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Unresolved Grief During Covid-19 Shows Mental Healthcare is an Ignored Sector

Unresolved grief tends to remain without any significant changes over time. Treatment involves encouraging patients to discuss their loss and guiding them through a normal grief reaction.(Representational Image: Shutterstock)

Unresolved grief tends to remain without any significant changes over time. Treatment involves encouraging patients to discuss their loss and guiding them through a normal grief reaction.(Representational Image: Shutterstock)

Without systemic or structural change, mental healthcare proves to be inadequate in reversing the detrimental effects of social disadvantage.

With the upcoming surge in Covid-19 cases due to the Omicron variant, research suggests that this variant is less severe than Delta, with the chances of being hospitalised being 40% lower than that of Delta. However, the impact of the second wave in India is imprinted on our minds. Resulting in 5.4 million deaths globally, and nearly 500,000 deaths in India alone, the pandemic made grief inescapable. Much of the world’s population is experiencing varying degrees of personal, economic, social, and political losses. While much of the focus has been on overcoming the virus, brewing under it was the staggering change in our experiences relating to loss.

The circumstances surrounding deaths during Covid-19 make it challenging to process loss in a meaningful way. From patients being unaccompanied in their last days to no possibility of family visiting hospitals to deprivation of funeral rites. Cumulatively, these act as factors to develop complicated grief resulting from a disrupted grief cycle.

Under general conditions, nearly 7% of those experiencing grief suffer from unresolved bereavement and other mental health-related problems, for reasons such as the inability to say goodbye, excessive guilt, and the lack of social support. This number is expected to rise after the pandemic hit, as indicated by research that evaluates relatives of patients who passed away in the ICU, which identified symptoms of complicated grief in 52% of them.

Complicated grief often results in depression, guilt, and anger with a possibility of turning into an adjustment or psychiatric disorder. Further, the phenomenon of survivor’s guilt, stemming from Covid-19 trauma has increased manifold in individuals suffering from Covid bereavement. This has led to holding negative cognitions and blaming themselves for the loss of loved ones.

Underlying anger and denial related to bereavement has been exacerbated by the state’s failure to prevent suffering and the death toll, especially in India.

The Importance of Saying Goodbye

Understanding the grief-stricken is fundamental in formulating systems meant to help them cope. Therefore, understanding the importance of post-death rituals as a fundamental component of cultural and religious mourning systems is imperative. They facilitate the offering of social and psychological support to the bereaved and afford an opportunity to convey love and respect for the deceased.

Rituals and ceremonies guide the grieving process, making the loss real and final, allowing the social support network to gather and facilitate family and friends to share feelings about the deceased. Pandemic-related protection measures have hampered such processes, leaving the bereaved vulnerable to develop chronic grief, further worsening their emotional isolation.

Protective measures due to fear of infection mean mourners lack expressions of physical comfort—they cannot touch the deceased and cannot hold social gatherings after the death of their loved one. Ultimately, they may not feel that they have bid farewell in a manner their loved ones would’ve wished for, often leading to added guilt in the bereaved.

Unresolved Grief

Combined with further social isolation-based global public policies, this culminates into unresolved or complicated grief in the bereaved. Clinically, this is characterised by the presence of

• Painful response to the recall of the deceased (crying spells or inability to cry, coupled with a subjective need to cry)
• Realisation of not having accepted the loss or of not being able to grieve
• Unaccountable depression, the emergence of medical symptoms on the anniversary of the loss, or both.
Unresolved grief tends to remain without any significant changes over time. Hence, pointing towards the need for active intervention when identified. It often goes misdiagnosed, leading to long and diffuse medical consultations.

Treatment involves encouraging patients to discuss their loss and guiding them through a normal grief reaction.

What to Expect?

The disruption of our usual living structure and social distancing have led to the loss of freedom and relationships. The manifestations of grief are unique in various sections of the population, becoming even more important to study in a socio-economically diverse country like India. Failure to identify and further address it could lead to under-detection, increasing psychological co-morbidity, and severely impairing one’s quality of life.

