Mental Health Disorders during COVID-19 Pandemic: A Review

India prides upon its youth, but its youth is being tarnished by mental health ailments which are significant shareholders of India’s non-fatal diseases. It is a significant primary reason for increasing substance abuse, suicide, and violence among Indian youth. If one person is suffering from depression or any other mental ailments, then the patient's family, friends, and work colleagues are all affected by it indirectly or directly; these ailments affect a person’s capability to judge a situation and his capability. It is an invisible illness but clearly visible among youth, yet still stigmatized so much that people often fear coming forward and getting help. Fortunately, some stigmas have been reduced, but there are miles to go before people are as comfortable seeking help in other diseases. Mental illness is still treated as either untouchability or a reason to justify one's action. To overcome this problem, we need to educate the population from an early age to create a safe environment to come out and report mental illness so that the treatment and counseling can start as soon as possible to save those who are being pushed into the depths of darkness and instability. But to address this problem ultimately, we will also need competent psychologists and psychiatrists. The psychiatrist to patient ratio is currently 0.75 psychiatrists for 100,000 patients, and the optimum is above three psychiatrists for 100,000 patients. According to experts, the current pandemic will increase mental instability amongst the population leading to higher substance abuse, suicide, etc. Review Article Tiwari et al.; JPRI, 33(64A): 522-528, 2021; Article no.JPRI.81570 523


INTRODUCTION
According to the World Health Organization, health is "a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity." [1] Therefore mental health is an integral part of health; it is the foundation of well-being and effective functioning of individuals [2]. Key factors in maintaining mental well-being are prevention of mental disorders, treatment, and rehabilitation. Only by improving in all these areas can we achieve a society with good mental health and a healthy society as a whole. To promote mental health and reduce the causes of mental disorder we have to acknowledge the presence of mental health; according to a study conducted in the north Indian region about the perspective of people towards mental health, 60% of patients face derogatory responses from their family, and 39.8% faces these issues from their friends and colleagues [x]. To treat those affected as early as possible, apart from just reducing the stigma, we also need to boost the health in fracture to handle these patients effectively. India also needs to improve the standards of its rehabilitation centers.
Around the globe, before the covid-19 pandemic, most people were not aware of the seriousness of the word pandemic, but now everyone is aware and receptive to the information available. Similarly, a few decades back, people never considered mental health. In the 1940s WHO, defined health and introduced mental and social wellbeing as a part of health. But even today, for most people, health is a mere absence of any pathological disease and deformity.
From the above, it is clear that mental health is an integral part of health, and awareness about the same is currently low but rising. Now moving to facts and numbers, India is ranked as the most depressed country in the world [3]; around 14% of India's population has suffered from one or the other form of mental disorder in 2017. And if we look at a bigger picture, out of 7900 million humans on earth, around 450 million are suffering from mental disorders [4], [5]; which is 5.7 percent approximately. To give the reader a context, the total cases of covid-19 around the globe are 220 million, i.e., 2.8 percent approximately. We want to convey through these numbers that we already are suffering from a pandemic of mental disorders, and it is high time we acknowledge it and work towards creating a better world.
The main factors contributing to this mountain of mental disorders are: low income, disrupted work-life balance, low education, low doctorpatient ratio, the stigma associated with mental health, lower living standards, early exposure to social media, etc.
India launched its first national mental health policy in 2014 and revised the mental healthcare act in 2017. Its objectives were to provide universal, equitable, and affordable access to mental healthcare [6]. Yet even today, only a few people are benefited from this, and as this pandemic has added a vast number of mental disorders to Indian health care infrastructure, India needs to increase the awareness about the program and level up the infrastructure, and last but not least improve the doctor/consultant patient ratio. Imagine a scenario where the psychiatrist has a mental disorder; then the current ratio will be even worse. As the load on psychiatrists will increase tremendously due to the pandemic and many of them would also have lost their loved ones, these things will collectively contribute to the increasing number of cases of mental health disorders among mental health experts.
If failed to control mental health ailments, the outcome will be worse than the current pandemic. Untreated mental disorders include suicide, homicide, aggressive behavior, etc.

