Premise: Psychosocial burden of COVID-19

It is more than a year of the unprecedented coronavirus disease-2019 (COVID-19) crisis. When the World Health Organization (WHO) declared COVID-19 as a public health emergency of international concern on 30th January 2020, and subsequently as a pandemic on 11th March 2020, little did we know that the causative virus severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) will bring the world down on its knees. With 140 million people affected worldwide and more than 3 million lives lost till date (as of 17th April 2021), the outbreak has affected lives and living in more ways than one (Worldometer, n.d.). The consequent lockdown has affected economies, travel and relationships, measures of social distancing, and face masks have affected ‘social touch’ and restricted emotional expressions, and finally the fear, stigma, and uncertainty due to the pandemic itself have led to a myriad of adverse psychosocial consequences (Torales et al., Reference Torales, O'Higgins, Castaldelli-Maia and Ventriglio2020). Tandon in his editorial in 2020 aptly focused on the mental health burden of the pandemic, highlighted the role of mental health professionals (MHPs), and called for ‘preserving humanity, maintaining sanity, and promoting health’ amidst the crisis (Tandon, Reference Tandon2020).

Historically, infectious disease outbreaks always had intersections with psychological health. Besides increasing the prevalence of psychiatric disorders such as depression, anxiety, psychosis, adjustment disorders, post-traumatic stress, and insomnia, coronavirus disease-2019 (COVID-19) and resultant situations have affected the symptom severity and treatment of people living with mental illness (Pfefferbaum and North, Reference Pfefferbaum and North2020; The Lancet Infectious Diseases, 2020; Vindegaard and Benros, Reference Vindegaard and Benros2020). Furthermore, the psychological morbidity has increased in the form of social stigma, discrimination, domestic violence, impaired psychosexual health, panic, isolation, loneliness, problems in interpersonal relationships, and bereavement (Douglas et al., Reference Douglas, Katikireddi, Taulbut, McKee and McCartney2020; Vindegaard and Benros, Reference Vindegaard and Benros2020). The frontline workers, elderly, and socio-economically impoverished are the vulnerable groups more prone to these effects. Also, the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) itself has shown to cause short-term and long-term neuropsychiatric complications, with delirium, confusional states, seizures, encephalitis, cognitive impairment, and strokes being the common ones (Banerjee and Viswanath, Reference Banerjee and Viswanath2020). In the largest study so far, a 6-month retrospective cohort study using electronic health records, Taquet et al., reported neuropsychiatric outcomes in 2,36379 COVID-19 survivors. Nearly one-third of them had at least one such disorder, among which 12.8% received such a diagnosis for the first time in life. Severe infections and ITU admissions were related to higher incidence of neuropsychiatric complications. Ischemic strokes, parkinsonism, dementia, anxiety, and psychotic disorders were the common ones reported (Taquet et al., Reference Taquet, Geddes, Husain, Luciano and Harrison2021a). This clearly provides an indication of the psychiatric comorbidity that has been there over the last year and warns about its likely increase as the second wave of infections emerges globally. Here comes the vital role of MHPs.

Crucial role of the MHP

The crucial role of psychiatrists and other MHPs (clinical psychologists, psychiatric social workers, psychiatric nurses) is paramount during the ongoing crisis. Their role is not limited to addressing the increasing burden of psychiatric disorders, but also encompasses public mental health education and promotion, integration of mental healthcare at all levels, facilitation of problem-solving and crisis management, empowerment of those at high-risk, and encouragement of self-care and coping among the medical fraternity (Banerjee, Reference Banerjee2020). MHPs also foster community resilience-building, distinguish and manage healthy v. unhealthy stress responses during pandemic crisis, understand human behavior and panic, deal with medical misinformation, address unhealthy lifestyle patterns and use of technology, and importantly, carry out their roles as physicians as well (Onyemaechi, Reference Onyemaechi2020). Considering the present circumstances, MHPs can be entrusted with a vital yet challenging role, i.e. their involvement and responsibilities related to the COVID-19 vaccination. The professional capacity to study and modify problematic human thinking and behaviors place MHPs in a unique role to enable global vaccination drives, which are long-term processes influenced by complex human attitudes, cognitions, and socio-political dynamics.

