Various Facets of Anxiety during the Pandemic in India - Critical Issues

Abstract

The COVID-19 pandemic has brought on a lot of challenges. Among these challenges, the most pressing causes for concern are mental health issues. Anxiety is one such mental health concern that statistics has shown as increasing since the beginning of the pandemic. Numerous causes have contributed to these rising levels of anxiety. Health related concerns, loss of income, are just some of the many reasons that individuals have attributed their anxiety to. The Indian population has especially seen a massive number of jobs that have been lost, and the first lockdown in April 2020 saw a major domestic migrant crisis. In addition, a number of groups, such as the elderly, women, and the youth have faced anxiety provoking situations of their own. While India is currently facing a second wave exactly a year later, the facets of anxiety to take into consideration are numerous. The chapter looks at various facets of anxiety that have been encountered during the pandemic from an Indian context.

1. Introduction

The COVID-19 pandemic with its widespread global impact on health, healthcare infrastructure and the psycho-social and economic disruption has never been seen in modern times. The virus causing it is a new one and hence not only do we not know the optimum management of it [1]. After a year of the pandemic, we are yet struggling to overcome it. It is rare in a pandemic where a vaccine has been synthesized and manufactured within a year and now with different more infectious variants spreading and the second, third, fourth and fifth waves in some countries (USA, Canada) we seem to be in the learning curve with this pandemic. Considering the proportion of the pandemic affecting almost all the countries in the world and some of them having high morbidity rates, the fear & anxiety is high [2]. There is a tremendous amount of information/misinformation that is so easily available in the social media. The psychological complications are increasing rapidly. A year into the pandemic and we are facing the second wave in India which seems to be worse than the first. Unlike the first wave we now seem to be facing fatigue not only in the general population but more so in the healthcare and frontline workers. There are various forms of anxiety that have been encountered during the pandemic and this chapter looks at these various forms of anxiety from an Indian perspective.

2. Factors that can impact and cause anxiety during the pandemic

A number of factors in the Indian context, with reference to COVID-19 can affect and lead to anxiety. Among economic factors, one of the biggest is the sudden loss of income due to unemployment during lockdowns. Single income households face a massive financial crunch, and not being able to afford daily food can be a very stressful experience. From daily wage laborers to business owners, the loss of money and income has posed a serious dilemma of risking their safety to go to work, versus having some form of income to run their households [3]. The following sections shall now look at the various forms of anxiety seen during the pandemic.

3. COVID related anxiety or Corona-anxiety

COVID related anxiety is a major form of anxiety. Especially during the early days of the pandemic, when India was under lockdown, individuals faced major anxiety at the thought of themselves or their families being infected. Popularly known as ‘coronaphobia’ this fear of the virus itself causes a lot of anxiety over the possibility of being hospitalized, or even dying [4]. A study done on this fear among the Indian population using a scale revealed that 54.8% of the population reported low fear, however female married healthcare workers with low educational status reported high levels of fear in this context [5]. Media information via news channels and social media have witnessed a lot of sensationalism and even fake news. This constant access to news updates about rising numbers, buildings being sealed and first-hand accounts of hospitals are a source of anxiety and stress. The advent of social media journalism has led to fake news that does not come from credible sources. A classic case of the boy who cried wolf, this can be a factor that can seriously cause anxiety [6].

4. Health anxiety related to procuring COVID-19

Health anxiety Denotes a continuum of behaviors and cognitions of an individual that can range from persistent worries about illness which may vary from mild to severe forms bordering on hypochondriasis. Risk factors which influence health anxiety include personality and mood characteristics. Consequently, the potential for adaptation is through resilience that is the ability to adapt and withstand emotional and physical distress. Anxiety symptoms and anxiety disorders are distinct entities and anxiety symptoms frequently correspond to an adaptive and physiological response to a stressor requiring little, if any specific treatment and management. Compulsory contact tracing and long periods of quarantine which are measures taken to control the epidemic increase people’s anxiety and the remorse regarding passing on the infection and its consequences along with the stigma attached. Health anxiety has led to everyone attributing routine cold and cough to COVID and getting themselves tested when there is no need [7, 8].

5. Work from home induced anxiety

Work from home is not a new concept but has been enforced on a large population with the exception of healthcare professionals and frontline workers. The enforced stay at home and work from home along with the presence of other family members which may include other working members, the elderly and school going children or infants and preschoolers. This may lead to overcrowding, interpersonal strained relationships, a severe crunch of resources especially if multiple members are working from home for laptops and smartphones used for office and school work. The reduction in pay, difficulty in working from home while looking after other family members, elderly and children may add to the stressors especially for women. The skills needed to work from home may not be good and entails new learning and training which can prove to be anxiety provoking [9].

