Finding the Rainbow in the Deluge: Community Mental Health Perspectives on Psychosocial Impacts of COVID-19 in India

The COVID-19 pandemic has been the most disrupting global event of recent history. Not since World War II has any single event so thoroughly engulfed and transformed our world. No medical crisis has approached this magnitude since the 1918 influenza pandemic (also known as the “Spanish flu” pandemic of 1918). In the midst of such a crisis, existential questions of meaning have become day-to-day realities, not just for the academic philosopher but for the common person in the street. Discussions about the psychosocial impact of the pandemic have often centered on the immediate effects of the acute infectious phases of the pandemic on mental health conditions (e.g., fear and anxiety about the disease itself, grief due to the loss of loved ones). We highlight other areas in the context of community mental health in which the effects of the pandemic have been profound yet unrecognized and unaddressed (1).

In this Open Forum, we attempt to comment on the scenario of primary care psychiatry in low- and middle-income countries such as India—with its many challenges, including a shortage of trained specialists (2, 3)—and highlight the impact of the pandemic on this sector. We also propose a simple model to provide training in basic coping strategies in the context of primary care and to provide a framework that helps find meaning in the experience of the pandemic. We have experience in primary care psychiatry through the Shifa model (4) of community mental health in rural Madhya Pradesh—a low-resource model that serves 75 tribal villages—and we are also training physicians and other health care workers in basic mental health skills through online and blended methodologies with the distance education department of Christian Medical College in Vellore, India.

The Reality of Primary Care Psychiatry in India

Chronic shortage of mental health specialists such as psychiatrists, clinical psychologists, psychiatric social workers, and psychiatric nurses remains a significant problem in India. For example, the ratio of psychiatrists to the population remains a dismal 0.75 per 100,000 people, far below the desired figure of three to six per 100,000 seen in many high-income countries (5). In addition to this shortage, the distribution of these specialists across the country is skewed across states, and there is a very significant rural-urban divide (6).

This situation could have been mitigated had there been a strong primary care sector equipped in basic mental health skills (7). Unfortunately, undergraduate training in mental health skills in India is inadequate, and mental health skills among general practitioners are sorely lacking. There is poor awareness and tremendous stigma surrounding mental health issues in both rural and urban settings (8). Health systems remain in chronic imbalance, with urban areas having high-quality, private, tertiary care services that the poor cannot afford and rural areas having an extensive network of public health care infrastructure for primary care services that lacks skilled specialists (9).

Impact of the Pandemic on Primary Care Psychiatry

None of the aforementioned trends are new; rather, the pandemic exacerbated each of these existing trends in primary care psychiatry. Lockdowns and travel restrictions worsened access to care (10). The shortage of specialists was accentuated by the diversion of specialist services toward COVID-19–related work (11). There was a general neglect of health issues that were unrelated to COVID-19 (12), including chronic diseases and mental health conditions. Both undergraduate and postgraduate training across medical disciplines, including mental health, took a major hit when residential in-person training was challenged by social distancing norms and a significant drop in patient numbers in many teaching hospitals.

There were serious impacts on help-seeking behavior in the general population as well, because of the fear that hospitals and health professionals could be potential sources for contracting the disease. Finally, the impact of the pandemic fell particularly hard on vulnerable and often neglected populations (13) such as persons with disabilities and mental disorders, and anecdotal reports of increases in domestic violence and child abuse were seen as a direct result of the lockdowns and social restrictions (14).

Finding Meaning in the Pandemic: The “Rainbow in the Deluge” Model

Most mental health professionals are aware of and have suggested useful strategies for dealing with the tremendous stress caused by the pandemic, and much work has been done in this area internationally (15). What is often lacking, however, is a unifying narrative to combine these diverse strategies in a simple way that also provides meaning to the whole experience. Although the pandemic could be conceptualized as a stressor like any other, there are aspects of the pandemic experience that are unique and shared by all people in a unique way.

