|Year : 2020 | Volume
| Issue : 1 | Page : 12-21
Psychological management of mental health concerns related to COVID-19: A review of guidelines and recommendations
Narendra Nath Samantaray1, Romalin Pattanaik2, Kalpana Srivastava3, Preeti Singh4
1 Department of Clinical Psychology, Institute of Psychiatry and Human Behaviour, Bambolim, Goa, India
2 De-addiction-Unit, MKCG Medical College and Hospital, Brahmapur, Ganjam, Odisha, India
3 Department of Psychiatry, Armed Forces Medical College, Wanowrie, Pune, Maharashtra, India
4 Department of Psychiatry, Pt. Jawaharlal Nehru Memorial Medical College, Raipur, Chhattisgarh, India
|Date of Submission||03-May-2020|
|Date of Acceptance||07-Jul-2020|
|Date of Web Publication||07-Nov-2020|
Dr. Narendra Nath Samantaray
Department of Clinical Psychology, Institute of Psychiatry and Human Behaviour, Bambolim, Goa
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Many publications have delineated strategies for mental health care to respond to psychological concerns and ramifications related to coronavirus disease 2019 (COVID-19). The current review aims to encapsulate existing guidelines and recommendations of psychological management for mental health care for the general population, health-care professionals, children, and elderly populations, applied to a pandemic in particular reference to COVID-19. The literature on psychological care of such repercussions of COVID-19 was retrieved via a search in PubMed and Google database. Of 91 retrieved initial articles, only 18 were selected for final analysis, which was divided into two categories: (a) guidelines by government/public health bodies (n = 11) and (b) publications in peer-reviewed journals (n = 7). The recommendations can be summed but not limited to psychoeducation from a reliable source, normalization of stress, behavioral activation, scheduling of activities with a bespoke blending of recreational and daily chores, supportive care, staying digitally connected, relaxation techniques, ensuring rest, rotating shifts and short breaks during working hours, curtailing media consumption, fostering community resilience, seeking and sharing support from colleagues/supervisors, avoidance of abusing psychoactive substances, online consultation of mental health professionals on need, and participatory communication in a developmentally appropriate way with children. In the absence of observational and controlled studies on psychological management during pandemic times, we recommend such research soon.
Keywords: Children, coronavirus disease 2019, elderly, general populations, health-care professionals, mental health, pandemic, psychological management
|How to cite this article:|
Samantaray NN, Pattanaik R, Srivastava K, Singh P. Psychological management of mental health concerns related to COVID-19: A review of guidelines and recommendations. Ind Psychiatry J 2020;29:12-21
|How to cite this URL:|
Samantaray NN, Pattanaik R, Srivastava K, Singh P. Psychological management of mental health concerns related to COVID-19: A review of guidelines and recommendations. Ind Psychiatry J [serial online] 2020 [cited 2020 Nov 25];29:12-21. Available from: https://www.industrialpsychiatry.org/text.asp?2020/29/1/12/299941
The outbreak of coronavirus disease 2019 (COVID-19), declared as a pandemic, has witnessed not only physical suffering but also psychological repercussions to the public in general, health workers, and confirmed or suspected people with COVID-19. In the study of Wang et al., comprising public, more than half of the respondents rated themselves to have a moderate-to-severe psychological impact and about one-third reported to have moderate-to-severe anxiety. The limited knowledge about the outbreak and overwhelming news has caused public fear, panic, stress, and worry about becoming infected., Further strict quarantine and mandatory contact tracing policy by the administration were speculated to have cause boredom, disappointment, irritability, societal rejection, financial loss, discrimination, and stigmatization., A study  has highlighted health-care professionals as high-risk populations for psychological morbidities during COVID-19. They face challenges of heightened workload, isolation, and discrimination. A recent study  found that half of health-care professionals (HCP) in COVID-19 care reported to have depressive symptoms and other significant percentage reporting of anxiety and sleep disturbances. In their statement, the World Health Organization stated that elderly people are at the highest risk from COVID-19 and also added 95% of deaths during this pandemic occurred in those older than 60 years. In a recent study  and previous pandemic study, on severe acute respiratory syndrome (SARS), has stated the increase in mental health risk of the elderly population in such adverse times. In addition, the implication of isolation, a needed public health intervention in the pandemic, and social disconnectedness in the etiology of affective and other mental health problems in the elderly are well cited. Second, recently, it is asserted that the population's psychological reactions are imperative in controlling the spread of the disease, distress, and civil order during and after the pandemic outbreak. Third, psychosocial factors have been documented to be important predictors of protective health behaviors in general  and also vital in adherence to public health measures  such as self-isolation and random tests.
