Coronavirus Disease 2019: The Global Problem Statement
The outbreak of coronavirus disease 2019 (COVID-19) in Wuhan, China, posited a new global public health challenge, which brought forth the urgent need to strengthen the medical and psychological services across the globe. As per the World Health Organization (WHO), the global tally of deaths has crossed two million, with a whopping 110 million confirmed cases as of date. The situation in India is worsening, with 10.9 million confirmed cases and >150,000 total deaths due to COVID-19.
A global strategy to combat the pandemic has been suggested by the WHO. It includes preventing the spread of illness by maintaining hand hygiene, by ensuring physical distancing, and through respiratory etiquettes. The drastic step of imposing nationwide lockdowns has been a crucial element in the containment of the COVID-19 strategy. It is imperative to note that the call for partial or complete nationwide lockdowns by the governments of >100 countries across the world has adversely impacted the psychological health of the general population. The imposed preventive measures of lockdown, home-confinement strategies, and social distancing have led to an emergence of perceived psychological distress as well. The psychological impact of isolation and quarantine can range from irritability, anger, frustration, insomnia, loneliness, confusion to serious outcomes such as suicide. Several measures to contain the pandemic such as travel restrictions, quarantine, and social distancing have disrupted social structures, living, and lifestyles that can potentially bear emotional, social, and ecological implications. The significant fear and uncertainty around the viral infection due to lack of medical treatments have been the major contributing factor to increased psychological distress in the population. The WHO has thus called for global mental health action, which entails messages to support mental and psychosocial well-being in various target groups and vulnerable populations, such as the general public, frontline healthcare workers, team leaders, carers of children, older adults, as well as people in isolation. The basic thrust of these mental health considerations lies in extending emotional support to near and dear ones, maintaining quality communications through online/virtual mediums, reducing the intake of anxiety-provoking news and information related to COVID-19 from unreliable sources, building hope and optimism by engaging in communication about corona-recovered patients, the importance of maintaining daily routines or creating new personal routines in case circumstances change, etc.
Coronavirus Disease 2019 and the Lockdown: Effect on Psychological Well-Being
Recent research has brought to light the psychological symptoms as a response to the pandemic and lockdowns. Young adults, especially in the age group of 18–30 years, as well as older adults above 60 years of age, reported the highest levels of posttraumatic distress in a nationwide survey, with a sample of >52,000 Chinese participants. Stress in young adults has been explained by the high access to fake and sensationalized social media information. This “information overload” triggers stress. On the contrary, high levels of distress in old age are due to the facts presented by the public health agencies, regarding high mortality rates in this group. Family care is essential, especially for older adults who become angry, stressed, anxious, and withdrawn during isolation in COVID 19 times.
Research has also provided evidence for the gender and age differences in the impact of lockdown on psychological well-being. Studies conducted on the residents of Wuhan reported that posttraumatic stress symptoms were higher among females, among the younger population under 35 years, and among those who watched the news at least thrice a day. Frequent media exposure increased “digital screen time,” and trusting information from unauthenticated nonreliable sources added to the distress. In comparison to men, women reported more severe symptoms of mental health problems such as depression and anxiety. Moreover, a significant relationship was reported between social media usage and mental health toll on users. Even though social media was rewarding in terms of access to emotional, informational, as well as social support, yet increased dependency on social media and its excessive usage led to depression and secondary trauma. Likewise, physical distancing impacted the mental health of adolescents due to perceived lack of affect. Lack of social/affective touch is a vital factor affecting psychological well-being, immunity, psychological response to stress, and ultimately the response to the infection. Banerjee et al. (2021), in their comprehensive review, highlighted the biopsychosocial facets of affective touch and its intersections with psychiatry and neurodevelopment. Besides, the authors also discussed the impact of social distancing, stigma, “othering,” xenophobia and fear of infection on physical separation and interpersonal discord during the pandemic, which can further compound the chronic stress leading to the accumulation of “touch hunger.” Readers are requested to go through this paper for a more detailed discussion on “touch hunger” and its neurobiological underpinnings. Since social interactions, group activities, and peer influence form a basic need in adolescent years, depriving them of this need led to negative impacts of perceived social exclusion.