6. Quarantine anxiety

One of the preventive measures for COVID-19 infection is quarantine for a period ranging from 14 days and more depending on the presence of symptoms and Covid test results. This becomes an extremely stressful period with different coping mechanisms employed individually. Being isolated and alone during an extremely vulnerable period of illness increases the chances of anxiety and depressive disorders, substance use disorders and PTSD. The loneliness and uncertainty regarding prognosis, financial burden and worries about the health of the near and dear ones leaves one emotionally and physically vulnerable. There have been instances where a member of the family is admitted in the hospital and the rest of the family is quarantined leaving no support system for the family. The problems are increased if there are young children in the family. Social media platforms can prove to be a solace as well as a nuisance depending on how much importance and belief is attached to it. Vicarious somatization may be seen in the general population due to the explosion of information available [10].

7. COVID recovery anxiety

Hospitalized patients who are stable show a high prevalence of symptoms like insomnia, generalized anxiety, depression and psychosis [11]. Patients who were in the ICU reported post COVID complications like reduced lung functioning and reduced exercise capacity. In the ICU, panic disorder and specific anxiety disorders like claustrophobia are seen. The loss of human touch in the ICU with healthcare professionals being in PPE kits leads to extreme loneliness and feelings of helplessness in an excruciatingly vulnerable state. Acute respiratory distress syndrome (ARDS) in ICU survivors of COVID-19 may occur with an expected survival rate of approximately 25% [12]. The survivors may have psychological and neurological sequelae due to the prolonged ICU stay. Stressors include immobility, separation from family and friends, pronounced sedation, anxiety about health and survival and financial concerns. About 30% of them may suffer from PTSD and panic disorders and other mental health problems. Aggravation of panic attacks is high in survivors of COVID-19 due to prominent respiratory symptoms and panic attacks which may be triggered by fear conditioning to difficulty in breathing. The prolonged time taken to recover from post-covid complications adds to the anxiety along with the fear of reinfection [13].

8. Obsessive compulsive disorder and COVID

Sanitizing and disinfecting protocols brought on by COVID-19 particularly can cause individuals suffering from OCD a lot of anxiety and overwhelming thoughts, leading them to indulge in compulsive behaviors. The fear of contaminated surfaces and repeated handwashing is one of the main challenges these individuals have to face. A study done revealed that 72% of their participants reported an increase in their symptoms, and were negatively impacted by the pandemic. In the Indian context, OCD can manifest itself in the form of hoarding groceries and resources by panic buying in fear of lockdowns [14]. Items like masks, sanitizers, and disinfectants could be bought in bulk as a way to keep themselves safe. Hand hygiene is one of the main protocols given by the World Health Organization [15]. Compulsive, repeated hand washing and sanitizing can manifest itself as one of the most serious symptoms of OCD with regards to coronavirus. A report in the Times of India has mentioned that OCD patients are visiting hospitals due to dermatological issues during the COVID-19 pandemic in India [16]. Studies have mentioned aspects of OCD such as increased hand washing, involving family in disinfecting procedures, and the fear of having outsiders in the house as ritualistic behaviors that OCD patients indulge in [17].

9. Generalized anxiety disorder, panic and pre-existing anxiety

From quarantine, to the impact of media and statistics, there are a number of factors that can impact those who have been diagnosed with generalized anxiety disorder, panic attacks and phobias such as germophobia. For example, an individual with general anxiety who tests COVID-10 positive and has to be quarantined in a room away from others can have very severe complications in addition to the physical diagnosis of COVID [18]. With jobs lost during the pandemic, financial insecurity can also be a massive anxiety provoking factor, especially among those who rely on daily wages for mere survival. The diagnosis of COVID, along with job insecurities has led to an increase in the reporting of panic attacks in India [19]. A report revealed that anxiety, depression and stress were some of the mental health concerns in the context of the pandemic. Older adults, children, frontline workers and individuals with mental health conditions were among the most vulnerable. Watching the news for updates, and increased screen time can also provoke anxious feelings. In this day and age of Whatsapp forwards and fake news, such messages can cause unnecessary panic and anxiety [20]. COVID-19 related fear can also induce panic attacks. The thoughts of a loved one getting the virus, loss of life, and the fear of contracting the virus are all anxious thoughts that can have disastrous impacts. Another study done revealed that among their sample of 2004 participants, the prevalence of anxiety was 2.29%, obsession 13.47% and fear 46.9%. This fear involves complications arising due to social distancing measures, and general COVID related fear [21]. The uncertainty and lack of information about this new virus contributes to this fear. Mysopobia, or the fear of contamination is a very relevant phobia in this context. The fear of contaminated surfaces, groceries or delivery parcels can lead to the development of this phobia [22].