COVID-19 vaccines and the MHPs

The COVID-19 vaccine is intended to provide acquired immunity against SARS-CoV-2. The viral genetic sequence data were shared by GISAID on 10th January 2020 and since then there has been growing work on the development of vaccines (Thanh Le et al., Reference Thanh Le, Andreadakis, Kumar, Gómez Román, Tollefsen, Saville and Mayhew2020). Till date, several COVID-19 vaccines have demonstrated up to 95% efficacy in preventing symptomatic COVID-19 infections. Like any other vaccination, the goal is to prevent severe and life-threatening infections, hospitalization, and mortality. Thirteen vaccines have been authorized by the national regulatory authorities for public use in various countries as of April, 2021 (Kim et al., Reference Kim, Marks and Clemens2021, p. 19). Data from Vaccine Centre, London School of Hygiene and Tropical Medicine, 2021 show that there are 308 vaccine candidates in various stages of development with clinical research focusing on higher efficacy and coverage of mutant strains. As we speak, many nations have implemented national vaccination programs, focusing on the vulnerable populations such as the frontline workers, elderly, and immunocompromised groups. Officially published reports from global health agencies mention that as of 16th April 2021, 878.16 million COVID-19 vaccine doses have been administered worldwide (COVID-19 Vaccine Tracker, 2021). There have been active scientific discourse and debates about the extent of efficacy of vaccines, the interval between two doses, and the comparative efficacy between various types of vaccines. A detailed discussion of these aspects is not intended for this article. Notwithstanding these factors, general recommendations from global health agencies and popular research recommend vaccinations against COVID-19 (Kim et al., Reference Kim, Marks and Clemens2021, p. 19). However, national vaccination drives, and coordination and awareness about the need for vaccines are as challenging aspects in public health as the discovery and manufacturing of the vaccines themselves.

It has been well-researched how vaccination drives and coverage are prone to social stereotypes and public attitudes, which, in turn, are mediated by misinformation and disinformation (Burki, Reference Burki2019). Since the advent of COVID-19, it has been termed as an ‘infodemic’ (information epidemic), with increasing rumor-mongering, fake news, and conspiracy theories about its origin, spread, necessary precautions, and management. This has been further fueled by social media and increased ‘digital screen time’ during lockdown (Banerjee and Meena, Reference Banerjee and Meena2021). The WHO mentioned that, ‘the coronavirus disease is the first pandemic in history in which technology and social media are being used on a massive scale to keep people safe, informed, productive and connected.’ (Charpentrat, Reference Charpentrat2020). It becomes particularly critical when misinformation and personal opinions tend to go against evidence-based medicine. Vaccinations against pneumococcal infection, poliomyelitis, influenza and tuberculosis have all been challenged by medical misinformation (Burki, Reference Burki2019). Vaccine hesitancy and belief that vaccines are unsafe are significantly affected by fake news, which is propagated by digital media. In a recent large cross-country study using regression framework, Wilson and Wiysonge reported that a 2-percentage point drop in mean vaccination annual coverage was caused by a 1-point shift in a 5-point misinformation scale (Wilson and Wiysonge, Reference Wilson and Wiysonge2020). Marco-Franco et al., while discussing fake news and vaccination, called for a public health education approach at administrative and healthcare levels to fight fake news and improve protection against COVID-19 (Marco-Franco et al., Reference Marco-Franco, Pita-Barros, Vivas-Orts, González-de-Julián and Vivas-Consuelo2021). In a recent randomized controlled trial conducted both in the USA and UK, fewer people were shown likely to be ‘definitely’ accepting a vaccine for herd immunity, and ‘scientific-sounding’ misinformation, especially when repetitive, it was shown to reduce vaccination intent (Loomba et al., Reference Loomba, de Figueiredo, Piatek, de Graaf and Larson2021). This is of particular worry in the Asian context, where not only COVID-19 cases are surging, but the public healthcare infrastructure and limited resources in many low- and middle-income countries (LMIC) have to fight an added burden of snowballed misinformation. While arguably the right to get vaccinated or not is highly individualistic, the spread of biased opinions, deliberate disinformation, and fake news against evidence can distort public perceptions and decision making related to vaccines. This has detrimental effects on public health.

