Mental health vis-a-vis Covid-19 in lower-income and middle-income

countries with a special emphasis on India: Challenges and Policy strategy

to overcome

I. Introduction:
The nation has already witnessed two devasting waves of deadly COVID-19 and, its third wave
seems to be in the near future after the upsurging of cases of new variants called ‘Omicron’.
The pandemic has caused huge disruption throughout the world and created a global panic.
Lakhs of people have lost to their loved ones. Many people have recovered from it but due to
the high cost of expenses on medical facilities, their situation has become worst. None of the
aspects of life is being unaffected by it whether it is economy, employment or education.

The pandemic has caused a significant impact on the psychological and mental well-being of
people. The psychological impacts of the pandemic are best understood in terms of pre-
epidemic psychiatric and psychological issues, as well as the pathoplastic effects of the
pandemic on these issues; responses to social isolation and lockdown; and the psychological
response to the diagnosis.

The first death due to COVID-19 in India has taken place in March 2020. After this, fear and a
sense of clear and imminent danger were the first and predominant responses to this outbreak.
Fears have ranged from well-founded concerns to unfounded concerns based on
information/misinformation circulating in the media, particularly on social media. The
avalanche of information from global and local sources affects every one of us differently. This
can result in people becoming "worried well," developing distressing psychological symptoms
and maladaptive stress coping strategies, and eventually developing a mental condition. Fears
of contracting the illness are also common, with people misinterpreting any fever or cough as a
COVID-19 infection, requesting a test for comfort despite tight testing criteria, and hoarding
drugs despite no indications for their widespread usage.

There was a distressing situation all around. The brutality of this evil pandemic can be drawn
from the fact that the deceased was not getting a place in the moratorium and if somehow, they
were taken there, it was not their kith and kin to perform the last rites and other various rituality
related to a different religion. What could be horrific than this? All these incidents have a
significant and thoughtful effect on the life of people and their mental well-being.
 A. Literature Review:
For this research paper, the researcher has gone through various pieces of literature. This
includes various reports, articles and journal.
B. Statement of Problem:
This is harsh reality that we often neglect mental health of an individual which is pre-requisite
for a healthy life. The International Covenants on Economic, Social and Cultural Rights
(ICESCR) also recognizes “the right of everyone to the enjoyment of the highest standard of
physical and mental health.” The disruption that has been caused by the COVID-19 is
gruesome. Depression and anxiety symptoms have elevated sharply in general population, even
among people who had no prior mental health diagnoses. Work and social functioning
impairments caused by the pandemic were closely attributed to greater depression and anxiety
symptoms, as well as decreased psychological well-being. Financial hardship caused by the
pandemic, rather than job loss, was also a significant interpreter of poor mental health. Hence,
this paper will cover all these issues of mental health widely and will suggest some measures to
tackle this issue.
C. Research hypothesis:
1. Though mental health is very much recognised in various international treaty and
jurisprudence there is very little emphasis on it in lower-income and Middle-income
nation.
2. Issue of mental health is often neglected and there is not any policy to look upon the issue
of mental health.
D. Research Methodology:
The Research methodology adopted throughout the study is mainly doctrinal. The research
method adopted throughout the study can be broadly categorized as analytical and descriptive
research.
E. Research Objective:
1. To analyse the impact of COVID-19 on the mental health of general population.
2. To suggest some policy and strategy to overcome of it.
F. Research Question:
1. How COVID-19 has impacted mental health of people in lower-income and middle-
income countries?
2. What are policy and strategy to overcome of it and to give a good life to people in
the lower-income and middle-income nation?
 II. The impacts of the COVID-19 pandemic on mental health in lower-
income and middle-income countries
The majority of world’s population lives in lower-income and middle-income countries
(hereinafter refer as LMICs). They have received slightly or no resources to cope up with mental
health.1 The disastrous impact of COVID-19 has aggravated the suffering of people in LMICs.
Medical comorbidities such as diabetes or heart disease, 2 which are major risk factors for COVID-
19 mortality, are becoming more widespread in LMICs, particularly among those with lower
educational levels.3 It is possible that the long-term effects on mental health will be particularly
severe in the world's poorest and least resourced places, where mental health facilities were almost
non-existent prior to the pandemic.
 Immediate impact:
Emerging reports on the mental health effects of the COVID-19 pandemic have mostly revealed
an increase in symptoms of mental health distress, which could be a normal response to the
unprecedented uncertainty and difficulty faced by populations. For example, studies have shown
an increase in the prevalence of psychological distress among health-care workers, which can be
linked with stigma and anxiety associated with diseases. 4 Actions aimed at preventing the spread
of COVID-19 like lockdown and keeping the person in isolation, which many governments in
LMICs are taking, increase these distressing experiences.
These policies and actions have had unprecedented impacts on the economic and social sectors in
nations where the vast majority of people work in the informal economy and where risks to their
livelihood have already sparked public outrage and, in some cases, violence too. For instance, use
of force by law enforcement and the authorities has been reported in several countries. 5 There have
been instances of violence, arrests, and kidnappings of journalists and activists who were
recording shady government policies, corruption, and incompetence in response to COVID-19.

