COVID-19: South Africa in psychological distress

"Pandemic is not a word to use lightly or carelessly. It is a word that, if misused, can cause unreasonable fear, or unjustified acceptance that the fight is over, leading to unnecessary suffering and death" said Dr Tedros Adhanom from World Health Organisation (WHO) (Valentic, 2021, p. 1) As the world waged war in 2020 on an invisible enemy, "COVID 19", the impacts experienced across the world have been profound. This paper provides the background, origins and events leading up to COVID 19. The impact the virus has had psychologically on the population and society worldwide and in South Africa will be discussed. The literature relating to the psychological impacts of the virus and the suggested interventions will be critically reviewed as their relevance is considered within the South African context. Finally, the core issues relevant to interventions within South Africa will be discussed and considered. 

In December 2019, an outbreak of pneumonia was experienced in Wuhan, Hubei Province in China, which was linked with the severe acute respiratory syndrome (SARS) coronavirus 2 (Zi et al., 2020). Coronavirus is one of the significant microbes that principally focuses on the human respiratory system (Rothan & Byrareddy, 2020). Rothan and Byrerddy state that the patients admitted with the initial diagnosis of pneumonia were epidemiologically linked to wet animal markets and seafood. Zi et al., states that, in the weeks that followed, the infection of coronavirus spread rapidly in China and worldwide. The virus is deemed highly contagious and, due to its severe respiratory implications, is associated with high mortality rates (Lone & Ahmad, 2020). At the end of January 2020, the World Health Organisation (WHO) declared the outbreak an "international emergency", and on the 12th February 2020, they named the disease "coronavirus disease 2019" (COVID-19) (World Health Organisation (WHO), 2020). The clinical symptoms of COVID-19 may include fever, tiredness, diarrhoea, nausea, headaches,  loss of smell and taste; however, one may also be asymptomatic (Zi et al., 2020). COVID-19 has no available vaccine and, therefore, preventative measures were introduced throughout the world to reduce the spread of the virus. These measures included social distancing, national lockdowns, isolation (quarantine) and travel restrictions and, whilst they were implemented to contain the spread of the virus, they also wreaked havoc with the economy (Lone & Ahmad, 2020). There was, simultaneously, a saturation of media coverage of the disease and, in particular, regular updates on the number of people infected with Covid-19 and the number of resultant deaths. This contributed to a culture of fear amongst large sections of the world population. As the world went into social isolation with all attention focused on flattening the curve, beneath the surface, a further impending health crisis was brewing. The experts are predicting a "tsunami of psychiatric illness", with the World Health Organisation (WHO) and the World Psychiatry Association raising awareness of this critical mental health crisis (Guterres, 2020). Brooks et al., (2020) state that, based on empirical findings, the factors which increased psychological distress during quarantine are as follows: (1) the duration of the quarantine: longer periods correlated with a significant decline in mental health, (2) the fear of being infected or spreading the infection, (3) the feeling of being confined, bored, and alone, and the loss of routine, (4) not having sufficient basic supplies during the quarantine (food, water and shelter), and (5) a lack of information or clarity leading to stress and uncertainty. 

Tanhan et al., (2020) state that the mental and emotional turmoil which has been triggered as a result of COVID-19 will have far-reaching effects. Areas of concerns include depression, anxiety, stress, isolation and feeling alone, depression, behavioural disorders, post-traumatic stress disorder, burnout, and substance abuse issues. This range of mental health concerns creates stress at an individual, group and community level, therefore affecting the individual and society at large.  

Guterres (2020) acknowledges that the psychological distress is worldwide and many people are concerned about the direct impact of the virus on their health but also on their family and the potential loss of loved ones and family members. Furthermore, a vast portion of the population is confronted with financial concerns, having lost or being in danger of losing their income and livelihoods, and being unable to support themselves and their families. This also leads to the stress of a potential loss of social status. Furthermore, the constant misinformation about the virus and uncertainty about the future is also a common source of stress. Dong and Zheng (2020) acknowledge this source of stress, and refer to it as an unofficial psychological disorder known as "Headline Stress Disorder" first defined by a psychologist Dr Steven Stosny. He claims this is a heightened emotional response to a constant stream of reports from the media, thus resulting in feelings of severe anxiety and stress. 

