The unprecedented pandemic of Covid-19 has caused worldwide mortality and morbidity with three successive waves of the disease. It has destroyed the world economy and trade and social life too. There is heightened concern about the mental health issues and challenges to the general population, COVID-19-infected patients, elderly, children and even health professionals. This article discusses the various mental health challenges in the wake of COVID-19 pandemic.

The corona pandemic originated in Wuhan province in China in December 2019 and soon spread out to the whole world and in three successive waves has caused unprecedented death and disease (Sahai et al., 2020). This extremely contagious and deadly virus has so far claimed over 6.5 million lives and has affected over 549 million lives worldwide (Worldometer, 26 June 2022). SARS Cov-2 or COVID-19 as it is commonly known is the most significant and widespread pandemic known in the recent memory. The zoonotic viral has undergone several mutations with each new mutant more contagious than the previous one and COVID-19 has emerged as a major health crisis going on in the world currently. Over the past two years, there is a significant increase in mortality and morbidity due to this pandemic. With the disease still not giving any indication of tapering or getting tamed by the vaccines, countries are grappling with procuring the vaccines, personal protection equipments and precautionary measures with varying degrees of success (World Health Organization 2020a). WHO has mandated prevention or reduction in person to person contact, frequent washing of hands, and use of masks in public places for the containment of the disease. Medical professionals were the first line of casualty in the spread of the disease as the virulence of the pandemic was unprecedented and unknown. Later a very strict protocol of washing hands frequently and safe distancing emerged as the only way to reduce the risk of contamination and likely infection. The spread of the disease in three successive waves was so endemic that almost all the households suffered either having a death in the family or a family member seriously affected by the disease. Those who survived also went through a serious trauma both physical as well as financial crisis. The cost of treatment skyrocketed and coupled with widespread disruption in the industrial activity, the two year period was very tough on the people all over the world. During this period there were increased instances of mental health issues. These mental health issues arose due to the fear of death or due to a loss of family member or a financial distress, loss of job etc. the mental health issues were more severely felt by the elderly, children and people with daily wage earning jobs as they were the highest risk individuals (Duan and Zhu 2020; Chen et al. 2020 ). As the crisis was a never before occurrence the international health organizations were not prepared to deal with the mental health issues arising out of the pandemic.

Ever since the influenza outbreak of the a hundred years ago the world has not seen any killer disease on the scale of COVID-19. The footprint of COVID was very large and it affected the public health and the health support systems badly and exposed the unpreparedness of the systems to meet any such eventuality. The average mortality rate in the first and second wave was a little under 2% of the affected population with second wave being most dangerous and fatal. Following the second wave entire countries had to be locked down and the prolonged lock downs further affected the mental well being of people. People suffering from co-morbidity were susceptible to more serious clinical outcomes than those free from it. The psychological impact of the disease and the impending death or the risk of contracting the disease made people paranoid about sanitation and cleanliness and social distancing that the fear psychosis gripped them all (Wang et al., 2020). Previous studies such as the SARS and MERS have shown that following the recovery phase of the pandemic cycle affected more individuals from social and psychological stress (Bobdey and Ray 2020). The aged, children and at times the adults of the family who had to be confined for long periods in their home exhibited the early onset of the infection. Due to online switch of work and life, people and children spend more time either in home or watching their computer or mobile screens. The person to person exchange between people came down drastically and the physical exercise also went for a toss. People who just sat at home and worked from home settled in a cozy life and faced risks of heart attack and general fatigue months after their recovery.

The lockdown and the closure of schools and day care facilities also caused trouble for working women as while they stayed at home, they had to take additional responsibilities. COVID-19 was something for which no one was prepared and people were not emotionally prepared to take up childcare and old age relatives’ care at home while at the same time coping with their work pressures. This was particularly notable in the case of health workers (Heckman et al. 2020).

