For the past one week, 32-year-old Shraddha Kejriwal who runs a merchandising business in Pune has been waking up with nightmares. "I am unable to deal with this idea of an uncertain future," she said. Shraddha battles with anxiety and obsessive-compulsive disorder. She is immunocompromised too.
The spread of the deadly novel coronavirus that has now forced large parts of the country to go under lockdown, she said, has taken a big toll on her mental health.
Maharashtra, where Shraddha lives, has reported the highest number of COVID-19 cases in India including two deaths. To control the spread of the highly contagious disease which has affected over 3.4 lakh people worldwide, the Maharashtra government has imposed a curfew till March 31 during which only essential services will be allowed to function. Section 144 of CrPC, which prohibits the gathering of five or more people at public places, has been enforced .
"The Indian business was already in a tough time and now with this pandemic, I'm not just scared about my health, I am scared about the future," Shraddha said. Last week, when Pune started to shut down educational institutes and offices, she said, "It felt like the world is collapsing." Soon, she had to close the store as customers stopped visiting. The online business has also suffered after orders have dwindled. "We have to pay salaries, rent, and there are so many other expenses – but with no income and the uncertainty of how long all this is going to last, I have lost all sleep," Shraddha said.
While the outbreak has led to philosophical questions about survival, humanity and the future, the changes and the chaos that it is bringing in the lives of Indians are hard to cope with. It's slightly more difficult than washing hands.
Over 90 million Indians, or 7.5 per cent of the country’s population of 1.3 billion, suffer from some form of mental disorder, according to the World Health Organization (WHO). Most of them do not get any help. The findings of a countrywide 2015-2016 study by India’s National Institute of Mental Health & Neurosciences (NIMHANS) – an autonomous institution under the Ministry of Health and Family Welfare – revealed that nearly 150 million Indians needed active intervention while fewer than 30 million were getting it.
The outbreak has led scientists, doctors, public health officials and the governments across the world scrambling for a cure but the question that is often ignored is already staring at us: how will India cope with the mental health crisis?
Everyone is Anxious: Sleepless Nights, Worries
On March 19, a 23-year-old suspected of being infected with the novel coronavirus died after he jumped off the seventh floor of Delhi’s Safdarjung Hospital. The family complained that the doctors did not counsel the man who had just returned from Sydney with his mother. The Health Ministry issued a statement that read, "Patient reached around 9 pm and was taken to the seventh floor for admission and evaluation. When doctors reached the room, he wasn’t inside. At the same time, another doctor observed a body around 9.15 pm.”
Ruchita Chandrashekar, a trauma therapist, said that the coronavirus lockdown can amplify symptoms of depression and anxiety. "It also increases risk factors," she said. "People who have to remain quarantined in toxic home environments might be experiencing trauma triggers as well." Chandrashekar, who focuses on the LGBT community, said that the existing cases have been displaying signs of relapse for depression and experiencing heightened symptoms of anxiety.
"All of last week and even now, clients in therapy have reported experiencing panic attacks, exhaustion, anxiety-induced headaches, difficulty in sleeping and overall a heightened sense of anxiety in the light of COVID-19," said Sonali Gupta, a Mumbai-based therapist and a consulting psychologist who has a book coming out, titled, 'ANXIETY: Overcoming it to live without fear'.
For Shraddha, it's the uncertainty that has left her anxious. However, with the outbreak of the pandemic and imposed lockdown measures, the worries are many: "Am I washing my hands enough? Will I pass the virus to my grandparents? Should I move back with my parents? How safe is my job? How will I pay next month's rent? How can I live alone, with my own thoughts?"
A 30-year-old retail banker in Ahmedabad, Tapasree, squeezes a drop of sanitiser on her palm after every customer's turn at the counter. She gets up to wash her hands multiple times. "I am almost obsessing over this handwashing," she said, explaining the reason behind it. "I work in a retail bank and that means meeting 200 customers daily, on an average."
When she goes home, she video-calls her husband, who is in Mumbai, 500 kilometres away. Tapasree couldn't go back to Mumbai because her "transfer is on halt" and quitting isn't an option. She has been anxious. Her mother, who lives in Kolkata, had to cancel her ticket to Ahmedabad as India continued reporting more and more coronavirus cases. Her husband was supposed to meet her over the weekend, but they didn't want to risk it. "I am scared and anxious," she said.
Every fifth Indian suffers from an anxiety disorder.
A study published in The Lancet Psychiatry showed that the contribution of mental disorders to the total disease burden has doubled between 1990 and 2017. Depression and anxiety disorders, the most common mental disorders in India, the study revealed, are prevalent across the country. But it is relatively higher in the southern states and in women. Depression is the highest in older adults, which has significant implications for the ageing population of India.
The WHO had earlier predicted that by 2020, roughly 20 per cent of the Indian population will suffer from mental illnesses. That means, today, more than 200 million Indians may have mental illnesses. The caregivers for India's mental health crisis include 9,000 psychiatrists. That is one doctor for every 100,000 people. Assuming, as studies show, that the desired number of psychiatrists is three for every 100,000 people, India has a shortage of 18,000 mental health doctors. The WHO prediction, however, was before the outbreak of the novel coronavirus.
Self Isolation: How Even?
Ritesh Singh, 30, a software engineer based out of Pune, has moved back to his parent's house for a sense of calm. However, Aditi Sharma, 26, copy editor at a publishing house in Mumbai, is unable to go back home to Lucknow because travelling is "extremely risky". She has been working from home, out of her rented apartment, alone. It seemed relaxing to Aditi initially but not anymore.
