Prof. Sanjeev Jain
M.D (Dr. SJ) is a renowned psychiatrist from National Institute of Mental Health and Neuroscience (NIMHANS), Bangalore. He is an expert in the field of psychiatrist genetics and history of Indian psychiatry, who heads the molecular genetics laboratory of NIMHANS. Dr. Jain leads the largest national research programme on the biological basis of mental illness.
Q1
Dr. FPM: How does the mind work when we are hit with crisis or a pandemic like this?
Dr. SJ: There is obviously a flight or fight response to any disaster. But using the knowledge and critical capacities that humans have, the ‘fight’ response is called into play more often; and it should be. To achieve this, enough people must share that understanding, and the knowledge that is the basis of that understanding.
Q2
Dr. FPM: What is Psychological first aid?
Dr. SJ: This is a concept derived from the time of the World Wars with post-traumatic stress disorder; and thus is itself a 100-year-old idea. It was first developed to explain the responses of some soldiers to the extreme situations of modern warfare, where death could rain down from an invisible enemy (artillery and airplanes) and it morphed into responses in the face of overwhelming catastrophe. Natural disasters (earthquakes etc.) or man made (communal /ethnic violence); are often discussed; but not much experience with disease pandemics like this one. Especially when the enemy is, once again, ‘invisible’. BUT the methods of psychological first aid: providing support, sharing information, communicating concern and empathy, addressing basic needs and concerns are quite applicable to this situation. This is the MOST important single intervention at this point.
Q3
Dr. FPM: Some have mild reactions, whereas others may have more severe reactions. What are the contributing factors?
Dr. SJ: This is a natural variation between humans and societies. The strength to cope is amplified significantly by a sense of ‘we are all in it TOGETHER’. This is equally important when we communicate the various levels of interventions: from the basic knowledge to social and behavioural interventions. As an example, the Chinese first published the genome sequence, and then the mutation map; and almost simultaneously put the social interventions in place. This was not merely an academic exercise. It built confidence in their population that they KNEW what they were talking about. And thus people listened. And carried on with the data collection, dissemination and clinical research. The textbook on managing Covid is now in its 4-5 edition in 2 months. We must remember, that while fear is contagious, so are knowledge, and a sense of confidence!
Q4
Dr. FPM: How do we deal with this panic state to manage a healthy life and, life habits
Dr. SJ: This is critical in the near future, when people are confined to closed spaces. This can worsen mental health issues, especially for those who rely on support, and have pre-existing conditions. In the old days, one used to read about ‘encounter group therapies’ where people were confined to a barn for several days till their psychological issues were sorted out. Perhaps we need to look at this as an opportunity!! But jokes apart, it is important to make sure that both mental and physical health are attended to. Loneliness, and overcrowding, both have psychological consequences. Maintaining diversity in action and thought are critical for this, so keeping engaged in various tasks in both the real and ‘virtual’ space would be useful.
Q5
Dr. FPM: How do we deal with isolation? Why does people fear self-isolation?
Dr. SJ: Human beings ARE social animals. We cannot live isolated existence without a profound sense of anxiety, dread and depression. People begin to crave for social contact, and physiologically, the drive is as strong as that for food and water. My personal impression is that we should exchange the term ‘social isolation’ to physical isolation. We MUST NOT develop a psychological sense of social isolation. It is critical that we feel connected, despite the physical distances and the barriers to communication and movement that have emerged, but hopefully are temporary. And constantly reinforce SOCIAL TOGETHERNESS.
Q6
Dr. FPM: What are the effects of social isolation?
Dr. SJ: Social isolation has a deep impact on well-being. This was the major reason for shutting down Asylums and mental hospitals, as it was observed that social isolation actually worsened the illness. At the same time, it was also seen that those hospitals that encouraged and fostered a wholesome variety in their daily routine, and had activities like music, sport, recreation, and group engagements did better. At a time when we are converting the whole of society into a kind of Sanatorium condition, we can learn from those experiences. Watch ‘Meghe Dhaka Tara’ or ‘Elipathhyam’ and understand what social isolation really means.
Q7
Dr. FPM: What are the positive coping strategies?
