WELCOME

• Ministry of Health, Global Fund, Zambia Medical

Association

• COVID-19 TOT for Health Care Workers

• Meeting dates: 6th-8th February 2022

 Schedule Day 1
• Registration • Module 4: Diagnosis and differential
• Welcome Remark and introductions diagnosis of COVID-19 disease( radiogical)
• Official Opening • Module 5: COVID 19 and Mental health part
• Meeting Objectives and Schedule of II
Activities • Module 6: Therapeutics for COVID19
• Module 1 : COVID 19 and Mental health • Module 7: Triage and Hospitalisation
part I • Module 8: Introduction to Psychological first
• Module 2: Overview of COVID 19 aid
Virology & Trasnsmission –strains and
variants
• Module 3: Clinical Presentation and disease
classification
 Dr. Naeem DALAL; BScHB, MBChB, MMED
Psychiatry: University Teaching Hospitals.
Presentation Outline

• Introduction – COVID-19 Mental Health

• Case Series – Clinical Practice: Lusaka, Zambia
• The Impact of COVID-19 – On mental, neurological and
substance use services. Results of a rapid assessment
• Best Practices – Case for Investment in Mental Health

Safeguarding Africa’s Health | www.africacdc.org

 Session Objectives

• To discuss the mental health impact of • Mitigating stigma associated with

COVID-19 on individuals, families and COVID-19
community
• Caring for individuals in isolation • Psychological care of health
and quarantine workers involved in COVID-19
Global Health: COVID-19

Imagine if mental illness was infectious

 Lessons from COVID-19

We are as strong as our weakest link!

 Physical
Mental Health
Health
 • When you travel to low resource
settings and different communities
all over the world, including Zambia
• Mental health issues are rising
• This is why organisations such as the
WHO emphasise the NEED for MH to
Mental Health Physical Health
be incorporated in Primary Health
Care
 Mental disorders
Global burden of disease.
14 %

Why Mental Health?

2ND - 3RD leading cause
Suicide of death
15 – 29 years
among youth.

Impractical,
Ineffective, and
Resource-intensive to succeed in
lower resource regions.
Of global burden of mental health in low-
and middle-income countries.
75%
 Mental Health Literacy and Services

Brain Health Emotional

Biomarkers. Intelligence
Medical training.

Youth Mental
Health

Culture and Available

Service Coach influencers
Beliefs resources
mapping Train and empower
Stigma Community influencers, various
focused professional background
primary health to be trained.
care.
 Case 1: Reflection

• I have been unwell for 1 week, my chest has been feeling tight and I
have been having difficulties breathing, I have no flu, fever or cough
• I have been tested twice for COVID-19: first -when my wife was
positive, then after 14 days of quarantine both times my test was
negative
• I had decided to take HCQ and azithromycin as I had same
symptoms as my wife(as above) and completed a 5-day course but I
still I feel like I can’t breathe nicely
• I’m 30 years old, No HTN, DM or family history of heart disease I also
exercise regularly
 Case 2: History
• M, 41 hx of recent international travel
• Contact with known Covid-19 patient on a PMHx: RVD-r newly dx, 18 days, HTN^0, DM^0,
plane
C/O – nil
• Asymptomatic since admission to the
isolation centre 28 days ago
• By day 18 , patient was expressing the
belief that his SARS-COV2 was negative
and was only being kept for financial gain
• Kept telling staff he wanted to go home
and was often uncooperative towards
them
• Additionally started refusing treatment
• Mood: reports to be feeling ‘okay’.
Identified as having psychosocial stressors
• Sleep: Had difficulties maintaining sleep
(Average 7 hrs)
ROS, SGhx, FMhx, unremarkable
ASTHMA^0
DHx TLD, IPT
SHx Smoking ^0, alcohol^+ve
Examination:
O/E GC stable, Not in RD, P^0, J^0, C^0, Afebrile to
touch.
Vitals BP 139/89, p=89, SPO2= 96% on room air
Mental State:
Appearance and behaviour: Anxious and irritable
behaviour
Speech and Thought: Normal.
Mood and affect: Euthymic
Perception: No hallucinations
Systemic Examination : CVS , Chest, P/A,
unremarkable
Questions

1. Would you label case 2 as a difficult patient?

2. Why do you think he was refusing treatment?
3. What would your next step be in managing this patient?
Impact of COVID-19 in Individuals, Families and Community

