|Year : 2021 | Volume
| Issue : 1 | Page : 1-6
Trends and Determinants of Mental Health During COVID-19 Pandemic: Implications and Strategies to Overcome the Mental Health Issues - A Rapid Review from 2019-2020
Golden Catherine Thangaswamy1, Judie Arulappan2, Sudhakar Anumanthan3, Sathish Kumar Jayapal4
1 Dr. Jeyasekharan College of Nursing, Nagercoil, Tamil Nadu, India
2 Department of Maternal and Child Health, College of Nursing, Sultan Qaboos University, Muscat, Sultanate of Oman
3 Popular Nursing school and Paramedical Institute, Popular Institute of Medical Foundation, Varanasi, Uttar Pradesh, India
4 Centre of Studies and Research, Directorate of Planning and Studies, Ministry of Health, Muscat, Sultanate of Oman
|Date of Submission||24-Aug-2020|
|Date of Decision||22-Sep-2020|
|Date of Acceptance||29-Oct-2020|
|Date of Web Publication||12-Feb-2021|
Department of Maternal and Child Health, College of Nursing, Sultan Qaboos University, P.O. Box 66, Al Khoud, Muscat
Sultanate of Oman
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Thangaswamy GC, Arulappan J, Anumanthan S, Jayapal SK. Trends and Determinants of Mental Health During COVID-19 Pandemic: Implications and Strategies to Overcome the Mental Health Issues - A Rapid Review from 2019-2020. Int J Nutr Pharmacol Neurol Dis 2021;11:1-6
|How to cite this URL:|
Thangaswamy GC, Arulappan J, Anumanthan S, Jayapal SK. Trends and Determinants of Mental Health During COVID-19 Pandemic: Implications and Strategies to Overcome the Mental Health Issues - A Rapid Review from 2019-2020. Int J Nutr Pharmacol Neurol Dis [serial online] 2021 [cited 2021 Apr 13];11:1-6. Available from: https://www.ijnpnd.com/text.asp?2021/11/1/1/309283
| Introduction|| |
Mental health refers to the cognitive, behavioral, and emotional well-being of an individual. Mental health is an essential component of health necessary for the effective functioning of an individual. It helps to determine the way we handle stress and make choices. Mental health is not only important in childhood. It is very important in childhood, adolescence, and throughout adulthood. Good mental health can preserve a person’s ability to enjoy life. Preserving good mental health helps an individual to balance between life activities, efforts, and responsibilities to achieve psychological resilience. World Health Organization (WHO) relates mental well-being of an individual with the realization of individual‘s abilities, coping, productivity, and social contribution.
WHO states mental health as “subjective well-being, perceived self-efficacy, autonomy, competence, inter-generational dependence, and self-actualization of one’s intellectual and emotional potential, among others.” Mental health of an individual is not static, it changes from time to time. There are multiple factors that can constrain mental health. Mental illness refers to the health conditions characterized by alterations in thinking, mood, or behavior associated with distress or impaired functioning. Mental health and mental illness are continuous and related concepts. The people who do not have mental illness can have poor mental health. Likewise, people with optimal mental health can have a mental illness.
Issues with mental health disorders are of huge health concern. These affect the thinking, feeling, mood, or behavior of an individual and can contribute to the development of mental illnesses such as depression, anxiety, bipolar mood disorder, or schizophrenia. When developed, the illness can be acute or chronic and it affects social, emotional, and occupational functioning. An estimated >50% of individuals will have a mental illness or disorder during their lifetime. Research says 20% (one in five) of the children, have had a seriously debilitating mental disorder. Globally 10% to 20% of children and adolescents suffer from mental illness.
Mental health can be affected during pandemics and epidemics at large. The most common pandemics seen in the past were plague, influenza, cholera, smallpox, measles, tuberculosis, leprosy, malaria, HIV, and the current Corona Virus Disease 2019 (COVID-19). These infectious diseases have ruined human life and have changed histories. The current pandemic, the world faces is the outbreak of COVID-19. It is stressful for people and it triggers overwhelming and strong emotions in adults and children. Fear and anxiety about their health status, changes in sleeping or eating patterns, and abuse of drugs are the commonest concerns and it affects the mental health.
