Dr Manju Antil (Counselling Psychologist and Psychotherapist)

The coronavirus pandemic is causing widespread anxiety, worry, and fear among the general public, as well as specific groups such as older adults, teenagers, caregivers, and people with existing health conditions. In public mental health terms, the main psychological impact to date is elevated rates of stress or anxiety (S.M. Didar-UlIslama, 2020). Quarantine, self-isolation, social distancing, and financial crisis affect many people’s usual activities, routines, or livelihoods. Levels of loneliness, depression, harmful alcohol and drug use, self-harm, or suicidal behaviour are also expected to rise (Seyyed Mohammad, 2020). Children who are at home, away from school, classmates, and colleagues, may have more questions about the outbreak, and they look toward their parents or caregivers for answers.

Children and parents do not both respond to stress in the same way. Anxiety, depression, social isolation, and an unstable environment may all affect a child's mental health in the short or long term (OECD, 2020). Besides, due to the lockdown, and for preventing the spread of the virus, people cannot run their businesses properly. Many people have lost their job. The fall of the economy occurred in almost every country. As a result, people cannot meet their daily demands like before. Lifestyle has been changed. These factors are also increasing the stress and frustration of people, especially in middle-class and lower-class families (Bilal Javed, Abdullah Sarwer, Erik B. Soto, Zia‐ur‐Rehman Mashwani, 2020). Physical distance caused by the COVID-19 outbreak may have a severe detrimental influence on the mental health of elderly and disabled individuals. The mental health of the aged and disabled will be jeopardized by physical isolation among family members. Fear, tension, sadness, and even putting 7 them in a traumatic environment are all possible outcomes.

Elderly individuals rely on young people for their daily needs, and self-isolation may be damaging to a family structure. The elderly and disabled people living in nursing homes can face extreme mental health issues (Bilal Javed, Abdullah Sarwer, Erik B. Soto, Zia‐ur‐Rehman Mashwani, 2020). Doctors, nurses, and paramedics who are the front-line fighter or workers of the COVID-19 outbreak may be more vulnerable to mental health issues. Fear of contracting a disease, long working hours, lack of safety gear and equipment, patient load, lack of effective COVID-19

the drug, death of coworkers after COVID-19 exposure, social distancing, loneliness, and isolation from their family and friends, and the bad situation of their patients may play a negative impact on the mental health of health workers (Bilal Javed, Abdullah Sarwer, Erik B. Soto, Zia‐ur‐Rehman Mashwani, 2020).

Depression

Depression, unlike many conditions in the current psychiatric canon, has a lengthy and readily identifiable history. Indeed, it is perhaps the most easily recognizable psychological disorder throughout history; similar symptomatic descriptions occur over 2,500 years, representing what historian Stanley Jackson (1986, p. ix) calls a “remarkable consistency.” From the earliest medical texts in ancient Greece to the present Diagnostic and Statistical Manual of Mental Disorders (DSM), deep sadness and its variants—hopelessness, sorrow, dejection, despondency, emptiness, despair, and discouragement—have been mentioned as core features of depression. Related symptoms have included an aversion to food, sleeplessness, fatigue, irritability, restlessness, fear of death, repetitive focus on a few negative ideas, lack of pleasure or interest in usual activities, and social detachment.

There are multiple variations of depression that a person can suffer from, with the most general distinction being a depression in people who have or do not have a history of manic episodes. The depressive episode involves symptoms such as depressed mood, loss of interest and enjoyment, and increased fatigue. Depending on the number and severity of symptoms, a depressive episode can be categorized as mild, moderate, or severe. An individual with a mild depressive episode will have some difficulty in continuing with ordinary work and social activities, but will probably not cease to function completely. During a severe depressive episode, on the other hand, it is very unlikely that the sufferer will be able to continue with social, work, or domestic activities, except to a very limited extent. • Bipolar affective disorder typically consists of both manic and depressive episodes separated by periods of normal mood. Manic episodes involve elevated mood and increased energy, resulting in over-activity, the pressure of speech and decreased need for sleep.