• Biopsychosocial model of health

and illness.
• COVID-19 = Stress
• Acute and chronic stress directly
affects brain health
• Disrupts neuroplasticity which may
predispose to mental health
disorders
 Populations of interest, vulnerable groups : 1
Exposure to
Substance misuse, • Physical and learning
Changes and
• School closures
Gambling, difficulties
disruption to support
Domestic violence, • Neurodevelopmental
and routines, isolation,
Child disorders
and loneliness.
maltreatment,
Change and
Disruption of Children,
children behaviour. Young
people, Disabilities
families.
Moral injury,
Disruption of Relapse, disruptions to
services, isolation, the
Health-care People with
normal supportive
structures, existing possible exacerbation
loneliness, workers health of symptoms in
Work stress, and issues • NCD including Mental
response to pandemic-
• Fears of contamination
Retention issues,
• health related information and
Long working
physical fatigue.hours • CD behaviour

Emily A Holmes et el, Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science , April 15, 2020 https://doi.org/10.1016/ S2215-0366(20)30168-1 Lancet
Psychiatry 2020 Kang L., Li Y., Hu S., Chen M., Yang C., Yang B.X., Wang Y., Hu J., Lai J., Ma X., Chen J., Guan L., Wang G., Ma H., Liu Z. The mental health of medical workers in Wuhan,
Naeem Dalal, MD
China dealing with the 2019 novel coronavirus. Lancet Psychiatry. 2020;7(3):e14. NCD: Non Communicable Disease, CD Communicable Diseases
 Populations of interest, vulnerable groups : 1
• Socially excluded groups Face job and financial
• Low income, daily wage
insecurity, cramped
earners
Require a housing, and poor
tailored access to up to date
response information.
Prisoners, Low socio-
homeless,
sex workers economic
… class
Negatively affected
by increased health
Isolation,
Older
adults Social inequalities,
loneliness, - Increased food
Multimor Cohesion
end of life bidities bank
• Urban versus use,
Rural
care, and
• Generational
bereavement Divide inequalitiesincreased race-
based attacks, and
• communitarianism
other trauma

Emily A Holmes et el, Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science , April 15, 2020 Naeem Dalal, MD
https://doi.org/10.1016/ S2215-0366(20)30168-1 Lancet Psychiatry 2020
What does this mean for Mental Health?
 Projects Health Footprint of Pandemic

https://twitter.com/VectorSting
 • Many of the anticipated consequences of quarantine and associated social and
physical distancing measures are themselves key risk factors for mental health issues.
• These include:

Suicide and Self Harm

Anxiety, Maslow's hierarchy of

Mood, needs

Depressio
n,
PTSD
Naeem Dalal, MD

- O’Connor RC, Nock MK. The psychology of suicidal behaviour. Lancet Psychiatry 2014; 1: 73–85.
- 22 John A, Glendenning AC, Marchant A, et al. Self-harm, suicidal behaviours, and cyberbullying in children and young people: systematic review. J Med
Internet Res 2018; 20: e129.
- 23 Turecki G, Brent DA, Gunnell D, et al. Suicide and suicide risk. Nat Rev Dis Primers 2019; 5: 74.
 Mitigating Stigma Associated with COVID-19
• Achieving the right balance between infection control
and mitigation of negative socioeconomic effects is
needed.
• Communication and information dissemination is
required for mitigation of stigma.
• Answering frequently asked questions in the vast
infodemic to help curb stereotypes and myths
associated with COVID 19 tailored to communities.
• Including strategies to help individuals to stay
informed by authoritative sources, prevent
overexposure to media, and mitigate and help
manage the effect of viewing images with traumatic
content.

Maslow’s Hierarchy of Needs

 Psychological Care of Health Workers Involved in COVID-10
• Preparedness and trainings
• Adequate PPEs
• Information and communication, key
stakeholders in the fight
• Motivation (incentives)
• Personalised psychological approaches are
likely to be a key component to address moral
injury, coping mechanisms, and prevention.
The ASK!
Resilience patterns • Association between shifts and well-being
Confidentiality (mood, sleep, appetite)
Debriefing on cases • Research on mitigating the effect of caring for
Vulnerability circles COVID 19 on mental health and stress
response is required.