Changes in lifestyle routine and lack of physical contact with other family members and friends disturb the people at large. The growth and development of children may be affected drastically if are not taken care of. Hence, at this crucial point, it is important to raise concern over the mental health of people. Effective interventions need to be planned and delivered to avoid issues of mental health concern during this pandemic.
| COVID-19 Pandemic|| |
Infectious diseases are usually coined with words such as “pandemic,” “epidemic,” and “endemic” based on the nature of their occurrence. A pandemic is defined as “an epidemic occurring worldwide, or over a very wide area, crossing international boundaries and usually affecting a large number of people.” The Novel Coronavirus (COVID-19) was initially an epidemic when it was limited to Wuhan, China but because of its geographical spread, it turned out to be a pandemic. WHO declared it as a pandemic to gather political and financial support across nations.
Coronaviruses (CoV) are a family of viruses that originated in China. The symptoms range from common cold to respiratory distress. This is more similar to the Middle East Respiratory Syndrome (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS-CoV). This is also called SARS-CoV2. The current disease pandemic is due to this virus and it demands cautious pandemic preparedness. The clinical features include fever, cough, shortness of breath, breathing difficulties, pneumonia, severe acute respiratory syndrome, kidney failure, and even death. World is worried about the alarming spread and severity of the COVID-19 disease. Rational, proportionate, and reasonable measures are needed to contain this public health crisis.
| Quarantine|| |
A pandemic outbreak warns people about a disaster that may endanger a large cluster of human species if unattended. Being negligent, fearless, and unresponsive paves the way to loss of morality, human life, and social functioning. There are numerous measures taken by WHO and are followed across the globe with caution. Quarantine is one such method that separates and restricts individuals to be exposed to COVID-19. Quarantine prevents community transmission and may be done at home or in a facility. Quarantine isolates the asymptomatic healthy persons who may have been exposed to the COVID-19. The quarantine period for COVID 19 is usually 14 days from the date of last exposure. Currently, one-third of the world’s population is in quarantine.9
| Lockdown|| |
The world grapples with managing the new pandemic and it is a stressful time for people across nations. Lockdown has been implemented worldwide to curb the spread of the virus. The terms lockdown or shutdown are being used by many to describe more general and widespread restrictions on movement, work, and travel on all people in a city, region, or country.
| Psychological Impact of COVID-19 Pandemic Across the Life Span|| |
Parents of the under-five children are stressed and worried about the children’s growth and development. As the under-five developmental stage of the child is centered on neurological development, stress is being placed on parents to enable them to explore and learn from the green environment. However, this process is affected extremely during this COVID-19 pandemic.
Huge concerns and worries are experienced by the parents about the well-being of the school-age children. A recent survey was done on 5000 parents by the Co-SPACE (Covid-19 Supporting Parents, Adolescents, and Children in Epidemics). The study aimed to assess the mental health of school-aged children aged 4 to 15 years. The findings revealed that 50% of the parents’ were concerned and worried about the welfare and well-being of their children. Eighty percent of the parents felt the lockdown to be stressful as they could not control the behavior of the children. School children easily develop frustration and boredom. Children confined to home are often irritated and more demanding. Their academic achievements are halted and they become socially detached. Interventions are needed to improve the mental health of school-going children.
The mental health of adolescents is disturbed to a greater extent. Restrictions imposed by the pandemic has induced a huge amount of pressure on the adolescents as they are away from their normal routine. Health and well-being are also affected. Being confined to a space is more stressful. There is a distortion in the family and social relationships. Information overload makes them feel trapped and creates undue anxiety. They lack access to the outside world that makes them get obsessed with electronic gadgets. Psychiatric emergencies such as suicide, altruism, paranoid behavior, aggression, and panic attacks are commonly seen among adolescents. Besides the common mental health issues of adolescents, adolescents having chronic life-threatening illnesses face many challenges in coping up with their illness during this pandemic. These adolescents experience additional burdens and risks related to their health. Therefore, comprehensive health care interventions should be adopted by practitioners in caring for children with chronic illness to improve their quality of life.