While depression is the leading cause of disability for both males and females, the burden of depression is 50% higher for females than males (WHO, 2008). In fact, depression is the leading cause of disease burden for women in both high-income and low- and middle-income countries (WHO, 2008). Research in developing countries suggests that maternal depression may be a risk factor for poor growth in young children (Rahman et al, 2008). This risk factor could mean that maternal mental health in low-income countries may have a substantial influence on growth during childhood, with the effects of depression affecting not only this generation but also the next.

The earliest written accounts of what is now known as depression appeared in the second millennium B.C.E. in Mesopotamia. In these writings, depression was discussed as a spiritual rather than a physical condition. Like other mental illnesses, it was believed to be caused by demonic possession. As such, it was dealt with by priests rather than physicians. The idea of depression being caused by demons and evil spirits has existed in many cultures, including those of the ancient Greeks, Romans, Babylonians, Chinese, and Egyptians. Because of this belief, it was often treated with methods such as beatings, physical restraint, and starvation in an attempt to drive the demons out. Greek and Roman doctors used therapeutic methods such as gymnastics, massage, diet, music, baths, and a medication containing poppy extract and donkey's milk to treat their patients.

The Classical Tradition Writing in the fifth century B, C Hippocrates (460–377 B )C and the school of Hippocratic physicians that formed around him provided the first known description of melancholia (the Greek name for pathological states of depression), stated succinctly in Hippocrates’s Aphorisms: “Fear or sadness that last a long time mean melancholia” (Hippocrates, 1923– 1931, Vol. IV, p. 185). In addition to fear and sadness, the Hippocratic writings mentioned as symptoms of melancholia “aversion to food, despondency, sleeplessness, irritability, restlessness” (Hippocrates, 1923–1931, Vol. I, p. 263). This description is remarkably similar to the current definition found in the DSM-5 (American Psychiatric Association, 2013). Unlike DSM-5, however, the Hippocratic did not view depression as a free-standing condition but linked it with other conditions, especially anxiety (“fear”) and delusions. On the basis of the latter feature, melancholia was often characterized as “delirium without a fever.” A combination of anxious concerns and nameless fears, depressive symptoms such as blackness of mood and suicidal impulses, and paranoid tendencies such as sullen suspiciousness characterized melancholic conditions. Similarly, Galen (131–201 AD) indicated that although “each (melancholic) patient acts quite differently than the others, all of them exhibit fear or despondency” (Radden, 2000). He went on to note: “Therefore, it seems correct that Hippocrates classified all their symptoms into two groups: fear and despondency” (Jackson, 1986, p. 42). Although the Hippocratic agreed with contemporary accounts of the symptoms of melancholia, the Hippocratic definition of Aphorisms also specified the contextual constraint that the symptoms had to last an unusually long time to constitute melancholia. This indicates that it is not depressive symptoms alone but symptoms of unexpected duration that indicate a disorder. This insistence that the sadness or fear must be prolonged is a first attempt to capture the notion that disproportion to circumstances is an essential aspect of depressive disorder.

Hippocratic writings rarely focused on distinct external causes of melancholic disorders. Rather, their foundational principle was that health is a state of equilibrium within the body and that disease is due to a disturbance of this balance (Porter, 1997, pp. 55–62). The Greeks viewed mental diseases, like diseases in general, in terms of four basic senses of humour: blood, phlegm, yellow bile, and black bile. Each humour possessed two of four properties: hot, cold, moist, or dry. When the humour was in balance with each other, a healthy state resulted. Diseases, both mental and physical, stemmed from too much or too little of one of these humors, a notion that would recur when theories of neurochemical imbalance were developed at the end of the twentieth century. For the Greeks, melancholia was connected to an excess of black bile. Yet mental disturbances that resulted from an excess of black bile were not localized but disrupted a holistic relationship between individuals and their surroundings. A variety of factors, including diet, lifestyle, living conditions, and atmospheric elements, could lead to humoral imbalances. Given that the symptoms of normal sadness and depressive illness could be the same, ancient physicians understood that differential diagnosis required careful exploration that went beyond the symptoms to the context of the symptoms. For example, the Greek physician Aretaeus of Cappadocia (ca. 150–200 AD) explicitly separated melancholic patients who “are dull or stern, dejected or unreasonably torpid, without any manifest cause” from those who experience “mere anger and grief, and sad dejection of mind” (Jackson, 1986, pp. 39, 40). To illustrate the distinction, Aretaeus recounted his own version of the diagnostic triumph famous in ancient times of Erasistratus (304–250 BC), physician to King Seleucus of Syria, in which Erasistratus discovered through shrewd observation that the king’s son, Antiochus, was not suffering from melancholia as his symptoms suggested, but was instead suffering from unrequited (and unexpressible) love —for his father’s young wife! As Aretaeus tells it: A story is told, that a certain person, incurably affected, fell in love with a girl; and when the physician could bring him no relief, love cured him. But I think that he was originally in love and that he was dejected and spiritless from being unsuccessful with the girl, and appeared to the common people to be melancholic. He then did not know that it was love; but when he imparted the love to the girl, he ceased from his dejection, and dispelled his passion and sorrow; and with joy, he awoke from his lowness of spirits, and he became restored to understanding, love being his physician. (Jackson, 1986,)

