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

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).

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.”

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.