Stress has become a part and parcel of life after the corona era. Social distancing, fear of acquiring the infection, and prevention strategies practiced are causing enormous stress among adults. Adults are always on the watch in reducing the chances of acquiring the COVID-19 infection. Frequent checking, hoarding, and washing compulsion are a few of the obsessions that are developed during this period. Fear over losing loved ones cause immense anxiety and stress. The adults get detached from society and are at risk of developing mental health issues. The common mental health problems faced are depression, anxiety, and panic disorder. In addition to the common mental health problems in adults, studies have reported poor quality of life in the psychological and physical domain in the caregivers having family members with chronic disorders. Therefore, enhancing the psychological well-being of adults during this COVID-19 pandemic is very essential. Primary and secondary preventive measures must be taken while caring for the pregnant, postnatal mothers, and their newborns.
Stress and anxiety levels in pregnant women increases during the infectious disease outbreaks such as COVID- 19 outbreak. The pregnant women may experience anxiety and stress pertaining to the potential adverse obstetrical outcomes including fetal abnormalities and fetal death. Isolation, social distancing, and various changes in daily life increase the risk of depression among pregnant women.
Saccone et al. conducted a study to evaluate the psychological impact and anxiety in pregnant women during the COVID-19 outbreak in Italy. The study reported that the majority of the respondents rated their psychological impact of the COVID-19 outbreak as severe and most of the pregnant women reported that they experience higher than normal levels of anxiety. The pregnant women had higher levels of anxiety regarding the vertical transmission of the disease to the fetus. The anxiety and psychological impact of the COVID-19 epidemic was very severe in pregnant women during the first trimester of their pregnancy. Ravaldi et al. reported that Italian pregnant women are very much concerned about the impact of COVID-19 on their baby, partner, and elderly relatives. The pregnant women are experiencing worry, fear, loneliness, anxiety, and danger during this COVID- 19 outbreak. During pregnancy, maintenance of adequate physical and mental health is of paramount importance as pregnancy may increase the vulnerability to depression.
The emotional, mental, and physical health of the elderly is at higher risk. The fear of losing loved ones and acquiring infection makes them get detached from others. Fear of acquiring the infections makes them paranoiac. A study reported from china signifies the impact of the coronavirus on the health of individuals. The COVID-19 Peritraumatic Distress Index identified the highest stress index with mean (SD) 30.94, F = 929.306 at P < 0.001. The study also reported psychological problems such as panic disorder, anxiety and depression, and physical health issues among the elderly.
| COVID-19 Pandemic, Quarantine, and Lockdown Trends in India|| |
The first case of COVID-19 was reported on January 30, 2020, in India. India has the largest number of confirmed cases of COVID-19 in Asia and the world. As of July 17, 2020, the total number of confirmed cases in India is 1 000 000. Dramatic changes such as quarantine, lockdown, social distancing, and self-isolation have been the recent trends in this COVID era. The prolonged lockdown has affected the economy and the wealth of the nation. The COVID-19 pandemic in India is one of the worst-hit pandemics among the earlier seen pandemics. There is a scarcity of human resources to fight against this deadly disease. The public is worried about the data transparency of the government with regard to its morbidity and mortality rate. Information bombarding by the news broadcasting services and social media promoting unverified news makes people nervous and catastrophic in this situation.
| Global Trends of Covid-19 Pandemic, Quarantine, and Lockdown|| |
World Health Organization has declared COVID 19 as a Public Health Emergency of International Concern by the end of January 2020 due to its fast-spreading nature and its effect on the health of people at the community level. According to a study, COVID-19 is an unpredictable infectious disease and the outcome is poor. The progress of the disease is unclear and there are no drugs for the cure. In a global estimate, 28 countries were surveyed wherein 21 countries imported the virus before quarantine and seven countries post quarantine. It also emphasizes the need to strengthen interventions for disease monitoring and control.
| Determinants of Mental Health Issues During Covid-19 Pandemic, Quarantine, and Lockdown|| |
World Federation for Mental Health states “Mental health as a precious commodity and an asset that should be prioritized in the same way as physical health.” Pandemic, quarantine, and lockdown have brought a monumental challenge for children, adults, and the elderly. Job loss and financial distress create stress among the public. The infodemics spread across the global media are mostly unreliable and cause panic among the public. The myths regarding the virus and its spread confuse the common man.
Health practices such as frequent hand washing, masking, and social isolation hamper the individuality of a person. Some of them become more obsessive to perform these rituals and get themselves disconnected from reality. Issues related to mental health problems are on the rise during this crisis. Trauma-related mental health disorder is the current area of concern focused by mental health professionals. Depression and avoidance personality disorder is also a common mental health problem.