COVID-19 and psychiatric disorders: The ‘double jeopardy’

Psychiatric illnesses and the SARS-COV-2 infection have been shown to have a mutual association, i.e., those with mental illnesses tend to be more vulnerable to COVID-19, as well as the infection per se may lead to psychosocial outcomes (Taquet et al., Reference Taquet, Luciano, Geddes and Harrison2021b). A large-scale retrospective cohort analysis from the UK found out that about 12% of those tested COVID positive between March to July 2020, had a pre-existing psychiatric illness, including depression, anxiety, psychoses, and stress-related disorders (assessed both in-patient admissions and primary care visits due to psychiatric illness since 1981, using the database). There was an increased risk of COVID-19 infection (0.9% v. 0.4%) and related in-patient admission due to severity (0.7% v. 0.3%), and COVID-deaths (0.2% v. 0.1%) among those with pre-pandemic psychiatric condition compared to those without, with odds ratios of around 1.5 for infection and 2 for death, after adjusting for socio-demographic covariates. The researchers also found a higher risk in the older age group (>64 years). Total number of pre-existing psychiatric disorders had a significant association with current COVID-19 infection. Though the odds of infection were lower in primary care population, they were still statistically significant for the presence of psychiatric illnesses. These associations were found to be independent of body mass index, metabolic status, smoking, though compounded by the presence of physical comorbidities (Yang et al., Reference Yang, Chen, Hu, Chen, Zeng, Sun, Ying, He, Qu, Lu, Fang, Valdimarsdóttir and Song2020). Another case−control study reported a higher risk of COVID-19 diagnosis in patients with bipolar disorder, depression, schizophrenia (Wang et al., Reference Wang, Xu and Volkow2021b). Earlier studies have shown association between psychiatric conditions and symptoms such as stress, and severe infection, including respiratory problem (Pedersen et al., Reference Pedersen, Zachariae and Bovbjerg2010; Song et al., Reference Song, Fall, Fang, Erlendsdóttir, Lu, Mataix-Cols, Fernández de la Cruz, D'Onofrio, Lichtenstein, Gottfreðsson, Almqvist and Valdimarsdóttir2019; Cohen, Reference Cohen2021). There are several hypotheses regarding the underlying mechanism, which may be persistently raised hypothalamo−pituitary−adrenal (HPA) axis activity due to maladaptive stress response (as observed in depression and anxiety) leading to altered glucocorticoid cascade, and further, heightened inflammation and reduced immunity (Glaser and Kiecolt-Glaser, Reference Glaser and Kiecolt-Glaser2005; Wohleb et al., Reference Wohleb, Franklin, Iwata and Duman2016; Sadock et al., Reference Sadock, Sadock and Ruiz2017). Excessive proinflammatory cytokines and chemokines, and lowered bodily immune response are known to worsen infection status (Cohen et al., Reference Cohen, Janicki-Deverts, Doyle, Miller, Frank, Rabin and Turner2012; Morey et al., Reference Morey, Boggero, Scott and Segerstrom2015). In addition, medical comorbidities are common in persons with mental illness (PMI), making them more susceptible to infection. In severe mental illnesses (SMI) such as schizophrenia, depression, bipolar disorder, medical illnesses, including diabetes mellitus, cardiovascular disorders, respiratory tract infections, neurocognitive disorders, obesity and smoking, are found to be higher than in general population, even after controlling for the contribution of psychotropic medications (Miller et al., Reference Miller, Paschall and Svendsen2006; DE Hert et al., Reference DE Hert, Correll, Bobes, Cetkovich-Bakmas, Cohen, Asai, Detraux, Gautam, Möller, Ndetei, Newcomer, Uwakwe and Leucht2011; Sadock et al., Reference Sadock, Sadock and Ruiz2017; Zolezzi et al., Reference Zolezzi, Abdulrhim, Isleem, Zahrah and Eltorki2017). Further risk factors mediating the link between psychiatric illnesses may be socio-environmental factors like homelessness, reduced access to healthcare, lack of information, high-risk living conditions, etc. (Wang et al., Reference Wang, Xu and Volkow2021b). These factors are more important in the LMICs where poverty is severe. The nexus between poverty, homelessness, and SMIs presents a unique challenge in the LMICs as explained by theories of social drift and social causation (Lund and Cois, Reference Lund and Cois2018). The mental health services are far from adequate, and often fail to cover the most vulnerable population (Narasimhan et al., Reference Narasimhan, Gopikumar, Jayakumar, Bunders and Regeer2019). The burden of SMIs, as a result, is not only substantial, but also difficult to manage. Various such intersections between COVID-19 and SMI are summarized in Table 1.

