Perspective Chapter: Psychosocial Impact of COVID-19 – A Global Scenario

Abstract

COVID-19 outbreak reminds us of nationwide lockdowns, home-confinement, overburdened hospitals, country wide curfews, violent and chaotic health-facilities and domestic scenario and gradual but steady rise of stigmatizing factors like fear of isolation, racism, discrimination and marginalization cumulatively intensifying the unavoidable stress, fear, anxiety, depression, poor life quality, substance abuse resulting in enhanced mortality risk particularly among the health-compromised population. With objectives to analyze the psychosocial impact of COVID19 and to delineate the process of impact, by looking into its pathophysiology a literature review was carried on. Various impacts and adaptations were found. With a proper mapping algorithm, their responses can be understood. Different states of individual showed different responses to the same stress creating a gamut of responses which led to different socio-economic, socio-political, professional and psychosocial impact. Identification of stress, mapping of response and a better preparedness from experience can all help us in preventing and controlling it next time.

1. Introduction

COVID-19 outbreak reminds us of nationwide lockdowns, home-confinement, overburdened hospitals, country wide curfews, violent and chaotic health-facilities and domestic scenario and gradual but steady rise of stigmatizing factors like fear of isolation, racism, discrimination and marginalization cumulatively intensifying the unavoidable stress, fear, anxiety, depression, poor life quality, substance abuse resulting in enhanced mortality risk particularly among the health-compromised population [1, 2, 3] . Survival through this turmoil highlighted the elemental role of mental health organizations, individual healthcare and research, social media, awareness programs at both personal and community levels in significantly combating the world’s psychosocial distress [4, 5, 6]. Although, COVID-19 bears the brunt of rising mental illness, a clear understanding of world’s disease response would certainly aid in improving our medical emergencies and coping skills around the world.

Psychosocial impact of COVID-19 has been widely discussed in literature but what remains untouched as with all other parts of psychiatry is that the cause of impact has not been discussed [2, 3, 4, 7]. It is often easy to label each and every disorder that a psychiatrist is seeing in COVID-19 patients or in patients or healthy beings having the effects somehow related to the pandemic to label as evidence. It thus becomes imperative to discuss the impact that a society is having through a unique lens that widens the perspective relating to the cause and consequence of each and every response that happens to the disease process. To help with this perspective, we shall use the model described by Kunal in his paper on hypothesis spanning the diversities of psychiatry and normalcy, in the section on pathophysiology [8]. But before we shall delve into this new perspective, we shall see what evidence has to say for the psychosocial impact of the pandemic.

2. Methodology

2.1 Objectives

1. To analyze the psychosocial impact of COVID19.

2. To delineate the process of impact, by looking into its pathophysiology.

2.2 Data acquisition

Literature was reviewed from PubMed and Google Scholar to find out articles describing the psychosocial impact of COVID19. A search was also carried out to find the explanations pertaining to different behavior of an individual to a given stress in order to justify the impact and explore management options.

2.3 Data analysis

The compilation of effects was studied and a way was formulated to better understand the psychosocial impact (Figure 1).

Figure 1.

Algorithm to show mapping of psychosocial impact of COVID19 based on literature.

3. Results and discussion

3.1 Social impact

When talking about social impact one needs to understand how a society is formed and functions. Society is like a big web of individuals who are inter-related because of friendship, families or workplace. There are visible and some invisible connections where a person relates to another person or set of person based on ideologies, principles or practice like in name of color, caste, creed or nationality. Invisible connections that often turn into sentiments of positivity or negativity. Stigmatization based on religion, social status and nationality has been a core of social discrimination in this pandemic [2, 9].

A revolution this pandemic brought was the strengthening of visible connections. Spending more time with families had both positive and negative impact. The bonding of families increased however spending too much of time together also had reportedly increased rates of divorce among couples [2, 10]. Veliyannoor coined this as ‘return of the repressed’ where old conflicts re-emerged during the lockdown due to prolonged forced togetherness between couples [10].

Joshi noticed in her review of psycho-social impact of COVID19 in India that adolescents and young people found it restricting and frustrating to be monitored by parents. Also, she pointed out how the conventional gender role expectations in an Indian society resulted in their overburdening leading to frustration and anger bursts. Family dynamics were also influenced by forced togetherness or separation [2].