Information Overload

With lower fatality rates in newer variants, we can learn from the Delta wave on the changes to bring about in policies when accommodating to the Omicron variant. Frequent reporting of the death toll has served to desensitise the population regarding their attitude towards Covid-19-related deaths. With a digital toll on a screen, many individuals have failed to realise that every increment signifies an actual human life and is not simply a statistic quoted in the news.

On the other end of the spectrum, the frequently reported death numbers with reference to ‘age’ and ‘underlying conditions’, while intended to reassure the masses, portrays those deaths are unavoidable and to a certain extent even acceptable, making those in similar age brackets and/or living with underlying conditions feel even more vulnerable and dispensable.

Negative atmospheres of blame, fear, and suspicion have also emerged in the global geopolitical arena, resulting in isolationist policies and a lack of faith in healthcare systems across populations.

Shift in Mental Health Services and Subsequent Challenges

Cumulatively, these circumstances point towards the need for a shift in mental health services to better adapt to these conditions. Populations are experiencing collective grief, thereby, urging collective action.
Mental healthcare services have started to adapt and shift to teleconsultation, which also comes with its own challenges. The inability to capture the patient’s non-verbal cues, physical and affective distancing while dealing with sensitive issues such as death, present as a burden in the therapeutic relationship. Additionally, maintaining privacy and confidentiality while attending therapy from the confines of one’s home becomes difficult.
Novel circumstances have generated a need to deliver certain services online, hence, necessitating skill development and newer training programmes in the healthcare setup.

The Way Forward: Pathway for Policy Change

The pandemic has exposed the mental health burden that arises in societies where grief is stigmatised, social isolation and digital immersion are pervasive, and collective structures for healing and mutual support are withering.

Recognising the need of the hour, Ministry of Health and Family Welfare (MoHFW) with the objective to address the shortage of mental health professionals in the country has increased the budget for the establishment of Centres of Excellence in Mental Health to Rs 369.6 million per centre. The District Mental Health Programme (DMHP) has been given financial assistance as well, now extending to 692 districts in the country. Additionally, mental health services are being integrated into general healthcare services like National Health Mission, PMSSY, Rashtriya Kishor Swasthya Karyakram, AYUSHMAN Bharat, PMJAY, etc. Further, financial assistance has been provided to the three central institutions NIMHANS (Bengaluru), Lokopriya Gopinath Bordoloi Regional Institute of Mental Health (Assam), and Central Institute of Psychiatry (Ranchi).

To address growing mental health concerns, the National Task Force was initiated in India in March 2020 by the Minister of Health and Family Welfare for the provision of psychological helpline services to distressed individuals. Trends observed under the task force were that a majority of distress calls are associated with anxiety, low mood, lack of sleep, fear, apprehension, etc. and the underlying grief is revealed only post the establishment of rapport. This takes multiple telephonic counselling sessions, with which come the limitations of digital consultation and accessibility issues.

So, is this enough? The coverage and functioning of the DMHP remains non-uniform across the country plagued with underutilisation of funds by states, administrative bottlenecks at the center and lack of enthusiasm. Moreover, fragmentation of responsibilities and poor intra/inter-departmental coordination has led to poor implementation and performance.

A comprehensive response across multiple sectors must include public psycho-education, stigma reduction, increasing access to mental health resources, active case finding and a step towards expanding the mental health workforce. Research consistently shows that without systemic or structural change, mental healthcare proves to be inadequate in reversing the detrimental effects of social disadvantage.

The novel challenge of collective grief brought on by the pandemic must be dealt with by practising the utmost sensitivity and bringing on board leading mental health professionals to drive policy change.

The article was first published ORF

The author is a research intern at ORF. The views expressed in this article are those of the author and do not represent the stand of this publication.

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