Focussing on ‘mental hygiene’ along with ‘hand hygiene’ in the times of COVID-19

As the COVID-19 outbreak has affected most countries globally, there are guidelines established by various national and international agencies to prevent the further spread of COVID-19. It has been seen that media and public health often focus on the biological/physical ramifications such as hand hygiene while ignoring the psychological impact. There is evidence that during and immediately after such outbreaks, many individuals directly or indirectly affected by the illness show increased symptoms of psychological nature, such as anxiety and depression1. A recent report has shown that the prevalence of psychiatric symptoms is on the rise during this pandemic as well, with rates of depressive and anxiety symptoms in the general population being >15 and 25 per cent, respectively2. Measures including maintaining a daily routine with exercise/meditation, following healthy eating, limiting alcohol use and avoiding negative newsfeed, have often been suggested to prevent the occurrence or recurrence of psychiatric illness3. These are important but not be sufficient for the preservation of mental health. In the Indian context, some issues may be more pertinent, like containing COVID-19 in the presence of poverty and unemployment. For example, saving a daily wage earner from contracting COVID-19 by employing measures such as lockdown, may eventually turn out to be more stressful due to the lack of income. An aspiring student's examinations may be delayed, and individuals graduating from different courses may have difficulty being recruited for jobs due to lack of jobs/recruitment procedures. In addition, it has often been observed that individuals infected with COVID-19, particularly healthcare and frontline workers, have borne the brunt of stigma due to the same4. Thus, it becomes important to focus on the concept of mental hygiene as a part of preventive psychiatry to face the uncertainties which are likely to persist as the new normal.

Mental hygiene has been defined as the promotion and preservation of that condition of the organism which enables it (the organism) to adjust itself efficiently and continuously to its changing environments. It does not limit to promoting positive mental health but also identifying and preventing factors which may be detrimental to mental health and restoring impaired functions5. Various principles of mental hygiene have been described6. One of the first tenets of mental hygiene described was to be born healthy. Though it has been conventionally described in the context of preventing the occurrence of psychiatric illness in predisposed children, such as children born to individuals with mental illness, it may well be extrapolated in the current scenario. For example, women in reproductive age groups, during the time of this pandemic, should be actively educated about contraception, stress related to planning pregnancies during COVID-19, the risk associated with frequent visits to the hospital for antenatal check-ups/delivery and not being able to get regular check-ups because of the risk of contracting COVID-19. However, clinicians should be aware of staying empathetic about those who still plan to get pregnant, without inducing excessive fear.

Another important principle of mental hygiene is maintaining the physical welfare of the individuals in all stages of development. Hence, efforts can be made to provide food at the doorstep to families below the poverty line and screening for infections or signs of malnutrition in children. Efforts in this regard have been made by the central government, various State governments as well as different non-governmental organizations78. The third principle is the provision of a satisfying home environment. This would include both psychological environment, that is good interpersonal relations, and physical environment, that is sanitation. This can also be dealt with by repeated information, education and communication activities conducted in a locality or through mass media. A way of ensuring the spread of such information is broadcasting such advertisements on radio or television through all channels at the same time so that more people would get covered.

The pandemic brings certain risks to children such as school closure, increased risk of domestic abuse and worsening of symptoms of known psychiatric disorders9. Some principles of mental hygiene are particularly described in the context of children, as they are in the stage of cognitive and emotional development and are more vulnerable. The fourth principle of mental hygiene is inculcating adaptive habits in children. This can be done by setting up their routine and learning by modelling. It has also been emphasized that home isolation/lockdown/school closure has led children to spend quality time with their parents and thus have got the opportunity to focus on their creativity10. The fifth principle governs the development of a sense of security, self-confidence and the ability to develop affectionate relationships among children. Parents must utilize the free time to develop fruitful communication with their children. Children can be introduced to the concept of spirituality and religion, as it is a known protective factor against psychiatric illnesses11.

Another challenge the pandemic brings is that it also affects the level of health anxiety in individuals. An increase in health anxiety may result in the increased interpretation of normal bodily sensations as illness and increased attendance of hospitals, or paradoxically avoiding visits to hospitals with the fear of contracting an infection. Healthcare workers, who are at a higher risk of exposure, may also fall victim to such symptoms12. Certain principles of mental hygiene adopt the example of various defence mechanisms, for example, to avoid defence mechanisms such as rationalization and projection. Health workers may be specifically prone to rationalize or project being infected or being in quarantine because they may believe that patient hides his/her symptoms from them. There should be regular education and training of healthcare workers on the precautions they must take during their duty and take responsibility for their own safety. Another defence mechanism that has been encouraged and described as part of the principles of mental hygiene, is sublimation. Hence, if one desires to avoid wearing a mask for a long time, he/she should consider staying at home as much as possible and working online. This will fulfil his/her desire in a socially acceptable manner.

Constructive escape, which means taking a break from their profession, or care for some other satisfying activity, is yet another principle of mental hygiene, which may be applicable in the times of COVID-19. While planning a vacation may be a common constructive escape mechanism, it may not be feasible in the current scenario. Other mechanisms could be inculcating new hobbies, social work, books, sleep, etc. One should be aware of not using maladaptive escape mechanisms such as alcohol use. In addition to constructive escape, the emphasis has been made on the principle of emotional regulation. It must be understood that emotions are not easily controlled, but individuals must be encouraged to control the physical expression of emotions. It is imperative that all workplaces and educational institutions should appoint a counsellor/psychologist/psychiatrist for regular monitoring, training, psychoeducation and management.

Some of the efforts made by the government with regard to mental hygiene deserve a mention: for example, the instructional videos and documents on mental health and COVID-19 released by the Ministry of Health and Family Welfare13. In addition, mandatory screening for psychiatric symptoms among patients diagnosed with COVID-19, their family members or those in the quarantine may be an important step. While those who get admitted may fill a checklist for screening common psychological symptoms such as feeling restless, having panic attacks, low mood and pessimistic ideations, along with a screening of various other medical comorbidities, those who are screened positive may be consulted by a psychiatrist (in-person or tele-consultation) during admission or after recovery, based on the seriousness of symptoms. Another way for screening individuals quarantined at home or other isolation facilities, may be with the help of apps specifically made for COVID-19 tracking such as Aarogya Setu, via daily/weekly/monthly pop-ups, or reminders. The integration of chatbots may also be helpful in situations where the mental health service gap is further going to expand. The media should be encouraged to present hopeful stories proportionate to their occurrence instead of sensationalizing and terrifying the audience by unfortunate incidents.

While it is important to appreciate the efforts by the frontline workers, it is important to encourage and train the general population to follow mental hygiene in order to make them self-sufficient, which will eventually lessen the burden on the mental health workers whose resources can be diverted to the care of those affected with COVID-19. The issues of stigma related to infectious illnesses are longstanding. Reinforcement of correct information with allaying of the associated myths through repeated measures of creating awareness among the lay public should be carried out. The concept of mental hygiene, which was introduced historically during the World War, is forgotten, and must be revived to fight the war against COVID-19 with a newer perspective and integrating the techniques of preventive psychiatry, thus enabling every individual from the general population to be the warrior.