1
Liese BH, Gribble RSF, Wickremsinhe MN. International funding for mental health: a review of the last
decade. Int Health 2019; 11: 361–69.
2
Jordan RE, Adab P, Cheng KK. COVID-19: risk factors for severe disease and death. BMJ 2020; 368: m1198.
3
Rosengren A, Smyth A, Rangarajan S, et al. Socioeconomic status and risk of cardiovascular disease in 20
low-income, middleincome, and high-income countries: the Prospective Urban Rural Epidemiologic (PURE)
study. Lancet Glob Health 2019; 7: e748–60.
4
Vigo D, Thornicroft G, Gureje O. The differential outcomes of coronavirus disease 2019 in low- and middle-
income countries vs high-income countries. JAMA Psychiatry 2020; 77: 1207–08.
5
Vigo D, Thornicroft G, Gureje O. The differential outcomes of coronavirus disease 2019 in low- and middle-
income countries vs high-income countries. JAMA Psychiatry 2020; 77: 1207–08.
The pandemic is also highlighting the fact that certain vulnerable groups, such as prisoners,
patients in psychiatric hospitals or social care homes, people with disabilities, and women
experiencing domestic violence or abuse, may be at even greater risk of psychological distress as a
result of pre-existing human rights violations, complicating other COVID-19-related mental health
consequences.6
Systemic social inequities across demographic (e.g., age, ethnicity, caste, religion, gender),
economic (e.g., income, assets, unemployment), neighbourhood (e.g., housing structure or
overcrowding), and sociocultural (e.g., social support, social capital, education) characteristics can
be seen as threats to mental health in the pandemic. 7 For example, we've seen the struggles of
migrant workers separated from their families thousands of kilometres away. Unprecedented
lockdown measures had placed them in a vulnerable position, with many of them unable to
support even their most basic needs. Similarly, sex workers are struggling to support their
livelihood and their problem get worse since, prostitution is not legalized in India and therefore,
they even were not entitled to get benefits of various scheme of government. The elderly is among
the most vulnerable to the consequences of the COVID-19 pandemic, both in terms of illness
severity and mortality. They're also more prone to have mental health issues. Isolation has
negative implications, which are aggravated by comorbid physical and medical disorders, as well
as a lack of access to care.8 Furthermore, lockdowns and the redirection of all health-care services
to COVID-19 control and care damage those with major mental illnesses, who have had difficulty
accessing mental health care during the epidemic. 9 Therefore, different section of people has
experienced its threat in a different manner but what is common to all that pandemic has led them
to suffer mentally.
 Long-term impacts:
The impact that COVID-19 has caused would have long term effects globally. Anxiety, mood, and
trauma and stress-related illnesses are among the mental health diseases most vulnerable to
unfavourable socioeconomic determinants, and they are already leading contributors to disability
worldwide, according to the Global Burden of Disease research. 10 Increased exposure to known