Table 1. Considerations for individuals with SMI during the COVID-19 pandemic

SSRI, Selective Serotonin Reuptake Inhibitors; TCA, Tricyclic Antidepressants; BZD, Benzodiazepines; SES, Socioeconomic status; LMIC, Low-and-middle-income countries; KAP, Knowledge Attitude Practice.

Source: Taquet et al. (Reference Taquet, Luciano, Geddes and Harrison2021b), Banerjee (Reference Banerjee2020), Choi (Reference Choi2021), The Lancet Infectious diseases (2020), Vindegaard and Benros (Reference Vindegaard and Benros2020).

The other direction of association is also significant. A study found 2.1 odds of developing a psychiatric disorder within 14−90 days of COVID-19 infection, with the highest odds of anxiety disorders, dementia, and sleep disturbances. Incidence of any psychiatric diagnosis was 18.1% within the same duration (Taquet et al., Reference Taquet, Luciano, Geddes and Harrison2021b). This risk was again irrespective of medical comorbidities, though socioeconomic conditions could play a part. Another study found the need for health information and perceived pandemic impact as two important mediators between physical symptoms resembling COVID-19 infection and psychiatric problems, where public mental health education and interventions have a significant role (Wang et al., Reference Wang, Chudzicka-Czupała, Tee, Núñez, Tripp, Fardin, Habib, Tran, Adamus, Anlacan, García, Grabowski, Hussain, Hoang, Hetnał, Le, Ma, Pham, Reyes, Shirazi, Tan, Tee, Xu, Xu, Vu, Zhou, Chan, Kuruchittham, McIntyre, Ho, Ho and Sears2021a). Similar neuroimmunoendocrine pathways are said to be implicated in this relation (Raony et al., Reference Raony, de Figueiredo, Pandolfo, Giestal-de-Araujo, Oliveira-Silva Bomfim and Savino2020). These findings emphasize the bidirectional relation between COVID-19 infection vulnerability and severity, and mental illnesses. In addition to this, it is important to mention here the role of digital misinformation in affecting the mental health of individuals. The ‘digital infodemic’, mentioned earlier, is responsible for multiple psychological issues such as anxiety, fear, agitation, uncertainty, noncompliance to precautions, stigma, due to the huge misinformation load. The increased screen time and unhealthy technology use, found in the population at large, further contribute to the mental health problems (Banerjee and Rao, Reference Banerjee and Rao2020; Banerjee and Meena, Reference Banerjee and Meena2021). Thus, it will be apt to say that preventing COVID-19 infection is instrumental in reducing incident psychiatric disorders, in improving the outcome of the infection in PMI, and fighting the battle of misinformation and its adverse consequences.

