Mental health professionals as ‘silent frontline healthcare workers’: perspectives from three South Asian countries

Mental health professionals across the globe foresaw the mental health impact of the coronavirus disease 2019 (COVID-19) pandemic. They have faced scarcity of trained professionals, rising morbidities, lack of protective gear, shortage of psychotropic drugs, and poor rapport building due to masking and social distancing. Amidst all, they have responded with approaches that focus on continuing mental health services to the patients already in care, education of the vulnerable people to help them cope with these stressors, and provide counselling services to patients (cid:68)(cid:81)(cid:71)(cid:3)(cid:73)(cid:68)(cid:80)(cid:76)(cid:79)(cid:76)(cid:72)(cid:86)(cid:3)(cid:68)(cid:4231)(cid:72)(cid:70)(cid:87)(cid:72)(cid:71)(cid:3)(cid:69)(cid:92)(cid:3)(cid:87)(cid:75)(cid:72)(cid:3)(cid:83)(cid:68)(cid:81)(cid:71)(cid:72)(cid:80)(cid:76)(cid:70)(cid:17)


LEAD-IN
e unprecedented impact of the coronavirus disease 2019 (COVID-19) pandemic has caused a jolt to various realms of life and various groups of people globally. ere is a plethora of mental health and psychosocial issues found to be associated with  e psychological repercussions of the pandemic in the general population and also, amongst health professionals may last a long time as compared to the acute medical crisis. e enduring outcomes of this pandemic are not possible to be fully estimated yet. Early screening of mental health and timely action can go a long way in improving the quality of people affected. [1,2] Mental health professionals across the globe foresaw the mental health impact of such an extraordinary crisis and have responded with approaches that focus on continuing mental health services to the patients already in care, education of the vulnerable people to help them cope with these stressors, and provide counselling services to patients and families affected by the pandemic.
Examples from all over the globe have proven mental healthcare workers have been on the frontline, but, in a peculiar manner to deal with the times of the crisis. Among other regions in Italy, in Lombardi, the region most severely struck by the pandemic, metal health services were provided to the citizens on priority and continuous provision was ensured. [3] e psychiatry service in Spain formulated a contingency plan reorganising human resources, closing some units and shi ing to tele-psychiatry practice, alongside two programmes specifically focusing on the homeless. [4] Comparable changes have been described and suggested in the United States [5] and France [6] to strengthen mental healthcare delivery during the challenging times. e United Kingdom Academy of Medical Sciences and Mental Health Charity took the initiative in the early weeks and suggested the acute need of quality research to find out the vulnerable groups and the effects of COVID-19 on the functioning of the brain.
[7] China provided tele-mental health services including supervision, training, and psychological services (counselling and psychoeducation) to the people highly susceptible to the infection. [8] In Australia, officials increased the funded services and appointed consultants and specialists, whereas they did not focus to facilitate the people in mental health services. [9] In Malaysia, online counselling services and psychological first-aid were provided to the people throughout the pandemic by utilising reactive support systems. [10]

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e authors have hereby thrown some light on their perspectives of the contributions of mental health professionals as frontline healthcare workers in India, Pakistan, and Nepal.

THE REPUBLIC OF INDIA
A report from the World Health Organization (WHO) mentions the government's total expenditure on the domain of mental health in India as 1.30 % of the overall government health expenditure and the country has only 0.29 psychiatrists per 100,000 people.
[11] ere is undeniably a shortfall in the quantity and quality of mental health services and its distribution in the country. Another publication estimates the number of psychiatrists in India currently as about 9000 and the number of psychiatry graduates per year as about 700. Based on these estimates India has 0.75 psychiatrists per 100,000 population, as against the preferable number of at least three psychiatrists per 100,000. Taking three psychiatrists per 100,000 population as the preferable number, the study mentions that the number of psychiatrists required to reach the desirable ratio in India as 36,000 and the country is currently short of 27,000 psychiatrists based on the current population. [12] According to a survey conducted by the Indian Psychiatric Society (IPS), there has been an increase in cases of mental health disorders in India by 20% within a week of commencement of the nationwide lockdown. In the subsequent months, the country can anticipate a major mental health crisis as a result of unemployment/loss of jobs, alcohol use issues, financial adversity, intimate partner violence, and monetary liabilities. e at-risk population comprises around 150 million persons with already existing psychological issues, survivors of COVID-19, frontline healthcare workers, youngsters, differently-abled persons, female adults, those working in unorganised sectors/immigrant workers, and older adults. e current need is to construct communitybased capacity to manage local issues long a er the acute stage of the pandemic. [13] Considering the potential of relapse of illness, if psychotropic medications are not made available to patients due to lack of fresh prescription, the society has asked to relax the norms so that patients can get their refills with old prescriptions or through online prescriptions till the crisis is over. [14] e various state branches under the aegis of IPS have made available a list of over 650 psychiatrists who have volunteered to meet the need of the affected population. is voluntary tele-psychiatry service will provide psychological support to patients with pre-existing psychiatric conditions as well as to healthcare workers involved in the care of COVID-19 patients. [15] To assist, educate, and advice psychiatrists towards providing tele-psychiatry services as a routine in their clinical practice, IPS and the National Institute of Mental Health and Neuro Sciences (NIMHANS) have brought out an operational guide aimed at practicing psychiatrists in India as well as low and middle income countries (LAMIC).
is guide covers legal, technology, electronic case documentation, consultation, online prescription, tele-therapy aspects, basic minimum standards for documentation, and proformas for ready reference and use by the patients/their relatives/ nominated representatives, and the psychiatrists. [16] With practice guidelines and standard operating procedures available, tele-psychiatry seems well set for gaining wider acceptance and adoption in India.

