Since Nigeria had its first case of corona virus diagnosed late in February 2020; there has been an increase in the number of people coming down with the disease. A wide range of mental health issues can occur at times of pandemics whether as a direct effect of the illness or as a consequence of the requirements for treatment including isolation and quarantine. Some of these mental health conditions include anxiety disorders, depression, delirium, substance use disorders. It is also important to note that the onset of a pandemic and its attendant implications may have an untoward effect on individuals with pre-existing mental health conditions.9 More specifically Wang and colleagues (2020) reported high rates of anxiety and depression among Chinese persons infected with the COVID-19
As with the best global practices the inclusion of mental health and psychosocial response team was set up as part of the larger Lagos state COVID-19 response team. A Psychosocial support team was constituted to offer the needed psychosocial services was an important piece in the wider response in caring for patients affected by the COVID-19 disease outbreak in the State.
The multidisciplinary composition of a psychosocial team with different cadres from the mental health field and lay persons as volunteers provide a robust team approach within an emergency response team. This ensured that key skills needed could be deployed promptly from within the team. Multidisciplinary teamwork is an encouraged strategy for any mental health and psychosocial support service in community disease outbreaks11.
Training of volunteers was provided on some key basic topics around COVID-19 diagnosis and management, Infection prevention and control. Other trainings were in psychological first aid, breaking of bad news techniques, coping skills, phone etiquette, utilisation of call guidance developed for the different calls and call log reporting process was put in place weekly. Knowledge on such topics has been found to allay a lot of fears in persons at risk or diagnosed with COVID-19 Infection.
In view of the highly infective nature of the corona virus along with the anticipated need for frequent and prolonged sessions when exploring mental health and psychosocial issues, the service delivery provided by this team was largely remote driven. There is good evidence that tele-health and face to face consultations can be equally effective. Service delivery was via; Tele-Mental health via remote technology platforms; Mobile phones, video calls, face to face consultation and group sessions were also provided.
At the outset of this index response, the psychosocial response began with the inpatient unit service supporting those on admission, over a short while it became evident as the response evolved that there was a need for the psychosocial team to support those receiving the COVID-19 diagnosis as many seemed to view the diagnosis as a death sentence fearing for their lives, reluctant for isolation and providing false data, thus making contact tracing difficult in those cases. Being grounded in the context of this community and being responsive to the needs of the population being served is a key attribute that effective response evolution of the team while on the field. This posture is recommended by the Inter Agency Standing Committee Reference Group for Mental Health and Psychosocial Support in Emergency Settings and summarises key mental health and psychosocial support (MHPSS) considerations in relation to the COVID-19 Pandemic and also further displayed in the response reports by Hyun (2020) et al in Korea where the teams’ response also evolved with the needs of the population it served. 11
The provision of telephonic result disclosure became imperative as the earlier weeks of the response revealed severe emotional reactions from individuals unprepared for a positive COVID-19 result. The Psychosocial team commenced providing disclosure using the SPIKES model of breaking bad news of positive COVID-19 result status to individuals, varied reactions were observed in the clients with many, on the one hand; there were several who also accepted the results, were grateful for the support and were willing to receive future support. On the other hand, however, others were refusing the results, which was understandably a maladaptive coping strategy of denial in the face of distressing news, querying the authenticity, refusing evacuation to isolation centers, and preferring to self-isolate at home.
Many countries including Nigeria have had to develop protocols for home self-isolation in the course of the response. The disclosure team routinely made effort to evaluate the level of knowledge about the virus and then educate the client on the next steps in the response and prepare them for other team members that will be in touch to provide care and support.
The patients treated in isolation centers received in patient support care, this mainly covered admission related concerns, requests for varied items from the isolation unit staff and requests for escalation of their medical needs since the care staff only came into the centers few times in the course of the day. Some experiences and concerns of patients while on admission included the concern about other loved ones at home, fear of their status and in a few cases actual guilt to have infected a family member was expressed. This is similar to reports of anxiety and distress among patients diagnosed with COVID-19.18
The home care support and discharge and follow up teams providing daily and weekly support groups along with follow up calls, respectively, helped unveil the psychological needs and answer medical questions in relation to the COVID-19 infection and the process of care. Issues around stigma and discrimination faced by the COVID-19 survivor was also important in the discharge follow up groups.
Frontline Healthcare workers were given a lot more detailed attention when identified either as a positive health care worker or as a frontline healthcare worker requiring mental health support in the course of providing care for patients within the State and also after decommissioning from the volunteer service in terms of; follow up calls and virtual debriefing/emotional support sessions. Structured psychosocial support was dedicated to these colleagues as part of the state response and details of this will be reported in another publication. General access to long term psychological follow up care is integrated into the COVID-19 follow up clinics.
Overall key findings in the course of Psychosocial support delivery found clients very anxious, in denial of their results and unwilling to be admitted into isolation centers. The reluctance for admission was mostly due to perceptions about the virus and initial fears that it may be a death sentence. The presence of fake news about causation and lack of trust in the disclosed results were also commonly expressed by clients all these along with accompanying anticipated stigma also made patients reluctant to accept the diagnosis nor cooperate with care in some of the clients. Crises management dealt with cases with overt complaints with core symptoms suggestive of a mental illness. These cases were handled in a lot more specific detail following clinical evaluation, mental status examinations, and regular follow up sessions. Some had to be formally referred and later commenced psycho-pharmaceutical agents. Besides, legal cases of stigma discrimination or unjust sack by employers concerning the COVID-19 diagnosis were escalated to the legal section of the state response via the incident manger to resolve.
Synchronisation of the entire response with other thematic areas on the response became an important strategy in the provision of Psychosocial support, which is a key item in the success planning for psychological support provision as part of pandemic responses as described by Inter-Agency Standing Committee, IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings 16 Further in depth details and description of the different streams of the psychosocial support are in other publications.
Challenges and Recommendations
Challenges faced in the course of providing psychological support for patients in the COVID-19 pandemic were varied and these include; patients reluctance and anger around accepting the COVID-19 diagnosis, disbelief of diagnosis, frustration and uncertainty, secondary trauma to volunteers, while some patients expressed mistrust in the government systems.
Some challenges must be innovatively addressed by finding affordable and sustainable workable solutions while still ensuring continued close collaboration of multidisciplinary mental health team members with other response teams.
In the face of inadequate funding, psychosocial support runs a risk of being ignored at the expense of other more urgent acute life support services, however the long term emotional risk outcomes that may follow such a wide spread outbreak makes it is necessary for response agencies to cater to the funding of a basic psychosocial arm of a response to ensure a smooth flow of services and support of affected persons. Tele-health toll-free lines provision either by government or from donations from private agencies will be useful to offset the costs of emergency services like this which rely on telecommunications.
The stigma and shame associated with contracting the virus also was a deterrent for voluntary isolation, acceptance of positivity and voluntary testing in the early days of the outbreak. Funding for and conducting early public enlightenment campaigns targeted at behavioural change must be ongoing to assist in addressing these.