key: cord-296536-s8n7kgkn authors: nagendrappa, sachin; shoib, sheikh; rehman, sajjadur; grigo, omityah; ransing, ramdas title: recognizing the role of animal-assisted therapies in addressing mental health needs during the covid-19 pandemic date: 2020-08-27 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102390 sha: doc_id: 296536 cord_uid: s8n7kgkn nan the current pandemic of corona virus disease has affected millions of lives across the world (tandon, 2020a (tandon, , 2020b . the majority of the countries have implemented a course of action such as lockdown of cities to contain the infection spread. the pandemic and lockdowns, the isolations, quarantines combined have an immense psychological impact tandon, 2020a) . a review study has shown elevated stress, anxiety, depression, and panic among the general population including the health care workers. people with pre-existing psychiatric illness, elderly and pregnant women, homeless people are more vulnerable to psychiatric morbidities (rajkumar, 2020; shoib et al., 2020) since prehistoric times there is a bond between humans and pets. pets are known to provide a sense of companionship and security. studies have shown human-animal interaction have a potential role in reducing the stress, fear, anxiety, depressive symptoms and promoting calmness and social interaction. increased oxytocin levels during human-animal interaction is one of the proposed mechanism (andrea et al., 2012) . pets can also act as a companion to prevent loneliness (rew, 2000) . another study suggested pets were implicated in providing intimate and secure relationships and proposed pets should be considered as the main source of support (brooks et al., 2016) . systematic review on animal-assisted interventions (aais) canines, farm animals, equines showed a wider range of applications in depression, anxiety, including severe mental illness schizophrenia. aai also noted to enhance coping skills, improving self-efficacy (maujean et al., 2015) . there are certain methodological limitations in these available studies like small sample size, controls, and blinding. there is also a concern regarding the risk of transmission of covid-19 infection from animals to humans, even though millions of people in the world have been affected by covid-19 infection, however, there are only a few reports of pets testing positive for the virus and no robust evidence related to pets transmitting the infection to their owners, and no available guidelines for covid-19 testing in pets (parry, 2020) . j o u r n a l p r e -p r o o f challenging task in low and middle-income countries as there is minimal access to health care and scarce resources. identifying and using the existing resources such as pets to address loneliness and mental health concerns is one feasible option. there is a paucity of literature in this field, immediate attention needed to recognize the role of pets through systematic and experimental studies. the role of pets in addressing mental health seems to be promising in this regard. . the authors declare that there was no funding for this work. we declare that we have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. psychosocial and psychophysiological effects of human-animal interactions: the possible role of oxytocin ontological security and connectivity provided by pets: a study in the self-management of the everyday lives of people diagnosed with a long-term mental health condition a systematic review of randomized controlled trials of animal-assisted therapy on psychosocial outcomes covid-19 and pets: when pandemic meets panic covid-19 and mental health: a review of the existing literature. asian journal of psychiatry 52 mental health interventions during the covid-19 pandemic: a conceptual framework by early career psychiatrists friends and pets as companions: strategies for coping with loneliness among homeless youth factors associated with covid-19 outbreak-related suicides in india covid-19 and mental health: preserving humanity, maintaining sanity, and promoting health the covid-19 pandemic, personal reflections on editorial responsibility none references: key: cord-302279-d1or6wty authors: kang, chuanyuan; yang, shuran; yuan, jing; xu, li; zhao, xudong; yang, jianzhong title: patients with chronic illness urgently need integrated physical and psychological care during the covid-19 outbreak date: 2020-04-07 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102081 sha: doc_id: 302279 cord_uid: d1or6wty nan with the global outbreak of the 2019 coronavirus disease (covid-19) (wang et al., 2020) , different quarantine policies have been implemented in different countries in order to control the epidemic in time. in this circumstance, patients with chronic diseases, such as cardiovascular diseases, active cancer, diabetes, stroke, dementia, schizophrenia, major depressive disorder, and so on, would suffer from emotional disturbance, anxiety, anger, confusion, and stigma as summarized by brooks et al. (2020) because of sudden separation from loved ones, shortage of living supplies, the loss of freedom, and uncertainty over disease status. in addition, some patients have been confronted with difficulties in routine medical treatments due to delayed transportation and shortages of medicines and human resources in hospitals (pellino and spinelli, 2020) . what's more, in this epidemic the mortality rate in elderly patients with chronic diseases is the highest. the data from china and italy showed that the presence of these comorbidities might have increased the risk of mortality independent of covid-19 infection (graziano et al., 2020) . so some old patients with chronic diseases dare not go to hospital. all these situations increase the possibility of relapse or even death. though it is known that socioeconomic disadvantage is a risk factor for many diseases, and that policy and health-care practice addressing psychological health issues in social context and early in the life course could be effective strategies (kivimäki et al., 2020) , however, even in daily clinical work, many psychological problems encountered by patients with chronic diseases will be neglected, not to mention in the current stressful epidemic. the abilities of medical care in the epicenter would be greatly decreased because most medical staffs are busy for combating the epidemic as it happened at hubei province in china from jan to march in 2020. that is why by february 28, 330 medical teams with more than 40 thousand medical staff had been sent to hubei province to support the local health service, of whom 400∼500 are psychiatrists. during two month from around january 22, a few of patients with chronic diseases can only consult doctors through the online platform, mainly about their physical status. even obtained the suggestions from doctors, there would be other problem exist that shortage of medications because of stopped transportation, which resulted in the treatment discontinuation. besides the physical care, psychological care for these patients with chronic diseases still needs to provide timely. even though there are lots of online psychological self-help services, however, it can only be a general consultation, and it is difficult for these patients to get diagnosis and treatment from mental health perspective. what is more, many questions remain unanswered with regards to online mental health services in low and middle-income countries (yao et al., 2020) . while the epidemic continues to ravage most of countries, becoming a worldwide public health emergency, and social isolation will be required for the whole society, the patients with chronic severe diseases would suffer from more and more difficulties. now the outbreak is under control for china since the middle of march, many patients flood into hospitals seeking for help, however, because some medical staffs from other provinces are still in hubei or in the quarantine last for14 days, in addition to the shortage of medical supplies, so medical physicians can only take care of some patients physically. in this context, psychiatrists can play pivotal role in supporting the well-being of those affected and their families, the at-risk healthcare staff as well as the public (banerjee, 2020) , including the patients with chronic severe diseases. therefore it is necessary and urgent to address the comprehensive physical and psychological intervention for the vulnerable population during the epidemic. there is no any funding source. cyk, xdz, jzy contributed to the conception of the manuscript, and wrote the manuscript. sry, jy, lx collected the materials and data. the authors declare no competing interests. the covid-19 outbreak: crucial role the psychiatrists can play the psychological impact of quarantine and how to reduce it: rapid review of the evidence case-fatality rate and characteristics of patients dying in relation to covid-19 in italy association between socioeconomic status and the development of mental and physical health conditions in adulthood: a multi-cohort study how covid-19 outbreak is impacting colorectal cancer patients in italy: a long shadow beyond infection a novel coronavirus outbreak of global health concern rethinking online mental health services in china during the covid-19 epidemic thanks to all health workers who are battling with the epidemic. key: cord-333371-aocp8mrh authors: ifdil, ifdil; fadli, rima pratiwi; suranata, kadek; zola, nilma; ardi, zadrian title: online mental health services in indonesia during the covid-19 outbreak date: 2020-05-05 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102153 sha: doc_id: 333371 cord_uid: aocp8mrh nan the covid-19 pandemic in indonesia started when an individual with symptoms was tested and diagnosed on march 2, 2020 (brahma, 2020) . this became the first case in indonesia and was directly announced by president joko widodo (almuttaqi, 2020) . this led to many reactions from the general public, including evaluations of the government's preparedness in handling the issue. the first case compelled the government to look for clusters to prevent the spread of the disease. from march to april, the number of confirmed cases increased to 5,923, and the number of deaths rose to 520 people. this situation has caused psychological disorders including anxiety. in addressing the outbreak, the world health organization (who) announced that covid-19 was a pandemic and issued several protocols to support mental and social well-being during the outbreak (brahma, 2020; who, 2020) . treatments in affected countries are focused on the physical health of infected patients. various efforts have been made by affected countries to find the cause (brake et al., 2020) and a vaccine (alshaabi et al., 2020) . the indonesian government has accelerated the handling of the confirmed cases and issued presidential decree r1 no. 7 of 2020 on march 13 concerning the task force team for responding to the disease. later, they issued a revision of the previous decree, called no. 9 of 2020. the handling team took action to prevent the spread of the virus through various measures published on the website covid19.go.id. the team also issued three protocols, namely the entrance protocol of the indonesian territory, the public transportation protocol, and the protocol in the area of educational institutions. publications and awareness created by the task force team were quickly responded to by regional heads in all areas of the country. the heads of regions, education, and other official services relating to the public have instructed people to study, work, and worship from home. the government has provided online services through the 119 hotlines during the outbreak. this service has become a tool for people to obtain valid information about the pandemic and has focused on how to educate the public to break the chain of the spread. however, the service does not address the mental health problems of the community. the anxiety caused by hoax information, an increased number of deaths, and dramatized news has not been optimized. the spread of the virus has had a psychological impact on indonesian society, including heightened levels of stress, anxiety, depression, and obsessive-compulsive disorder (ocd). optimum online mental health services are needed to deal with anxiety during the outbreak. based on this, several educational practitioners conducted online research about anxiety levels from march 20 th -30 th , 2020. therapists, psychologists, counselors, and educational practitioners have also opened online services to help individuals that are experiencing psychological disorders during the outbreak. the service is in the form of online counseling through whatsapp, meets, zoom cloud meetings, and other platforms. also, thoughts and feelings during the pandemic can be seen in 24 languages on twitter (alshaabi et al., 2020) . however, the psychological state of the community is greatly influenced by the news coverage relating to the virus (dong and zheng, 2020) , and considerable attention from the government should be devoted to amending this situation. during the outbreak in indonesia, several practitioners such as counselors, psychiatrists, psychologists, therapists, and social workers have developed their own initiatives to help with psychological first aid and to improve the general psychological state of the community, including addressing high stress levels, anxiety, depression, ocd, and other psychological conditions. the forms of intervention are done through online counseling, distribution of brochures on the prevention of the disease, websites, youtube video tutorials, videos, short movies, online discussions through whatsapp groups, and other means. this form of treatment is still administered separately by practitioners. therefore, this current situation needs the formation of a forum to handle the psychological conditions during and after the outbreak. presently, online mental health services in indonesia are developing; for example, the mobile app survey (amms) (sukmawati et al., 2019) and the online health use of social media. moreover, the coordination between indonesia and other countries in the surrounding region is very important. based on these concerns, the southeast asia mental health and counseling association (samhca) was established and initiated by ifdil ifdil, itsar bolo rangka, kadek suranata, and colleagues from various countries including indonesia, malaysia, brunei darussalam, and timor-leste. lastly, there is hope that, in the near future, this association can become a forum for mental health and counseling practitioners, to help people navigate the post-covid-19 era. they will achieve this by addressing the global psychological crisis and other psychological problems developing in these communities. we declare no competing interests. none the omnishambles of covid-19 response in indonesia how the world's collective attention is being paid to a pandemic: covid-19 related 1-gram time series oncologists and covid-19 in indonesia: what can we learn and must do? indones smoking upregulates angiotensin-converting enzyme-2 receptor: a potential adhesion site for novel coronavirus sars letter to the editor: headline stress disorder caused by netnews during the outbreak of covid-19 development and validation of acceptability of mental-health mobile app survey (amms) for android-based online counseling service assessment mental health and psychosocial considerations during the covid-19 outbreak none key: cord-263777-9rehacfy authors: ransing, ramdas; pinto da costa, mariana; adiukwu, frances; grandinetti, paolo; schuh teixeira, andre luiz; kilic, ozge; soler-vidal, joan; ramalho, rodrigo title: yoga for covid-19 and natural disaster related mental health issues: challenges and perspectives date: 2020-08-27 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102386 sha: doc_id: 263777 cord_uid: 9rehacfy nan the covid-19 pandemic has placed the world at risk of an increased incidence of mental disorders (e.g., anxiety, fear, post-traumatic stress disorder) smith et al., 2020; tandon, 2020) . though prevention and management of these conditions are imperative, delivery of evidence-based in person psychotherapeutic interventions (e.g., cbt) has hampered due to lockdown, physical distancing, and overburdened health care systems. the provision of these interventions via telecommunication has its limitations, like the digital divide in lowmiddle income countries, lack of adequate training in telepsychiatry in many countries , and lack of access to a telephone connection (malathesh et al., 2020) . consequently, the burden of mental illness may remain unaddressed for specific populations if unprovided with viable alternatives. some countries have to be ready to deal with the double risk presented by both covid-19 and natural disasters. for example, fiji and bangladesh and india have in may 2020 faced the consequences of cyclones harold and amphan, respectively. natural disasters have shown to have a significant impact on mental health (durrani et al., 2019) . unfortunately, natural disasters further increase the difficulties for people to access mental health care including digital. this dual risk presented by covid-19 and the possibility of natural disasters reinforces the need to identify and provide viable alternatives to the one of telecare. ideally, any suggested option should be evidence-based, self-reliant, feasible, acceptable, appropriate, and non-dependent on access to telecommunications. in this letter, we explore the potential utility of yoga as such an alternative. in 2014, the united nations proclaimed 21 st june as the international day of yoga. 'yoga' is a sanskrit word that translated as 'to join' or 'to unite,' symbolizing the union of body and consciousness. it is a multi-component discipline that includes three forms of practice, namely postures and physical exercises (asana), breathing regulation techniques (pranayama), and meditation-based (control j o u r n a l p r e -p r o o f of attention, dissociating oneself from the disturbing thought) activities. the world health organization (who) describes yoga as a valuable tool, one that increases physical activity, mental wellbeing, and decreases non-communicable diseases. the positive physical or psychological outcome of yoga intervention has hypothesized to be a result of complex pathways involving relaxation, physical flexibility, breathing exercise, coping strategies, acceptance, and self-efficacy (büssing et al., 2012) . yoga has been proposed as a non-pharmacological intervention for mental issues (e.g., stress, fear) and disorders, either alone or in combination with other interventions. for example, significant improvement in people with post-traumatic stress disorder has reported following yoga interventions (büssing et al., 2012) . also, it has been found effective in reducing perceived stress, reducing fatigue in patients with cancer, improving blood sugar regulation in diabetes mellitus, diastolic blood pressure, symptoms of menopause, chronic bronchitis, and asthma (büssing et al., 2012) . yoga can enhance emotional control, and to improve self-efficacy, selfconfidence, and overall quality of life. we searched two databases, pubmed and scopus till 23 rd may 2020, for publications (available in english) about the potential role of yoga in both the covid-19 pandemic and natural disasters. to our surprise, no studies were exploring the potential role of yoga as an intervention for mental disorders during covid-19, and there were only five studies on the role of yoga as a potential supportive intervention in disaster settings (table 1) (descilo et al., 2010; durrani et al., 2019; telles et al., 2010 telles et al., , 2007 thordardottir et al., 2014) . these studies were single centric conducted across three countries (india = 3, usa=1, iceland=1) covering four disaster settings (tsunami =2, hurricane =1, earthquake =1, and flood=1). yoga was found a beneficial, cost-effective, and feasible intervention in all except one study. but, these findings components: • physical activities of mild to moderate intensity. effects of yoga on mental and physical health: a short summary of reviews effects of a yoga breath intervention alone and in combination with an exposure therapy for post-traumatic stress disorder and depression in survivors of the 2004 south-east asia tsunami the effects of yoga in helping cancer patients and caregivers manage the stress of a natural disaster: a brief report on hurricane harvey response to: rethinking online mental health services in china during the covid-19 epidemic covid-19 effect on mental health: patients and workforce correlates of symptoms of anxiety and depression and mental wellbeing associated with covid-19: a crosssectional study of uk-based respondents the covid-19 pandemic yoga reduces symptoms of distress in tsunami survivors in the andaman islands post traumatic stress symptoms and heart rate variability in bihar flood survivors following yoga: a randomized controlled study effects of yoga practice on stress-related symptoms in the aftermath of an earthquake: a community-based controlled trial : an increase in selfrated anxiety.neither group showed changes in heart rate variability or breath rate small sample size, small effect size, short duration of follow up, all male participants (telles et al., 2007) tsunami, india key: cord-321945-bbzhrpwd authors: bhat, ritesh; singh, varun kumar; naik, nithesh; kamath, c. raghavendra; mulimani, prashant; kulkarni, niranjan title: covid 2019 outbreak: the disappointment in indian teachers date: 2020-03-28 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102047 sha: doc_id: 321945 cord_uid: bbzhrpwd nan coronavirus disease or commonly known as covid19 is the news of every single second since it originated from wuhan, china (wang et al., 2020) , which is declared as a pandemic disease by world health organization, said to be caused by a new strain of the virus. the disease is said to spread through droplets of saliva or discharge from the nose of an infected person, particularly when he/she sneezes or coughs (world health organization, 2020) . though the human coronaviruses have been recognized now for many years, the lack of immunity to the identified new strain, there is a large portion of the population susceptible to it (goyal et al., 2020) . besides, the latest trend of the exponential increase in the infected people, with a steep rise of 69.17 % within three days from 21st march 2020 to 23rd march 2020 (kiprosh, 2020) , and because of the lack of preventive vaccine (el zowalaty and järhult, 2020), there has been a high panic situation amongst the local public. to take control of the situations, the government of india issued the guidelines on social distancing and has been communicating to the entire population through different channels successfully (world asia, 2020). besides, 82 districts all over the country have been locked down to get control over the situation (hindustan times, 2020). however, another step taken to prevent the spread of the discussed epidemics is the closure of educational institutes in various states. nevertheless, the setback was that the closure included only the holidays declared to students and not to the faculty members. this decision of withholding the teachers back on the job has created a lot of psychological impacts on the morale of the teachers. the teaching community is trying to question back as how are they safe from the pandemic disease if not the students and on the other hand few educational institutes are mulling to terminate a few teachers for saving the money (times of india, 2020a). teachers irrespective of being in private or government institutes all over highly disappointed with the inhumane behavior with them compared to the industries and companies giving a work-from-home facility to their employees (times of india, 2020b). the magnitude of agitation has gone to such heights that recently, an online petition was circulated namely "#keepteacherssafe." the petition is being signed to ask the indian ministry of health and family welfare (mohfw) and health ministry and the human resource development ministry (mhrd) to immediately issue a directive asking all educational institutions (schools and colleges) to be closed till march 31, 2020, for teachers and other staff as well. in just four days, 53,325 faculty members have signed the petition (parekh, 2020) , which shows the disappointment of the indian teaching community. the disappointment here is not due to the lethargic attitude of teachers but the fear of getting infected and being a carrier for the family and neighbors. this if continued can bring the teacher's morale down and a teacher's moral is very complex as the research has proved very well how it affects the student learning process (mackenzie, 2007) . a frustrated and demoralized teacher have proved to have a negative behavior towards the students community (greenwood and soar, 1973) . in this situation, the indian government must think of balancing between keeping the teachers engaged in the academic area without risking their life. instead of forcing a teacher to get into the institute and load him with additional academic and non-academic duties, the government, universities and institutes must take specific alternative positive steps. for example, the teachers today are mostly computer educated and the era today is of the internet, so one can be instructed to get the administrative work done from home. also, the present time shall be utilized by the institutes by providing the teachers the free access to a few paid e-learning platforms or academic article databases and tell them to utilize it from their home. free online faculty development programs and conferences can be arranged. the inspiration given with care shall naturally boost the morale of the teachers. the continuous positive attitude towards teachers will lead to an improved teaching-learning system when they return to work after the unpredicted and unwanted break caused due to covid 2019 outbreak. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. from sars to covid-19: a previously unknown sars-cov-2 virus of pandemic potential infecting humans -call for a one health approach. one health 9 fear of covid 2019: first suicidal case in india! some relationships between teacher morale and teacher behavior hindustan times, 2020. 82 districts under lockdown over covid-19: what is shut and where covid-19 outbreak in india teacher morale: more complex than we think? close all educational institutions for teachers and other staff #keepteacherssafe [www document covid-19: schools closed in telangana, but teachers asked to work [www document]. times of india. url covid-19: schools closed in telangana covid-19 outbreak: karnataka teachers upset as department lists duties [www document phase-adjusted estimation of the number of coronavirus disease coronavirus: india issues guidelines on social distancing [www document all authors contributed equally. the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. none. key: cord-319969-wlnbilr5 authors: chatterjee, seshadri sekhar; vora, mansi; malathesh, barikar c; bhattacharyaa, ranjan title: worried well and covid-19: re-emergence of an old quandary date: 2020-06-18 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102247 sha: doc_id: 319969 cord_uid: wlnbilr5 • 'worried well', as a concept, was first described during hiv; • current covid-19 pandemic has given rise to wave of worried well again; • this leads to burden on already overburdened health care system. • having good “surge capacity”, “mild casualty centres” and effective triage of cases are the solutions. seshadri sekhar chatterjee, mansi vora, barikar as covid-19 hit the world, almost all the countries are tackling it with lockdown, increased testing, and other strategies. the developed countries have passed their peak, whereas developing countries are yet to flatten the 'hammer curve'. more than 40 million tests have been carried out till now and still the demand is ever increasing. moreover, even after the acute phase attenuated, there will be many postpandemic psychological and psychosocial effects to be dealt with (tandon r, 2020) (chatterjee ss, 2020) . as actual cases are continuing to overwhelm the health care, there is another set of people posing burden to the healthcare system, that is the 'worried well', a phenomenon referred clinically as a type of mass psychogenic illness. 'worried well', as a concept, was first described during hiv, when many people visited hospitals for consultation, for being tested or for reassurance (cochran and mays, 1989 ). pilch gave a categorical description that roughly divided these patients into three categories. -(a) individuals not exposed in a real way, yet experiencing symptoms of the disease in question, due to anxiety, (b) individuals who may have been exposed or fear that they will get exposed due to nature of their work etc, who do not have symptoms of the illness, but may seek medical services as a preventive measure or to alleviate their anxiety and reassurance, (c) individuals who experience anxiety or distress following traumatic events (pilch, 2004) . after the hiv epidemic attenuated, the research on this topic decreased but resurfaced recently with different diseases, namely dementia or mci (verity et al., mar) and bowel cancer screening (chapman et al., 2016) . there are previous reports about how these are different from somatoform disorder (smith et al., 2002) but these data should be taken with caution as most of the study were done in general practice settings as they invariably visit physicians. upon a medical diagnosis being ruled out, such patients are labelled 'worried well', but unfortunately with a negative connotation to it. by various unintended and unintentional acts of violation of preventive measures like social distancing, spreading the infection, frequenting hospitals to know if they have the illness or not, overburdening the health care system (cost, manpower, diagnostic kit, gloves, personal protective equipment), buying of drugs which are being circulated as possible prophylaxis, which could actually be used for those who need it more. these individuals can unintentionally absorb a great deal of attention in their pursuit of reassurance. their anxieties fail to be allayed by repeated negative tests. such situations create a panic like situation and increases the burden of an already pressured health care system. virtually all epidemics in history have noted this worried well phenomenon, but unfortunately there is also a negative connotation to it associated with type casting (gray et al., 2020) . some measures to deal such situations have been suggested in the past, like immediately imparting the right information through use of various print and broadcast media about symptoms and about who should visit the hospital and who shouldn't, having a good 'surge capacity' (hick et al., 2004) , triage of cases (ramesh and kumar, 2010) , having an arrangement like 'mild casualties centre' where people with mild symptoms are assessed, screened and sent to either required speciality or for counselling and to a psychiatrist when confirmed that symptoms are psychogenic. at present, illness anxiety disorder, anxiety nos, somatoform disorder might be the possible differential diagnosis. so, we should differentiate them from the true worried well. a psychiatrist may treat the patient based on the differential diagnosis and when it is an established 'worried well' case, reassurance and educating should be emphasized upon. to sum up, the main concerns in all the diseases are the same, over-utilizing the health service and resources, and should be taken seriously. being cautious, maintaining a balance and more organised study is warranted in this field, for better understanding and analysis, and to device better management plans for any future events. all the authors have contributed and approved the final manuscript. there was no financial assistance sought in any form for this work. over-age self referrals in the english bowel cancer screening programme -are they the worried well or the symptomatic needing something more? impact of covid-19 pandemic on pre-existing mental health problems women and aids-related concerns: roles for psychologists in helping the worried well the worried well health care facility and community strategies for patient care surge capacity the worried well: strategies for installation commanders homeland security digital library triage, monitoring, and treatment of mass casualty events involving chemical, biological, radiological, or nuclear agents minor acute illness: a preliminary research report on the "worried well the covid-19 pandemic, personal reflections on editorial responsibility the worried well? characteristics of cognitively normal patients presenting to a rural and remote memory clinic. the canadian journal of neurological sciences key: cord-315963-hs70zo48 authors: kar, sujita kumar; arafat, s.m. yasir; sharma, pawan; dixit, ayushi; marthoenis, marthoenis; kabir, russell title: covid-19 pandemic and addiction: current problems and future concerns date: 2020-04-10 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102064 sha: doc_id: 315963 cord_uid: hs70zo48 nan to the editor, covid-19 pandemic is a global public health emergency. it affected more than 512,000 people with 23,495 confirmed deaths in 202 countries by 28th march 2020 (organization, 2020) . the disease spread rapidly across the globe due to the unique properties of the virus (extraordinary genetic diversity, highly contagious, easy mode of spread, relatively unaffected by climatic variations) (mackenzie and smith, 2020) . people around the globe, during this crisis period, are expected to encounter several mental health challenges ranging from panic, phobia, health anxiety, sleep disturbances to dissociative like symptoms (banerjee, 2020) . along with these, addictive behaviors could be potential reasons for nuisance during the locked-down period and subsequently, newer behavioral addictions could emerge especially for the teens. people are advised to stay at home, maintaining social distancing and avoiding travel. schools, restaurants, pubs, offices, shops have been closed resulting in inaccessibility to substances. staying at home setting and isolating from the society, also reduces the risk of substance consumption. social celebrations and partying are restricted. these situations are conducive to substance use. to reduce the spread of covid-19, social distancing technique is often promoted; the morality behind it is not to limit socialization but to enhance physical distancing to prevent the spread of infection. an individual is free to socialize online, rather than offline; however, online socialization is unlikely to build peer pressure to that extent, which expected to happen in direct socialization. social distancing and limited socialization also reduce the possibility of peer pressure for substance use. hence, people who were addicted to any kind of substance use independence pattern are expected to experience withdrawal symptoms. the above factors convey that the social restriction and locked down states in most parts of the world can be a risky affair in the short-run, as many of the individuals can have severe withdrawal symptoms, which can be life-threatening at times (for example-alcohol withdrawal seizures and delirium tremens). on the other hand, as the sources of pleasure are limited to indoor activities, people spend a substantial period watching television and their electronic gadgets. as the impact of pandemic lasting for a long time, the binge-watching of television and electronic gadgets are also likely to persist; which may later result in behavioral addiction. there are higher chances for the young generation to develop behavioral addictions, especially in developing countries. another important area to look at would be the patients with opioid dependence and undergoing daily dispensing agonist treatment. missing a single dosage at the time of lockdown would lead to relapse. when the whole world is preparing to fight the pandemic they could be missed (russell, 2010) . also, it is an accepted truth that the patients with substance use problems are vulnerable populations during the time of pandemic both for being infected or regarding complications (o'sullivan and bourgoin, 2010) . furthermore, those who are addicted to specific drugs and could not obtain any supply due to the lockdown period, they might try to make home-made alcoholic spirits. the spirits might have a high risk of alcohol toxicity and can cause poisoning and fatality. there is an urgent need to address the mental health issues of people during this pandemic. most of the countries in the world are adapting lockdown measure to reduce the spread of the infection, the health services are struggling to deal with the daily rise of infected cases hence little attention is provided to the substance user during this pandemic so proper measures and support services should be established to help this vulnerable community. it is highly important to address mental health emergencies like severe and complicated withdrawal symptoms of substance use. milder symptoms can be addressed through online psychiatric consultation (yao et al., 2020) . there is a need to sensitize people about the addiction-related issues during this pandemic. a mental health helpline may be useful to address specific queries. a special focus for the young person to prevent them from developing the behavioral addictions could be thought as they are more prone to develop it. the covid-19 outbreak: crucial role the psychiatrists can play covid-19: a novel zoonotic disease caused by a coronavirus from china: what we know and what we don't vulnerability in an influenza pandemic: looking beyond medical risk coronavirus disease (covid-19) outbreak situation. coronavirus dis. covid-19 pandemic influenza pandemic, mental illnesses, addictions rethinking online mental health services in china during the covid-19 epidemic yasir arafat b , pawan sharma c , ayushi dixit d , marthoenis marthoenis e none. key: cord-279735-3sq7m3qw authors: yoshihiro, noda title: socioeconomical transformation and mental health impact by the covid-19's ultimate vuca era: toward the new normal, the new japan, and the new world date: 2020-06-22 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102262 sha: doc_id: 279735 cord_uid: 3sq7m3qw nan distance and remote work are recommended to prevent the spread of covid-19; however, such public health policies will consequently promote the rapid digitalization of social infrastructure. indeed, remote communication technologies are gradually being deployed in all areas of healthcare. in particular, telepsychiatry through the use of teleconferencing and other technologies is in a unique position to bring tele-digitalization efforts in psychiatry to the forefront (shore et al., 2020) . specifically, the early arrival of society 5.0 (fernandez-luque and imran, 2018), represented by virtual reality, augmented reality, artificial intelligence, and the ubiquity of the internet of things will accelerate the expansion of human cognition and physical functions, as well as the seamless construction and utilization of big data in conjunction with the digitalization of social infrastructure. however, some people may be unable to adapt well to the rapid digitalization of social systems. furthermore, the digitalization of the social environment is not only related to the mental health domain, but also to the question of existential readiness in how people adapt to the new normal (miao and cao, 2019) . specifically, a certain number of people may have mental health problems due to the "techno-stress" (la torre et al., 2019) associated with the rapid changes in social systems in the process of digitization of the social infrastructure. moreover, the stress of covid-19-related issues in the first place can be traumatic for some people and cause chronic anxiety and sleep disturbances. these chronic stresses can also cause people to fall into alcohol abuse and drug dependence. on the other hand, as we are going to shift into the post-covid-19 era, people may develop mixed feelings of relief and gratitude as survivors, or frustration, anger, and distrust over the covid-19-related issues. there will also be people who can gain personal growth and spirituality as they overcome these kinds of stresses through mental resilience (cosic et al., 2020; horesh and brown, 2020) . in the era of covid-19, there is "volatility" in that it is unclear when the second and third waves of the pandemic will strike, and there is "uncertainty" in that its resurgence and spread cannot be predicted. in addition, the covid-19 pandemic is "complex" because not all routes of infection can be traced, and since most of the infection takes the form of subclinical infections, the symptoms are "ambiguous" and its containment is not straightforward. thus, the issues related to covid-19 are the very same "vuca" (alkhaldi et al., 2017 ) that came to be used in the business industry in 2010s to describe situations such as "it is difficult to predict the future because of the rapidly changing social environment". therefore, the global covid-19 pandemic would force the general public to learn the "vuca" era mindset. the covid-19 pandemic embodied the ultimate world of "vuca," and the way of life in the age of vuca is fundamental to the strategies for confronting the covid-19 problem. furthermore, the impact j o u r n a l p r e -p r o o f of the pandemic on the real economy cannot be ignored, as the real economy and individual mental health are closely related. since the covid-19 pandemic is a medium-to long-term battle against an "invisible enemy," it will test people's ability to adapt to irreversible social change toward the new normal. in addition, as the pandemic is a fight against an "invisible enemy," conventional manpower tactics are not only ineffective but may even be harmful. the only way for humanity's wisdom to confront this challenge is the digital transformation of public mental health and psychiatry through the use of it. countries and regions that can technologically and economically paradigm shift to a society 5.0 world at the moment are very limited. however, countries around the world should urgently work to develop the infrastructure for the digitalization of mental health care in the future. sooner or later, a prolonged pandemic will qualitatively change people's lifestyles. the deregulation and changes in the social system triggered by this social crisis would be a good opportunity to strategically build a post-covid-19 digital mental health world. specifically, industry, government, and academia must work together globally to build a platform (barton et al., 2020) that can collect and store not only information on covid-19 infection but also life and medical data seamlessly and ubiquitously. such initiatives will contribute to the rational management of the mental health as well as realize an organic system that can analyze big data in real-time and immediate feedback the results to society. are you ready? crisis leadership in a hyper-vuca environment call for transparency of covid-19 models eco-epidemiological assessment of the covid-19 epidemic in china impact of human disasters and covid-19 pandemic on mental health: potential of digital psychiatry humanitarian health computing using artificial intelligence and social media: a narrative literature review traumatic stress in the age of covid-19: a call to close critical gaps and adapt to new realities definition, symptoms and risk of techno-stress: a systematic review high-performance work system, work well-being, and employee creativity: cross-level moderating role of transformational leadership telepsychiatry and the coronavirus disease 2019 pandemic-current and future outcomes of the rapid virtualization of psychiatric care the covid-19 pandemic, personal reflections on editorial responsibility key: cord-307313-sox12zfo authors: kalaitzaki, argyroula e.; tamiolaki, alexandra; rovithis, michael title: the healthcare professionals amidst covid-19 pandemic: a perspective of resilience and posttraumatic growth date: 2020-05-15 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102172 sha: doc_id: 307313 cord_uid: sox12zfo nan once covid-19 was recognized as a global health threat and a public health emergency of international concern (wang, 2020; world health organization, 2020), national health systems started to face a disproportionate threat and an overwhelming pressure to cope with the profound effects of the pandemic (chopra et al., 2020) . healthcare professionals are at the front-line of this crisis and are those who are actively engaged in the process of providing care for patients with covid-19 while managing critical issues daily (e.g., lack of hospital facilities, personal protection measures, exhausting working hours, fear of contagion and spreading the virus).most of the reports and studies have examined the obvious negative outcomes on health professionals, such as increased levels of stress, anxiety and depression (lai et al., 2020) . vicarious traumatization (vt), secondary traumatic stress (sts), compassion fatigue or 'cost of caring' (cf) have all been used interchangeably -despite the nuanced differences-to describe the detrimental effects of being exposed to the trauma reports of others and the empathic engagement with their traumatic experiences. undoubtedly, the exacerbation of existing or the onset of new mental health symptoms and disorders should be a priority and a serious public concern. that said, at this point, we would like to argue that the covid-19 pandemic should signify a shift toward the study of how patient care can be a positive experience for the professionals and their well-being by focusing on the psychological assets and resources that empower people to cope. in j o u r n a l p r e -p r o o f both research and intervention, a salutogenic framework should be adopted, aiming at examining and enhancing the factors that help people achieve health and well-being while exposed to stress. studies have shown that positive effects in the face of adversity and trauma are possible and likely to occur. abundant research evidence suggests that promoting resilience in both formal and informal caregivers may buffer them from the detrimental effects of distress and caregiving and have a positive impact on their quality of life. if "bouncing back" is what resilience is all about, posttraumatic growth (ptg) is "bouncing forward". it is increasingly recognized that a number of personal assets and resources (e.g., communication, social support, coping strategies) are positively associated with either resilience or posttraumatic growth (palacio et al., 2019) . recognizing and further strengthening these should be a priority for health professionals. coordinated and cooperative efforts worldwide should conduct large-scale cross-sectional and longitudinal studies despite the difficulty in accessing and recruiting participants, such as specific professional groups. the pandemic also calls for new interventions, both theory and research driven. evidence-based interventions aiming at safeguarding health professionals from the negative effects of the pandemic, while concurrently -and mainly-strengthening their personal assets and resources, are of paramount importance both for the safety of all the parties being involved (i.e., professionals and patients), and the quality of patient care itself. these efforts should be developed amidst the pandemic and be intensified after the pandemic. tailored-based interventions addressing the specific needs of diverse groups of health professionals are needed. the psychological empowerment of those professionals will guarantee a physically and mentally healthy workforce devoted to high-quality care provision. the world health organization has the potential to make use of evidence-based sets of resourceenhancing tools and interventions for professionals and proliferate their use internationally. to conclude, we would like to draw the attention of the experts in the field (i.e., researchers, policymakers) to an alternative perspective. rather than adopting a loss and deficit framework or a wear hypothesis, a positive salutogenic perspective can and should be applied by all. we should be mobilized to pay attention to what covid-19 pandemic crisis can teach us and what we can learn. j o u r n a l p r e -p r o o f how should us hospitals prepare for coronavirus disease 2019 (covid-19) factors associated with mental health outcomes among health care workers exposed to coronavirus disease resilience in caregivers: a systematic review a novel coronavirus outbreak of global health concern coronavirus disease 2019 (covid-19): situation report declaration of interests: we declare no competing interests. the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.acknowledgements: none key: cord-297711-6zi9xgu4 authors: r., varalakshmi; k., arunachalam title: covid 2019 – role of faculty members to keep mental activeness of students date: 2020-04-09 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102091 sha: doc_id: 297711 cord_uid: 6zi9xgu4 nan world health organization (who), declares as on march 30, 2020, globally 693,282 confirmed cases of coronavirus disease 2019 , which includes 33,106 deceased (https://www.who.int/docs/ default-source/coronaviruse/situation-reports /20200330-sitrep-70covid-19.pdf?sfvrsn=7e0fe3f8_4; coronavirus outbreak, 2020a,b) . the virus was first identified in wuhan state of china during december 2019 and it was started to spread across the globe. the virus will affect the respiratory system with fever and cough (wuhan municipal health and health commission, 2020) . the world health organization (who) termed this virus as 2019 novel coronavirus (2019-ncov). though, initial patients were due to animal-to-person transmission and sooner more cases were reported are medical staff and others, indicates human-to-human transmission of virus (liu et al., 2020) . the virus mainly spread via respiratory droplets from sneezing or cough of infected people during close contact with others. in india, the first case was reported in the last week of january 2020 (https://www.indiatoday.in/india/story/kerala-reports-firstconfirmed-novel-coronavirus-case-in-india-1641593-2020-01-30). the outbreak has been declared an epidemic by world health organization (who). to reduce the spread of the virus, the government of india issued the various guidelines include hand hygiene practices, wearing masks, avoiding public gathering, social distancing and quarantines etc. and through different media, the message has been broadcasted to all the people (https://www.livemint.com/news/india/govt-calls-forsocial-distancing-as-confirmed-coronavirus-cases-rise-to-124-11584384445401.html). during the 2 nd and 3 rd week of march 2020, many state government were shut down the educational institutions including schools and colleges upto 31.03.2020. on 22.03.2020, as insisted by the prime minister, india has observed a 14 -h voluntary public curfew. on 24.03.2020, considering the nature of virus spreading, the prime minister of india announced a complete nationwide lockdown, starting from midnight for 21 days till 14.04.2020 (https://www.independent. co.uk/news/world/asia/india-coronavirus-lockdown-modi-speechcases-update-news-a9421491.html). as the health of the nation is very important and social distancing reduce the spread of the virus, the steps taken by the indian government are highly appreciable. from the above facts, it is observed that more than 4 weeks has been declared holiday to the student's fraternity. in general, the classes for the even semester will be held between december to march and in april end semester examination will be conducted. during even semester festivals including christmas, new year, pongal will be celebrated. also, co-curricular and extra-curricular activities including cultural, sports, hostel day, institute day, department symposium etc., are also conducted during this semester. as the part of performance evaluation, internal assessment, model examinations, laboratory examinations, semester examinations etc are also conducted in march. in this present scenario, if the students are not attending the classes, then the students will spend their time in watching television, playing games, internet surfing, chatting etc. the faculty member plays a vital role in keeping the young budding professional in active mode. the students are to be engaged in a proper manner and they have to utilize this time in a productive manner. on 25.03.2020, the university grants commission (ugc) has issued the circular in connection with ict initiatives of mhrd and ugc (https://www.ugc.ac.in/pdfnews/1573010_on-line-learning-ictinitiatives-of-mhrd-and-ugc.pdf). these initiatives are highly informative to the faculty members and the students to enhance their knowledge either in their fundamentals course (or) in advanced course (or) in preparing for a competitive examination (or) in a specific field of his / her interest. the initiatives include: their course to the respective students, the following online methods can be adopted for various steps in teaching-learning process. teaching can be either offline or online. in offline mode, the lecture video will be recorded using powerpoint, webcam with good quality noise cancellation microphone. a digital drawing tablet with pen would add value for mathematical teaching, derivation, numerical examples etc. the video can be uploaded in youtube and the link can be shared to the students. the limitation is the faculty member cannot ensure whether all the students viewed the lecture video or not. in online mode, tools like google hangout, skype, zoom etc can be used. the faculty member can schedule an online class and ask all the students to present. this would require a good broadband internet connection for video streaming. the faculty member can able to clarify the doubts raised by the students. after the classes, in order to understand and evaluate the student, online assignments and online evaluation can be made. the quiz can be created using google forms, either multiple choice question or short answer. the faculty members can able to provide feedback, marks secured, instruction etc. with the help of microsoft teams, the students can collaborate and do group assignments, prepare and edit of their project report. for student interactions among themselves, they can use google hangouts, skype, zoom etc. social media like facebook, whatsapp etc., can also be used without invading their privacy. lecture materials, notes, presentation, short videos and other related information can be shared to the students using blackboard, or google classroom, moodle etc. though, many ict tools are widely available (https://en. todaysteachingtools.com/list-of-ict-tools.html), to the best of the knowledge of the authors, a list of ict tools to engage the students actively inside the classroom and outside the classroom are given below (in alphabetical order in this situation, as per the direction of ministry of human resource development (mhrd), india, the faculty member should engage the students academically through online for the benefit of their career. also, the faculty members should engage themselves actively in upgrading their knowledge, writing research papers, attending webinars etc. this will gain their confidence. also, students will be in phase with the academic calendar. this constant student engagement activity will strengthen the teaching-learning and it is sure that it will break the chain of spreading of covid 2019. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. wuhan municipal health and health commission's briefing on the current pneumonia epidemic situation in our city transmission dynamics of all authors contributed equally. the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. none. key: cord-280361-242yq90p authors: emmanuel, stip; ostlundh, linda title: psychiatric adverse events with hydrochloroquine during covid-19 pandemic date: 2020-06-20 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102203 sha: doc_id: 280361 cord_uid: 242yq90p • hydrochloroquine, well known in rheumatology, dermatology and tropical medicine is now considered in the treatment and prophylaxy for the sars-covid19. • mental and neurological manifestations should be assessed following the use of hydrochloroquine particularly following prophylactic use. • for acute malaria studies, hydroxychloroquine was associated with high prevalence of mental neurological manifestations amongst anti-malaria drugs. • recommendations of using hydrochloroquine in covid are variable and sometimes contradictory depending on agencies and countries. psychiatric adverse events with hydrochloroquine during covid-19 pandemic. emmanuel stip *stipe@uaeu.ac.ae, linda ostlundh *corresponding author: emmanuel stip, affiliation: cmhs, united arab emirates university, department of psychiatry and behavioural sciences, al ain, uae +9171 505315058 highlights  hydrochloroquine, well known in rheumatology, dermatology and tropical medicine is now considered in the treatment and prophylaxy for the sars-covid19 .  mental and neurological manifestations should be assessed following the use of hydrochloroquine particularly following prophylactic use.  for acute malaria studies, hydroxychloroquine was associated with high prevalence  of mental neurological manifestations amongst anti-malaria drugs.  recommendations of using hydrochloroquine in covid are variable and sometimes contradictory depending on agencies and countries. the directives and evidence concerning drugs for the treatment and prophylaxis of covid-19 are rapidly evolving. covid-19 is now pandemic and recent publications in the asian journal of psychiatry have fruitfully synthesized the impact of the pandemic on mental health (mukhtar 2020 , rajkumar 2020 , tandon 2020 , zhao 2020 . in such a context and given the worldwide experience, it is notable that the mental health of frontline health care providers is affected (mohindra 2020). with this pandemic, some people receive hydrochloroquine (hco) either as a treatment or as a prophylaxis (abena 2020 , colson 2020 , cortegiani 2020 , icmr 2020 , liu 2020 , rathi 2020 . precautions have to be taken because of the psychiatric vulnerability in some individual and the side effects of this drug (juurlink 2020 , stip 2020 , touret 2020 . for instance, the fda has authorized clinicians to prescribe chloroquine and hydroxychloroquine for patients admitted to hospital with covid-19, and in parallel there were warnings from scientific advisers that no randomized controlled trial has been completed to date to support the drugs' safety and efficacy in this covid-19 population (lenzer 2020 , owens 2020 insomnia and psychomotor agitation. the blood count, electrolytes, kidney, hepatic function, glycemia were normal, the thick smear microscopy was negative, no biological inflammatory syndrome, urine drug screen negative, as well as the ct scan, eeg and ecg. the chloroquine level was 0.5 mg / l. chloroquine was stopped. evolution was good after an 8-day stay in the psychiatric ward. she received olanzapine 7.5 mg 5 days and the episode was attributed to a psychiatric adverse event (pae). before going to india, the patient wants to be reassured and get evidence-based information. chloroquine is used to prevent and treat malaria. the addition of a hydroxide derivative to hydrochloroquine has also attracted attention as a possible treatment or prophylaxy for the covid-19 (mitja 2020). in recent years, biological and clinical work has shown that beyond its anti-inflammatory and immunomodulatory action, hydroxychloroquine can improve the risk vascular by acting directly on the lipid profile and has antithrombotic property (frimpong 2018) . it shows also an in vitro antiviral activity against a range of rna viruses. its mechanism of action is likely acting via the golgi vesicle, lysosome ph increase. psychiatric side effects could be related to the cholinergic imbalance and to the down regulation of p-glycoprotein. to answer the patient, a literature review was performed using pubmed and scopus to identify relevant all-language articles published through april 2020. search terms included various psychiatric symptoms or side effects (depression, anxiety, psychosis) and hydrochloride. search terms for relevant publication types (case reports, case series, rcts, systematic reviews and meta-analysis) were also included (see table 1 ). we found 113 relevant case reports, 12 systematic reviews/meta-analysis and 18 rcts. additional relevant articles were identified from the army registry from different countries (france, korea, uganda, italy, uk usa) (migliani 2014 ,korwal 2005 , duparc 2020 , touze 2001 , 2007 ,yeom 2005 . active clinical trials were chloroquine and hydroxychloroquine for the prevention or treatment of novel coronavirus disease (covid-19) in africa: caution for inappropriate off-label use in healthcare settings antimalarial drugs and the prevalence of mental and neurological manifestations: a systematic review and metaanalysis chloroquine for the 2019 novel coronavirus neurological and psychiatric safety of tafenoquine in plasmodium vivax relapse prevention: a review safety and effectiveness of antimalarial therapy in sickle cell disease: a systematic review and network meta-analysis safety considerations with chloroquine, hydroxychloroquine and azithromycin in the management of sars-cov-2 infection neuropsychiatric adverse events of chloroquine: a real-world pharmacovigilance study using the faers database malaria control strategies in french armed forces use of antiviral drugs to reduce covid-19 transmission an outbreak of malaria in us army rangers returning from afghanistan covid-19: us gives emergency approval to hydroxychloroquine despite lack of evidence hydroxychloroquine, a less toxic derivative of chloroquine, is effective in inhibiting sars-cov-2 infection in vitro issues relevant to mental health promotion in frontline health care providers managing quarantined/isolated covid19 patients psychosis following chloroquine ingestion: a 10-year comparative study from a malaria-hyperendemic district of india exacerbations of bipolar disorder triggered by chloroquine in systemic lupus erythematosus-a case report chloroquine psychosis chloroquine psychosis masquerading as pcp: a case report transient global amnesia following ingestion of chloroquine psychosis likely induced by hydropxychloroquine in a patient with chronic q fever: a case report and clinically relevant review of pharmacology antimalarial psychosis revisited toxic psychosis due to chloroquine psychiatric symptoms induced by hydroxychloroquine behavorial toxicity and equivocal suicide associated with chloroquine and its derivatives hydroxychloroquine-induced acute psychosis in a systemic lupus erythematosus female suicide by skull stab wounds: a case of drug-induced psychosis chloroquine-associated psychosis mimicking very late-onset schizophrenia: case report manic episode lovestone s. chloroquine-induced mania psychose aiguë après prise de chloroquine prolonged neuropsychiatric effects following management of chloroquine intoxication with psychotropic polypharmacy chloroquine psychosis: a chemical psychosis? toxic psychosis during chloroquine treatment two cases of chloroquine psychosis psychotic symptoms in volunteers serving overseas insomnia lupus reis j. insomnia induced by chloroquine in the treatment of lupus erythematosus disseminatus psychiatric complications with chloroquine and quinacrine chloroquine-induced recurrent psychosis toxic psychosis due to quinacrine and chloroquine serious psychiatric symptoms after chloroquine treatment following experimental malaria infection chloroquine seizures psychosis with paranoid delusions after a therapeutic dose of mefloquine: a case report toxic psychosis : a complication of antimalarial therapy key: cord-279382-e0vqn7t5 authors: mackolil, julia; mackolil, joby title: why is the mental health of geriatric population at a higher risk during the covid-19 pandemic? date: 2020-09-01 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102401 sha: doc_id: 279382 cord_uid: e0vqn7t5 nan this is a pdf file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. this version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. adults but also make them highly dependent. there is also a regression in economic status owing to retirement or inability to work. in addition, older adults often have to deal with the emotional toll associated with the death of their spouse or peers. further, the opportunities to seek help are limited due to problems related to immobility. these stressors are topped by the increase in elder abuse during the pandemic. studies show that elder abuse has increased by ten times during this pandemic which includes physical, verbal and emotional harm; financial exploitation and neglectful behaviour with low dignity (world health organization, 2020). these can have severe psychological effects which often go unattended. the need to socialise during these adverse times is often met through online media. online platforms are used to stay connected and to avail services and products without being in direct contact with others. however, the older adults belong to the age group that is neither skilled nor comfortable with using technology and online platforms. this places them at a disadvantage as their social needs are not met. in addition, they are at a higher chance for illinformation and fake news as they might lack the skills required to check for authenticity of the news. this could lead to issues related to health anxiety, fear and loss of hope. they are not able to avail any of the services that is now offered online including religious/spiritual services, medical assistance, home-delivery services and virtual therapy sessions. this further affects their immunity and quality of life as they are forced to live with limited access to services and necessities. with these increased vulnerabilities, they are at a higher risk for panic and anxiety. for older adults who live alone, the arrival of family members and visits of dear ones are a major source of social interaction and joy. the social distancing measures due to covid-19 require people to confine in their homes with limited contact to the outside world. this leads to social isolation among older adults and an intensified worry about the safety of their loved ones. social isolation can have detrimental effects on the geriatric population including cognitive decline (wilson et.al, 2007) , reduced physical wellbeing and higher mortality. studies have shown that health risks due to isolation equate to that of smoking and obesity (holt-lunstad, smith & layton, 2010) . social isolation and loneliness are specifically damaging in the geriatric population due their increased dependence on others. they depend on servants or other family member for their day-to-day functioning including medication, j o u r n a l p r e -p r o o f dietary needs and housekeeping. the containment laws have adversely affected older adults as servants have stopped providing service and relatives are no longer visiting them. the irony is that, the social distancing measure introduced to ensure protection of older adults has led to a reduction in their overall quality of life and increased the likelihood of depression. in addition, some older adults might not be able to comprehend instructions regarding selfhygiene, respiratory etiquette and safe distancing leading to hostility, neglect and isolation. this can push older adults into loneliness, worry and depressive thoughts of being a burden. the first step towards mitigating the problem is creating awareness about these vulnerabilities and providing timely interventions. ensuring that older adults receive authentic information about the pandemic, helping them stay connected with family members (over the phone) and providing necessary psychological assistance can help to curb problems related to ageism and anxiety. in addition, mental health professionals should prioritize contacting older adults with disabilities as they might not get the opportunity to seek help. providing updated directories of helplines and equipping the geriatric population with selfhelp and stress management skills can help to reduce elder abuse. further, avoiding unhelpful coping strategies like overthinking and substance abuse can ensure psychological wellbeing during this pandemic. social relationships and mortality risk: a meta-analytic review addressing psychosocial problems associated with the covid-19 lockdown novel coronavirus 2019-ncov: prevalence, biological and clinical characteristics comparison with sars-cov and mers-cov loneliness and risk of mortality: a longitudinal investigation in alameda county covid-19 and mental health: preserving humanity, maintaining sanity, and promoting health loneliness and risk of alzheimer disease addressing violence against children, women and older people during the covid-19 pandemic: key actions (no. who/2019-ncov/violence_actions/2020.1). world health organization key: cord-252250-hhdawwjf authors: menon, vikas; padhy, susanta kumar title: ethical dilemmas faced by health care workers during covid-19 pandemic: issues, implications and suggestions date: 2020-04-28 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102116 sha: doc_id: 252250 cord_uid: hhdawwjf nan the unexpected and unprecedented challenges brought on by the covid-19 pandemic has inflicted tremendous strain on health care resources, even in developed countries. the sheer magnitude of numbers coupled with high virulence of the infection has triggered country wide lockdowns across vast swathes of the globe. one group expected to work as usual in these trying times are health care workers and, therefore, the impact of covid-19 pandemic on the mental health of frontline health care workers is gaining legitimate attention (ayanian, 2020; lai et al., 2020) . in this regard, we point out a few moral and ethical dilemmas that can be faced by health care workers (hcw) while attending the call of duty: j o u r n a l p r e -p r o o f 2. dilemma 2 -should i retain ventilatory support for a critical patient who is unlikely to survive or use the ventilator for a less critical patient with better prognosis? as much as doctors are bound by the hippocratic oath that entrusts every doctor to treat all sick patients to the best of their abilities, in times such as these, triaging of finite resources is a pragmatic consideration. consequently, frontline hcw's may find themselves in an unpleasant situation where they have to make a choice of allocating scant resources for those who need them the most. adding a further layer of complexity to this issue are laws governing passive euthanasia in india, which state that a medical board constituted for the purpose by the hospital should first discuss the issue with family members and only after obtaining their written consent, proceed with withdrawal of ventilatory support. clearly, for an acute illness like covid 19, it is going to be an onerous task to convince emotionally charged family members about the limited chances of their loved one's survival and ask them to be 'altruistic' enough to spare the ventilator for another sick patient with better chances of survival. 3. dilemma 3 -if i have some respiratory symptoms and i think i may have been the above dilemmas, apart from being very personal, may also have larger ramifications for health care delivery. as these thoughts pre-occupy the mind, juxtaposed with other considerations such as looking after the needs of their families, their own physical and mental health care needs, as well as day to day demands of work and caregiving, judgment of hcw's may become clouded. this, in turn, may affect clinical decision, increase chances of medical errors and eventually increase the risk of burnout. we offer some suggestions to tackle the above scenarios: j o u r n a l p r e -p r o o f 1. institutions need to be upfront about their plans, policies and standard operating procedures to its staff and health care workers. availability of patient care, safety equipment and risk stratification protocols must be communicated clearly and updated on institutional websites. all health care workers should be briefed periodically about the rational use of ppe so that their safety concerns are addressed and at the same time, resources are utilized rationally. there must not be any attempt to paper over cracks; instead an open admission of possible shortcomings and steps taken to overcome them will allay anxieties and allow hcw's to mentally prepare themselves for challenges. as covid-19 duty is admittedly stressful, institutions may consider giving reduced shift hours (for instance, 4-6 hours) per work day to prevent burnout. 2. institutions must consider giving accommodation and quarantine facilities for its staff. if there are resource constraints, this facility must be made available at least to the hcw's during the period of covid duty as many of them may not feel comfortable going back to their families every day during the covid duty period. 3. pre-counselling of hcw before going to the frontline may help to allay concerns and provide opportunities for clarifying safety queries. the above mentioned ethical and moral dilemmas can be discussed beforehand so that hcw's are mentally prepared to handle such scenarios. involvement of mental health professionals at this stage would add value to the process by enabling utilization of their specific expertise in crisis counselling and problem-solving skills. 4. setting up of a covid support cell in every institution would serve as a one stop resource for mental and physical health care needs of hcw's. it also provides a forum for hcw, who may feel overwhelmed from time to time by the demands of caring, to discuss ongoing concerns and help to prevent burnout. as mentioned earlier, every hcw matters and their mental health often correlates with workplace productivity (duffield et al., 2014; kim et al., 2018) . health care team leaders should be trained to recognise signs of burnout among junior doctors as early identification and intervention is key (greenberg et al., 2020) . 5. ultimately, personal health is an individual responsibility. if an hcw has respiratory symptoms and does not wish to endanger others, the onus is on them to stay back and give a proper explanation for their decision. when in doubt, it is desirable to apply the ethical self-test as follows; "if my colleague at work had these symptoms, would i prefer him to come for duty?" setting out standard operating procedures for hcw's j o u r n a l p r e -p r o o f in this regard would remove ambiguity, facilitate individual decisions and lessen discrimination. extraordinary times call for extraordinary measures. we hope that the measures outlined above would assist institutions and team leaders in providing the best possible working conditions for their staff and health care workers. this will enable and motivate frontline health care workers to give their best while simultaneously preserving themselves for another day. financial disclosures: there are no financial disclosures or sources of support for the present work. the authors declare no conflicts of interest relevant to the contents of the manuscript. acknowledgments: none mental health needs of health care workers providing frontline covid-19 care a comparative review of nurse turnover rates and costs across countries managing mental health challenges faced by healthcare workers during covid-19 pandemic mental disorders among workers in the healthcare industry: 2014 national health insurance data factors associated with mental health outcomes among health care workers exposed to coronavirus disease key: cord-265186-zldwyuhz authors: john, john p.; prasad, krishna; sadh, kamaldeep; a.s., bhaskaran; lhamu, tshering; basavarajappa, chethan; dahale, ajit; senthil kumar reddi, v.; murthy, pratima title: issues related to testing for covid-19 in a psychiatric emergency setting date: 2020-08-04 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102338 sha: doc_id: 265186 cord_uid: zldwyuhz nan the ongoing novel corona virus disease (covid)-19 pandemic and the lockdown imposed to tackle its community spread raise several challenges in the management of mental health conditions in psychiatric hospitals. here, we present the challenges faced in the evaluation and management of a patient with acute psychosis at the emergency psychiatry and acute care (epac) services of the national institute of mental health and neurosciences (nimhans), bangalore, india. the management protocol described here may benefit psychiatrists working in emergency settings during this pandemic. a 30-year-old migrant worker, mr. l, was brought by the police and co-workers to the epac services with a report of him having climbed up a mobile phone signal tower fearing persecution by others. mr. l.'s co-workers gave a history of him showing altered behavior, suspiciousness, irritability, sleep disturbance, disinhibition and causing disturbance to others during the preceding two weeks. he was initiated on involuntary treatment in view of his lack of capacity to consent and was administered intravenous haloperidol 5mg and lorazepam 4mg to reduce agitation. we decided to do a pre-emptive testing for severe acute respiratory syndrome-corona virus-2 (sars-cov-2) despite mr. l. not showing any overt clinical symptoms of infection for the following reasons: his travel history-migration 3 months back; no reliable information regarding possible exposure to covid-19; overcrowded living conditions; impaired judgement that may have limited his ability to take precautions to avoid exposure; and severity of symptoms warranting inpatient care, which necessitated a decision to be made regarding whether he can be admitted at nimhans or referred to a covid-designated general hospital for further management. the process of obtaining a nasopharyngeal and oropharyngeal swab for testing was explained in detail to the patient and his co-worker (who was unrelated to the patient) in their vernacular. following this, both provided their signed consent for testing. however, in view of mr. l's lack of full capacity to consent, the epac team took this as the patient's assent and proceeded with the swabbing procedure. the swabbing took more than one hour since the patient became suspicious and refused to co-operate with the procedure and needed repeated reassurances as well as demonstration of the harmless nature of the procedure on his co-worker. mr. l was admitted to the inpatient unit of nimhans after the test results returned as negative. following improvement in his condition, a reconsenting was done after 10 days. the mental health review board of the department of psychiatry at nimhans was intimated regarding the processes followed. testing for sars-cov-2 and/or antibodies against the virus constitutes one of the cornerstones in limiting community spread (hamzelou, 2020) . a conservative approach towards testing, limiting it to cases where there is a high index of suspicion may compromise efforts at early targeted isolation and prevention of potential exposure to a large number of vulnerable persons in inpatient mental health settings (zitek, 2020) , especially when the exposure history is unreliable/insufficient, or when the patient's living condition does not permit adequate social distancing. furthermore, psychiatric emergency services should formulate protocols and guidelines for testing that aim to prevent the spread of infection while optimally treating the underlying psychiatric disturbance, keeping in mind the challenges in collecting specimens in acute psychiatric emergencies as highlighted above. other specialists in general hospitals may find the management of acute psychiatric emergencies challenging, and therefore it is important for psychiatrists in emergency settings to undergo training in swab collection. a nasopharyngeal swab is preferred for sars-cov-2 testing in an asymptomatic patient (2019-ncov| cdc). however, other alternatives include oropharyngeal swab, nasal middle turbinate swab from both the nares, or a swab from both the anterior nares. the centre for disease control (cdc) recommends the latter two for symptomatic patients (2019-ncov | cdc). diagnosis requires the detection of viral rna by rt-pcr (cdc). alternatives to rt-pcr include antibody testing or imaging. however, even when serology or chest ct/radiography are suggestive, viral rna testing is required for confirmation (cdc) . acutely agitated patients may be calmed down by tranquilization before testing, but administration of short-acting anaesthesia is not recommended without the support of intensivists. the caregiver accompanying the patient in the hospital should also be tested prior to admission. a substantial majority of hcws who contract the infection, work in non-covid-19 settings (wockhardt chairman). swabbing and "holding" patients who scream, shout or spit in psychiatric emergency settings may involve heightened risk of hcws coming in contact with their oral and upper respiratory secretions (tandon, 2020a) . moreover, the testing procedure itself may turn out to be lengthy. therefore, it is recommended that all hcws in psychiatric emergency services should take adequate precautions and don full ppes throughout their duty shifts. the covid-19 response teams of all hospitals should ensure availability of adequate personal protective equipments for hcws, communicate with them on a regular basis, be open in their communications regarding the constraints that they work under and suggest protocols to ensure the safest environment possible within the existing limitations (tandon, 2020b) . finally, all hcws including psychiatrists working in psychiatric emergency settings should try and enhance their subjective well-being through adoption of positive mental health approaches and not hesitate to seek professional help when they experience symptoms of physical or psychological distress. who expert: we need more testing to beat coronavirus infection spread from non-covid section of mumbai hospital: wockhardt chairman [www document the covid-19 pandemic, personal reflections on editorial responsibility covid-19 and mental health: preserving humanity, maintaining sanity, and promoting health the appropriate use of testing for covid-19. the western journal of emergency medicine key: cord-256212-ominfc0a authors: ritish, daniel; dinakaran, damodharan; chander, rakesh; murugesan, manisha; ibrahim, ferose azeez; parthasarathy, rajani; pandey, pankaj kumar; sharma, manoj kumar; pandian, dhanasekara; manjunatha, narayana; reddi, senthil kumar; moirangthem, sydney; kumar, chennaveerachari naveen; suresh, bada math; gangadhar, bangalore n. title: mental health concerns in quarantined international air passengers during covid-19 pandemic – an experiential account date: 2020-08-25 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102364 sha: doc_id: 256212 cord_uid: ominfc0a nan coronavirus disease 2019 is characterized by mild-to-severe respiratory illness with fever and cough. first covid-19 case was reported in india on 30 th january 2020. as a preventive measure, the government of india issued a mandatory compliance of travel advisory. in-bound air passengers who arrived from different countries were placed under compulsory home/institutional quarantine for a minimum period of 14 days (immigration, 2020) . quarantine regulations are one of the most effective and nonspecific public health measures for preventing and controlling the spread of pandemic. recent reprots demonstrated negative psychological impact associated with quarantine (ozamiz-etxebarria and dosil-santamaria, 2020, brooks et al., 2020 , tandon, 2020 , lei et al., 2020 , huang and zhao, 2020 ). this naturalistic observational study conducted at bengaluru, karnataka, india aimed to assess and briefly address the mental health concerns in recently quarantined individuals. as directed by the supreme court of india and government of karnataka, quarantined travellers were contacted over telephone (voice call) within one week of their quarantine period. a total of 2274 recently returned international air passengers were approached to provide psychological and mental health support. 592 of them could not be reached due to logistic reasons. out of the remaining 1682, 1602 (95.2%) were willing to participate in the study and provided oral consent. participants were assessed using a semi-structured questionnaire and details like socio-demographic profile, anxiety, depressive symptoms, suicidal ideas, sleep disturbances, and stress levels were collected. the telephonic assessments and brief interventions were done by a multidisciplinary team that consisted of qualified psychiatrists, clinical psychologists, or psychiatric social workers. upon assessment, wherever indicated, j o u r n a l p r e -p r o o f the participants were reassured and provided brief intervention. quarantined individuals were informed about the available facts regarding the current pandemic, the purpose of quarantine, the need for physical distancing and personal hygiene measures. if further intervention was necessary, they were referred to the higher centers. in case of emergency, they were provided with helpline contact of the experts. the study included a total of 1602 quarantined individuals of which 1109 (69.2%) were males. the mean age of the study sample was (mean± sd)(34.1±12.9) years. in the study sample, 216(13.5%) reported anxiety symptoms, 64 (4%) depressive symptoms, 30 (1.9%) suicidal ideations, and 71(4.4%) sleep disturbances. however, there was no significant gender difference in the distribution of symptom profile. the mean stress levels reported on a vas scale of 0-100 was 7·7 ±15. a total of 58 (3.6%) participants were referred for further care. this included predominantly the persons who expressed suicidal ideations or death wishes. the prevalence of elicited psychiatric symptoms is provided in table-1. this is the first experiential account report from india aimed at understanding the mental health concerns of quarantined air passengers. a sizeable proportion (13.5%) of the quarantined individuals reported symptoms of anxiety which is similar to the findings of another study conducted in north spain(ozamiz-etxebarria and dosil-santamaria, 2020). the prevalence of anxiety symptoms in our study population was two times more when compared to a similar study (jeong et al., 2016) . one of the reasons could be that the pandemic was at the initial stage during our study period (march last week) and the uncertainty could have led to increased apprehension. the prevalence of depressive symptoms was 4% which is low when compared to other studies(ozamiz-etxebarria and dosil-santamaria, 2020, lei et al., 2020) . the prevalence of depressive symptoms reported by (lei et al., 2020) was 22.4%. in another study(ozamiz-etxebarria and dosil-santamaria, 2020), 8.7% had mild depression and 4% had moderate depression. our assessment was j o u r n a l p r e -p r o o f conducted almost within a week of quarantine which may be too early for primary depressive symptoms or syndromal depression to manifest and that standardized scales were not administered. the low depressive symptoms may also be attributable to the fact that most participants were young, gainfully employed and working from home. this might have also reduced the likelihood of boredom and might have supported their well-being. around 2% of the participants reported suicidal ideation or death wishes during the interview. in general, whilst the overall suicide risk in india is 0.9%, the above suggests that a significant proportion of developed suicidal risk in a brief period (gururaj et al., 2017) . this is of particular concern as it is well established that psychosocial factors in the absence of mental illness contribute to suicide in the indian population which required immediate attention. the prevalence of sleep disturbance was 4% which is lower when compared with another report (huang and zhao, 2020) that observed impairment in the quality of the sleep being 18%. the same study also reported 35% of the study sample had anxiety disorder and 20.1% had depressive symptoms. sleep disturbances appear consistent with the reduced prevalence of common mental health issues in our study population. additionally, low levels of stress and depression in our study population might underlie the lower prevalence of sleep disturbances. standard structured assessments were not used in this study which is an important limitation. the interview was done over the telephone (audio) and that has its own limitations as well as advantages during the pandemic. though this study provides a cross sectional snapshot of the j o u r n a l p r e -p r o o f the psychological impact of quarantine and how to reduce it: rapid review of the evidence chinese mental health burden during the covid-19 pandemic advisory: travel and visa restrictions related to covid-19 05-05-2020 ed. india: government of india mental health status of people isolated due to middle east respiratory syndrome comparison of prevalence and associated factors of anxiety and depression among people affected by versus people unaffected by quarantine during the covid-19 epidemic in southwestern china stress, anxiety, and depression levels in the initial stage of the covid-19 outbreak in a population sample in the northern spain the covid-19 pandemic, personal reflections on editorial responsibility the authors would like to acknowledge the following organisations/persons for their contribution to this study. key: cord-290394-fc6xnbju authors: jha, amrit kumar; arora, alisha title: the neuropsychological impact of e-learning on children date: 2020-07-13 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102306 sha: doc_id: 290394 cord_uid: fc6xnbju nan the covid-19 pandemic has forced school closures worldwide leading nearly 1.95 billion children being out-of-classrooms or away from school in almost 195 countries (tandon 2020a; unesco, 2020) . this has resulted in the boom of e-learning, defined as the use of internet technologies to deliver a broad array of solutions that enhance knowledge and performance (rosenberg and foshay, 2002, p. 28) . built upon the fabric of internet and communication technology, e-learning is being touted as the most viable alternative to the traditional classroom teaching and learning in days ahead. the covid-19 pandemic has led to a massive upsurge in the demand for the e-learning platforms worldwide as children have been instructed to attend classes online from their homes to maintain continuity of formal learning (li and lalani, 2020) . while neuroplasticity offers opportunity to adapt the sudden change in the modality of classroom transaction from face-to-face interaction to the technology mediated learning, it may wreak havoc for the growing brain of children. indeed, being the new partner in their mode of education, e-learning, poses an adaptability risk for the young brains. brain's plasticity sheds light upon how neural circuitry in young brains respond to digital learning, given the fact that the formation of higher-order j o u r n a l p r e -p r o o f functions take place during childhood years (zelazo and muller, 2002) . several studies indicate that multi-method screen exposure leads to structural changes such as reduced volume of the cortex with loss of integrity pertaining to the white matter region (takeuchi et al., 2018) and decreased grey matter in prefrontal regions viz. the right frontal pole and anterior cingulate cortex (loh and kanhai, 2014) . such alterations, consequently, impede attentional competence, processing speed, verbal intelligence, and sustained attention, respectively. additionally, searching, locating, and reading online content reduces the functional connectivity of regions around temporal gyrus, responsible for long-term memory formation and retrieval of learned material (liu et al., 2018) . it may also be note that the overuse of visual modality and exposure to the computer screen for long hours may yield adverse effects of the visual system. a study by firth et al. (2019) has indicated how functional changes impair attentional capacities, memory processes, and social cognition abilities in individuals. the online platform of learning requires the brain to rapidly switch between tasks, consuming the metabolic energy, and time at the neural level. the visual stimuli presented are usually complex and multi-method based (involving audio-visual graphics, text, and animations), prompting digital multitasking, resulting in impaired recall. one major reason is the overload upon working memory, which impedes an individual's ability to register, process, and remember information with accuracy. cognitive overload, as a product of multi-method based learning and divided attention, impacts the quality of comprehension, prioritization, and deep-level processing of incoming information, which in turn, critically determines consolidation of memory into long-term memory (carr, 2010) . consequently, it leads to poor processing and understanding of what is taught or said. besides, the absence of a school setting impairs social cognitive abilities such as empathy, teaming, and peer relationships among children. new challenges demand novel approaches to the process of teaching-learning. educators can provide individualized goals, the scope for individual discussions, and provide visual reminders to combat digital distractions. besides, there is also a need for sensitizing teachers for dealing with the heterogeneity of executive functioning at the grade level by custom designing the contents to be delivered. the daily screen time and access to the devices by children need to be judiciously regulated and supported by all the stakeholders (jamir et al., 2019; tandon, 2020b) . it is relevant to note that the sars outbreak in year 2003 proved as a tipping point to the e-commerce industry, leading to its widespread surge. however, projecting the same trajectory to the e-learningwould be unfair and detrimental for the children in the long run cognitively, emotionally, and socially. they cannot be treated as a commodity to be packed and sold in the market, rather an active agent for a vibrant future. co-opting the use of technologies for education has been a long-standing controversy. the content taught through various platforms may be relevant, but a class devoid of reflection and review may not plant the seeds of critical and deep thinking skills required in the trajectory of their lives. while presenting the guidelines for a healthy lifestyle for children, the who director had recently opined that "achieving health for all means doing what is best for health right from the beginning of peoples' lives" (who, 2019) . this needs to be followed earnestly as an overarching principle for setting the right precedent for the future of tomorrow. the authors did not receive any fund for this work. the authors have no conflict of interests. j o u r n a l p r e -p r o o f the shallows: what the internet is doing to our brains the "online brain": how the internet may be changing our cognition epidemiology of technology addiction among school students in rural india 2020. the covid-19 pandemic has changed education forever internet search alters intra-and inter-regional synchronization in the temporal gyrus how has the internet reshaped human cognition? theneurosci e-learning: strategies for delivering knowledge in the digital age impact of frequency of internet use on development of brain structures and verbal intelligence: longitudinal analyses covid-19 and mental health: preserving humanity, maintaining sanity, and promoting health the covid-19 pandemic, personal reflections on editorial responsibility billion learners are still affected by school or university closures, as educational institutions start reopening around the world, says unesco to grow up healthy, children need to sit less and play more executive function in typical and atypical development in all gratitude, we would like to express our sincere respect to mrs. anju jha, prof.girishwar misra, and ms. shipra saini for their timely and insightful contribution towards enhancing the depth and readability of the manuscript. key: cord-264769-gp2tie7k authors: xiangng, qin; de deyn, michelle lee zhi qing; loke, wayren; chan, hwei wuen title: a framework to deal with uncertainty in the age of covid-19 date: 2020-06-20 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102263 sha: doc_id: 264769 cord_uid: gp2tie7k nan uncertainty seems to be a constant in this evolving pandemic. our current understanding of the sars-cov-2 is still limited, especially with regard to the epidemiologic features of the virus (wang et al., 2020) . we are 'assaulted' with new (and even contradictory) findings and interpretations on an almost daily basis. research studies are being published at a feverish pace (laine et al., 2020) ; researchers have now highlighted and then disputed a previously underappreciated reservoir of asymptomatic 'spreaders' (gandhi, yokoe & havlir, 2020; wei et al., 2020) . there is also no definitive treatment or vaccine at present. many have touted the efficacy of hydroxychloroquine despite the lack of rigorous clinical data (molina et al., 2020) . this can be seriously confusing and dangerous for the layperson. in an extreme example, an arizonian man died from consuming a form of chloroquine used to clean aquariums, days after the anti-malarial drug was touted by some as a potential cure for covid-19 (waldrop, alsup & mclaughlin, 2020) . governments worldwide have also adopted an assortment of approaches, from the partial or complete closures of public facilities and spaces, rigorous contact tracing to a less intensive approach, albeit with variable success (forman et al., 2020) . there is a need to recognise which approaches and proposals work. the vuca framework, which is commonly applied in business and military settings (bennett & lemoine, 2014) , well encapsulates the challenges individuals and governments face in these uncertain times. the framework also outlines the approach one should take, with due consideration of the amount of information available and the certainty of the situation. we adapted some of the key elements of the vuca framework and correspondingly, we see in figure 1 , that the complexity and uncertainty inherent in the covid-19 pandemic mandates that governments must face "unknown unknowns". this also means enlisting the expertise j o u r n a l p r e -p r o o f of relevant specialists and building up resources to address the complexity; and being transparent with information to alleviate the ongoing uncertainty of the situation. an important lesson we have learned from this evolving pandemic is that the lack of transparency creates further confusion and undermines public trust (alwan et al., 2020; tandon, 2020) , and the bureaucratic process should aid and not hinder crisis management. early reports of a 'sars-like' illness were ignored by the chinese government (enos, 2020) , which led to widespread outrage at the injustice and inaction. (stafford, 2020; cousins, 2020) . on the other hand, much j o u r n a l p r e -p r o o f evidence informing the uk's covid-19 public health response must be transparent. the lancet what a difference a word makes: understanding threats to performance in a vuca world new zealand eliminates covid-19. the lancet how the chinese government undermined the chinese people's attempts to prevent and respond to covid-19. heritage foundation backgrounder 12 lessons learned from the management of the coronavirus pandemic. health policy asymptomatic transmission, the achilles' heel of current strategies to control covid-19 thinking globally, acting locally-the us response to covid-19 public health interventions for covid-19: emerging evidence and implications for an evolving public health crisis covid19-the need for public health in a time of emergency no evidence of rapid antiviral clearance or clinical benefit with the combination of hydroxychloroquine and azithromycin in patients with severe covid-19 infection covid-19: why germany's case fatality rate seems so low the covid-19 pandemic personal reflections on editorial responsibility. asian journal of psychiatry fearing coronavirus, arizona man dies after taking a form of chloroquine used to treat aquariums. cnn health the global impact of covid-19 and strategies for mitigation and suppression who collaborating centre for infectious disease modelling, mrc centre for global infectious disease analysis, abdul latif jameel institute for disease and emergency analytics unique epidemiological and clinical features of the emerging 2019 novel coronavirus pneumonia (covid-19) implicate special control measures presymptomatic transmission of sars-cov-2 -singapore covid-19 coronavirus pandemic the authors report no conflicts of interest. