“I was at home for a full year. I had nothing to challenge me - no job, no university, no social life. At times I really wanted to run away because things started to get to me. My screen time increased dramatically since I would spend days playing video games or on my phone”, Z*, a 26 year old student from Karachi shared. “I started getting flashbacks. I would feel low, not because of any external stressors but because the negative experiences from my past were hitting me like a truck since there was nothing to distract me from it”.
Most people can relate to what Z was going through following the virus outbreak that turned the entire world upside down. The mental health fallout from the pandemic and the ensuing lockdowns has been unprecedented. Fear of the virus, job losses, and feelings of anxiety, sadness and isolation due to a crippled social life had a detrimental effect on our physical and mental wellbeing. Globally, there has been a surge in cases related to anxiety, depression, trauma and stress-related disorders, substance use and suicidal ideation amongst adults.
Home is not always a haven
According to The Sustainable Social Development Organisation, there was an increase in the reported cases of child abuse and domestic violence in the last six months of 2020 with Punjab constituting for 80% of the total reported cases. The data analysis reveals that there was over 300% increase in the child abuse cases during the second quarter of the year 2020 as compared to the first quarter. Research suggests that the general trend has been that child abuse and domestic violence escalates during times of crisis.
Aftab Shah, a forensic psychologist and lawyer, shared that in his practice, he has seen an increase in cases of domestic abuse and violence lately. He posits an explanation. “There are a lot of dormant violent men in Pakistan who thrive on control, and the more control they exercise, the more powerful they feel. The lockdown disrupted their schedule, and as a result these men felt that they lost control and power of their movement and routine.” He added that in order to compensate for this lack of control, verbal abuse without a reaction from the victim (children/spouse) is a way of feeling in control and powerful. “The need to assert oneself physically can come from inadequacy of control or distorted ideas of masculinity”, Shah added.
Inequity in access to mental health
Besides socioeconomic status, prolonged indoor confinement and reduced contact with loved ones also led to elevated levels of mental health distress. Dr Uroosa Talib,Consultant Psychiatrist and Chief Medical Officer at Karwan-e-Hayat, one of Pakistan’s largest psychiatric rehabilitation institute, reported that people who were educated and had means to seek support has increased since COVID as more and more organisations transformed their health care support to online versions. However people deprived of these services and belonging to lower socioeconomic strata have been alienated since they have little to no support from government or private agencies.
She further stated that due to sudden lockdowns, our premature health care systems couldn't help people in need. People were also reluctant to visit hospitals due to COVID which made mental health issues more critical and unmanageable. “We have seen a sudden rise in new patients as well as worsening of stable patients during this time. Almost all of them belong to slum areas of Karachi and their average age is between 25 to 40 years old. All sorts of illnesses are present from minor mental ailments including anxiety and depression to severe or chronic mental illnesses like bipolar disorder, schizophrenia and substance related issues.”, Talib went on to add.
One of the biggest obstacles for many was acclimating to indoor confinement. M*, a 26 year old Pakistani who lives in Canada said,“we had a strict stay at home order there and I was working remotely. My routine became monotonous since nothing exciting was happening. Everyday was the same day, without any highs and lows”.
Shiza Anwar, a Psychiatric Rehab Practitioner at The Recovery House shared that one of the most important things for people with mental illnesses is structure and routine. “What happened during COVID is that the physical structure people were relying on to keep their mental health intact fell apart. Therefore, even clients who were previously doing well relapsed. Most of the families who admitted their loved ones post Covid, reported that isolation was a major trigger for the worsening of their symptoms.Therefore it is highly likely that the Covid lockdowns played a major role in exacerbating mental illnesses.”
Aman TeleHealth (ATH), 24/7 non-emergency medical helpline provides psychological support through tele-counseling sessions in Pakistan. Due to the virus and the ensuing lockdowns, a negative psychological impact has been observed and documented globally as well as in Pakistan. “This pandemic has limited the coping strategies to deal with the stressors, which is creating mental health issues.” Dr. Nafeesa Bano, Head of Aman Telehealth shared.
She further reported that the mental health issues of their callers ranged across a spectrum - worsening of already existing mental health issues, stress due to lack of resources (emotional and financial) and perceived social support due to lockdown were amongst the most frequent concerns. Unemployment, lack of better work opportunities (no promotion or increment) and a reduction in work productivity were also major stressors. She added that absence of recreational activities that contributed as a protective factor amplified stress levels.
Majority of the people I talked to in Pakistan reported that frequent domestic disputes and family frictions were their major stressors during lockdown. This could very well be a manifestation of cabin fever which involves feelings of claustrophobia, distress and irritability following prolonged confinement indoors. Living alone, this can plunge you into depression or self-harm. Living with someone, it might cause you to squabble or lash out at them. A 27 year old student reported how dealing with escalating household tensions while quarantining intensified his clinically diagnosed depression.
