• panic disorder
• psychiatry
• mental health services

Dear Editor

We read with interest the editorial by Qiu et al ¹ about the psychological distress among the general population in China during the COVID-19 pandemic and policy recommendations. The elderly are more vulnerable to increased mental health problems during COVID-19, which has raised significant challenges for community mental health services.1 2 Older people with comorbid conditions, including cardiovascular diseases, lung diseases, diabetes and hypertension are more likely to be severely affected and die because of COVID-19, which is caused by SARS-CoV-2.3

Bangladesh is one of the most densely populated countries in the world, making it more vulnerable to the rapidly spreading COVID-19. As of 28 May 2020, 38 292 cases of COVID-19 have been confirmed in Bangladesh, including 501 deaths.4 Although only 8% of the total patients with COVID-19 were elderly persons (aged >60 years), they account for almost 42% of total deaths.4 In 2015, there were 12.5 million (7.5% of the total population) older people (aged ≥60 years) in Bangladesh.5 However, the proportion of older people is almost 5% lower than the overall ratio of geriatric people worldwide (ie, about 12.5% or 901 million people globally were aged 60 years or above in 2015).6 Among the older people in Bangladesh, around 53.8% have multicomorbidities,5 making them more vulnerable to the COVID-19 infection.

As SARS-CoV-2 has high transmissibility and is mainly transmitted from person to person,3 to prevent the aggressive and rapid outbreak of the pandemic, the Government of Bangladesh has advised people to stay at home. Therefore, during the COVID-19 outbreak, older people are suffering from lack of social contacts and physical activities. The lack of social connections and the overall situation of the pandemic, including the rapid transmission of SARS-CoV-2 and high death rate, can result in combined effects of fear, stress, anxiety, depression and mood disorders in older people, which can be overwhelming and cause strong emotions.1 7–10 The sedentary lifestyle, idleness and physical inactivity might increase the prevalence and severity of obesity, diabetes, stroke and hypertension in aged people, which can lead to severe disabilities, deformities, functional incapacity and social rejection.11 However, the COVID-19 pandemic has posed significant challenges for healthcare services throughout the world, including Bangladesh. The number of hospital admissions has dramatically increased, and many people in the community are facing challenges in seeking both emergency and primary healthcare services, as the public health system has already been overburdened with patients with COVID-19. Moreover, healthcare professionals on the front line are at increased risk of being infected with COVID-19, and they are also highly vulnerable to physical and mental health problems, which may affect their services.7 Besides, older people in the community may avoid inpatient and outpatient services due to fear of infection, which can increase the severity of the diseases.

Mental disorders are highly prevalent in Bangladesh. Recent studies have reported a higher prevalence (55.5%) of geriatric depressive symptoms in Bangladesh.12 During the epidemic, people with a mental health problem may be at a higher risk from social isolation.1 2 13 Recent continuous media coverage and reports of older adults being prone to infection and dying because of COVID-19, forecasting of economic recessions and a possible famine have resulted in increased psychological and mental pressure among older people.13 This might lead to increased psychological and mental health problems in the older age group in Bangladesh. People with psychiatric disorders may face more difficulties in dealing with the COVID-19 situation.

Current approaches to COVID-19 prevention include wearing masks; avoiding close contacts; frequent hand washing; avoiding touching the eyes, nose or mouth with unwashed hands; avoiding handshakes, which might increase the risk of infection. However, older people with severe comorbid conditions (ie, strokes), mental disorders (ie, dementia), advanced age, who are uneducated, lack information, awareness or self-protection skills might face more difficulties in applying these skills to combat COVID-19. Therefore, for the well-being of these older adults, there is a need for additional care and mental support. Mental health remains highly neglected by the health planners and policy-makers in Bangladesh, with only 0.073 psychiatrists per 100 000 population.14 As the COVID-19 pandemic is overwhelming, healthcare services, healthcare professionals and the geriatric mental health services are facing significant challenges.7–9 15 To this an effective alternative are public health services that provide essential mental health services.7–9 16 Telemedicine or online healthcare services for older people can be an effective alternative way of providing health services, like in China, while still keeping social distance.1 7–9 16 However, Bangladeshi older adults have limited access to the internet and the ability to avail such services. Therefore, mass media, mainly television, can play a proactive role by telecasting special mental health programmes for aged people. However, currently, most of the television programmes and social media has not provided any such services. Therefore, appropriate mental health programmes, including motivational and educational programmes, need to be provided for the older people in Bangladesh during, and post, this COVID-19 epidemic. Moreover, telemedicine or online healthcare services can also be helpful for people who have access to the internet and relevant services (eg, smartphones, computers and technical knowledge to use it).1 7–9 16

Additionally, family support can play a significant role in the physical and mental well-being of older people during the COVID-19 pandemic. A previous study showed that family support was significantly associated with a decreased level of depressive symptoms.17 Therefore, there is an urgent need for emotional and practical support from family members, including children of older people. Traditionally, older people used to live with their male offspring and depended on them for all their needs.18 19 Additionally, they were highly respected and enjoyed a prime position in the family. But, because of modernisation and urbanisation, the traditional joint families have started splitting into nuclear or small-size families, and at the same time, the position of the older people has changed, and elder abuse has increased severely.18 19 At present, with limited senior care homes in Bangladesh, most older people live alone or with their older partners or their children.5 However, in the grievous situation of COVID-19, the family members should be more dutiful and careful and regularly contact older people through phone calls if they do not live together. For the psychological and physical well-being of older people, these practices are also recommended after the epidemic is over. However, family members or caregivers of older people may have limited knowledge about mental health support, which is another concern; therefore, effective programmes to learn about providing such support is also needed. In Bangladesh, experts providing emergency education programmes about mental health support to the older people through mass media, such as television, newspaper and radio, and through social media, such as Facebook and Youtube channels, would be fruitful.

In summary, older people are more susceptible to psychological problems during the COVID-19 outbreak. Specialised mental health programmes through television, effective telemedicine services and adequate family support can play a proactive role in the mental and physical well-being of older people in Bangladesh and elsewhere during, as well as after, the pandemic.

Sazedur Rahman completed his undergraduate and master's program in Statistics from Khulna University, Bangladesh. He is an independent researcher in the Statistics Department of Khulna University, Bangladesh. During his master's program, his thesis title was ‘Fear of Falling and Its Relationship to Depression and Loneliness among the Elderly’. He was involved with different public health projects in various national and international organizations, including the International Centre for Diarrhoeal Disease Research, Bangladesh; Unicef; Cornell University, USA; Khulna University, Bangladesh and iDE PROSHAR funded by USAID. Mr. Rahman has published 15 articles in different scholarly journals. His main research interests include the areas of public health and geriatric mental health.