These above factors have intensified a call for a timely understanding of the mental health status of society  and a wide public pronouncement of guidelines and recommendations of psychological management for mental health concerns related to the COVID-19 pandemic. Nevertheless, a summarized chronicled version of such is needed to enable the mental health professionals and other stakeholders to select an objective choice of mental health strategies during their practice in required settings. In line with these, the present review aims to encapsulate existing guidelines and recommendations of psychological management for mental health concerns for the general population, HCP, children, and elderly populations related to a pandemic in particular reference to COVID-19.
| Methods|| |
The current study, a narrative review, of the guidelines and recommendations on psychological management of mental health concerns related to a pandemic in special reference to the COVID-19 pandemic. In April 2020, electronic literature was searched via PubMed and Google database using keywords “general population”, “elderly”, “old age”, “health care professionals” “novel coronavirus”, “COVID-19”, “psychological intervention”, “mental health intervention”, “government”, “public health”, “guidelines”, and “recommendations”, with required Boolean operators, truncation, and permutations. Besides that, we also did forward chronological search of relevant articles.
By the above-mentioned search strategy, we found a total of 91 records see [Figure 1]. Then, we next identified and excluded duplicate articles (n = 36). Inclusion criteria were then applied: (1) guidelines by government or public health agencies and recommendations in terms of research publications, (2) psychological intervention or recommendations, and (3) reported in the English language. On reviewing, few articles were excluded because they were of other languages than English (n = 4), dealt with other aspects of the COVID-19 outbreak (n = 15) such as recommendations of pharmacotherapy, organizational/structural modifications, and policies modifications, and other guidelines (n = 18) were excluded because they were not published by public/government-owned agencies.
By the above process, 18 articles were finally selected for analysis, which comprises government/public health department guidelines (n = 11) and scholarly publications (n = 7) in peer-reviewed journals. None of the scholarly publications were neither experimental study nor designated as “original research”/empirical evidence instead are recommendations in the forms of commentary, correspondence, letters to the editor, or editorials and a review-related to mental health intervention relating COVID-19. Hence, a narrative review was preferred to systematic or meta-analysis.
| Results|| |
Literature on guidelines by government or public health agencies
[Table 1] summarizes guidelines (n = 11) of government/public health agencies for psychological management of mental health concerns of general populations, HCP, elderly, and children related to a pandemic in particular reference to COVID-19. Of these eight guidelines relating to COVID-19 are published in the year 2020, and the other three are previous guidelines for a pandemic in the past.
|Table 1: Government/public health guidelines for psychological management for mental health concerns related to a pandemic in special reference to coronavirus disease 2019|
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Promoting self-care (82%, n = 9); psychoeducation (73%, n = 8) about seeking relevant information from a credible source and communication of information in a developmentally appropriate way to children and behavioral activation (BA) including activity scheduling comprising recreational, routine activities, yoga, or meditation (73%, n = 8); limiting media intake (55%, n = 73); normalization of stress (64%, n = 7); staying connected with friends and family or enhancement social network digitally or in a secured manner (55%, n = 6);avoiding abuse or illicit use of psychoactive substances (36%, n = 4); and promoting community resilience (CR) (36%, n = 4) are recommended by mentioned guidelines for mental health care of the general population, HCP, and elderly.
Literature on recommendations published in peer-reviewed journals
[Table 2] comprises scholarly recommendations (n = 7) published in peer-reviewed journals. None of them are experimental studies. For general populations, the most recommended strategies for mental health care are limiting news intakes to mitigate feelings of being overwhelmed, BA, or activity scheduling comprising meaningful and recreational activities, enhancing social support systems, improving CR, and staying connected digitally or within the family under safe conditions. Other suggestions were avoiding erroneous misinformation and using a reliable source for updates. The least mentioned strategies were the use of structured cognitive behavioral therapy and mindfulness meditation.
|Table 2: Recommendation for psychological management for mental health concerns related to Coronavirus disease 2019|
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For HCP, conspicuous recommendations were frank assessment of situations, avoiding false reassurance, clear communication, supportive care from colleagues, seniors and administration, screening of mental health problems, shorter working hours, regular rest periods, rotating shifts, and online video feedback to their family members. In addition, one article  reflected the demand for adequate restrooms for HCP. While two articles recommended the use of mental health professionals in other settings during COVID-19, one article  advocated against such pacing of mental health professionals in other health settings. All these are discussed in the subsequent session.
