Psychological Responses to a Pandemic - by Dr. Manasa Seshadri

Whoever you are... Whichever country you belong to... From whatever walk of life - These are the recurring questions in everyone's mind nowadays:

What’s happening exactly?

When will this be over?

When can things go back to normal?

Will it ever be normal as I know it?

Whats going to happen to my money?

Will I die?

The Covid pandemic has caused tense ripples all over the world. Just one day, you want to look up to one country where there is some good thing happening , and before you googled to read what it was, there is some breaking bad news happening there.  I have forgotten how I used to start my day before all of this started.

These are some of the most common psychological responses from people all over the world to the ongoing pandemic. It is your responsibility as a citizen of the world to be aware of them. And if you allow your kind self to, empathise with some of these responses. Further, if there is a rare chance, help a few people feeling these adverse thoughts and mental reactions.

1. Lockdown:

Needless to say , we want to make the choice of when to visit our relatives and family - When to go out to dine or drink, to hit the gym or take a swim. None of us can bear that freedom being taken away from us. For those of us who are staying away from our parents and working, this is a harder phase. The uncertainity of not knowing as to when we can confidently visit our families and walk out to catch a break , is crippling.  

2. Stigma:

Our country; it seems goes into a shell when faced with an illness rather than demanding care. We have all seen patients and attenders hide information about travel and contact, cringe at the utterance of “COVID” and cry when diagnosed with the illness.

While it does make our job harder to explain the terms and conditions of the illness when faced with families like this, it is also unfortunately inevitable to understand where they come from. Most of our country people are ignorant about health care , and feel they are punished when they are diagnosed with an illness or that they have been cursed to live with it. This line may seem like coming from a century ago, but with some modifications, it is still largely true.

3. International influence:

Some part of the psychological responses in our country at this point of time,  are reactionary to what is happening in other countries in the world. There is a morbid fear of what’s next? We haven’t seen our worst yet. We are just warming up. E.g. “Will we fare as bad as those countries?”, “We will do far worse”, “I know my country” e.t.c.

4. Social media:

At times of disaster,  it is our biological instinct to feel prepared. We want to be aware. Avoid surprises.

The easily available go-to source of information, unfortunately is the unfiltered social media. And our inability to stop. The tendency to read and grab “news” way after you satisfied your appetite for it.

Realistically , there maybe 10-12 new Covid related things that happen in a day. And that takes about 10 minutes of reading. But what we want to read ahead is how did he/ she react to this news? We want a guidance system to react. Whose response should we imitate. Who in the world is coping the best? I want to be him. Or her. So that’s selecting a best response from amongst 8 billion people.

5. Children:

The opportunity of playing outdoors is taken away from the children. Inevitably , they become more engaged in finding entertainment online, and this can bear a risk of them becoming socially isolated and defining normalcy in their own way , as we emerge from the pandemic.

Children also copy their parents in reacting to situations. The more worried the parents are , the more worried the child is.

6. Elderly:

While it is hard to accept the challenge of retiring and spending more time at home in normal circumstances , it is all the more challenging when they don’t have an option to choose otherwise.

Worrying about not getting the essential medicines, worrying about having a fall and injuring themselves, burdening their children to take them to a hospital are some of the recurring thoughts.

7. Health care workers:

We are not one of them. We are the distinguished lot compared to the common public during the pandemic time. We are working under exceptional circumstances. We are doing a brave deed for our fellow citizens. We are in the thick of a thankless job that may not end any time soon. Most times, we choose to conceal the psychological burden we face, under the pressure to rehabilitate and provide. That’s who we are. Yes to all of that.

I did not put “health care workers” at the beginning  of the essay, because we are also one among them. We are not immune to the mental health burden of a time like this and we have absolutely no need to assume that we are. We live in the same society as everyone else. We feel the same things that they do. We are as confused about all this as everyone else is.

The common binding factor for all of us is that our response to a crisis situation stems from a biological instinct for survival and keeping our clan safe. Having said that , we should not shy away from accepting that we are facing hard times, probably the hardest time of our career. Some of our days on floor get very bad , some days are good , some days we surprised ourselves and did better than how we imagined we would. But we all need help when we do, and there is no changing that.

I am pinning down the top five crippling worries faced by frontline health care workers such as ourselves , the emergency physicians from all over the world here. My source of information include the AIIMS (New Delhi) guidelines for mental health for health care workers, NIMHANS manual for Guidelines for General Medical and Specialised Mental Health Care Settings titled “ Mental Health in the times of COVID-19 Pandemic “ , tweets from emergency physicians from all over the world, few surveys of mental health and psychological burden in health care workers from all over the world.

1. The day doesn’t seem to end.. Working for way too many hours!

• Most hospitals have staggered shifts with prolonged working hours to reduce exposure of health care workers to the increasing patient load. The emergency shifts are as it is exhausting, we never sit down. We never say , “ok, next half hour, there won’t be any patient coming, I have time for coffee”. We were on an edge all the time. But now,the pandemic has asked a new level of preparedness from us.
• And like it or not , believe it or not , we have slowly learnt to give a lot more than we thought we could. And with each passing day , we are learning to push ourselves in our own little way and that’s all is needed. 