As the world began reeling from COVID-19, South Africa was filled with a silent dread that once again, the world would watch them emerge battered and bruised as they have before (Naidu, 2020). Naidu (2020) states that South Africa has a history of having been ravaged by the effects of apartheid, the HIV pandemic, and excessive mental health issues that became of great concern as they exceeded levels seldom seen outside of wartime. COVID-19 in South Africa is representative of another trauma in addition to the collective traumas this country has faced. All of this accumulated trauma on the already fragile mental health of the South African population, is expected to cause a sharp rise in mental health issues. 

In order to address the issue of the mental health of the population, therapeutic interventions and strategies would need to be implemented in order to deliver mental health care to persons affected by the COVID-19 pandemic. This raised the concern that, within South Africa, one of the many obstacles that would be faced whilst considering interventions to assist with mental health issues in the population was the perception amongst the black community that COVID-19 was only a "white people's virus" (Kim, 2020, p. 2). Kim further explains that some individuals also believed that China created the virus as part of a conspiracy to gain control and implement regulations in order to reinforce their power. The implication of these perceptions would make it challenging to implement the necessary healthcare interventions and to enforce the COVID-19 guidelines in order to prevent the spread of the virus.   

Rajkumar (2020) reviews eight studies which explore the underlying reasons for the mental health impact of COVID-19 on the population. The studies used were from Brazil, Singapore, Japan, Iran, Canada and China. The study from Iran emphasised the role of uncertainty, the significance of the illness and social isolation, and misinformation as being a leading contributor to stress and mental health concerns (Zandifar & Badrfam, 2020). The authors also emphasised the need for mental health services with a focus on vulnerable populations. The study from Japan (Shigemura et al., 2020) emphasised the impact of COVID-19 on the economy and the knock-on effect of well-being with high levels of panic and fear behaviours manifesting in stockpiling resources. This study focused on those individuals deemed to be at higher risk of mental health concerns such as patients who had contracted the virus, their family members, health care workers, and individuals who had existing mental health disorders. (Lima et al., 2020) states that the dominant response to the pandemic is that of anxiety. The papers from Canada (Asmundson & Taylor, 2020) refer to health anxiety as an outcome of COVID-19 stress. This is explained as bodily sensations that one misunderstands during the outbreak of an infectious disease which is further heightened by misleading or sensationalist information from the media. 

At an individual level, the health anxiety can become excessive and manifest as maladaptive behaviours such as repeatedly visiting a medical practitioner or stockpiling items they believe they will need. At a societal level it can manifest as mistrust of authority figures such as Government. The authors underlined the need to increase evidence-based research into health anxiety so that interventions could be implemented to combat this (Asmundson & Taylor, 2020).   The factors outlined above would also be causatory of the rise in mental health issues in South Africa. However, in addition to these factors the South African population had one of the world’s strictest national lockdown regimes imposed on them which only allowed individuals to leave home to get food, medical treatment, or for work in essential services (Kim, 2020). Kim (2020) also explains how, in contrast to other countries, the Government in South Africa imposed strict rules regarding inter-city and intra-provincial travel, and a complete ban on the sale of cigarettes and alcohol. The sudden termination of these products would only serve to heighten stress and anxiety amongst those who were dependent on the product. Furthermore, non-adherent communities were dealt with harshly by way of police brutality, military enforcement, and the demolition of informal settlements, thus resulting in traumatised and mistreated families across the country. This was particularly the case in low-income communities which lacked the resources to comply with the lockdown rules, with high-density living conditions being a significant factor All of these factors, compounded with the context of racial inequality, further contribute to the already fragile mental health of South African society where statistics show that one in three individuals in their lifetime will develop a psychiatric disorder (Herman et al., 2011; Reddy et al., 2020). 