For the elderly population, one article  recommended the use of online technologies to harness social support networks and a sense of belonging; frequent telephone contact with significant others, family, voluntary organizations, and HCP; peer support with community outreach projects; and online cognitive-behavioral therapy to counter loneliness and improving mental well-being.
| Discussion|| |
Responding to the proliferation of distress and other mental health conditions during COVID-19, evidenced by various pieces of literature, many national guidelines and other recommendations from the academic sphere have delineated psychological techniques for populations in general, children, elderly, and HCP. These can be summated but not limited to psychoeducation from a reliable source, normalization of stress, BA, scheduling of activities with a bespoke blending of recreational and daily chores, supportive care, staying digitally connected, relaxation techniques, ensuring rest, rotating shifts and short breaks during working hours, curtailing media consumption, fostering CR, seeking and sharing support from colleagues/supervisors, avoidance of abusing psychoactive substances, online consultation of a mental health professional on need, participatory communication in a developmentally appropriate way with children, etc.
Intervention for general population
Resilience humanitarianism  approaches which annex development and focuses on people and institutions as the first responders during a crisis and bridges it with relief in disaster risk reduction  was reflected in various recommendations and guidelines ,,, in the present review psychosocial care for GP. One such leaf of advice is neither labeling people with the disease as “COVID-19 cases” nor with any ethnicity or country rather referring them as “people who have COVID-19” which agrees with professional ethics and collective identity, a vital cog for strengthening CR  from a global perspective. The importance of combining and linking humanitarian approach with CR in managing national disaster is seen in studies and practice. This has further highlighted the role of CR in improving public health, which has found conspicuous mentions in literature.,, Hence, previous recommendations , for mitigation of stress by promoting CR during a pandemic may be intelligibly synced with the present crisis. Perhaps in his address to the nation, prime minister of India urged to ring bells  and light lamps or candles  on a specified date, and time during the COVID-19 crisis is one such measure to strengthen CR. Putting onus on the public the pronouncement ,,, of supporting others when respecting social distancing, like checking by telephone on neighbors or other people in the community who might need extra assistance, giving paid leaves to employers might be examples of community solidarity in reinforcing resilience.
Pronouncements ,,,,, in the current review recommended limiting consumption, on COVID-19, to avoid feelings of being overwhelmed. Such directions agree with experimental studies showing a direct relationship between negative news exposure and negative emotional states., A very recent study  also commented that negative news perceptions were related to more negative affect and less positive affect which can be explained in the lines of cognitive appraisal theory where negative news is a stressor which needs to be evaluated and reacted to.
As per the present study, psychoeducation ,,,,,, has been one of the most recommended techniques during COVID-19. Across the literature of trauma and anxiety, it has also been documented as a favored strategy. In the suggested context, one of the key inscriptions of psychoeducation is relying on authentic source such as regional, national, or international government agencies for COVID-19 facts and updates as other studies  have shown that user-generated source of social media which are viewed by the population during a crisis may be a source of misinformation and hoaxes where individual assimilation of inaccurate medical information would jeopardize their health.
“Normalization” in studies has been documented  as an essential part of mental health literacy, where people should be told to comprehend reactions as an understandable phenomenon in the context of extraordinary events which would help them comfort and realize that their emotional experiences are within the natural range and are biologically adaptive. Hence, literature in the review ,,,, emphasized to acknowledge stress reactions as common and understandable.
A meta-analysis has supported  the evidence of BA as an effective treatment in mental health. Various guidelines on pandemic have thus reflected the implementation of its philosophical construct in terms of (1) increasing engagement in adaptive activities (consisting of a balance of experiencing pleasure and mastery) and (2) decreasing engagement in activities that maintain depression or increase the risk for depression. In line with these, in the current study, the recommended BA strategies ranged from self-monitoring of activities and mood, activity scheduling or structuring daily routine for engaging oneself like board or indoor games, writing gratitude journal creative work, routine chores, social engagement or digital engagement with loved ones, educating young ones, physical exercise, meditation, relaxation exercises, etc.