Ravi Philip Rajkumar, COVID-19 and mental health: A review of the existing literature, ASIAN JOURNAL PSYCHIATRY, 10.1016/j.ajp.2020.102066, PMCID: PMC7151415 Elsevier Naeem Dalal, MD
 The impact of COVID-19 on mental,
neurological and substance use services

Results of a rapid assessment

This report of a survey completed by 130 countries

during the period June-August 2020 provides
information about the extent of disruption to
mental, neurological and substance use services
due to COVID-19, the types of services that have
been disrupted, and how countries are adapting to
overcome these challenges.

https://www.who.int/publications/i/item/978924012455
The impact of COVID-19 on mental, neurological and substance use services: results of a rapid
assessment. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO.

© World Health Organization 2020

Response plans.
COVID 19 sensitizations training of health care
workers on incorporation of MHPSS in COVID-
19 sensitization.
Multisectorial approach
Socioeconomic determinants of health

Gap in inclusion of Mental Health in

63% Gap
COVID-19 response.

© World Health Organization 2020

© World Health Organization 2020
Countries have responded to the disruption of
MNS services in multiple ways

© World Health Organization 2020

Best Practices

© World Health Organization 2020

Case 2: Next Steps?

• Application of Psychological First Aid: Active/Empathetic listening.

• Grounding technique applied. (Breathing and relaxation.)

• 3 days later:
‘Difficult' patient has been very cooperative, after the grounding exercises.
• Overall irritability and anxiety improved.
• Still anxious about going home, but much better mentally.
 There are Direct & Indirect Consequences of
COVID-19 on Mental Health and Wellbeing
Development,
Incomes
Loss of
exacerbation and
and
livelihoods breadwinners relapse of a range of
Bereavement
MNS
Economic
Scarcity
of
disorders
Pandemics Fear of
turmoil resources
Infodemic infection and
re-infection

COVID-19 Pandemic
Delirium/
Confinement encephalopathy,
COVID-19 itself is
agitation, stroke,
associated with
insomnia, loss of
Isolation neurological and
sense of taste and Working
mental complications from home School
smell, anxiety, disruptions
depression
Engaging
in Restricted
addictive interactions
Suicide
behaviours
risk

10
 Mental Health Complications

• Nearly 1 in 5 Develop Mental Illness Following

COVID-19: One in five COVID-19 patients are diagnosed with a psychiatric
disorder such as anxiety or depression within 3 months of testing positive for the virus
• Coronasomnia: Pervasive Sleeplessness, Self-
medicating Raise Concerns: The loss of sleep may be the most
widespread
• COVID-19 Symptoms Persist Months After Acute
Infection: Patients with COVID-19 had symptoms of fatigue or muscle weakness,
sleep difficulties, and anxiety or depression
 Mental Health Complications

• Reviews report on general mental

health or symptoms or diagnoses - Psychological distress,
of mental health problems, - Emotional exhaustion,
including - Alcohol intake and substance
- Anxiety, abuse,
- Depression, - Adjustment disorder,
- PTSD, - Grief, and
- Acute stress disorder, - Eating disorders.
- Burn-out,
- Sleep problems or insomnia,
Uphoff EP, Lombardo C, Johnston G, Weeks L, Rodgers M, Dawson S, et al. (2021) Mental health among healthcare workers and other vulnerable groups during the COVID-19 pandemic and other coronavirus
outbreaks: A rapid systematic review. PLoS ONE 16(8): e0254821. https://doi.org/10.1371/journal.pone.0254821

COVID-19 SARE
INSTITUTE
 Mental Health Complications

• Reviews report on general mental

health or symptoms or diagnoses - Psychological distress,
of mental health problems, - Emotional exhaustion,
including - Alcohol intake and substance
- Anxiety, abuse,
- Depression, - Adjustment disorder,
- PTSD, - Grief, and
- Acute stress disorder, - Eating disorders.
- Burn-out,
- Sleep problems or insomnia,
Uphoff EP, Lombardo C, Johnston G, Weeks L, Rodgers M, Dawson S, et al. (2021) Mental health among healthcare workers and other vulnerable groups during the COVID-19 pandemic and other coronavirus
outbreaks: A rapid systematic review. PLoS ONE 16(8): e0254821. https://doi.org/10.1371/journal.pone.0254821

COVID-19 SARE
INSTITUTE
PFA and COVID-19

• PFA appropriate intervention

•To overcome stigma and to promote better

emotional well being among staff who were
struggling with the increased workload.