Studies in the Indian context reported similar findings. A study by Varshney et al. using an online survey with a total of 1106 respondents from 64 cities in India aimed to assess the initial psychological impact of COVID-19 and the lockdown. Impact of event-revised scale was also used to assess the psychological impact. One-third of the total respondents reported a significant psychological impact. Likewise, younger age, females, and those having comorbid physical diseases were predictors of higher psychological impact. A study on a sample of Kashmiris revealed the participants' perception that lockdown leads to new psychological problems (67.5%), social problems (53.5%), and economic and academic problems. A sample of 507 participants from West Bengal (India) reported that 71.8% felt more worried and 24.5% felt depressed due to the onset of COVID-19. Respondents (25.6%) mentioned that the pandemic caused a threat to their existence, and 30.8% of the participants reported difficulty in adjusting to the new routine due to the lockdown. Another study conducted on an Indian sample using a mixed-methods approach found higher rates of anxiety during COVID-19 among sexual minorities, people with a high risk of contracting the infection, as well as those with a past history of loneliness or depression.
The prevalence of depression (27.5%), anxiety (26.9%), and stress (26.5%) has been revealed in a sample recruited from Northern Spain. Interestingly, this study indicated that men had higher incidence of depression as compared to women. However, the levels of anxiety were similar in both genders. As expected, the younger population and people with physical comorbidities showed greater symptoms.
The unprecedented times added to the stress of frontline workers. Healthcare workers reported adverse mental health outcomes due to long working hours, fatigue, lack of protective equipment, separation from family, and feelings of loneliness during COVID-19. Another research indicated the active need for mental health services in critical care units to reduce high stress and depression. Unfortunately, the stigma and fear related to the spread of COVID-19 have led to a basic lack of socioemotional support for the healthcare workers, making this challenging period even more difficult. A systematic review of the impact of COVID-19 on the psychosocial and mental well-being in South Asian countries by the Indian Psychiatric Society (IPS) revealed two-fifths of the sample population to suffer from anxiety, depression, stress, sleep disturbances, substance abuse, and unhealthy use of technology. The article also reported the advocacy statement published by the IPS calling for multidisciplinary collaboration related to mental health during COVID-19 and the need for psychotherapeutic interventions to improve sleep, daily structure, and interpersonal relationships.
The pandemic has also unfolded the age-old evil of prejudice and “othering,” that traditionally increase during infectious disease outbreaks, contributing to national and international tensions. The increased stigma and prejudice attached to the people who contracted the deadly disease by labeling them as “COVID 19 cases,” “victims,” “COVID-19 families” have led to reduced social and emotional support needed to fight the illness. This is in line with the disease-avoidance model that explains the rise in xenophobic tendencies during the spread of various infectious disease outbreaks. A recent study by Ahuja et al. from India revealed a direct relationship between fear of infection and xenophobia, which were inversely related to collectivism and hope. Infectious diseases have bidirectionality with prejudice and social stigma, where certain communities and groups are selectively blamed and marginalized. This further creates panic, fear, and social chaos and contributes to disruption of the interpersonal and social dynamics.
Coronavirus Disease 2019 and Social Disruption: Role of Stressors and Sleep
Consequent to the pandemic, social relationships are among the worst-hit aspects in people's lives. The pandemic has taken a major toll on the social welfare of individuals. The lockdown has been a very different social experience and has had a great impact on the organization of schedules, playing out of lifestyles, and structuring of relationships. While some of them are strengthened, the others are being severed owing to the current scenario. People have found themselves confined for long periods of time with their families mostly and have experienced conflicts with each other which may have altered the quality of life. Marital discord, familial conflicts, and domestic violence have been on the rise, reported in multiple studies. Funneling of relationships occurs as some connections are prioritized and given more importance by investing care, time, and support and are facilitated with regular communication, while other connections have apparently fizzled out due to lack of communication and distance. In this section, we also discuss changes in the living patterns which have given rise to various stressors that can contribute to psychosocial distress. The authors would like to stress here that “social disruption” not only refers to the mis-scheduling of a day for an individual but also different forms of stigma, chaos, abuse, and fear prevalent in the community secondary to the pandemic.