People are not able to access rehabilitation services, socialization activities, and daycare centers. Educational assistance and personal support services are chiefly affected during this pandemic as innovative remote mental health services are unavailable. Most of the psychiatric hospital units have been converted into COVID-19 units and many of the community mental health centers have been closed. As the outpatient services are limited only to emergency cases, there is a limited service to people. Although in some countries, mobile teams are available to assist the psychosocial needs of people, such health care services are not equally distributed across the globe.
The disabled and fragile people are experiencing outbreaks in the health care facility. In many countries, there is very little opportunity for self-isolation due to limited space. The caregivers of patients with severe mental illness battle to cope without adequate and necessary support including counseling, respite care, and support. The people are getting exposed to viruses due to a lack of facilities for self-isolation, and living in congested communities. Homeless people are affected as they lack basic support systems.
In low- and middle-income countries, mental health care is already limited that is a major concern during the pandemic. The places such as mental hospitals, nursing homes, social care homes, halfway homes, and other institutions are at risk as these places are at increased risk of contracting the virus. As mentally ill patients have cognitive disabilities, they do not know to avoid the spread of infection. The migrant populations living in the camps are socially disadvantaged and they contract the illness more quickly.
Although feeding camps and food relief measures are available in all the countries, the need for health protection and psychosocial support is highly essential during this pandemic. Therefore, proactive measures and actions to address the physical, mental health, and social needs to be taken. Also, economical and psychosocial needs must be met. An emergency mental health plan should be drafted. The government should implement a centralized plan to care for the psychosocial and mental health problems of people during this pandemic.
| Implications of COVID-19 Pandemic, Quarantine, and Lockdown on the Psychological Well-being of People|| |
A recent web-based survey identified posttraumatic stress symptoms, depression, anxiety, insomnia, perceived stress, and adjustment disorder symptoms as mental health issues due to the corona crisis. Social distancing, lockdown, and stay-at-home policy have worsened the vulnerability of mental health. People are experiencing serious psychological effects including frustration, anxiety, depression, and boredom with posttraumatic symptoms.
The number of domestic violence reported to police increased to 13% in Taiwan. The children with preexisting comorbidities have developed novel neuropsychiatric symptoms due to prolonged social distancing. In Spain, females reported to have severe loneliness and distress than males during the lockdown period of COVID-19. Two different studies have reported that older people had poorer clinical features and prognosis than younger ones if being infected with COVID-19.,
A recent study reported that the stay-at-home measure due to the COVID-19 pandemic negatively affected internet use and gaming behavior among treatment seekers. The medical health care workers with somatic disorders, workers in contact with COVID-19 patients, and female workers were at higher risk of developing anxiety, insomnia, depressive symptoms, and obsessive-compulsive disorder. Qi et al. reported that anxiety was more common and prevalent among female adolescents during the COVID-19 outbreak suggesting timely screening and appropriate interventions to reduce the anxiety in adolescents.
In a systematic review, Xiong et al. explored the impact of COVID-19 on the mental health of the general population. The review reported that higher rates of symptoms of anxiety were found in 6.33% to 50.9% of the general population, depression in 14.6% to 48.3%, psychological distress in 34.43% to 38%, posttraumatic stress disorder in 7% to 53.8%, and stress in 8.1% to 81.9% of the general population during COVID-19 pandemic in Spain, China, Italy, Turkey, Iran, the United States, Nepal, and Denmark. The distress was reported to be higher in females, younger age group <40 years, presence of psychiatric and chronic illness, unemployment, students, and frequent exposure to social media and news related to COVID-19.33
It is noticed in general that children face many psychological issues including stress, anxiety, and depression due to online education. This occurs due to limited socialization. Research should be directed to identify the psychological problems of children with online education during this COVID-19 pandemic. The parents too have expressed that they are unable to monitor their children in their online education. It poses many concerns to the parents and family members. The educational institutions are facing challenges and are unable to predict the opening of schools. Further research is needed to explore the psychosocial needs and problems of people across all ages and the interventions to reduce the occurrence of psychosocial and mental illness in people.
