas to indicate the distance that they must keep between themselves. I mean, I think people should not, while people should not be overly anxious, people should not become very complacent that they are not at risk. I think it's very important for people to be careful, whether it's using masks, whether it's continuing to use hand hygiene. The other thing is overcrowding. And I think the biggest problem in our country, particularly in the low socioeconomic strata, is even when you look at houses, there are sometimes eight to ten people living there. When people are working, especially the migrant population, they're living in extremely crowded circumstances. And these can be hotspots where, you know, where the problem can increase, and it can be extremely difficult in such situations. Sandip Roy Do you think it would help in terms of what you were just talking about, for us to get into a mind-frame, especially after the lockdown is lifted, whenever it's lifted, of living with the virus around us rather than the messaging being all about defeating the virus and kicking it out of India. Dr Pratima Murthy Absolutely, I think anybody will tell you that in these flu like epidemics, there is a huge kind of wave of the flu, and then it kind of lingers on for years together. So I think we need to adjust to a life where we manage ourselves in a sensible manner but we go about our work. And one of the things, you know, one of my colleagues told me is as a civilization, we actually wash quite a bit. We wash our hands before lunch, we wash our hands before we accept anything from somebody, but I think that needs to translate into making sure we don't touch unfamiliar surfaces, that we don't spit in public. And I think if one lesson can occur from this pandemic, it is to make sure that as a civilization, as a society, we stop spitting. Sandip Roy The Prime Minister, you know, when he announced that lockdown, he called for Sainyam and Sankalp, restraint and resolve, but what followed was panic. Whether it was migrants trying to go home or the upper middle class rushing to supermarkets. As this sort of lockdown keeps getting extended, how will we cope with that psychologically? Dr Pratima Murthy And panic is not just migrants. Panic is not just about buying. There is panic everywhere. I can tell you, I work in a hospital, our doctors are constantly in a panic as well because they're worried about their health, about taking infection home to their families. So I think generally, I mean, I think the word PANdemic is a very appropriate thing because it also causes PANic. When you look at societies and groups of these collectives, you know, getting into a panic, I think the only way is to have good communication, is to offer them support, is to tell them exactly the rationale for various things that are being done, is to have a sense of preparedness. And when I say preparedness, for example, I think people should have been told when the lockdown occurred and let's say alcohol outlets were being closed, I think we should have communicated to people that they can take help from healthcare settings. I think that's a very important lesson for us in terms of preventing panic. Whether it's food supply, whether it's information giving, whether it's health related facilities being set up, I think we need to do all that to prevent this. Sandip Roy Yeah, well, one way I deal with anxiety around this is I try and avoid all COVID News, Whatsapp university or general news, after 8pm. After 8pm no more COVID. Dr Pratima Murthy I think if you have a small window, where do you know where to get information and get information from valid sources and then forget about the rest of it. I think that's very important. We have a world and a life outside of COVID. And we shouldn't forget that. Sandip Roy And the thing that you mentioned about the stigma of acquiring the infection. Do you think this is going to require a cultural response? Like, and I'm thinking about HIV AIDS, I mean the stigma associated with that, and how a lot of the work that was done to address that stigma was actually cultural. Dr Pratima Murthy Now, the difference between stigma related to HIV and this is that contracting HIV is from a particular behaviour. In conditions like HIV, the stigma is moralistic. Here the stigma arises directly from fear. And I think stigma around fear is something that can be very, very challenging to deal with. And as you said, as we learn to normalise this as part of our ongoing journey of living with flu, I think the stigma will also reduce. Sandip Roy And Dr Murthy, what do you think might be or what do you foresee as the long term mental health implications, if any, of this pandemic even after it dies down? Are there mental health issues that people may still face as a result of going through this period of lockdown and in lockdown extensions? Dr Pratima Murthy I'm an eternal optimist. I believe that most people are resilient, they will grumble, they will have some degree of anxiety now, but things will settle down and people will go back to normal. But having said that, there will be people who have undergone intense emotional trauma and we know that when you undergo intense emotional trauma, unless you're supported following the trauma, there can be what we call Post Traumatic Stress Disorder (PTSD) or worsening of anxiety and depression. In addition, there are families who have family members living in distant locations in different countries and I think there is a lot of stress around that. The other thing, of course, is we know that if emotional stress is chronic and not addressed, it can actually worsen our health outcomes. I remember you mentioned 'flight or fight' earlier, you know, even if there is no flight or flight response, if there is chronic psychological stress, it can indeed worsen the outcome or hypertension, diabetes, cancer, what we call the non-communicable diseases as well. So I think we would do very well to integrate our physical and mental health. Stay physically healthy but as well make ourselves a little more mentally resilient. But I would like to again end on an optimistic note that civilization has seen this before, we will all bounce back. Sandip Roy What's your anxiety coping mechanism? Dr Pratima Murthy I have no time (Laughs). So strangely enough everybody says that 'There's so much time, what do I do?' My constant refrain is I have no time to get bored, I have no time to be anxious. So I think keeping yourself busy is extremely important. And I think staying connected with people, using humour as a response, you know, learning to laugh over things that you cannot control, I find that very, very alleviating in terms of allowing me to relax. Staying connected with friends and family members, spending a little time in the evening, you know, cooking, baking something that I wouldn't normally do, watching the movie, which we all do as a family, I think these are hugely relieving things. Sandip Roy Dr Pratima Murthy, well thank you very much for taking the time to join us on the show today. Dr Pratima Murthy Thank you, Sandip. Sandip Roy Dr Pratima Murthy is the Head of the Psychiatric Department at the National Institute of Mental Health and Neurosciences. Their COVID helpline number is 08046110007. 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