The entire scenario has pervasively affected the quotients of psychosexual health and intimacy among partners. According to Perlman and Duck, the “physicality” of relationships and physical proximity can have a great impact on their nature and quality, thereby altering them for better or worse. This has been evident in previous outbreaks as well. Chua et al. explored the psychosocial consequences of the severe acute respiratory syndrome (SARS) outbreak and suggested an increase in sexual dysfunction, decreased arousal, and increased marital discord over issues of intimacy. The long-term psychosocial outcomes of healthcare workers managing SARS patients highlighted a rise in erectile dysfunction, premature ejaculation, lack of sexual satisfaction in partners, and heightened performance anxiety. This led to burnout, work stress, absenteeism, substance abuse, and depressive disorders. Unfortunately, sexual well-being and intimacy are often neglected in the face of more pressing concerns. People are scared to engage in intimate activities because of the highly contagious nature of the illness. This generates fear and frustration associated with intimacy. According to Banerjee and Rao, this fear is even more intense among frontline workers against COVID-19 who self-quarantine themselves to prevent interaction with their families. This, in turn, leads to frustration, guilt, stress, and health anxiety. The authors critically discussed the changing scenes of sexuality during the pandemic, digitalization of sexuality, and advocated safe sexual practices during such times of crisis. Confinement at homes during the pandemic has also given rise to the issues of domestic violence, severing the familial ties further. The most affected and vulnerable segment of the population is the elderly, the children, and women. The incidents of violence against women are on the rise since the beginning of the lockdown. According to the statistics released by the National Commission for Women in India in the early April 2020, there has been a significant increase in complaints pertaining to violence against women after the implementation of the lockdown across the country. This increase has compelled the National Council for Women to announce Mental Health Helplines for those experiencing any sort of domestic violence. Previous researches have demonstrated the link between exposure to natural disasters or extreme conditions and a consequent rise in the prevalence of domestic violence.
The lockdown measures have placed the children, women, and older people living in abusive environments at a heightened risk of violence, due to the increased time being spend with and exposure to their abusers.
Lay-offs and salary cuts have had deleterious effects on the psychological well-being of many individuals, mostly men. Loss of income can lead to a sense of instability and stagnation, along with feelings of uncontrollability over their financial condition. The patriarchal context places financial responsibility and accountability of the men of the house. The feelings of lack of control and job uncertainty can further be manifested in the form of aggressive behavior. Such aggressive impulses can be displaced on the vulnerable members of the house-women, children, and elderly in the form of violence, primarily in order to fulfill their need to control. Employment and financial independence for women are likely to serve as a bolster against violence since their income supplements the family. Unemployment of married women implies being dependent on their spouses for their financial needs, which may lead to greater vulnerability to the displaced aggression of their spouses.
Confinement can also yield to a greater propensity for alcohol consumption and other substances to escape the current stresses. This can be linked to the perpetuation of violence.
In the case of children, fewer alternative opportunities to access help are available other than their parents. Younger children do not have much understanding or access to channels through which they can seek help. Schools often served as safe spaces for children; with schools closed, there is a paucity of social support networks.
Stay at home orders and an unprecedented long-term entrapment in many cases may increase the frequency of demands for sexual intimacy from a partner and hence increase the likelihood of forced sexual activities. Heightened stress and limited accessibility to contraception resources may also lead to indulgence in unsafe sexual practices. Financial dependence on men can also result in economic abuse.
The older population is highly vulnerable to domestic violence, primarily because they experience mobility issues, because of which they are less likely to move out to seek help. Usage of technology can be a challenge for the majority of the older population. Technology may act as a buffer against domestic violence and may suggest some coping mechanisms and solutions.
