[UPDATE: A day after the publication of this article, the Ministry of Health announced that allied health services – such as psychology – conducted outside of public healthcare institutions have been re-categorised as essential services, effective from Wednesday (29 April). Read here.]
SINGAPORE — Growing fears about unemployment and the adequacy of medical or food supplies amid the COVID-19 pandemic in Singapore.
Heightened tensions within an already fractured family during the circuit breaker period.
A sense of impending doom and frustration as more safe distancing measures are implemented, blurring the boundaries between work and personal space.
These are among the mental health issues faced by Singaporeans attended to by psychiatrists and counsellors, who have seen a rise of up to 30 per cent in patients in the past few months.
Such anxieties about an unstable future permeate every level of society, experts observed, from students, taxi drivers, home-makers, young couples, civil servants, to even top-level executives.
“The COVID-19 pandemic has created an unprecedented state of uncertainty across the world, and is understandably affecting the mental health and well-being of many individuals,” said Dr Marcus Tan, consultant psychiatrist at Nobel Psychological Wellness Centre, a member of Healthway Medical Group.
“(But) the psychological reactions we are seeing during this pandemic are normal responses to this abnormal situation.”
Studies into the mental health impact of previous outbreaks, such as the 2002-2003 severe acute respiratory syndrome (SARS) epidemic, showed an increase in suicide rates and the number of health care workers who had experienced emotional distress.
But the impact of the COVID-19 is unprecedented, as billions around the world struggle with being isolated and facing the prospect of a prolonged pandemic even if social distancing measures were to be eased.
Experts have warned of the pandemic’s "profound and pervasive impact" on global mental health.
The novel coronavirus, which emerged in China as early as November last year, has infected over three million people globally and killed almost 208,000 to date.
Singapore’s first case of COVID-19 was reported about two months later on 23 January. In a span of just three months, over 14,000 here have been infected – the majority of whom are foreign workers living in dormitories – while 14 have died from COVID-19 complications.
As numbers spiral into the thousands, the Singapore government announced the decision to extend the city-state’s partial lockdown for an additional four weeks till 1 June, with tighter controls in place.
“Since January, we have seen an estimated 20 to 30 per cent increase in the number of new patients at our clinic,” said Dr Tan, noting that the majority of them present with symptoms of anxiety and depression.
These can include physical symptoms such as elevated heart rate, hypertension, headaches, increased sweating or gastrointestinal discomfort.
However, there have been one or two cases who present with acute reactive psychosis, “a more severe form of response to stress”, Dr Tan added. People who suffer from such psychoses can encounter delusions, speech disorders, and hallucinations lasting from a day to even a month.
Rise in obsessive behaviours
One patient he saw – a middle-aged office worker – had started experiencing panic attacks during the initial days of the pandemic while he was overseas for work.
Following the man’s return to Singapore “after some difficulty”, he continued to remain anxious and suffered frequent panic attacks.
He was also “obsessing about” having contracted the virus, despite him – and his family members – having been well for more than a month after his return, Dr Tan said. The man’s condition has since stabilised while he is on a regime of medication and psychotherapy.
Another group particularly affected by the pandemic are those who suffer from mysophobia – a pathological fear of contamination and germs – observed Praveen Nair, director and senior consultant at Raven Counselling & Consultancy.
“The present situation, with all the palpable warnings, has made it difficult to control ritualistic tendencies, such as the excessive washing of hands,” said Praveen.
For instance, a client of his, who had been diagnosed with obsessive-compulsive disorder (OCD), was very reluctant to leave his home prior to the roll-out of the “circuit breaker” measures in April.
The number of times he displayed his ritualistic behaviours had also increased. These included holding his breath while taking the lift and wiping down almost any surface within one metre of his body with wet wipes, said Praveen.
Tensions at home
With more families in lockdown worldwide, higher rates of domestic violence have been reported in several countries, prompting the United Nations to call for urgent action in combating a “horrifying” global surge in such abuse.
Similarly, authorities here said they have received more referrals and inquiries related to domestic conflicts than before the start of the circuit breaker period.
Sheena Jebal, principal counselling psychologist at NuLife Care and Counselling, noted that more households – with pre-existing family issues – have approached them for counselling during the circuit breaker period.
In the case of one young teenager, her mental health was improving before the partial lockdown but dramatically worsened once she was made to stay home with her family, according to Sheena. Among the signs, the patient was slipping back into depression and suicide ideation.
Due to the family’s huge age gap and other issues, staying in close proximity in the house and not being able to meet her counsellors face-to-face had caused her much anxiety, Sheena said.
Much like the teenager, a number of cases who are facing marital issues are forced to stay home together with their partners for possibly months on end during the circuit breaker period, she added.
“It's not like they can pack their bags and walk out.”
More calls seeking help
Helplines providing counselling services here have also seen an increase in distressed individuals calling in during the outbreak to seek help for their mental health.
The Singapore Association for Mental Health (SAMH) said its SAMH Insight Centre, which provides counselling services, saw an increase of 50 per cent in phone calls into their toll-free helpline over a two-month period from February to March, compared with a seven-month period from April last year to January.
The association also reported about a 30 per cent in such calls and email inquiries to other service centres it manages, such as creative service and mobile support service.
While not all inquiries revolve around COVID-19, many who have called in have expressed stress due to the outbreak, especially in areas of employment and financial support, the SAMH said.
Likewise, the number of calls attended to on the Samaritans of Singapore (SOS) 24-hour hotline rose more than 22 per cent in March, compared with the same period last year, as more callers expressed concerns about the pandemic.
“Several callers have also cited the fear of contracting and becoming an asymptomatic coronavirus carrier, and passing it unknowingly to loved ones,” said the non-profit suicide prevention agency’s chief executive Gasper Tan.
Such anxieties and the loss of a sense of control over a prolonged period of time can be “overwhelming to an individual with intense feelings of hopelessness and worthlessness”, he added.
Mental health services ‘essential’
In order to offer emotional support to those in need during the outbreak, the government set up a 24-hour National Care hotline, open for calls since mid-April.
Over 300 psychologists, counsellors, social workers, psychiatrists, and trained public officers from some 50 agencies have volunteered to man the hotline.
“Mental health support during a crisis is essential and should not only fall on the shoulders of the government or a single organisation,” said SOS’s Gasper of the initiative.
Describing it as a “good first step”, Dr Tan noted the hotline doubles up as a screening tool to help identify individuals who may need more focused care.
But experts say more can be done in this aspect. One way is to commission large-scale research to understand the true scale of the psychological impact of the pandemic, said Praveen.
The data collected will be invaluable for customising programmes and initiatives that may be more targeted, he added.
“While the hotline may be a good initiative on paper, it is difficult to study with regards to efficacy as such mechanisms tend to perform better in western cultural contexts where people tend to be more expressive and empowered with the notion of individual rights,” explained Praveen.
He also called for private mental health services to be categorised as “essential services”. Unlike the private players, community mental health services fall under the category and are exempted from workplace closure during the circuit breaker period, but have been requested to be delivered remotely where possible.
Echoing the sentiment, Dr Geraldine Tan, director and principal psychologist at The Therapy Room, said it was “disappointing” that mental health is perceived as secondary and “non-essential” here.
“As practitioners, we know how important the nation needs to receive holistic help. It is evident in natural disasters like earthquakes, tsunamis, disasters like war and pandemics,” she noted.
In the meantime, many practitioners have stepped up efforts to reach out to those who need help, said Geraldine. For instance, the Singapore Psychological Society has pooled together a group to do pro bono counselling for the healthcare workers, she added.
Create a structured routine, stay connected
To cope with the mental stress caused by the outbreak, mental health experts stressed it is crucial that people maintain a structured routine during the isolation period and stay connected with loved ones.
“Create a schedule for yourself that mirrors how you would go about a normal day. This routine helps to provide structure to your days, which can be especially helpful when working from home and personal and workspaces merge,” said Dr Tan.
Gasper stressed that maintaining a strong social connection – be it via social media, texts, or calls – is as important as having a healthy diet and sleep pattern.
“This period is also an opportunity to catch up and engage in meaningful conversations with family members,” he added.
To cope better during this period, one can also cut down on reading news stories about the pandemic if they are causing distress.
“You can still check reliable and official sources to keep yourself informed but limit your media consumption to once a day or to a specific time of the day,” said Gasper.
Another way is to think positively about the situation and take the opportunity to learn new hobbies and relaxation exercises.
“Having a gratitude journal may help us remember the blessings more,” said the SAMH.
“Tap on the many resources and ground initiatives available, such as activities for seniors, mindfulness sessions, webinar, etc, to learn new things and create some fun time together as a family.”
Importantly, do not shy away from reaching out for support, be it from a close friend or available community resources, experts stressed.
“It helps to be able to have an open conversation about your thoughts and feelings with someone you trust,” said Gasper.
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