Based on age, Dubey et al. showed various psychological issues that can happen in different groups and suggested intervention accordingly [7]. Authors showed that children are more prone to boredom, anxiety related to educational development, irritability and fear of infection. Indeed these fears might have been cultivated in them by their parents or guardians to prevent them from going outside. Though the psychological treatment should aim to control extreme fear, casual fear is indeed protective. Proper parenting, online education, and inculcation of healthy habits can provide a feasible solution but this can result in obsession for cleanliness sometimes which if not controlled earlier can get incorporated in psyche and lead to development of OCD (see section on pathophysiology). Young adults developed more anxiety due to low experience in coping with facing distress. Elderlies had irritability, anger issues, fear, anxiety and cognitive decline. Deprivation from pre-scheduled checkup or follow-up can lead to aggravation of their current conditions thus exacerbating the impact. Telepsychology or sessions via telephone or online consultations proved to be useful in all these cases [11]. Telemedicine has gained a lot of popularity during last 2 years and has almost replaced for physical visits except for emergencies at least at some point of time. Though it is not a true alternative to physical consultations it can have advantages in times of distress where risk–benefit ratio might be high for the physical visits for simple follow-ups or chronic illnesses.

Education builds society into a framework as we see and want to see. Conventional education has long been debated but has never been challenged at this scale. Pandemic showed the world a new perspective towards education in terms of online education system. The cellphones which were till an year back not allowed in many schools have become an integral part of education system and has also given food for thought as whether our thought process of keeping these at bay mattered? Long term effects are yet to be seen and short term reports have shown that not going to school may have psychologically affected children but again what impact it shall have on overall growth of a child is yet to be found out. Educational impact can be understood in three different ways- one on parents, one on children and one on teachers. While parents are still doubtful of new education system, it may be difficult for teachers too as maintaining the sanctity and discipline of class could not be strictly possible in addition to the fact that it is not possible to look after every student in classroom now. Also, teachers may face a constant struggle for validation as this technique of teaching is new for many and they might be under supervision of hundreds of parents who might be listening to what they speak. For students the learning experience has changed, as the way they interact with teachers and fellows have been changed. But not only the schools, even the crucial education deliveries have changed like that of medical training program even though examination patterns have remained nearly same. How this will change the social dynamics is yet to be seen in future [12, 13, 14].

The increasing role of social media cannot be overlooked in context of COVID19. The major role it played in pandemic has both positive and negative sides. Positive side includes spreading awareness, helping out friends and locals in times of need like shortage of supplies, finding hospitals etc. seeking help in times of distress (which inculcated a sense of hope in lockdown and quarantines) and enhance bonding among people. But nothing comes without a cost, like enhanced bonding promoted stigmatization of particular community or nationality, outbursts of racism and therapeutic misadventures tried by lay people misleading the general public about treatment or prophylaxis. Coronavirus ‘infodemic’ is another concern that was created on social media in which panic was created by laying out unchecked mind-boggling rumors [15]. Also it helped to promote the disobedience attitude among people who failed to recognize the disease as pandemic and labeled it as hoax created by world governments to divert the commoners from daily problems.

3.2 Socio-economic impact

Economic profiles can lead to formation of two groups in society- one whose livelihood has been greatly affected like those of laborers or small businessmen and another those whose work were less affected like those of HCPs, government servants, big businessmen and those working in private sector companies that still ran work-from home. The latter group had lesser financial implications, while former group went nearly bankrupt. Financial implications along with separation from families led migrant workers into great despair. Daily wage earners could not get enough wages to support family. Movement in groups and living in poor conditions predisposed them to infection and stigmatization of being carriers. The ill planned distribution of health services and expense of medical treatment led to hoarding of supplies, black marketing and other health crimes [9].

3.3 Socio-political impact

This section shall be incomplete without the mention of social and political revolutions. Revolution does not see the face of pandemic to break out. A very crucial aspect of any society is opposition to the laid rules. Protest is common in democracy as problems do not cease to exist in democracy. These people are marginalized and unheard, complicated by existence of pandemic, media often ignore either their plea or glorify their ignorance towards safety guidelines like wearing of masks, grouping together or following proper guidelines. The protestors may also have a feeling of vulnerability and learned helplessness as described for those people who have patients admitted in hospitals and must break social protocols to be able to provide proper care.

Social inequities like belonging to marginalized sections with poor health facilities often expose to chronic diseases leading to higher mortality when contracting COVID19 which has been reported by Osofsky et al. They also reported how poorer connectivity can affect seeking help in times of distress [16]. The solution to this cannot be made in a day but it points towards a poor preparedness for any such catastrophic event.

3.4 Social impact on health care

Based on health care the society was clearly divided into two strata during the pandemic- one providing health service and the other at receiving end. Patients developed anxiety, depression, panic, irritability, while the attendants developed a sense of uncertainty, helplessness, worthlessness and a fear of infection [1, 7, 17]. The kin of those who died developed prolonged grief, depression, substance abuse, and stigma related to spread of infection [7]. Inability to do a proper funeral further accentuated the problem. The visuals of ill treatment of dead bodies or mass funerals can further develop a sense of despair in individuals who could not say a proper good-bye to family and same could be for the families too. Another perspective could be for those persons who have their patients admitted in hospitals. They might develop fear of contracting the infection on one hand and on other might feel helpless in not being able to maintain social restrictions thus depicting learned helplessness [7].