The Anatomy of Melancholy

Subsequent to early Greek and Roman medicine almost no new developments in medical thinking about melancholy occurred until the end of the eighteenth century. Rober. Burton’s The anatomy of melancholy. published in 1621, illustrates the persistence of the classical tradition. It is the most renowned of all classical discussions of melancholy and perhaps of any volume ever written about depression. Burton described three major components of depression—mood, cognition, and physical symptoms—that are still viewed as the distinguishing features of the condition. However, he insisted that melancholic symptoms are not in themselves sufficient evidence of disorder. According to Burton, only symptoms that are without cause provide evidence of disorder. As he explained in this codicil to his definition: “without a cause is lastly inserted, to specify it from all other ordinary passions of Fear and Sorrow.” And, he noted, “signs in the mind” of melancholia included “Sorrow ... without any evident cause; grieving still, but why they cannot tell.” 

Burton emphasized that a propensity to melancholy was present in all men, and was a normal and ubiquitous aspect of the human condition: Melancholy ... is either in disposition or habit. In disposition, it is that transitory melancholy which goes and comes upon every small occasion of sorrow, need, sickness, trouble, fear, grief, passion, or perturbation of the mind, any manner of care, discontent, or thought, which causeth anguish, dullness, heaviness, and vexation of spirit....And from these melancholy dispositions, no man living is free, no Stoic, none so wise, none so happy, none so patient, so generous, so godly, so divine, that can vindicate himself; so well composed, but more or less, some time or other, he feels the smart of it. Melancholy, in this sense, is the character of mortality.

Burton’s work is clearly situated within the Hippocratic tradition. In effect, medical commentators throughout the eighteenth century relied primarily on Greek physicians, especially Galen, as authorities on depression and other mental illnesses (Simon, 1980). Likewise, the association of sadness and fear under the general melancholic umbrella persisted for centuries. The humoral theory of disease also endured in medical understandings and treatments of melancholy until the end of the seventeenth century and, sometimes, beyond then. Humoral thought was foundational not only in the culture of physicians but also in the medical lore of common people and lay healers. Diseases resulted from imbalances between the various senses of humour: treatments aimed to correct such imbalances and restore the body to appropriate equilibrium. Hippocratic preferences for altering lifestyles continued to prevail over more intensive medical interventions. Fresh air, exercise, good sleeping, eating, elimination habits, and control of passions remained prominent treatments for melancholy. Such treatments were typically intertwined with religious, magical, and folkloric methods (Shorter, 1992). In addition to this serious melancholia, a new category of “nervous disorders” began to emerge that viewed the nervous system as the source of health and illness, emphasizing the importance of nerves, fibres, and organs. Accordingly, the causes of nervous conditions were found in physiology, particularly brain lesions. Depressive symptoms were viewed as one component of a syndrome of “nervous disease,” “nervous illness,” “neurosis,” or, later, “neurasthenia” which referred to nonpsychotic conditions related to problems of the nervous system. The depressive component of such states was not seen as distinct from the variety of heterogeneous anxious and physiological symptoms that comprised this diagnosis. Nervous disorders encompassed anxiety, fatigue, somatic preoccupations, and obsessions (Shorter, 2013). Because these conditions were related to an organic system, they were not seen as mental problems. Nervous disorders fell under the domain of general physicians, neurologists, and spa doctors (Micale, 2008).