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. the authors alone are responsible for the content and writing of the article. none. key: cord-030930-ny31tml2 authors: mathur, parul; sharma, lavanya p; h nanjundaswamy, madhuri; s chandra, prabha title: training needs of psychiatry residents in handling intimate partner violence (ipv) in clinical situationsa survey date: 2020-08-27 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102379 sha: doc_id: 30930 cord_uid: ny31tml2 nan who multi-country study on women's health and domestic violence against women") (national family health survey 2017) . ipv refers to any behaviour within an intimate relationship that causes physical, psychological or sexual harm to those in the relationship ("who | who multi-country study on women's health and domestic violence against women"). ipv and mental health issues share a bidirectional relationship, where women subjected to violence seek mental health care more often than non-abused women. also, women mental health service users are at a higher risk of experiencing ipv (oram et al., 2013) . ipv is also associated with increased vulnerability towards developing mental health problems such as posttraumatic stress disorder (ptsd), depression, anxiety, sexual problems, suicide, self-harm, chronic pain and substance abuse (stewart and chandra, 2017) . healthcare providers are likely to be the first point of contact for women facing ipv and health settings have been considered to be the most appropriate setting to ask about ipv and provide interventions or direct victims to appropriate resources. however, there are numerous barriers both to disclosure and to the enquiry, which may be responsible for low rates of detection. the most common reasons for non-disclosure have been reported to beembarrassment, shame, fear of threats and further violence or confinement from the perpetrator; re-traumatization; hopelessness; inability to recognize violence (particularly emotional), the stigma associated with one's mental illness, and lack of privacy (stewart and chandra, 2017) (vranda et al., 2018) . mental health professionals may also be reluctant to ask about ipv and common barriers identified include personal discomfort, therapeutic nihilism, fear of offending, causing re-traumatization and time constraints (stewart and chandra, 2017) (trevillion et al., 2012a) . table 1 . responses with more than one option marked, rendering them ambiguous, were excluded. the results indicate fairly low rates of spontaneous disclosure of ipv by women approaching mental health services as well as low rates of routine clinical assessment of ipv by residents (table 1 ). the majority of the residents perceived difficulties in responding to ipv or asking about it and mentioned lack of knowledge, comfort, safety concerns and concerns about medicolegal issues as prominent reasons. nearly 71% of residents reported not receiving formal training as being a barrier. currently, training on ipv as part of clinical rotations is varied and depends on the individual consultants' emphasis on gender issues rather than it being part of the curriculum. these findings are similar to that of a uk-based study among 131 mental health professionals (psychiatrists and psychiatric nurses) where the majority of participants (60%) felt that they lacked adequate knowledge of support services, and 27% noticed that their workplace did not have sufficient referral resources for domestic violence (nyame et al., 2013 ). an australian study that assessed psychiatrists' and trainees' preparedness in dealing with ipv, found that comfort and skill levels were directly correlated with the number of hours of training they had received. the training programme included assessment techniques, safety planning, knowledge about existing resources and referral pathways (forsdike et al., 2019) . based on the findings of this survey, and the available literature, we conclude that residents may benefit from training in responding to ipv in clinical settings as part of their residency program. this would include improving assessment skills, how to triage, being alert to clinical conditions that could indicate ipv, as well as training in addressing ipv once disclosed, knowledge about access to services, and ensuring safety. the world psychiatric association (wpa) has developed a competency-based curriculum (stewart and chandra, 2017) for training and describes the skills and knowledge that psychiatry trainees should have when dealing with ipv. how formal training about ipv for psychiatry trainees improves comfort and skill as well as service user satisfaction, and how much it is sustained over time, is an important area of study. centre where study conducted: national institute of mental health and neurosciences (nimhans) bangalore, india j o u r n a l p r e -p r o o f the pandemic paradox: the consequences of covid-19 on domestic violence wpa international competency-based curriculum for mental health providers on intimate partner violence and sexual violence against women exploring australian psychiatrists' and psychiatric trainees' knowledge, attitudes and preparedness in responding to adults experiencing domestic violence domestic violence and mental health, 1 edition a survey of mental health professionals' knowledge, attitudes and preparedness to respond to domestic violence prevalence of experiences of domestic violence among psychiatric patients: systematic review the response of mental health services to domestic violence: a qualitative study of service users' and professionals' experiences experiences of domestic violence and mental disorders: a systematic review and meta-analysis barriers to disclosure of intimate partner violence among female patients availing services at tertiary care psychiatric hospitals: a qualitative study who | who multi-country study on women's health and domestic violence against women key: cord-315159-c9n8cro3 authors: soni, vivek kumar; mehta, arundhati; shukla, dhananjay; kumar, sujeet; vishvakarma, naveen kumar title: fight covid-19 depression with immunity booster: curcumin for psychoneuroimmunomodulation date: 2020-09-01 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102378 sha: doc_id: 315159 cord_uid: c9n8cro3 nan beyond infection, the covid-19 pandemic has affected individuals through associated anxiety and stress and caused a collateral damage (tandon, 2020) . real and perceived fear of infection and distorted daily activities invites psychiatric illness including depression (banerjee and viswanath, 2020; kumar and somani; , tandon, 2020 . void for specific therapeutic measures also contributed to this psychotic illness. a 'tsunami of psychiatric illness' will follow as predicted by various organizations and imminent experts (tandon, 2020) . therefore, attention towards this mental health crisis approaching worldwide is necessary (tandon, 2020) . along with preventive measures, incorporating 'immunity boosters', including established food ingredients/herbs, are advised. recently, uncovering the potential of ayurveda was exigencies to combat covid-19 outbreaks through modulation of pyschoneuroimmune (pni) response . curcumin is the bioactive component of turmeric, one of the key ingredients of prescribed ayurvedic interventions and spices used in meal preparation in south-east asia vishvakarma, 2014) . therefore, critical evaluation of the psychopharmacological potential of turmeric in covid-19-pandemic-associated psychosomatic disorders is warranted. the inter-dependent nature of immunity and psychological state is established and decides the outcome of disorders. an immune response can be largely affected by mental well-being, and depression can negatively affect its outcome zalachoras et al., 2020) . targeting either one of depression or immunity may face insufficiency; dual-acting drug hold promise to improve health amid covid-19 pandemic. known for immunoboosting aptitude, curcumin can alleviate the covid-19 associated ill-effects including cytokine storm (liu and j o u r n a l p r e -p r o o f ying, 2020) . alleviating psychological stress by curcumin will also adjunct its immunoboosting potential. curcumin can avert the anxiety and the stress-driven manifestation of depression through modulation of the monoaminergic troupe (dopamine, glutamate, serotonin, and noradrenaline) by curcumin . depression-disorders in covid-19 prevention measuresdriven social distort are possibly brought by oxidative stress . curcumin, through nuclear factor erythroid-2-related factor 2 (nrf2), can prevent such stress and improve antioxidant glutathione (gsh) production . gsh prevents the physiological damage to brain cells during stress. nrf2 also balances the tone of the immune response (lopresti and drummond, 2017; zalachoras et al., 2020) . major depression disorders (mdd) associate with disturbances in the hypothalamus-pituitary-adrenal (hpa) axis. curcumin can correct the hpa disturbances and avert elevated glucocorticoids, their receptor as well as inducers (cortisone and adrenocorticotropic hormone) (lopresti and drummond, 2017) . along with evident immunomodulator, turmeric component, especially curcumin exhibit antidepressant activity, and improve cognitive/mood function (lopresti and drummond, 2017) . the potential of curcumin containing nutraceutical in covid-19 has been predicted both through pni modulation and 'meaning response' . moreover, curcumin can alleviate the overt inflammatory consequences (vishvakarma, 2014; soni et al., 2020) , even those associated with covid-19 (liu and ying, 2020) , and thus will improve physical wellbeing. ayurvedic utilization of turmeric as a concoction, spices and/or golden milk (turmeric in warm milk) provide pni benefits through alleviated anxiety/depression along with modulation of neurotransmission (through monoamine and gamma-aminobutyric acid) . reports indicate the onset of post-traumatic stress disorder j o u r n a l p r e -p r o o f chronic stress elevates proinflammatory cytokines (il-1, il-6, tnf-α) which triggers the production of catabolites of tryptophan (trycats) through stimulation of indolamine-2,3-dioxygenase 2020); thus may improve mdd through pni modulation. high proinflammatory cytokines in mdd individuals wreck the hematopoiesis and weaken the immunity curcumin can improve the hematopoietic differentiation of immune cells (vishvakarma and thus can mitigate ill effects even through reinstating immune cells number. moreover, curcumin improves neurogenesis and hippocampus functioning 2020), antidepressant effect, and neurogenesis (zalachoras et al., 2020, lopresti and drummond, 2017) may also improve the mood function and ward off anxiety neuropsychiatric manifestations of covid-19 and possible pathogenic mechanisms: insights from other coronaviruses dealing with corona virus anxiety and ocd the inhibitory effect of curcumin on virus-induced cytokine storm and its potential use in the associated severe pneumonia. frontiers in cell and developmental biology efficacy of curcumin, and a saffron/curcumin combination for the treatment of major depression: a randomised, double-blind, placebo-controlled study conceptual reframing of major depressive disorder-acute 'psychitis'? ayurveda and covid-19: where psychoneuroimmunology and the meaning response meet curcumin circumvent lactateinduced chemoresistance in hepatic cancer cells through modulation of receptor-1. the international journal of biochemistry & cell biology covid-19 and mental health: preserving humanity, maintaining sanity, and promoting health. asian journal of psychiatry novel antitumor mechanisms of curcumin: implication of altered tumor metabolism, reconstituted tumor microenvironment and augmented myelopoiesis therapeutic potential of glutathioneenhancers in stress-related psychopathologies key: cord-281185-myfuzsh7 authors: yan, bin; ni, guohui; huang, yeen title: china’s experience on mental health in response to the covid-19 pandemic date: 2020-06-12 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102205 sha: doc_id: 281185 cord_uid: myfuzsh7 nan 1. create a comfortable environment conducive to maintenance of patients' mental health: first, adjust the lighting according to the treatment requirements, hospitals could try to keep the ward lights in a certain circadian rhythm and dim the lights at night. second, assist patients to keep in touch with their family and friends through mobile phone or internet and try to strengthen their confidence to overcome the disease with family and social supports. third, provide online lectures on infectious diseases and health education to the patients with mild symptoms. fourth, distribute booklets of mental health knowledge according to patients' disease conditions, and provide government-recommended online health education platform. encourage patients to self-study and help each other, obtain scientific outbreak information and mental health knowledge, carry out self-psychological evaluation and adjustment, and seek online professional help. fifth, recommend a daily activity schedule for mild patients, for helping them to develop an orderly daily activity plan, and establish a regular routine in an unfamiliar environment (national health commission of china, 2020; li & gang, 2020). 2. deliver psychological assistance and crisis intervention to patients: first, identify patients who is in need of psychological assistance and help them with self-adjustment. participate in medical care shifts and ward rounds to identify patients who need psychological assistance and help them adopt psychological assessment, and develop specific plans based on the patient's mental status. if necessary, perform rapid psychological interventions and help patients do self-adjustment such as relaxation training. second, identify patients with psychosocial problems, provide crisis intervention and psychiatric medication. organize psychiatric consultation in time for patients with emotional agitation, difficulty in treatment and management, and mental and behavioral problems, such as delirium, impulse, anxiety, depression, and suicidal tendency. provide crisis intervention and psychiatric drug treatment, mainly symptomatic treatment, rapid relief of symptoms, pay attention to the drug interactions between the patient's physical condition and psychiatric treatment. third, keep the files of patients with psychological assistance. for discharged patients who need continuous j o u r n a l p r e -p r o o f psychological assistance or psychiatric drug intervention, the information handled by the psychiatric department should be recorded in medical documents and referred to the corresponding isolation places, so as to continue to provide psychological assistance and social work services, to avoid extreme events. 2. provide psychological support and psychological crisis intervention for healthcare workers: first, in the healthcare workers rest area, set up a spiritual post station, including two rooms. a room contains some snacks, beverages, books, or brochures, and is equipped with tv or computer playback equipment to play audios and videos, such as relaxation training audio, instructions on how to do self-relaxing, how to use the relevant psychological network platforms and so on. the other room can have a certain degree of privacy and is used for one-on-one psychological assessment and intervention, which is recommended for on more than 10 minutes at a time. second, make videos or reading materials on psychological assistance for typical problems, such as patients' not cooperating with treatment, fear of infection, sense of healthcare exhaustion, guilt and even self-worth and professional negation. third, if there are mental and psychological symptoms that persist and can not be alleviated, which affect j o u r n a l p r e -p r o o f daily work, one-to-one psychological crisis intervention can be carried out or be transferred to other positions with less pressure. indeed, psychiatric treatment should be provided if necessary. fourth, given the condition, group support activities such as group psychological counseling can be carried out in the healthcare workers accommodation area or rest area. fifth, one-to-one psychological assessment and psychological crisis intervention should be carried out for medical personnel who's relative has recently died or in a serious condition. 1. when referring to people with covid-19, do not attach the disease to any particular ethnicity or regionality. be empathetic to all those who are affected, in and from any regions. 2. do not refer to people with the disease as "the covid-19 cases", "victims", "the covid-19 families", or "the diseased". it is important to separate a person from having an identity defined by the covid-19, in order to reduce stigma. 3. minimize watching, reading, or listening to news about the covid-19 that causes the public to feel anxious or distressed; seek information only from trusted sources and mainly so that people can take practical steps to prepare their plans and protect themselves and loved ones. seek information updates at specific times during the day, once or twice. gather information at regular intervals from the who website and local health authority platforms in order to help people distinguish facts from rumors. this study did not receive any funding. psychological interventions for people affected by the covid-19 epidemic guideline for psychological assistance and social work services in designate hospital for covid-19 the covid-19 pandemic, personal reflections on editorial responsibility progression of mental health services during the covid-19 outbreak in china we express our heartfelt respect to all the people who are fighting the pandemic around the world. key: cord-313264-3fbikatx authors: banerjee, debanjan; nair, vasundharaa s. title: handling the covid-19 pandemic: proposing a community based toolkit for psycho-social management and preparedness date: 2020-05-07 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102152 sha: doc_id: 313264 cord_uid: 3fbikatx nan own homes, as a measure to contain the outbreak (who situation report as on 9 april 2020). as the therapeutic focus is mainly restricted to biological therapies worldwide to develop an effective cure for the virus, the deep-rooted psycho-social repercussions are often neglected (singhal, 2020) . research on pandemic protocols in the past have shown the role of psychosocial preparedness in improving the resilience during a 'biological disaster' like such largescale infections. though there are well-known international guidelines for disaster management in general, specific ones guided to pandemic-preparedness are lacking, though some countries have formulated their own policies (colizza et al., 2007) . effectiveness, applicability and feasibility are attributes which indicate that the psychosocial interventions are going to be more appropriate in the community as the knowledge, attitude and practice (kap) regarding any new infection improves the preparedness in both the health-care professionals and the general public. preparedness towards any form of disasters is vital to reduce their impact. as the global situation related to covid-19 is changing rapidly each day, 'community based disaster preparedness'(cbdp) is perhaps the method of management. cbdp is a response mechanism in an attempt to save the maximum and effective community triage (troy et al., 2008) . this leads to multi-pronged but flexible interventions to reduce vulnerability and build a self-reliant and resilient society. it is true that pandemics of such epic proportions cannot be fully controlled by any degree of preparedness but the goal here is more of harm-reduction. earlier outbreaks have highlighted important areas. during the zika outbreak in brazil that eventually spread to north and south america, who had declared it too as a public health emergency of international concern, just like covid-19 (who, 2017) . research had been conducted to j o u r n a l p r e -p r o o f understand the preparedness of community-based psychosocial toolkit for zika virus affected-areas (nair et.al., 2020) , wherein it was understood that the lack of understanding about a new condition and uncertainty about it has a direct correlation with the preparedness among the healthcare professionals, and thereby implying policy planning and training needs to gear up towards this. the purpose of this proposed intervention toolkit is to aid facilitators to bring about ownership for sustainability of the process during a pandemic. better preparedness during an infection leads to better preparedness which in turn helps better intervention planning and community integration ( figure 1 ). here we use the model of the zika virus preparedness toolkit to propose a similar one for the ongoing covid-19. a stepped-approach to psycho-social interventions j o u r n a l p r e -p r o o f step 1: collection of basic information before planning any intervention, the first step is always gauging the problem statement and understanding the basic attitudes and beliefs of the people towards the crisis. considering the pandemic as an ongoing process, regular updated data should be collected and assimilated from the global health agencies like who, cdc, and regional health ministries (like the icmr and ministry of health and family welfare in india, cdc in china, etc.). collaboration with the media to provide unbiased information will be helpful. as social distancing makes field visit difficult, online surveys or telephonic communication might yield valuable information. the content of queries from the helplines and crisis intervention at the hospital emergency settings will help understand the various types of psycho-social problems. people with pre-existing mental disorders, people in isolation, the elderly and those institutionalized are more vulnerable and thus need to be contacted separately to ensure that their physical and medical needs are met. liaison with nearby health-care centres and integration of alternative medicine specialists will be helpful. step 2: crisis management: knowledge, attitude and practices in the advent of a biological disaster (table 1) pre-assess introduction of the intervention programme ice breaking games in this section post the interventions, the goals are  to understand that situation, focussing on current 'crisis at hand' and hence survival, protection and sustenance are necessary.  minimise the contact, maintain the essential services and to maximise the help to others but maintaining the prevention.  immediate ideal response might not be possible but to reduce the infection, exposure needs to be reduced and insight needs to be improved. step 4: individual  self-isolation and restrict travel  physical but not 'social' distancing  protection of self (hand and respiratory hygiene)  reduce 'digital screen time'  address panic, uncertainty and fear: encourage active usage of helplines step 5 the steps mentioned above can be organized in the form of pamphlets and other iec materials to ensure the sustenance and easy dissemination of the module. it liaison can be sought for to even incorporate them in smart-phone applications and software for easy accessibility. module training can also be done online for the paramedical personnel and health-care support staff. such community based stepped interventions using precautionary and psychological strategies have been used for emergency care workers, health-care staff and quarantined people in wuhan, china and found to increase the degree of work satisfaction, decrease absenteeism j o u r n a l p r e -p r o o f and increase the compliance to quarantine instructions (chau et al., 2020) . earlier studies during the nipah and influenza virus outbreaks, also impress upon the need for useful communication techniques, as reaching out to the masses is the key (kumar and kumar, 2018) . our module proposes to include the same. the world health organization has standard protocols during periods of epidemics and pandemics which work the best in accordance with the set rules of any country, but the focus remains that for a long period of time various administrative agencies have not implemented or modified the strategies to suit the crisis needs (melnychuk and kenny, 2006 at times when an unknown infection threatens community transmission in many countries, causing panic and hysteria at the societal level, it is important to have structured psychosocial interventions to improve awareness and ensure that the first level steps taken by the primary health-care workers, can provide some degree of damage control. we expect the proposed toolkit to serve this purpose. challenges can be its effective implementation, standardisation of the steps, impediment by social distancing as well as comparability in different countries and socio-economic strata. however, as our studies are in progress in india using the tool-kit at the community level, we expect more consistent findings to supplement this literature in the near future. ethical considerations: no subject has been recruited j o u r n a l p r e -p r o o f sars epidemic on chinese health professionals: implications for epidemics including ebola modelling the worldwide spread of pandemic influenza: baseline case and containment interventions deadly nipah outbreak in kerala: lessons learned for the future pandemic triage: the ethical challenge knowledge among nursing students on zika preparedness enhancing community-based disaster preparedness with information technology who toolkit for the care and support of people affected by complications associated with zika virus key: cord-280806-2x98989a authors: zhang, jinsong; shuai, lan; yu, hui; wang, zhouye; qiu, meihui; lu, lu; cao, xuan; xia, weipin; wang, yuanyuan; chen, runsen title: acute stress, behavioural symptoms and mood states among school-age children with attention-deficit/hyperactive disorder during the covid-19 outbreak date: 2020-04-09 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102077 sha: doc_id: 280806 cord_uid: 2x98989a nan attention deficit hyperactivity disorder (adhd) is one of the most frequently occurred neurobehavioral disorder among children (american academy of pediatrics, 2000) , which has negative impact on a wide range of aspects including learning ability, interpersonal relationships, self-esteem, and emotions (lecendreux et al., 2011; wang et al., 2017) . previous meta-analysis showed that the prevalence of adhd among children and adolescents in china was 6 % (wang et al., 2017) . in the event of covid-19 outbreak, schools in china are shut down and students are restricted to staying at homes. primary and secondary schools in china open online official educational websites in order to allocate students to continue the education (xinhua net, 2020). children with adhd face noticeable challenges during this period. firstly, the loss of daily routine and the lack of interpersonal and social interaction could work as potential risk factors for mental health problems or could worsen adhd symptoms. in addition, majority of the adhd children receive care from primary care settings (patel et al., 2017 ; subcommittee on attention-deficit/ hyperactivity et al., 2011) . children with adhd could not get timely and professional care from home setting. most of the parents of these children can be assumed not to be the domain experts but are forced upon the educational responsibility in addition to handle all the children's emotional and behavioral problems 24/7. moreover, the pandemic of covid-19 is a serious challenge to everyone including the adults. their worry of the situation may further exacerbate the children's psychological wellbeing and worsen their behavioural problems. this study aims to investigate the mental health related conditions of children with adhd during the covid-19 outbreak. we hypothesised that children's adhd symptoms could be significantly worse compared to normal state during school closedown. in addition, we examined what key variables are associated with the changed behaviours in this special time. a total of 241 parents of school aged children with adhd diagnosis were invited to participate in this survey. the school aged children described in the study were 6-15 years old (m = 9.43, sd = 2.39), and there were 194 boys and 47 girls. the study obtained the ethical approval from shanghai xinhua hospital. the following information were collected (1) adhd behavioural symptoms were measured by swanson, nolan, and pelham scale (snap-iv)parent form, (gau et al., 2008) . (2) the acute responses of children in the event of 2019-ncov breakout was measured using the child stress disorders checklist (csdc) (saxe et al., 2003) . (3) time allocation of https://doi.org/10.1016/j.ajp.2020.102077 received 1 april 2020; accepted 2 april 2020 children's activities was measured the approximate time allocation on activities (including: studying, using electronic devices, entertainment without using electronic devices, and interacting with the parents). (4) mood state of the children and parents were asked by a single item each, rated on a 1-4 scale, with higher score indicated worse mood. (5) attention to media coverage of the 2019-ncov outbreak how much attention the children and parent paid to media coverage of the 2019-ncov outbreak was rated on a 1-4 scale. children's adhd behaviours during the covid-19 outbreak were rated by their parents. a one-sample t-test revealed that the average of children's adhd behaviours (m = 2.25, sd = 0.54) were significantly worsened in comparison to their normal state (95 % ci = 2.18-2.32 which was significantly higher than the rating of "2"-no difference), t (240) = 7.11, p < .001. fig. 1 presented the reported severity of adhd behaviours in comparison to normal state. the bivariate correlations among the study variables were summarised in supplementary table 1 this is the first study focusing children with adhd during the time of covid-19 outbreak. during the covid-19 outbreak, children's adhd behaviours significantly worsened in comparison to their normal state. in consistent with previous studies, we found children's negative mood state was associated with adhd symptoms. our results showed that parent's mood state also impact children's adhd symptom. researchers have indicated that parents of adhd children experienced high level of daily child-rearing stresses (pelham jr and lang, 1999; yousefia et al., 2011) . the special arrangement of school close-down and children staying at home might bring elevated difficulties and stress for both the children and their parents. our results have significant clinical implication in placing the importance of treatment and control of negative mood. the study time was negatively associated with the increase adhd symptoms. during the covid-19 duration, children are arranged to online studying at home. the results indicated that adhd symptoms reduced with the longer study time. although future studies are needed to confirm the results, this could be a potential strategy for decreasing adhd symptoms for children at home. conversely, the children who could use online study more effectively may be the ones who could focus longer; the mechanism of this association needs further investigation. in view of the rapid increase of online education accelerated by this pandemic, this direction of study is particularly useful. the current study has several limitations should be noted. first, this was a cross-sectional study, and the casual relationship between adhd symptoms and related factors cannot be confirmed. second, data were reported by parents, rather than reported by children directly. it is possible that children may rate their own emotional and behavioural responses differently. finally, the relationship between the worsened behaviours among children with adhd and their medication status was not directly tested. some parents feedbacked their concerns of the limited access to psychiatric medicine for their children during this special period. future study must include clear criterion testing this association. nevertheless, the support of special medicine for specialneed groups should be prioritized during crisis like this. in conclusion, during the covid-19 outbreak, children's adhd symptoms were significantly worse compared to normal state. the results alerted the important of focusing special vulnerable group during the disease outbreak. attention is required for the identification of appropriate approach for adhd children in terms of disaster risk reduction activities. this study support by shanghai top-priority clinical key discipline (2017zz02026). the funding body had no role in the design of the study and collection, analysis and interpretation of data and in writing the manuscript none clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder psychometric properties of the chinese version of the swanson, nolan, and pelham, version iv scale -parent form prevalence of attention deficit hyperactivity disorder and associated features among children in france care provision and prescribing practices of physicians treating children and adolescents with adhd can your children drive you to drink?: stress and parenting in adults interacting with children with adhd child stress disorders checklist: a measure of asd and ptsd in children adhd: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents prevalence of attention deficit/hyperactivity disorder among children and adolescents in china: a systematic review and meta-analysis xinhua net, 2020. china focus: schools start online courses as epidemic control postpones new semester. xinhua net parenting stress and parenting styles in mothers of adhd with mothers of normal children we thank all the participants participating in the study. supplementary data associated with this article can be found, in the online version, at https://doi.org/10.1016/j.ajp.2020.102077. key: cord-291596-lp5di10v authors: singh, shweta; dixit, ayushi; joshi, gunjan title: “is compulsive social media use amid covid-19 pandemic addictive behavior or coping mechanism? date: 2020-07-07 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102290 sha: doc_id: 291596 cord_uid: lp5di10v nan "is compulsive social media use amid covid-19 pandemic addictive behavior or coping mechanism? 1 dr. shweta singh, 2 ayushi dixit, 3 owing to easy accessibility of internet, globally there are more than 3 billion social media users accounting for 49% of the world's population. in india, the number of social media users stands more than 376 million with a population of more than 1.36 billion (statista, 2020) . the mental health impact of covid-19 is not limited to affected persons, their families and the healthcare force but embraces society's response at large (tondon, 2020). amid the pandemic and subsequent nationwide lockdown, there has been a surge in social media usage which is also reflective of a social response worldwide. for instance, in india 87% people reported increase in its usage with 75% spending increasing amount of time on facebook, twitter and whatsapp (business today, march 30, 2020) . given the backdrop of this alarming data, it is pertinent to debate two questions i.e. (a) "does the current pattern of social media usage suggest a trend towards addictive behavior or has it become a coping mechanism to deal with current global crisis?" and (b) "what are the current and future implications of this trend on addictive behavior and mental health of people?". considering its widespread use across ages, social media is known to be a source of social reinforcement and validation. this platform provide people with an opportunity to share ideas, interact socially, form relationships, draw attention of others and create social image (kietzmann et al., 2011) . during the current global crises when 'social distancing' has become a norm, over-engagement in social media has become a 'psychological necessity' thereby helping people to address their needs of human j o u r n a l p r e -p r o o f interaction and coping with the pandemic. therefore, despite the precautionary guidelines of social distancing, it provides people a platform to remain socially connected and universalize distress caused by the current crisis. apart from socialization, social media is also being used for academic and workrelated purposes like conducting online lectures, webinars, meetings and ensuring work from home. one of the major advantages of social media is that it facilitates awareness and provides mental health support by making resources available to those facing distress caused by lockdown and to those who are isolated as a result of being quarantined. with the help of this platform, data scientists and healthcare professionals have recently surfaced as social media influencers with the aim to mobilize people for taking proactive steps to deal with the crisis (the economic times, 2020). in the ongoing scenario, social media has become one of the major sources for updating information on covid-19 for people. however, it's irresponsible use poses the challenge of 'infodemics' i.e. a situation when 'misinformation' spreads rapidly thereby affecting thinking and subsequent behavior of people. recently who had cautioned people against social media rumors which lead to panic, stigma and irrational behavior (who, 2020). given the rise in usage of this media, it becomes necessary to address its association with mental health. the relationship between social media disorder and mental disorders becomes controversial which is attributable to diagnostic complications (pantic, 2014) . research in the past has shown that compulsive usage of social media impacts physical and mental health including cardio-metabolic health, sleep, affect, self-esteem, well-being and functioning, especially in adolescents (turel et al., 2016 , cheng et al., 2014 van rooij and schoenmakers, 2013) . in light of the present pandemic, mental health conditions are found to be associated with the amount of social media exposure. for instance, a study during covid-19 outbreak in wuhan china, found the prevalence of depression, anxiety and a combination of depression and anxiety (cda) to be 48%, 23% and 19% respectively. moreover 82% participants who were frequently exposed to social media reported high odds of anxiety as well as cda (gao et al,2020) . it is well known to us and also resonated by research that 'internet addiction' is predominantly linked to increased social media or gaming activities schoenmakers, 2013, van rooij and prause, 2014) . while dsm-5 (apa, 2013) and the stable version of icd-11 (who, 2018) have identified 'internet gaming disorder' (igd) as a provisional disorder, social media disorder is still not acknowledged. increasing research is advocating that social media disorder should be considered an addictive disorder just like igd (pantic, 2014; ryan et al., 2014) . according to the dsm-5, a person is diagnosed as having igd if there is fulfillment of 5 (or more) of the 9 criteria (preoccupation, tolerance, withdrawal, persistence, escape, problems, deception, displacement, and conflict) during a period of 12 months. since social-media disorder and igd both relate to internet use, researches refer to nine igd j o u r n a l p r e -p r o o f criterion of dsm-5 for constructing diagnostic tools and establishing internet / social media addiction (regina et al, 2016; van den eijnden, 2016) . since covid-19 outbreak began from end of 2019 and crossed international borders from the beginning of 2020, undeniably '12 months dsm 5 criterion' is not applicable. but it is difficult to say if five or more igd dsm-5 criteria are fulfilled by the excessive social media users. it comes with a word of caution that excessive social media usage is known to be highly addictive due to its psychological, social and neurobiological basis. during current pandemic, like many other uncertainties, it is unclear whether this compulsive use of social media is just a 'phase' and a coping mechanism or an indication of addictive behavior having mental health implications. hence, in terms of current research implications and management, it is imperative to keep the contextual issue of global pandemic in mind and differentiate between addictive and extremely involved behavior. it can be explored whether (apart from the criterion of 12 month duration) people fulfill at least 5 out of 9 igd criterion of dsm-5. here it would be worthwhile to add that because of unique sociocultural context, experience of various asian countries during covid -19 pandemic needs to be studied and shared with the world (tondon, 2020). moreover, any research conducted on addictive behaviors in the current time should consider longitudinally the pre-present-post lockdown social media usage pattern and its mental health implications among individuals across all age groups. the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. diagnostic and statistical manual of mental disorders, fifth edition internet addiction prevalence and quality of (real) life: a metaanalysis of 31 nations across seven world regions mental health problems and social media exposure during covid-19 social media? get serious! understanding the functional building blocks of social media online social networking and mental health the social media disorder scalecompute rs in human behaviour the uses and abuses of facebook: a review of facebook addiction the covid-19 pandemic, personal reflections on editorial responsibility health outcomes of information system use lifestyles among adolescents: videogame addiction, sleep curtailment and cardio-metabolic deficiencies the social media disorder scale a critical review of "internet addiction" criteria with suggestions for the future het (mobiele) gebruik van sociele media en games door jongeren covid-19 pheic global research and innovation forum: towards a research roadmap the new indian express). covid pandemic,social media and digital distancing-the new indian express url how covid-19 has made data experts the new-age social media influencers -the economic times 87% people reported increase in its usage with 75% spending increasing amount of time on facebook (statista) 2020. number of social media users worldwide mental health professionals serving selflessly during current global pandemic. key: cord-264233-0nyzwb44 authors: das, nileswar; narnoli, shubham; kaur, apinderjit; sarkar, siddharth title: pandemic, panic, and psychiatrists what should be done before, during, and after covid-19? date: 2020-06-15 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102206 sha: doc_id: 264233 cord_uid: 0nyzwb44 nan since the world health organization (who) has declared coronavirus disease as a pandemic in january-2020, more than 200-countries have been affected with over 3million confirmed cases. although the part to be played by psychiatrists to pacify global panic in peri-pandemic period is not defined anywhere, psychiatrists should take a leadership role, both in crisis intervention, and long term mental health mentoring (tandon, 2020) . this is a time of uncertaintiesall individuals are uncertain about their health and economic outcomes. also, there is overwhelming misinformation, stigma, prolonged isolation, and disruption of daily routines. all these factors can impact one's psychological-wellbeing j o u r n a l p r e -p r o o f (brooks et al., 2020) . fear and anxiety had led to suicides, communal disharmony, and crimes against essential service providers (sharma et al., 2020) . not only individuals with confirmed or suspected covid-19 but several other vulnerable groups (e.g. health care workers, persons with mental illness etc.), despite remaining uninfected, will continue to suffer from psychological infirmity. therefore, we need an intervention plan to address mental-health problems during the pandemic (das, 2020) .  psychological preparednessto what is coming. it can help individuals to take stock of their coping and prepare them to deal effectively with stressful situations.  early detectionof psychiatric manifestations and distinguishing normal reactions to stresses from mental disorders.  psychiatric interventionto take care of psychological trauma following the pandemic. psychosocial/psychiatric rehabilitationcommunity reintegration.  performing researchesto generate an evidence base for formulating further course of action and policy-making. what are the possible roles to be played by psychiatrists during various phases of the pandemic?  public awarenessproviding the right health information is vital during this time of crisis -(i) to address hand hygiene and safe physical distancing, (ii) to reduce panic j o u r n a l p r e -p r o o f shopping and hoarding of medical equipment (e.g. masks, hand-sanitizer, antibiotics), (iii) to follow the national lockdown to avoid widespread community transmission, (iv) to maintain adequate mental and physical wellbeing and (v) misinformation restriction to avoid chaotic and stressed environments in the country (bhatia, 2020) , (sharma et al., 2020) . one possible solution could be reaching the common public through local leaders and influential celebrities using the same media.  homeless, immigrant and migrant crisisproviding shelter and food can mitigate the problem to some extent. but the huge psychological stress and possible future adversities remain to be addressed. providing adequate psychological support from others, including family members, by being in contact on the phone, along with the resources provided by the government, may be crucial to saving many lives.  medical preparednesslockdown is a relative measure to buy time for medical preparedness. establishing designated hospitals, provision of personal protective equipment and life-saving drugs are crucial but providing psychological support and trauma preparedness training to the emergency care providers can reduce their anxieties and significantly reduce the future psychological trauma in these work-groups (lai et al., 2020) .  resource allocation -during the pandemic, one of the important things that needs to be done is testing of suspected individuals, contact tracing and isolation of suspected cases. allocation of both man-power and fund to this needed activity would be necessary. mental health care providers here may also need to take up the role of a primary health care provider when needed and as per their training statutes.  psychological wellbeing of vulnerable groups -most vulnerable groups needs to be taken care of. we need to step-up in providing telepsychiatry consultation to the individuals who may not physically follow up for various reasons.  continued psychiatric follow up services -it is important to provide continued services to the previously registered mentally-ill patients to refill or adjust their medication without any need to visit hospital. this is particularly important both because lockdowns have made it difficult to travel, and continued social distancing practice can enforce hospitals to restrict number of non-emergency patient visits in coming future .  shutdowns, lockdowns, and forced quarantines -it is very likely to have prolonged lockdowns during pandemic progression. ensuring the supply of daily needs is one aspect, while at the same time, the real challenge would be maintaining one's psychological wellbeing. digital media can be used as a source to train individuals and promote the ways of (i) upholding a healthy lifestyle, (ii) maintaining a near-normal daily routine, (iii) relaxing exercises to deal with stress and, (iv) other ways of coping.  social distancing vs physical distancing -'social' distancing appears to be a misnomer in the present time. in this tough time, maintaining social contact with friends and families is very crucial while maintaining safe physical distancing (galea et al., 2020) . psychiatrists can promote social bonding through the use of telecommunications to minimize the loneliness in these already scary times. can lead to fear and anxiety, and may also lead to stigma. it is also important to 'avoid labelling' the affected individuals or community as 'victims'. it would be necessary to support emergency service providers and to stop spreading rumours. one should seek adequate help if someone is annoyed being identified with illness or being marginalized in society. studies have shown stigma to be directly associated with poor mental health outcomes in the long run (kane et al., 2019) .  disaster management -in the aftermath of covid-19, the situation would be more similar to a natural disaster. with a high number of individuals being under stress, many may show signs of anxiety, depression, posttraumatic stress disorder, among many other psychological disturbances. economic difficulties consequent to the pandemic may also lead to an increase in rates of mental health problems, substance use disorders, and suicides. integration of mental health care with already existing public health services to provide basic psychological support may help to combat long term psychological adversities in the societies. the role of mental health care providers divided above into various phases of the pandemic may not follow the strict pattern and may overlap in reality. they also have to play usual role addressing the mental health of those admitted in in-patient, emergency or intensive care units (acute psychosis, acute mania, catatonia, suicide and delirium); role in breaking badnews and also the mental health providers themselves to keep their calm (avoid getting overwhelmed by the rise in mental morbidity). in summary, covid-19 is anything but only an infectious disease. various far-reaching psycho-socio-economic adversities will have serious mental health issues. psychiatrists and other mental health professionals need to step up, utilizing 'all-out' resources to prevent a post-covid-19 mental-illness pandemic. the authors do not have any conflicts of interest to report financial disclosure the present study was non-funded. the authors do not have financial disclosures public engagement is key for containing covid-19 pandemic the psychological impact of quarantine and how to reduce it: rapid review of the evidence psychiatrist in post-covid-19 era -are we prepared? the mental health consequences of covid-19 and physical distancing: the need for prevention and early intervention a scoping review of health-related stigma outcomes for highburden diseases in low-and middle-income countries factors associated with mental health outcomes among health care workers exposed to progression of mental health services during the covid-19 outbreak in china a chaotic and stressed environment for 2019-ncov suspected, infected and other people in india: fear of mass destruction and causality the covid-19 pandemic, personal reflections on editorial responsibility none j o u r n a l p r e -p r o o f key: cord-308762-lxhq9ga4 authors: sharma, manoj kumar; anand, nitin; singh, priya; vishwakarma, akash; mondal, ishita; thakur, pranjali chakraborty; kohli, tavleen title: researcher burnout: an overlooked aspect in mental health research in times of covid-19 date: 2020-08-25 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102367 sha: doc_id: 308762 cord_uid: lxhq9ga4 nan the sars-cov-2 related lockdown has not only adversely affected the mental health but also behavioral and mental health research (torales, o'higgins, castaldelli-maia & ventriglio, 2020) . however, continued lockdown and physical distancing measures pose a challenge to conduct behavioral research as most of it requires in-person, detailed assessment, and clinical interviews. the challenges have been observed in the form of delay in getting expedited ethical clearance for conducting research (ma, wang, gao, he, he, yue, et al., 2020) . the choice of an appropriate sampling strategy either online or offline or a combination is getting affected due to difficulty in the collection of data because of the implementation of social distancing measures. as a result, behavioral science researchers find it very difficult to convince people to participate in their research studies. the covid-19 related lockdown has also decreased the accessibility to research participants, in addition to existing challenges such as funding not coming through in time, the pressure to achieve results, to write grants, revise grant applications, and face non-acceptance of research grants proposals. the studies which involve qualitative research methods are impacted j o u r n a l p r e -p r o o f even more significantly in comparison to quantitative research. the existing guidelines on social distancing is making it difficult for researchers to conduct interviews with the participants and even if the lockdown is being relaxed with certain conditions, people are continuing to wear masks that is interfering in collecting the nonverbal information as the face is understood to be the index of mind (mehta, venkatasubramanian, chandra, 2020) . to overcome, these existing challenges in research, there is a spurt in data collection via digital platforms. however, it has been criticized for the applicability of obtained results, low response rates, and privacy and confidentiality issues existing with open source software programs (ameen & praharaj, 2020) . it also contributed towards the excessive use of digital devices and digital platforms to manage research work in times of covid-19. also the boundaries for work and leisure activities have also become blurred as for both activities the modality requires digital presence which can lead to the maintenance of stress and burnout. the on-going uncertain situations concerning covid-19 and uncertainties related to research progress appear to be a major contributor towards stress which is likely manifesting itself in researchers and their teams in terms of sleep disturbance, poor appetite, increased interpersonal problems, decreased motivation to continue with research demands, procrastination, absence of other offline leisure activities and experiencing guilt feelings for not completing work. the authors have presented here an experiential account of the challenges experienced by around 15 researchers working in the field of behavioral research in the times of covid-19. the likely ongoing stress among researchers of under accomplishment in the times of covid-19 can cause them to get trapped in the burnout cycle which starts with feelings of heightened and prolonged stress with decreased interest. it is followed by short-term enhancement of attention, energy levels, and experience of anxiety and exhaustion. if the stressful situation does not improve, the final stage usually starts with the experience of despair, bleak and pessimistic views which eventually contribute to a feeling of burn out (burisch, 2014) . it is understood that poor levels of workplace well-being can lead to reduced productivity among researchers via both absenteeism and more crucially through presenteeism, where despite present at the workplace the productivity levels are lower. when such concerns remain unresolved it can impact the quality of research and the levels of commitment towards their research and to their institutions (susan, lichten, belle, ball, knack, & hofman, 2017) . it is true that the covid-19 is presenting itself as an extraordinary threat to the psychological wellbeing of clinical and community population and its impact on mental health is just beginning to be understood. covid-19 pandemic has caused a transitory pause in a number of on-going or planned researches. the researchers and research funding agencies can consider taking a number of steps j o u r n a l p r e -p r o o f which can help the researchers avoid experience of researcher burnout and can help them to continue being efficient in conducting research. a few of these perspectives can include researchers reprioritizing their research and also view it as an opportunity to explore the interface between covid-19 and mental health. the researchers need to consider making pragmatic decisions to reprioritize the on-going clinical research. these decisions can be made by evaluating situations in terms of risk benefit ratios of continuing with research study visits, interviews, assessing risk of pandemic at their study site, optimizing the staff functioning and seeking local and national guidance from health departments to minimize risk to both participants and study teams. besides this research funding agencies and ethics committees to be approached for taking permission for revision of study protocols to allow for data collection using online applications such as skype, microsoft teams and other digital applications. however, if a participant visit is required then it should be conducted by implementing all protective measures as per the advisories of international and national health agencies (keshavan, 2020). the available evidence indicates that many participants appear to be supportive towards continuation of medical research during the epidemics (padala et al., 2020) . illness are coping during covid-19? whether social distancing is likely to increase the experience of loneliness and precipitate mental health symptoms (narita et al., 2020) . in addition, neuropsychiatric and neuropsychological research is also needed to understand how covid-19 affects the neurological and neuropsychological functions of the brain. at present, there is emerging j o u r n a l p r e -p r o o f evidence which indicates that sars-cov-2 impacts the brain . the research also suggests that neuropsychiatric symptoms were observed in 36 % of hospitalized patients (mao et al., 2020) . besides, a mental health pandemic may emerge which results from the experience of trauma, grief, social isolation, loneliness and as well from secondary impact of covid-19 related quarantine and its associations with abrupt changes in lifestyle. emergence of this research data driven insights will help health professionals become prepared for an effective response to the ongoing as well as future pandemics. in addition to repositioning research by researchers, the journals need to encourage the researchers for submitting research articles reporting the mental health impact of covid-19 and interventions implemented to address its impact. besides this there can be special focus given to research emerging out of asia as the covid-19 pandemic started from asia and different asian countries have taken different approaches to manage this challenge. the outcomes across asian countries and from rest of the world are likely to vary and there is much to learn from each other. this will help the relevant information to be made available to researchers and the health professionals in a timely manner (tandon, 2020) . researcher's burnout and mental health needs unlike burnout among members of the health care and teaching professions, have likely not been studied in other epidemics as well like mers and sars and the evidence is limited (susan, lichten, belle, ball, knack, & hofman, 2017) . the authors in their search could not locate much research on researcher burnout. however, there is emerging evidence that covid-19 pandemic has an impact on the mental health of healthcare professionals responding to the covid-19 pandemic . this indicates that covid-19 is relevant to the field of mental health and mental health aspects of covid-19 need to be investigated among all kinds of health professionals including researchers working in the field of mental health research (tandon, 2020) . thus, there appears to be a need for novel and innovative research approaches to explore the burnout and mental health needs among mental health researchers and to actively create mechanisms for its management and especially during the challenging times of a pandemic like covid-19. research focus in this aspect of mental health will be beneficial for enhancing researcher's well-being and productivity and will help in being better prepared during similar other unpredictable situations that may arise in the future. j o u r n a l p r e -p r o o f problems in