Humans are highly social beings. Our ability to communicate, form large societies through ideologies and be immensely interconnected has been postulated to be our greatest advantage in amassing Nature’s gifts. Hence, it is not surprising that our mental health and emotional well-being depends greatly on our day-to-day social interactions and relationships with the ones we love. SARS-CoV-2, the causative virus of COVID-19 pandemic, not only impacts the physical health of the worldwide population but also threatens to breakdown our emotional well-being. Several months into this pandemic and already reports of increasing mental health issues such as anxiety and depression among the general population and also, key groups have emerged. For instance, the World Health Organisation (WHO) even rephrased the public health measure ‘social distancing’ to ‘physical distancing’ to highlight the need to stay socially and emotionally connected while being physically apart.
Desolation from isolation
For these past few months, which is nearing a year now, we have been advised to practice social distancing measures. These actions, such as staying at home and avoiding physical interaction with others can make us feel isolated and lonely. Feeling of helplessness, boredom, loneliness and anxiety can develop due to lack of interaction and connection with others. This is particularly worse in those who stay alone or in those who are quarantined after overseas travel, away from family.1
For those who have been tested positive, they might feel contaminated and may blame themselves for catching the virus. They may also be afraid of how the society will view them after the quarantine period is over. False perceptions about contagiousness may be prevalent due to preconceived ideas. Furthermore, mass criticism in social media to those who are infected may cause additional stress to those infected. They might also experience a sense of betrayal towards their loved ones, especially for families who struggle with social and financial issues.
For healthy people on Movement Control Order (MCO), and its derivatives of EMCO (Enhanced MCO), CMCO (Conditional MCO) and RMCO (Recovery MCO) (depending on their location), limited access to normal daily activities, such as going to work, shopping malls and travelling also imposes its own challenges. For working adults, being deprived of their jobs, they might lose a sense of purpose such as those who work as teachers, motivational speakers and customer service agents. Furthermore, working online can be overwhelming and the lines between work and life can be blurred.
Loss of job, loss of mind
Losing one’s job is also one of the leading factors causing anxiety among Malaysians. Malaysia reported a 17.1% increase in unemployed persons this year.2 Labour force recorded in March 2020 also fell by 0.2% compared to February 2020. During the same period, employed persons decreased by 0.7%. Majority of these were own account workers such as small traders or entrepreneurs who earn daily income. They were exposed to the risk of unemployment and job loss that can affect income during the MCO because partly, they were unable to run their businesses.
Occupation can give us a meaning in life. It keeps us intellectually stimulated and allows for social networking, teamwork and peer interaction. It provides a structure and discipline to our days, weeks and months. Work and earnings give a deep sense of security in terms of emotional, psychological and financial aspects for workers and their families. This is why job loss can be so anxiety-provoking, stressful and life-altering.
What is true and what is not?
Infodemic is defined as an overload of information, often false or unverified, about a problem, especially a major crisis. Sensationalisation is something people look for but there is also fear and the fear factor is very high as people are now worried, anxious or even curious. During these times, some people would come up with all sorts of theories, concepts that are not science-based which may be misleading or worse, provide false assurance.
Among such news to flood the public spheres are home-cooked remedies or products that claimed to be an effective tool or cure against the outbreak, most of these, however, have little to no scientific data to back their claim. The Ministry of Health has since debunked several irresponsible media reports claiming drinking warm water, eating kangkung or the ikan singgang dish, or even wearing a so-called “anti-viral health tag” can cure the coronavirus infection. This has affected people’s ability to differentiate between real and fake news. Since most fake news are sensationalised half-truths preying on the minds of the public, they provoke unnecessary fear and anxiety.