In any case, no domestic commercial airlines shall fly with effect from the midnight of March 24 for a week. The Indian Railways has cancelled all its passenger trains as well. This would, however, mean longer periods of social isolation for people living alone, in most cases, away from home and family.
Aakriti Joanna, who runs an online counselling platform 'Kaha Mind', said that the work-from-home situation under a lockdown will mean creating new rules and routines. "A lot of the information on the pandemic that we've been receiving from social media and news outlets has been negative and this can also cause one's mental health to really spiral," she said. Aakriti said that more people are now reaching out to her through her online platform to figure out ways and methods to cope during this time.
Trauma therapist Ruchita said this long period of self-isolation is affecting people who already have existing mental health concerns. "Mild and managed symptoms are transitioning to moderate and severe," she said. Her therapy sessions are now more dedicated towards safety planning and symptom management. The ones who used to book one session every week, now book two.
Ruchita said being cooped up inside homes, many are resorting to the available coping skills. Some of which aren't the healthiest. She listed them: "Resorting to older patterns of eating habits where they sought comfort in foods rich in sugar and salt because access to other coping strategies involves outside home activities, and sleeping more than usual. They are overwhelmed by the news updates and worried about their loved ones, especially the ones who live far away."
While Ruchita's therapy is exclusively online, 'Kaha Mind' that offered therapy sessions both online, as well as offline, has moved all sessions to videos and call, considering the safety of therapy-seekers.
However, Sonali pointed out, that for many who live with families, videos or calls aren't easy. "They feel they don't have the privacy," she said.
Bengaluru-based Lakshmi Sharath suffers from anxiety and has been in therapy for the past year. The travel blogger who recently discovered that she has endometriosis was just learning to overcome the pain and get on with life. "The last few months have been difficult. The current crisis has made it worse," she said. Three weeks ago, she moved to Chennai to take care of her mother. She did a session with her therapist in Bengaluru over Skype. A few days ago, she had a mild attack. Still cooped up inside her mother's home, Lakshmi is struggling to find a slot in her therapist's very busy schedule.
With schools and colleges closed, some of Ruchita's younger patients who have not informed their family that they are seeking clinical services, often get interrupted by parents during their session. "A parent will step into their room and ask who they are talking to, and they have to lie and say it's a friend. Then the parent will ask the name of the friend and the patient has to come up with an excuse or keep requesting the parent to not disturb them for a while," she narrated. She said that while this causes some disruptions during the session, it is completely "understandable and unavoidable".
"Accept that this is unusual, and we're all in this together. You are not alone," Aakriti said, listing out coping mechanisms for people dealing with anxiety. "Reach out. If you want to speak to a therapist online, then do that. If you want to schedule regular calls with friends, do that. Despite the social distancing that's essential, do not isolate yourself emotionally," she said. "Give journaling a try, cook, paint." But most importantly, she said, "take care of yourself". "Eat well, hydrate, and practise some breathing exercise. Check in with one another. That friend who lives by themselves, an elderly couple, your family," she added.
In a Twitter thread, Ruchita has listed out warning signs for anxiety and how to deal with it.
Sonali emphasised on maintaining a schedule for those working from home. "Have fixed meal times, take a bath in the first half, choose to work office hours," she said.
The Cost of Mental Health
A 26-year-old journalist in Delhi said that the last couple of months got so difficult for his mental health that he had to take leave from work. "First, it was the Delhi riots. And now this," he said. Last week, his organisation asked him to quit.
Aakriti said people who are at the forefront of understanding, managing and reporting the global health crisis that has led to 15,000 deaths across the world are more vulnerable to mental health issues. She also pointed out that entrepreneurs – small and big – are likely to be affected too. "A lot of industries are facing a complete drop in demand. Business owners and employees are worried about how this will affect their markets and jobs," she said. The therapist added that it might look bleak "but we've got to be there for one another". "It's important to be empathetic now more than ever," she said.
But India has not shown much enthusiasm for bearing the cost of mental health. Not before, and perhaps not when there's a major looming health crisis to battle with already.
In the financial year 2019, the budget allocated to the National Mental Health Programme (NMHP) was brought down to Rs 40 crore from Rs 50 crore in the previous financial year. This is 0.06 per cent of the country's health budget of Rs 62,398 crore. The funds actually spent were much lower – only about Rs 5 crore each during the years. The previous budget did not increase the allocation of mental healthcare.
While MHCA (Mental Healthcare Act) guarantees every affected person access to mental healthcare, and treatment from services run or funded by the government has been hailed as a major step towards destigmatising mental health disorders, the resources for it aren't available. According to a study by the Indian Journal of Psychiatry, the conservative annual estimated cost on the government to implement the Mental Healthcare Act, 2017 would be Rs 94,073 crore. However, the actual current spending is not even a fraction of the figure.
A medical journal in January reckoned that India had 2.3 ICU beds per 100,000 people. Amid a growing health crisis, the numbers paint a gloomy future. With the public healthcare system in a shambles, many are looking at the government measures with suspicion, in turn, creating complications for health authorities. The biggest of the trouble is fleeing from quarantine facilities. In all of this, mental health takes a side note but sits there quietly, and sometimes not so quietly.
"It's the feeling of helplessness. The situation is so out of control," said Shraddha. The disinfectants and the sanitisers may keep the infection at bay, but it's not doing anything to change the feeling of uncertainty.