using whatsapp groups for survey research das burnout-syndrom : theorie der inneren erschöpfung -zahlreiche fallbeispiele -hilfen zur selbsthilfe mental health care for medical staff in china during the covid-19 outbreak the brain, another potential target organ, needs early protection from sars-cov-2 neuroinvasion neurologic manifestations of hospitalized patients with coronavirus disease challenges and strategies to research ethics in conducting covid-19 research the "mind" behind the "mask": assessing mental states and creating therapeutic alliance amidst covid-19 loneliness and psychotic experiences in a general population sample conducting clinical research during the covid-19 pandemic: investigator and participant perspectives understanding mental health in the research environment: a rapid evidence assessment. rand corporation the covid-19 pandemic, personal reflections on editorial responsibility the outbreak of covid-19 coronavirus and its impact on global mental health satyam dst,india awarded the grant to dr manoj kumar sharma compliance with ethical standard:there was no conflict of interest in relation to present work as well as informed consent of the human subjects had been taken prior to inclusion in the study. disclosure of potential conflict of interest:not applicable conflict of interest: authors of the paper did not have any conflict of interest. statement of human right: the studies have been approved by the institutional and/or national research ethics committee . research involving human participants and/or animals:.all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards. key: cord-340110-nvjit17f authors: singh, rakesh; baral, kedar prasad; mahato, sharika title: an urgent call for measures to fight against increasing suicides during covid-19 pandemic in nepal date: 2020-06-20 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102259 sha: doc_id: 340110 cord_uid: nvjit17f nan nepal, one of the lmics, ranks seventh in the world and second in south asia in terms of total number of suicides (khatri pp, 2019) . the country has been experiencing increasing deaths due to suicide each year with 5124, 5317, and 5785 suicides in the year 2017, 2018 and 2019 respectively (dhungana, 2020) . during covid-19 pandemic, suicide cases in nepal have increased by 20% and the rate of mental health illness is predicted to see a further rise after the pandemic (my republica, 2020) . starting from 24 th march 2020, within 74 days of lockdown measures to reduce transmission of covid-19, on an average 16.5 people have lost their lives in a day while in the year 2019 the rate was 15.8 a day (the jakarta post, 2020) . the increase in suicide cases is somehow linked to covid-19 pandemic and its responses in nepal (my republica, 2020) . covid-19 has brought many stressors including lost jobs, lost home, business loss, intimate part violence and child abuse due to enforced measures such as lockdown, social distancing and travel restrictions (clay, 2020) and are primarily related to people's movement and interaction and income. disrupted daily activities may be exacerbating preexisting mental illnesses. disturbed academic routines including suspension of classes, suspension of examinations of students and quick shift of teaching method applied in schools and colleges may be posing fear and threat towards mental wellbeing of the students (clay, 2020) . similarly, limiting the social networks among young people and keeping them apart from their loved ones and peers may act as key stressors among youths (clay, 2020) . at the same time, travel restrictions and physical distancing have been endangering the lives ofpeople affected with mental illnesses and those who are at the verse risk of developing mental illnesses, as it has been urged by most of the hospitals to ask people and patients not to visit health facilities, unless in an emergency condition. on one hand, this in turn will make both new and old patients having, complaints of and suffering from, mental illnesses unable to -seek health services as psychiatric medicines are also not available over the counter at the pharmacies (the jakarta post, 2020) . on the other hand, those in access of health facilities may feel fear to contract covid-19 infection while seeking health services in the hospital. moreover, mental health problem is a stigma in nepal and the ones who share their feeling attracted towards ending their lives are often labeled as chicken-hearted which encourages an j o u r n a l p r e -p r o o f individual to commit suicide. social isolation, entrapment, and loneliness are the risk factors of suicide (o'connor and kirtley, 2018) and these conditions are likely to increase during the pandemic. all these reasons including stressors, stigma, and increased risk of mental health problems have some connections behind the increase in the number of suicide cases and suicidal ideation. although, there is no such study that has established causal relationship between covid-19 and suicides, crisis during pandemics have been linked towards increased suicidal cases. when compared the deaths due to suicide with deaths due to covid-19, the former is far ahead in nepal. though, it is very important to prevent covid-19 transmission and deaths related to it, it is equally essential to promote and protect mental wellbeing of the people with especial focus on suicide prevention strategies. in line with this, while seeking healthcare services at health facility by covid-19 patients, their assessment of mental health status should also be done in coordination with psychiatrists and/or psychologist. however, the indicators of mental health services are not optimal in nepal with: services being concentrated in the big cities, with 0.22 psychiatrists and 0.06 psychologists per a population of 100000, 1.5 beds per a population of 100000 for mental health patients, and less than 1% of its total healthcare budget on mental health (uprety and lamichhane, 2016) . so, task shifting approach can be a viable strategy to delivering mental health needs of the people in nepal. task shifting approach means the shifting of tasks, from more to less highly trained individuals to make efficient use of these resources, allowing all providers to work at the top of their scope of practice. this includes primary care health workers (phws) or lay health workers (lhws) such as doctors, nurses and other general paraprofessionals not specialized in psychiatry or psychology, and community workers (cws) such as teachers, who may perform a particular mental health function in delivering promotion, prevention, high risk identification and treatment interventions (patel et al., 2007) . the taskshifting approach has shown to being effective across a wide range of mental conditions in lmics (van ginneken et al., 2013) . further, a mechanism should be established to follow-up the discharged covid-19 recovered patients via telephone by lhws or cws or phws to assess their mental health status and provide counseling service to help prevent stress, depression and mitigate suicidal thoughts as j o u r n a l p r e -p r o o f covid-19 recovered patients are at higher risk of discrimination leading to loneliness (singh and subedi, 2020). also, lhws can be involved in educating caretakers and family members of the covid-19 recovered patients to assess mental health risks and deliver appropriate preventive measures should be an alternative approach to protect mental wellbeing of covid-19 recovered patients. psychiatrists, psychologists, psychiatric nurse, and trained lhws and phws should do their best not only to aware patients but everyone else on ways to recognizing warning signs of suicide and how to keep them safe with needed care and support (clay, 2020 showing rage or talking about seeking revenge; and displaying extreme mood swings (rudd et al., 2006) . also, at large scale, registration free webinars/video conferencing sessions using online media to aware people on identifying warning signs of suicide, its risk factors and stress management techniques should be a priority for healthcare professionals during crisis. moreover, during covid-19 pandemic with social distancing measures at place, to avoid social disconnection among people, the most viable media have been mobile, telephone and social media applications using internet. in this line in nepal, currently nepal telecom and ncell, being the major communication sector, as a corporate social responsibility in response to covid-19, have been educating public at large regarding mitigating measures of covid19 including social distancing, hand washing, use of personal protective equipment (such as face mask), anyone can be vulnerable or affected, and sign-symptoms, and if experience symptoms seek health services immediately. while these measures are keys to fight against covid-19 pandemic, it is also very important to protect and promote one's mental wellbeing in this unusual situation which could lead an individual to stress, depression, suicidal ideation thoughts among people due to perceived isolation and loneliness (singh and subedi, 2020) . along with this, it could be a rational way to integrate health education messages directed towards identifying warning signs of stress, depression and suicidal ideation via the communication sectors while making phone calls as j o u r n a l p r e -p r o o f caller tune in the background to relay messages to seek mental healthcare services from nearest healthcare centers; simple messages showing importance of sharing feelings with family, friends, teachers, colleagues in protecting mental wellbeing; messages displaying or relaying helpline numbers to seek immediate counseling services. moreover, while disseminating the messages these should be in local language as per culture and community considering the common language being spoken. similarly, for those who fear from getting discriminated and contracted covid-19 at health facility, helplines are the suitable ways to help provide them required support to prevent them from adverse consequences including suicide. these include but are not limited to: the tribhuvan university teaching hospital suicide hotline (9840021600) and patan hospital crisis helpline for suicide prevention (9813476123) operating 24 hours a day; the transcultural psychosocial organization (16600102005) provides helpline services between mondays to friday from 9:30 am to 4:30 pm (the jakarta post, 2020) . similarly, measures such as keeping self-busy, listening to music, involving in physical exercises and meditation and involving self in gardening activities could be possible strategies to protect and promote mental wellbeing while people are having limited social network, and social distancing measures are at place during crisis situations as that of covid-19 pandemic. in conclusion, the issue of mental health during covid-19 pandemic has come to the forefront in nepal with extremely concerning impact which includes increased suicidal deaths and suicidal ideation. the suicidal crisis presents an urgent need for launching a massive public awareness campaign across the nation so as to educate every member of the families about warning signs of suicide in order to identify those at risk, provide them with care and support, help them protect their mental wellbeing and prevent suicide. covid-19 and suicide -covid-19 special report suicide cases remain a challenge for law enforcement agency even during lockdown multidisciplinary research priorities for the covid-19 pandemic: a call for action for mental health science suicide leading cause of deaths suicide cases on the rise, mental health experts warn of a 'grim situation the integrated motivational-volitional model of suicidal behaviour treatment and prevention of mental disorders in low-income and middle-income countries warning signs for suicide: theory, research, and clinical applications the covid-19 pandemic, personal reflections on editorial responsibility over 1,200 people killed themselves during 74 days of lockdown in nepal mental health in nepal -a backgrounder non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in low-and middle-income countries world health organization who, 2020. suicide prevention j o u r n a l p r e -p r o o f key: cord-276300-6xy8bwfl authors: sahoo, swapnajeet; mehra, aseem; suri, vikas; malhotra, pankaj; yaddanapudi, narayana; d puri, g; grover, sandeep title: lived experiences of the corona survivors (patients admitted in covid wards): a narrative real-life documented summaries of internalized guilt, shame, stigma, anger date: 2020-05-30 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102187 sha: doc_id: 276300 cord_uid: 6xy8bwfl covid-19 pandemic has emerged as a disaster for the human beings. all the governments across the globe have been preparing to deal with this medical emergency, which is known to be associated with mortality in about 5% of the sufferers. gradually, it is seen that, many patients with covid-19 infection have mild symptoms or are asymptomatic. due to the risk of infecting others, persons with covid-19 infection are kept in isolation wards. because of the isolation, the fear of death, and associated stigma, many patients with covid-19 infection go through mental distress. in this report, we discuss the experience of 3 persons diagnosed with covid-19 infection and admitted to the covid ward. the covid-19 pandemic has taught the entire human fraternity a big lesson. it is a severe blow to the healthcare system of the entire world and had affected millions of people across the world. covid-19 is associated with a very high rate of infectivity, which has led to a high level of fear and anxiety of getting infected. resultantly, the pandemic has led to severe restrictions on the free movements of human beings, and the lockdown of almost all countries across the world, etc. the literature on laboratory testing, preventive measures, and management protocols to tackle the highly infective virus are ever-expanding. even the data related to the mental health issues in the front line warriors/ health care workers is well-documented. however, the real-life experiences of the patients admitted in the covid wards and their wellbeing in the covid-19 era is largely neglected. there are few blogs/youtube videos of the recovered patients/ corona survivors about their experience (about how they had fought with the infection, how much they felt lonely during the admission etc.) during their hospital stay, yet no descriptive data is available (busby, 2020; collinson, 2020; kwch, n.d.; "what does covid-19 feel like?" n.d.) . in this report, we discuss the psychological issues and the lived experiences of 3 persons who were admitted with the covid-19 infection during their hospital. the covid-19 designated center is being managed by a core covid-19 team consisting of doctors from internal medicine, anesthesia, pulmonary medicine, and hospital administration. during the initial few days, it was seen that most patients admitted with the infection had some or other mental health issues such as anxiety, excessive worries, irritability, low mood, frustration, distress, feeling isolated/loneliness, etc. this led to the involvement of mental health professionals to provide mental health support through videoconferencing/telephonically. the 3 summaries discussed in this report are the mental health issues and other experiences shared by 2 persons and a family admitted in the covid center. ever forgive him, will they maintain a good relationship with him in future, whether his family members will recover or not. such thoughts would persist for most of the day. he would also remain preoccupied with thoughts such as 'how would face his friends, neighbors, and fellow villagers'. he would often worry that in future himself and his family members will be outcasted, and he losing his political career. he did not have any history of mental illness or any history of substance use. a diagnosis of acute stress reaction was considered. supportive sessions were taken by the psychiatrist by teleconferencing. all his concerns were heard and his anxiety related to his worries was allayed. during the sessions, he came up with his worries, expressed his inability to help his family members, about his future, and the anticipated stigma. with the supportive sessions, he started feeling better and relaxed. besides supportive sessions with the patient, one of his cousin (uninfected) with whom the patient was in constant touch was involved in the treatment, who was asked to motivate the patient to stay active and remain busy watching videos/movies on youtube channels, read things of his likings on the internet and pray to god. he was discharged after his repeat tests came out to be negative. he is being followed up telephonically, supportive sessions are being continued to avoid any other negative psychological consequences. a family comprising of the couple, who were non-resident indian and their 10-month-old child were admitted to the covid ward, after being found positive for the infection. the husband was 35 years old and the wife was 32 years old. both, the husband and the wife had minimal physical symptoms during the initial 2-3 days. however, psychologically, both of them felt angry about themselves, especially about their decision to come to india to visit their family, cursed their fate, and would remain apprehensive about the outcome of their baby. the mother would frequently check the baby for any rise in body temperature and would get very anxious if the baby would cry. the couple was also very much distressed because of the non-availability of airconditioning, which was maintained with less venting to prevent air circulation and aerosol generation. on the 3 rd day of their admission, their 8 years old daughter and the mothers of both the partners (59 years and 57 years old) tested positive. the mother of the male partner was admitted at our center, went on to develop respiratory distress, and had to be shifted to the covid intensive care unit (icu). this triggered a deep sense of 'guilt' in the male partner and he started having thoughts that ' i infected my mother and my daughter', ' will my mother be able to survive', and ' will i be able to see her again', etc. he started following the updates about covid-19 infection in india and the world more closely, started to remain worried and tensed when he would see the mortality rates/figures of india and of the world in which the elderly are at extreme risk. his partner would be also going through similar mental issues. the couple would discuss their worries with each other, would try to reassure each other. but they would get more worried when they would stay away from each other (as they were isolated i.e. had to stay in different roomsa mother with the baby and father alone). the couple would keep on calling the relatives to know about the progress of other relatives and check with the hospital staff about the progress in the health of their mothers/ mother-in-laws. over the next 1-2 days, the psychological symptoms worsened and the female partner started remaining irritable and distressed, would repeatedly ask about her discharge date. when she was explained that she would be discharged after a particular time frame, the female partner started arguing with the health care professionals on duty. gradually the tussles increased significantly and led to the intervention by the psychiatrist. the female was assessed by teleconferencing and all her worries were heard. a diagnosis of acute stress reaction was considered and supportive psychotherapy was started. initially the patient was allowed to ventilate her worries and concerns. this led to a reduction in her distress and anxiety. steps were taken to look after the welfare of the couple, i.e. allowing them to meet 2-3 times a day with precautions of hand hygiene and social distancing. after 2-3 days, things started to settle, the mother of the male partner admitted to icu became stable and was shifted to the ward. this led to a further reduction in worries and distress. after 14 days when the couple was tested to check for their covid-19 status, the husband and wife were found to be negative but to their 10-month-old child was still found to be positive. this led to further frustration and distress in the female partner. she would remain irritable, get angry at the staff, and would argue about the credibility of the tests being done, etc. these issues were again addressed in the ongoing supportive sessions, in which she was allowed to vent out her anger and was explained about the testing protocol, sensitivity, and specificity of the test and the implications of discharging people if they are still positive for covid-19. this led to a reduction in her distress. after mutual agreement, it was decided to discharge the male partner and the female partner, who stayed in the hospital, along with the infant. both the partners are continued on the supportive sessions. a 23 years old man was admitted after being tested positive for covid-19, who had contracted the infection after meeting a friend who returned from abroad. he described his experience of initial few days of being angry on his friend, would call his friend (who was admitted in another hospital-medically stable), would abuse him for infecting him and would ask him never to show his face again to him. he would be worried about his parents, who had multiple physical comorbidities and would be pre-occupied with their covid-19 status. his parents and other family members were tested and none of them were found to be positive. he did not have any severe respiratory difficulty and was medically stable throughout his stay. by the second week of his stay in the covid-19 ward, he started to report that he is feeling bored, he would not find surfing the internet to be enjoyable anymore, would keep on moving inside his room and look outside through the windows of his room. while on routine screening by the mental health professional telephonically, he expressed difficulty in passing his time. he expressed that he missed his computer/laptop, want to play video games, and would demand the same. gradually his distress started increasing. supportive sessions were taken and the activity schedule was planned for him. he was asked to make an activity schedule for himself and watch music videos of his choice. on exploring his hobbies it became apparent that besides, playing video games, he also pursued photography as an alternate hobby. he was given daily tasks by the text messages, as to see photography from specific sites of his choice and send it to the psychiatrist by using the whatsapp. he was asked to look for any online photography training and to remain busy in gaining more knowledge of photography. after 3 rd day of starting the intervention, he reported that he was able to spend his time in interesting things, which he always wanted to pursue. he reported, "sometimes i feel like i am in jail but then when i remember it is a temporary phase, i can control my emotions, i never tried to show my agony and pain to my parents and i feel cheered up when i get your (psychiatrist's) message or call". he was tested negative after 16 days and was congratulated for his recovery at discharge. he is being followed up and the supportive therapy is being continued. the above-mentioned narrative lived experiences of the corona survivors or patients admitted to the covid ward are beyond one's imagination. the stress, mental agony, internalized stigma, feelings of guilt of infecting near and dear ones, the shame of infecting others, anger directed towards self, cursing one's fate, thinking "why god has punished me and my family" adds on to the pain of remaining socially isolated from the family in a 'locked up' state is highly distressing. all these issues suggest that mental health is taking a big toll on the people diagnosed with covid-19 infection and admitted to the covid wards. the systems are preparing themselves to deal with more severe cases, i.e., those who are going to require icu and ventilator support, but the mental health of a major proportion of people, who are going to develop mild to moderate symptoms of covid-19 infection is not being discussed. these lived experiences of the people bring to the forefront the issue of "no health, without mental health". as is evident from these cases, the mental health issues would not have come to the forefront, if the mental health professionals were not involved in the management of these cases. this could have led to severe untoward consequences, such as relationship issues between the patient and the treating team and the patients progressing to severe depression. in these above mentioned narrative experiences, timely psychological evaluation, and brief supportive sessions carried out telephonically or by video conferencing helped the people going through the infection. mental health professionals need to recognize that besides anxiety, depression, and insomnia, guilt, anger, frustration and internalized stigma are also going to be the major issues of these patients and they need to address the same. these case descriptions suggest that apart from the psychological issues of the health care workers, there is an urgent need to handle and understand the mental health issues of the patients suffering from covid-19 during admission/ward stay and during quarantine (banerjee, 2020) . the uncertainty of having a dreadful illness, limited family support, fear of death of self, and near ones imposes a severe stressful mental state, and therefore mental health evaluation and mental health support to the patients' needs to be routinely done. world health organisation mentions that psychological issues need to be taken into considerations during the covid-19 pandemic for the general public (world health organization, 2020). many authors have also stressed the psychological first aid to be provided to the patients admitted in the covid wards xiang et al., 2020) . based on our experience we suggest that all the covid-19 wards and services should be planned to keep the mental health of the people at large. all covid wards and other services should have mental health professionals, who should be involved right from the time of screening the persons for covid-19 (grover et al, 2020) . the mental health professionals involved with the covid-19 wards should screen all the patients daily and address their issues and the interpersonal issues arising as a result of isolation and other ensuing issues. as many patients would be asymptomatic or would gradually become asymptomatic and stable after the initial few days, the stress and isolation would come to the forefront and will become an issue rather than any other medical/clinical issue. routine evaluation by mental health professionals should be a part of the treatment protocol which is at present not mentioned/documented for holistic management of stigmatized, aggrieved corona fighters, and survivors. further, psychiatrists and mental health professionals should be prepared to tackle with post-covid era mental health consequences too (das, 2020) . none the covid-19 outbreak: crucial role the psychiatrists can play it was the most terrifying experience of my life three harrowing stories of surviving covid-19 psychiatrist in the post-covid-19 era -are we prepared? patients recovering from covid-19, symptoms of virus share experiences progression of mental health services during the covid-19 outbreak in china what does covid-19 feel like? one patient shares his experience world health organization, 2020. mental health and psychosocial considerations during the covid-19 outbreak timely mental health care for the 2019 novel coronavirus outbreak is urgently needed none key: cord-258072-6d5ieakl authors: kochhar, anuraj singh; bhasin, ritasha; kochhar, gulsheen kaur; dadlani, himanshu; mehta, viral vijay; kaur, roseleen; bhasin, charanpreet kaur title: lockdown of 1.3 billion people in india during covid-19 pandemic: a survey of its impact on mental health date: 2020-06-18 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102213 sha: doc_id: 258072 cord_uid: 6d5ieakl nan covid-19 pandemic presented as a black swan event, and as a measure to curtail it the governments of different countries took various approaches (tandon r). however, most countries announced complete lockdown, with draconian travel and social restrictions. on march 24, 2020, the government of india ordered a nationwide lockdown for 21 days, limiting movement of the entire population of 1.3 billion. though this was probably a requisite, even short term lockdowns, quarantine and social distancing can precede long term effects such as symptoms of mental stress and disorder, including insomnia, anxiety, depression, and post-traumatic stress symptoms (wang et al, 2020; brooks et al, 2020) . although there is a deluge of studies published regarding covid-19, there is a paucity of published data regarding the mental health status of the general population. therefore the present survey was intended to assess the mental health impact of the current lockdown on the population of new delhi, india, a week after its imposition to assist the government agencies and healthcare professionals in safeguarding the mental health wellbeing of the community. after reviewing the pertinent literature which included scales such as, impact of event scale -revised (ies-r), perceived stress scale 10 (pss-10), and the international guidelines, a self administered, pre-validated web-based questionnaire with 18 questions in english, exploring age and domains of knowledge about covid-19, understanding reasons for lockdown, stressors which included fear of infection, helplessness and boredom, scarce supplies, and post quarantine stressors related to work, finances and stigma was floated on a famous social media site, facebook (groups from new delhi). those who accepted the invitation and confirmed they were residents of new delhi, were above 20 years of age and had a minimum graduate level education received the questionnaire. the study population consisted of 992 participants (out of the 2876 invited) of which 11.2% were aged between 21-35 years, 46.3% between 36-50 years, 6.5% were over 65 years of age and the remaining 35% were between 51 to 65 years. ethical clearance and consent were obtained for the same. the data was subjected to statistical analysis using spss j o u r n a l p r e -p r o o f 20.0. shapiro-wilk test indicated the data to be normally distributed. results were segregated based on the variable of age and domains that indicated significant association with age have been highlighted in table 1 (p<0.05). chi-square indicated significant associations were observed between age groups and the multivariate variables of knowledge about covid-19, effects of covid-19 on humankind and how the participants felt about the present situation. of the bivariate variables, significant association of age was noted with effects on work and income with sleep and diet pattern changes (graph-1). pearson's correlation analysis of bivariate variables indicated that an increased understanding of the meaning of social distancing enabled its increased practice. also, negative correlation between age and travel plans indicated that decreasing age was associated with increasing possibility of modifications in travel plans. while an increase in fear of acquiring covid-19 by meeting people was correlated with an increase in dietary pattern changes, it displayed negative correlation to sleep pattern changes. the covid-19 outbreak has led to diversified mental health responses depending on the individual's strengths and weaknesses (wang et al, 2020) . knowledge about the disease and the reasons for lockdown are vital tools for successful disease containment (brooks et al, 2020) . in the present study, 92.5% and 97.5% respondents were well acquainted with the knowledge of covid-19 and social distancing or isolation respectively, with 98.2% following it (p<0.05). there was a positive correlation between the awareness of social distancing or isolation and those who were practicing it. present survey revealed 78.5% participants were optimistic and believed that together the disease could be curtailed (p<0.05). however, it has been contemplated that greater the number of individuals following updates about the same, higher are the anxiety levels (moghanibashi-mansourieh, 2020). although social media has played a pivotal role in these times with a splurge of knowledge, information must be gathered from health authorities in order to help distinguish facts from rumours, as facts can help minimize fears. 12.1% participants felt helpless & depressed suggesting that containment, loss of daily schedule, and diminished social and physical contact with others can cause mental fatigue, dissatisfaction, and a feeling of confinement from the remainder of the world. 12.1% participants felt helpless & depressed suggesting that containment, loss of daily schedule, and diminished social and physical contact j o u r n a l p r e -p r o o f with others can cause mental fatigue, dissatisfaction, and a feeling of confinement from the remainder of the world (brooks et al, 2020) . following the imposition of the lockdown, 91.6% of respondents altered or canceled their travel plans. when asked about effects of the disease on mankind, 60.2% believed that it would lead to loss of human lives, 29.8% people were concerned about possible economic slowdown while 1.9% people believed it to be a mere social media hype. when enquired about the activities during the lockdown, only 11% were occupied with hobbies whereas who advises engaging in regular exercising, daily chores, and hobbies during the present covid-19 pandemic for mental health well-being (who, 2020). significant associations were observed between age groups and the multivariate variables of knowledge about covid 19, effects of covid 19 on mankind and how the participants felt about the present situation. sleep disturbances have been shown to be a risk factor for mental disorders. also, sleep quality has been found to be dependent on anxiety, stress and self-efficacy (xiao et al, 2020). moreover, short sleep duration in some individuals has been associated with suicidal tendencies (weber et al, 2020). in current study 55.3% complained of trouble sleeping during this lockdown period, of which people who feared contracting the disease and participants between the age group 35-50 years witnessed maximum alteration in sleep. this could be associated with high levels of anxiety and stress because of isolation, indicating adverse mental health. (rajkumar, 2020) nutritional factors are interlaced with human behaviour, and emotions while playing a critical role in not just the initiation, but also the severity and duration of depression. numerous reports support the view that stress can either increase or decrease caloric intake, and chronic stress exposure can lead to either obesity or anorexia (sathyanarayana rao et al, 2008) . variations in eating patterns were observed in the present study in 79.5% of participants, with people aged 35-50 years experiencing maximum alterations in diet patterns that were positively correlated with the practice of social distancing and fear of acquiring the disease on meeting someone. though not significant, 26.3% of respondents stated that they started consuming more alcohol/drugs/tobacco, raising an alarm, as isolation might lead to an escalation in alcohol misuse and probable development of alcohol use disorder in high-risk persons during and after the pandemic (clay & parker, 2020) . it has been reported that during quarantine, inadequate basic supplies can cause resentment. 35.4% of the participants commented that they could sustain lockdown; however majority of the respondents could not manage either due to lack of basic amenities and medical needs (31.8%) or due to emotional reasons (32.8%) blendon rj also stated that lack of regular medical care was a concern for participants (brooks et al, 2020) . financial hardships are often experienced by individuals during quarantine. lockdown majorly affected the work and income of 63.4% of the population that was positively related to people aged 35-50 years, followed by 50-65 years, impacting their financial status. even though 49.7% of the study population claimed to have sufficient funds to manage the lockdown situation, remaining were either uncertain about it or did not have the resources to sustain it. monetary loss is a stressor during and post isolation because people are unable to work and professional activities are interrupted unprecedentedly; the effects appear to be long lasting. financial loss due to quarantine created severe socioeconomic distress (pellecchia et al, 2015) and was established to be a contributing factor for symptoms of mental health disorders, anger and anxiety (mihashi et al, 2009) . although stigma has aggravated the anguish from many major epidemics in the past, with various studies suggesting that patients were being treated differently, being avoided, treated with fear and suspicion and received critical comments (wilken et al, 2017) , in the current study 71.7% believed that acquiring covid-19 was not a social taboo. the present lockdown which was initially proposed for 21 days was eventually extended for another 3 weeks. longer quarantines have a direct correlation with the mental health outcomes and the duration of the lockdown is a predominant stressor affecting the mental health of individuals (brooks et al, 2020) .during the sars outbreak, many studies investigated the mental health impact on the non-infected community, revealing significant psychiatric morbidities (sim et al, 2010) . even when people adhere to the lockdown, rather than comply, various moral and mental health issues are raised, creating a debate about individual rights versus such public health interventions during a crisis. however, if authorities are strategic in their planning, lockdowns may become more effective and with fewer effects on the mental health of people. author contributions: 1. dr. anuraj singh kochhar: conception and design of the study, acquisition of data and analysis of the same. drafting the article, critically evaluating and giving final approval for the same. 2. dr. ritasha bhasin: conception of design, drafting the article, and critically evaluating it. approving the final version. 3. dr. gulsheen kaur kochhar: conception of design for the study, analysis of the data, drafting the article, revising it and critically evaluating it. approving the final version. 4. dr. himanshu dadlani: conception and design of the study, acquisition of data, or analysis and interpretation of data, drafting the article, critically evaluating and giving final approval. 5. dr. viral vijay mehta: the conception and design of the study supervising the acquisition of data along with analysis and interpretation of data. critically evaluating the article and giving the final approval. 6. ms. roseleen kaur: conception and design of the study, acquisition of data and analysis of the same. drafting the article, revising it, critically evaluating and giving final approval for the same. 7. ms. charanpreet kaur bhasin: condensing the article in its present form. no fees and grants from, employment by, consultancy for, shared ownership in, or any close relationship with, an organisation whose interests, financial or otherwise, has been received by any of the authors. 1. authorship of the paper: authorship has been limited to only those who have made a significant contribution to the conception, design, execution, or interpretation of the reported study. credit author statement attached with the cover letter. 2. originality and plagiarism: the authors have ensured that they have written entirely original manuscript, and if the authors have used the work and/or words of others, that has been appropriately cited or quoted. 3. data access and retention: the datasets used and analyzed during the current study are available from the corresponding author on reasonable request. 4. multiple, redundant or concurrent publication: this manuscript has not been published before and is neither under consideration for publication elsewhere since it was originally submitted to asian journal of psychiatry. the manuscript in its current form is approved by all authors. 5. acknowledgement of sources: proper acknowledgment of the work of others has been specified wherever used. 6. disclosure and conflicts of interest: submitted separately 7. fundamental errors in published works: when ever such an error would be noted / discovered, it will be promptly notified to the journal editor or publisher and cooperated with the editor to retract or correct the paper. 8. reporting standards: work is accurately performed and discussed in its significance. 9. hazards and human or animal subjects: there was no indication of unfavorable effects on safety/risk to the participants of the study. 10. use of patient images or case details: ethical committee approval and informed consent of volunteers obtained, which is documented in the manuscript. no conflict of interest reported by any of the authors. the psychological impact of quarantine and how to reduce it: rapid review of the evidence alcohol use and misuse during the covid-19 pandemic: a potential public health crisis? the lancet public health j o u r n a l p r e -p r o o f key: cord-251970-r5cbuvcw authors: cai, wenpeng; lian, bin; song, xiangrui; hou, tianya; deng, guanghui; li, huifen title: a cross-sectional study on mental health among health care workers during the outbreak of corona virus disease 2019 date: 2020-04-24 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102111 sha: doc_id: 251970 cord_uid: r5cbuvcw the spread of corona virus disease 2019 (covid-19) has become a global major public health event, threatening people's physical and mental health and even life safety. this study is to investigate the psychological abnormality in health care workers battling the covid-19 epidemic and to explore the associations among social support, resilience and mental health. a total of 1521 health care workers, of whom 147 had public health emergency experience while 1374 showed no experience, completed the symptom check-list-90 (scl-90), chinese version of connor-davidson resilience scale (cd-risc) and social support rating scale (ssrs). χ(2) test, t test and multiple regression analyses were used in statistical analysis. the results showed that people without public health emergency treatment experience showed worse performance in mental health, resilience and social support, and tended to suffer from psychological abnormality on interpersonal sensitivity and photic anxiety. this finding suggested that high levels of training and professional experience, resilience and social support were necessary to health care workers who are first taking part in public health emergence. corona virus disease 2019 originated in wuhan has spread throughout china from december 2019, which has seriously threatened human health (huang et al., 2020) . on 30th january, who announced the novel coronavirus pneumonia (ncp, later renamed as covid-19) epidemic as public health emergency of international concern (who, 2020) . according to the statistics of the national health commission of the people's republic of china, 81,054 confirmed cases, 687,680 suspected cases and 3261 deaths had been reported in chinese mainland up to 24:00 on march 21 (nhcprc, 2020) . the outbreak of covid-19 as a major health care event has exerted a negative impact on daily life, threatened people's health both mentally and physically, and endangered social and economic development (ma et al., 2020) . in the face of such a severe situation, the government and the health department have issued various prevention and control policies, and actively taken various prevention and control measures to contain the epidemic. since covid-19 is the largest public health emergency in china in the past ten years, many young health care workers take active part in battling the covid-19 epidemic. different from the experienced ones who have ever joined the public health emergency such as sars, h1n1, the fresh health care workers at around 30 years old are confronted with the much more occupational stress, which is also a big challenge to their resilience and mental health. resilience is an individual's capacity to deal with significant adversity and quick recover (fletcher and sarkar, 2013) . previous study showed that psychological resilience can protect individuals against mental illness and thrive from the adversity (perlman et al., 2017; hu et al., 2015a, b) . thus, it might help predict the workers' mental health by assessing their resilience. social support is individuals' perception or experience in terms of being involved in a social group where people mutually support each other (cao et al., 2018) . family, friends or any other important relatives could provide material and spiritual support, which probe to be positively associated with mental health (rothon et al., 2012) . due to highly contagious covid-19, the health care workers have to cut off the direct contact with other people, and spend time alone after work. therefore, the availability of social support might be of importance to medical team. this research is to investigate the mental health among the health care workers battling the covid-19 and to explore the associations among social support, resilience and mental health. https://doi.org/10.1016/j.ajp.2020.102111 received 24 march 2020; received in revised form 2 april 2020; accepted 3 april 2020 a total of 1521 health care workers were recruited in this study. they all took part in battling the covid-19 epidemic in jiangsu province. among them, 147 people had public health emergency experience before (experienced staff), while 1374 people had no experience (fresh staff). all participants completed the symptom check-list-90 (scl-90), chinese version of connor-davidson resilience scale (cd-risc) and social support rating scale (ssrs). the scl-90, designed by derogatis and his colleagues (derogatis et al., 1973) , is a questionnaire to assess self-reported symptom intensity including a number of different subscales. the 90-item scale consists of 10 factors including somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, photic anxiety, paranoididefition, psychotieism, and additionalitems. responses to items are measured on a 5-point likert scale ranging from 0 (none) to 4 (severe). items are added and converted to obtain the subscale scores and total score. if any subscale score is higher than 2, positive items are higher than 43, or the total score is higher than 160, it suggests psychological abnormality. the scl-90 has been widely used in previous studies with high reliability and validity (crespo-maraver et al., 2018; holi et al., 1998; wei et al., 2018) . it exhibited strong internal consistency (cronbach's alpha = 0.983) in the current sample. we evaluated resilience using the cd-risc, which was first developed by connor and davidson (connor and davidson, 2003) , and was later revised into chinese version evolved by yu and her colleagues (yu et al., 2007) . the 25-item scale contain three conceptually distinct subscales: strength (e.g., coping with stress strengthens), tenacity (e.g., when things look hopeless, i don't give up) and optimism (e.g., see the humorous side of things). responses to items are measured on 5-point likert scale ranging from 0 (not true at all) to 4 (true nearly all the time). items are added to obtain scores between 0 to 100, with higher scores denoting great resilience. the chinese version of cd-risc has shown good reliability and validity (cai et al., 2017) , and it also exhibited strong internal consistency (cronbach's alpha = 0.954) in the current sample. the ssrs, designed by xiao (1999) , is a multidimensional self-report scale assessing social support. the 10 items comprise 3 factors: objective support (e.g., what's the sources of financial support and help to solve practical problems when you were in an emergency situation), subjective support (e.g., how many close friends do you have to get support and help), and availability (e.g., how to ask for help in case of trouble). item scores are summed together to obtain the total score 0-50 with higher scores denoting stronger social support. the ssrs has been widely used in chinese populations showing high reliability and validity (liu et al., 2016) , and it exhibited strong internal consistency (cronbach's alpha = 0.949) in the current sample. this study was approved by the ethics committees of the second military medical university. all participants received an informed consent before data collection, so that they could choose whether or not to participate, and withdraw at any time if they wished. frequencies, percentages and standard deviations were calculated for descriptive analysis. demographic and occupation backgrounds of health care workers with and without psychological abnormality were compared using χ 2 test. the differences of mental health, resilience and social support between fresh staff and experienced staff were compared via simple independent sample t-test and multiple regression analyses were used to examine the associations among resilience, social support and mental health in fresh staff and experienced staff. p＜0.05 was considered statistically significant. spss 22.0 (spss inc, chicago, il) was used to conduct the analysis. the prevalence of psychological abnormality was 14.1%. as shown in table 1 , public health emergency treatment experience was significantly associated with a decreased prevalence of psychological abnormality. besides, there was a marginal significant association between the length of service and the prevalence of psychological abnormality. to address the cohort effect of age, we further compare prevalence of psychological abnormality between fresh group and experienced group in the over-30. 