For R*, A 32 year old male from Lahore who currently lives in Oslo, lockdown was specially tough. ” Oslo already has a very antisocial society where people prefer a lot of personal space. The government here took the lockdown seriously which exacerbated social isolation. Living in a confined space,especially during a lockdown for extended periods is like living in a box and has adverse effects on one’s mental health. Days go by and you don't even feel it.”, he elaborated. R found that moving to a larger apartment mid lockdown was helpful since now he at least had adequate space indoors. Another way of coping for him was organizing long, 4-5 hours Zoom or Whatsapp calls with friends. He started reading and working on DIY projects like maintaining indoor plants while at home. When we talked, R was looking forward to the imminent lifting of the lockdown rules the following week. “A nice day would be sitting outside in a cafe, having a cheesecake and coffee, just looking at people and the life around.”
Blurring of work-life boundaries
Working from home has not been an easy transition for many people. T*, a software engineer, added that previously “there was social pressure while working in the office that you are being monitored or people are expecting you to accomplish some tasks. I had to work within 8 hours which would push me to get everything accomplished during those hours and not bring my work home. Now since home is work and work is home, I work 2 hours then take an hour break, then work another 2 hours.So working remotely has extended my 8 hours work time to 12 hours. It has totally messed up my work ethic.”
H*, a 26 year old male also realized that since both work and leisure time was now at home, his work stress would spillover on his free time so that “I never really get any time off.” He discovered that no mobility might be contributing to his low mood and combatted that by exercising. “I followed Youtube fitness channels to workout at home. Playing video games with my siblings was also helpful in creating a better home environment.”
Maintaining a healthy home environment while homebound is imperative for everyone’s mental well being. Dr Hadia Pasha, Associate Director of Counselling Services and Wellness Office at Aga Khan University works mainly with university students. According to her, COVID impacted this population in several ways, the most obvious ones being interruption of their studies, career progression, social life, and in some cases, financial pressures and loss of family members. “The immediate family environment suddenly became much more relevant. Hence, students coming from highly controlling families and dysfunctional environments fared the worst. These young adults enjoyed a sense of autonomy and support by spending a major portion of their waking hours in their academic institutions. Now with no way to escape the perpetual monitoring and judgment, they spiralled into constant feelings of depression and helplessness, in some cases leading to suicidal ideation.”
Z, an MPhil student is an introvert by nature. She had some symptoms of social anxiety previously but the lockdown aggravated it.Going back to university since the last few months made her condition worse. “I could not speak in a large group of people. During my classes, I found out that I no longer had the confidence to ask questions or participate.” Additionally, she realized that she has gotten so used to hiding herself behind a mask, she no longer felt comfortable without it. “Barring precautions,I like to keep my mask on since I feel more confident. Taking the mask off makes me feel nervous and I think it might be linked to my social anxiety.”
Another student from Karachi who found himself stuck in London during the lockdown, spent more than a few months completely alone after which he would get panic attacks just stepping out of his house, once the restrictions were lifted.
M, a Masters student found that the constant feeling of uncertainty during COVID made him unable to concentrate on his exams. “This, compounded with my already high procrastination levels, rendered me totally unable to carry out tasks which demand focus and a long attention span.” Dr Pasha mentioned how post pandemic she had witnessed an unprecedented number of students having panic attacks before exams in her practice, especially those who were already struggling with academic anxiety.
Technology to the rescue
While Covid took a significant toll on our mental health, it also presented new ways for us to cope with it in interesting, novel ways. There was a spike in the global popularity of apps and platforms that aid virtual social interaction. Tik Tok downloads surged since people were looking for new ways to entertain themselves at home. Zoom and Microsoft Teams became a staple in the life of all working professionals. The Zoom app racked up almost 300 million downloads from Jan-June 2020.
An overseas Pakistani student shared that amidst a strict lockdown so she started using Clubhouse which is a voice-chat social network featuring rooms which users can join based on their personal interests. “I joined rooms related to mental health, which are quite popular, and coping with anxiety. I was thinking of taking therapy but realized that what I really needed was to connect with people going through similar experiences and hear stories which I could resonate with. I found that in the Clubhouse.”
The pandemic has led to a marked increase in the usage of fitness and mental wellness apps. Statistics reveal that the 10 largest mental wellness apps saw a combined 2 million more downloads during April 2020 as compared to January 2020.
Headspace and Calm are currently leading in the increasingly crowded field of mindfulness apps. They offer guided meditations, sleep casts and workouts designed to alleviate stress and anxiety. Strava, a social fitness app which provides motivation by allowing users to track their own exercise, as well as others and compare results also gained wider popularity.
Woebot is a text-based chatbot app designed to help those struggling with substance use, confidence, cravings, depression, and anxiety. B reported turning to substances initially to cope with her issues but then started using Woebot which proved to be helpful and a convenient substitute for counseling. Taskeen, a local non-profit has launched Pakistan’s first mental health chatbot which provides online distress screening and also aims to eventually provide psychoeducation and dispel mental health stigma.
Mental health professionals and sufferers have both identified usage of digital platforms to improve emotional well being. These include telehealth or meditation apps as well as social media platforms and video communication apps. However, nothing in excess is good in the long run so every once in a while, a digital detox helps in rebooting our headspace.
(*Some names have been changed to hide identities)