| Strategies to Overcome the Mental Health Issues During Covid-19 Pandemic, Quarantine, and Lockdown|| |
There is a need for more evidence-based information regarding the mental health issues during this pandemic. Myth busters regarding the pandemic must be promoted. There is a need for establishing public health communication networks. Media and community awareness is the need of the hour. Governments should coordinate and communicate with agencies to promote mental health during the pandemic situation. Support can be sought from global organizations such as the WHO, United Nations Children’s Fund, the International Federation of Red Cross and Red Crescent Societies, Centers for Disease Control, or the Ministry of Health and Family Welfare (MoHFW), and the Government of India for matters of international concern. Updating the strategies practiced by the World Health Organizations, the governmental and local authorities ensure the spreading of accurate information and help breaking the myths.
A comprehensive framework needs to be planned to overcome the mental health issues during the COVID-19 pandemic. Disseminating platforms regarding COVID needs to be tailor-made according to the geographical background, culture, and virus virulence. Care must be taken to spread legitimate information. Nations must reinforce and necessitate the need for being in isolation or quarantine. Strategies improving mental and psychosocial well-being during the outbreak must be communicated. Empathetic and compassionate care is essential for people with COVID. Information technology and social media must be scrutinized before they spread information. Positive thinking and resilience can improve mental health. Listening, responding, and reacting to children during this pandemic would be helpful. Recommendations provided by qualified health professionals must be considered.Online services for counseling and mental health through nongovernmental agencies should be facilitated. Fear, anger, anxiety, isolation, and panic must be monitored and addressed through hotlines. Relapse of already existing mental illness must be prevented through community follow-up. Education of the family and rehabilitation must be planned and executed through online services. Coping strategies can be taught to people with a poor coping mechanism. Telemedicine consultation practice must be encouraged and people must be made aware of such services. Post-COVID psychological intervention must be formulated to treat the aftermath. The involvement of mental health professionals in the COVID team will prevent the mental health crisis. Preparing the frontline personnel to deal with mental health problems is essential.
Screening of mental health problems through rating scales and inventories helps identify mental health issues at an early stage. Community resources such as media, advertising, and allocation of funds will help fight the fragile situation caused by COVID. Higher social support may decrease the uncertain and fearful feeling in the pandemic and increase confidence in coping with COVID-19. Health professionals should develop alternative ways such as telephone visits to provide social support for the public, especially for those who are quarantined.
| Conclusion|| |
It is high time to build a more sustainable world for a living. Each and every individual must be socially responsible and must follow guidelines as laid by the governmental organizations. They must be enlightened about the disease and the ways to control it. Mental health and its impact on psychosocial performance need to be closely monitored. Mental health policies must be framed and structured to meet the trends of the current situation.
Financial support and sponsorship
Conflicts of interest
The authors reported no conflicts of interest.
| References|| |
Lopez SJ, Pedrotti JT, Snyder CR. Positive Psychology: The Scientific and Practical Explorations of Human Strengths. Thousand Oaks, CA: Sage Publications; 2018.
World Health Organization. Promoting mental health: concepts, emerging evidence, practice: a report of the World Health Organization, Department of Mental Health and Substance Abuse in collaboration with the Victorian Health Promotion Foundation and the University of Melbourne. Geneva, Switzerland: World Health Organization 2005.
The world health report 2001-Mental Health: New Understanding, New Hope (PDF). WHO. Retrieved 4 May 2014. Retrieved 4 May 2014. https://www.who.int/whr/2001/en/
Kessler RC, Angermeyer M, Anthony JC et al.
Lifetime prevalence and age-of-onset distributions of mental disorders in the World Health Organization’s World Mental Health Survey Initiative. World Psychiatry 2007;6:168-76.
Huremović D. Brief history of pandemics (pandemics throughout history). In Psychiatry of Pandemics. Cham, Switzerland: Springer 2019. p. 7-35.
Carlouise J, Arulappan J, Chandrasekaran S, Samuel A, Carlouise S, Chandy SS. Holistic humanized nursing care strategies on physiological and psychological parameters among adolescents with HIV − an interventional study. Int J Nutr Pharmacol Neurol Dis 2019;9:146-55. [Full text]
Zhou X, Snoswell CL, Harding LE et al.
The role of telehealth in reducing the mental health burden from COVID-19. Telemed E-Health 2020;26:377-9.