Role of Interpersonal and Social Rhythm Therapy: A Pragmatic Crisis Intervention
A fertile premise
Interpersonal and social rhythm therapy (IPSRT) is tailored to enable individuals to improve their affective state by understanding and dealing with their biological and social rhythms. It was originally crafted as a form of psychotherapy for a single clinician and a single client; however, the intervention has now been adapted to work in a broad array of settings entailing the groups of both inpatients as well as outpatients. IPSRT is efficacious supplemental therapy for people with mood disorders, primarily bipolar disorder. It enumerates strategies to facilitate and enhance adherence to medications, deal with environmental stressors, and reduce irregularities and disruptions in social rhythms. This therapy instills skills in the patients, which can enable them to regulate their emotional state and aid them in preventing the recurrence of future episodes.
The primary idea behind this approach is that if the regularity of the patient's daily routine can be increased, majorly, their irregular sleep/wake schedules, meal timings and times of rest versus activity, and their erratic and vulnerable circadian systems can be strengthened.
This therapeutic approach amalgamates the perspectives of social rhythm theories into the framework of interpersonal psychotherapy, originally formulated by Klerman et al. as a treatment for unipolar depression. IPSRT is essentially committed to the stabilization of a person's schedule while enriching their interpersonal relationships and the performances of important social roles and duties. It also serves as an aid to improve a person's current affective state and level of functioning and to equip them with the necessary skills and protective abilities to prevent the occurrence of new affective episodes.
The behavioral aspect of IPSRT emphasizes an evaluation of the extent to which the timing of a patient's schedule varies throughout any given week. For this purpose, a self-report charting instrument called the social rhythm metric (SRM) is used, which helps patients to effectively monitor and keep track of when he or she sleeps, wakes, has their meals, goes to work, or forms social contacts.
The behavioral approach of IPSRT is amalgamated with work on the four key problem areas identified by Klerman et al. in their interpersonal psychotherapy: unresolved grief, role transitions, role disputes, and interpersonal deficits. There can be several explanations as to why the reduction of interpersonal and social role stress is integral in the process of achieving wellness, especially at the time of a global pandemic.
First, stressful events, especially during the lockdown, have the capacity to impact the circadian system via an increase in autonomic arousal that can have to affect the sleep-wake cycles, timing and amount of food consumed, and normal physiological circadian cycles. Second, irrespective of the stress level being experienced, events of any size or severity can result in significant alterations in the everyday schedule. Third, major life stressors such as quarantining or being separated from one's friends or family or not being able to procure basic amenities and losing jobs because of economic disruption can not only have a negative impact on the psychological well-being of an individual, but it may also lead to disturbances in social rhythms. Working from home, especially online work at night, the “new norm,” imposed by the pandemic, can disrupt daily structures in the absence of a set “work–personal time divide” and impact resilience as well as emotional regulation.
Interpersonal and Social Rhythm Therapy: Basic Tenets
The structure of IPSRT consists of four phases. The first phase of the treatment is always focused on understanding the history and background of the person. The importance of this phase lies in identifying the key problems that the person is dealing with, essentially pertaining to his/her interpersonal interactions and disturbances in routine, thereby developing the basis for the therapy. In addition, social support also matters in achieving desired therapeutic outcomes. The therapist can educate and inform the patient as well as the people close to them about the nature of the key issues experienced by the individual as one's family and friends can help them to monitor their progress.