105 fresh staff and 9 experienced staff turned out to be positive. there was also a marginal significant association between public health emergency treatment experience and prevalence of psychological abnormality in over-30 populations (χ 2 = 3.471, p = 0.062). we further compared the mental health differences between experienced staff and fresh staff. as shown in table 2 , statistically significant differences in interpersonal sensitivity and photic anxiety were noted between groups (p＜0.05). besides, there was a marginal significant difference in obsessive-compulsive (p＜0.10) and no significant differences in other seven subscales. table 3 shows that fresh staff had significantly lower scores in cd-risc total and three subscales than experienced staff (p＜0.001). in compared with experienced staff, fresh staff has presented a significantly lower level of resilience, and the significance held across the three aspects: tenacity, strength, optimism. table 4 shows that fresh staff had significantly less scores in objective support, subjective support and ssrs total scores than experienced staff (p＜0.05). nevertheless, there was no significant difference in availability of support between groups. table 5 shows the result of multiple regression analysis predicting mental health by resilience and social support in fresh staff and experienced staff. tenacity, strength, objective support, subjective support and availability of support could significantly predict the mental health in fresh staff. however, there is no factors significantly predicting mental health in experienced staff. previous study showed that occurrence of psychiatric symptoms were linked to younger age and less family support (su et al., 2007) . the current study further revealed that people without public health emergency experience showed worse mental health, resilience and social support, and tended to get psychological abnormality on interpersonal sensitivity and photic anxiety. apart from working at the front line, they stayed at room alone without any face-to-face interpersonal communication. lack of social support leads to much more depression and anxiety especially in high-risk working conditions (plaisier et al., 2007) . in order to prevent cross infection, the social distance between people had to be increased. when others had fevers or cough, people became more sensitive and tended to show some obsessive-compulsive symptoms such as washing hands repeatedly. the daily increasing numbers of confirmed cases and deaths also increase the level of anxiety and terror in the fresh staff. nevertheless, majority of the experienced staff had taken part in previous public health emergence before, such as severe acute respiratory syndrome (sars) and h1n1. they knew how to protect themselves better and had the confidence to overcome the disease compared with fresh staff, which was of benefit to enhance their resilience and mental health. therefore, constructive peer-support (banerjee, 2020) , effective online mental health service (yao et al., 2020) and early screening and interventions (zandifar and badrfam, 2020) were necessary to address mental health needs in health care workers. another intriguing finding from our study is that resilience (tenacity, strength) and social support (objective support, subjective support and availability of support) could significantly predict the mental health in fresh staff. resilience is regarded as a protective factor to mental health (hu et al., 2015a, b) . the fresh staff with high strength and tenacity showed greater courage and would not quit in this medical battle. certainly, good social support might also have buffered the average severity of symptom among people in high risk work (chen w. cai, et al. asian journal of psychiatry 51 (2020 ) 102111 et al., 2005 dyregrov et al., 1996) . therefore, it is important to have a high level of training and professional experience in health care workers engaging in public health emergence, especially for the fresh staff. several limitations in current study need to be mentioned. one is that we lack of investigation on fatigue status and sleep quality of health care workers. the usual rhythm of work and life was disrupted, which might lead to their insomnia and fatigue. on the other hand, the cross-sectional design failed to explain it thoroughly whether the weak resilience and less social support in fresh staff caused their much more psychological abnormality. since the public health emergence has a long-term effect on health care workers' anxiety, depression and sleep quality (chen et al., 2006) , the following researches are suggested to adopt a within-design study to evaluate the mental health and potential factors of health care workers during the public health treatment. on the basis of our findings, health care workers without public health emergency experience showed worse performance in mental health, resilience and social support, and tended to get psychological abnormality on interpersonal sensitivity and photic anxiety. a high level of training and professional experience, resilience and social support were necessary for health care workers who are first taking part in public health emergence. none. no conflict of interest exits in the submission of this manuscript. the covid-19 outbreak: crucial role the psychiatrists can 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periodic assessment study in taiwan psychological status of volunteers in a phase i clinical trial assessed by symptom checklist 90 (scl-90) and eysenck personality questionnaire (epq) international health regulations emergency committee on novel coronavirus in china social support rating scale. chin rethinking online mental health services in china during the covid-19 epidemic factor analysis and psychometric evaluation of the connor-davidson resilience scale (cd-risc) with chinese people iranian mental health during the covid-19 epidemic key: cord-284829-dge21g0g authors: dinakaran, damodharan; manjunatha, narayana; naveen kumar, channaveerachari; suresh, bada math title: neuropsychiatric aspects of covid-19 pandemic: a selective review date: 2020-05-30 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102188 sha: doc_id: 284829 cord_uid: dge21g0g corona virus disease (covid-19) has been declared as a controllable pandemic by the world health organization (who). covid-19 though is a predominantly respiratory illness; it can also affect brain and other organs like kidneys, heart and liver. neuropsychiatric manifestations are common during viral pandemics but are not effectively addressed. fever and cough are common symptoms only in infected individuals but headache and sleep disturbances are common even in uninfected general public. in this selective review, the authors report the available evidence of neuropsychiatric morbidity during the current covid-19 crisis. the authors also discuss the postulated neuronal mechanisms of the corona virus infection sequelae. a meta-analysis conducted on the studies from the current outbreak had suggested that fever (88%) and cough (58%) are predominant complaints and overall 20% of the infected individuals needed intensive care unit admission (1). hypertension (17%), diabetes (8%) and cardiovascular diseases (5%) were common co-morbidities (2) . bilateral pneumonia on chest radiograph (ground glass pattern) (73%), decreased albumin (78%), high c-reactive pattern (58%), high lactate dehydrogenase (57%) and lymphopenia (43%) were the prevalent laboratory findings (1). early reports on case fatality rates varies widely between 0.15% and 5% (3) . though emerging reports are reassuring, it is important to note that not all the countries across the world are adequately enabled to provide effective responses against the virus (4, 5) . global coordination is important to provide a coherent response to this challenge (5) . it is essential to understand the varied presentation of this illness to equip oneself to handle the potential crisis. in this selective review, the authors present the neuropsychiatric manifestations and postulated mechanisms of covid-19. the authors searched pubmed and ebsco independently with the following search terms "covid-19" "and", "neurology", "mental health", "neuropsychiatry", "delirium" and "psychosis". the authors identified 188 manuscripts. the search was restricted to manuscripts in english language and time (till may 8 th 2020). after removing duplications, review articles, commentaries, opinion letters and manuscripts not relevant to neuropsychiatry, animal studies, and other newer manuscripts from cross-references were added and the total unique manuscripts identified for the final review were "12". synthesis of information from these manuscripts is provided below. neurological manifestations could be secondary to direct neuroinvasion by the corona virus. similar to many respiratory viruses, corona viruses are observed to have direct effects on neuronal systems (6) (7) (8) . the spread could happen through haematogenous route but most commonly reported entry is through the olfactory neural pathway (9) . this invasion could result in meningitis, encephalopathy or at minor instances seizures (7, 10). direct invasion might be possible through the activation of angiotensin converting enzyme 2 (ace-2) receptor expressed in both capillary and neuronal endothelium (9, 11) . secondary immune alterations are hypothesized to underlie the chronic neuropsychiatric sequelae (12) (13) (14) . dysregulated immune response that might result in excessive inflammation is postulated to play an important role in the severity of the infection (13, 15) . possible direct medullary neuron destruction might precipitate respiratory failure in severely ill patients (16, 17) . altered sensorium or delirium might be secondary to direct neuroinvasion by virus, central immune activation, secondary to multi organ failure, hypoxia, metabolic derangements and treatment related (9, 18) . additionally, patients also exhibit increased prothrombin time and coagulopathy that ultimately might contribute to thrombosis or hemorrhage (19) . stress during virus outbreak is postulated to activate hypothalamo-pituitary-adrenal axis releasing increased levels of steroids. steroids released impairs the immune system functioning and might precipitate the infection or worsen the severity. viral infection further leads to neurasthenia and chronic fatigue. psychiatric symptoms could also manifest secondary to side effects of drugs used to treat covid-19 like oseltamivir, corticosteroids and interferons (20) (21) (22) . a pharmacovigilance study had reported significant neuropsychiatric adverse effects like amnesia, delirium, hallucinations, depression and loss of consciousness associated with exposure to chloroquine (23) . chloroquine and other antiviral drugs can cause toxic neuropathy and myopathy (24, 25) . sars-cov-2 virus is primarily a respiratory virus that has a predilection towards lower respiratory tract. though the most common presentation is a self limiting viral illness with fever and dry cough, severe infection is reported in 15-20% of the affected population (26) . lungs are involved in more than two-thirds of patients with severe infection. pneumonia with ground glass opacities in middle and lower lobes of lungs are reportedly characteristic of the infection. in about 5% of the severely ill patients, acute respiratory distress syndrome (ards), multi organ involvement and septic shock leads to further clinical deterioration. case fatality rate ranges between 2-3% and elderly individuals with medical co-morbidities are more vulnerable to develop fatal illness (26) . other organs involved include but not limited to kidneys, liver and heart. these organs are involved in about 15-30% of severely ill patients (27) . headache and myalgia are commonly noted in covid-19. in mild to moderate infection, headache, altered smell and taste, cough, asthenia and myalgia are the most common symptoms (28) . there are reports of encephalopathy (29) , encephalitis (30), meningitis (31), stroke (32-35), seizures, dysexecutive syndrome, neuromuscular disorders, guillain barre syndrome and other neuropathies. neurological manifestations are reported in one hospital based study from china (36) . 78 out of 214 admitted patients (36%) were identified to exhibit one or more neurological symptoms. such presentations were analyzed broadly under illness effects on central nervous system, peripheral nervous system and musculo-skeletal system. central nervous system symptoms include dizziness (16%), headache (13%), altered sensorium (8%) and cerebro vascular events (3%). reduced taste (5%) and reduced smell (5%) perceptions are peripheral nervous system manifestations. myalgia with significant muscle injury happened in 12% of admitted patients (36) . a multicentre european study had reported olfactory and gustatory dysfunction in 85% and 88% of mild/moderately ill patients respectively (37) . smell and taste disorders were reportedly more common in covid-19 patients than in influenza (38). acute brainstem dysfunction has been reported during the 2 nd week of covid-19 illness (30) . aberrant immune response to covid-19 might lead to neuro-ophthalmological manifestations like miller-fisher syndrome and polyneuritis cranialis (39, 40). acute polyradiculopathy (guillain barre syndrome -gbs) has been reported related to sars-cov-2 infection (41) (42) (43) (44) (45) (46) . another study from china had showed that among the deceased patients, 22% had altered sensorium and 20% exhibited features of hypoxic encephalopathy (47) . the neuropsychiatric sequelae of currently evolving covid-19 pandemic are still unclear. however, there is a growing concern about a crashing wave of neuropsychiatric burden (48) . such neuropsychiatric manifestations include encephalopathy (49) , delirium (50) (51) (52) (53) , mild cognitive impairment (54) , mood swings (31), insomnia (55, 56) , suicide (57) and psychosis (48, 57, 58) . existing evidence suggest 0.9-4% of infected individuals develop psychotic spectrum disorders. psychosis may be secondary to viral illness, treatment provided and increased psychosocial stress during pandemics (59). neuropsychiatric sequelae of covid-19 are discussed in table1. patients with pre-existing mental illness who develop covid-19 and individuals developing mental health concerns during the pandemic are advised to be treated with psychotropic drugs along with the standard treatment for the viral illness. the following drugs are suggested as safe considering the tolerability and minimal drug interactions: benzodiazepines (oxazepam and lorazepam), antidepressants (citalopram and escitalopram), antipsychotics (olanzapine) and mood stabilizer (valproate) (60) . delirium is one of the atypical presentations of the covid-19 illness (52) . in most instances, delirium is poorly assessed and inadequately intervened (18, 61). assessment using a standard tool and identifying the precipitating factors are essential in delirium management (62). benzodiazepines are to be avoided and among antipsychotics, quetiapine is preferred especially in elderly (62) and oral haloperidol (0.5-1mg) otherwise (63) . additionally, melatonin is suggested for sleep wake rhythm and consciousness disturbances and in severely 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patients? sleep medicine j o u r n a l p r e -p r o o f nil j o u r n a l p r e -p r o o f key: cord-323690-dp51djtz authors: arora, alisha; jha, amrit kumar; alat, priya; das, sitanshu sekhar title: understanding coronaphobia date: 2020-09-06 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102384 sha: doc_id: 323690 cord_uid: dp51djtz covid-19 pandemic, in addition to being a global health emergency, has multiple socioeconomic and psychological ramifications. covid-19 research and media reports have revealed a rise in fears related to contracting the virus. though fear is a common psychological outcome during pandemics, the covid-19 pandemic is a continuously evolving disease outbreak and has unique risk factors. therefore, fear related to covid-19 might manifest in not only fear and anxiety related to disease contraction and dying but also associated socio-occupational stress. we attempt to understand the psychosocial process of the development of coronaphobia and postulate what constitutes coronaphobia, a new emerging phobia specific to covid-19. we present a conceptual model delineating the risk factors causing coronaphobia and the underlying mechanisms, for a better understanding of its developmental process. from review of relevant research, the factors identified are, an unforeseen reality, unending uncertainties, need of acquiring new practices and avoidance behavior, loss of faith in health infrastructure, contraction of covid-19 by head of states, cautionary statements from international bodies, and infodemia. these factors are assumed to cause interference with routine life, catastrophizing interpretation of benign symptoms, and social amplification of risk which lead to coronaphobia. the conceptualization of coronaphobia and the model will aid future research in developing psychometric measure of coronaphobia for use in clinical and research settings and design of policies and interventions for mitigating risk factors. review of relevant research, the factors identified are, an unforeseen reality, unending uncertainties, need of acquiring new practices and avoidance behavior, loss of faith in health infrastructure, contraction of covid-19 by head of states, cautionary statements from international bodies, and infodemia. these factors are assumed to cause interference with routine life, catastrophizing interpretation of benign symptoms, and social amplification of risk which lead to coronaphobia. the conceptualization of coronaphobia and the model will aid future research in developing psychometric measure of coronaphobia for use in clinical and research settings and design of policies and interventions for mitigating risk factors. keywords: covid-19; coronaphobia; fear; anxiety; pandemic in the covid-19 pandemic, as in other pandemics, fear, anxiety, and worries have been the major psychological consequences (roy et al., 2020; tandon, 2020a; xiang et al., 2020) . covid-19 related fear, mortality rates, unemployment, protective strategies have become the most searched topics in google search history (charlton, 2020; sullivan, 2020) . researchers have used the expressions "fear of covid-19" (ahorsu et al., 2020; mertens et al., 2020) and 'coronaphobia' (asmundson & taylor, 2020) to indicate the fear of contracting covid-19. now that there is unanimity that covid-19 is an endemic (bbc, 2020b; kissler et al., 2020) and living with the coronavirus with constant precautions becomes the new normal, fear may become more pronounced (tanner, 2020) . covid-19 affects all spheres of life and the risk factors are more unique, numerous, and diverse than in other pandemics. therefore, fear may extend beyond falling ill or dying due to contracting the virus and evoke other fears such as that j o u r n a l p r e -p r o o f of economic adversity (yoon, 2020) and infecting others. this paper attempts to postulate the contents and antecedents of coronaphobia, identify the associated risk factors and the underlying mechanisms of its development which might inform policy decisions and healthcare activities. a phobia is an anxiety disorder characterized by persistent, excessive, unrealistic fear of an object, person, animal, activity or situation. phobia makes people avoid the triggers of fear; when such avoidance is not possible, it causes anxiety and distress (american psychiatric association, 2013) . a search in the scopus database using the keywords "covid-19" and "coronavirus" with "fear", "anxiety/anxious", "uncertainty", "worry/worries/worried", "phobia", "public place" and "public transport" resulted in 499 studies after excluding studies with no abstract or in a language other than english. various components and outcomes of covid-19 fear have been reported such as functional impairment leading to hopelessness, suicidal ideation, and coping deficits (lee, 2020) , fatal cognitions leading to association of covid-19 with terminal end (dubey et al., 2020; goyal et al., 2020; huang & zhao, 2020) , and anxiety and depression while coping with the 'new normal' (cao et al., 2020; chakrabarty & chatterjee, 2020; haleem et al., 2020) . based on a review of these studies, we define coronaphobia as an excessive triggered response of fear of contracting the virus causing covid-19, leading to accompanied excessive concern over physiological symptoms, significant stress about personal and occupational loss, increased reassurance and safety seeking behaviors, and avoidance of public places and situations, causing marked impairment in daily life functioning. the triggers involve situations or j o u r n a l p r e -p r o o f people involving probability of virus contraction, such as, meeting people, leaving house, travelling, reading the updates or news, falling ill or going for work outside. the definition implies three essential components, which reinforces the process of fear: i. physiological: the fight or flight response of fear is triggered, on being exposed to antecedent event. constant worry can cause symptoms such as palpitations, tremors, difficulty in breathing, dizziness, change in appetite, and sleep (wang et al., 2020) . cognitive , leading to phobia ( (table 1) . we observe fear of specific stimuli in all kinds of phobia, accompanying triggered physiological responses, cognitions of lack of control, helplessness, and/or death. phobias share pattern of behavioral avoidance and reassurance which is beyond realistic proportions. while coronaphobia share similarities with the other phobias, the fear in it is not only limited to only public places/situations/objects, but, primarily coming in contact with human, physically. given the novelty and transmission rate of the covid-19, the coronaphobia is intense, widespread, and involves socio-occupational and personal domains, with j o u r n a l p r e -p r o o f apprehensions ranging beyond the self and the present time. it might be perceived as equivalent entity in syndromes of phobia, given the presence of unique triggers and fear of the unknown. traumatic events can lead to specific phobias (garcia, 2017) . (goodenough, 2020) . the genetic mutation of the virus is quite mysterious with asymptotic cases, fast mutation, incubation period of 2-14 days with some cases even reaching 19-27 days, adaptability to changing environments, and variable strains (kaplan et al., 2020; kumar, 2020; worldometres, 2020b) . unforeseen reality -change in any form is threatening initially, as it disturbs the equilibrium and the stability, seeding insecurity. the enforced instability due to covid-19 is threatening, compulsive, and unpleasing. the termslockdown, quarantine, and self-isolation, which now are frequently in use among the masses, normally carries negative connotations and were assigned to prisoners, making them experience chronophobia (naguy et al., 2020) . similarly, j o u r n a l p r e -p r o o f people locked during the early and peak days of this pandemic, dwelt over thoughts related to the unlocking of the lockdown and the hardships. acquiring new practices and avoidance behavior -acquiring new behavioral change requires considerable thoughts, mindfulness, and change in habits. the recent forced behavioral changes-social distancing, wearing mask, consistent hygiene practices of hand washing, and avoidance behavior including avoiding touching face and large gatherings-will initiate a vicious loop of discomfort, fear, and anxiety. a human normally touches their face on an average 23 times an hour (kwok et al., 2015) . now that touching face is a risk factor, people have to be mindful of not engaging in a practice which was practiced mindlessly since birth (markman, 2020) . inculcating a habit of not performing a practice is primarily discomforting, ineffective, and requires a habit reprograming, which further requires 68 to 254 days to acquire and done involuntarily (lally et al., 2009 ). unable to acquire such changes in a short span will further create fear and anxiety. people then tend to panic more and lose control, making them more susceptible to the coronaphobia. even our unconscious mind operates to reduce the contagion and produce unconscious psychological responses, termed behavioral immune system (murray & schaller, 2016) , acting as a first line of defense, warning us from the possible infection. however, being instinctive in nature, the system attacks rationality and leads to alternations and errors in decision-making. statements from the international organizations -people deeply rely on international organizations and their predictions for hope and optimism. un and imf terming the covid-19 as the worst global crisis ever since the great depression of 1930s respectively (bbc, 2020a; un, 2020), has further set the tone for a scary future and uncertainty. world economic forum (scott, 2020) , had even referred this pandemic as several crises packed in one, namely, j o u r n a l p r e -p r o o f healthcare crisis, economic crisis, energy crisis, and humanitarian crisis, worsening the geopolitical risks, globally. who and studies have further cautioned that covid-19 hasn't run its full course with the worst yet to unravel (tandon, 2020b) . the relentless infodemia taking the shape of an infodemic -the pandemic is witnessing global infodemia facilitated by social media and other online resources. who had warned of the infodemic accompanying covid-19, an over-abundance of informationsome accurate and some notthat makes it hard for people to find trustworthy sources and reliable guidance (who, 2020b, february 2). the covid-19 infodemic, considered as the first true social-media infodemic (hao & basu, 2020) . it has established how social media can be global public health threat (larson, 2018) due to conflicting and manipulative misinformation in the form of fake news about possible cures, symptoms, and mortalities. these platforms have become breeding grounds for distorted thinking, leading to panic, confusion, racism, and threat perception of an unrealistic intensity (kulkarni et al., 2020) . why do people become fearful or fall into a panic state? epidemic psychology has seen its roots in the order and routine of human species (schutz, 1970) . the human brain is pre-wired to thrive on certainty and has disdain for uncertainty, which represents danger (robinson, 2020) . for the brain, anticipating a pain is acceptable, but not an uncertainty. stability is indispensable to humans' schema and meaning-making. normally, people have a blueprint of each day, with a taken-for-granted array of solutions for the life tasks which is a part of their personal consciousness (strong, 1990) . a daily life is more assumed rather than planned. we do innumerous tasks daily, pay attention to few, while others are conducted on 'auto-pilot' mode. a crisis like current pandemic disturbs the set system and questions the certainty with which we were habituated, forcing us to reset. the mystery over the origin of the virus and the associated j o u r n a l p r e -p r o o f and prolonged uncertainties give rise to fear of the unknown, considered a fundamental fear of human (carleton, 2016) . less portion of our life remains steady, demanding us to change our ways and coping mechanisms. such an attack of uncertainty on our fragile life and temporal stability lead to outburst of irrational and negative emotions, like panic and phobia. furthermore, humans are cognitive miser (fiske & taylor, 1986) , making them more vulnerable during crisis to fall for decision-making biases, fueling anxiety and fear. based on the cognitive-behavioral model, it can be said that pandemic reactions such as misinterpretations of health-related stimuli, cognitive distortions, irrational beliefs, maladaptive behaviors, and attention processes have a central role in coronaphobia (leventhal et al., 2016; taylor & asmundson, 2017) . for instance, in agoraphobia, the person fears getting a panic attack in a 'specific' situation (mineka & zinbarg, 2006) or appraises the bodily sensations in catastrophizing manner (barlow, 2004) . hence, it is the appraisal of the threat in the situation which causes phobia. appraisal of bodily sensations, such as fever, cough, tiredness, and breathing difficulty, reported as the most felt symptom of covid-19 (who, 2020c), together with the selfevaluation of inability to cope with such threatening cues can lead to health anxiety. subsequently, individuals may then seek consultation, not only because of the physical discomfort, but also due to presence of varied anxiety-provoking cognitive events. for instance, the knowledge that covid-19 spreads through human contact, may get connected to an outside symptoms are related to covid-19 (sinha & dev, 2020) . such catastrophic interpretations may not be satisfied by the clinical measurements and hence, they are preoccupied with symptoms and seek repeatedly reassurance, leading us to the behavioral part of coronaphobia. reassurance can be sought in a variety of subtle ways, including repeated checking on bodily sensations, measuring fever, self-medicating, reading news, and discussing with family, as in agoraphobia, where patients seek presence of a 'safe' reassuring person (carter et al., 1995) to cope up. long term engagements in such safety seeking behaviors may lead to overdoing of activities which will provide them gratification and sense of protection, or prevent the threat fueling physical changes and elevation of the stress, consequently leading to state of coronaphobia. the social and cultural model of pandemic encapsulates fear and phobia as born out of risk perception and response based on psychological, sociological and cultural factors, commonly referred as 'social amplification of risk' (kasperson, 2017) . factual risk of events combines with socio-cultural perspectives and amplifies public responses. this occur through two processes -(a) transfer of information about risk, and (b) mechanism of social response. in the former, individuals learn about risk from various sources, called 'amplification stations'. such information colors risk perceptions and levels of concern and act as a key factor in deciding the volume of risk, disputation of information, and its symbolic connotations. this is followed by j o u r n a l p r e -p r o o f the interpretation of the risk in the context of social, institutional, and cultural factors, such as social groups, stigma attached, and polarized social views. hence, an amplified risk perception builds up, leading to heightened behavioral response, like phobia. the 'amplification stations' enormously influence the social construction of the risk presentation and transmission. these include loved ones, scientists, researchers, risk managing organizations, leaders, and news agencies (kasperson, 2017) with social media and networking sites being the latest entry. during the sars outbreak in 2002-03, news agencies were held responsible for the exaggerated display of news, leading to mass anxiety, and xenophobia (muzzatti, 2005) . hence, the perception of the health threat comes from the perceptual and symbolic representation, created by the media and digital platforms. at present, two of the widely used social media platforms -facebook and whatsappare flooded with unverified information related to covid-19 and contain inaccurate information (tewari, 2020) . the rapid spread of unverified news can create a ripple effect of misinformation. elevated worries and avoidance behavior has been reported in agoraphobics, wherever they were exposed to catastrophic visuals of infections, deaths, and separation from family (day et al., 2004) . such unreliable information creates panic and phobia for even neutral things, places, and situations the paper attempts to extend the existing limited research on fear of covid-19 through a detailed conceptualization of coronaphobia including definition, risk factors, and underlying psycho-social processes. this conceptualization can aid future research on development of psychometric measures of 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rajan; sagar, rajesh title: the quality of online media reporting of celebrity suicide in india and its association with subsequent online suicide-related search behaviour among general population: an infodemiology study date: 2020-08-29 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102380 sha: doc_id: 351448 cord_uid: jowb5kfc the literature reports increased suicide rates among general population in the weeks following the celebrity suicide, known as the werther effect. the world health organization (who) has developed guidelines for responsible media reporting of suicide. the present study aimed to assess the quality of online media reporting of a recent celebrity suicide in india and its impact on the online suicide related search behaviour of the population. a total of 200 online media reports about sushant singh rajput’s suicide published between 14(th) to 20(th) june, 2020 were assessed for quality of reporting following the checklist prepared using the who guidelines. further, we examined the change in online suicide-seeking and help-seeking search behaviour of the population following celebrity suicide for the month of june using selected keywords. in terms of potentially harmful media reportage, 85.5% of online reports violated at least one who media reporting guideline. in terms of potentially helpful media reportage, only 13% articles provided information about where to seek help for suicidal thoughts or ideation. there was a significant increase in online suicide-seeking (u = 0.5, p < 0.05) and help-seeking (u = 6.5, p < 0.05) behaviour after the reference event, when compared to baseline. however, the online peak search interest for suicide-seeking was greater than help-seeking. this provides support for a strong werther effect, possibly associated with poor quality of media reporting of celebrity suicide. there is an urgent need for taking steps to improve the quality of media reporting of suicide in india. suicide is a major public health problem, and is one of the leading causes of mortality globally (naghavi, 2019) . the reported deaths due to suicide in india is highest among countries worldwide (dandona et al., 2018) . studies have reported that media reports of celebrity suicide stimulate imitation acts in vulnerable population (gould et al., 2003) . also, repeated insensible media coverage may act as a source of misinformation that suicide is an acceptable solution to ongoing difficulties in life. this has been supported by the bulk of available literature, with a recent meta-analysis reporting a 13% increased risk of suicide (95% confidence interval of 8-18%; median follow-up duration of 28 days) in the period following the media report of celebrity suicide death (niederkrotenthaler et al., 2020) . media reporting of suicide is a double-edged sword, with inappropriate and sensational reporting of suicide news leading to copycat phenomenon or werther effect. whereas, sensible media reporting of suicide along with media involvement in spreading preventive information shown to minimise copycat eff ects, and has been shown to be eff ective in reducing suicide deaths (cheng et al., 2018) . thus, researchers have advocated for a more responsible descriptive reporting of suicide news, with emphasis on sharing preventive information related to suicide. this includes reporting upon how people could adopt alternative coping strategies to deal with life stresses or depressed mood along with sharing links of educative websites or suicide helplines; and has been shown to be associated with decreased suicide suicidal behaviour and ideation in vulnerable population (niederkrotenthaler et al., 2010; till et al., 2017) . therefore, media reporting of suicide-related preventive information has been associated with positive effects on subsequent suicide rates and ideation. this is described as the papageno effect, and acts as a counterforce to the werther effect responsible media reporting of suicide is considered as the best available strategy to counter the harmful effects of media reportage (niederkrotenthaler et al., 2020) . in recent years, internet is being increasingly used by the public for seeking health-related information; and information related to mental health related disorders or problems also being widely available online (amante et al., 2015) . it is understandable, that several researchers have expressed concerns about vulnerable individuals either using internet to access pro-suicide information (e.g. methods of suicide) or inadvertently being exposed to online news or information which negatively affects their thoughts or mood and promote suicidal behaviours in them (arendt and scherr, 2017; till and niederkrotenthaler, 2014) . however, internet also provides a host of suicide prevention related information and resources which could in turn decrease the risk of suicide (biddle et al., 2008) . further, news over internet and social media is able to reach to a large number of vulnerable and difficult to reach youth population; and has been shown to potentially influence the public opinion, attitudes, and behaviours over wide range of topics (kaplan and haenlein, 2010) . thus, it is important to explore the quality of online media reporting of celebrity suicide in india. this would in turn help in better understanding the role played by this new electronic medium in either predisposing or protecting people with suicidal ideas or death wishes. there has been limited literature available assessing the quality of media reporting of suicide in india. most of the studies assessed media reporting of suicide in general population, and only one study had focused on celebrity suicide specifically (harshe et al., 2016) . however, that study took death of robin williams (hollywood movie actor of us origin) as the reference event and was done about four years back. further, all the available studies have assessed newspapers in a particular region and were conducted prior to press council of india (pci) issuing media reporting guidelines on suicide and mental illness in india. the pci has adopted the guidelines of world health organization (who) report on preventing suicide (press council of india, 2020). it forbids undue repetition of stories, placing stories in prominent positions, explicit description of the suicide method, providing details about the suicide location, using sensational headlines and reporting photographs of the person. there might be some change in the quality of media reporting of suicide in recent years, more specifically after the pci guidelines. further, the who guidelines for responsible reporting are valid for all types of media, and it is important to explore the role played by the online media in current digital world. moreover, to the best of our knowledge there has been no study from indian context yet exploring the association between media reporting of death of celebrity by suicide and subsequent suicidal behaviour in the general population. the official figures for deaths due to suicide in india is released by the national crimes record bureau (ncrb) in india. however, the ncrb has stopped releasing this data since 2016 and the official suicide statistics have not been made public till now. further, it is usually available at the end of the year and does not provide data on a weekly basis. moreover, any other system of directly recording suicide statistics in india will face the challenges associated with collecting vital statistics through sub-optimal existing vital registration system, misclassification, and under-reporting of suicide deaths due to associated legal complications and social stigma around suicide death in the family . additionally, the restrictions imposed on movement of people and social distancing guidelines to be followed during the current covid-19 pandemic, makes it even more difficult to access the study population in a systematic manner for assessment of suicide risk using traditional research methods (bidarbakhtnia, 2020) . the above described limitations could be addressed by employing research methods and techniques involving the study of internet-based search behaviours and social media content. infodemiology has been defined as "the science of distribution and determinants of information in an electronic medium, specifically the internet, or in a population, with the ultimate aim to inform public health and public policy" (eysenbach, 2009) . google trends is an analytical tool available for tracking the online search interests of the population. the evidence supporting correlation between increased online search interest for particular suicide-related search queries using google search engine and the actual number of suicides in that region during that particular time-period has been increasing over the past two decades (lee, 2020) . moreover, recent studies have shown that data obtained using google trends for suicide-seeking keywords could be used for predicting actual monthly suicide numbers at the country level (kristoufek et al., 2016) . thus, in the present study we monitored the changes in internet search volumes for keywords representing suicide-seeking and help-seeking behaviours using the google trends platform as a proxy marker to assess the impact of recent celebrity suicide in india. sushant singh rajput (ssr) was a much-loved indian actor who died by suicide on june 14, 2020. this was reported by various national and international media, and was considered as the reference event in this study. thus, the present study aimed to assess the quality of online media reporting of a celebrity suicide in india, and evaluate its adherence with the who guidelines for responsible media reporting of suicide. further, we aimed to examine the change in internet search volumes for keywords representing suicide-seeking and help-seeking behaviours of the population immediately following the celebrity suicide. this would provide indirect evidence for either existence or absence of the werther and the papageno effect at the population level in india. the online media reports related to the theme of death of ssr by suicide on 14 th june were retrieved using the google news online platform (https://news.google.com). the search was conducted on 20 th june, 2020 in the tor browser, using search terms "sushant", "singh", "rajput", "died", "death" and "suicide". the search period was restricted between 14 to 20 june, 2020. this corresponded to first week immediately after the reference event. a total of 214 reports published on various international, national, and regional online news and entertainment media portals were retrieved. fourteen of them contained either only videos or were not related to theme of the present study, and were excluded. thus, a total of 200 articles were selected for further analysis. the news headlines were analysed to generate a word cloud (using a word cloud generator available at https://www.wordclouds.com) representing the commonly used terms in the online media reports covering ssr death. two authors independently reviewed and extracted information related to different news report characteristics using a pre-designed format in microsoft excel. it included information pertaining to descriptive characteristics of the news report such as the date of publishing, name of the news publisher, type media agency, and primary focus of the article being descriptive or commentary. the quality of articles was evaluated using a checklist prepared on the basis of who j o u r n a l p r e -p r o o f responsible media reporting of suicide guidelines (see supplementary table 1) , and is similar to that used in previous studies . the items were coded as "1" if the guideline was violated and "0" if the guideline was adhered to in the report. two trained researchers independently reviewed and extracted information following the above described procedure. any discrepancy or disagreement between the two researchers was resolved by consensus. the third author was consulted if needed. the data were analysed using spss version 23.0 (ibm corp, armonk, ny). the descriptive (frequency and percentage) and inferential statistics (chi-square and fishers' exact test) were conducted. a p-value of less than 0.05 was considered significant for all tests. the google trends utilizes an algorithm to give normalized relative search volume (rsv) for the keyword(s) searched for a specified geographical region and time period. the rsv represents how frequently a given search query has been searched on the google search engine, compared to the total number/volume of google searches conducted in the same geographical region over the selected time period. the rsv values range from zero (representing very low search volumes) to 100 (peak search volume for that query). google trend analysis was conducted to evaluate the online search interest for keywords representing suicide-seeking and help-seeking behaviours of the population for the month of june 2020. the initial list was made based on the review of available literature, which was finalized by the process of consensus building between two authors r.g. and s.s (qualified psychiatrists with clinical and research experience of working with people with mental illness and suicidal ideas/attempts) based on the face validity of search terms. the examples of suicide-seeking keywords included in the study were 'commit suicide', 'suicide method', and 'kill myself'. whereas, the helpseeking keywords such as 'suicide help', 'suicide treatment', and 'psychiatrist' were used. the four google trends options of region, time, category, and search type were specified as india, from 1 june to 30 june 2020, all categories, and web search in the present study. the "plus" (+) function from google trends was used to integrate the search volume (rsv) of all suicide-seeking terms and help-seeking keywords. a graph showing daily variation in rsv for suicide-seeking and helpseeking keywords was constructed. the change in mean rsv value for the suicide-seeking and helpseeking keywords after the reference event, when compared to baseline was analysed by applying the mann whitney-u test. the complete list of keywords used in this study along with other details pertaining to the google trends methodology are described in supplementary table 2. the information used in this study involved published online media reports and data related to the volume of anonymized web searches made during a given time period, both of which were freely available in the public domain. further, no patient or participant was approached directly in this study. thus, no written ethical permission was required from the ethics committee. the frequency of different words used in the headlines of the 200 media reports analysed in the present study were depicted as a word cloud, with the size of font used being representative of its frequency (figure 1) . apart from the words in the name of ssr, the most commonly used words were "suicide", "death", "actor", "police", "bollywood", "mumbai", "rhea", and "kapoor" in decreasing order of frequency. this suggested that a significant proportion of headlines used words like suicide, police or bollywood to sensationalize or glamourize the headlines, with no significant difference between news media (37.5%; 37/122) and entertainment media (42.0%; 37/88) headlines (χ 2 =0.426, p=0.56). the term "suicide" was used with similar frequency in both news media (n=18;16.1%) and entertainment media (n=15;17%) headlines. only two news media reports (n=2;1.8%) mentioned 'hanging' term in the headlines. the location of suicide was mentioned in two news media (1.8%) and two (2.3%) entertainment media headlines. the selected media reports were published from various media platforms: international news group, 9% (n=18); national news group, 28.5% (n=57); regional news group, 18.5% (n=37); and entertainment blogs, 44% (n=88). seventeen news media platforms had reported the story four or more times in the immediate one-week period following the ssr suicide, with hindustan times (6), ndtv (6), republic world (6), times of india (5), dna (5), india tv (4), the indian express (4) and times now (4) contributing to 41.5% (n=83/200) of the articles. around 17% (n=34) articles were published on 14 th june, 2020, while 49.5% of articles (n=99) were published on 18 th june,2020. about 45.5% (n=91/200) articles were focussed at direct descriptive reporting of suicide. the descriptive analysis of media reports for different potentially harmful and helpful media report characteristics are described in table 1 and 2 respectively. about 85.5% of reports violated the recommendation provided in the guideline, by including at least one potentially harmful information. there was significant association between the type of news media and the use of sensational language [χ 2 (3)=9.774 (p<0.021)]. regional and entertainment media used more sensational language compared to national and international media. there was significant association between the type of news media and provision of information about where to seek help [χ 2 (1)=15.98 (p<0.001)]. mainstream news media provided such information more than entertainment media. final social media posts were shared more by national media compared to international, regional and entertainment media [χ 2 (3)=9.91 (p<0.019)]. the median and inter-quartile range (iqr) values of rsv for suicide-seeking keywords in the twoweeks before and after the death of ssr on 14 june 2020 were 12 (iqr: 11.5-13.5) and 22 (iqr: 18-25) respectively. whereas, the median and iqr values of rsv for suicide-seeking keywords in the two-weeks before and after the death of ssr were 11 (10-11.5) and 14 (13-19) respectively. there was a significant increase in rsv for suicide-seeking (u=0.5; z= -4.62; p<0.001) and help-seeking (u=6.5; z=-4.39; p<0.001) keywords after the reference event, when compared to baseline. however, the online peak search volume and search interest for suicide-seeking was greater than help-seeking as shown in figure 2 . the present study analysed the online media reports related to the theme of a popular bollywood movie actor's suicide, and compared it against the who media reporting guidelines for suicide. the story of this recent celebrity suicide received widespread coverage across different online news platforms, including national and international news agencies. overall, majority of articles showed poor adherence with the who guidelines while reporting the celebrity suicide. the reports had minimal focus on educating the public the regarding suicide. further, the change in online search interest for different keywords related to "suicide-seeking" and "help-seeking" behaviours after this event were analysed to explore for possible werther and papageno effects. a substantial proportion of articles did not follow most of the recommendations. about 58% articles used sensational language, 59.5% articles mentioned suicide site, 17% articles suggested possible cause for suicide which was not related to poor mental health. a study assessing the quality of suicide reporting in indian print media found increase in prominence of suicide reports after the celebrity suicide (harshe et al., 2016) . it speculated that the most likely reason for sensationalism in media reporting of suicide might be to enhance the readership. further, only 13% articles provided information about where to seek help for suicidal thoughts. a previous study evaluating the newspaper coverage of celebrity suicide in united states against 'mindset' recommendations for reporting suicide, found 46% articles provided details about suicide method and only 11% provided information about help-seeking (carmichael and whitley, 2019) . previous studies from india found minimal adherence to media reporting recommendations for suicide in the print media. menon et al found that the method of suicide was reported in 99.1% articles and locations of suicide was reported in 86.5% articles (menon et al., 2020) . chandra et al showed that 80% articles reported suicide location and 61% suggested monocausality for suicide (chandra et al., 2014) . the high frequency of harmful reporting characteristics observed in the present study is consistent with the low adherence to who guidelines reported in other neighbouring asian countries as well (s.m. yasir . studies from bangladesh (s. m. yasir , indonesia (nisa et al., 2020) and sri lanka (brandt sørensen et al., 2019) have also reported non-adherence to who recommendations in print media such as reporting of suicide method, description of suicide note and inclusion of personal identification characteristics in reports. the headlines of the online reports included in the current study used the term 'suicide' in 18% articles. previous studies on print media from india reported "suicide" mentioned in headlines of 68.6% articles (chandra et al., 2014) and 30.31% articles (harshe et al., 2016) . refreshingly, in the present study 81.5% articles did not use the word 'commit' or related terms while reporting suicide, and 65.5% articles did not mention the suicide method in the reports. this is a welcome improvement in media reportage of suicide, which might be due to the positive effect of pci adopting guidelines on media reporting of suicide in september 2019 based on the who guidelines (vijayakumar, 2019) . however, photograph of the celebrity was provided by 47.5% of news media reports and 38% of entertainment media reports. publication of photograph of a person with mental illness without the individual's or his/her next of kin's consent in case of suicide violates section 24 (1) of the mental health care act, 2017 in india ("mental healthcare act," 2017). further, sensational language was used to report celebrity suicide by majority of news media and entertainment media reports. among the news media, regional media used sensational language more frequently than national and international media. final social media posts were reported by 8.9% news media and 3.4% entertainment media. among the different media platforms, national media shared final social media posts more frequently than international, regional and entertainment media. mainstream news media provided information about where to seek help more frequently than entertainment media. this is in line with a study on print media from india, that reported vernacular newspapers to be more compliant with who suicide reporting guidelines compared to english language newspapers (menon et al., 2020) . moreover, in terms of providing potentially helpful information, only one article provided research findings and population level statistics regarding suicide. only two percent articles included expert opinion from health professionals while reporting suicide. also, 28.5% articles tried to address the link between suicide and poor mental health in the present study. this highlights the need to emphasize the importance of including such information in media reports of suicide among journalists and news editors. it helps in increasing the awareness about mental health problems among the general population and encourage them to seek treatment for the same. a previous study assessing south indian newspapers found that a few articles recognised the link between suicide and psychiatric disorders or substance use disorders (menon et al., 2020) . similarly, previous studies from india evaluating the reporting of suicides in newspapers found that only few articles tried to educate public about the issue of suicide by including opinion from health professionals, research findings or information about suicide prevention programmes (chandra et al., 2014; harshe et al., 2016; menon et al., 2020) . one possible solution is to have a uniform national suicide reporting guideline for the media of the entire country. a similar approach has been shown to be beneficial in improving the overall quality of media reporting of suicide in australia (pirkis et al., 2009) . however, as prior researchers have pointed out (vijayakumar, 2019) , merely framing of guidelines may not help in improving the quality of media reporting of suicide. a continuous collaborative approach involving both mental health experts and media professionals should be adopted to sensitize them about the available research evidence backing these media reporting guidelines has been shown to successful in improving adherence to media reporting guidelines (bohanna and wang, 2012) . also, there should be regular workshops held for media professionals to provide them with adequate training and support in covering mental health and suicide-related topics. the findings from google trend analysis showed a significant increase in online search interest for terms representing both suicide-seeking and help-seeking behaviours after the ssr death. the surge in internet search volume for suicide-seeking keywords along with media reports of copycat suicides from different parts of india provides evidence of the werther effect (hindustantimes, 2020; news18, 2020, p. 18; timesofindia, 2020) . there are several possible mechanisms described in the literature to explain the observed increase in suicidal behaviour among the general population associated with media reporting of celebrity suicide (niederkrotenthaler et al., 2020) . first, people may identify with the deceased celebrities, which is usually more common in case of entertainment celebrities due to their strong public identity and following. second, repeated insensible media reporting might lead to normalization of suicide as an acceptable way out of their problems by the vulnerable population. third, media reporting about the method of celebrity suicide might increase the cognitive availability of that method and remove ambivalence about which method to choose for suicide in vulnerable individuals, leading to an increase in suicide by the same method among the vulnerable population. interestingly, there was also smaller but significant increase in the internet search volume for helpseeking keywords. the peak search volume for help-seeking and suicide-seeking keywords was observed on the day of ssr's death, with a lower peak rsv and subsequently lower daily rsvs for help-seeking terms as compared to suicide-seeking terms among the general population. this suggests a weaker papageno effect as compared to the werther effect, possibly due to poor adherence to the who suicide reporting guidelines by the online and other types of media in india while covering the celebrity suicide (newslaundry, 2020) . there only a few studies that have assessed the fidelity of suicide reporting in india, with almost of the studies having evaluated the quality of media reporting of suicide in general population and included only few print media newspapers. thus, our study provides valuable addition to bridge these gaps in the existing literature on media reporting of celebrity suicide from india. further, a wide range of online media reports were analysed in this study for the first time in indian settings to the best of our knowledge. further, the use of a novel google trends analysis to show an increased online search interest for suicide-seeking keywords immediately after the reference celebrity suicide provided support for the existence of werther effect in the indian context. however, there are certain limitations as well which should be kept in mind while interpreting the findings of this study. the study focussed only on english language media reports. we did not assess print media without online version, television, radio and social media. this might be an important area for future research, since studies from western countries suggest television coverage or social media (e.g. twitter) to be associated with increased suicide rates (jashinsky et al., 2014) . further, the relationship between people searching for suicide-seeking keywords might not be as clear as that observed for people with certain infectious disease like the influenza, with google trends analysis of data about searching for disease symptoms or other disease-related information being used to predict their incidences or outbreaks prior to the traditional methods of reporting an outbreak (cao et al., 2017; ginsberg et al., 2009; zhang et al., 2018) . this is likely due to the fact that that someone who searched about suicide might not be actually suicidal, and may or may not kill themselves during the specified study period. further, the keywords representing suicide-seeking and help-seeking behaviours were derived from review of literature from western countries mostly followed by consensus amongst the authors based on their face validity. however, the search methodology used for doing the google trends analysis in the present study is in accordance with the guidelines for conducting a robust google trends research (nuti et al., 2014) . the quality of media reporting of celebrity suicide on online media in india is poor when compared to adherence with the who guidelines or the pci guidelines. in terms of including potentially harmful information, about 85.5% of reports violated at least one recommendation provided in the guideline. further, compliance with recommendations of including potentially helpful information about creating awareness about suicide and possible ways of seeking help for suicidal thoughts was very low, with only few articles 13% articles providing information about where to seek help for suicidal thoughts or ideation. there was a significantly greater increase in the online search interest for suicide-seeking keywords after the recent celebrity suicide. this in turn provides support for a strong werther effect, possibly associated with poor quality 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exploring papageno v. werther effects patna: girl hangs self after watching sushant singh rajput's suicide news | patna news -times of india media matters in suicide -indian guidelines on suicide reporting using internet search data to predict new hiv diagnoses in china: a modelling study j o u r n a l p r e -p r o o f key: cord-318809-v3505tq3 authors: goh, tze jui; lim, tammy; foo, magdalene; ong, sze kiat alan; aishworiya, ramkumar; tanuja, nair; kang, ying qi; agarwal, pratibha keshav; sung, min title: supporting individuals with autism spectrum disorder in medical settings during covid-19 date: 2020-10-09 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102441 sha: doc_id: 318809 cord_uid: v3505tq3 nan tze jui, goh a* , dpsych, tammy the novel coronavirus, covid-19, became a pandemic situation globally in a short span of time. while we are becoming attuned to the effects of the pandemic on mental health and wellbeing of the general population (ghebreyesus, 2020) , the impact on vulnerable populations such as special needs individuals, as well as their caregivers is currently unknown. it is imperative that the needs of the vulnerable groups not be neglected (tandon, 2020) . as mask-wearing and staying at home directives become the new norm, drastic changes in routines exacerbated by the fluidity of the situation make it challenging for individuals with special needs, particularly those with autism spectrum disorder (asd) and intellectual disability (id), to cope (den houting, 2020). they not only have had to adjust to the loss of their regular routines, but also have had to adapt to changes in societal rules, and reduction of access to the outdoors. in addition, some individuals may be unable to maintain personal hygiene or adhere to safe-distancing measures and mask-wearing, especially for those with sensory stimulatory needs or aversions (hazen et al., 2014) . they are also vulnerable to anxiety, which can be further exacerbated when they are processes in a step-by-step format. these include testing procedures such as nasopharyngeal swabs, blood tests and x-rays; and scenarios to expect, such as encountering healthcare workers in personal protective equipment (ppe). instructions to alleviate and manage anxiety, such as breathing and relaxation exercises, are also included. an animated video clip of the whole process was also produced to enhance engagement and improve clarity (figure 1 ). figure 1 in addition, explanatory information for the medical team regarding the use of the resources and simple strategies to support the care of the person with special needs are also provided. personalisable/ replicable templates in the form of information sheets about the individual with special needs further allow for customization to the unique profiles of each individual. an example of a visual schedule is shown in figure 2 . the physical copies of the resources and materials were disseminated and implemented at frontline settings, from the general practitioner (gp) clinics, ambulances, and emergency services to treatment facilities. soft copies are also made available via online platforms 2 . the materials were made to be adaptable and applicable for situations beyond the current covid-19 pandemic, and generalisable for use with different populations such as individuals with communication barriers (i.e. children with language delays or individuals who may not be fluent in or comprehend the english language).with the special care kit, frontline healthcare services will be better prepared and have some basic resources to support individuals with special needs who require medical services, whether during infectious disease outbreaks in the future, or in other medical scenarios. the materials are easily accessible and free for use on the online platforms. we hope these materials can also benefit the international community, especially populations with limited resources, and also improve access and preparedness of frontline healthcare services to support special needs individuals. continual dialogue about the experience of the pandemic situation from the perspectives of the special needs community, especially about areas requiring support, and understanding of existing resilience will be important, so that we can be better prepared and respond in the future. dr. sung and dr. goh conceptualized and drafted the initial manuscript. dr. lim, ms foo, dr. ong, dr.ramkumar, ms nair, dr. kang and dr. agarwal reviewed and edited different components of the manuscript. all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. funding source: this work did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. the authors have no financial relationships relevant to this article or conflicts of interest to disclose stepping out of isolation: autistic people and covid-19 addressing mental health needs: an integral part of covid-19 response sensory symptoms in autism spectrum disorders anxiety and depression in adults with autism spectrum disorder: a systematic review and metaanalysis content you can use handle the autism spectrum condition during coronavirus (covid-19) stay at home period: ten tips for helping parents and caregivers of young children covid-19 and mental health: preserving humanity, maintaining sanity, and promoting health anxiety disorders in children and adolescents with autistic spectrum disorders: a meta analysis mitigate the effects of home confinement on children during the covid-19 outbreak promoting physical activity for children with autism spectrum disorders during coronavirus outbreak: benefits, strategies, and examples we would like to express our gratitude to all contributors of the special care kit. additional thanks goes to ms. sharrie lu yuyi, mr. nicholas goh kun lie, ms. soh chui pin and ms. jane teo sze-hui for assisting in the compilation, editing and distribution of the special care kit. we would also like to thank our colleagues from the corporate communication departments of the imh, nuh, kkh as well as our colleagues at moh, for their immense support of the project. key: cord-345443-6jxlqswz authors: karim, mustafa abdul; wadoo, ovais; reag, shuja m.; amro, raed; abdulla, majid al title: telepsychiatry in the arabian gulf regionimplications beyond the covid-19 pandemic date: 2020-08-29 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102397 sha: doc_id: 345443 cord_uid: 6jxlqswz nan this is a pdf file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. this version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. -19 -11 march 2020," n.d.) . the state of qatar confirmed its first positive case on 29 th february 2020, and by june we had the highest infection rate per million population ("covid19 home," n.d.). this public health emergency prompted large-scale lockdown and home confinement to limit the spread of infection. the ministry of public health in qatar advised minimizing direct contact with patients for non-urgent care. these restrictions had a huge impact on provision of psychiatric services. as the pandemic was evolving, it became clear that mitigation strategies need to be put in place, and in march 2020, telepsychiatry services were introduced. these services used telephone or videoconferencing to limit face-to-face interaction in the delivery of outpatient psychiatric services. we analyzed the data on the number of new and follow-up cases and the rate of non-engagement (no-show rate) in the mental health outpatient setting in the four months following the introduction of telepsychiatry, and found that j o u r n a l p r e -p r o o f the total number of individuals accessing mental health services between march and june of 2020 increased by approximately 36.5% compared to the same period in 2019, with a similar pattern following differential analysis of new and follow-up cases. in addition, a trend towards higher rate of engagement (less percentage of no-shows) was also observed when comparing the corresponding time periods. no discernible differences were found following gender stratification (table1). of note, the total population of qatar is about 2.79 million as of june 2020, compared to 2.63 million in june 2019, indicating that the significant rise in demand on mental health services was most likely due to covid-related distress than would be expected from population growth alone ("monthly figures on total population," n.d.). qatar has a predominantly state-funded mental healthcare system (saeed et al., 2020) . lack of engagement at psychiatry outpatient clinics stands as a crucial barrier to effective mental health care delivery and leads to waste of important resources. in 2019, the total psychiatric appointment default rate at hmc was 22%, comparable to internationally reported figures (adelufosi et al., 2013; hull et al., 2002; pang et al., 1995) . the initial results of using telepsychiatry in qatar are indeed promising, encouraging us to consider its implementation as an additional component of a mental health delivery system even after the pandemic. this is particularly important given the anticipated increase in demand on mental health services post pandemic, dearth of trained mental health professionals and reluctance of families to engage with mental health services due to stigma (kehyayan et al., 2020) . telepsychiatry services have been implemented in many countries even before the pandemic and are shown to be clinically effective delivery methods of mental health services that enhance access to care (hubley et al., 2016) . however, given the wide disparity of this region's sociocultural milieu in comparison to j o u r n a l p r e -p r o o f other countries where it has been assessed, it is paramount that the use of telepsychiatry in this region is evaluated for its feasibility, acceptability and effectiveness. in addition, the establishment of stringent governance mechanisms is necessary to ensure the protection of patient autonomy, confidentiality, and privacy. this is in keeping with the recommendation by the editorial of this journal (tandon, 2020) , which advocates service changes to be based on data to address the short and long-term impact of the continuing covid-19 pandemic. none funding: this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. ethics consideration: permission was granted to publish this anonymized aggregate data from hospital directors of the corresponding mental health services. no patient records were accessed, and hence irb approval was not required. author contributions: all authors contributed to the conception, analysis and drafting of this letter. j o u r n a l p r e -p r o o f pattern of attendance and predictors of default among nigerian outpatients with schizophrenia review of key telepsychiatry outcomes a waste of time: nonattendance at out-patient clinics in a stigma and mental illness: insights from the literature and implications monthly figures on total population an audit study of defaulters of regular psychiatric outpatient appointments in hong kong mental health in qatar: challenges and prospects covid-19 and mental health: preserving humanity, maintaining sanity, and promoting health who director-general's opening remarks at the media briefing on covid-19 -11 follow-up cases seen total seen new cases no show key: cord-323859-rkxgtyoq authors: patel, khushboo title: mental health implications of covid-19 on children with disabilities date: 2020-07-02 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102273 sha: doc_id: 323859 cord_uid: rkxgtyoq nan teaching children with visual impairments or those who are hard-of-hearing (hills, 2020) . challenges of online learning coupled with a lack of recreational activities that can be done at home can prove to be frustrating for children with such physical disabilities. furthermore, developing social skills and social interaction has been one of the hardest issues for children with autism spectrum disorder (asd). the current situation of social distancing and having no access to outdoor activities deteriorates their development. a lack of routine and the attached uncertainty can make children with autism spectrum disorder (asd) feel more anxious, grumpy, restless, and develop unpleasant feelings. tandon (2020), in their work has rightly pointed out the relation between covid-19 and psychiatry, and vice versa. experiencing negative emotions, changes in moods, and changes in the sleeping and eating patterns of children put them at a greater risk of experiencing relapse of mental illness as well as exacerbating existing mental health issues. with medical care being prioritized for those affected by the pandemic along with closure of mental health clinics serves as a source of stress, anxiety, and fear. for instance, in india, 7.8 million children between 0-19 years of age have a physical or mental disability, and one fourth of them do not attend any educational institute (unesco, 2019). this becomes a cause of concern as there is already a lack of physical infrastructure, inclusive education, and assistive technologies in countries like india. coupled with this, being confined to home during the pandemic leads to an elevated level of frustration and helplessness in such children. on the other hand, united states has seven million children between 3-21 years of age who have been receiving special education classes at school (national center for education statistics, 2020). shifting classes online leads to a dearth of providing special education assistance to children as parents cannot replace special education teachers and there exists a lack of assistive technologies. this impacts development of children as effective communication about sensitive information has long-term effects of psychological wellbeing for a child (dalton, rapa, & stein, 2020) . fear along with insufficient knowledge about the pandemic also leads to a lack of understanding leading to incorrect decision making (tandon, 2020) . thus, caregivers should aim to spend quality time with their children. a system of online clinics and volunteer based psychological interventions should be set up as immediate priority to mitigate effects of covid-19 on children with mental health issues (holmes et al., 2020) . conducting international research on mental health consequences on children with physical and mental disability is of utmost importance to seek long-term solutions to combat this issue. as an immediate remedy, guidelines by unicef providing resources on children with disability during covid-19 can be effectively followed (unicef, 2020). in conclusion, everyday lives for individuals across the globe have been severely affected due to covid-19. amidst this, it becomes important to keep children with physical and mental disability not only physically safe, but also look after their psychological and emotional wellbeing. in particular, social distancing and its effects are extremely novel and difficult to understand for children, especially those experiencing developmental and intellectual delays. this affects their wellbeing and places them at a higher risk for clinically significant mental j o u r n a l p r e -p r o o f resources for supporting children's emotional wellbeing during the covid-19 pandemic protecting the psychological health of children through effective communication about covid-19 the pandemic is a crisis for students with special needs. the atlantic multidisciplinary research priorities for the covid-19 pandemic: a call for action for mental health science children and youth with disabilities the covid-19 pandemic, personal reflections on editorial responsibility state of the education report for india 2019; children with disabilities leaving no child behind during the pandemic: children with disabilities and covid-19 key: cord-326256-s9nhzdm3 authors: nanjundaswamy, madhuri h.; pathak, harsh; chaturvedi, santosh k. title: perceived stress and anxiety during covid-19 among psychiatry trainees date: 2020-07-04 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102282 sha: doc_id: 326256 cord_uid: s9nhzdm3 nan dear editor, covid-19 has induced fear and panic among everyone especially in older adults, health care providers and people with underlying health conditions. medical professionals are more susceptible to be infected. this widespread outbreak is also associated with adverse mental health issues like anxiety, depressive symptoms, obsessive-compulsive disorder and posttraumatic stress disorder (shuja et al., 2020) . the current survey aimed to evaluate subjective mental health status, stress and anxiety related to covid-19. an online survey was conducted among the consenting junior and senior psychiatry resident doctors in a tertiary care post graduate mental health institute in south india. the survey focussed on worries related to covid-19 infection, psychosocial impact of lockdown and their mental health status in the preceding 2-3 weeks, what coping strategies residents had developed to deal with the situation and how much support was perceived to be received by the residents. the questionnaire was sent through the online portal to all 137 residents, followed by two reminders. the anonymity of responses was maintained. out of 137, 106 (77%) residents completed the questionnaire on stress and anxiety during covid-19 pandemic. table 1 highlights some of the common worries related to covid-19 pandemic. healthcare workers are at significant risk of adverse mental health outcomes due to long working hours, risk of infection, shortages of protective equipment, loneliness, physical fatigue, and separation from families (pfefferbaum and north, 2020) . medical workers face discrimination, stigma and isolation as reported in chinese and pakistan medical workers (zhai and du, 2020) . in our survey, 31 (29%) residents were afraid to go home after work and 14 (13%) reported fear of stigma or discrimination in their neighbourhood. also, the impact of lockdown was reported to some extent by 57 (54%) and to great extent by 37 (35%), with some common themes of anxiety, apprehension, loneliness, sadness, uncertainty, sadness leading to frustration and irritability. majority of the residents 69 (65 %) perceived their mental health either same or even better than before in the last 2-3 weeks; another one-third reported j o u r n a l p r e -p r o o f it to be worse than before. mental health is a crucial aspect during lockdown which may have varied presentation such as anxiety, depression, loneliness, panic, financial constraints, apprehension about future which was noticed among a majority of residents in our survey also (hiremath et al., 2020) . the steps taken by the institute in handling the mental health issues were found to be helpful by 59% of the residents. also, various coping strategies were employed by the residents to address their concerns were following a daily routine, indulging in indoor hobbies, yoga, meditation, physical exercises, increased virtual interaction with friends and family, talking to peers, seniors, as well as supervisors and few, practised mindfulness. some of them used distraction techniques like watching tv series, reading novels, cooking, painting, music etc. a recent study on medical and nursing staff showed, 34% and 22 % had mild mental and moderate mental health disturbances respectively during the immediate period of the epidemic. among them 36% had accessed psychological resources materials like books, 50% had accessed online psychological resources as coping strategies and 17% underwent counselling (kang et al., 2020) . the current pandemic has posed a huge challenge on the health care staff who were unprepared. moral injury has been described in medical students, who have difficulty coping with working in prehospital and emergency care when they were exposed to trauma for which they were unprepared (greenberg et al., 2020; murray et al., 2018) . this might be similar to the current situation which we are facing. considering the unprecedented nature of the problem health care workers need adequate support to work efficiently. the routine services provided to persons with mental health problems have been withdrawn during the lockdown, giving rise to potential aggravation of their mental health status. this is yet another challenge for trainees (chaturvedi, 2020) . hence, early support includes preparing the staff for the job and associated challenges and by providing straight forward assessment of what they might face. also, as the situation progresses team leaders should help staff to discuss decisions and well-being using the schwarz rounds model. this is a forum for healthcare staff to safely discuss the emotional and social challenges of caring for patients led by the team leaders. during the aftercare i.e., once the crisis is over, supervisors should ensure to reflect upon and learn from the difficult experiences to create a meaningful rather than distressing experiences (flanagan et al., 2020; greenberg et al., 2020) . there is definitely a need for the reduction of stress and psychological distress among health professionals. the important measures are normalization of strong emotions and stress, the fulfilment of basic needs, social support, clear communication and distribution of tasks, flexible j o u r n a l p r e -p r o o f working hours and the utilization of psychosocial and psychological help without stigmatization (petzold et al., 2020) . screening for mental health problems, psychoeducation, and psychosocial support will help in the prevention of serious mental health issues among the psychiatry trainees. the authors declare that they have no known compe5ng financial interests or personal rela5onships that could have appeared to influence the work reported in this paper. nil. none of the authors have any conflict of interest. covid-19, coronavirus and mental health rehabilitation at times of crisis reflection for all healthcare staff: a national evaluation of schwartz rounds managing mental health challenges faced by healthcare workers during covid-19 pandemic covid 19: impact of lock-down on mental health and tips to overcome impact on mental health and perceptions of psychological care among medical and nursing staff in wuhan during the 2019 novel coronavirus disease outbreak: a cross-sectional study are medical students in prehospital care at risk of moral injury? dealing with psychological distress by healthcare professionals during the covid-19 pandemia mental health and the covid-19 pandemic covid-19 pandemic and impending global mental health implications mental health care for international chinese students affected by the covid-19 outbreak. the lancet psychiatry none. key: cord-310914-e2ot5fnv authors: sarkar, siddharth; majumder, pradipta title: covid 19 draws attention to the adaptive evolutionary perspective of certain personality traits date: 2020-06-12 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102215 sha: doc_id: 310914 cord_uid: e2ot5fnv nan this is a pdf file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. this version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. as the covid 19 swathes across the world, it has necessitated changes in the usual behavioral repertoire in the form of adjusting to social distancing and lockdown norms (cohen and kupferschmidt, 2020) . the pandemic has unmasked distress due to loneliness and restrain from the gregarious assembly. however, not everyone is distressed to the same extent, and coping of different individuals are likely to vary (chew et al., 2020) . as we make forays into understanding the impact of the pandemic on psychiatry and vice versa (tandon, 2020) , an opportunity has been provided to explore the theoretical adaptive angle of personality traits and personality disorders. cluster a personality disorders comprise of paranoid, schizoid, and schizotypal personality disorders, and are marked by social aloofness. individuals with paranoid personality are suspicious of intentions of others; those with schizoid personality do not want social relationships. similarly, individuals with schizotypal personality have peculiarities of thoughts and behaviors and do not gel well with others. opposed to anxious avoidant personality j o u r n a l p r e -p r o o f disorders, they are not interested in developing close relationships with others. in the situation of pandemics, such cluster a personality characteristics may offer certain evolutionary advantages. individuals with these personality features are less likely to be exposed to the transmission of microbial agents, due to their preference for solitude. also, these personality characteristics are not significantly internally distressed by loneliness, leading to a lesser likelihood of resumption of social contacts when the wave of infection abates prior to the resurgence of another wave. the behavior immune system has been discussed (schaller et al., 2015) which posits that people's way of engaging in certain activities that offer some protection against acquiring infectious diseases. an individual's personality is generally an amalgam of multiple personality traits and personality disorders are the prototypical organizations of a spectrum. these traits confer resilience and, at the same time, lead to distress based upon circumstances, combinations, and intensities. certain traits that are otherwise adaptive, like histrionicity and narcissism, may become problematic if they cause personal and inter-personal distress due to lack of opportunities of expression. obsessive-compulsive personality disorder has been considered as a continuum of the spectrum of obsessive compulsive disorder, which in turn has been suggested to have an evolutionary advantage in pandemic situations due to features of fear of contamination and hoarding (rajkumar, 2020) . the coping mechanism employed by individuals with various personality structure also differs. the current pandemic has tested individuals on their coping patterns and has led to symptoms of anxiety and depression when coping fails (huang and zhao, 2020) . also, uncertainties in livelihood and economic constraints are likely to test the resilience in the future. an unaffected predisposition of schizoid and fantasy of schizotypal may insulate those with these characteristics from undue distress. on the other hand, manifest anxieties in paranoid, emotionally unstable, dependent, and anxious-avoidant personalities may increase. in the j o u r n a l p r e -p r o o f severest of circumstances, antisocial personality characteristics may help individuals to appropriate resources regardless of social norms. the pandemic provides an opportunity to assess how personality features mediate the stress, depression, anxieties, and other health outcomes related to covid-19 and help in building resilience to deal better with the circumstances. the authors do not have any conflict of interest to disclose there was no funder for the study ss conceived the idea and pm elaborated upon it. the first draft was written by ss, which was further modified by pm. all authors have materially participated in the research and/or article preparation. all authors have approved the final article the authors do not have any financial disclosures countries test tactics in 'war' against covid-19 narrative synthesis of psychological and coping responses towards emerging infectious disease outbreaks in the general population: practical considerations for the covid-19 pandemic generalized anxiety disorder, depressive symptoms and sleep quality during covid-19 outbreak in china: a web-based cross-sectional survey implications of the behavioural immune system for social behaviour and human health in the modern world contamination and infection: what the coronavirus pandemic could reveal about the evolutionary origins of obsessive-compulsive disorder the covid-19 pandemic none. the study was not funded key: cord-287361-cpd4yl6c authors: ng, qin xiang; de deyn, michelle lee zhi qing; lim, donovan yutong; chan, hwei wuen; yeo, wee song title: the wounded healer: a narrative review of the mental health effects of the covid-19 pandemic on healthcare workers date: 2020-06-20 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102258 sha: doc_id: 287361 cord_uid: cpd4yl6c nan health systems and healthcare workers worldwide are experiencing tremendous stress because of the growing coronavirus disease 2019 pandemic. in many ways, the causative virus, the severe acute respiratory syndrome coronavirus 2 (sars-cov-2), is unlike the common flu or the 2003 sars virus. it is highly contagious and infected persons may remain relatively asymptomatic (tandon, 2020) . much j o u r n a l p r e -p r o o f about the virus also remains unknown, including its incubation period and transmission dynamics . cases increase at an exponential rate, may have complicated needs and are typically not discharged until at least 10 days later . expectedly, there have been increasing reports of high rates of anxiety and depressive symptoms amongst frontline medical staff (lai et al., 2020; tan et al., 2020) , and calls for healthcare workers involved in the fight against covid-19 to receive screening and counselling by professional mental health providers. a rapid review of the pubmed and google scholar databases using the text words, "covid-19" or "ncov" or "sars" or "sars-cov-2" and "mental health" or "psychiatry" or "psychology", "anxiety" or "depression" or "stress", up to 5 may, 2020, we found ten observational studies on the mental health effects of the covid-19 pandemic on healthcare workers. these studies and their key findings are summarised in table 1 . -levels of social support for medical staff were significantly associated with self-efficacy and sleep quality and negatively associated with the level of anxiety and stress. -levels of anxiety were significantly associated with the levels of stress. this negatively impacted self-efficacy and sleep quality. -anxiety, stress, and self-efficacy were mediating variables associated with social support and sleep quality. notably, the studies were all from asia (singapore, india and china). the chinese studies generally found that female gender and direct contact with covid-19 patients were significant risk factors associated with higher levels of psychological distress (lai et al., 2020; lu et al., 2020; kang et al., 2020; . poor sleep quality and insomnia may also be more prevalent amongst healthcare workers (huang & zhao, 2020; xiao et al., 2020; . besides the demanding nature of the work and other occupational hazards, being in direct contact with a covid-19 patient puts healthcare workers at higher risk of disease exposure. there may also be anticipatory anxiety and fear of spreading the virus to family members living in the same household. the studies conducted in singapore found overall lower prevalence of psychological symptoms compared to the chinese studies chew et al., 2020) , but reported higher prevalence of physical symptoms e.g. headache, which could reflect somatization. the studies also highlighted the importance of pandemic readiness and preparedness, especially for non-medical staff, who may be less familiar with communicable diseases. wearing full ppe is exhausting and proper work-rest cycles should be ensured. skin damage due to frequent handwashing and enhanced infection-prevention measures could also compound one's psychological distress (lan et al., 2020) . in the current climate, even the best among us can feel overwhelmed, emotionally distressed and be left with the scars of vicarious traumatization. an effective pandemic response must also include a mental health response, both for the public and also the healthcare force. it is important to continually support healthcare workers and their psychological needs. as resources could be scarce at the moment, timely psychological support could take many forms (ng et al., 2020) . these include availing counselling services, informal or formal supervision and establishing peer support systems j o u r n a l p r e -p r o o f among colleagues. future studies on this subject should also employ a mixed-methods design to explore specific themes and intervention strategies. swiss psychiatrist carl jung famously said that, "it is his own hurt that gives the measure of his power to heal [..] this, and nothing else, is the meaning of the greek myth of the wounded physician." in the same vein, i hope all healthcare workers can draw strength from their struggles and transform despair into hope. keywords: covid-19; pandemic; mental health; healthcare workers; doctors; nurses no conflict of interest to declare. none. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. not applicable. none a multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during covid-19 outbreak. brain, behavior, and immunity psychological symptoms among frontline healthcare workers during covid-19 outbreak in wuhan. general hospital psychiatry generalized anxiety disorder, depressive symptoms and sleep quality during covid-19 outbreak in china: a web-based cross-sectional survey the mental health of medical workers in wuhan factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019 skin damage among health care workers managing coronavirus disease-2019 vicarious traumatization in the general public, members, and non-members of medical teams aiding in covid-19 control. brain, behavior, and immunity psychological status of medical workforce during the covid-19 pandemic: a cross-sectional study psychological impact of the covid-19 pandemic on health care workers in singapore the covid-19 pandemic personal reflections on editorial responsibility. asian journal of psychiatry unique epidemiological and clinical features of the emerging 2019 novel coronavirus pneumonia (covid-19) implicate special control measures the effects of social support on sleep quality of medical staff treating patients with coronavirus disease 2019 (covid-19 mental health and psychosocial problems of medical health workers during the covid-19 epidemic in china. psychotherapy and psychosomatics none.j o u r n a l p r e -p r o o f key: cord-351892-rmf0azon authors: maldonado-castellanos, isaac title: ethical issues when planning mental health services after covid-19 outbreak date: 2020-07-13 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102285 sha: doc_id: 351892 cord_uid: rmf0azon nan recently, a paper written by ransing et al. (2020) adressed a conceptual framework aiming to guide the development, implementation and evaluation of mental health interventions during the covid-19 outbreak. the proposed model includes the following main topics coordination and preparation, monitoring and assessment, reduction of the mental distress due to misinformation and "myths", sustainability of mental health services and communication. in addition to this, ethical considerations should be incorporated when planning novel mental health programs. it is widely known that covid-19 pandemic has changed people's lives. as a consequence, a new social dynamic has been stablished where people need to engage in healthy preventive behaviors by adopting social distance measures. in this respect, uncertainty on the duration of confinement actions, the unavailability of vaccines or treatments for covid-19 and the increase of the number of people infected might increase worry, fear, confusion, or anxiety making adaptation process difficult to these new circumstances during a public global emergency. in this context, the increase of mental health problems among socially distanced and selfisolated people is one of the major concerns encompassed by mental health professionals. ransing et al. (2020) have described that mental health problems are common during a j o u r n a l p r e -p r o o f pandemic, but they need to be well identified by proper epidemiological studies. as a consequence, people have opted the use of digital technologies like telemedicine or hotlines to cope with mental health issues during the confinement actions taken by governments to stop the spread of the virus. these alternative approaches represent a non-traditional ways of mental health services delivery that might facilitate access to health services but at the same time, they rise new ethical challenges. for instance, protection of personal data is a major concern of mental health users that might lead people to feel unsteady when talking about intimate issues ethical principles like justice, integrity, beneficence, nonmaleficence and autonomy must be incorporated in a new ethical framework to regulate the use of digital technologies related to health services. culture practices are been transformed after the covid-19 and new ethical controversies on mental health digital services are yet to be identified (bauer et al., 2017) . to accomplish this challenge, professionals need to discuss, and review topics related to informed consent, data protection, patient privacy, identity confirmation or digital medical j o u r n a l p r e -p r o o f prescription in order to incorporate these subjects when developing contemporary mental health programs. as a psychologist, i think there is an opportunity to adapt to a new social digital complexity by developing new codes of conduct aimed at psychologist, psychiatrist and other mental health professionals. things are changing. apa's ethical principles of psychologists and code of conduct and other ethical codes for psychologists and psychiatrists need to habituate to this current humanity's challenge. we are facing a paradigm shift in psychological and psychiatric services provided through digital platforms that need a comprehensive and contemporary ethical analysis. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. author declare no conflicts of interest in connection with this paper the consejo nacional de ciencia y tecnología (conacyt) through doctoral scolarship. ethical principles of psychologists and code of conduct ethical perspective on recommending digital technology for patients with mental illness mental health interventions during the covid-19 pandemic: a conceptual framework by early career psychiatrists towards the design of ethical standards related to digital mental health and all its applications key: cord-348246-prwg2wvm authors: gabriel, andrade title: the role of psychiatrists in addressing covid-19 conspiracy theories date: 2020-09-01 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102404 sha: doc_id: 348246 cord_uid: prwg2wvm nan ajman university. united arab emirates. as tandon (2020) mentions in a previous editorial for the asian journal of psychiatry, this journal is strongly committed to publishing research on the covid-19 pandemic, and thus, the editor invited authors to reflect on this issue. in such a manner, i believe the role of conspiracy mongering and its implications on mental health ought to be explored. the etiology of covid-19 has not so far been well-established. it has been posited that it developed from bat origin coronaviruses that may have been harbored in a wet market of wuhan, china (rothan, h. a., & byrareddy, 2020 ). yet, that has not stopped conspiracy theories from emerging. some of these conspiracy theories have political overtones. in the united states, some people have accused chinese scientists of engineering covid-19 in labs as a bioweapon; in china, some people have accused the us of importing covid-19 to wuhan, in the context of international military games in august 2019. some other non-political conspiracy theories are also increasingly popular. it is claimed that 5g networks accelerate the spread of the virus. bill gates is also frequently blamed for deliberately spreading the virus, so as to make money selling the vaccine. these rumors are of great concern to public health officials. if the wider public does not accept the conventional explanation for the origin of covid-19, then it will be more difficult for healthcare workers to persuade people to accept treatment and prevention options. covid-19 has now become yet another medical conspiracy theory, and as andrade (2020) shows, medical conspiracy theories are detrimental to public health efforts. in order for the public to comply with principles of treatment and prevention, physicians and healthcare workers must be trusted. however, if medical conspiracy theories are rampant, the implementation of public health policies becomes more difficult, because people are unlikely to comply, given their mistrust. psychiatrists have a significant role to play in addressing the spread of conspiracy theories regarding covid-19. in order to eradicate such conspiratorial thinking, we ought to understand where it comes from. in the same manner that psychiatrists must recur to an accurate diagnosis for adequate treatment, psychiatrists can now use their diagnostic concepts in order to j o u r n a l p r e -p r o o f 2 determine the comorbidity of conspiratorial thinking with particular psychopathologies, and on the basis of that knowledge, some concrete public health policies can be proposed. research has established that people who are prone to accept conspiracy theories are predisposed to suffer from paranoid personality disorder (darwin et al, 2011) . in this disorder, patients have a generalized mistrust of others, they may be hypersensitive, feel easily insulted, and are constantly on the watch for what others may do to them. additionally, they are eager observers, seeking for patterns that most of the time are inexistent. these features are clearly present in all the versions of conspiracy theories regarding covid-19. people with paranoid ideation are unlikely to accept that a virus that has turned so devastating, is simply a natural phenomenon. people with paranoid personalities are far more likely to believe the world is an evil place, and therefore, any catastrophe as big as the current pandemic, had to be designed by evil people. studies have also established a correlation between proneness to believe conspiracy theories, and prevalence of schizotypal personality disorder (chichoka et al, 2016). in this disorder, patients feel unease relating to others and keeping close relationships; likewise, a frequently observed feature is odd behaviors (particularly related to dress modes) and magical thinking. some conspiracy theories relate to the magical realm, by invoking the intervention of beings such as aliens, vampires, fairies, etc. in the context of covid-19 conspiracy theories, such entities have not been typically invoked. yet, conspiracy theories about covid-19 nevertheless preserve schizotypal ideation, to the extent that such theories are deeply irrational, and engage with some measure of magical thinking. people with schizotypal personality disorder are frequently uninterested in meaningful social relationships, but they tend to compensate that by having a rich inner mental life; in this endeavor, they may fantasize with conspiracy theories, and ultimately come to believe them very strongly. narcissist personality disorder is another diagnosis that researchers have correlated with proneness to accept conspiracy theories (golec de zavala and feredico, 2018) . in this disorder, patients have exaggerated feelings of self-importance, and require an excessive need for admiration, usually to the point of lacking empathy towards other people. this makes it more likely that, whenever such patients get infected with covid-19, their sense of selfaggrandizement compels them to believe that, given their importance to the world, such j o u r n a l p r e -p r o o f misfortune could not be a mere accidental feature of the natural world, but rather, it had to be an attack by some sinister cabal. now, it is important for psychiatrists to keep in mind that ideation about conspiracy theories is not necessarily pathological. research has shown that paranoid traits (on which conspiracy theories ultimately rely) exist on a continuum in the general population (bebbington et al, 2013) ; the same can be said of schizotypy and narcissism. consequently, people with no particular diagnosed psychopathologies can and do believe in conspiracy theories. however, if those three mental disorders (paranoid personality disorder, schizotypal personality disorder, narcissistic personality disorder) have higher levels of prevalence in any given population, then it is more likely that conspiracy theories will more easily spread in that particular population. people who accept already circulating conspiracy theories are not necessarily pathological, but people who come up with such theories in the first place, are more likely to suffer from mental disorders. therefore, even if belief in conspiracy theories about covid-19 is not necessarily pathological, one effective way of (at least partially) eradicating such beliefs is by contributing to a more robust public mental health. during the current pandemic, and as a result of the effects of enforced quarantine, stress levels have been particularly high. consequently, psychiatrists have been requested to address this. yet, psychiatrists must not leave aside that, in the current context, their specialty is crucial, not only to treat patients who may be suffering depression and anxiety as a result of the current state of affairs, but also to provide coping techniques to patients with particular personality disorders. by so doing, these patients will be less inclined to accept conspiracy theories about covid-19, and such ideas will circulate less in society. medical conspiracy theories: cognitive science and implications for ethics the structure of paranoia in the general population they will not control us": in-group positivity and belief in intergroup conspiracies belief in conspiracy theories: the role of paranormal belief, paranoid ideation and schizotypy collective narcissism and the growth of conspiracy thinking over the course of the 2016 united states presidential election: a longitudinal analysis the epidemiology and pathogenesis of coronavirus disease (covid-19) outbreak covid-19 and mental health: preserving humanity, maintaining sanity, and promoting health key: cord-317857-of1w23xr authors: dan, zhaokui title: china adopts non-contact free consultation to help the public cope with the psychological pressure caused by new coronavirus pneumonia date: 2020-04-10 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102093 sha: doc_id: 317857 cord_uid: of1w23xr nan china adopts non-contact free consultation to help the public cope with the psychological pressure caused by new coronavirus pneumonia. clinical medical college, hubei university of science and technology, xianning 437100, china e-mail address:509852081@qq.com a novel coronavirus pneumonia outbreak occurred in wuhan, hubei province, china in december 2019, and was followed by worldwide concern. like all outbreaks, the first possible psychological response of the general population is fear and panic of being infected. they also fear that the epidemic will continue. at present, there is a lot of information about the epidemic on the internet. we don't know whether it is true or false. because of the novel coronavirus pneumonia, we cancelled all kinds of parties and could only stay at home, so life was boring. at this time, some people may have anxiety, depression, despair, anger and other emotional reactions (xiang et al., 2020) . people buy a lot of things by hearsay, such as masks, disinfectants and even vegetables in supermarkets. therefore, in fighting novel coronavirus (2019-ncov) in 2019, special attention should be paid to the mental health issues of the public (zandifar and badrfam, 2020) . how to alleviate the mental health of ordinary people is very important to control the epidemic situation and their own long-term health. for most of the public, emotional and behavioural responses are part of an adaptive response to extraordinary stress, and psychotherapy techniques such as those based on the stress-adaptation model might be helpful (folkman and greer, 2000) . iranian scholars believe that what is important is that controlling the disease requires proper and comprehensive management (zandifar and badrfam, 2020) . as the chinese government has strong cohesion and efficiency, it has just an advantage in this respect. on january 27, 2020, the national health committee of china released the guidance on national psychological crisis intervention in 2019, which provided various guidances for people's mental health in epidemic areas. in order to better cope with the mass psychological injury and social impact caused by the epidemic, on march 18, 2020, the national health commission of china announced the psychological counseling for novel coronavirus pneumonia. to solve these mental health problems, the local government of xianning city, which is adjacent to wuhan city, implemented the helpful policies in time. as psychiatrists can play pivotal role in supporting the well-being of those affected and their families, the at-risk healthcare staff as well as the public (banerjee, 2020) , the local government have organized psychological consultation team and mental health team to provide free psychological consultation service to relieve j o u r n a l p r e -p r o o f the psychological pressure of the masses. because people are isolated at home, the traditional face-to-face psychological consultation becomes impossible. basically, all psychological counseling is carried out through