Countries around the world have responsive track and trace systems (or are considering building those) to combat COVID-19. But immediate health effects aside, the pandemic is pulling citizens across the globe into a mental health crisis. The South Indian state Kerala has found a way to tackle that.

This systematic psychosocial program is part of Kerala’s responsive medical care system. On January 27, Kerala reported India’s first coronavirus case. About four and a half months later, Kerala has only around 2,700 cases with 21 deaths, and has no reports of community transmission. Most Indian states are becoming a hotbed for the virus, with the country exceeding 380,000 cases and 12,500 deaths by June 19.

From the date the first case was reported, Kerala’s health department led by Health Minister KK Shailaja adopted World Health Organisation (WHO) guidelines to test, trace, isolate and support. Her team’s response goes beyond the immediate effects of the virus.

In 2013, the National Health Mission (NHM) launched Direct Intervention System For Health Awareness (DISHA), a 24/7 telehealth helpline in Kerala. The mission was to provide a reliable healthcare response to its citizens. From the beginning of the pandemic, electronic media and social media carried out mass advertising campaigns on how people can contact this toll-free helpline.

They received over 4,000 calls per day in March and April, most relating to mental health. Now the calls have reduced to 2,000

DISHA is a guild of social workers and health professionals. Kerala has 14 districts. An effective District Mental Health Program (DMHP) functions in all districts in Kerala. In every district, DMHP consists of psychologists, clinical psychologists, psychiatrists, social workers and nurses.

When DISHA receives an inquiry, they direct it to the DMHP in the relevant district. According to Akhila V Nair, Floor Manager at DISHA, they received over 4,000 calls per day in March and April, most relating to mental health. Now the calls have reduced to 2,000 per day. This centralized COVID-19 helpline is completely free of charge.

Albin Eldhose, Clinical Psychologist at the District Mental Health Program in Idukki District summarized the mental health issues caused by the pandemic. Many people experience anxiety. In the initial days, the possibility of catching the virus was a stressor. There were adjustment difficulties to the new normal. As elsewhere, unemployment and financial crisis are the biggest issues leading to anxiety and acute depression.

“Many Keralites work in Gulf countries and Europe. Now back home, they constantly stress over the future of their employment status,” Eldhose said. Prolonged Isolation and lack of social interactions lead to depression. Acute stress reactions and post-traumatic stress disorder are common among people in quarantine. Others experience insomnia.

DMHP contacts every person who is in government quarantine facilities or home quarantine to inquire whether they experience any psychological disturbances. As per the guidelines issued by Kerala’s communist government, everyone gets a follow-up call to reassure their well being.

DMHP provides basic psychosocial education to those in quarantine. “Prevention is the key,” Eldhose said. Eldhose and his team of psychologists provide psychological first aid and psychotherapy treatments such as breathing exercises and cognitive behavioural therapy to those with mild symptoms.

“When possible, we use new media tools such as Google Hangouts, Zoom and WhatsApp for treatments. Some patients don’t have a smartphone so we limit it to audio calls and SMS,” Eldhose said. If the symptoms continue and lead to a chronic disease, they refer the patient to a psychiatrist in their team.

Kerala’s population is 34.8 million. The state’s GDP per capita is $2,731 (as a country who’s managed the situation well, with 4.8 million population, New Zealand’s GDP per capita is $41,945). Eldhose stated that mental health services including medications provided by DMHP are completely free of charge. When patients don’t show improvement, the DMHP provides them direct therapy after the quarantine period.

Treating substance abuse issues is also part of the DMHP. Alcoholism prevails in many parts of Kerala. In 2018-2019, the state recorded $1.9 million in liquor sales. When bars closed down during the lockdown, many people suffered from alcohol withdrawal symptoms such as loss of appetite, confusion and anxiety. Eldhose and his team conducted regular telehealth check-ups for patients with mild symptoms. Patients who experienced severe symptoms were admitted to the hospital.

Nikhil RR, Project Coordinator at the Indian Institute of Technology in Palakkad, Kerala believes that mental health programs wouldn’t be effective if the government didn’t take care of vulnerable populations.

When the lockdown began from March 25, community kitchens organized by panchayats (smallest governing body in Kerala) provided meals for those who were affected by food scarcity and unemployment.

Kudumbashree is a poverty eradication and female empowerment program implemented by the government. They conduct counselling and economic programs for single mothers, and widows affected by the pandemic. Other measures include providing shelter and free meals to migrant workers from other states of India and Break the Chain campaign to promote good hygiene.

Mental health programs wouldn’t be effective if the government didn’t take care of vulnerable populations

The state's Anganwadis (free child care centres for young children) had been delivering groceries and meals for kids during the lockdown. Since schools and preschools are now closed, parents receive check-up calls from Anganwadi workers regularly to ensure kid’s mental health and share tips on engaging activities like water colouring, storytelling and small games.

Amrithabh Sajeev, Psychiatrist at Amrita Institute of Medical Sciences in Kochi, Kerala, said that the private healthcare sector has adapted government procedures for social well being. His team provides teleconsultation, conducts webinars and educational programs on the hospital's television channel. The private hospital receives 40-50 inquiries per day, not only from Kerala but from other parts of India and across the world related to mental health and substance abuse issues.

Eldhose, on the other hand, believes that there’s a clear decline of stigma surrounding mental health now. People approach DISHA and DMHPs, and are aware of psychotherapy more than ever before. While he states that the state needs more manpower in clinical psychology, governments elsewhere can learn from Kerala’s approach to tackle long term mental health issues piling up due to the pandemic. – Zinara Rathnayake

(Photo credit: Unsplash)