6
Rajkumar RP. COVID-19 and mental health: a review of the existing literature. Asian J Psychiatr 2020; 52:
102066.
7
Vigo D, Thornicroft G, Gureje O. The differential outcomes of coronavirus disease 2019 in low- and middle-
income countries vs high-income countries. JAMA Psychiatry 2020; 77: 1207–08.
8
Reger MA, Stanley IH, Joiner TE. Suicide mortality and coronavirus disease 2019—a perfect storm? JAMA
Psychiatry 2020; 77: 1093.
9
Castro-de-Araujo LFS, Machado DB. Impacto do COVID-19 na saúde mental em um país de baixa e média
renda. Cien Saude Colet 2020; 25: 2457–60.
10
Whiteford H, Ferrari A, Degenhardt L. Global Burden of Disease studies: implications for mental and
substance use disorders. Health Aff (Millwood) 2016; 35: 1114–20.
risk factors such as economic stress, job insecurity and unemployment, social isolation, decreased
access to community support, barriers to mental health treatment, and exacerbated physical health
problems, especially among older adults, are laying the groundwork for a potential worldwide
suicide increase as a result of the pandemic. 11 According to a model that combines data from a
variety of countries, including both HICs and LMICs, employment losses due to COVID-19 could
result in up to 9570 more suicides every year globally.12
Following the pandemic in the United States, time-trend regression models predicted 3235
extra suicides over two years attributable to the economic downturn (3.3% increase per year) if
the unemployment increase is moderated, and 8164 extra suicides over two years (8.4%
increase per year) if the increase is extreme. 13 However, no such models exist for countries like
India but it can be predicted that suicide rates could increase markedly in these countries. A
review of Indian media on COVID-19 and suicide supports this notion. 14 Due to the inherent
stigma, as well as other cultural or religious reasons, suicides are frequently under-reported or
classified as different causes of death in many LMICs.15 As a result, in the months and years
ahead, it will be critical to ensure transparent and rigorous reporting and monitoring of suicides,
not only to fully assess the pandemic's effects, but also to identify whether there are regional
differences in suicide rates and develop responses to mitigate these risk factors.
Long-term school closures are expected to have a significant impact on the mental health of
children, adolescents, and young people around the world.16 Aside from the important academic
benefits of schooling, schools play an important role in shaping young people's mental
wellbeing by providing a structured and supervised space for socioemotional development,
friendship and social support networks, protection from risk-taking behaviours and exploitative
labour, deferral of early marriage and childbearing, and gatekeeper services to detect and
intervene early to prevent child abuse. Furthermore, in LMICs like India children get midday
meal in the school.17 This is an essential source of nutrition among poor children and also help
11
Bao Y, Sun Y, Meng S, Shi J, Lu L. 2019-nCoV epidemic: address mental health care to empower society.
Lancet 2020; 395: e37–38.
12
Kawohl W, Nordt C. COVID-19, unemployment, and suicide. Lancet Psychiatry 2020; 7: 389–90.
13
McIntyre RS, Lee Y. Preventing suicide in the context of the COVID-19 pandemic. World Psychiatry 2020;
19: 250–51.
14
Balaji M, Patel V. Hunger, fear and isolation: an analysis of media reports of COVID-19 related suicides in
India. Research Square 2020; published online Oct 30. https://doi.org/10.21203/rs.3.rs-99851/v1 (preprint).
15
Hagaman AK, Maharjan U, Kohrt BA. Suicide surveillance and health systems in Nepal: a qualitative and
social network analysis. Int J Ment Health Syst 2016; 10: 46.
16
oseph SJ, Bhandari SS, Ranjitkar S, Dutta S. School closures and mental health concerns for children and
adolescents during the covid-19 pandemic. Psychiatr Danub 2020; 32: 309–10.
17
Wang D, Fawzi WW. Impacts of school feeding on educational and health outcomes of school-age children
and adolescents in low- and middle-income countries: protocol for a systematic review and meta-analysis. Syst
Rev 2020; 9: 55.
 in cognitive development but due to closure of school, they have been denied its access.
Therefore, School closure in response to the pandemic may have the unintended consequence
of increasing child food insecurity, which has a poor impact on mental health.

III. The response to mental health needs:

For a variety of reasons, there is limited evidence on the impact of mental health programmes
to date: The COVID-19 pandemic is still spreading in many countries, most programmes are
being deployed in the midst of a real-world public health disaster with little resources for
evaluation, and there hasn't been enough time since the outbreak to conduct and publish
comprehensive evaluations. As a result, the goal of this part is to emphasise the diversity and
inventiveness of the programmes that have been launched. The willingness and competence of
governments in LMICs to construct COVID-19 mental health strategies is a noteworthy
observation in and of itself. Similarly, the ability to create and administer a variety of
programmes addressing population-level and individual clinical needs teaches us about
implementation, even if most of these initiatives have yet to be shown beneficial. Going
forward, it will be critical to assess implementation processes and outcomes, not least to inform
the mental health resilience to future health care, such as the extent to which the shift in care
delivery from in-person to remote adequately addresses individual clinical needs or the extent
to which low-cost positive psychology approaches adequately address population mental health
needs.
 Population initiative:
Since the outbreak, there has been an increase in attempts to provide international advice,
national policies, and resources for LMICs to address mental health and psychosocial support
(MHPSS) needs. The Inter-Agency Standing Committee, which coordinates humanitarian
responses, provided one of the first briefing papers with MHPSS recommendations for COVID-
19 in February 2020.18 The brief included strategies for dealing with certain demographics, such
as the elderly, children, front-line workers, and persons under quarantine, as well as advice on
overcoming stigma. The International Federation of Red Cross and Red Crescent Societies
(IFRC) recommended for widespread use of psychological first aid, including remote delivery to
people in quarantine, health workers, and populations with previous vulnerabilities (e.g., mental

