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Hemmed inside their homes for months on end as a pandemic raged outside, millions of people are emerging timorously into a world that has drastically changed — an uneasy adjustment process resulting in a spectrum of mental health issues ranging from depression to that final step, suicide.

The dread of contracting the disease combined with the realisation that the incidence of COVID-19 spiralled instead of being contained in the lockdown and that the days of suspending life as they knew it could extend indefinitely has been profoundly disturbing for many.

Add to this new normal, ill-health, joblessness, financial crises and the everyday stresses that people anyway had to deal with and the COVID-19 tunnel stretches dark and seemingly endless with no light at the end of it.

“This prolonged uncertainty has led people to feel a lot more anxious. So people who were on a mild anxiety spectrum earlier have moved to moderate and severe anxiety. When anxiety gets severe, the kinds of behaviour of self harm increase,” said Arvinder Singh, psychologist, psychotherapist and director of the Ashoka Centre for Well-Being in New Delhi.

As India’s COVID-19 tally crossed 4.85 million on Monday, Singh’s concerns find echo across the country.

The worries are rooted in reports of more people inflicting injuries on themselves, several ending their lives and many complaining of depression and severe anxiety.

In Gujarat, for instance, the 108 emergency ambulance service received about 800 cases of “self injuries” and 90 cases of suicide in April, May, June and July, officials said. The numbers began to spike soon after the nationwide lockdown, which came into effect on March 25.

Vikas Bihani, 108 service official, said the suicide prevention and counselling helpline usually got around eight to nine calls per month but the numbers have doubled since March.

“Between March and August, we got 142 calls from depressed people. A majority of the callers were facing economic, family or mental health related issues and wanted to end their lives,” he said.

Some people who test positive for coronavirus inflict injuries on themselves because they cannot tolerate “disappointment”, B N Gangadhar, director of the Bangalore-based National Institute of Mental Health and Neurological Sciences (NIMHANS), told PTI.

His colleague V Senthil Kumar Reddi, coordinator at NIMHANS’ department of psychiatry, said the reasons behind cases of self-inflicting injuries need to be studied.

Gujarat-based psychologist Prashant Bhimani said the economic crisis is fuelling “suicidal thoughts”.

“There is a 70 per cent increase in the number of patients suffering from depression and obsessive compulsive disorder due to the coronavirus. People are worried about what will happen to them if they contract the coronavirus,” he added.

Though there are no exact figures, the anecdotal evidence of people choosing to end their lives is mounting.

Just last week, a newly married couple were found hanging in their home in Panipat. Aawed (28) and his wife Nazma (19) had got married barely a month back, according to reports.

Aawed was upset at losing his job as a welder during the lockdown and was hoping to get work in the unlock period. But that did not happen and he got increasingly desperate, his brother Jawed was reported as saying.

In Uttar Pradesh, migrant labourers Chutku and Rambabu ended their lives in their village in Banda. Both had no work and were stressed, their family members said.

The distress cuts across classes.

In Barabanki, 37-year-old Vivek whose business had failed allegedly poisoned his wife and three children before hanging himself at his home.

In the national capital, two brothers, both in their 40s, were found hanging in their jewellery shop in Chandni Chowk. They left behind a suicide note, apologising to their families and citing financial crisis as the reason behind the extreme step.

And sometimes, it’s just about the disease.

A 50-year-old man in Odisha’s Bolangir district, for instance, allegedly killed himself by jumping into a well after his nephew tested positive. He feared he might also have contracted COVID-19.

The stories of mounting stress and the inability to handle it are many and from all parts of the country.

“There are common anxiety issues…  like whether they have contracted Covid. People feel anxious if they have a common cold or cough. They are also worried about jobs, economy and EMIs. They are worried about the uncertainty of the future.” said Samir Parikh, director, Mental Health and Behavioural Science, Fortis Healthcare.

The numbers of patients being referred to the psychiatry department of Lucknow’s King George’s Medical University has gone up significantly, said Adarsh Tripathi, additional professor at the department.

“Economic activities came to a halt, businesses shut down. Besides, insecurity about the future, jobs, marriages and education all had a direct psychological impact,” he added.

In Tripathi’s view, the 15-25 age group is most vulnerable to self-harm and suicidal ideas.

Kolkata-based psychologist Sanchita Pakrashi said the single most important factor is collective anxiety about the future.

“I am getting patients of all ages. Till February, the complaints came mainly from students and young professionals suffering from job stress and personal crisis. Now it is collective crisis which shows no sign of abating,” she said.

Jaipur-based psychiatrist  R K Solanki agreed.  He said cases of anxiety disorders, stress and suicidal thoughts have increased in the last three-four months, most related with situations emanating from the lockdown and the spread of the coronavirus.

“During lockdown, people were mostly emotionally depressed. Now, worries related to the future are among the main reasons for anxiety and depression in many young patients,” Solanki said.

The coronavirus pandemic may also impact some children’s mental health and emotional well-being and parents should address their needs with compassion and a friendly approach, added S K Mattoo, head of the psychiatry department at PGIMER, Chandigarh.

Faced with the escalating mental health crisis, several institutions are conducting programmes for their staff.

AIIMS, Patna, has tied up with Médecins Sans Frontières to provide training to its medicos and paramedical staff on how to deal with the mentally disturbed or depressed COVID-19 patients at the hospital.

About 30 per cent of coronavirus patients at the facility are found to be mentally disturbed, Sanjeev Kumar, the institute’s COVID-19 nodal officer, said.

Anand Nadkarni from Mumbai’s Institute of Psychological Health recommends a  30-day crash course on clinical psychology for regular practitioners so they can provide basic support to patients complaining of stress and anxiety.

“There is no doubt that the cases of people suffering from stress, anxiety and depression are on the rise. The lockdown has not only led to a relapse in people who were on the recovery path, but also triggered stress and anxiety related disorders among those who earlier never had any symptoms,” Nadkarni said.

The Arunachal Pradesh government is also taking measures to reduce stress among COVID-19 patients undergoing treatment at various care centres and hospitals.

“Besides supportive counselling,  treating physicians liaise with psychiatrists and initiate treatment for mild symptoms of anxiety, insomnia, if necessary,” state Health Secretary P Parthiban said.

Thousands of kilometres away in Kerala, a helpline set up by DISHA, a joint venture by the National Health Mission (NHM) and the Department of Health and Family Welfare, has been receiving hundreds of calls a day.

“We have been receiving hundreds of calls everyday seeking help. Some people seek help after getting frustrated of the lockdown. Some are depressed and worried about the pandemic,” a counsellor told PTI.

Explaining the protocol, Akhla, a floor manager at DISHA, said, ”We speak to them first, then hand over their case to the respective district mental health programme officers.”

It’s a pan India problem that has been growing and evolving through the months.

Tabassum Sheikh, clinical psychologist, Apollo TeleHealth, said, “When the lockdown started, the calls were related to people facing issues in handling work stress and the household chores. Ever since July, the calls are more about interpersonal problems.”

Parikh added  that people who are struggling need a support system and friends and family are key. He also said people should feel free to seek help if they are struggling.

Advice that must be acted on before it gets too late, stress experts.