The two leading diagnosticians of the late nineteenth century took sharply different approaches to depression. German psychiatrist Emil Kraepelin (1856–1926), who spent his entire career practising in mental asylums, focused on the melancholic type of depression. He linked depression with mania under the general umbrella of manic depressive conditions, sharply distinguishing it from his second psychotic state of dementia praecox (schizophrenia). Manic depression and dementia praecox were homogeneous and distinct entities that presumably had entirely different causes, prognoses, and outcomes (Kraepelin, 1921). Early in his writings on classification and diagnosis, Kraepelin (1903) described melancholia as a separate disorder unrelated to manic-depressive psychosis. Subsequently, however, he was impressed by the fact that in some cases that initially looked like melancholia, eventually—often after long periods of time—there developed a manic episode. He was also persuaded by a study by Dreyfus (1907) that the nature of melancholia and of the depressive pole of manic-depressive illness is in fact qualitatively indistinguishable, and thus likely represent the same underlying aetiology. Kraepelin thus eventually combined all depressive and manic-depressive mood disorders into one category that, although encompassing a variety of clinical presentations, had as its hypothesized source the same underlying pathophysiology: “Manic depressive insanity as it is to be described in this section, includes, on the one hand, the whole domain of so-called periodic and circular insanity, on the other hand ... the greater part of the morbid states termed melancholia... In the course of the years, I have become more and more convinced that all the above-mentioned states only represent manifestations of a single morbid process” (Kraepelin, 1921/1976, pp. 1–2). However, with the subsequent development of treatments specific to bipolar versus unipolar illness, all the Unipolar forms were united under the DSM’s major depressive disorder.

In contrast to Kraepelin, who was generally concerned with the conditions of severe, hospitalized patients, the second towering figure of the time, Sigmund Freud (1856– 1939), had little concern with psychotic conditions. Instead, Freud was centrally involved with nervous conditions found in community practices. Yet Freud gave short shrift to depression, giving anxiety pride of place in his pantheon of neurotic symptoms. Freud’s sole major essay on depression, “Mourning and Melancholia,” focused on the distinction between the normality of grief and the disorder of melancholia: Although grief involves grave departures from the normal attitude to life, it never occurs to us to regard it as a morbid condition and hand the mourner over to medical treatment.

We rest assured that after a lapse of time, it will be overcome, and we look upon any interference with it as inadvisable or even harmful. Freud emphasized that symptoms associated with mourning are intense and are “grave departures from the normal,” in the sense that grief is greatly different from usual functioning. Nevertheless, grief is not a “morbid” condition; that is, it is not a medical disorder that represents the breakdown of a biologically normal response and in fact does not require medical treatment. Medical intervention, he suggested, could actually harm the grieving person by interfering with this natural process. By the early decades of the twentieth century, then, depression was sharply split into melancholic conditions marked by serious symptoms that were linked to psychoses and neurotic depression which was one of the psychoneuroses. Whereas melancholic depression was thought to be due to some as yet unknown brain dysfunction, nonmelancholic conditions were seen as products of various psychosocial adversities, especially the loss of a love object. The former usually required some form of inpatient treatment while the latter could be handled within outpatient settings.

The DSM-II also grouped psychotic depression with states of mania, much in Kraepelinian fashion. It defined the category of major affective disorders as follows: “This group of psychoses is characterized by a single disorder of mood, either extreme depression or elation...” (American Psychiatric Association, 1968, p. 35). It continued to submerge depressive neurosis within the broader category of anxiety conditions, stating that “Anxiety is the chief characteristic of the neuroses” (American Psychiatric Association, 1968,). In contrast to the prominence these manuals accorded psychotic forms of depression, they viewed psychoneurotic depression as one type of defence mechanism against anxiety. During the 1950s and much of the 1960s, nonpsychotic forms of depression were largely submerged into the broader conception of psychoneuroses.