•Peer‐to‐peer concept

• Training of community health workers and

community health volunteers on PFA.

• Enable access to psychological support for

those in distress during the pandemic
particularly at the grassroots level.
 Principles of Psychological First Aid
PFA Action Principles

LOOK LISTEN LINK

Naeem Dalal, MD

- Observe safety. -Approach people who may need support. - Help people address basic needs and access services.
- Observe for people with obvious urgent basic -Ask about people’s needs and concerns. - Help people cope with problems.
needs. -Listen to people, and help them to feel calm - Give information.
- Observe for people with serious distress reactions. - Connect people with loved ones and social support.

\Naeem Dalal, MD
Bhugra et al., (2017). The WPA-Lancet Psychiatry Commission on the Future of Psychiatry. The Lancet Psychiatry. 4. 775-818. 10.1016/S2215-0366(17)30333-4.
Caution! REG FLAG!
G
A
I P
m G
p A
r P
o
v
i
n
g
.
Return on Individual/ Return on Investment

https://bit.ly/35bN96N
 Recommendations

Culture Specific Build gap in Mental health service

Coping strategies Mental Health care professionals.
Build pyramid at all levels.

Local Language Research and implementation

Awareness, acceptance and Evidence based interventions.
health promotion.

Brain Health Incorporate in COVID 19 response

Science over stigma specific psychosocial interventions:
Mild- Moderate- Severe example, Psychological first aid.

Mental Health Literacy Mental Health

Services.
YOUTH!!!!
 References

• The impact of COVID-19 on mental, neurological and substance use services: results of a rapid assessment. Geneva: World Health
Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO.
• https://www.verywellmind.com/what-is-a-crisis-2795061 Kendra Cherry
• https://www.dshs.wa.gov/book/export/html/490
• Psychological First Aid PFA Guide for Field Workers (WHO, WTF and WVI, 2011), in multiple languages https://bit.ly/2VeJUX7
• Doing What Matters in Times of Stress: An Illustrated Guide (WHO) https://bit.ly/3aJSdib\
• Ford T, Vizard T, Sadler K, et al. Data resource profile: the mental health of children and young people surveys (MHCYP). Int J
Epidemiol 2020; published online Jan 18. DOI:10.1093/ije/dyz259.
• Collishaw S. Annual research review: secular trends in child and adolescent mental health. J Child Psychol Psychiatry 2015; 56:
370–93.
Armitage R, Nellums LB. COVID-19 and the consequences of isolating the elderly. Lancet Public Health 2020; published online
March 19. https://doi.org/10.1016/S2468-2667(20)30061-X.
• Robotham D, Sweeney A, Perôt C. Survivors’ priority themes and questions for research. 2019. https://www.vamhn.co.uk/
uploads/1/2/2/7/122741688/consultation_report_on_website.pdf (accessed March 30, 2020).
• Emily A Holmes et el, Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science ,
April 15, 2020 https://doi.org/10.1016/ S2215-0366(20)30168-1 Lancet Psychiatry 2020
• Kang L., Li Y., Hu S., Chen M., Yang C., Yang B.X., Wang Y., Hu J., Lai J., Ma X., Chen J., Guan L., Wang G., Ma H., Liu Z. The mental
health of medical workers in Wuhan, China dealing with the 2019 novel coronavirus. Lancet Psychiatry. 2020;7(3):e14.
• O’Connor RC, Nock MK. The psychology of suicidal behaviour. Lancet Psychiatry 2014; 1: 73–85.
• John A, Glendenning AC, Marchant A, et al. Self-harm, suicidal behaviours, and cyberbullying in children and young people:
systematic review. J Med Internet Res 2018; 20: e129.
• Turecki G, Brent DA, Gunnell D, et al. Suicide and suicide risk. Nat Rev Dis Primers 2019; 5: 74.
• Bhugra et al., (2017). The WPA-Lancet Psychiatry Commission on the Future of Psychiatry. The Lancet Psychiatry. 4. 775-818.
10.1016/S2215-0366(17)30333-4. Safeguarding Africa’s Health | www.africacdc.org