Intervention for health-care professionals
Studies have shown health-care professionals as high-risk populations for psychological morbidities during COVID-19, and some highlighted that for successful health-care delivery, it is important to safeguard the moral and mental health of HCP. Hence, psychological interventions for HCP are brought up in guidelines and academic recommendations.
For the general population, as we have discussed, literature in the current study ,, has also recommended the “normalization” of stress reactions in HCP as salient. Previous , and the current study affirmed to view it as a normal experience and not as a sign of weakness. HCPs are advised to monitor, acknowledge, and accept it so., Managing such is vital as physical well-being  for optimal functioning.
Adequate rest and opportune short breaks during working hours are helpful coping abilities during a strenuous formidable routine. The need of rest was more highlighted where many HCPs despite psychological problems were reluctant to receive direct help from psychologists instead demanded more facility of a specific place of uninterrupted rest in hospitals where they can self-isolate for few hours. Some studies have recommended shorter working hours, recurrent rest periods, and rotation of shifts for HCP working in high-risk areas.
During the unprecedented scenario, HCP should not be given false reassurance; instead, a full and frank assessment of likely things they would face should call for., Staff members assigned for breaking the unpleasant news might experience burnout and moral injury. Proper psychological counseling instead of single-session debriefing is recommended for them. They are advised to stay digitally connected, by text, audio, or video mode, with their loved ones, and such timely video feedbacks can mitigate their self and family concerns, fear, and distress.,,
Some studies , have also endorsed placement of multidisciplinary mental health teams in COVID-19 hospitals/centers. However, some  has not supported mental health professionals to work in other health settings citing that people with preexisting mental health will be at increased risk of infection with COVID-19. However, in China, medical bodies and research center  responded to mental health care of HCP by building a psychological intervention medical team that provides online courses to medical staff to deal with psychological problems and planned group activities to release stress. Further, literature  has also recommended the use of adaptive coping mechanisms of relaxation training by deep breathing and avoiding unhelpful maladaptive strategies of using tobacco, alcohol, or other drugs.
Intercoordination and organizational and social support by colleagues/supervisors have been found  to reduce psychiatric symptoms in a pandemic. Superiors should make a conscious effort in supporting staff during need, and a peer support system could be facilitated. Team leaders should facilitate the staff in comprehending the challenging decisions being made. They, too, can lead discussions based on Schwarz rounds, which provide a forum for HCP to safely confer on the socioemotional challenges of caring during a pandemic. Seeking social support from colleagues is also encouraged as they might have similar experiences that can foster normalization and ventilation for both. Furthermore, partnering inexperienced workers with experienced colleagues are again suggested. It is recommended , that senior and other staff should know whereabouts of mental health psychosocial support services and facilitating access to such during need.
Even at a later stage, a study  recommended that supervisors ensure supportive care by inviting a reflective narrative of learning from the arduous experiences to create a meaningful rather than traumatic narrative once the crisis is over. Clinicians even should not avoid talking about guilt or shame in HCP during their therapy sessions; otherwise, it would be detrimental.,
Intervention for the elderly
The contemporary literature concerns an increase in mental health problems in elderly people, especially those who are isolated or cognitively declined  are in tandem with previous studies on SARS pandemic , and recent isolation research.
Remaining indoors is a rule during pandemic times, but with no exception, all guidelines have accentuated on staying connected with other family members and loved ones.,,,,,,, Such emphasis of remaining connected for elderly care is following recent study  which stresses the role and need for social connections for the elderly in bringing positive mental health and a sense of belonging during general and pandemic times too. The use of online or digital methods for supportive and therapeutic care, as recommended in the literature of current review, is well documented in a recent experimental study  and review. Hence, digital methods may be essential for fostering well-being for both young and older adults who might be enmeshed in distant places during a lockdown.