OBJECTIVES
To provide the readers with- 1. An overview of mental health 2. Overview of various mental health disorders 3. Mental health of health care workers 4. Overview of the standard methods available for the treatment of these disorders

MATERIALS AND METHODS
PubMed and Google search engine were used to search the following key terms-"Covid-19", "mental illness," "doctor-patient ratio," "anxiety," "depression," "national mental health policy," "stigma associated with mental illness," "mental disorders among health care professionals," " mental health and doctors" and from the results of these search such as articles and news were selected and used for writing this review. Microsoft Word tools were used to create the pie charts, tables, and other illustrations.

AN OVERVIEW OF MENTAL HEALTH
The world health organization (WHO) defines mental health as "a state of well-being in which the individual realizes his or her abilities, can cope with the normal stresses of life, can work productively and fruitfully, and can contribute to his or her community" [7]. In simpler terms, a person can be called mentally healthy when they can typically perform their day-to-day work and add something to their community while staying happy.
The key factors needed for maintaining mental stability are work-life balance, a positive environment, stable social life, and periodic break from work. Finally, a person should not be overburdened with responsibilities or work.
The main issue with mental health problems is that the person suffering from it cannot open up or communicate the issues they are facing with anyone because of the stigma associated with it.
Often the person suffering from mental health issues doesn't even realize that they are suffering from it even after repeatedly being told so by their acquaintances. Even when someone tries to open up, they often are neglected or made fun of, and even if they are heard, the other person in front of them generally are unaware of how to handle the situation and tries to uplift their mood temporarily rather than treating the root cause of the problem.

Depression
It is a type of mood disorder. It is generally considered a combination of mood fluctuation and shortlived emotional responses to day-to-day events, but it is a much bigger term described as depressed mood, lethargy, loss of interest, and enjoyment.

Anxiety
It can be defined as intense, excessive, and persistent worry and fear about everyday situations.

Schizophrenia
It is a combination of hallucination, delusion, disordered thinking, and behavior.

Bipolar Disorder
It is a brain disorder that causes changes in a person's mood, energy, and ability to function.

Obsessive Compulsive Disorder
It is a condition in which people have recurring thoughts, ideas, or obsessions that make them feel driven to do something repeatedly.

Post Traumatic Stress Disorder
It is seen in people who have witnessed a traumatic event such as a natural disaster, accident, or been to war, etc.

Phobia
It is an irrational and intense fear of something that poses little or no real danger.

MENTAL HEALTH OF HEALTH CARE WORKERS
May there be peace, war, or pandemic, hospital and health care workers play a crucial role in all these circumstances. The health care system and law and order, i.e., police, are golden assets. They are like the fuel for the nation; without health and law and order, any nation's economy will collapse as there won't be a workforce available.
Yet, the professions with the highest suicide cases and the maximum number of mental health disorders are among health care workers and police. The irony is that when doctors have a mental disorder are not able to get help due to various stigmas such as personal, professional, and institutional stigma.
The factors contributing to these high number of mental disorders among health care providers are workplace environment, inhuman working hours, lack of protective equipment, increased risk of infection to family members, and the recent pandemic resulted in even longer working hours and higher workload, with insufficient knowledge about the disease and horrifying visuals of people suffering and high death rates.
As doctors have to see death up close almost every day, and there are times when they can do nothing but ease the patient's pain, they face a lot of mental trauma daily. And in a country like India, where violence against doctors is increasing day by day, mental disorders will only go up if a safe and healthy environment with reasonable work hours is not provided. Along with all this, patients also need to understand that doctors are not gods and can't treat every disorder, there will be complications, and these situations will never be in anyone's control. Therefore, patients should be a little humbler and cooperative with doctors.
A study conducted in India focusing mainly on health care providers in Maharashtra reveals that 47% of the people had symptoms of depression, and 50% reported anxiety symptoms. Among 197 health care professionals assessed, 45% of them had low quality of life [9]. These numbers show the severity of the situation, as not much has changed even after two waves of covid-19, and the third wave is almost knocking on India's doors. The health infrastructure needs funds and safety and support in these difficult times. On the contrary, they only receive the backlash of someone's death and violence in return for their selfless services towards their nation.