10. Anxiety in patients with pre-existing psychiatric disorders

Patients with mental health disorders are more vulnerable to stress related events and find it difficult to cope with their original disorder along with the negative life events. Mental health disorders are a risk factor for developing symptoms like insomnia and anxiety during the pandemic. They also have a higher mortality rate. It is also a fact that mental health disorders are often neglected during a disaster and this makes them more vulnerable compounded by the inability to access healthcare during lock downs. This causes nonadherence to medication causing a relapse or deterioration of the already existing illness [23]. Patients with mental health disorders are more likely to utilize maladaptive coping strategies when faced with stress. Patients with affective and anxiety disorders are more concerned about external environment than patients with schizophrenia. Hence the increase in anxiety and insomnia in anxious or depressed patients is more likely due to COVID-19 related issues and availability of drugs while in patients with schizophrenia it is more likely due to irregular intake or stopping of medication [24]. Nil to mild levels of anxiety, depression and insomnia in a patient with mental health disorder is associated with an increased risk for worsening anxiety, depression and insomnia. This is due to the ceiling effect i.e. the higher the initial degree of psychopathology the less the deterioration is seen. Poor sleep hygiene due to disruption in the daily routine may exacerbate insomnia [25].

11. Anxiety in frontline health workers and their families

A number of studies around the world have addressed mental health concerns of doctors, nurses, and other frontline workers in the context of the pandemic. Unbelievably long hours, making life or death decisions, and the trauma of working through a pandemic comes with immense challenges of its own. The lack of PPE kits, masks, the fear of contracting the virus are all extremely anxiety provoking and cause a lot of psychological trauma. One of the main causes of anxiety could possibly be contracting the virus, and infecting others like colleagues and family members. In addition, the lack of beds, oxygen, and ventilators can lead them to make decisions as to which patient has access to what resource [26]. These decisions are quite literally, “life or death” decisions, and can cause intense anxiety. A survey done on the prevalence of anxiety and depressive symptoms among healthcare workers in India [27] revealed that 37% of their participants reported symptoms of anxiety. Among healthcare workers, the risk factor included female nurses in the age bracket of 20 to 35. However, those participants who had been in the profession for twenty years or more seemed to report less symptoms of anxiety. A study done by the Center of Healing in Delhi revealed that mental health professionals are seeing an increase in their work hours. Burnout and compassion fatigue in this context are just some of the facets of anxiety that healthcare workers can face. Government employees in India have had to report to duty and put themselves as well as their families at risk. Traveling in public transport and being at physical office space all increase the chances of contracting the virus. This has been a major cause of anxiety for government employees [28].

12. Psychosocial factors leading to anxiety

Humans are social animals, and need some form of interaction for basic survival. With homestay restrictions for safety purposes, we must consider its impact on mental health. Social isolation also leads to increased screen time, and an overload of media information. This media overload can cause a lot of anxiety. Seeing daily numbers rise, and staying at home in the midst of a full blown second wave can be very anxiety provoking. For Indians, the first lockdown saw large numbers of migrants struggling financially due to a sudden job loss. Trains across the country saw uncontrollable crowds of migrants going back to their hometowns, without any social distancing measures. Further, they had lost their jobs overnight, so their anxiety was twofold- financial insecurity and the chances of contracting the virus while traveling back to their hometowns [29]. A number of students, especially Indian students living abroad, have dealt with the anxiety of the sudden closure of universities, having to pack up all their belongings, and take international flights overnight back to India. The anxiety of testing positive after returning to India, along with the fear of being sent to a quarantine center can be a stressful experience [30].

Screen fatigue, being awake at odd hours of the night due to time zones have a disastrous impact on their mental health, and cause anxiety due to not being able to give exams in the correct frame of mind. An interesting study revealed that all around the world, the negative sentiments individuals expressed on social media platform Twitter were anxiety related, due to the loss of jobs, and social isolation [31]. Another study done revealed that out of their sample size of 403 participants, students and healthcare professionals were most adversely impacted by anxiety in this context. Families who did not have sufficient resources during the lockdown, and family affluence were negatively correlated with anxiety. It is interesting to note however, that mental health professionals reported anxiety within the normal range [32].