Guidelines and recommendations, for the general population and for elderly,,,, in the current review, have stressed BA and scheduling of everyday activities as a measure to counter depression, stress, and boredom. During isolation, planning out the days is suggested to restore a sense of purpose and control in one's regular living. It is advised  to balance schedule with indoor-based leisure and routine activities of professional or domestic importance. Few instances of this, but not limited to these, maybe being creative, watching online videos for a scheduled time, maintaining gratitude journals, daily chores like gardening, cleaning or cooking, etc.,,, Along with this, engaging in yoga, exercise, meditation, or walking indoors is recommended both for the physical and mental health of the elderly. Similar findings are also reflected in a recent review, and experimental studies , have shown that BA significantly reduces depression, subthreshold depression, and anxiety symptoms and improves the quality of life and functional disability in older people in the community. Similar findings in a study  on pleasant events' intervention for senior residents resulted in a decrease in depressive symptoms and a significant increase in subjective global mood or improved affective functioning. In addition, in the current study literature, respectful clarified communication with elders is considered imperative. Demonstrations of prevention measures and use of written or pictorial methods are encouraged.
Considering the previous studies across literature ,, which evinced a negative impact on mood by constant media intake. The present study, too, recommends that the elderly limit pandemic news intake to avoid being overwhelmed; rather, watching once or twice can be endorsed as a pragmatic practice during pandemic times.
Intervention for children
Guidelines in the present review have suggested guardians educate their children about COVID-19 in a developmentally appropriate way.,, Importance of such age-appropriate and child-friendly communication has been mentioned in general international guidelines  and other studies , on the health literacy of children.
Suggestion from guidelines , in the present review about encouraging the child to talk, enquiring them of their knowledge about COVID-19, and clarifying their queries about COVID-19 found a scientific resemblance with previous studies, UNICEF project, and professional ethics control, which has highlighted the importance of participatory approach which emphasizes on interactive responsive and voluntary and personal nature, rather than one-way communication with children.
Current recommendations and guidelines ,, relating to teaching children to avoid stigma by reminding the child that anyone may be diagnosed with COVID-19 irrespective of their religion, race, or caste are found to be in consensus with previous study  and a recent study  which have accentuated the link of stigma in increasing fear, outbreak, and treatment complications during the pandemic.
The relevance of physical activity and BA of children and young people in prevention and reduction of mental health symptoms and boredom are found considerably in literature.,,, Similarly, the proposals in the present guidelines to devise a routine for the child, including activities such as academic learning through fun activities, daily chores, indoor games, increased family time in vis-à-vis, and digitally if required, and teaching healthy respiratory etiquettes,, are seen.
Current recommendations , about keeping children with parents, unless unavoidable, agree with previous studies., These studies identify parents role in children's exposure to secondary adversities, helping children process the traumatic experience, restoring activities, rechanneling children from maladaptive thoughts to more productive endeavors and limiting children's exposure to media coverage.
The suggestion in literature ,,,, of the current review about an online referral to mental health professionals should be amenable across previous literature on disaster  if the distress persists in children.
The current study has a few notable limitations. We have not studied recommendations for mental health care of migrant workers who were enmeshed in shelter homes, distant from their native place, during the COVID-19 pandemic. A review of guidelines for such is suggested for further research. In addition, we have not much focused on the review of techniques that are novel like the use of structured letter therapy for consultation. Another inherent limitation was a choice of study design of selected articles as in the absence of empirical studies, at present, on psychological intervention, we focused on publications, along with government guidelines, inform of review, commentary, correspondence, letters to the editor, or editorials related to mental health intervention concerning COVID-19.
| Conclusion|| |
The current review has delineated a chronicled version of public health guidelines and scholarly recommendations of psychological strategies for mental health care of the general population, HCP, children, and elderly care during a pandemic in special reference to COVID-19. Psychoeducation from a credible source, curbing stigma, normalization of stress, BA and scheduling of activities with a bespoke blending of recreational, relaxing and daily chores, limiting media consumption, social support enhancement, staying connected digitally, fostering CR, avoiding psychoactive substances, and seeking online consultation of a mental health professional on need are advised for all. Besides these adequate rests, rotating shifts, short breaks during working hours, a frank assessment of the situation, seeking and sharing support from colleagues/supervisors, and online support for mental health care for HCP are recommended. In addition, for children, developmentally appropriate and participatory approaches of communication by caregivers are suggested. Although all such recommended management strategies are theoretically grounded and have been studied in other related settings, empirical studies specific to pandemic times are lacking; hence, we recommend such soon.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]