**3.4 Social impact on health care**

Based on health care the society was clearly divided into two strata during the pandemic- one providing health service and the other at receiving end. Patients developed anxiety, depression, panic, irritability, while the attendants developed a sense of uncertainty, helplessness, worthlessness and a fear of infection [1, 7, 17]. The kin of those who died developed prolonged grief, depression, substance abuse, and stigma related to spread of infection [7]. Inability to do a proper funeral further accentuated the problem. The visuals of ill treatment of dead bodies or mass funerals can further develop a sense of despair in individuals who could not say a proper good-bye to family and same could be for the families too. Another perspective could be for those persons who have their patients admitted in hospitals. They might develop fear of contracting the infection on one hand and on other might feel helpless in not being able to maintain social restrictions thus depicting learned helplessness [7].

Another special set of patients that needs special mention is psychiatric patients. Violence, addiction and disturbed routine follow-up were common issues faced by them. Xiao proposed novel approach of structure letter therapy while Saladino *et al*. and Zhou *et al.* emphasized the use of telepsychology and telehealth [11, 18, 19]. Another aspect for proper health care delivery to these patients would be to ensure that supply of prescribed medicines should be monitored and checked to prevent any lapse and family members or caretakers should also be looked for as they might develop their own set of problems.

On the other hand, psychological impact on HCWs could be very different. They felt overworked, unable to attend to family duties and guilt of not being able to save the patients. Those not involved in direct care of patients could have felt worthlessness for not being able to help [7]. Overwork can lead to burnouts, depression and anxiety [5]. Lack of facilities can also produce secondary traumatic stress disorder where HCWs have to decide who can access and who cannot access the facilities [20]. Lai *et al.* reported that nearly half of HCWs working in COVID wards had depression followed by anxiety and insomnia and nearly three-fourth had distress [21]. The problems faced by HCWs can be broadly labeled into three categories: those faced by them related to work and family needs, those faced by problems related to patient care and those faced by colleagues distress created by news of violence against doctors, work under poor safety guidelines, eviction of doctors from their rented house in various resident communities and death while providing services to patients. Though all three creates a similar type of stress pattern, psychotherapy shall aim at different roots when going for consultations. In most cases, these HCWs would not seek professional opinion and these distresses would be transient though theoretically affecting the patient care sometimes by reducing efficiency or indirectly affecting other colleagues or family member who might feel helpless in saving him or her.

### **3.5 Professional impact on training**

Trainee doctors and medical graduates were also affected in their training. Reduced patient contact led to decrement in development of skills [22, 23]. Surgeons faced redeployment and decreased operation theater postings which in turn affected their surgical skill development [24]. Adaptation to online learning and problems with submission of dissertation was also a challenge and all these stress added to psychological impact on them [24–26]. A positive statement was that with online classes and posting in backup teams, these trainees got time to let the steam off and de-stress them. The training of not only health care workers but also every sector suffered tremendously thus also creating a question mark for not only training modules in past but also in future of the trainees trained during COVID19. Although, detailed discussion is out of scope of this chapter.

#### **3.6 Risk factors for psychosocial impact**

Romm *et al.* reported that females and sexual minorities were at risk for increased depression while males were at greater risk for decreased physical activity. Whites when compared to Blacks were at greater risk for increase in mental health impacts while Asians had greater chances of alcohol abuse. Hispanics were at greater risk for decreased relationship quality, physical activity, and increased sedentary activity [27]. Fteropoulli *et al.* found that factors associated with poorer outcomes for psychosocial impact include medical profession, female gender, frontline work and use of avoidance as coping skill [6]. They also reported depression and burnout to be strongest predictors of poor quality of life parameters, similar to findings reported by Suryavanshi *et al.* in Indian HCWs [28].

#### **3.7 Pathophysiology- a fresh perspective**

So what caused this impact? This is not a direct impact of the virus. Let us consider COVID-19 as a stress- a newly found one (**Figure 2**), according the "third-eye model' [8]. It is a new experience and in some way have affected every person even the dead who could not get proper funerals and good-byes. And indeed that too has affected the living. **Figure 3** shows normal response to stress. Whenever a stress strikes, it tends to push the brain cycle into NREM phase. A person always tries to end it and mount a REM response based on conditionings in brain. Conditionings are the coping skills that a person had learned during lifetime, so technically children will have lesser conditioning than adults and young will have lesser conditioning than elders. Thus problems with children will focus on what they do as in difficulty in concentrating, boredom, irritability, restlessness, nervousness, sense of loneliness, uneasiness, and worries, while adults would have anxiety, depression, burnouts, loneliness, panic, and substance use disorders.

But not all people suffer from psychological impact at a given time. If one believes that the stress shall be controlled and it is indeed controlled then the behavior is more towards normalcy like with those whose income was not affected- pensioners, HCPs and government employees. Even though many times they worked under the fear of getting infected sometimes this fear was casual but at times where situation was not under control like working with limited supplies or exposure to large number of COVID patients or working long shifts, this could turn into anxiety or panic.