2. Am I infected?... Am I infectious?... Will I give it to my family?

• We are constantly worried about housing the virus in our body. “I definitely have it”. “Matter of time before I become symptomatic”. “I will never forgive myself if I give it to my family”. While it is normal to err on the cautious side, there is also only so much that we can do. 
• We have to set boundaries to ourselves about how much exposure we can control and how much of it is inevitable when you are cohabiting with someone who is not a health care worker.
• We can share our worry of “giving the diease” to our family, discuss it and set up our own guidelines of physical distancing and safety precautions at home. Most times, this should suffice.
• If all members of the family are very worried about exposure and are unable to function because of this worry , we , the health care workers , could find alternate living arrangements till the anxiety settlles down in both parties and there is room for a rational conversation.  We, health care workers go through the drill of protocols every working hour, while our family is educated from only the news.

3. Have not seen my family in months? How long before I see them again?

• Many of us have been working and staying away from home. Some of us have been forced to stay in hospital campus and hostels. While initially, it seemed like a blessing that our current living condition doesn’t put our family at risk,with each passing day, it has become hard to cope with.
• What makes it worse is not knowing when this arrangement will change. when could we relax our pre set restrictions and visit our family? Can we risk it?
• The answer is a blaring “don’t know” . We can momentarily stop seeking any answer beyond that. If we have made some peace with video calling our parents and family , we could slowly try and make that our new normal, instead of fighting hard not to. Till we tide through this.

4. Cant stop thinking about stuff that happened during the shift!

• The recurring thoughts about the clinical decisions taken on the shift, the thoughts of getting exposed with an aerosol generating procedure, risk of exposing our team .. “Did I really have to intubate that guy?”, “My team hates me now for taking that decision”. We are finding it hard to unwind and unload ourselves after getting back home from work.
• The decisions we took and the work we did during the shift, comes back  to haunt us and seeming very prominent and significant once the shift gets over.
• The reason for this is, we might have excelled and worked “as if normal” during the shift while the truth is that we have worked under tremendous pressure and our ego keeps the magnanimity of it to bare minimum to allow us to function. Once the shift gets over, all the pressure we kept locked inside seeks a vent out and comes back as recurring thoughts for us to reconsider and re-evaluate.
• We could share a word of encouragement or two with our colleagues, our juniors, our nursing staff and the EMT’s after our shift, so that when they go home and the day’s work haunts them, they can find comfort in your words of appreciation. We could also request those staying with us at home to share a word of appreciation for us when we get back home, so that we find cozy corners in our mind to go to, when we are bothered by recurrent thoughts about the shift that we just had.

5. I don’t know how to talk to her!... or him!... or them!

• “That patient’s family just didn’t seem to understand”.... “I had to tear my lungs trying to get the point across to them”… We face difficult patients, difficult attenders every day. Patient’s attenders are now more skeptical of what doctors say, more than ever before. It has become difficult to utter “Covid” in front of the attenders. It is almost equivalent to beaking bad news, even if the patient is fit to go to a ward.
• There are also creeping issues of interpersonal strains in communicating with a colleague on the shift. The difference in opinions which we were able to brush aside before the pandemic and work for the sake of getting work done, are now becoming more pronounced. Our colleagues are as stressed as we are, and when we can, we could take the high ground and take a break from the conversation if it is getting tense and return to it when we have a break.
• When it comes to talking to a patient’s family, it is in our best interest and patient’s interest to be empathetic towards patient’s needs very early in the conversation. This will give us a better advantage to be prescriptive later about clinical decisions with them. These clinical decisions may include the need for mechanical ventilation, having to admit the patient in ICU and the like. We could always call for help when some families becomes very challenging to talk to. They may respond better to your colleague’s bandwidth than yours, and as long as we get the work done, it doesn’t matter who says it.
• Our job has always been to provide and we chose to be here. Some families make it harder for us , but we have , like always found ways to circumvent or deal with obstacles to provide care. We could be understanding of their stigma and be comforting rather than losing our patience with them. Other than soothing them, it also helps us maintain our cool for the rest of the shift.

6. I am already an anxious person!... I hate losing control of things!... I want to feel happy!

• This time is all the more challenging for those of us who have otherwise also have been a little too anxious, for those of us who get boggled down quickly when we face an adverse situation.
• It is a hard time for those of us who love being in control of things, fond of keeping things in order, religious about maintaining a routine to be given such a gigantic piece of uncertainty thrown at us. It challenges our desire for perfection and order.
• It is also a hard time for some of us who always preferred social isolation and didn’t easily mingle with friends and family from before. It may feel overwhelming to see it become a world order now.
• Some of us may have been habituated to drinking or smoking as a method to destress ourselves. Some of us might have been doing it a little too much and now find the craving disabling. The bottomline is, it is ok to feel overwhelmed. All of our stress response may not be apparent and easily visible.
• It is common for our pre existing personality traits to get highlighted at times of distress. It may become challenging to deal with , along with carrying out our responsibilities as a doctor. Seek a friend . A buddy. Someone you relate to, on an emotional level and find ways to vent these things with him/her.
• If things are getting out of hand, if we feel them go out of hand, or our colleague points it out to us that we are not working to our optimum best, seek help. Seek professional psychiatric help. Honestly, I happily would, if need comes!

To concude, these are hard times to deal with, for all of us. It is normal to feel anxious. It is normal to not have answers to all the questions. Our human instincts always guide us towards betterment of ourselves and our community. Whenever you find a way of dealing with any issue that you have been facing, be kind to share it with those around you.

About the author: Dr. Manasa Seshadri (MBBS, DPM, DNB(EM)) currently works as a Senior Resident, Dept. of Emergency Medicine at St. John's Medical College and Hospital, Bengaluru. She can be contacted at drmanasa.seshadri@gmail.com.