non-contact way. contacting by phone, qq or wechat, "one-to-one" psychological counseling can be carried out. the network also provides a variety of free movies and tv plays for the public to enjoy. as an affiliated hospital of the local medical college, our hospital has set up a psychological intervention group. the professional psychological doctors who have received the psychological assistance training in response to the 2019-ncov provide psychological consultation for the public. some experts argue that it is debatable whether such interventions are universally appropriate for targeted populations, which include lay people, frontline responders, and family members of patients with covid-19 (yao et al., 2020) . but in the case of isolation of the whole country, online psychological consultation is the only way to be adopted, which is better than nothing. our practice also proves that most of the psychological pressure of the people who accept these interventions has been relieved. in march 31, 2020, 0 novel coronavirus pneumonia case was confirmed in hubei province, including 0 in wuhan and 0 in 16 other cities. most of the local citizens have successfully overcome the psychological discomfort caused by the isolation period. the non-contact free psychological consultation has played the key role and may be used j o u r n a l p r e -p r o o f for reference for the efficiency and quality of future crisis intervention by the chinese government and other governments around the world. this work is supported by the doctor initiated fund project of hubei university of science and technology (bk1415). the funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. none of the authors have any conflicts of interest to disclose. the covid-19 outbreak: crucial role the psychiatrists can play promoting psychological well-being in the face of serious illness: when theory, research and practice inform each other timely mental health care for the 2019 novel coronavirus outbreak is urgently needed rethinking online mental health services in china during the covid-19 epidemic iranian mental health during the covid-19 epidemic pay tribute to all health workers who are battling with the epidemic. key: cord-348351-naktgl9o authors: rajkumar, ravi philip title: suicides related to the covid-19 outbreak in india: a pilot study of media reports date: 2020-06-05 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102196 sha: doc_id: 348351 cord_uid: naktgl9o nan the covid-19 pandemic, caused by infection with a novel coronavirus (ncov-2), has reached the level of a global health crisis, generating a variety of emotional responses among the general public. this includes fear-related behaviour (shultz et al., 2016) which can lead to psychiatric morbidity and even suicide in vulnerable individuals. a review of historical data from past pandemics such as influenza and severe acute respiratory syndrome (sars) showed that these outbreaks were followed by significant increases in suicidal deaths (wassermann, 1992; chan et al., 2003) . it is of interest that suicidal deaths related to covid-19 have already been reported in the asian journal of psychiatry (goyal et al., 2020; mamun and griffiths, 2020) . the dissemination of information related to suicide during the covid-19 outbreak, particularly as it pertains to asian countries, is of importance to healthcare providers and policy-makers, and is in keeping with the objectives set out by the journal in its position statement (tandon, 2020) . as direct interaction with the families of suicide victims is difficult during a disease outbreak, information regarding such deaths must be obtained through indirect means. one such method is the review of media reports. in this light, we conducted j o u r n a l p r e -p r o o f a pilot study of all english-language media reports containing the words "covid-19", "suicide" and "india", and accessible online through the google news aggregator, covering the period march 12 th to april 11 th , 2020. only reports of individual completed suicides were considered for data analysis. in case there was more than one report of the same incident, all available reports were used as a data source. the data extracted from the reports included: (a) socio-demographic details, (b) any possible diagnosis of mental illness or substance use disorder, (c) triggering circumstances, (d) remote predisposing factors. these categories were based on the stress-diathesis model of suicide (mann, 2002) . a total of 49 relevant reports were retrieved, covering 23 suicidal deaths. the majority of reported victims were adult men (20/23, 87%). three suicides occurred in elderly people. six of the deaths occurred in hospitalized patients who were placed in isolation for symptoms of suspected covid-19. there was one incident suggestive of a suicide pact involving a husband and wife. information regarding the method of suicide was available in 18 cases. the most common methods adopted were violent methods such as hanging (10/18, 55.6%), jumping from a height (3/18, 16.7%) and cut-throat injuries (3/18, 16.7%). one death each occurred through self-immolation and medication overdose. in seven cases, a possible psychiatric diagnosis was mentioned. four victims were reported as suffering from depression based on reports from relatives, and three victims were noted to have alcohol dependence with withdrawal symptoms. alcohol-related suicides were j o u r n a l p r e -p r o o f reported exclusively in south indian states, while depression was reported in victims from north and central indian states. at least one precipitating factor was reported for each victim. covid-19 related factors formed the bulk of these, especially fears of being infected (9/23, 39.13%) or having influenza-like symptoms (7/23, 30.43%). only one of the deaths occurred in a patient with confirmed infection, and one death occurred in a victim who underwent stigmatization and ostracism despite testing negative. triggers unrelated to the disease were reported less frequently (6/23, 30.43%) and included alcohol withdrawal (n=3), separation from family due to transport restrictions (n=1), abrupt loss of a job in a migrant worker (n=1), and alleged work stress in a disaster management official (n=1). predisposing vulnerability factors were reported in 5 victims and included bereavement (2 cases), migrant worker status (2 cases), and financial hardship. these reports reveal certain common themes that are of importance in preventing suicides during the covid-19 outbreak. first, fears of infection played a major role in several number of attempts. such fears are often the result of inadequate or inaccurate information. up-todate and valid information regarding the covid-19 outbreak can reduce these fears. similarly, symptoms suggestive of covid-19 infection are associated with psychological distress, and patients with such symptoms should be evaluated for features of anxiety and depression as well as for suicide risk (wang et al., 2020) . it is possible that such measures, as well as greater vigilance at the hospital level, could have prevented some of these deaths. this is underlined by the fact that one-fourth of deaths in this series occurred in hospital settings high number of reported suicides that occurred in hospitalized patients (over ¼ of the cases in this series). pre-existing psychiatric or substance use disorders were found in 30% of the deaths reported. patients with existing mental disorders are at risk of symptom exacerbation during a disease outbreak, and this can be compounded by restrictions on access to care. it is important to ensure continued access to mental health services for these patients during an outbreak, perhaps by implementing telemedicine services (yao et al., 2020) . even in the absence of a fear of infection, the protective measures necessitated by a disease outbreak can be a source of stress in vulnerable individuals, such as migrant workers (nayar, 2020) , older adults, and those in high-stress occupations, including healthcare workers. interventions aimed at addressing the physical, emotional and socio-economic needs of these individuals could reduce their risk of suicide. though the results presented here are subject to many limitations, particularly reporting biases (armstrong et al., 2018) , they provide preliminary information on the factors related to suicide during the covid-19 outbreak in india. it is hoped that these findings will be of use to researchers as well as to policy-makers. the author has no sources of funding or other financial disclosures concerning the above article. the author has no conflicts of interest to declare with reference to the above article. assessing the quality of media reporting of suicide news in india against world health organization guidelines: a content analysis study of nine major newspapers in tamil nadu elderly suicide and the 2003 sars epidemic in hong kong fear of covid 2019: first suicidal case in india! asian first covid-19 suicide case in bangladesh due to fear of covid-19 and xenophobia: possible suicide prevention strategies a current perspective of suicide and attempted suicide the long walk: migrant workers and extreme mobility in the age of corona west africa ebola virus disease outbreak the covid-19 pandemic immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china the impact of epidemic, war, prohibition and media on suicide: united states,1910-1920 patients with mental health disorders in the covid-19 epidemic key: cord-265424-vbn3vwnn authors: mansoor, marium; najam, shireen; nadeem, tania; allaudin, sunita; moochhala, mariya; asad, nargis title: integrating mental health in covid-19 crisis: staff mental health referral pathway date: 2020-07-29 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102339 sha: doc_id: 265424 cord_uid: vbn3vwnn nan in february 2020, the first case of covid-19 was detected in pakistan (shahid, 2020) , a lower middle income country with scarce resources. as the number of confirmed covid-19 cases and fatalities increased, there was an influx of patients for assessment and treatment at akuh, which is a quaternary care teaching hospital. this is known to lead to immense pressure on all health care workers (hcw) due to increased workload, anxiety regarding acquiring infection or passing it on to a family member and fears of death (chen et al., 2020; adams &walls, 2020) ,which also affects their attention and decision-making ability, and overall wellbeing (maunder et al., 2005) . unfortunately, the psychological ramifications due to an outbreak's direct and indirect effects remain widely unaddressed (chan et al., 2016; tandon, 2020) . anticipating the mental health fallout, the department of psychiatry (dop) initiated a pathway to provide rapid, confidential and accessible help to all hcws during this crisis. the dop in liaison with human resources department formulated an evidence based pathway (chen et al., 2020; liu, 2020; zhang et al., 2020) to address mental health needs of hcws. the service was free of cost and built on the existing sparse resources (ahmad, 2007) , with regular review of process in weekly meetings. the purpose of this paper is to describe the structure of this pathway so it can be replicated in other institutes, especially those working with limited mental health personnel. the hcws of akuh were provided with a hotline number that could be used during work hours, to help with covid-19 related anxiety (refer figure 1). the first point of contact was the assistant head nurse of the psychiatry department. guidance and supervision was provided to her by members of faculty, regarding interviewing staff members about their anxiety. screening was done using a brief questionnaire. she was also trained in providing information on basic relaxation techniques and a cbt outline for mapping their thoughts.  for mild problems: hcws were encouraged to use self-help, structured routine, and web based resources will also be shared. on follow up call the hcws showing improvement were encouraged to continue advice, in case of no improvement; specialist appointment was scheduled.  for severe problems: hcws were given urgent appointments on next working day in faculty tele-psychiatric clinics dedicated for hcws. faculty members decided the aftercare as per their evaluation. the record of the evaluation was maintained in a separate folder by the dop to ensure staff confidentiality. this was a free of cost service and notes were kept in a separate folder. there are three main challenges that we might face. 1) resistance to seek help and fear of stigma and confidentiality of hcws. to address this, the record of the evaluation is maintained in a separate folder in lock and key by the dop. 2) some hcws are utilizing the pathway for pre-existing mental health needs which is not our primary objectives. such hcws are redirected to clinics as usual. our staff mental health pathway was initiated in a crisis situation, with the expectation of optimistic staff outcomes (bronkhorst eet al., 2015) amongst the uncertainty. we aspire to minimize the invisible burden of mental health illnesses on our hcws, support and built on their capabilities towards a pathway of minimal employee under-performance and absenteeism (harnois & gabriel, 2000) . the aforementioned pathway can be contextualized to resource limited settings in pakistan and elsewhere according to the organizations' respective service structure. j o u r n a l p r e -p r o o f supporting the health care workforce during the covid-19 global epidemic shortage of psychiatrists a problem in pakistan organizational climate and employee mental health outcomes: a systematic review of studies in health care organizations. health care manage rev the psychosocial and interpersonal impact of the sars epidemic on chinese health professionals: implications for epidemics, including ebola. the psychosocial aspects of a deadly epidemic mental health care for medical staff in china during the covid-19 outbreak mental health and work: impact, issues and good practices online mental health services in china during the covid-19 outbreak applying the lessons of sars to pandemic influenza two coronavirus cases confirmed in pakistan the covid-19 pandemic, personal reflections on editorial responsibility recommended psychological crisis intervention response to the 2019 novel coronavirus pneumonia outbreak in china: a model of west china hospital financial disclosure: none acknowledgement: none key: cord-297157-16ciqu9w authors: mamun, mohammed a.; griffiths, mark d. title: first covid-19 suicide case in bangladesh due to fear of covid-19 and xenophobia: possible suicide prevention strategies date: 2020-04-07 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102073 sha: doc_id: 297157 cord_uid: 16ciqu9w nan the novel coronavirus 2019 (covid-19) pandemic has become a global concern. healthcare systems in many countries have been pushed to breaking point in an attempt to deal with the pandemic. at present, there is no accurate estimation about how long the covid-19 situation will persist, the number of individuals worldwide who will be infected, or how long people's lives will be disrupted (suicide awareness voices of education, 2020; zandifar and badrfam, 2020) . like previous epidemics and pandemics, the unpredictable consequences and uncertainty surrounding public safety, as well as misinformation about covid-19 (particularly on social media) can often impact individuals' mental health including depression, anxiety, and traumatic stress (cheung et al., 2008; zandifar and badrfam, 2020) . additionally, pandemic-related issues such as social distancing, isolation and quarantine, as well as the social and economic fallout can also trigger psychological mediators such as sadness, worry, fear, anger, annoyance, frustration, guilt, helplessness, loneliness, and nervousness. these are the common features of typical mental health suffering that many individuals will experience during and after the crisis (ahorsu et al., 2020; banerjee, 2020; cheung et al., 2008; xiang et al., 2020) . in extreme cases, such mental health issues can lead to suicidal behaviors (e.g., suicidal ideation, suicide attempts, and actual suicide). it is well stablished that around 90 % of global suicides are due to individuals with mental health conditions such as depression (mamun and griffiths, 2020) . similar situations have been reported in previous pandemics. for example, the suicide rate among elderly people increased in hong kong both during and after the sars (severe acute respiratory syndrome) pandemic in 2003 (cheung et al., 2008) . on march 25 (2020), after returning from dhaka, a 36-year-old bangladeshi man (zahidul islam, from the village of ramchandrapur) committed suicide because he and the people in his village thought he was infected with covid-19 based on his fever and cold symptoms and his weight loss (somoy news, 2020). due to the social avoidance and attitudes by others around him, he committed suicide by hanging himself from a tree in the village near his house. unfortunately, the autopsy showed that the victim did not have covid-19 (somoy news, 2020). the main factor that drove the man to suicide was prejudice by the others in the village who thought he had covid-19 even though there was no diagnosis. arguably, the villagers were xenophobic towards mr. islam. although xenophobia is usually defined as a more specific fear or hatred of foreigners or strangers, xenophobia is actually the general fear of something foreign or strange (in this case covid-19 rather than the victim's ethnicity). given that the victim believed he had covid-19, it is also thought that he committed suicide out of a moral duty to ensure he did not pass on the virus to anyone in his village. a very similar case was reported in india on february 12 (2020), where the victim, returning from a city to his native village, committed suicide by hanging to avoid spreading covid-19 throughout the village (goyal et al., 2020) . based on these two cases, it appears that village people and the victim's moral conscience had major roles in contributing the suicides. in the south asian country like bangladesh and india, village people arguably less educated than those that live in cities. therefore, elevated fears and misconceptions surrounding covid-19 among villagers may have led to higher levels of xenophobia, and that xenophobia may have been a major contributing factor in committing suicide. suicide is the ultimate human sacrifice for anyone who cannot bear the mental suffering. however, the fact that the fear of having covid-19 led to suicide is preventable and suggests both research and prevention is needed to avoid such tragedies. at present, it is not known what the level of fear of covid-19 is among the bangladeshi population although levels of fear are high among countries where there have been many deaths such as iran according to a recent study examining fear of covid-19 (ahorsu et al., 2020) . we would suggest there is an urgent need to carry out a nationwide epidemiological study to determine the level fear, worry, and helplessness, as well as other associated issues concerning mental health in relation to covid-19. this would help in developing targeted mental wellbeing strategies (e.g., such as those who live in villages). additional mental health care is also needed for patients confirmed as having covid-19, patients with suspected covid-19 infection, quarantined family members, and healthcare personnel . we would also suggest the following to the general public: (i) avoid unreliable and non-credible news and information sources (such as that on social media and what neighbors say) to reduce fear and panic surrounding covid-19, (ii) help individuals with known mental health issues (e.g., depression, anxiety) in appropriate ways such as consultation with healthcare professionals using telemedicine (i.e., online interventions) where possible, (iii) offer support and signposting for individuals displaying pre-suicidal behavior (i.e., talking about death and dying, expressing feelings of being hopeless and/or helpless, feeling like they are a burden or that they are trapped), (iv) offer basic help (e.g., foods, medicines) to those most in need during lock-down situations (suicide awareness voices of education, 2020; yao et al., 2020) . we would also recommend online-based mental health intervention programs as a way of promoting more reliable and authentic information about covid-19, and making available possible telemedicine care, as suggested in recent previous papers (liu et al., 2020; xiang et al., 2020; yao et al., 2020) . finally, as suggested by banerjee (2020) , the role of a psychiatrist during a pandemic such as covid-19 should include as (i) educating individuals about the common adverse psychological consequences, (ii) encouraging health-promoting behaviors among individuals, (iii) integrating available healthcare services, (iv) facilitate problem-solving, (v) empowering patients, their families, and health-care providers, and (vi) promoting self-care among health-care providers. self-funded. the authors involved in this research project do not have any relationships with other people or organizations that could inappropriately influence (bias) their work. the authors of the correspondence do not have any conflict of interest. fear of covid-19 scale: development and initial validation the covid-19 outbreak: crucial role the psychiatrists can play a revisit on older adults' suicides and severe acute respiratory syndrome (sars) epidemic in hong kong fear of covid 2019: first suicidal case in india online mental health services in china during the covid-19 outbreak a rare case of bangladeshi student suicide by gunshot due to unusual multiple causalities preventing suicide during and after the covid-19 pandemic. retrieved by timely mental health care for the 2019 novel coronavirus outbreak is urgently needed rethinking online mental health services in china during the covid-19 epidemic iranian mental health during the covid-19 epidemic none. key: cord-279207-azh21npc authors: sharma, manoj kumar; anand, nitin; vishwakarma, akash; sahu, maya; thakur, pranjali chakraborty; mondal, ishita; singh, priya; sj, ajith; n, suma; biswas, ankita; r, archana; john, nisha; tapatrikar, ashwini; murthy, keshava d. title: mental health issues mediate social media use in rumors: implication for media based mental health literacy date: 2020-05-07 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102132 sha: doc_id: 279207 cord_uid: azh21npc nan research involving human participants and/or animals:.all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards. j o u r n a l p r e -p r o o f social media use has recently become immensely popular not only for its leisure activities through connecting people over the world, but also for keeping updated with the current trends through news and sharing information. it provides a perfect platform to interact with others by offering opportunities to share a user's thoughts, emotions, pictures, videos and creative ideas through posts or blogs (kuss & griffiths, 2011b , 2011a . hence, one important characteristic of social media platforms is rapid spreading of information through its users which is usually impactful. another concern is when it comes to health related information sharing on social media. as open to all, anyone can produce information and publish in the digital forum, share experiences, form their own perspectives which remain unverified by any professional news channel, editors or factcheckers (sommariva, vamos, mantzarlis, uyên-loan đào, & tyson, 2018) . thus, social media comes with its own limitations for misinformation in the form of rumours or fake news (zubiaga, liakata, procter, wong sak hoi, & tolmie, 2016) . moreover, once rumors begin to spread on social media, they are very difficult to control with updates or corrections (jones, thompson, dunkel schetter, & silver, 2017) . among these, health rumors which are unverified information regarding the practice of medicine and healthcare, often endanger public health (oh & lee, 2019) . hence, it is important to understand the role and impact of social media in spreading rumours and verify information before sharing it with others. research literature has found that social media has power in influencing people's behavior when there is an outbreak of epidemic or pandemic. over the decades, social media has been flooded with misinformation on diabetes, anorexia as well as anti-vaccination content along with the recent zika virus or ebola epidemic (fernández-luque & bau, 2015; sommariva et al., 2018) . the news of the ebola epidemic created a climate of global nervousness with rumours and misinformation quickly spreading through social media platforms. similar trend is being observed with current occurrence of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) which has been declared as a pandemic. studies have also documented that during crisis events, people often seek out event-related information to stay informed of what is happening. if there is lack of official information, people may be at risk for exposure to rumors that fill the information void (jones et al., 2017) . additionally, constant assault of information through social media also leads its users to easily consume available information irrespective of its authenticity. in this is the era of "headline stress disorder", a lot of negative feelings like anxiety, hopelessness, despair, and sadness is fueled by being regulated by the (sharma & seshadri, 2020) . similarly, suicide is another public mental health problem where media and social media play a significant role in either increasing or curtailing the problem within the society. the available literature in bangladesh and india suggests that media reporting about suicide includes information which offers details name of the victim, their occupation, method of suicide, images of suicide victims, suicide notes and citations form suicide notes. this is the information which works to make the news attractive and shares details which increase access to information for harming self and may also work to create misinformation or rumors (arafat, mali & akter, 2020; armstrong et al., 2018; jain and kumar, 2016) . however, the media does not highlight information to educate the general population about what are early signs of suicidal behaviors, prevention plans and expert opinions from mental health professionals, helpline numbers for support and availability of emergency services in hospitals. these findings further suggest that the reports in media on suicide do not follow the guidelines issued by the world health organization (who) and other health regulatory bodies on reporting of suicide in media (arafat, mali & akter, 2020; armstrong et al., 2018; cherian, lukose, rappaia et al., 2020; jain and kumar, 2016) . there are similar irregularities j o u r n a l p r e -p r o o f which indicate reporting of sensitive information about suicide in a detrimental manner in media in china as well (chu et al., 2018) . thus, in the light of the existing information, it becomes understandable that media in all its formats have a huge impact and more significantly has a role to report responsibly the information in an educative format which is related to health of the population. in addition, it needs to be more sensitive and responsible in reporting about public health problems like the sars-cov-2, and suicide where the focus is on offering information which is helpful for prevention, details the steps to take in times of the health emergency, offers expert opinions from mental health professionals, helpline numbers for support and emergency services in hospitals. this role of media will surely work to minimize the digital content which leads to creation of misinformation or rumors. to summarize, in addition to the responsible role of media in reporting about public health problems, the individual's members of the population, the government, policy makers, health regulatory bodies and health professionals need to collaborate and develop guidelines for responsible dissemination of information over all kinds of media formats with respect to public health problems. such guidelines will also work to improve the media based literacy about health and mental problems among the population and will be extremely helpful for use in times of public health emergencies like the sars-cov-2 pandemic. the development of such guidelines are crucial as the pattern of epidemics and pandemics changes over time, but the cycle of rumors or fake news or inaccurate media reports continues to revolve around media formats and especially in social media likely due to stress, anxiety and other psychological factors of individuals which requires to be studied in greater detail. is suicide reporting in bangla online news portals sensible? a year-round content analysis against world health organization guidelines assessing the quality of media reporting of suicide news in india against world health organization guidelines: a content analysis study of nine major newspapers in tamil nadu adolescent suicide in india: significance of public health prevention plan assessing the use of media reporting recommendations by the world health organization in suicide news published in the most influential media sources in china health and social media: perfect storm of information is suicide reporting in indian newspapers responsible? a study from rajasthan distress and rumor exposure on social media during a campus lockdown daria j . kuss and mark d . griffiths excessive online social networking : can adolescents become addicted to facebook ? education and health online social networking and addiction -a review of the psychological literature when do people verify and share health rumors on social media? the effects of message importance, health anxiety, and health literacy adolescence: contemporary issues in the clinic and beyond spreading the (fake) news: exploring health messages on social media and the implications for health professionals using a case study analysing how people orient to and spread rumours in social media by looking at conversational threads key: cord-322235-ttjja4r2 authors: kahambing, jan gresil s.; edilo, shienazile r. title: stigma, exclusion, and mental health during covid19: 2 cases from the philippines date: 2020-07-11 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102292 sha: doc_id: 322235 cord_uid: ttjja4r2 nan this is a pdf file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. this version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. amid the coronavirus disease 2019 pandemic, the world health organization (who) called for considerations that might include stigma and social exclusion as mental health and psychological concerns. the editor of the journal has thus justly linked the relevance of the crisis to psychiatry as it has effects on mental health (tandon, 2020) . psychiatry is vital in the crisis since it exposes psychosocial problems that, in the case of mental health, feed on the response of the people and society at large (tandon, 2020) . mackolil & mackolil (2020) then lists anxiety and stigma and their proliferation as contextual effects of misinformation, uncertainty, hesitation to 'disclose or seek help,' fear, and 'unawareness about [sic] health promoting strategies.' in the philippines, some provinces have a lesser number of covid cases due to quarantine measures and distance from the metropolises with a densely larger population. for the first five months (january to may), the province of southern leytepart of the eastern visayas region of central philippinesenjoyed zero positive cases. as of the 18 th of june, however, there are already 33 with 342 total cases in the region (department of health, region viii, 2020). but the following cases were before the announcement of those who got positive results. one of the crucial aspects that may stem from this is the fact that stigmatization and exclusion may not necessarily be tied to empirical evidence but only in the criterion of whether or not the cases fit the contextual 'shared belief.' there is informed consent from the case persons for the publication of the study. this is a young priest of the iglesia filipina independiente (philippine independent church) in padre burgos, southern leyte. he was objectively well and healthy and actively serving his church. but he was allegedly discriminated by his parishioners due to misconceptions. exploration of the history revealed that while driving home, he mentioned that he passed by a man he recognized and let him in the car since they were heading to the same destination. the man was said to be in contact with a suspected covid case and was therefore thought to be exposed. the news spread around their church that immediately caused ruckus and fear to their community. the people in their church discriminated him including his altar boys to the point that harsh words were hurled at them. almost everyone deliberately avoided them. the priest was very upset and hurt after learning this. this resulted in anxiety around his parishioners. he felt specially excluded and shied away because these people were no strangers to him. the manner of exclusion derails some of his relationships, even to his close friends. he was very worried that his case was not an ordinary incident of prejudice leading to stigma because he represents the church as its pastor and he provides service to those who need spiritual support. "how can i work efficiently if the people are getting rid of me?" he said. a conference held with his fellow clergy and their bishop days after the incident showed the pandemic's effect on him and their churches. his instance of discrimination became a tool for social exclusion and this sadly includes his fellow churchmen. this is a 25-year-old institutional worker of a privately owned hospital in sogod, southern leyte. he was discriminated by his workmates after learning that he suffered from flu-like symptoms. he was advised by the attending physician to self-isolate for 14 days at home as per the covid prevention protocol. luckily, it was just ordinary flu and he came back at work after the advised length of time. however, upon returning, his colleagues regarded him indifferently. some of his close friends at the hospital, for instance, advised him to just go home and leave. though in a form of jest, some said they would sign a petition to let him be suspended for several days. these kinds of remarks created psychological inputs for him since the jokes resemble a certain degree of seriousness and truth in them. additionally, the bantering that borders on bullying becomes physical when he was intentionally avoided by some. openness seemed to be blocked especially when he tries to start a conversation with them. due to the degrees of 'hostility' that he claims to have experienced when he got back to work, he developed resentment against his colleagues due to the incident. he was unable to work properly and was therefore unable to finish his job efficiently. this has caused many absences. with the drive to work and social interaction impeded, self-doubt, lowered self-esteem, and feelings of vulnerability from being excluded prevailed in his disposition. the impact of this situation has a certain traumatic element as this was for him the first time that he experienced such treatment. health care workers in the philippines often suffer from the abuse that comes from stigma (reuters, 2020) and this was shown even among themselves in the second case. in the first case, there is the denial of access to the benefits of the group, as the priest can no longer enjoy the j o u r n a l p r e -p r o o f company of his parishioners. this denial forms part of the negative effect on the health of those socially excluded (samers, 1998) . without comfort from contemporaries, the situation may not be effectively handled. having a good and empathetic support group and confidence in one's belief are potential factors for recovery. on the other hand, what the second case shows is a kind of disempowerment that is a negative result of stigma and exclusion (kai & crosland, 2001) . the disempowered perform less in their functions and lose motivation in the workplace, which can jeopardize the outcome of the workforce. emphatic interventions at home or providing safe places for openness with friends can help ease the effects of exclusion. good management support from hospitals must also assure employees that evidence-based results must prevail over false beliefs. moreover, both case persons were young. this has to be taken seriously since "mental health problems early in life can be associated with a trajectory of exclusion and disadvantage" for example through "reduced participation" or "exclusion from civil society" (evans-lacko et.al, 2014) . one critical problem in the philippines is not xenophobic as in multiracial societies but the misinformation or the hesitance to confer with verified information that provokes discrimination. the authors certify that they have each made a substantial contribution so as to qualify for authorship. none. j o u r n a l p r e -p r o o f the state of the art in european research on reducing social exclusion and stigma related to mental health: a systematic mapping of the literature lockdowns case of mass hysteria perspectives of people with enduring mental ill health from a community-based qualitative study addressing psychosocial problems associated with the covid-19 lockdown covid-19: philippines health care workers suffer abuse, stigma imigration, 'ethnic minorities', and 'social exclusion' in the european union: a critical perspective the covid-19 pandemic, personal reflections on editorial responsibility world health organization, 2020. world health organisation. mental health and psychosocial considerations during the covid-19 outbreak the authors would like to thank the case persons for their openness. jan kahambing would like to thank april cabezada and leo omamalin for their constant updates on the cases.j o u r n a l p r e -p r o o f none.. key: cord-301842-2jydfrf0 authors: grover, sandeep; chakrabarti, subho; sahoo, swapnajeet; mehra, aseem title: bridging the emergency psychiatry and telepsychiatry care: will covid-19 lead to evolution of another model? date: 2020-09-23 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102429 sha: doc_id: 301842 cord_uid: 2jydfrf0 nan telepsychiatry is understood, as a subset of telemedicine, which involve providing a range of services including psychiatric evaluations, therapy, patient education and medication management through telepsychiatry services (american psychiatric association, n.d.; chakrabarti, 2015) . according to american psychiatric association, the term telepsychiatry should be limited to video conferencing (american psychiatric association and the american telemedicine association, 2018). the ongoing covid-19 pandemic has brought the videoconferencing based telepsychiatry services to the forefront. the government of india (goi) notified the telemedicine guidelines on 25 th of march, 2020 (medical council of india and niti aayog, 2020). this provided a boost to the telepsychiatry services. according to the telemedicine guidelines, as issued by goi, telemedicine services should be avoided for emergency care, when alternative in-person care is available. emergency telemedicine consultation should be limited to first aid, life-saving measure, counseling and advice on referral (medical council of india and niti aayog, 2020). further, these guidelines state that in all emergency cases, the registered medical practitioner (rmp) should notify the emergency to the patient and advise an in-person interaction at the earliest. however, during the telepsychiatry consultation, the rmp is required to take adequate desired steps that could be life-saving. the rmp is also required to provide guidance and counseling. it is seen that, during the ongoing pandemic, there has been an upsurge of mental health issues (tandon, 2020a (tandon, , 2020b . however, due to lockdown various mental health services, such as inpatient, outpatient and other services have been reduced; there was an expansion of the telepsychiatry services, both in the institutional set-ups and the private practice set-up across the country (grover et al., 2020a; grover et al., 2020b) . in psychiatry, one of the major emergencies is the suicidal behaviour of the person. telemedicine guidelines have specifically not addressed this issue. hence, psychiatrists are not clear, as to how to handle such a situation, while providing telepsychiatry services and there are no clear-cut answers to the same. in general, it is suggested that, in case of emergency, the patient should be advice for in person consultation or should be advised to seek help at the local medical facility. keeping the issue of suicidality, having two phone numbers of the patients (one of which is of the relative of the patient, j o u r n a l p r e -p r o o f preferably staying with the patient) at the time of registering the patient, and ensuring that someone is present with the person while providing teleconsultation can help the psychiatrist in ensuring that the person is guided for the in-person consultation and first aid care is ensured. an important aspect of medical practice is supervising or guiding other colleagues in providing care to the patient. this can involve patient to been seen by a local physician, who shows the patient to a specialist (in this case psychiatrist) through video-teleconferencing, during which patient is also independently assessed by the specialist sitting at the remote place. the specialist is able to make his independent impression about the patient's problem, advises the physician to carry out the physical examination as per the requirement, and advises for investigations. the patient is retained at the local health care facility and the patient is again reviewed by the specialist with the available investigation findings and treatment plan is formulated, which is executed by the physician seeing the patient locally. this ensures care at the local health care facility without having the patient to travel to long distances. in the western countries, emergency telepsychiatry services have been growing steadily (reinhardt et al., 2019) . these services involve providing psychiatry services to various emergency set-ups through videoconferencing. for this, a psychiatrist at the remote location assesses the patient through videoconferencing, facilitated by the emergency physician. based on the assessment, the advice is made for pharmacotherapy, discharge and admission to an inpatient facility. the emergency telepsychiatry services are considered to be acceptable, feasible, possibly cost-effective, and leads to a reduction in waiting time in the emergency for the patient (reinhardt et al., 2019) . at our centre, which is a tertiary care hospital, psychiatry services are provided to all the emergency set-ups (medical, surgical, pediatrics, trauma) by the consultation-liaison psychiatry team. this is a 3-tier system, in which the patient is assessed by a trainee psychiatrist, who is present in the emergency setting (rather than being on call). this has ensured increase in overall referrals from various emergency physicians (grover et al., 2015) . once the emergency trainee resident assesses the patient, the patient is seen by a senior resident, who is a qualified psychiatrist, who carries out the further assessment. finally, the patient is seen/discussed with the consultant and final treatment plan is made and patient is managed in the emergency setting for duration varying from 2 hours to 72 hours, with occasional patient kept in emergency for longer duration. during the ongoing covid-19 pandemic, the routine outpatient services have been substituted with the telepsychiatry services. keeping the issue of suicidality in mind, we have tried to embed the emergency and telepsychiatry services (figure-1) . accordingly, if any patient seen at the telepsychiatry services requires an emergency care, patient and family are encouraged to attend the emergency services, where the team is already alerted about the patient's possible arrival. once the patient arrives at the emergency, patient is evaluated by the emergency team, appropriate management is carried out and then patient is attached back to the telepsychiatry services. on the other hand, when a patient directly comes to the emergency, patient is assessed by the emergency team, and the patient is attached with the telepsychiatry services for further follow-up. this system of combining both the services has ensured that patients, seen in the telepsychiatry services, can assess the emergency in-person consultation and those directly seen in emergency are being seen through the telepsychiatry services ensure continuity of care. however, it is important to note that this may not be feasible across the country, but similar models, needs to be developed, where the patient can be seen by a local physician to provide emergency psychiatry care, under the supervision of the psychiatrist. this also requires modification of the telemedicine guidelines to incorporate the tele-supervision. if this modification is done, in long run, this can lead to evolution of a telepsychiatry model, where the patients at the remote rural places can be managed by the specialists with the help of local physician, without having to travel for long distances. financial disclosure : we have no financial disclosure to make . the authors declare that they have no conflict of interest. american psychiatric association, n.d. what is telepsychiatry? american psychiatric association, the american telemedicine association usefulness of telepsychiatry: a critical evaluation of videoconferencingbased approaches state of mental health services in various training centers in india during the lockdown and covid-19 pandemic impact of covid-19 pandemic and lockdown on the state of mental health services in private sector in india consultation-liaison psychiatry services: difference in the patient profile while following different service models in the medical emergency telemedicine practice guidelines-enabling registered medical practitioners to provide healthcare using telemedicine use of telepsychiatry in emergency and crisis intervention: current evidence covid-19 and mental health: preserving humanity, maintaining sanity, and promoting health the covid-19 pandemic, personal reflections on editorial responsibility key: cord-334865-be6q5774 authors: das, nileswar title: psychiatrist in post-covid-19 era – are we prepared? date: 2020-04-07 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102082 sha: doc_id: 334865 cord_uid: be6q5774 • first communication from india with psychiatry residents perspective. • authors had first-hand experience of working in the covid designated areas. • highlights the need of the hour. at the time of writing this letter (end march 2020) the world is facing one of the most feared pandemic of all time named -covid-19, caused by a novel corona virus, sars-cov-2 (anon., 2020). although the disease started in december 2019 in china, but rapidly progressed to affect more than half a million people across 176 countries (till 27.03.2020) and these numbers are only expected to rise further. a time when world's best health-care facilities and global public-health researchers are in dare setback, it's worth raising the question that, are we prepared enough to handle the psychological ill-effect and psychiatric issues that are anticipated in post-pandemic periods? fear and anxiety are common psychological response during disastrous situations like this (dong and bouey, 2020) . but undue prolonged stress with social isolation can act as a table 1 niche for developing a pathological mental state (goyal et al., 2020) . while higher income countries already apprehending worse recession and socioeconomic setbacks, low-and-middle income countries like india is high likely to face the worse. many already proven social factors like: being sick, prolonged hospitalization, death of loved ones, loss of job, months of forced quarantine, lack of supply, stigma -is likely to hit us all, especially those who are more vulnerable to stress and already suffering from mental illness (mak et al., 2009; brooks et al., 2020) (table 1) . we are among few, in our institute, being involved since beginning in active management of covid-19 cases. we found, many patients in the designated isolation ward had reported -excessive fear, restlessness and sleep disturbances during hospital stay. many frontline healthcare workers had shown signs of anxiety and depression. therefore, we as psychiatrists need to take urgent action in finding and managing such issues. acute medical emergency may last many months and may be year (s) -and therefore until we have an effective preventive or curative treatment for covid-19, primary focus would continue to be manpower development and resource allocation for detection and management of active cases. however, at the same time we cannot ignore the psychological aftermath of this pandemic. three primary concerns to be addressed by fellow psychiatrists are: (1) generating evidence by well conducted studies, (2) generating awareness and psychological preparedness among common men and essential service providers, (3) delivering active psychological and psychiatric intervention to those in need. well-conducted studies are needed to assess, (i) the magnitude (i.e. spectrum and severity) of various psychological problems -aiding the policymaking process, (ii) the immediate and long term psychological consequences of such life-changing events in various subgroups of the population, and (iii) the response to various therapeutic interventions. we believe, use of digital media (telepsychiatry) for early and active search of individuals with psychological infirmity, and also as mode of delivering information and psychological interventions can be an effective tool to reduce the sufferings of all vulnerable individuals (liu et al., 2020) . later, integration of public mental health -delivering essential psychiatric and psychological services may become pivotal. humanity has faced worse during two previous world-wars but we cannot wait until we heal. psychiatrists have to be the flag-bearer of the best known medicine of all time -hope. the present study was non-funded. the authors do not have financial disclosures the authors do not have any conflicts of interest to report table 1 possible vulnerable groups, risk factors and psychological symptoms in the aftermath of pandemic. naming the coronavirus disease (covid-19) and the virus that causes it the psychological impact of quarantine and how to reduce it: rapid review of the evidence early release -public mental health crisis during covid-19 emerging infectious diseases journal -cdc 26 fear of covid 2019: first suicidal case in india! online mental health services in china during the covid-19 outbreak long-term psychiatric morbidities among sars survivors dr siddharth sarkar, assistant professor of psychiatry, aiims, new delhi -for his constant encouragement and constructive inputs. key: cord-346279-tk06xftj authors: ganesh, aurobind; sahu, prashant; nair, shruti; chand, prabhat title: a smartphone based e-consult in addiction medicine: an initiative in covid lockdown date: 2020-04-22 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102120 sha: doc_id: 346279 cord_uid: tk06xftj nan centre for addiction medicine, national institute of mental health and neurosciences bangalore, is a government-funded specialized treatment center with thrice a week outpatient, 80-bed inpatient facility and round the clock emergency services. in the wake of covid 19, a complete lockdown was announced by the indian government on 24th march 2020. the hospital was closed, except for emergency service. the lockdown suspended the sale of alcohol and tobacco products. many people with substance use disorder (sud) could not access care or continue the ongoing treatment like buprenorphine maintenance treatment, anti-craving drugs, and withdrawal management. a recent study has shown that in india, as just about one in 37 people affected by alcohol use disorders and one in 20 affected by drug use disorders have received any treatment, ever (ambekar et al., 2019) . nimhans digital academy, with the collaboration of project echo (extension of community healthcare outcome), has been involved in developing capacity for the management of sud by using telehealth technology. six thousand five hundred health care providers, i.e., doctors, nurses, counselors, have received substance use and mental health online-training under the above online program since 2014. some training is brief (up to a maximum of 8 h), whereas others are intense (up to 60 h) (mehrotra et al., 2018) . realizing the need during the lockdown, the centre of addiction medicine, nimhans initiated an e-consultation portal between these trained healthcare workers and addiction specialists. electronic consultation (e-consult) is an online hipaa compliant program that provides enhanced communication between primary care providers and specialists regarding treatment (vimalananda et al., 2015) . econsults are typically responded to in less than 24 h and, while providing prompt guidance and contingency planning, can also provide focused educational content (raney, 2017) . the trained health providers were informed about the same through emails and text messages. the mobile, responsive e-consult consisted of 13 questions (e-consult, 2020). it included a conditional logic, drag and drop, and a provision to upload of any previous prescription. the first half dozen questions were related to the information on health providers, including consent, and the next seven about the demographics of the patient, a summary of the case, and any specific query to the specialists. the specialists received real-time notification of the case submission in his/her mobile app. after reviewing the case, the recommendation, along with a focussed educational material, was reverted to the health provider with a secured email. the turn over time, between case submission and sharing recommendation, kept less than 4 h during day time and 8 h during night time. the health providers could make a call to the specialist in case of an emergency or vice versa. the specialist would call back or email if the case summary is not complete to suggest a recommendation. (fig. 1) as per analytics, 1880 have viewed the e-consult form in 2 weeks since lockdown. the vast majority accessed by using smartphones (92 %) with the conversion rate, i.e. viewing and filling up, is 4 %. the average time taken is 8 min to fill the form. total 102 health care providers across india, including 49 doctors, have filled up for consultation. any digital initiative needs regular updates and changes to keep it relevant. on 25th march 2020, the ministry of health and family welfare released the telemedicine guidelines in india (governors, 2020) . pursuing this, a consenting process was included in the e-consult. some of the providers would send minimal information about the case or skipping a few essential patient-related data. the mandatory word count was made to above 100 for elaborate details about the cases. at the same time, we are cognizant of the fact that more than 90 % were using a smartphone to enter the case summary and tried to maintain a balance. the number of submissions would increase with the periodic announcement about this facility. apart from sending focussed educational content, we compiled digital materials like guidelines on alcohol and tobacco management, counseling tips in the local language, and converted to a mobile responsive flipbook. during this period of lockdown, e-consult can be a promising approach as it offers rapid, direct, and documented communication between health care providers and specialists (vimalananda et al., 2015) . it is asynchronous and combines both consultative and educative components. hence it can suit a busy work schedule of the specialists (raney, 2017) . at this point, the telemedicine guideline (governors, 2020) does not allow a medical practitioner to prescribe narcotic and psychotropic drugs directly to the patient. hence e-consult, along with existing online mental health services, has the potential to enable costeffective and convenient care for patients in this covid crisis as well as the future (liu et al., 2020) . nothing to disclose. none. national survey on extent and pattern of substance use in india. ministry of social justice and empowerment, government of india and nddtc tobacco and other drugs telemedicine practice guidelines: enabling registered medical practitioners to provide healthcare using telemedicine new dehli online mental health services in china during the covid-19 outbreak effectiveness of nimhans echo blended tele-mentoring model on integrated mental health and addiction for counsellors in rural and underserved districts of chhattisgarh integrating primary care and behavioral health: the role of the psychiatrist in the collaborative care model electronic consultations (e-consults) to improve access to specialty care: a systematic review and narrative synthesis none. key: cord-341624-02bmonj6 authors: liem, andrian; sit, hao fong; arjadi, retha; patel, anushka r.; elhai, jon d.; hall, brian j. title: ethical standards for telemental health must be maintained during the covid-19 pandemic date: 2020-06-12 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102218 sha: doc_id: 341624 cord_uid: 02bmonj6 nan public health measures, including physical distancing during the covid-19 pandemic, necessitate telemental health, such as videoconferencing, to maintain continuity in clinical care for psychiatric outpatients. the use of technology in telemental health services is not only for curative purposes but also for assessment and monitoring as part of psychological first aid for the covid-19 pandemic. 