Unique roles and opportunities

MHPs, especially psychiatrists, are uniquely positioned to deal with some of these public health challenges in the following ways:

1. 1. Prioritizing vaccinations in individuals with SMI and substance use disorders (SUD) in public health: Literature mentions people with SMI and SUD to be vulnerable groups besides their propensity for physical comorbidity, and recommends urgent vaccination in them (Mazereel et al., Reference Mazereel, Assche, Detraux and Hert2021). As we have discussed in the previous section, studies have shown bidirectional associations between pre-existing psychiatric disorder and severity of SARS-CoV-2 infection as well as illness-related hospitalization, morbidity and mortality (Yang et al., Reference Yang, Chen, Hu, Chen, Zeng, Sun, Ying, He, Qu, Lu, Fang, Valdimarsdóttir and Song2020; Taquet et al., Reference Taquet, Luciano, Geddes and Harrison2021b; Wang et al., Reference Wang, Xu and Volkow2021b). Dysregulated immunity, chronic stress and sleep disturbances are a few other additional vulnerabilities for SMI-COVID-19 interactions (Mazereel et al., Reference Mazereel, Assche, Detraux and Hert2021). Social factors such as poverty, homelessness, stigmatization, discrimination, and social stereotypes not only contribute to the COVID-19-related stress, but also to the access to healthcare and vaccination (Torales et al., Reference Torales, O'Higgins, Castaldelli-Maia and Ventriglio2020). The older people deserve special mention here, who are susceptible both to the biological as well as psychosocial offshoots of COVID-19. They often tend to get ‘marginalized’ with reduced healthcare access and are at an enhanced risk of mortality and morbidity due to the pandemic (Banerjee et al., Reference Banerjee, D'Cruz and Rao2020). This is compounded by mental illness, sensory and cognitive deficits. Prioritizing vaccination for them is imperative. Psychiatrists have multifold roles in COVID-19 vaccination for PMI, including calling for prioritization of vaccination in SMI, assessing and managing socio-environmental mediators, educating the general populations, PMI, caregivers, and other stakeholders regarding the need for urgent vaccination, and lending their expertise regarding the effect of SMI on COVID-19 vaccination as well as interactions with psychotropics.

2. 2. Addressing the barriers and advocating the enablers for vaccination access in people with SMI: Barriers to vaccination include attitudinal (e.g. beliefs about vaccines, trust in healthcare system, motivation), socio-environmental (e.g. stigma, cultural unacceptability, misinformation-led cognitive bias), and structural (access to healthcare including transportation, cost, etc.) barriers (Fisk, Reference Fisk2021; Who Technical Advisory Group on Behavioural and Insights and Sciences for Health, 2020). MHPs can liaise with other specialties in improving vaccine awareness and education, creating resources for vaccination programs, promoting engagements, monitoring of vaccination drives, and discussing with administrators for policies related to cost and access to vaccines in people with SMI. The ideal center for vaccination can also be decided: inpatient or residential facilities, community mental health centers, primary care clinics, public health clinics, at home or local pharmacies. MHPs can participate in vaccine awareness, education, and destigmatization in the general population as well.

3. 3. Improving public and preventive psychiatry: COVID-19 has already been mentioned as an opportunity to revamp the mental healthcare services in many nations. MHPs can play the role of ‘integrators’ of vaccination drive in the community, as it bolsters awareness, sense of security, and psychological safety in individuals (Dandona and Sagar, Reference Dandona and Sagar2021). This will help integrate mental healthcare for the ongoing pandemic crisis as a public health priority together with the vaccination programs.

4. 4. Fighting fake news and misinformation: As already mentioned, MHPs can act in a unique capacity in this regard. Various psychological processes like cognitive biases, social modelling, misattribution, fear-reasoning, etc. play in the genesis of fake news (Banerjee and Rao, Reference Banerjee and Rao2020). Similar misinformation and stigma exist in relation to mental illness as well. It has been shown by Zhang et al. that fact-checking information by health professionals, especially through social media, can have beneficial effects on public attitudes towards vaccination (Zhang et al., Reference Zhang, Featherstone, Calabrese and Wojcieszak2021). Public education and awareness programs can help modify and address some of the public misconceptions similar to stigma-mitigating strategies and psychoeducation used in mental health practice. This will help curb the mistrust, paranoia and uncertainty that arise out of this misinformation. Further research is also warranted into the psychology of misinformation and approaches to curb them.