Another special set of patients that needs special mention is psychiatric patients. Violence, addiction and disturbed routine follow-up were common issues faced by them. Xiao proposed novel approach of structure letter therapy while Saladino et al. and Zhou et al. emphasized the use of telepsychology and telehealth [11, 18, 19]. Another aspect for proper health care delivery to these patients would be to ensure that supply of prescribed medicines should be monitored and checked to prevent any lapse and family members or caretakers should also be looked for as they might develop their own set of problems.

On the other hand, psychological impact on HCWs could be very different. They felt overworked, unable to attend to family duties and guilt of not being able to save the patients. Those not involved in direct care of patients could have felt worthlessness for not being able to help [7]. Overwork can lead to burnouts, depression and anxiety [5]. Lack of facilities can also produce secondary traumatic stress disorder where HCWs have to decide who can access and who cannot access the facilities [20]. Lai et al. reported that nearly half of HCWs working in COVID wards had depression followed by anxiety and insomnia and nearly three-fourth had distress [21]. The problems faced by HCWs can be broadly labeled into three categories: those faced by them related to work and family needs, those faced by problems related to patient care and those faced by colleagues distress created by news of violence against doctors, work under poor safety guidelines, eviction of doctors from their rented house in various resident communities and death while providing services to patients. Though all three creates a similar type of stress pattern, psychotherapy shall aim at different roots when going for consultations. In most cases, these HCWs would not seek professional opinion and these distresses would be transient though theoretically affecting the patient care sometimes by reducing efficiency or indirectly affecting other colleagues or family member who might feel helpless in saving him or her.

3.5 Professional impact on training

Trainee doctors and medical graduates were also affected in their training. Reduced patient contact led to decrement in development of skills [22, 23]. Surgeons faced redeployment and decreased operation theater postings which in turn affected their surgical skill development [24]. Adaptation to online learning and problems with submission of dissertation was also a challenge and all these stress added to psychological impact on them [24, 25, 26]. A positive statement was that with online classes and posting in backup teams, these trainees got time to let the steam off and de-stress them. The training of not only health care workers but also every sector suffered tremendously thus also creating a question mark for not only training modules in past but also in future of the trainees trained during COVID19. Although, detailed discussion is out of scope of this chapter.

3.6 Risk factors for psychosocial impact

Romm et al. reported that females and sexual minorities were at risk for increased depression while males were at greater risk for decreased physical activity. Whites when compared to Blacks were at greater risk for increase in mental health impacts while Asians had greater chances of alcohol abuse. Hispanics were at greater risk for decreased relationship quality, physical activity, and increased sedentary activity [27]. Fteropoulli et al. found that factors associated with poorer outcomes for psychosocial impact include medical profession, female gender, frontline work and use of avoidance as coping skill [6]. They also reported depression and burnout to be strongest predictors of poor quality of life parameters, similar to findings reported by Suryavanshi et al. in Indian HCWs [28].

3.7 Pathophysiology- a fresh perspective

So what caused this impact? This is not a direct impact of the virus. Let us consider COVID-19 as a stress- a newly found one (Figure 2), according the “third-eye model’ [8]. It is a new experience and in some way have affected every person even the dead who could not get proper funerals and good-byes. And indeed that too has affected the living. Figure 3 shows normal response to stress. Whenever a stress strikes, it tends to push the brain cycle into NREM phase. A person always tries to end it and mount a REM response based on conditionings in brain. Conditionings are the coping skills that a person had learned during lifetime, so technically children will have lesser conditioning than adults and young will have lesser conditioning than elders. Thus problems with children will focus on what they do as in difficulty in concentrating, boredom, irritability, restlessness, nervousness, sense of loneliness, uneasiness, and worries, while adults would have anxiety, depression, burnouts, loneliness, panic, and substance use disorders.

Figure 2.

Algorithm showing basic response to any stress (further algorithm is given in Figures 3–5).

Figure 3.

Algorithm showing response when a patient can control the thoughts provoking mental stress and possible responses.

But not all people suffer from psychological impact at a given time. If one believes that the stress shall be controlled and it is indeed controlled then the behavior is more towards normalcy like with those whose income was not affected- pensioners, HCPs and government employees. Even though many times they worked under the fear of getting infected sometimes this fear was casual but at times where situation was not under control like working with limited supplies or exposure to large number of COVID patients or working long shifts, this could turn into anxiety or panic.