Dr. SJ: These can obviously be person, family or socially directed. As a person, ensure some exercise, practice or enjoy hobbies or whatever gave a sense of joy, and keep engaged. At the family level, try and make sure that space and time are shared out, so that chores and roles shared, and the ones who require extra attention (the young and the elderly) are looked after. Socially, try and get involved in community work, in the virtual or real world. Get in touch with friends and family, reassure them and feel connected. Help out with providing assistance to others, in whichever way possible.
Q8
Dr. FPM: What is the significance of social connection during the phase of physical distancing?
Dr. SJ: This isolation should not become the new ‘normal’. No man is an island, as the saying goes. This is an unusual crisis, which can threaten the very nature of what we call humanity, if we are not careful. As mentioned above, social connection is biological urge; and its complexity is what enriches us. Just like the virus does not respect geography, race or class, it can only be defeated by compassion, concern and care that does not pay heed to these differences. So a coming together, metaphorically, is very important, at this time of isolation.
Q9
Dr. FPM: In this situation as physicians and treating doctors we may face ‘crisis within a crisis’. For example lockdown that prevents your patient to seek medical care for an acute vision loss. As a physician we have to deal with the patients anxiety and the worry/ helplessness from our side.
Dr. SJ: This is very true. We have been responding to the best of our ability, adjusting medicines over the phone, trying to do a long distance triage, and maintain a balance between addressing the need of the individual patient, and the risk of spreading the disease if the person comes to a hospital. Or, being unable to provide the necessary care, as other services are now diverted. There are no answers here, except that we each have to manage as best as we can, and keep assuring our patients that we are concerned about their welfare. And, that normal services WILL resume.
Q10
Dr. FPM: As a health service provider we remain anxious about ourselves and more so our family who indirectly can be exposed. There is a fear. A piece of advice from you.
Dr. SJ: This is unavoidable. Medical services ARE the frontline, and that is what we signed up for. At the same time, unnecessary risk can be avoided and we must assure everyone that we are taking all the appropriate and feasible precautions. We must insist that the systems that we work within are responsive to these concerns. And wash, disinfect, clean in a repetitive manner.
Q11
Dr. FPM: Some health care workers can experience avoidance by the community due to stigma of fear?
Dr. SJ: This is really the effect of disinformation and lack of communication about the nature of the illness. Very often, our systems perpetuate a policy of ‘Do as I say’ rather than ‘Do as I do’. Thus the dismay about the British PM testing positive, as he obviously did not do what he was telling other to do! Within India, we are forcing people to walk for days, while being in the incubation period! We don’t have facilities in the cities, so imagine what will happen if the disease starts affecting villages or small towns.
Q12
Dr. FPM: Which strata of the society are more vulnerable and need special attention in such crisis as far as mental health is concerned?
Dr. SJ: These would obviously be two broad groups.
As a psychiatrist and a doctor, my first concern would be those who are already identified as being ill, and thus under risk. Because they are in hospitals in any case, or are on drugs that may increase risk, or their symptoms are such that they do not understand the complex responses that are now required; or are disabled and need support; and those in special needs services (mental hospitals; old age homes/assisted living centers; halfway homes, beggars homes, orphanages etc etc). Many of these often lack the skills and services that may be necessary to avoid infection, or its spread. They need to be looked after as the weakest in the chain.
The other group would be the socially disadvantaged in the broader sense. About 75% of India lives on less than 2-dollars a day; and that too earned on a daily basis. The previous response measures, during disasters, of feeding camps/ work for food, where hundreds are housed together, are not applicable with this disease. So we will HAVE to make proactive efforts to deliver care in a distributed manner, while reducing the risk of contagion.
Q13
Dr. FPM: How do we deal with children including adolescents? How do they respond to stress?
Dr. SJ: Restraint is much more difficult; but fortunately resilience is much better. A funny piece in one of the papers reported on the stress of having teenagers under the same roof!! Thankfully, they have more imagination and a wider experience of the imaginary, play and the virtual world, so by itself it would be OK. Of course, to see others ill, especially family members and elders will have its own consequences for the particular child/teenager.
Q14
Dr. FPM: What about our elderly family members? Since they are also aware that they fall under high-risk group for COVID19.
Dr. SJ: These obviously need great attention. Reducing the risk of contagion is paramount. And so is a avoiding a feeling of abandonment. This is a tightrope walk, and we will have to tread this as best as we can. Getting connected to their loved ones can keep the stress at bay. Keep them involved in daily activities and, cutting down on news reports will also help to maintain a healthy mind.