The mental health team of the distance education department of Christian Medical College in Vellore, India, has used the “rainbow in the deluge” model to train people in simple coping strategies while providing the framework for an overall narrative that helps people find meaning in the experience of the pandemic. The model is based on two short acronyms: DELUGE and RAINBOW, described as follows. (A full description of the “rainbow in the deluge” model is also available as an online supplement to this Open Forum.) Borrowing the analogy of the biblical story of the Great Flood (or “Deluge”) as a backdrop, the model was designed by thematically analyzing anonymous questions put forward by an online audience before a virtual session for nonmedical people of various backgrounds titled Mental Health During the Pandemic. Primary concerns that had been raised in the questions were grouped into headings that formed the DELUGE acronym, and proposed strategies for addressing these concerns were grouped into headings that formed the RAINBOW acronym. The model has been found useful in training both medical and nonmedical individuals through interactive online sessions. It has been used to train a variety of groups: physicians and staff involved in COVID-19 work, community health teams, nonmedical volunteers of organizations and nonprofits in both urban and rural settings, and youth groups.

The biblical story of the Great Flood is remarkably consistent with similar stories in the folklore of several cultures around the world. Its theme of renewal amid destruction forms a powerful backdrop for understanding the human experiences during such catastrophic events. Although much work has been conducted in describing and addressing mental health concerns during the pandemic, the “rainbow in the deluge” model provides a simple approach for teaching coping strategies in a practical and meaningful way to nonspecialist audiences, including through an online platform. The model provides a broad framework and is not designed to be prescriptive in the specifics of its suggested interventions, recognizing that there are culturally and regionally different approaches that may be relevant in each of the broad categories suggested by the “rainbow.”

DELUGE: How Has This Pandemic Affected Our Lives?

D: Death and disease.

This refers not only to the COVID-19–related infections and deaths but also to the terrible burden of mental illness and chronic diseases aggravated by the pandemic.

E: Emotions all over the place.

We can all experience a great variety of emotions during these uncertain times, including anxiety, fear, sadness, anger, and guilt. We often find that channeling these emotions appropriately is difficult.

L: Lifestyle changes in every aspect of our life.

Sweeping lifestyle changes, from social distancing and hygiene measures to reduced travel and changes in work and education, have affected every aspect of life.

U: Understanding of self is shaken.

New demands and stressors have resulted in a devaluation of the sense of self and purpose in life.

G: Grappling with new demands.

Adjusting to the new skills and requirements at work and home because of the pandemic has caused stress.

E: End of the world as we know it.

The world after the pandemic will never be exactly as it was before 2020. Some changes will continue postpandemic and will require constant readjustment.

RAINBOW: What Can We Do to Cope Better With What Lies Ahead?

R: Rest, reflect, and renew.

Use this time to pause and reflect on life before the pandemic and how we can do things differently—what was good and what can we do better. Make adequate time for sleep, exercise, and leisure.

A: Accept and adapt.

Accept and adapt to the new realities—both the struggles and the opportunities.

I: Identify ourselves as rooted in our worldview.

Remember to look for our larger purpose in life and find meaning in our life story.

N: Normalize emotions.

Recognize that experiencing distressing emotions in the context of the pandemic is perfectly normal and that we must give ourselves the space to experience them.

B: Be good stewards of time.

Bear in mind that time is limited; we can establish a regular routine to help stabilize ourselves during these difficult times.

O: Open up and seek help.

The greatest barrier in finding help is often our own reluctance to seek it. When distress is overwhelming, seeking help from available and culturally acceptable resources is important to improving coping.

W: Work-family balance.

Neither should take precedence over the other; attention to both should be balanced as much as possible.

Conclusions and the Way Forward

The search for meaning during a crisis is a deeply personal and urgent need that requires individualized and culturally sensitive psychosocial interventions. We think that, despite the challenges, the pandemic has provided opportunities to reexamine current approaches to training and services in primary care psychiatry in India. With its vast network of primary health care centers and village health workers, India has the potential to provide significant primary care psychiatric services.

Strengthening the existing primary care services by using simple protocols, making use of the opportunities provided by online and distance learning practices and targeted training of nonspecialist health care providers who are already working in areas of need are ways to address this. In addition, encouraging high-quality training in telephone and online consultation services can supplement these efforts in areas where such services are feasible.