Whenever the stress is identified as stress like a person believes that abnormal response to COVID19 is validated, a justification happens for stress. If this justification is for a process that just a mirror image of what a person usually saw this could lead to adjustment disorders giving sense of irritability or loneliness to the person but if it backed by emotional turmoil or magnification where COVID19 is seen to impact the lives of people like never before killing thousands, breaking families, blowing the finances of families or simply loss of very close one who had no disease otherwise can lead to PTSD. It is often the effect of COVID19 that tends to cause adjustment disorder and PTSD than itself. Multiplied by isolation and long stays at home it is not difficult to imagine that bereavement reaction can also be prolonged.

Now all of this may comprise a normal response to a pandemic because the person still has some control over thoughts of stress and often the problem would lay on impact of stress as in death of a person, inability to help others, financial breakdowns and social cut-offs rather than COVID19 itself. Once the stress is incorporated in psyche of an individual, the principle of inertia decides as to whether the psyche can overcome the persistence of thoughts. If it tries to overcome it, it searches for a manipulation (remember here the thoughts have persisted and cannot be simply overthrown by mounting a response as explained in above text). From Figure 4, we can see if the manipulation is specific to stress it can be lead to anxiety if the manipulation is feasible for psyche but patient cannot do that. Another common way to mount a response is to mount a response which is very feasible to psyche like washing hands repeatedly as in OCD or shifting to over smoking or over drinking for stress relief. Sometimes this substance abuse can be an excuse for stress where the patient may be trying to gain sympathy or needs a leave from workplace and do not want to malinger which indeed can be very common due to non-specific and objective complaints of COVID-19 which can be practically anything from myalgia to loose stools. If the patient is already not ill can present with a spectrum of somatization and this could be for same reason except for the fact that malingering or claiming false symptoms is not feasible to psyche, i.e. the person does not want to malinger or do substance abuse which can be due to ethics, emotions or rationality.

Figure 4.

Algorithm showing response when a patient cannot control the thoughts provoking mental stress and still tries to find possible ways to control its inception in thought process.

Although, the above pathologies are not uncommon but another common response pattern is where the NREM state induced by stress is only controlled to some extent or cannot be controlled at all (Figures 2 and 5). In any of these cases, giving up to brain cycle is difficult as these people would have otherwise stronger will to control the brain. COVID19 is a pandemic and has affected everyone in some extent and thus does not target any specific group and is a boon for others. This feeling helps the person to control rather than be controlled by brain. Dysthymia has a definition to fulfill and can be underreported or can be diagnosed as depression by many. Low mood is not uncommon as it does not require any specific action from the person, it is like ‘going with the flow’.

Figure 5.

Algorithm showing response when a patient cannot control the thoughts provoking mental stress and cannot find possible ways to control its inception in thought process.

Each and every response can be mapped and the therapy oriented at that, however it is beyond the scope of this chapter to discuss every disease and intervention in detail [8].

3.8 Future prospects

Studying the impact can help us delineate the stress parameters and try to streamline treatment modalities. Saladino et al. recommended the same as primary prevention modality [11]. Under secondary prophylaxis, they recommended sensitizing the general populace on telepsychology, training next generation of psychotherapists in managing online devices and developing new tools of support and psychological treatment. However they mostly related to psychological issues needing treatment often the part unlooked is the iceberg below the tip. Those unreported psychological impact can be overcome by better preparedness for next pandemic by government, people, and society in general. A change is inevitable so rather than resisting the change, we shall look at its brighter side: incorporate healthy habits, give time to family and friends, look at education in terms of learning and prepare for medical emergency.

4. Conclusions

The visuals of people dying despite best health facilities puts the question forward for us as to what are we in front of nature? How much have we learned and how much we are we prepared for catastrophe? The rapid response and adaptability of general population cannot be overlooked. But it has left a deep impact with long term unforeseen effects. We shall not only study the effects in its past form but also anticipate further damage it can cause in late future. Other than teaching us the fact that we need a lot of medical preparedness, it also taught us that healthy individuals can also become transiently stressed and show symptoms which may not be deemed as psychologically fit. This blemish had to be erased to bring people to talk about psychological issues with even non-medico or non-psychiatrist friends and colleagues. Ignorance had been a bliss for ignorant but not for those who suffered in silence. It is the awareness that has brought us together in the face of crisis.

COVID19 came as wave and swayed the humanity. Different states of individual showed different responses to the same stress creating a gamut of responses which led to different socio-economic, socio-political, professional and psychosocial impact. Identification of stress, mapping of response and a better preparedness from experience can all help us in preventing and controlling it next time.

Conflict of interest

The authors declare no conflict of interest.