THE ISLAMIC REPUBLIC OF PAKISTAN
In Pakistan, mental health service providers have responded in similar ways, and have faced special challenges. ere is a dearth of mental health professionals with only a few hundred fully trained psychiatrists and almost nonexistent psychotherapeutic services in the country. e current pandemic has worsened the situation even further. Psychiatrists and other mental health professionals have responded with various programmes to mitigate the impact of COVID-19 on the mental health of the citizens and the mental health services. Almost all hospitals across Pakistan provided free tele-psychiatry services to patients in their respective areas. Similarly, the Pakistan Psychiatric Society has been active in supporting the mental health of the nation, carrying out social media awareness campaigns and making suggestions to the Government of Pakistan to take steps in this direction. [17] e Aga Khan University Hospital, Karachi launched a mental health programme for children and adolescents to help and train parents so that they can do therapies at home and enable them to deliver rehabilitation to their children in such needs. [18] Likewise, an Online Mental Health Rapid Response Team started providing counselling to patients from the remote areas of Pakistan. [19] Probably, because of the lack of reliable internet connectivity across the country, especially in rural areas, and low education rates, providing internet-based services has not been without a problem of its own. e consensus among psychiatrists is that patients have not been seeking tele-psychiatry services as expected. Similarly, the response of the Government of Pakistan has been lukewarm.

THE FEDERAL DEMOCRATIC REPUBLIC OF NEPAL
e Nepalese society harbours a belief that a doctor should always work selflessly despite pain. Health professionals in Nepal have already been facing anxiety and depression.
[20] Lack of personal protective gears, inadequate hospital infrastructure, stigma towards healthcare workers, and lack of governmental preparedness have worsened the burnout that was already prevalent in resource deprived health system. [21][22][23][24] Mental health workers (MHW) face additional hindrances. Uses of mask and social distancing in psychiatry have only blunted the interview and therapeutic effects due to poor rapport establishment and slowed communication.
[25] MHWs have been working in situation where psychiatric pandemic is looming over. ey are known and expected to spend considerable amount of time than other professionals due to extensive history taking, psychotherapy, and counselling. Either during pandemic or later they are expected to listen patiently and lend tissue to weeping patients on day to day basis. us, limited contact or exposure is impractical.
Most of the psychiatrists in Nepal are known to serve through satellite clinics. ey have not been able to continue that since country-wide lockdown was implemented on March 24, 2020. [26] In the absence of consultation, there has been worsening of old cases and increased suicide rate during the pandemic. [21] Unavailability of medicines in rural areas has added to the misery. Local pharmacists tend not to provide psychotropic drugs in the absence of prescription. Nepal has only 0.36 psychiatrists per 100,000 population. [27] Amidst this, they have been working without complaining. Additionally, they have used online social platform and telepsychiatry to serve the needy. Most of the service they offer is for free. e Psychiatrists' Association of Nepal has provided free helpline numbers. Local psychiatrists have volunteered where each one has received up to 30 calls per day! Some have been posting educational videos while the others are attending webinars and discussions on social media with an aim to alleviate anxiety and combat depression in general population. Several pages and blogs have been created over last few months and the only reward expected is someone being benefitted. is has been found to be useful in LAMIC before. [28] In conclusion, the silently working Nepalese psychiatrists are likely to have increased work a er lockdown is completely li ed in near future. We suggest task shi ing as handy tool to serve Nepalese who are remotely located on difficult landscape. We need to train local community workers and paramedics to assist the overworked MHWs.

LEAD-OUT
Hopefully, perspectives from these three South Asian countries would take the readers through a roller coaster ride of the role of mental health professionals in the frontline. It highlights the lack of mental health professionals to face impending psychiatric pandemic. e common hindrances faced by India, Pakistan, and Nepal are poor social connectivity, possible scarcity of psychotropic drugs, and failed outreach clinic. e difficult landscapes, especially in northern part of all these three countries have to add to the misery. However, the silver lining that appears to be is telepsychiatry that can make it possible to reach the socially and geographically distanced population (Table 1).
It is also imperative to focus on survivors and healthcare professionals following the pandemic in alleviating the burden of distress in humans. is anguish can be alleviated by providing peer support, encouraging social connections, and improving physical safety. Social distancing need not be emotional distancing. Also, there cannot be a better time than now to promote Mental Health Gap Action Plan (mhGAP). us, psychiatrists can train local practitioners and primary care physicians for treating and counselling local patients under supervision. is is likely to alleviate mounting stress of mental healthcare workers. At last but not the least, health of MHWs needs to be prioritised by respective government in order to sustain the health system during psychiatric pandemic that is likely to follow. Mental health professionals as 'silent frontline healthcare workers'