Q15
Dr. FPM: We believe that there is strong link between physical health and mental health either way, how does that work? Is it true that mental health sets the body right?
Dr. SJ: This is both a simple and complex issue. The brain and the body are intertwined at every level: from the genetics, physiological or biochemical (the mechanisms involved in most diseases are not exclusive to one space of ‘physical’ or ‘mental’); and the social (the experiences and culture, of the person and the society, affect the working of the brain and produce the mind). So every disease will have components of both. To take blindness as an example: blindness in the young reduces risk of schizophrenia; but in the elderly it raises risk of hallucinations. And this is even without the social and emotional factors of cataract, myopia, astigmatism etc.; which in addition have a profound impact on neuroplasticity. The long-term effects on our brains, minds and culture that this epidemic will have can only be imagined. But then, disease an pestilence have been with us for a long time, and its only over the past 100 years or so that we seemed to have an upper hand. Perhaps its just biology’s way to telling us that we may have been too vain!
Q16
Dr. FPM: Do you think that frequent hand washing and hygiene can flare up or exacerbate stress related disorders like Obsessive Compulsive Disorders (OCD)?
Dr. SJ: Fear of contamination is the basis of OCD, and how people who have this condition cope with this invisible strand of RNA as a source of contamination is perhaps material for a good clinical paper! At another level, ensuring cleanliness, and order, again as a social good may be benefited. Comforting people, that their constant worrying about this, is NOT OCD, may also be necessary.
Q17
Dr. FPM: This is a desperate situation where we “don't know” about many things, like how long, what next, and when, there is uncertainty in mind?
Dr. SJ: This uncertainty is the essential human condition. We can have a philosophical shrug, and say, ‘so what’ and ‘I don’t care’. But thankfully the arc of human progress is different. We have made considerable progress over the past 500 years of science to develop a reasonably valid understanding, which is constantly being refined and improved. Even of medicine, the youngest of the sciences! We should and will know how long, what next but perhaps never ever when. Statistics and chance are paramount!! And so is biology………..we forget we are rather one insignificant part of Life on earth, as this essay pointed out 15 years ago!
“Over the past 600 million years the Bacteria, Archaea and microbial Eukarya have continued to evolve into brand new niches. As it happens, a few branches of Eukarya — plants and animals — grew freakishly huge bodies. They also created both new substances for bacteria to exploit, such as plant lignins, and new environments for microbes to inhabit, such as feathers and urinary tracts. Indeed, some of the richest and most interesting ecologies on Earth can be found inside the animal gut.
One of the huge species, Homo sapiens, got remarkably self-important. But when, to his surprise, a virus wiped him out, most of life on Earth took no notice at all.”[https://www.nature.com/articles/435429a ]
But still, since we are in a fish bowl, we still need to believe that: One disease should NOT force us to revert to mythological notions of Biblical wrath (as a patient called to tell me!) or Kayamat or Pralay. That would be our duty as doctors and scientist, and believers in human progress as a part of the human condition.
Q18
Dr. FPM: Lastly, coming to social media influencing the mental and psychological status of an individual- it is all about CORONA THE PANDEMIC, how do we take necessary precaution to remain psychologically unaffected by this?
Dr. SJ: Please, tell them: AISA KARO NA!!
One is tempted to recall George Orwell's term of double-speak, when things mean the opposite of that their name suggests. The 'social' media, as we realize, often borders of the dys-social or even the 'anti-social', with every rumour, superstition, prejudice and paranoia getting widespread circulation! Though it is convenient to express moral outrage and dismiss it, it is not so simple. It is, after all, a tool invented by us; and like any tool can be used for good or bad. So at a time when the pernicious influence is more evident, the good should not remain silent. So please use the social media. It is like the children's game of having two equal lines of the same size, and trying to 'shorten' one, without using an eraser. The clever, and sensible, response being to make the other line longer! Make sure the 'sane' voices are heard more than those of the trolls and cranks.
Mental health toll free helpline number: 080-46110007
Interview taken by
Dr. Fairooz P. Manjandavida
Member, Scientific Committee, AIOS
M.S (Dr. FPM) is a specialist in Oculoplasty, Orbit and Oncology at HORUS Specialty Eye Care, Bangalore, India.