The mental health risks of vulnerable populations during COVID-19 are reviewed by Rajkumar (2020), making use of seven studies across various countries.  The vulnerable populations as identified in these reviews are the elderly (Yang et al., 2020), migrant worker, the mentally ill, the homeless, and pregnant women (Duan & Zhu, 2020; Tsai & Wilson, 2020; Yao et al., 2020). Yao et al., (2020) state that individuals with pre-existing mental disorders are at a higher risk of relapsing or developing new symptoms due to the increased levels of stress associated with COVID-19. Application of the above to the South African context reveals that a large portion of these vulnerable populations within South Africa have limited access to healthcare. Docrat et al., (2019) states that only 27% of patients who have severe mental illness in South Africa are receiving care and only 16% of the population has medical health insurance. Furthermore, research shows that mental health expenditure in South Africa is only allocated 5% of the total public health budget (Docrat et al., 2019) . Before COVID-19, it was reported that depressive symptomology was on the increase in South Africa, and findings show that it was fuelled by social marginalisation (Gibbs et al., 2016). The study confirms that depression was rising rapidly in informal settlements, and socio-economic factors and the role of gender inequality were contributing significantly to this rise in depressive symptomology. The impact of COVID-19 on women in South Africa is alarming as the unemployment rate of black women increases further, there is an increase in the domestic and childcare burden, as well as a rise in domestic violence during the lockdown period (Pillay & Barnes, 2020). South Africa has also experienced an increase in stigmatisation, discrimination and violence towards the LGBTI community since the lockdown was imposed (Pillay & Barnes, 2020). In addition, South Africa’s high HIV infection rate also contributes to increased mental health struggles. Healthcare workers in South Africa require support as they are instrumental in the fight against Covid-19. They are working long hours in facilities which lack resources and in a profession that requires emotional and physical stamina. This places them in a highly vulnerable position and highlights the importance of interventions focused on these frontline workers.

Rajkumar (2020) reviews five papers which look at addressing the specific strategies used to deliver COVID-related mental health care (Duan & Zhu, 2020; Liu et al., 2020; Xiao, 2020; Yao et al., 2020; Zhou et al., 2020). Specific therapeutic strategies noted from the papers include the suggestion of a team of qualified specialists who can address emotional anguish and the training of community members who practice in the health sector (Duan & Zhu, 2020).  Liu et al., (2020) propose making use of surveys (online) to gain an understanding of the mental health concerns the population is facing. Further proposals include developing online material which can be used to psycho-educate individuals on mental health and the implementation of online therapy and self-help services. Xiao (2020) suggests the use of structured letters as a form of asynchronous teletherapy consultation, which will include a component of diagnosis and counselling (Zhou et al., 2020). 

Online platforms have been recommended as an avenue for providing mental health services.  Liu et al., (2020) state that in China, mental health professionals have made use of internet services and smartphones to provide online mental health services during COVID-19. This was deemed to be a "safer" option as face to face psychological interventions would pose a risk of transmitting the virus. Counselling services were provided via 24 hour online platforms by health professionals and students throughout the country. The online self-help option was also available using Cognitive Behaviour Therapy (CBT) techniques to treat depression, anxiety and insomnia. There was also the use of artificial intelligence to flag individuals who were posting on the sites that were deemed to be a high risk for suicide. They would be contacted and assisted accordingly. Liu et al., adds that further online platforms such as Weibo and TikTok were also used during the outbreak as a way of providing psycho-education to the public and health workers. 

Yao et al (2020), however, raise the concern that online mental health services may not be accessible to individuals who are from a lower socio-economic status. This concern is highly relevant in South Africa where unemployment, discrimination, poverty, and disease are some of the pre-existing societal conditions which foreground the ability to implement health care interventions (Kim, 2020). Further concerns relating to online use is the high cost of data and internet devices which would be required to partake in these interventions. This is unfortunately not accessible to those from vulnerable populations. 

When considering the recommendations and interventions used in other countries, it becomes apparent that the context of South Africa requires further exploration as there are some unique factors at play. The healthcare system of South Africa was burdened before COVID-19 and is now so heavily burdened with the additional pressure on hospitals and healthcare workers that the lack of resources is exponential. The strategy of training community members or healthcare workers, whilst beneficial in the long term, places a demand on resources that the country does not currently have. South Africa can make use of online platforms as a way of providing counselling services. However, this would only be reaching that small segment of the population who have access to electronic devices and internet usage. This is a critical consideration relating to the online services as it poses the risk of excluding the vulnerable lower socio-economic segment of the population who are predisposed to suffering from mental health issues. Further to this, ethical considerations regarding privacy, confidentiality and the expertise of the person providing the online therapy need to be factored in (Yao et al., 2020). 

Liu et al., (2020) state that, in China, they developed several books relating to the prevention of COVID-19 and psychological self-help books which were published and made readily available to the public at no cost. Whilst this idea of using self-help books is beneficial and could be distributed and made accessible, one major obstacle within South Africa is the large segment of the vulnerable population who are uneducated and thus unable to read. Further to this, South Africa has 12 official languages, making the translation of such material into all languages burdensome and expensive. Xiao (2020) suggests structured letter therapy as a way of engaging in psychological services whilst adhering to social distancing rules. The benefits of this approach are that it merges consultation, diagnosis and treatment into one letter-writing exercise. This serves as a suitable method of communicating with a mental health specialist and serves as an outlet for the individual. However, within the South African context, the letter writing technique could be problematic once again due to the issue of illiteracy and the numerous languages as mentioned above. Pimple and Agrawal (2020) explain that, in India, an approach was adopted using positive psychology as a basis. Their findings show positive results in using the practice of yoga, mindfulness, meditation and positive psychology interventions (PPIs). Focusing on positive experiences can assist in combatting negative emotions being experienced during COVID-19. Whilst there may be South Africans who can engage in positive psychology, this may be a difficult concept for those that subscribe to more traditional practices. There is also the constraint of sourcing a sufficient number of professionals in this particular field, conversant in all 12 languages and able to reach all areas of the country. This could be interpreted as not being culturally sensitive or being directed only at a higher LSM segment of the population. However, there are benefits to understanding self-care, implementing breathing exercises and mindfulness as a way to decrease stress in one's life and this approach should, therefore, be considered as a potential option. 

The core issues in South Africa, which are relevant for interventions, are firstly the immense pressure that COVID-19 has placed on an already depleted healthcare system.  Healthcare workers are deemed the most important resource as they operate on the frontline to care for those infected with COVID-19 (Robertson et al., 2020). The frontline healthcare workers will primarily feel the impact of this as they attempt to juggle their professional duties with their own fears of contracting the virus, the safety of their family members, financial constraints and their well-being. The questions this raises is how does one intervene in the South African context in a way that can be meaningful. Robertson et al., states that healthcare workers can only respond effectively to their duties if they are mentally and physically healthy. As the pressure increases, they run the risk of suffering from psychosocial stress which can impact their ability to function optimally. In order to ensure that they are supported, it would be suggested that the primary intervention be targeted at them by providing psychological support in the way of online counselling individually or even in groups. 

Further to this, it would be beneficial to psycho-educate healthcare workers on how to implement stress management strategies, implement training on resilience and self-care, and ensure they understand the importance of work/life balance (Robertson et al., 2020).Further to this is the immense poverty experienced by the population, the lack of access to healthcare, the stigma of mental health issues, and over-crowded living environments.  All of this results in an increased exposure to Covid-19 due to the lack of resources and people fearing judgement or stigmatisation; in addition, individuals do not have sufficient means to acquire their basic needs. Poverty will also impact the population's access to resources such as the internet which makes it challenging to provide psychological interventions online. The crowded living conditions have put vulnerable populations at risk of spreading the virus and increased their incidence of mental health issues. It has also made it challenging to implement interventions which can be done (without social contact) via psycho-education using means of reading and writing as there are elements of illiteracy in the more vulnerable populations. Disadvantaged communities have also not had access to information which can assist them in being educated on the virus and the procedures and protocols they need to follow. Culture and religion is also a challenge as the population of South Africa have diverse cultures. This impacts their worldview and their ingrained belief systems. As a result, they may not be open to non-traditional ways of seeking treatment; as a result, interventions need to be developed that are culturally sensitive. Ultimately referral pathways must be provided to the community so that they can make use of free services such as SADAG, Lifeline and Childline. 

This paper has mapped the events originating in Wuhan, Hubei Province in China, which lead to the Pandemic of COVID 19. The impact of the virus has been discussed touching on the far reaching social, economic and health implications which have left the world and South Africa in a state of psychological distress. South Africa has faced a range of socio-economic challenges and disparities that make interventions difficult or near impossible. International literature on various psychological interventions has been critically reviewed to evaluate their relevance in the South African context. The need for intervention in South Africa is clear, but there are many challenges to the methods being used internationally. Literacy levels, cultural differences and limited access to the internet are three such challenges. Nonetheless, a collaboration of some of the proposed interventions can be used to reach as much of the population as possible in order to deal with the many mental health issues being exacerbated by this invisible threat.

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