The fear and anxiety of losing a loved one due to COVID is a facet to take into consideration, because of the sudden trauma faced. Social distancing, quarantine and lockdowns have kept individuals away from their families, and children living away from their aged parents often face the anxiety of them possibly never seeing them again. For the elderly living away from home, there is the fear of dying alone, without any support. The current procedures in India do not allow the family to see the individual in hospital, and the cremation procedures are done by local government bodies. The thought of not cremating the loved one who died due to COVID-19 is traumatic, and this trauma can cause a lot of anxious thoughts and reactions. The fear of a family member not having access to life saving resources is an uncontrollable situation and this uncertainty for the family causes a lot of anxiety [33].

While India sees the concept of multi-generational families and joint families living together under one roof, this could be both, a bane and a boon. Living together reduces the social isolation faced, however if by chance even one family member gets infected, the anxiety lies in the fact that a ten members household, with members of all age groups could potentially catch the virus. There have been multiple reported cases of false positive COVID cases. Having a positive result in the first place is a stressful experience, and quarantine procedures have to be strictly followed. The added uncertainty of then knowing that the result was false can cause anxiety due to the doubt of credibility. Quarantine procedures in India for a covid case have known to last for 21 days, and in these 21 days, the patient has no contact with others. Being alone in one room, along with physical symptoms can be a lonely experience that raises mental health concerns [34].

13. COVID-19 and anxiety in the elderly

There are a number of elderly individuals who live in cities away from their children. COVID-19 poses a number of risk factors for anxiety for this age group as well. COVID-19 has caused the highest number of deaths among senior citizens due to a number of age-related factors and associated comorbidities. The anxiety of contracting the virus is twofold, because of the fear of dying due to COVID-19, without having anyone to be there for them. The media has revealed grim statistics of ventilators not being available to elderly patients suffering from COVID-19. Further, hearing about relatives and friends succumbing to the virus can cause a lot of anxiety. Grieving for a spouse, sibling, or a friend who died due to covid once again, can cause long term mental health effects [35]. Another facet of anxiety faced by the elderly population is access to daily necessities and resources. Many of the senior citizens living alone have to visit banks and grocery stores for their day-to-day living. During the lockdown and for safety reasons, the elderly could not venture out of their homes for such basic necessities. This poses a serious risk factor for anxiety, as they are unsure about who will purchase the staple ingredients for them. The advent of technology and the smartphone age has always been a fear that the elderly have faced. However, with COVID, this fear can manifest itself as a form of anxiety. During lockdowns, the best way to stay in touch with family is via phone calls and video calls. Without a Wi-fi connection or the ability to understand how technology works, the elderly is thus virtually as well as physically isolated. This isolation brings with it challenges of its own, one of the biggest being anxiety. Without a wireless connection, virtual consultations with doctors and psychiatrists are impossible, making them unable to have access to their daily medications [36]. In some cases, mental health concerns in India among the elderly have led to suicides. A report done on elderly suicides in India has revealed reasons such as the fear of being in isolation wards, and COVID associated fears for ending lives [37].

There are various concerns like isolation, dependency on others for their basic needs, living alone and in nursing homes, social isolation and quarantine increases the risk of anxiety and depression in the elderly. The elderly also has a relatively weak immune system. From its initial stages the pandemic has been portrayed as a problem of older ages thus resulting in increased ageism around the world. This leads to increased stigmatization in this marginalized population increasing their feelings of loneliness and anxiety. They suffer from issues like fear of contracting the infection for self and family members, fear of quarantine or hospitalization, death of oneself and family members, fear of being abandoned, loneliness, anxiety related with daily provisions, illness and their medications & lack of physical exercise [38]. Death anxiety is a feeling of panic, fear or great worry caused by thinking of death, being detached from the world or what would happen after life. Elderly with pre-existing mental illness is at a risk of relapse or exacerbation of symptoms due to the stressors and also due to nonavailability of routine clinical follow-ups and hence nonadherence to treatment [39].

14. COVID-19 and anxiety in women

Two factors might be taken into consideration while discussing anxiety among women in India. These two factors are pregnancy, and domestic violence. Within just a few weeks of lockdown being announced in India in April 2020, the National Commission of Women saw a 100% rise in reported cases of domestic violence [40]. Being at home has led to women being locked inside with their abusers, without any escape. The anxiety caused due to the trauma and pain inflicted can have disastrous impacts on their mental health. There is no way they can have a support system, or register a formal complaint with the police during this time. COVID-19 can also be a particularly anxious time for pregnant women in India. The possibility of being infected at the time of labor, without any support due to hospital measures can be an anxious time, especially in small towns and villages that have limited medical facilities [41].