Whenever the stress is identified as stress like a person believes that abnormal response to COVID19 is validated, a justification happens for stress. If this justification is for a process that just a mirror image of what a person usually saw this could lead to adjustment disorders giving sense of irritability or loneliness to the person but if it backed by emotional turmoil or magnification where COVID19 is seen to impact the lives of people like never before killing thousands, breaking families, blowing the finances of families or simply loss of very close one who had no disease otherwise can lead to PTSD. It is often the effect of COVID19 that tends to cause adjustment disorder and PTSD than itself. Multiplied by isolation and long stays at home it is not difficult to imagine that bereavement reaction can also be prolonged.

*Perspective Chapter: Psychosocial Impact of COVID-19 – A Global Scenario DOI: http://dx.doi.org/10.5772/intechopen.104974*

#### **Figure 2.**

*Algorithm showing basic response to any stress (further algorithm is given in Figures 3–5).*

Now all of this may comprise a normal response to a pandemic because the person still has some control over thoughts of stress and often the problem would lay on impact of stress as in death of a person, inability to help others, financial breakdowns and social cut-offs rather than COVID19 itself. Once the stress is incorporated in psyche of an individual, the principle of inertia decides as to whether the psyche can overcome the persistence of thoughts. If it tries to overcome it, it searches for a manipulation (remember here the thoughts have persisted and cannot be simply overthrown by mounting a response as explained in above text). From **Figure 4**, we can see if the manipulation is specific to stress it can be lead to anxiety if the manipulation is feasible for psyche but patient cannot do that. Another common way to mount a response is to mount a response which is very feasible to psyche like washing hands repeatedly as in OCD or shifting to over smoking or over drinking for stress relief. Sometimes this substance abuse can be an excuse for stress where the patient may be trying to gain sympathy or needs a leave from workplace and do not want to malinger which indeed can be very common due to non-specific and objective complaints of COVID-19 which can be practically anything from myalgia to loose

#### **Figure 3.**

*Algorithm showing response when a patient can control the thoughts provoking mental stress and possible responses.*

stools. If the patient is already not ill can present with a spectrum of somatization and this could be for same reason except for the fact that malingering or claiming false symptoms is not feasible to psyche, i.e. the person does not want to malinger or do substance abuse which can be due to ethics, emotions or rationality.

Although, the above pathologies are not uncommon but another common response pattern is where the NREM state induced by stress is only controlled to some extent or cannot be controlled at all (**Figures 2** and **5**). In any of these cases, giving up to brain cycle is difficult as these people would have otherwise stronger will to control the brain. COVID19 is a pandemic and has affected everyone in some extent and thus does not target any specific group and is a boon for others. This feeling helps the person to control rather than be controlled by brain. Dysthymia has a definition to fulfill and can be underreported or can be diagnosed as depression by many. Low mood is not uncommon as it does not require any specific action from the person, it is like 'going with the flow'.

*Perspective Chapter: Psychosocial Impact of COVID-19 – A Global Scenario DOI: http://dx.doi.org/10.5772/intechopen.104974*

#### **Figure 4.**

*Algorithm showing response when a patient cannot control the thoughts provoking mental stress and still tries to find possible ways to control its inception in thought process.*

Each and every response can be mapped and the therapy oriented at that, however it is beyond the scope of this chapter to discuss every disease and intervention in detail [8].

#### **3.8 Future prospects**

Studying the impact can help us delineate the stress parameters and try to streamline treatment modalities. Saladino *et al.* recommended the same as primary prevention modality [11]. Under secondary prophylaxis, they recommended sensitizing the general populace on telepsychology, training next generation of psychotherapists in managing online devices and developing new tools of support and psychological treatment. However they mostly related to psychological issues needing treatment often the part unlooked is the iceberg below the tip. Those

#### **Figure 5.**

*Algorithm showing response when a patient cannot control the thoughts provoking mental stress and cannot find possible ways to control its inception in thought process.*

unreported psychological impact can be overcome by better preparedness for next pandemic by government, people, and society in general. A change is inevitable so rather than resisting the change, we shall look at its brighter side: incorporate healthy habits, give time to family and friends, look at education in terms of learning and prepare for medical emergency.

#### **4. Conclusions**

The visuals of people dying despite best health facilities puts the question forward for us as to what are we in front of nature? How much have we learned and how much we are we prepared for catastrophe? The rapid response and adaptability of general population cannot be overlooked. But it has left a deep impact with long term unforeseen effects. We shall not only study the effects in its past form but also anticipate further damage it can cause in late future. Other than teaching us the fact that we need a lot of medical preparedness, it also taught us that healthy individuals can also become transiently stressed and show symptoms which may not be deemed as psychologically fit. This blemish had to be erased to bring people to talk about psychological issues with even non-medico or non-psychiatrist friends and colleagues. Ignorance had been a bliss for ignorant but not for those who suffered in silence. It is the awareness that has brought us together in the face of crisis.

*Perspective Chapter: Psychosocial Impact of COVID-19 – A Global Scenario DOI: http://dx.doi.org/10.5772/intechopen.104974*

COVID19 came as wave and swayed the humanity. Different states of individual showed different responses to the same stress creating a gamut of responses which led to different socio-economic, socio-political, professional and psychosocial impact. Identification of stress, mapping of response and a better preparedness from experience can all help us in preventing and controlling it next time.