The communist Government of China, due to its image, was blamed for several conspiracy theories for the origin of Covid-19. There were unconfirmed rumours of a deliberate effort to spread the disease to an experiment in biological warfare having gone wrong and this was fuelled by the television and print media. During the lockdown people were looking for news and information and were more than willing to consume. Several scientific studies also came down forecasting the spread and end of each successive waves and were cause of further panic and fear among the people. The pandemic disrupted all walks of life including health, society, business, education and the world economy (Djalante et al. 2020).

COVID-19 pandemic emerged as a global health crisis with the diagnosis and discovery of a remedy not available instantly. Further the lagging health issues for the survivors would have taken a long time to discover and treat. Even at present (June, 2022) the after effects of COVID-19 are still being documented and a complete listing of the mental health issues arising out of COVID-19 is not yet available. There have been several studies evaluating the issues of mental illness and health and slowly the information is

trickling in for analysis. We discuss the mental health issues seen by the general public, people with co-morbidity issues and finally the frontline healthcare workers in the following sections.

With the unending onslaught of COVID-19 and the speed at which it spread, affected and claimed the lives, it created a general state of panic and stress. Coupled with the stress arising out of the job losses and large scale migration and the fear of the impending illness and possible death raised the mental health issues such as stress and anxiety. Incomplete and inadequate knowledge about the cause of the pandemic, type of the virus, incubation period and the duration of illness, availability of traditional treatments and lack of proven safety measures caused further fear and anxiety sending people scurrying about more information which was not available in the first place (Dasgupta and Sahai, 2020; Ho et al. 2020; Goyal et al. 2020). Initially the three week lockdown was thought adequate to contain the epidemic was gradually increased to six months and this led the common public to believe that there was no end to lockdown and this fuelled the fear of the unknown and uncertain future with no remedy or treatment for the virus in sight (Li et al. 2020). The lockdown further gave rise to monotonous life, disappointment, helplessness, listlessness and irritation during the lockdown. Goyal et al. (2020) reported wide-ranging health issues which could aggravate pre existing health disorders and also give rise to new maladies. Rath et al. (2021) discussed the listlessness and anxiety leading to a rise in cases of suicides during the lockdown. There was no vaccine available for the first year of the disease and amid a lot of uncertainty over the rising mortality rates coupled with lack of the medical facilities, ICU beds spread the fear of dying , falling sick or contracting the contagion from those affected by the disease led to a spurt in cases of mental disorders and breakdowns (Goyal et al. 2020).

Those suspected of having COVID-19 contagion have generally felt some kind of social exclusion as the disease was known to be highly contagious and virulent and without any cure almost always fatal. Early in the pandemic it was nearly fatal all the time and by the time second wave receded some precautionary protocols were known (Wang et al. 2020). The governments resorted to placing people in quarantines where the relatives were not allowed to see or visit them. In many cases the patients never returned alive and there was a fear that once picked up for quarantine there was no way to recovery. Further governments all over the world resorted to marking the affected houses, buildings or entire societies as containment zones which were carefully avoided by all. People in quarantine had nothing to do with even the healthcare workers taking all precautions and keeping minimum of contact. This led to the quarantined people to endless boredom, anxiety, despair and hopelessness and even suicidal tendencies. The survivors who returned after several days in quarantine faced difficulties in re integration in their families due to the unknown nature of the viral disease and a fear of relapse. These survivors therefore experienced symptoms of withdrawal, loneliness, anxiety and depression. Due to emphasis on safety measures, washing of hands after touching any surface which might be contaminated many developed obsessive compulsive disorder (Li et al. 2020). Till the vaccines were authorized for use several medications were tried as a possible cure for Covid-19. Corticosteroids were also prescribed to save the patients with known cases of co-morbidity like hyper tension and sugar and these had adverse effects at times which included spurt in sugar levels or arrhythmic heart beat. Symptoms of COVID-19 such as high fever or reduced oxygen levels or loss of smell and taste led to heightened stress, anxiety and mental stress in people. COVID cases were almost always associated with heightened psychological fear among the affected people (Liu et al. 2020).