15. COVID-19 and pregnancy related anxiety

Pregnancy is one of the most important events in women’s life. It is associated with many physiological, psychological and social changes. They are prone to psychological problems like fatigue, emotional disorders, mood disorders and anxiety disorders. They also have the extra burden and challenges of caring for the other children and family members. Pregnancy related anxiety (PRA) is a common problem during pregnancy. PRA is related to fears and concerns regarding the pregnancy, delivery, neonatal health and childrearing. This can negatively affect women’s physical and mental health and their children’s overall physical, emotional, behavioral and cognitive development. A major source of PRA is infectious diseases especially during epidemic and pandemics. Epidemics are known to cause negative clinical outcomes in pregnant woman such as death, spontaneous abortion, premature birth and fetal death [42]. The COVID-19 pandemic has reduced pregnant women’s access to routine prenatal care services due to rapid spread of disease, lack of effective treatment, necessity of quarantining and its subsequent loneliness during affliction, stigmatization and despair. The anxiety is more in women with comorbid disorders like diabetes mellitus hypertension and renal disorders. The prevalence of anxiety in them varies from 15 to 23%. During the pandemic, 50–71% were worried about their health status. They are concerned about their own health & that of their unborn child, access to healthcare facilities, lack of family & social support & quarantine in case they get infected. Due to lockdown there’s poor access for prenatal examinations & many women faced difficulty going to hospitals. The women in 2nd & especially the 3rd trimester showed more signs of anxiety [43].

16. COVID-19 and children, adolescents, and youth

When speaking of young children, their childhoods are supposed to be spent outdoors, at school, with friends. However, the advent of the pandemic has made children of all age groups stay at home, with increased hours of screen time. While the government and education ministries have released guidelines to control screen time, online classes bring with them mental health concerns. Among older children and college going students, having access to an electronic device can cause a lot of anxiety. There is a major digital divide between various regions of India, and a recent article has revealed that in the state of Maharashtra, only half the students have access to forms of online learning [44]. The inability to attend online classes due to a lack of electricity, or internet connection poses a serious problem to students, as their classes and even exams get hindered. The youth have also developed a more ‘relaxed’ attitude towards covid 19 as they do not believe that it is dangerous within their age group. As a result, they have violated social distancing norms. The youth can actually have a reverse effect- by feeling anxious due to not meeting friends and peers for long periods of time. This, popularly known by the youth is called FOMO, or the fear of missing out [45].

Children and adolescents when infected with COVID-19 have milder symptoms, fewer hospital admissions and a low fatality rate. However, there is a small percentage of children manifesting a hyper inflammatory state similar to Kawasaki disease due to the pandemic. Children and youth have suddenly lost many of the routine activities like school, extracurricular activities, physical activity and social interactions. This has led to a drastic modification of children’s routines. Learning and all other activities have moved into the home. Physical activity is reduced, parents and children are spending more time together at home which maybe good or maybe a cause for concern depending on the parenting skills, family environment and psychopathology present in parents [46].

Not all homes are safe and children may become more vulnerable to abuse. The screen time has increased and there is a lack of supervision over internet access which can increase vulnerability to accessing sexually inappropriate content and online offenders. There may be increased frustration, agitation, aggression and worsening of school performance. There may be more mental health issues in children from lower socio-economic conditions due to unavailability of appropriate access to internet and smart phones, iPads or computers. Children who had a family member or a friend infected with COVID-19 had higher levels of anxiety and depression. Anxiety symptoms were more in females and in children studying in higher grades. However, for some children especially those suffering from social anxiety disorder remaining at home and online schooling may temporarily relieve their anxiety, however may result in overwhelming anxiety when they have to return back to school [47].

17. COVID vaccine related anxiety

Anxiety about COVID 19 vaccine-most vaccines are developed over a few years. However, with COVID-19 first being reported just a year ago many people are concerned about if a vaccine developed in such a short time frame can truly be safe. Without years of trials, it is difficult to predict long-term side-effects. Most people including healthcare workers have been living and working with a high degree of uncertainty for a long time now. The state of the pandemic changes daily and recommendations from government officials fluctuate as well and hence the anxiety regarding vaccines is understandable. The choice & availability between 2 vaccines coupled with inadequate data leads to a lot of ambiguity & confusion regarding the safety and efficacy of the vaccines. There may be a feeling that they are being used as a Guinea pigs rather than being protected. The side effects of the vaccine like fever, body ache is misinterpreted as signs of COVID-19 infection increasing anxiety and panic. The staggered manner in which vaccines are administered depending on the priority and availability of the vaccine makes the pro vaccine lobby anxious. There’s also the downside of people becoming relaxed regarding the precautions to be taken, after getting the vaccine may lead to an increase in the number of cases rising [48].