The initial phase of treatment is also partly focused on the process of information gathering, which is also referred to as the interpersonal inventory. Through the semi-structured interview, the therapist can understand the nature and quality of the patient's present interpersonal relationships. Once these evaluations are made, the therapist proceeds to appraise the regularity of an individual's social routines by making use of SRM. The initial part concludes by narrowing down an interpersonal problem area (unresolved grief, role disputes, role transitions, or more interpersonal deficits) upon which there is a mutual agreement between the individual and their therapist. This combination of formulating the case history and information inventory enables the therapist and the patient to reach a consensus about which of these four problem areas is most pressing and amounting to current distress and irregularities in the daily schedule. The next phase is the intermediate phase that stresses reorganizing social rhythms. Following the second phase is the maintenance phase that entails sustaining and reinforcing new social rhythms and building confidence in skills and techniques learned earlier in treatment. The final phase deals with the reduction in the frequency of visits to proceed toward the termination of therapy. Although there is empirical literature highlighting and exploring the usage and efficacy of IPSRT in clinical populations, primarily patients with bipolar depression, IPSRT can be viewed as a viable therapeutic option for the nonclinical population as well.
Suitability for the Pandemic Crisis?
In the wake of COVID-19, people are grappling with the stressors of an entirely novel environment, with further amounts to a lack of predictability and control over one's life. Managing and regulating one's routine has become a major concern. Amid the perpetual stress and anxiety in the current scenario, the interpersonal component has been immensely impacted. The irregularities in people's biological clock, coupled with the disturbances in interpersonal relationships, have made it difficult for people to cope with this unusual setting.
Many seemingly, benign life events that are associated with changes in daily routines, especially during the current context, have come to place considerable stress on the body's attempt to maintain a regulated sleep-wake, appetite, energy, and alertness cycles or rhythms. Discourses around circadian rhythm refer to the exogenous environmental cues that regulate the circadian cycle as zeitgebers or “time givers.” The most powerful zeitgeber is sunrise and sunset, i.e., a physical zeitgeber. However, in today's era wherein light is available during the entire day, social factors such as the timing of work, meal timings and even the timing of specific television programs can have significant influence on the diurnal rhythm. Work patters and lifestyle changes during COVID-19 have irregularized these zeitgebers leading to sleep and mood disturbances. Frank also asserted that alterations in such social time cues could produce brief disturbances in circadian rhythms.
In this pandemic time, the lifestyles of people have changed dramatically, including sleep and dietary patterns. With most people primarily working from home and being schooled from home, the balance between work and life has severely been impacted. In addition, the interpersonal lives of the people have also become strained due to the enforcement of the norm of social distancing for the containment of the virus. All these adversities and changes amount to disruptions in one's biological clock. Social isolation during the pandemic has gravely affected the sleep quality of people, one of the basic facets of biological rhythm. Lin et al. have reported on a timely study that investigated the early impact of the COVID-19 pandemic on sleep in a large sample of adults (n = 5641) living in China. Both healthcare workers and adults from the general population completed an online survey of insomnia, anxiety, depression, and acute stress during the peak of COVID-19 spread in China in the early to mid-February 2020. The main findings threw light upon very high rates of clinically significant insomnia. In another study, 140 healthcare workers from India were assessed for perceived stress and insomnia. A factor analysis revealed that hours of duty, disruption of pre-COVID schedule, and periods of quarantine significantly predicted sleep disturbances. There have been several other studies from the Indian context on the effect of COVID-19 lockdown on sleep patterns. Gupta et al. conducted an online survey in the early May 2020 (during the Indian lockdown period), which revealed a marked change in daily sleep-wake schedules. There was a reduction in night-time sleep and conversely enhanced daytime napping. Importantly, depressive symptoms were associated with poor sleep quality. In another study on corporate professionals “working from home” as well as undergraduate and postgraduate students, it was found that compared to times before lockdown, there was a marked increase in daytime sleepiness, headache, digestive problems, and fatigue that caused worry, isolation, and daily life routine disruption.