5. 5. Managing the ‘worried well’: The concept of ‘worried well’ encompasses those unexposed but developing some symptoms, those seeking medical advice due to fear of exposure, and those experiencing anxiety after any sort of trauma. This category needs a separate mention because of the significant associated psychological distress, as well as the high usage of healthcare services. With or without any diagnosable psychiatric syndromes such as somatoform disorder, hypochondriasis, these patients experience sufficient stress and anxiety, worsening their mental health and general well-being (Chatterjee et al., Reference Chatterjee, Vora, Malathesh and Bhattacharyya2020). This presentation may be relevant to the vaccination also, including worries about vaccine and its side effects, perceived severity and lethality of post-vaccine physical symptoms, fear of vaccine-related complications and refusal of vaccine, thereby increasing the public health risk. Thus, adequate management, often in form of psychoeducation and supportive treatment, is necessary to reduce the burden on both the medical care, patient, and public health consequences (KINI et al., Reference Kini, Karkal and Bhargava2020).

6. 6. Empowering the vulnerable groups: Age and gender minorities, frontline workers, poor socio-economic class, migrants, homeless, and individuals with SMI all are high-risk populations for COVID-19. As many of them have associated psychosocial morbidity as well, MHPs can serve as advocators for their mental as well as physical wellbeing, helping them access an early vaccination drive. They can also assist public health officials in estimating decisional capacity and consent for vaccination in these individuals, so that it stays respectful to their autonomy.

7. 7. Role modeling: The American Psychiatric Association (APA) has issued a statement calling on the Department of Health and Human services to issue guidance advising states to include mental health and addiction service providers to be included in priority groups for vaccinations (American Psychiatric Association, 2021). Psychiatrists frequently serve as a prolonged and trusted point of contact between people with mental illness and the health system. Thus, they can serve as role models to alleviate the doubts and improve faith regarding vaccination in the PMIs. Though it is always a personal choice whether to get vaccinated, but MHPs can always help take an informed decision, both for themselves and the community.

8. 8. Caveats in low- and-middle-income countries (LMIC): The infection burden is found to be higher in the LMIC along with mortality (Choi, Reference Choi2021). COVID-19 has compounded the pre-existing difficulties in these countries, such as poor sanitation, crowded living conditions, endemic infections, and a substantial inadequacy of healthcare. Strict public health measures of lockdown, curfew may impact the socio-economically disadvantaged people significantly, thus, adding to the challenges. The vaccine supply and distribution are also differential across high-income countries and LMICs (Choi, Reference Choi2021). Along with the shortage and inequitable distribution of vaccines, specific caveats encountered in LMICs, as mentioned before, are low awareness and hesitancy regarding vaccination, misinformation, stigma, lack of adequate number of professionals for the population, to name a few.

MHPs, therefore, here have a more elaborate part to play. There was an article in 2019 pointing out the psychiatrist−patient ratio in India. It has been found from several registers that the ratio is around 0.75 per 100000 population in India, whereas the desirable ratio is at least three psychiatrists per 100000 population. They estimated that 2700 more psychiatrists are required in the next 10 years to bridge this gap (Garg et al., Reference Garg, Kumar and Chandra2019). In view of around 700 psychiatrists post-graduating every year, the number is difficult to reach in the next couple of years. In this pandemic, this dearth can be managed by training primary care physicians and other professionals in mental health. A significant number of patients present to the primary care and to other disciplines (gastroenterology, neurology, endocrinology, dermatology, general medicine, etc.) with various psychological problems. Thus, training and educating the professionals and the grassroot workers like Anganwadi workers, multipurpose health workers in the basic assessment and management of psychiatric issues, identification of appropriate referral requirements, and in vaccination advocacy along with addressing vaccine-related barriers will be important in supporting and promoting mental health in relation to the pandemic as well as vaccination. The telemedicine guidelines released by the Government of India in 2020 can be used in this context by psychiatrists and other MHPs alike, to overcome the geographical barrier to the access to mental health education, awareness, training, and treatment (The Ministry of Health and Family Welfare, Government of India, 2020).