18
Inter-Agency Standing Committee. Interim briefing note addressing mental health and psychosocial aspects of
COVID-19 outbreak (developed by the IASC’s Reference Group on Mental Health and Psychosocial Support).
https://interagencystandingcommittee.org/iasc-reference-group-mental-health-and-psychosocial-support-
emergency-settings/interim-briefing-note-addressing-mental-health-and-psychosocial-aspects-covid-19-
outbreak. (Accessed December 24, 2021).
and substance use disorders).19 During the COVID-19 pandemic, the Mental Health Innovation
Network and WHO launched Stories from the field: delivering mental health and psychosocial
support to communicate MHPSS innovation and best practise through personal experiences from
health-care workers all around the world.20
 Detection and care:
Various employees of the health-care system, from community health workers to mental health
experts, have been trained to help detect people suffering from mental illness or psychological
distress in many nations. People in need of care have been identified and referred through phone-
based programmes in Kerala, India.21 However, continuous in-person mental health care have
been disrupted in most LMIC contexts, and individuals with serious mental illness and substance
use disorders are frequently unable to get prescriptions, attend treatment centres, or receive
social services. People with severe mental illnesses and intellectual disabilities, as well as people
with a variety of other disabilities, are disproportionately prone to be in institutions, which are
frequently unsafe in terms of SARS-CoV-2 risk. Hospitals and drug and alcohol services in
several regions of India have been swamped by significant influxes of patients experiencing
substance use withdrawal as a result of the lockdown, with many countries halting alcohol sales
during the lockdown.22
Face-to-face services have been preserved in areas of some LMICs, demonstrating significant
variation in the mental health-care system's response. For example, “Opioid drug replacement
therapy has been effectively adopted in Punjab, India. 23 Furthermore, many LMIC governments,
health-care providers, and other institutions have adapted to the challenges posed by physical
distancing, disrupted public transportation, and lockdowns by shifting to remote services, which
range from suicide and mental health helplines to voice-only phone-based services to video
services over smartphones or other digital devices. However, not everyone has equal access to
these therapies. All of these services are unavailable in settings that restrict phone, energy, or
WiFi access. People with disabilities who are exposed to other social determinants of mental ill

19
International Federation of Red Cross and Red Crescent Societies. COVID-19 response update.
IFRC Go - COVID-19 Response Update #3 (Accessed on December 24, 2021).
20
Mental Health Information Network, WHO. Stories from the field: providing mental health and psychosocial
support during the COVID-19 pandemic. https://www.mhinnovation.net/stories-field-providing-mental-health-
and-psychosocial-support-during-covid-19-pandemic. (Accessed on December 24, 2021).
21
Narayanan D. Is Kerala’s well-managed COVID-19 fight threatening to unravel? July 5, 2020.
https://economictimes.indiatimes.com/news/politics-and-nation/is-keralas-well-managed-covid-19-fight-
threatening-to-unravel/articleshow/76788706.cms. (Accessed on December 24, 2021).
22
Nadkarni A, Kapoor A, Pathare S. COVID-19 and forced alcohol abstinence in India: the dilemmas around
ethics and rights. Int J Law Psychiatry 2020; 71: 101579.
23
Directorate of Information Public Relations. OOAT clinics and all de-addiction centres to provide take-home
dose for 2 weeks to registered patients: Balbir Singh Sidhu. March 29, 2020.
 health as well as COVID-19 frequently face practical difficulties to receiving help, and many of
the solutions available are inaccessible to those with sensory impairments. 24 Mental health
services for children and adolescents that would have been provided by school counsellors or
student health services have been disrupted as a result of school and university closures.25

IV. Reimagining the principles of global mental health:

The COVID-19 pandemic has shattered many previously held beliefs about how societies are
organised, as well as the relationship between governments and their citizens and between
nations; however, it also provides an opportunity to rethink old assumptions and re-evaluate
global mental health priorities and approaches. I propose that global mental health can and must
do more to address the mental health concerns posed by COVID-19 on a global scale. These
efforts will entail hastening the change away from the treatment gap concept, which implies a
biological focus, and toward a broader care gap approach, increasing acknowledgment of civil
society's and local leadership's critical contributions, as well as efforts outside of the health
sector, to improve the environments in which people grow up, live, and work. Work, as well as
age, are more conducive to mental wellness. To achieve this goal, we need to identify critical
opportunities.