Renford NG, Arulappan J, Thomas KD, Karuppiah KM, Chinnathambi K, Thangaswamy GC. Quality of life of caregivers of children with autism spectrum disorder in Tamil Nadu, South India. International J Nutr Pharmacol Neurol Dis 2020;10:57-64.
Seshan V, Alkhasawneh E, Al Kindi S, Al Simadi FA, Arulappan J. Can gestational anemia be alleviated with increased awareness of its causes and management strategies? Implications for health care services. Oman Med J 2018;33:322-30.
Saccone G, Florio A, Aiello F et al.
Psychological impact of coronavirus disease2019 in pregnant women. Am J Obstet Gynecol 2020;223:293-5.
Qiu J, Shen B, Zhao M, Wang Z, Xie B, Xu Y. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations. Gen Psychiatry 2020;33:e100213.
World Health Organization. Statement on the second meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (2019-nCov). Geneva, Switzerland: WHO, 2020
Armitage R, Nellums LB. COVID-19 and the consequences of isolating the elderly. Lancet Public Health 2020;5:E256.
Hamzah FB, Lau CH, Nazri H et al.
CoronaTracker: worldwide COVID-19 outbreak data analysis and prediction. Bull World Health Organ 2020;1:32.
Chinazzi M, Davis JT, Ajelli M et al.
The effect of travel restrictions on the spread of the2019 novel coronavirus (COVID-19) outbreak. Science 2020;368:395-400.
Brooks SK, Webster RK, Smith LE et al.
The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet 2020;395:912-20.
Goh KK, Lu ML, Jou S. Impact of COVID‐19 pandemic: Social distancing and the vulnerability to domestic violence. Psychiatry Clin Neurosci 2020.
Graziola F, Garone G, Di Criscio L et al.
Impact of Italian lockdown on Tourette syndrome at the time of the COVID-19 pandemic. Psychiatry Clin Neurosci 2020;74:610-2.
Losada-Baltar A, Jimenez-Gonzalo L, Gallego-Alberto L et al.
“We’re staying at home”. Association of self-perceptions of aging, personal and family resources and loneliness with psychological distress during the lock-down period of COVID-19. J Gerontol B Psychol Sci Soc Sci 2020:gbaa048. https://doi.org/10.1093/geronb/gbaa048
Liu K, Chen Y, Lin R et al.
Clinical features of COVID-19 in elderly patients: a comparison with young and middle-aged patients. J Infect 2020;80:e14-8.
Zhou F, Yu T, Du R et al.
Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020;395:1054-62.
Higuchi S, Mihara S, Kitayuguchi T et al.
Prolonged use of internet and gaming among treatment seekers arising out of social restrictions related to COVID‐19 pandemic. Psychiatry Clin Neurosci 2020;74:607-8.
Zhang WR, Wang K, Yin L et al.
Mental health and psychosocial problems of medical health workers during the COVID-19 epidemic in China. Psychother Psychosom 2020;89:242-50.
Qi H, Liu R, Chen X et al.
Prevalence of anxiety and associated factors for Chinese adolescents during the COVID-19 outbreak. Psychiatry Clin Neurosci 2020;74:555-7.
Xiong J, Lipsitz O, Nasri F et al.
Impact of COVID-19 pandemic on mental health in the general population: a systematic review. J Affect Disord 2020;277:55-64.
Rossi R, Socci V, Talevi D, Mensi S, Niolu C, Pacitti F et al.
COVID-19 pandemic and lockdown measures impact on mental health among the general population in Italy. Frontiers Psychiatry 2020;11:790.
Inter-Agency Standing Committee. Interim Briefing Note Addressing Mental Health and Psychosocial Aspects of COVID-19 Outbreak (developed by the IASC’s Reference Group on Mental Health and Psychosocial Support)| IASC [Internet]. 2020. [cited 2020 Apr 20].
Chatterjee SS, Malathesh Barikar C, Mukherjee A. Impact of COVID-19 pandemic on pre-existing mental health problems. Asian J Psychiatry 2020;51:102071
Medical Council of India. Telemedicine practice guidelines—Enabling registered medical practitioners to provide healthcare using telemedicine. Available from: https://www.mohfw.gov.in/pdf/Telemedicine.pdf
. Accessed March 30, 2020.