Often overlooked – Domestic violence, stigma and suicide
Since March 18th 2020, there has been an increase in distress calls to ‘Talian Kasih’ hotline by 57%.3 Notably, these calls are because of stress from abusive partners while we are confined to our homes. The Woman Aid Organisation also noted about 10.5 calls per day since March to May. According to News Strait Times published on 31 March 2020, there was a 13% increase in the number of calls received by The Befrienders Kuala Lumpur during the first week of MCO, whereby 9% of those calls were either due to issues related to COVID-19 or the MCO. The Befrienders executive director, Kenny Lim, said that apart from anxiety, being confined indoors has instilled fear, stress and helplessness among people. In the United States, experts are foreseeing an increase in the number of depression, substance abuse, post-traumatic stress disorder and suicide in view of the over flooding reports of mental health crisis registered on the federal emergency hotline for people in emotional distress.3
Models created based on the study of Great Recession in 2007 suggest that if unemployment caused by this pandemic rises 5 percentage points to a level similar to the Great Recession, an additional 4,000 people could die of suicide and another 4,800 people could die from drug overdoses.4 While some are depressed from unemployment, the frontliners especially the healthcare workers are mentally harmed from being overworked both physically and emotionally. Suicide are seen among this group of individuals. In New York, two healthcare workers have committed suicide.5 Interestingly, Japan reported a 20% fall in the suicide rate in April as compared to the same time last year. Theories postulated less commuting to work, working from home instead of long working hours and closure of schools have caused less stressors to the Japanese. A similar drop of cases was seen in 2011, the year of the giant earthquake, tsunami and nuclear meltdowns at Fukushima. However, as mentioned by Yukio Saito, a former head of telephone counselling service who also served as chair of the Japanese Association for Suicide Prevention, a prolonged economic downturn caused by the pandemic could lead to a rebound in cases sooner than later.6
The COVID-19 outbreak has also precipitated stigmatising and discriminatory behaviours. CDC listed the vulnerable groups as follows; certain racial and ethnic minority groups, including Asian Americans, Pacific Islanders, and black or African Americans, people who tested positive for COVID-19, have recovered from being sick with COVID-19, or were released from COVID-19 quarantine, emergency responders or healthcare providers, other frontline workers, such as grocery store clerks, delivery drivers, or farm and food processing plant workers, people who have disabilities or developmental or behavioral disorders who may have difficulty following recommendations, people who have underlying health conditions that cause a cough, people living in congregate settings, such as homeless people. During this war against pandemic, this stigma is unhelpful as it can drive people to hide the illness to avoid discrimination, prevent people from seeking health care immediately, discourage them from adopting healthy behaviours and cause isolation, depression and anxiety. Some of the ways suggested to avoid stigma and discrimination are by maintaining confidentiality of patients including those under investigation and surveillance, correcting negative languages, disseminating facts and accurate information about the disease and using media channels to speak out against stereotyping certain groups of people inflicted by Covid-19.7,8
What Can We Do?
Here are some of our thoughts which are technically practical, and suggestions put forth for our local context9. During the MCO the Ministry of Women, Family and Community Development could work with the National Health Council to formulate Standard Operating Procedures in relation to domestic abuse. These domestic abuse victims should be given access to transport and clearance within 10km radius from their home to escape from their abusers. Department of Social Welfare (Jabatan Kebajikan Masyarakat) should be given clearance in their work to help these domestic abuse survivors. Financial aid should also be given to these survivors that are financially dependent on their abusers. Emergency shelters for survivors should also be provided by collaborating with women NGOs and state governments. They should also be given skill training and employment assistance to become financially independent during post pandemic period.9Combating domestic violence at home is essential to prevent mental health issues such as major depressive disorder or anxiety disorder cases that are budding during this pandemic.
Psychological support program could be enhanced during the MCO to reduce anxiety for target groups. Foremost, we should screen the mental health status of a particular community by assessing their mental health using Depression, Anxiety and Stress Scale (DASS) through a Google Form or an online platform. From the results, we could define our target groups to tackle their anxiety level.
For those in the rural areas, the health officers in the villages could do home visits to assess the mental health of the villagers and provide counselling verbally and physically as they might not be accessible to social media. This would be a good way to tackle domestic violence. In addition, the Ministry of Health could collaborate with NGOs to sponsor the funding for COVID-19 swab tests for those with underlying illness and would be using the hospital equipment.