The COVID-19 vaccines have caused a lot of stir, and the initial lack of information has led to speculation, causing anxiety and fear. Information in the news about vaccine related complications has also led people to rethink their choices about which vaccine to take. Recent news about life threatening side effects can cause a lot of anxiety, especially if the individual has taken the particular vaccine in question. A number of individuals have reported hesitancy and concerns over long term effects of the vaccine. In India, the recent shortage of vaccines can be a potential facet of anxiety, given the full blown second wave that the country is facing [49].

Trypanophobia, or needle phobia, is another possible facet of anxiety to consider with respect to taking the vaccine, or any medical form of treatment for COVID. There is a chance that the patient is so afraid of needles, that they avoid taking the shot in the first instance. Further, the side effects that individuals face after taking the shot can cause a lot of anxiety to their family members too. Another factor to take into consideration is testing positive for COVID after taking the vaccine for the same. This is important to note, since many in India have begun to resume life in the social sense after taking their first dose of the vaccine. While the diagnosis is a milder form of covid, the fact that the patient has to go through the quarantine procedure can be a stressful experience that is anxiety provoking [50].

18. Financial and economic factor related anxiety

Months of lockdown for a developing country’s economy has had disastrous impacts on the stock market, businesses, factories and daily wage laborers. The pandemic has put many migrant and blue-collar workers under tremendous pressure. We have already seen that over the last year, most of India’s factories had to close temporarily and the only people who were affected were those who were usually doing manual labor. This is since most white-collar jobs can and are done from home without much hassle. These blue-collar workers are the primary people experiencing stress which might cause them to suffer from long term anxiety in the future. There are many reasons for this increase in stress. The first reason is the volatility of the current economic situation. India has struggled to curb the spread of coronavirus and with a lockdown being the only measure when cases get too high, this means that workers are at the mercy of the lockdown policies. Workers who earn a daily wage are at the most risk of job loss and are also the most vulnerable to new restrictions in movement and trade by the government. This uncertainty of not knowing how they will pay for their next meal can cause massive anxiety that can manifest itself as multiple physical symptoms as well. The second reason why these workers have increased stress is that they are worried about infecting their loved ones at home. In India, it is very common when compared to the Western world to live with your extended family. This means that the bread earners, not only have to take care of themselves, but also have to be extra cautious and lessen family interaction since they could spread the virus to their elderly parents and also their children [51, 52].

19. Second wave COVID anxiety

India is currently facing a full blown second wave, that is far worse than the first wave. Despite vaccination drives going smoothly, a number of factors have contributed to the second wave. In the state of Maharashtra particularly, there has been the highest spike of cases, accompanied by a shortage of vaccines, oxygen, and hospital beds. With new lockdown like restrictions, the situation arising out of the second wave is one that is likely to cause a lot of anxiety for all groups. Businesses and day to day economic activities are once again going through uncertainty, students are facing anxiety over announcement of exams and admission procedures, and a large number of individuals are going back to their hometowns and villages. Traders in Maharashtra conducted protests against a potential lockdown, fearing that their daily activities would be totally stopped in the event that a lockdown would be reimposed. It’s highly possible that the same situation that India faced exactly a year ago is back, with even worse implications. It is at this time that mental health needs need to be taken care of. The situation poses a grim threat that is far worse than the second wave. The absence of crowd control measures, incorrect wearing of masks, and COVID-19 numbers rising every day are some of the facets of anxiety that have sprung up once again in the second wave. Learning from the lockdown experience a year ago, it is important that the mental health of citizens be taken care of [53].

20. Conclusions

There have thus been many factors that leads to anxiety during the COVID scenario that has been seen in the Indian scenario. The pandemic has caused new anxieties, revoked healed anxieties and exacerbated existent anxieties. The chapter has looked at all these anxieties and there may be new anxieties that may stem as the pandemic progresses and even probably after the end of the pandemic. Mental health policy makers need to work on pandemic preparedness and prepare people for handling anxiety at all fronts.