V. Mental Health Rehabilitation in times of COVID-19:

The consequences of the Covid19 pandemic have been felt all around the world. Several 'non-
essential' services have been temporarily closed due to social distancing and lockdowns. During
the pandemic, rehabilitation was declared a non-essential service, and many rehabilitation
facilities, with the exception of residential centres, were shut down. Therefore, it become very
much important to rehabilitate the victim of mental health trauma. This section details the policy
measures to support the people and in ensuring a good mental health.
Mental rehabilitation is a method of gradually assisting people with psychiatric disabilities
(PwPD) in achieving their intended life goals. PwPD can benefit from rehabilitation in terms of
activity planning, gainful engagement, sociability, skills training, self-confidence building,
symptom stability, and reaching desired life objectives. To minimize the suffering of people and
to rehabilitate them, following actions should be taken:

24
Armitage R, Nellums LB. The COVID-19 response must be disability inclusive. Lancet Public Health 2020; 5:
e257.
25
oseph SJ, Bhandari SS, Ranjitkar S, Dutta S. School closures and mental health concerns for children and
adolescents during the covid-19 pandemic. Psychiatr Danub 2020; 32: 309–10.
 To integrate mental health service into UHC:
An effort should be made collectively to recognize issue of mental health in the same way as
other physical disability has been recognised. The particular focus for investment should and
must be collaborative care methods for increasing community capacity, based on primary care
setup for community care and linkages with specialist providers. 26 The government should
make policy to ensure that victims of mental health are able to take rehabilitation measures and
financial status is not acting as a blockade. It is critical to prevent financial hardship and
catastrophic health-care costs when seeking mental health treatment.
 Improving access and coverage of psychosocial interventions:
The community delivery of psychosocial treatment by front-line caregivers such as community
health workers and peers is a critical part of UHC for mental health care. These professionals
are needed to address COVID-19-related mental health issues and to implement a variety of
innovations, such as digital training and competency assessment, peer supervision, and
quantifiable quality metrics, in order to help build a workforce that can close prevention and
treatment gaps.
 Incorporating technological innovations in mental health services:
The COVID-19 pandemic has spurred a profound transformation in the integration of electronic
platforms for numerous mental health-care operations. The capabilities provided by digital
technology could help to combat stigma, discrimination, isolation, and marginalization, as well
as detect persons at risk (via social media footprints) and assist with front-line worker training
and supervision. Therefore, effort should be made to boost the technological advancement and
incorporating new technologies. However, it is equally important to ensure than no one should
be denied to access it and disparities in accessing of these technologies should be lessened.
 Eliminating coercion in mental health care:
The Convention on the Rights of Persons with Disabilities has established the underlying
values of a society in which coercion must be removed in all parts of health care and for all
individuals, and it has devised a number of ways to aid rather than replace decision-making.
Peer support activities have been linked to better treatment outcomes and the advancement of
human rights. Therefore, it is important to ensure that a better treatment should be given to
people having mental illness.

26
Kohrt BA, Bhardwaj A. Training and supervision. In: Stein DJ, Bass JK, Hofmann SG, eds. Global mental
health and psychotherapy: adapting psychotherapy for low- and middle-income countries. London: Elsevier,
2019: 47–65.
VI. Conclusion:
The pandemic will have a long-lasting impact on our life. It has evolved as a global
phenomenon which has impacted each and every section of society in a multiple way. These
effects will contribute to huge human misery, premature mortality, and social breakdown, as
well as slowing economic recovery, unless they are handled vigorously and immediately.
Therefore, there is a need to follow a robust measure and laid some important measures in
mitigation its evil effect in the lower-income and middle-income countries. Among all these,
the issue of mental health occupies an important space. We all are aware of the poor health
infrastructure and little investment on the matter concerning mental health which leads to
devasting effects. Therefore, it become very important that an effort should be made to
recognize the issue of mental health. There is need to bring changes in people’s perception
towards mental health. It should not be taken as a stigma. Also, special measures should be
taken for those who are already marginalized and neglected. As a result, I advocate for a
balanced approach that takes into account both the socioeconomic determinants of mental
health and the particular clinical requirements of patients with mental illnesses.