Fig. 1. Flowchart of treatment modes
Self-treatment is helpful in problems with less severity, i.e., at the initial stage. It includes lifestyle changes such as exercise, reduced intake of alcohol, tobacco, and other intoxicants, and socializing with friends and family.

Psychotherapy
It is also known as talk therapy. Its primary focus is to make a person realize the source of the problem and make them more emotionally aware. The essential requirement for psychotherapy is an empathetic and accepting atmosphere. Even people without any mental disorder find therapy helpful. Therefore, it is often recommended for somatic treatment patients.

Somatic Treatment
It includes external drugs and methods which help in modifying brain function. A few methods and drugs used can be generally classified into two types: 1. Stimulants elevate brain functions and are useful in depressive disorders. 2. Depressants: These are used to lower brain activity and are helpful in excitatory disorders such as mania.

DISCUSSION
The failure to acknowledge the existence of mental health ailments by society is a prime example that the understanding of mental health is impoverished in society. The efforts of the government are falling short as the number of mental health experts in India is very low, due to which there is not much that the government can do, it can only start preparing for the future by promoting mental health and, at the same time increase the no of mental health experts as well as develop the infrastructure needed for management of mental health ailments. The corporate world has also started to work towards the mental stability of their employees, and only with the combined efforts of government and the community, a mentally stable world is possible. Once the stigma is reduced, only the actual number of cases will present themselves and gradually be managed. Counselling also needs to be promoted, and the number of councilors should also be increased.

CONCLUSION
To conclude, with the Covid-19 going on, the number of mental health issues will only increase as a large sum of the population have lost their jobs, many have lost their loved ones and were not even able to do their last rites properly, and those who were not severely affected by the illness and economic problems directly will undoubtedly be affected by the horrific visuals of the country and the world as a whole. Floating dead bodies in rivers, mass burials, nonavailability of medicines or hospital beds are just the tip of the iceberg. Many difficulties and horrific visuals created due to the pandemic will only lead to an increased number of mentally unstable people with PTSD and other mental disorders.
Everyone has seen the scenario where medical care was not available due to the heavy burden on our health system; mental disorders impose a similar burden, but the only difference between COVID and this scenario is that COVID is more fatal, but mental disorders leave the person alive without the will to live. Suppose appropriate steps are not taken to prevent and stop the boom of cases of mental disorder. In that case, the world is just a few inches away from another deadly pandemic which we won't be able to control with any vaccine.
In 2017 the president of India, Ram Nath Kovind, said, "India does not simply have a mental health challenge. It is facing a possible mental health epidemic" [10]. He also addressed a shortage of mental health professionals in the country. The ideal ratio is above three, and India's current ratio is 0.75. Even if India wants to fight against this deadly manifestation, it can't as the mental health professionals who are the nation's weapons against mental disorders are suffering from the same due to the excessive and inhuman burden on the Indian healthcare infrastructure [11][12][13][14][15].
To fight this situation, India needs to create more mental health experts, but first, it needs to develop an accepting and empathic environment, which will help the people to open up and thus reduce the number of cases that go unreported.
In creating an accepting environment, we need a nationwide campaign to reduce the stigma and collect the feedback of these campaigns; we also need extensive research in mental health and its associated areas. The primary motive of the campaign should be to help people acknowledge the existence of mental health and mental health ailments. The majority of patients constantly face criticism and comments that stop them from undergoing treatment. These researches help provide points around which a better policy can be formed and act as feedback but also help by finding out various new methods and factors that affect the mental health or helps understand the topic better.

CONSENT
It is not applicable.

ETHICAL APPROVAL
It is not applicable.