Researchers argued over whether these depressions were continuous or discontinuous with psychotic forms, on the one hand, or with normality, on the other. They disputed how many forms neurotic conditions took and even whether they had any distinct forms at all. Diagnosticians who argued for discrete types could not agree on how many types existed. Some concluded that in addition to a melancholic, psychotic type, depression had only a single neurotic type (Kiloh & Garside, 1963). Others suggested that three or more distinct, neurotic states of depression existed (Hamilton & White, 1959; Paykel, 1971; Raskin & Crook, 1976). Various classifications of depression embraced from a single to as many as nine or more separate categories (Kendell, 1976). Still, others conceived of neurotic depression as more closely resembling a personality or temperament type than a disease condition (Eysenck, 1970). Nor was it known whether some milder forms of depression were early indicators of eventual psychotic forms. In addition, little consensus existed about the particular symptoms that were essential to definitions of nonpsychotic forms of depression and more disputes abounded over whether depression should be classified according to its symptoms, aetiology, or response to treatments.

Major Depression also became the major target of a new class of drugs, the selective serotonin reuptake inhibitors, which came on the market in the late 1980s. Because the DSM-III depression criteria could encompass such a wide variety of everyday psychosocial problems, it made the most marketing sense to call them “antidepressants.” In fact, these capacious drugs were, and are still, used to treat an enormous variety of conditions including not only depression but also anxiety, obsessions, alcohol abuse, eating disorders, and a host of undifferentiated symptoms. The label “antidepressant” reinforced the popularity of the depression diagnosis because if some condition was treated with an antidepressant it must be depression. In the urgent quest for reliability, the adoption of the current depression criteria for the most part inadvertently rejected the previous 2,500 years of clinical diagnostic tradition that explored the context and meaning of symptoms in deciding whether someone is suffering from intense normal sadness or a depressive disorder. The DSM-III criteria, which persist into the present, also blurred the traditional distinction between melancholic and neurotic depression, calling both forms “Major Depression.” The unwitting result of this effort, especially as psychiatry turned from the serious conditions of inpatients to the far more heterogeneous conditions of outpatients and community members, was to be a massive pathologization of normal sadness. Ironically, this can be argued to have made depressive diagnosis less, rather than more, scientifically valid. The sole remnant of the “disproportionate to cause” tradition was the bereavement exclusion that remained in DSM IV-TR. The removal of this criterion from the diagnostic criteria in DSM-5 indicates that far from making diagnostic progress, the recent history of the mood disorders shows significant regression in understanding the most basic of all distinctions the difference between normal sadness and depressive disorder.

A study reported by WHO, conducted for the NCMH (National Care Of Medical Health), states that at least 6.5 per cent of the Indian population suffers from some form of serious mental disorder, with no discernible rural-urban differences. Though there are effective measures and treatments, there is an extreme shortage of mental health workers like psychologists, psychiatrists, and doctors. As reported latest in 2014, it was as low as ''one in 100,000 people''. The average suicide rate in India is 10.9 for every lakh people and the majority of people who commit suicide are below 44 years of age. According to American Psychological Association (APA, 2018), “Depression is more than just sadness. People with depression may experience a lack of interest and pleasure in daily activities, significant weight loss or gain, insomnia or excessive sleeping, lack of energy, inability to concentrate, feelings of worthlessness or excessive guilt and recurrent thoughts of death or suicide”.

Depression is one of the common mental health issues prevailing among people of different age groups worldwide and it can adversely affect our feeling about ourselves, the way we think, act and our whole perspective on life. It also causes various emotional and physiological disturbances and can seriously impair the ability of an individual to perform different tasks. Any traumatic experience or physical or psychological loss may cause depression. It may be the loss of a job, death of a loved one, loss of possession or any serious injury. Depression leads to feelings of loneliness, sadness, and loss of interest in activities of the day today life. It is a serious illness caused by changes in brain chemistry. The problems caused by depression are made worse by the fact that most people suffering from the disease are never diagnosed. Other factors like genetic characteristics, changes in hormone levels, certain medical illnesses, stress, grief, or substance abuse may also contribute to the onset of depression.