IPSRT can be implemented to enhance the quality of one's lifestyles which further improves their circadian rhythms. In fact, the Task Force of the European Cognitive Behavioral Therapy-Insomnia has recommended implementing elements of interpersonal therapy to deal with anxiety, limited social interactions, and schedule dysregulation of prolonged home confinement. It was also highlighted that managing sleep problem using psychotherapy would help in limiting stress and preventing disruption of social relationships. Initially, therapists need to understand the nature and severity of these disruptions in the social routines as well as interpersonal complications and to what extent they are contributing to the irregularities in the circadian patterns. Individuals can also be taught how to manage these disruptions by their own self by making use of the SRM regularly, which helps them track changes in their routines. In addition, during the middle phases of the treatment, sleep hygiene strategies can be provided to improve the quality of sleep. For the “interpersonal” component of the therapy, the individual can be assisted in identifying the primary concerns in the interpersonal arena that disrupt one's routine life. For instance, social isolation, loneliness, unable to meet a loved one, and stress-induced interpersonal breaches and conflicts can be some of the common concerns during the pandemic, which can impact one's social health. To minimize these concerns, patients can be taught a repertoire of strategies such as assertiveness training, perspective taking, role-play techniques, and problem-solving skills. Communication analysis can also be used to enable individuals to identify the problem areas in one's communication. Decision analysis also helps people to weigh and introspect on the potential risks and advantages of alternative choices and decisions with respect to a particular problem. These techniques can help people maintain healthy interpersonal connections even in the dawn of social distancing, thus leading to better well-being. To summarize, the persistent social isolation, interpersonal discord, risks of abuse, changes in lifestyle and social prompts, as well as grief due to loss of loves and physical distancing, can lead to disruption in social and biological rhythms, which in turn can cause various psychological and social problems. The biological vulnerability in certain individuals and the widespread stressors (financial, social, and emotional) can further influence and compound this mediating factor of schedule disruption [Figure 1]. IPSRT can potentially help by addressing these role transitions and interpersonal discord as well as regulating the sociobiological rhythms.
It can be concluded that COVID-19 had an impact on the social factor zeitgebers. For example, due to the imposition of lockdown, there were changes in the timing of meals and work schedules of various family members. The disruptions in these external cues led to a cascading of neurohormonal events and impacted circadian physiology, manifesting in somatic or cognitive distress. Thus, according to this social zeitgeber hypothesis, life events such as the spread of the pandemic, which disrupts daily routines, can be linked to social disruption, sleep-wake disturbances, impaired quality of life, and psychological well-being, all of which can increase the risk of mood disorders and sleep disturbances. There are several psychosocial offshoots of the pandemic which have been discussed in the earlier sections. The authors do not intend to state that IPSRT would be beneficial for every other distress mentioned before. However, it is evidence based that many of these issues such as depression, anxiety, panic, fear of infection, panic buying, dietary changes, body dissatisfaction, and sleep disturbances are mediated through a change in social relationships (role change), schedule disruptions to a “new normal” (role transitions), loss/separation of loved ones (grief), and difficulties in interpersonal relationships, all of which form the targeted domains for IPSRT. This form of therapy comes to the rescue in stabilizing body rhythms as well as in re-establishing social roles and maintaining satisfactory interpersonal relations following a destabilizing event like the outbreak of COVID-19. It seems reasonable that an IPSRT-based intervention tailored to the specific needs of the target group can be undertaken at the earliest to assess its effectiveness in coping with stressful times of pandemic. Given the levels of increased stress and workload, the efficacy of IPSRT shall be more critical for highly vulnerable groups, including frontline workers. Their psychological health is of significant importance in battling infectious disease. IPSRT may help in improving their level of functioning by stabilizing their routines and enhancing their performance to pivotal social roles. Although research has been conducted to explore the efficacy of IPSRT in patients with bipolar disorder, its role in other stressful situations such as the current crisis and disruption of daily routines given the imposition of global lockdown and travel restriction is yet to be systematically studied. Moreover, there is a dearth of literature on understanding the effectiveness of IPSRT on the prevention of social disruptions during this “abrupt lifestyle change.” The viral caseload is still on the rise, and the future is uncertain, though the psychosocial burden of the outbreak is only expected to amplify with time. Using elements of the “SRM” in psychotherapeutic interventions is expected to have promise and scope in mitigating the “structural disruption” imposed by the pandemic and in the postpandemic aftermath.
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