Besides that, online group counselling sessions on platforms such as Zoom, Google meet or Microsoft Team could be carried out for patients with existing medical conditions. Each of the people are allowed to register via a link, and they would be divided into groups for the counselling. Each group shall contain a psychiatrist, psychologist and social worker so that different issues faced by the patients could be managed accordingly. The same concept could also be used for online cognitive behavioural therapy, online prayer group, and online breathing exercise teaching. By doing this, we could continue to deliver mental health care while staying safe within the space of our homes.
Written by:
Subashan A/L Vadibeler*, Angeline Ooi Ying Ying*, Hamzatul Aqilah Abd Jalil*, Hani Hazira Binti Hairul*, Ng Xuan Xuan, Raja Nur Shahirah Binti Raja Harun*, See Hai Liang*, Mahmoud Danaee**, Farizah Mohd Hairi**
*Final Year MBBS students, Universiti Malaya
** Department of Social and Preventive Medicine, Faculty of Medicine, Universiti Malaya
References:
- Zaharieva R. The dangers of social isolation during a pandemic – EPHA [Internet]. EPHA. 2020 [Date accessed, 15 June 2020]. Available from: https://epha.org/the-dangers-of-social-isolation-during-a-pandemic/
- COVID-19: Tackle The Fear of Loss of Jobs [Internet]. BW people. 2020 [Date accessed, 15 June 2020]. Available from: http://bwpeople.businessworld.in/article/COVID-19-Tackle-The-Fear-of-Loss-of-Jobs/21-04-2020-189851/
- MCO-linked domestic violence rises l New Straits Times [Internet]. NST Online
https://www.nst.com.my/news/exclusive/2020/04/581233/mco-linked-domestic-violence-rises
- Befrienders KL sees more calls during MCO | New Straits Times [Internet]. NST Online. 2020 [Date accessed, 13 June 2020]. Available from: https://www.nst.com.my/news/nation/2020/03/580036/befrienders-kl-sees-more-calls-during-mco
- The coronavirus pandemic is pushing America into a mental health crisis [Internet]. The Washington Post. 2020 [Date accessed, 13 June 2020]. Available from: https://www.washingtonpost.com/health/2020/05/04/mental-health-coronavirus/
- Blair G. Japan suicides decline as Covid-19 lockdown causes shift in stress factors [Internet]. the Guardian. 2020 [Date accessed, 13 June 2020]. Available from: https://www.theguardian.com/world/2020/may/14/japan-suicides-fall-sharply-as-covid-19-lockdown-causes-shift-in-stress-factors
- Coronavirus Disease 2019 (COVID-19) [Internet]. Centers for Disease Control and Prevention. 2020 [Date accessed, 13 June 2020]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/reducing-stigma.html
- A guide to preventing and addressing social stigma [Internet]. Who.int. 2020 [Date accessed, 13 June 2020]. Available from: https://www.who.int/docs/default-source/coronaviruse/covid19-stigma-guide.pdf?sfvrsn=226180f4_2
- Immediate and long term plans needed to address rise in domestic abuse cases during MCO, says Penang Institute |Malay Mail [ Internet] .Malaymail Online. [Date accessed, 13 June 2020]. Available from: https://www.malaymail.com/news/malaysia/2020/05/04/immediate-and-long-term-lans-needed-to-address-rise-in-domestic-abuse-case/1862715
Written by:
Subashan A/L Vadibeler*, Angeline Ooi Ying Ying*, Hamzatul Aqilah Abd Jalil*, Hani Hazira Binti Hairul*, Ng Xuan Xuan*, Raja Nur Shahirah Binti Raja Harun*, See Hai Liang*
Supervised by:
Mahmoud Danaee**, Farizah Mohd Hairi**
*Group 7A Community Posting, Final Year Medical Student, University of Malaya
** Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya
Dr Mahmoud Danaee is a scientist and statistician, currently a Senior Lecturer at the Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya
Dr Farizah Mohd Hairi is an Associate Professor and a Public Health Medicine Specialist at the Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya