Balancing all the 4 Humors, beyond COVID19!

- Perspectives on the dire need for addressing Mental Health during and after the pandemic!

“The Human body contains blood, phlegm, yellow bile and black bile. These are the things that make up its constitution and cause its pains and health. Health is primarily that state in which these constituent substances are in the correct proportion to each other, both in strength and quantity, and are well mixed. Pain occurs when one of the substances presents either a deficiency or an excess, or is separated in the body and not mixed with others.” - W.N. Mann (1983). G.E.R. Lloyd (ed). Hippocratic writings

Hippocrates and two other prominent Greek thinkers, Galen and Socrates, each developed the idea of there being four essential elements to the human body: blood, bile, black bile, and phlegm. The unique characteristics and personalities of human beings could be attributed to the idiosyncratic balances of these so-called “humors.” When the humors were out of balance, mental illness was the result!

Like few of the rare expats who had the opportunity to return to India before COVID19 lockdown, Ram who is a Financial Analyst with a popular investment firm, is doing his is best to cope up with new normal of 90% time in Zoom/Webex/Skype meetings, rest in Citrix/VPN troubleshooting, changing the WiFi from one device to another etc. Happy to eat and sleep at his apartment among & after all these in an urban town of Southern India.

“I forgot the meaning of ‘call it a day’ these times & surviving with what comes on the way”, he says, “every day remains the debate about working hard and seeing everyone hardly working”. “Life seems all new, I am feeling low”, he utters as he closes his Macbook.

He is much concerned about his aged parents who live in a distant remote village, too far to visit even, and equally worried about his son’s exam schedule which broke midway, the anti-expatriate talks happening in his own Apartment’s Resident Association, which houses close to 400 families!

Why wouldn’t be he under stress, anxiety and on his way to a mild distress?

Post traumatic fear, anxiety, hopelessness, depression, all these may lead to an epidemic as a side-effect of the COVID19, the present pandemic. Considering the length of the suffering (be it the lockdown, be it the social distancing, be “stay safe, stay home”!), the individualistic and familial setbacks (could be loss of a relative, unemployment, loss in business or financial crisis, could be any other form), a small portion of people are going to develop a PTSD and a possibly two thirds of affected regions will end up with a post traumatic growth. While a majority learns positive attitude towards life, a minority survivors will end up searching for the real meaning out of the whole traumatic incidents. A further smaller subset of the positive thinkers even start thinking about what changed them & how, absence of a convincing answer or reason may lead them to despair. These two minorities form a sizeable & needy segment for effective therapies and guidance.

A permanent ‘invisible emotional strand’ could become the long-term impact for many, which has the possibility of leading to post traumatic anxiety and related imbalances. Could be from prolonged fear of virus itself, could be from unacceptance to social and physical distancing, isolation, separation, could be from physiological reasons as well. Before we examine post COVID19 time & forthcoming mental illness epidemic let us quickly consider the present-day situation, when the pandemic is still on. We have people who are already devastated by COVID19 outbreak (people in the US, China, most of Europe), we have the people on the brink of a sigh or a cry (Korea, rest of Asia, Australia), people who are still observing but has to fear the most about (Africa). All these subsets are going through tremendous psychological pressure even now, resulting in to fear, anxiety, depression, dissociation etc. Those are causing significant distress to day to day functioning, compromises in terms of substance or alcohol use. On top of that, we have people who have known psychotic or psychic problems, going through regular counselling, treatments, prophylaxis & now deprived off regular face-to-face interactions with physicians or therapist, few others who face trouble in getting the refills, sessions, advises etc. on time.

The complexity of sources, dimensions and situations leading to these fear, anxiety and depression are so diverse compared to a typical traumatic situation. Those could include, but not necessarily restricted to some of the below :-

While most of the above could be a day to day possibility with or without COVID19, the probability increases exponentially with contextual, situational and psychological factors from the pandemic. Hence strategic & tactical actions would need to be planned, executed and persisted to prevent, avoid, control and address the impacted mental health issues.

If we stratify the overall population into directly affected (survivors of COIVID19 virus), indirectly affected (one among the family was affected by COVID19, lost a relative to the virus etc.), likely to be affected (who are on the brink/fear of getting affected sooner or later), health workers, patients (who already have some form of mental disorders), subsets like women, working women, children, students — it will be a complex matrix or grouped clusters however. As the level, onset, impact and interrelations may vary for each cluster, need for cluster specific strategies would be more likely to be effective. Systemic thought process would throw up challenges of reinforcement, balancing loops, constraints etc. A system thinking examination shows a combination of these.

As we could observe in the above archetype, the reinforcing feedback loop causes exponential growth to mental disorder possibilities among general citizens. However, with the perceived actions needed balancing loop is yet to come into effect as most of the countries are pretty much engrossed in containing the contagion as opposed to proactive measures for long term impacts. While 1st things 1st has to be the policy, there must be a team which works closely with psychological experts and researches to device the strategic and tactical plans to address the next epidemic which is likely two thirds of the world with some form of mental disorder.

While need is to be looking at immediate term, midterm and long-term plan of actions separately, all the possible ones would start with psychological intervention, formally/officially/securely. If these interventions need to be successful, they ought to be jointly done with all other forms of medical care & community services and not as a separate initiative under some misomered sub department. Studies indicate that people who crossover such pandemic situation might end up with varying degrees of stress disorders, even as the pandemic and its widespread impact gets over. They need to be analysed for disease course, clinical symptoms and respective severities, place of treatments and hence offered specific measures to reap the interventions. One among the immediate term actions should be to train the frontline or last mile Health Worker with screening questions to assess the need for psychological interventions. These workers also may be equipped with tactical methods to keep the anxiety/stress under control such as tips on: -

So a stepped care approach, with nontraditional people offering psychological first aid and triaging stands among the highest priority actions for public health institutions, voluntary organizations and communities. Thus lead the way to make mental healthcare as an integral part of public health to face the post pandemic impacts. An interdisciplinary effort between private providers in the mental health space and authorities/communities would hasten the outcome. “All hands in the society” approach involving the necessary stakeholders is likely to yield rapid results.

Post widespread period, the right strategies would revolve around the target segment. However, all the actions need to be coordinated nationwide to be effective. Mental health embedded in public health services and in collaboration with various local bodies and decision makers. Electronic media and technology supported initiatives like

Above and more focused programs similar to alcoholics anonymous could be devised targeting specific groups like youth, children, working class, women, business persons, autistic forums and more.

On the longer run and strategically, primary aims should be enhancements to population wide health protective and response behaviours, country wide or territory wide or community wide. Mental Health surveillance programs, data & evidence driven direct services addressing PTSD, depression, altered substance use and also psychosocial need. Further more, facilitation of administrative and medical data for research purposes continuously and thus provide means to identify health & behavioural effects at scale.

Establishing a system in place nationwide for surveying whole population and specific interest groups, using epidemiologically robust methods, which in turn support in evidence based ascertainment of mental health and relative actions. Communication strategy will hold the key in the future, fostering a rapid and coordinated response regarding health messaging from authorities and simultaneous deployment of systems which are embedded in communities will remain a viable solution. Facilitating research on the impacts of the virus itself on brain, nervous system, immune system etc. not to be missed out as means of assessing the biological learnings and related interventions for future. So high quality data collection, assimilation should also remain among the top priorities.

Boosting the resilience of population, motivating & enabling the people themselves to prepare psychologically and plan practically for possible future scenarios and there by fostering collective mindsets for people’s own care and concern for others! While the population and community being addressed as a whole, for one exclusive segment which is the Health Worker community, be it physicians, clinicians, technicians, nurses, front line workers, etc. a conscious, continuous and curriculum-oriented plan of action need to be in place right from the helm of education.

Empowered societies, who are capable of managing such future instances clinically, cognitively & caringly could be the idealistic target for all authorities and organisations.

“I cannot but give enthusiastic witness to their moral qualities. Never, except in romances, have I seen spouses more worthy to be cherished, more tender fathers, passionate lovers, purer or more magnanimous patriots, than I have seen in hospitals for the insane, in their intervals of reasonableness and calm; a man of sensibility may go there any day and take pleasure in scenes of compassion and tenderness” — Philip Pinel

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Reference: — Coronavirus Anxiety Scale: A brief mental health screener for COVID-19 related anxiety, by Sherman A Lee. (https://www.tandfonline.com/doi/full/10.1080/07481187.2020.1748481?scroll=top&needAccess=true )

An analysis of variance (ANOVA) showed that there were some race differences in CAS scores, F(4,770) = 14.88, p < .001. Post hoc analyses using the Scheffé criterion for significance indicated that Asians (M = 10.39; SD = 5.39) had significantly higher CAS score than Whites (M = 7.38; SD = 5.76) and Blacks (M = 6.79; SD = 4.37). No other race differences were found in CAS scores. Correlation analysis showed that younger adults and people with higher education reported higher CAS scores than their counterparts. In terms of social attitudes, CAS scores were also positively correlated with approval of President Trump’s responses to the coronavirus outbreak and likelihood of avoiding Chinese food and products in the future. There were no relationships found between CAS scores and gender, history of anxiety, and likelihood of changing future plans.