1, 2 telemental health is also a strategy to close the global mental health treatment gap, especially within low-and middle-income countries. 1, 3, 4 despite increased interest in telemental health, the pandemic created a sudden switch from offline to online modalities challenging clinicians to rapidly adapt to meet patients' needs. for example, more than two-thirds of psychologists in a highincome country like the us have never conducted videoconferencing to deliver their therapeutic services. 5 this number is higher in low and middle-income countries in asia, for example, about 85% of clinicians in bangladesh have never provided telemental health services to their patients. 6 early career clinicians in iran provided digital support groups through chatting apps (e.g., whatsapp and telegram) and social media (i.e., facebook), and some of them did not use this digital remote support previously. 1 neophyte online clinicians might not be aware of possible ethical and privacy concerns related to technology use in their practice. 7, 8, 9 additionally, telemental health services may not be regulated yet in health law, particularly in asian countries. 10 there are five key ethical concerns clinicians need to be aware of before engaging in telemental health. 11 first is to ensure confidentiality due to the complexities inherent in online treatment. 9 for example, clinicians must ensure that their online communication has end-to-end encryption, to prevent access by a third party. one of the most widely used video conference providers was recently j o u r n a l p r e -p r o o f challenged on its stated privacy policy. 12 second, clinicians must have practical competence to deliver online interventions, including assisting patients when they face logistical issues. third, clinicians need to update their knowledge and comply with the newest regulations related to online interventions. for instance, clinicians in the us may use smartphones (in addition to desktop computers) in delivering their telehealth services during the covid-19 public health emergency. 7 also, the benefits for treatment should be weighed against the possibility that either clinicians or patients may not have adequate resources for conducting online interventions (i.e., a stable and secure internet connection). fourth, similar with in-person interventions, clinicians are obligated to seek informed consent prior to intervention, and review risks and benefits of treatment. this is even more critical for telemental health, given the privacy concerns already mentioned. fifth, clinicians must engage in contingency planning for emergency services (i.e., suicidal intent), first determining the patient's physical location pre-emptively beforehand, in case the application used in delivering the intervention malfunctions. a brief checklist covers these five ethical standards for telemental health is provided in table 1 and can complement the available mental health interventions during the covid-19 pandemic. 1, 2, 13 telemental health is promising for use during the covid-19 pandemic, including in asian countries. therefore, clinicians must maintain the highest ethical standards in order to deliver quality treatment that safeguards the welfare and best interests of their patients. professional organisations and educational institutions should also include training in telemental health in the future. we declare no competing interests. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. we declare no competing interests.  assure that any software / program that used in the session is end-to-end encrypted to protect the data. if end-to-end encrypted software / program is not available, clinicians must explain the risks of being hacked or privacy violation to patients.  assure no one else could listen the session (unless it is a part of the intervention and being agreed prior to the session, for instance, parent or legal guardian for the minors).*  parents or legal guardians of minors should grant privacy during online sessions.  adequate knowledge and competency in using the software, hardware, and network for providing online interventions, including problem solving skills on related-logistic issues that patients may experience.  consider patient's cognitive and clinical status as well as their comfort in using technology effectively and safely.  clinicians should be culturally sensitive, approaching patients with cultural humility, regardless the modality of intervention.  check and comply with regulations and policies related to reimbursement eligibility / procedure from insurance company / health care system for online interventions.*  check and comply with regulations and policies from the government (local and national level) and professional organisations related to online interventions.  inform and discuss the potential risks and benefits of online interventions and how it differs from in-person sessions with the patient.  if needed, discuss how the online session will be billed.  collect a signed consent from patient (or parent or legal guardian of minor). secure electronic signing platform (i.e., dochub) can be used if the patient cannot sign a hardcopy form.  obtain at least one emergency contact for the patient prior to the session in case the patient is in a crisis.  provide a phone number that can be reached by the patient in case any technical problems with the hardware, software, or internet connection arise.  prior to the session, find the closest health services with patient's location in case patient needs emergency response.  clinicians should discuss how the patient's physical environment, family composition, personal privacy, and living arrangements may impact their treatment engagement. clinicians should then collaboratively problem-solve for anticipated barriers (e.g., strategic use of the chat function on secure videoconferencing apps when family members may be in rooms). note. * = may also applied for patients. clinician should not rely on this table only and should seek more detail ethical standards from their government and professional organisation before providing telemental health services. mental health interventions during the covid-19 pandemic: a conceptual framework by early career psychiatrists remote consultations in the era of covid-19 pandemic: preliminary experience in a regional australian public acute mental health care setting internet-based behavioural activation with lay counsellor support versus online minimal psychoeducation without support for treatment of depression: a randomised controlled trial in indonesia psychiatrist in post-covid-19 era -are we prepared? survey of psychologists' telebehavioral health practices: technology use, ethical issues, and training needs a survey on the assessment of the present states and opportunities of telemedicine in bangladesh what the covid-19 telehealth waiver means for psychology practitioners how secure is mental health providers' electronic patient communication? an empirical investigation technology use in mental health practice and research: legal and ethical risks telemedicine practice guidelines: enabling registered medical practitioners to provide healthcare using telemedicine digital health applications in mental health care for immigrants and refugees: a rapid review zoom, the video conferencing app everyone is using, faces questions over privacy the covid-19 pandemic personal reflections on editorial responsibility. asian journal of psychiatry references: key: cord-326414-kq8gru3c authors: aryal, shreyashi; pant, sagun ballav title: maternal mental health in nepal and its prioritization during covid-19 pandemic: missing the obvious date: 2020-07-04 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102281 sha: doc_id: 326414 cord_uid: kq8gru3c nan this is a pdf file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. this version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. dear sir, covid-19 pandemic has taken a toll on all health services and reproductive health has also been bearing its brunt. there should be no divided opinion that psychiatry is related to covid-19 and more so in asian countries due to their political and economic vulnerabilities (tandon, 2020) . under-prioritization of womens' psychiatric issue at these times would be missing the obvious. nepal has a high maternal mortality ratio of 239 deaths per 100,000 live births (ndhs, 2016), due to which safe motherhood, contraception and abortion have always been a priority despite having an impoverished health system. on the other hand, mental health issues of women which j o u r n a l p r e -p r o o f is also burgeoning but under-acclaimed problem, is under-researched and grossly overlooked (regmi et al., 2015) . reproductive health and mental health are interwoven and a complete well being cannot be obtained without their integration. the first witnessed covid related death in nepal was a young woman in her postpartum period and this has paramountly increased the stress that millions of pregnant women are currently facing. mental health in pregnancy and puerperium is not addressed to the extent of its necessity and this pandemic has increased the ever present gap in maternal mental health issues. nepal has just above 57% institutional deliveries and this pandemic may force women to go back screening for maternal mental health issues is a low priority in nepal and addressing this issue should be a priority now than ever before. when the focus is in covid positive cases, policies to detect early signs of mental illnesses which are increasing in non covid women also have to be formulated. culturally validated screening tools can be used for all antenatal care packages, and question on suicidality must be accessed. a liaison plan should be made with the involvement of mental health service providers to identify antenatal and postnatal psychiatric issues during hospital stay. video conferencing for antenatal care and tele-psychiatry can be a cost effective method for screening, evaluation and management of pregnancy in nepalese context, where there is scarcity of health professionals. but these may not always be feasible due to low literacy rate especially in rural areas. mobilization of female community health volunteers at the community level, to detect pregnancy at risk including mental illness can be continued while maintaining rules of physical distancing. obstetrics is one clinical subject where continuity of care is inevitable. pregnancy and labor cannot wait and along with this comes mental health care. this is the time when women need to exercise their reproductive rights more than ever before and obstetric service providers play a pivotal role in ascertaining that they are able to do so. we need to make sure that these women go through a pleasant birth experience through the integration of physical and mental health. the crisis may always remain, so living with it with essential precautions, innovations and improvisations is the only option. the covid-19 pandemic personal reflections on editorial responsibility psychiatric caseness and its obstetric correlates in pregnant population attending antenatal clinic in tuth potential maternal and infant outcomes from coronavirus 2019-ncov (sars-cov-2) infecting pregnant women: lessons from sars, mers, and other human coronavirus infections pregnant algeria doctor who was denied maternity leaves dies of coronavirus why are so many nepali women killing themselves? a review of key issues reproductive health issues and depression in wives of labor migrant workers from the frontline of covid-19 -how prepared are we as obstetricians: a commentary a new covid-19 crisis: domestic abuse rises worldwide. the new york times key: cord-300064-t3qexner authors: kumar, krishan; mehra, aseem; sahoo, swapnajeet; nehra, ritu; grover, sandeep title: the psychological impact of covid-19 pandemic and lockdown on the migrant workers: a cross-sectional survey date: 2020-06-20 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102252 sha: doc_id: 300064 cord_uid: t3qexner nan covid-19 pandemic and the resultant lockdown strategy has affected everyone (tandon, 2020) . however, the impact has been more prominent on the lives of the migrant workers/laborers. lockdown brought the lives of migrant workers to a standstill, as neither have they had any work to do, nor were they able to travel back to their native places. this is compounded by the fact that some of them are not able to meet their daily requirements due to financial constraints. the very basic social distancing strategy could not be ensured in this population as they mostly reside in densely polluted communities and rooms with minimal space per person. the migrants are more prone to social, psychological, and emotional trauma in such situations, emanating from fear of neglect by the local community and concerns about their families' wellbeing and safety in their native places. migrants belong to the most marginalized sections of the society who are dependent on daily wages for their living, and in times of such distress, need sympathy and understanding of the community (hargreaves et al., 2019) . immediate concerns the migrant workers face relate to food, shelter, health care, fear of getting infected or spreading the infection, loss of wages, concerns about the family, anxiety, and fear (singh, 2020) . sometimes, they also face harassment and adverse reactions to the local community. governments of india and state governments have been making efforts to address migrant laborers' issues by keeping them at shelter homes and providing them food. however, how much this is helping the migrants is not very well understood. every day there are media reports of migrant workers travelling to their native places far off from their current location by walking or by cycling. many have succumbed to death after reaching their destination or during their journey ("indian migrant workers during the covid-19 pandemic," 2020; staff, 2020) . there are also reports of a tussle between the different governmental agencies, concerning making j o u r n a l p r e -p r o o f these migrants reach their native places. all these factors are leading to severe mental distress among migrant workers. accordingly, it is essential to understand the psychological issues of this marginalized group of people. accordingly, this study aims to evaluate the mental health issues among the migrant workers living in shelter houses, provided by the administration because of covid-19 to assess the immediate and long term psychological impact of isolation. it was a cross-sectional study conducted in the chandigarh, a union territory, in north india. the migrants' workers identified by the government of india, who were living in the shelter house or government authorized buildings, were recruited. the verbal informed consent was obtained before recruitment. to be included in the study, the participants were required to be aged>18 years, of any gender, able to understand hindi, were co-operative, medically stable, and provided the written informed consent. the ethical clearance was obtained from the institute ethics committee. the data collection was done during the 5 th week of lockdown with adherence to social distancing norms and other infection control measures. they were assessed on the following instruments. we used two brief screening instruments i.e. patient health questionnaire-2 (phq-2) (kroenke et al., 2003) and generalized anxiety disorder-2 (gad-2) (skapinakis, 2007) to assess depression and anxiety respectively. both these scales have been used previously in many studies with adequate sensitivity to screen depression and anxiety (hughes et al., 2018; whooley et al., 1997) .perceived stress scale-4 (pss-4) was used to assess perceived stress which has been reported to be the most useful and feasible in the situations where a short questionnaire is required such as telephonic interview (lee, 2012) . all the participants were administered these questionnaires by a trained clinical psychologist. the data collected were analyzed using spss 20.0 version, and descriptive statistics were applied. the study included 98 laborers, all of whom were of males, with a mean age of 32.7 (sd: 10.1) years and the mean a number of years of education being 2.4 (sd: 1.7) years. the mean income of the participants before the lockdown was 8280 indian rupees. majority of the participants were married (69.4%). about three fourth of the participants (73.5%) were found to be screen positive for depression on the phq-2 and about half of the participant (50%) were found to be screen positive for anxiety on the gad-2 (table-2 ). on pss-4, the mean score on the pss was 7.1 (2.3). about one-fifth of the participants screened positive for depression only. nearly half (49.9%) of participants screened positive for both anxiety and depression. overall, about three-fourth (73.5%) screened positive for at least one psychiatric morbidity (table-1) . in india, migrant laborers form a significant workforce in many parts of the country. many of these people work on daily wages or a fixed salary, with no job security. possible only recreation for these people is going back to their homes, whenever they are free from their work responsibility (singh, 2020) . they often stay away from their homes for a considerable time (maybe several months or even years) and visit their native place only during festivals, marriages, or during harvest season. covid-19 pandemic has brought them to a situation, where j o u r n a l p r e -p r o o f neither they have any work, nor are they able to travel to their native places. accordingly, it is expected that the emergent situation will lead to a lot of stress and distress among the migrant laborers. keeping this in mind, the present study, aimed to evaluate the mental health status of the migrants who have been kept in the shelter homes, after the imposition of lockdown, due to covid-19 pandemic. the present study suggests that about three-fourth (73.5%) of the participants screened positive for either depression or anxiety. all the migrants who screened positive for anxiety also screened positive for depression, suggesting high co-morbidity. additionally, about one-fifth of the participants screened positive for only depression. additionally, on the self-designed questionnaire, a significant proportion of participants reported a marked increase in negative emotions and feelings such as loneliness, tension, frustration, low mood, irritability, fear, fear of death, and social isolation. these findings suggest that the lockdown and the ongoing pandemic have a significant negative impact on the mental health of the migrant laborers. although the present study was based on use of screening instruments like phq-2 and gad-2, but when we compare the findings of the present study with that reported in national mental health survey (nmhs) (murthy, 2017) , which reported a community prevalence of mental morbidity to be 10.6% for depression and anxiety, it can be said that screen positivity in the present study of about 7 times that of nmhs, suggests that there is definite worsening of the mental health status of the migrant labourers. further, the findings are twice that seen in an online survey of the general population, done during this lockdown period (grover et al., 2020) . if we compare to the findings of the online survey done during the lockdown period, another important fact, which is evident from this study, is that a higher proportion of the participants screened positive for depression, rather than the anxiety. these differences possibly suggest different psychological reactions of people j o u r n a l p r e -p r o o f belonging to different socioeconomic strata. the online survey perhaps included people of middle and higher income who probably had a higher level of anxiety, which could be related to the ongoing pandemic per se. in contrast, in the present study, a significantly higher proportion of participants had both depression and anxiety. a higher prevalence of depression possibly suggests a difference in the kind of stress for people of different socioeconomic strata, even when they are faced with the same pandemic and the lockdown. this high-level negative impact on the mental health of migrant laborers can be understood from a different perspective. first, they have lost their livelihood, which leads to significant financial insecurity and stress about the future. second, the high level of psychological distress could also be due to worries related to the health of self and significant others back home. the third reason could be because they are alone and possibly will not be able to support their family soon. these findings suggest that besides providing the logistic help such as food and shelter, the migrant laborers need to be screened in detail for the mental morbidity. further, there is a need to develop a plan to provide them with psychological aid. this can be done, both at the individual level and by carrying out group-level interventions. the present study has certain limitations. the present study was based on the use of brief screening instruments which although have low reliability and validity and the results needs to be interpreted keeping this fact in mind. however, we have used these scales so as to ease out the interview process and assessment in short time during the pandemic situation (to keep a short interview time).the use of a more detailed questionnaire and better scales with adequate validity/reliability could have yielded better information. the assessment was cross-sectional, and the specific ongoing stressors, coping mechanisms, etc. were not evaluated. future studies j o u r n a l p r e -p r o o f must attempt to overcome these limitations. the other confounding factors, including a history of depression, substance use, or physical illness, were not taken. to conclude, the present study suggests that the current covid-19 pandemic is causing severe anxiety and depressive symptoms in migrants' workers. therefore, it is equally important to focus on the mental health issues of this vulnerable population. these people's mental health needs must be made an urgent public health priority because social isolation or living in a shelter house can have a significant impact on their mental health. financial disclosure : we have no financial disclosure to make . a global measure of perceived stress psychological impact of lockdown 'as covid-19 social distancing strategy': an online survey from india occupational health outcomes among international migrant workers: a systematic review and meta-analysis diagnostic and clinical utility of the gad-2 for screening anxiety symptoms in individuals with multiple sclerosis indian migrant workers during the covid-19 pandemic the patient health questionnaire-2: validity of a two-item depression screener review of the psychometric evidence of the perceived stress scale national mental health survey of india 2015-2016 mental health of migrant laborers in covid-19 pandemic and lockdown: challenges ahead the 2-item generalized anxiety disorder scale had high sensitivity and specificity for detecting gad in primary care covid-19: at least 22 migrants die while trying to get home during lockdown [www document the covid-19 pandemic, personal reflections on editorial responsibility case-finding instruments for depression the authors declare that they have no conflict of interest. we thank all the migrant population who had taken part in this study. key: cord-344197-whwyy9kq authors: menon, vikas; yasir arafat, s.m.; akter, hasina; mukherjee, srijeeta; kar, sujita kumar; padhy, susanta kumar title: cross-country comparison of media reporting of celebrity suicide in the immediate week: a pilot study date: 2020-07-10 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102302 sha: doc_id: 344197 cord_uid: whwyy9kq nan this is a pdf file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. this version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. a growing body of evidence suggests that media reporting of suicide in south-east asia is imbalanced and poorly adherent to suicide reporting recommendations (arafat et al., 2020b (arafat et al., , 2020a ; this is despite substantial evidence indicating a clear link between explicit media portrayals of suicides and the probability of copycat suicidal behaviour among vulnerable individuals (pirkis et al., 2006) . media reporting of celebrity suicide is a phenomenon worthy of investigation due to its potential to trigger suicide contagion; these assertions are supported by studies which found nearly a 10% increase in suicides in the two months that followed the suicide of robin williams, a popular and acclaimed american entertainment celebrity (fink et al., 2018) . to our knowledge, no published evidence exists on quality of media reporting of celebrity suicide in world health organization south-east asian (who-sea) region. to fill this gap in the evidence, we carried out the present research to assess and compare the quality of media reporting of celebrity suicide against who suicide reporting guidelines in india and bangladesh; two neighbouring countries that share similar culture and appetite for bollywood movies. to enhance comparability, we chose only media reports in bangla; the predominant language spoken in bangladesh as well as in the neighbouring state of west bengal in india. the reference event was the suicide of sushant singh rajput (ssr), a popular mainstream bollywood actor, who committed suicide on june 14, 2020. bangladeshi bangla newspapers and television channels, to identify news articles that reported the celebrity suicide between june 14, 2020 to june 21, 2020. news articles where the focus was on reporting information related to the celebrity suicide such as interviews of prominent personalities, condolence messages and expert opinions were excluded. next, the investigators performed a content analysis of the included news reports and coded all items using an online data collection proforma, which was prepared using the who media suicide reporting recommendations checklist, and has been used in earlier studies (menon et al., 2020) . simple descriptive statistics (frequency and percentages) were used to depict data. cross-country comparisons were done using fisher's exact test. because we only examined j o u r n a l p r e -p r o o f information in the public domain, no approval from an ethics committee was sought for this work. a total of 21 bangla news reports were found; 10 from india and 11 from bangladesh. the overall analysis revealed more similarities than differences and the overall quality of media suicide reporting in both the countries was sub-optimal and imbalanced. on the one hand, reporting breaches in relation to mentioning the identification details of the decedent such as name and occupation, and mentioning the suicide method were found commonly; while on the other hand, there was very little focus on educating people about suicide while covering the event in both countries. a few statistically significant differences in reporting were noted between the countries; gender of deceased and link with life events were more commonly reported in indian bangla media while inclusion of photograph, tantamount to sensationalizing the report, was more common in bangladeshi bangla news reports (table 1) . these differences could be partly explained by increased access of indian media to personal information such as life events of the deceased, who is an indian celebrity, while, bangladeshi media may have felt the need to include the victim's photographs to 'compensate' for lack of information. our findings are limited by the small sample and inclusion of only regional language media reports. bias arising from single investigators coding the data was sought to be addressed by however, as prior researchers have pointed out (vijayakumar, 2019) , merely framing guidelines may not help; they need to be embedded in a larger strategy that will most likely involve novel and collaborative approaches, involving media and health professionals, to adequately sensitize media professionals and bring sustainable changes in the quality of media reporting. we hope that this report spurs action in this regard. the authors declare no conflicts of interest relevant to the contents of the manuscript. financial disclosures: there are no financial disclosures or sources of support for the present work. quality of media reporting of suicidal behaviors in south-east asia quality of online news reporting of suicidal behavior in bangladesh against world health organization guidelines media and suicide prevention in southeast asia: challenges and directions increase in suicides the months after the death of robin williams in the us do tamil newspapers educate the public about suicide? content analysis from a high suicide union territory in india media guidelines on the reporting of suicide guidelines adopted by the pci on mental illness/reporting of suicide cases media matters in suicide -indian guidelines on suicide reporting preventing suicide: a resource for media professionals key: cord-333701-zefd3yw5 authors: fang, min; hu, sydney x.; hall, brian j. title: a mental health workforce crisis in china: a pre-existing treatment gap coping with the covid-19 pandemic challanges date: 2020-06-25 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102265 sha: doc_id: 333701 cord_uid: zefd3yw5 nan on 17th apr 2020, the chinese national bureau of statistics released news that china's economy shrank 6.8% in the first quarter of 2020 compared to the previous year. this signals that thee road toward recovery will likely be long. risks to mental health come not only from the covid-19 pandemic (rajkumar, 2020) , but also the consequences of the economic downturn. unemployment and lost income can be expected among marganizalized and disadvantaged such as the migrant workers (liem, wang, wariyanti, laktin, & hall, 2020) . rural citizens are another significant group of vulnerable people. they have already lost income for months, in addition to losses to their initial agricultural investment, since roads were blocked causing no access to buy feed for their livestock. these groups of people are likely to encounter high level of psychological burden, as they may have less savings, let alone protection against financial catastrophe. loss of employment and financial stressors are wellrecognised risk factors for suicide (nordt, warnke & seifritz et al, 2015) . as the vicious circle of pychological distress and income inequality continues, online counseling services for people affected by the covid-19 crisis will be needed (dan, 2020) , but they may be far from sufficient (liem, sit, arjadi, patel, elhai, hall, 2020) . on top of the large pre-existing treatment gap, china might face a mental health workforce crisis. since 2010, the chinese government began to prioritize mental health infrastructure development due to a high burden of mental disorders and gap in available services. a recent prevelance estimate of mental disorders in china was 16.6% (huang, wang, wang, et al., 2019) . several steps were taken. firstly, the annual budget for all psychiatric hospitals rose from 301.324 million yuan (44.58 million usd) in 2009 to 1271.502million yuan(184.276 million usd) in 2018 with an annual growth rate of 20%. secondly, china invested a large amount of funding to improve the basic construction and facilities of psychiatric hospitals. for example, since 2009, the central government has directly invested 10.59 billion yuan (usd 1.57 billion), and the civil affairs department invested 2.8 billion yuan(usd 0.41 billion) aiming to build new or expand existing hospitals to achieve full coverage of mental health services in each prefecture-level city. consequently, from 2009 to 2018, the total number of psychiatric beds in china increased rapidly from 191,225 to 506,637, with an annual increase of 11.75% and 35.3 beds per 100,000 people, which is above the world average (who, 2018) . the number of psychiatrists increased from 18,842 in 2009 to 36,610 in 2018, at an annual rate of 7.63%; however,the number of hospital beds per psychiatrist only increased from 10.1 in 2009 to 13.8 in 2018. the workforce gap continues to grow, and investment into the mental health workforce has yet to catch up. below are some of the major reasons. 1. currently, there are about 2, 200 new psychiatrists each year. however, less than half of this group receive formal psychiatric training; they receive only short-term psychiatric training before "transitioning" to psychiatric service work. there are 53,825 primary health care institutions in china, but few have access to psychiatrists. other types of professionals such as psychologists, social workers, and occupational therapists have not increased. china has roughly 5,000 clinical psychologists, compared to the united states, which has roughly 200,000 psychologists, for a population of one-quarter in size. also, only a small number of economically welldeveloped areas in china have social workers serving mental health patients. underlying this lack of mental health resources in primary care might be the predominance of a biomedical model of health. 2. the public funding mechanism is hospital-based. currently, the allocation of funding is based on the number of beds and the number of psychiatrists. under the double stimulus of fee for services payment and inadequate budget for hospitals, which only accounted for 23% of the total hospital revenue, most psychiatric hospitals have strong incentives to provide inpatient services for profit. in fact, in 2018, 97% of psychiatric services were provided in hospitals. 3. effective monitoring and evaluation of the performance of mental health services have not been established. currently, the most important performance indicators are the overall cure rate and improvement rate of psychiatric inpatient care. these indicators ignore a large number of community patients who were discharged or those who are not yet screened and diagnosed. internationally, a range of comprehensive indicators are used to measure service performance, for example, suicide-related indicators during and after hospitalization, as well as mortality rates of patients with schizophrenia and bipolar disorder (oecd, 2017) . china has made progress mostly in the medical care of severe mental disorders in hospitals. common mental health conditions, including depression and anxiety, especially remain unaddressed. in china, like in most developing countries in the world, less than 20% of people with mental disorders sought advice or treatments (gbd, 2016) . low perceived need for treatment, lack of available treatments, and stigma are among barriers to care (shi, shen, wang, hall, 2020) . at the same time, few health professionals like nurses, social workers, and even doctors specialized in psychiatry, would like to specialize in mental health, partly due to lower status relative to other specialties (chen, conwell, cerulli , et al., 2018) and fear of medical violence (xiong, hu & hall, 2016; hall, xiong, chang , et al, 2018) . to reduce the burden of population' mental health caused by covid-19 and other disasters and emergencies, a large expansion of well-trained mental health providers is urgently needed. financial disclosure: none declarations of interest: none. primary care physicians' perceived barriers on the management of depression in china primary care settings china adopts non-contact free consultation to help the public cope with the psychological pressure caused by new coronavirus pneumonia asian journal of psychiatry global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the global burden of disease study prevalence of medical workplace violence and the shortage of secondary and tertiary interventions among healthcare workers in china prevalence of mental disorders in china: a cross-sectional epidemiological study the neglected health of international migrant workers in the covid-19 epidemic ethical standards for telemental health must be maintained during the covid-19 pandemic covid-19 and mental health: a review of the existing literature barriers to professional mental health help-seeking among chinese adults: a systematic review the covid-19 pandemic, personal reflections on editorial responsibility mental health atlas 2017. world health organization violence against nurses in china undermines task shifting implementation the work described has not been published previously and is not under consideration for publication elsewhere. the publication is approved by all authors and tacitly or explicitly by the responsible authorities where the work was carried out, and that, if accepted, it will not be published elsewhere in the same form, in english or in any other language, including electronically without the written consent of the copyright-holder. to verify originality, the article may be checked by any originality detection service.j o u r n a l p r e -p r o o f key: cord-337816-ivj1imsk authors: patel, vikram title: empowering global mental health in the time of covid19 date: 2020-05-20 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102160 sha: doc_id: 337816 cord_uid: ivj1imsk nan i could hardly have imagined that mental health would have become such a commonly sought after topic in a world gripped by the fear of a marauding virus. never before have i seen so many webinars, so many pundits, and so many listeners on this topic. but then, we live in times where so much of what we took for granted has been thrown under the bus. who could have imagined even just a few months ago that much of the world would be looking down the barrel of an economic recession unlike any witnessed in our lifetime? but let me be clear about one thing: mental health has become a key concern globally not because of any direct impact of the virus, but as a consequence of the reaction of the media and governments to the epidemic. just the word 'pandemic' and the dramatic way it was announced by the who after weeks of the epidemic unfolding around the world was a hairraising moment. then, there was the apocalyptic messaging by modellers about the millions of dead bodies that would be littering our cities and by the media on the risk the disease posed-for example failing to communicate that the median age of death was in the mid-70s; emerging data demonstrating the vast number of asymptomatic individuals suggests the overall mortality rate is well below 1%, falling to nearly zero in young people. the ghoulish reporting of cases, without any nuancing about what those numbers actually mean, served to confirm in people's minds that the virus was inexorably sweeping the world. the final nail in the coffin were the unprecedented national lockdowns, nowhere as brutal, unplanned and sweeping as the one in india, announced with just four hours' notice late in the evening, with a scope and stringency that has never been seen in history. in this context, unless you are an epidemiologist who is well-informed to correctly interpret the numbers and read between the lines, the wide-spread reactions of panic and fear are totally understandable. indeed, if one considers the constant uncertainty about when, if ever, life will return to a semblance of what we used to experience, the torrent of mixed messages about the science (real or fake) around the virus, and the complete lack of consensus on what the post-lockdown scenario for the containment of the virus might look like, i think it might even be somewhat unexpected for an individual to report being in great mental health in these times! it is not at all surprising that experiences of anxiety, fearfulness, sleep problems, irritability and feelings of hopelessness have become widespread. they are mostly rational responses of our minds to the extraordinary realities that we are facing. that said, if the curve of the severity of mental health symptoms (apologies to those who are fed up of seeing the word 'curve') has shifted to the right, i.e. towards greater severity, one will also be seeing a rising incidence of clinically significant mental health problems and suicide, as was observed in a previous coronavirus epidemic in hong kong (cheung, chau, & yip, 2008) . furthermore, thanks to lockdowns and the pivoting of health care services to this one virus, there is emerging evidence that routine mental health care has been seriously disrupted affecting not just incident illness episodes but also the continuing care of preexisting mental health problems. certainly, a rise in the burden of clinically significant mental health problems is what we should expect as the impact of the economic recession, the widening of inequalities in countries, the continuing uncertainties about future waves of the epidemic and the physical distancing policies begin to bite deeper into our mental health. this would not be surprising, given the strong association between unemployment, acute poverty and indebtedness with poor mental health (lund et al., 2018) . "deaths of despair" have been documented as the cause for the increased mortality and reduction in life expectancy in working-age americans following the economic recession in 2008 (case & deaton, 2020) . tracing the source of these deaths ultimately to a deeply unfair economic system, the authors point out that these deaths were not so much due to material hardship but because of loss of hope due to the lack of employment and rising inequality. suicide and substance use related mortality accounted for most of these deaths. many low and middle income countries share the ills of us society, from its profound inequality to its weak social security net and fragmented health care systems; in addition, these countries are also home to the largest number of poor people in the world, already enfeebled by hunger and myriad diseases of poverty. this toxic combination of absolute poverty with rising levels of inequality is a recipe for a similar surge of depths of despair in the region. mental health care systems in most countries will be illequipped to deal with this surge, not only because of the paucity of skilled providers, but also because of the narrow biomedical models which dominate mental health care. while there has been a flourishing of initiatives to address the rising tide of mental health problems, most notably through telemedicine platforms, these suffer from the same barriers that have so limited the coverage of mental health care in the past: most rely on specialist providers who are very scarce in number. this is compounded by yet another barrier: digital literacy and adequate internet connectivity still remains a distant goal for large swathes of the world's people, particularly amongst the poor and rural populations. still, one welcome aspect of this development is the recognition of the possibility of remote delivery and the value of psychological therapies, often ignored in mental health care and, at best, playing a poor cousin to medication options. at the same time, low-resource settings have been a laboratory for some of the most transformative innovations to improve access to evidence based psychological therapies in psychiatry with a flurry of randomized controlled trials for depression, psychoses and harmful drinking reframing the way we can enhance the coverage of these interventions. this critically important clinical and implementation science is now influencing global policies and, incredibly, also the way mental health care is organized in rich countries which enjoy so much more mental health resources. the impressive body of evidence generated by global mental health researchers has generated a range of innovative strategies aimed at addressing the structural barriers to the scaling up of psychosocial therapies, notably the demonstration that pared down 'elements' of complex psychological treatments packages can be just as effective as standardized treatment protocols (for e.g. behavioural activation for depression, compared with cognitive behaviour treatments); that providers can be trained to learn a library of such 'elements' targeting specific types of mental health experiences (for example, mood problems, anxiety problems, trauma related problems) and to use simple decision making algorithms to 'match' patients' problems with specific treatments elements; that one does not require a formal diagnosis to trigger care, greatly simplifying the dissemination of effective treatments; that these pared down treatments elements and trans-diagnostic protocols can be effectively delivered by non-specialist "therapists", such as community health workers; that these delivery models are highly acceptable to consumers; show recovery rates comparable to specialist care models, and economic analyses show they are excellent value for money (kohrt et al., 2018; singla et al., 2017) . more recent innovations seeking to scale up these approaches demonstrate the acceptability and effectiveness of digital training in the delivery j o u r n a l p r e -p r o o f of psychological treatments and of peer supervision for quality assurance (muke et al., 2019; singla et al., 2014) . this range of innovations, when combined and scaled up, can transform access to one of the most effective interventions in medicine. this is exactly the goal of the empower program, an initiative of harvard medical school (https://globalhealth.harvard.edu/empower-building-mental-health-workforce) which is seeking to scale up evidence based psychological therapies, with an initial implementation focus on communities in the usa and india. over the coming years, we intend to build on the ongoing work of the essence program, a nimh funded research hub, led by sangath in partnership with the government of madhya pradesh, to digitize the curriculum of a brief behavioural activation treatment for depression (patel et al., 2017) , its competency assessments and the supervision and quality assurance protocols. ultimately, this platform will offer a career path which enables front-line providers an opportunity to achieve the status of an expert, motivating them and ensuring sustainability of the most expensive mental health professional resource. future enhancements include evaluating the effectiveness of the scaling up on population mental health and harnessing big data opportunities to develop prediction models to refine treatment element selection algorithms to optimize patient outcomes. the use of digital platforms for building the workforce is not only aligned with the use of tele-medicine but also with the urgent need for digital approaches for training and supervision in the light of physical distancing policies. but, of course, implementers will need significant resources to realize these kinds of ambitious projects and here we need to anticipate the biggest threat to mental health consequent to covid19: the pushing back, once again, of mental health from the global health agenda. i recall this happening way back in the late 1990s when it appeared that mental health would finally be recognized as a priority by the world's leading development agencies only for it to be left off the table by the millenium development goals of 2000. fifteen years later, mental health found its rightful place in the sustainable development goals and i could begin to sense its inclusion in the priorities of funders who had previously given it a pass. and now we are in the first half of 2020 and all funding and health care action has entirely pivoted towards one disease-covid19. already some of the funding i had come close to securing for empower has been stalled. and some of it may never be realized. it is deeply worrying that despite the strong mental health concerns in the light of the pandemic, there seems to be no meaningful role played by mental health professionals in guiding public policies on the epidemic. once again, mental health risks are being shoved back into the shadows. this is a timely moment for diverse stakeholders concerned with mental health, from psychiatric associations and global mental health practitioners to civil society advocates, to unite with one message, that the pandemic and its socio-economic consequences will have profound effects on population mental health and that some of the financial resources being pumped into the covid19 response must be allocated to 'build back better' mental health care systems in all countries. j o u r n a l p r e -p r o o f deaths of despair and the future of capitalism a revisit on older adults suicides and severe acute respiratory syndrome (sars) epidemic in hong kong the role of communities in mental health care in low-and middle-income countries: a meta-review of components and competencies social determinants of mental disorders and the sustainable development goals: a systematic review of reviews acceptability and feasibility of digital technology for training community health workers to deliver brief psychological treatment for depression in rural india the healthy activity program (hap), a lay counsellor-delivered brief psychological treatment for severe depression, in primary care in india: a randomised controlled trial psychological treatments for the world: lessons from low-and middle-income countries improving the scalability of psychological treatments in developing countries: an evaluation of peer-led therapy quality assessment in goa, india 