The family members and close friends of the affected people also came under the clouds of stress. One they had the uncertainty about the health outcome of their close one and two they were afraid to get the disease themselves as it was almost inevitable. Fear of being drawn out to quarantine and not being able to see the family again caused a great psychologically traumatic experience for the family members and friends. Instances are known where closest family members stayed away from the cremation of the dead family members and friends (Goyal et al. 2020). Young patients who were sick or quarantined had deep traumatic stress and were likely to develop grief and desolation (Shah et al. 2020). Post traumatic stress disorder was reported among one third of children. Loss of one or both parents also caused severe mental health issues including mood disorders or suicidal tendencies (Shah et al. 2020; Rath et al., 2021).

COVID-19 pandemic was a worldwide medical crisis and the doctors, nurses, paramedics were immediately pressed into service. Such health workers had a high risk of contracting the disease from the patients. The demand for healthcare arose dramatically. Many countries including India had a high population density and low number of doctors per thousand population as compared to the developed nations. However during the pandemic even the developed nations did not do any further. In India the final year students were pressed into service to meet the shortage. The frontline health givers were constantly exposed to the infection and many succumbed while serving in the hospitals. Increased workload, longer shifts, sleep disorders isolation and uncomfortable protective wear for healthcare workers resulted in emotional disturbances and sleep disorders (Ho et al., 2020). The healthcare workers reported depressive symptoms, anxiety and stress due to high fatality of patients and fear of contracting disease themselves. Further there were fewer opportunities for providing counseling to the overworked healthcare workers who worked under constant threat of infection of the deadly virus. They not only exposed themselves but also unwittingly exposed their family members at a heightened risk level. Following a daily decontamination routine of washing hands, bathing and disposing of protective equipment and washing of clothes before being able to be in the company of their family. Many healthcare workers maintained a distance from their children and wives to protect them and faced psychological issues like stress. Frontline health workers frequently reported mental disorders such as withdrawal, anxiety, stress and emotional disturbances (Goyal et al. 2020).

Old age reduces immunity to fight infections. There are several people who had preexisting conditions of hypertension and sugar and they were at a heightened risk. Many casualties were reported from patients who were older than 60 years or had blood pressure and diabetes. This group of people was placed at a high risk of mortality and therefore developed a high degree of fear, worry and concern for their health and life. This led them to psychiatric shocks which arose due to mental disorders and reduced levels of immunity (World Health Organization, 2020). Those with known severe mental illness were the worst affected during Covid-19. Those with chronic cases of diabetes, heart or kidney diseases faced difficulties in getting regular medical care as hospitals reserved space for treating COVID patients on priority. Further no patient would be admitted unless he was COVID negative and this led to several patients dying as they waited for the test reports.

During the pandemic a sharp focus was placed on finding the cure and isolating the affected and containing the pandemic by lock downs or movement restrictions. Not much attention was initially given to mental health issues for those locked up in their homes. Due to lack of socialization opportunities and prolonged stays at home people faced emotional breakdowns. Ho et al. (2020) showed that a sudden outbreak like COVID-19 can have a devastating effect on the mental health condition of those with preexisting mental health issues.

The constant and at times incorrect news reporting on print, electronic media and social media a distressing situation emerged. To cope with such a situation, Center for Disease Control in US advised to reduce exposure o news, to stay in touch with friends and family and positive thinking through yoga and meditation and similar practices (CDC, 2020). During attacks and bouts of anxiety the patients are advised to use controlled breathing, sharing with friends and trying to get some sleep. Psychiatrists from the government hospitals started help lines especially for patients who needed mental support and succor (Rath et al., 2021). People can combat mental health issues with support and also change in lifestyle.

COVID-19 has caused unprecedented mental health issues yet there is a dearth of research in these issues. Now that the three waves have receded, the severity of the mental health is being recognised. Those affected by the viral epidemic are still nursing their wounds and are discovering newer challenges as they unfold. With the life back to normal after nearly two traumatic years it is time to take a new look at the mental health issues such as stress, post traumatic stress, anxiety and depression. Practices such as spirituality, religion, yoga and breathing techniques in conjunction with psychiatric consultations are likely to help people regain the control of their lives. There is a need to evaluate the suitability of online psychotherapeutic assistance during such unforeseen yet important events.

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