Begin by stating a tentative thesis (what you think your paper might argue). Then use the MEAL plan paragraph structure to write one rough draft paragraph that could support this potential thesis in your research essay. The evidence from the Evidence section of your paragraph should come from the source you located on your topic.

My research topic is : How has the COVID 19 pandemic affected people’s mental health and substance abuse.

Paragraphing:
The MEAL

Plan

Effective paragraphing is a central skill in academic writing. Many writers have been told a paragraph

should contain a single idea; many have heard paragraphs have to be a minimum length—three sentences,

for instance. In reality, paragraphs come in different shapes and sizes, and some so-called “rules” may put

writers in a straightjacket that unnecessarily hampers their ability to convey their ideas as needed in a

particular piece of writing. Nevertheless, grasping the general form of a paragraph provides a good

foundation. Once you have this basic building block at your command, you can vary from it by conscious

choice when needed.

One way to envision a body paragraph is as a “complete MEAL,” with the components being the

paragraph’s Main idea, Evidence, Analysis, and Link back to the larger claim.

The Main Idea

The main idea is the paragraph’s central thrust. In academic writing, that thrust is often argumentative—a

paragraph makes an assertion that’s part of the writer’s larger claim. Often the main idea appears in the

paragraph’s first sentence, where it is sometimes called the “topic sentence.” However, some paragraphs

offer their main idea in the second, third, or last sentence; some don’t have a single sentence that

encapsulates the main idea. That said, your reader should come away from each paragraph with a clear

understanding of its main idea. He or she shouldn’t have to stop and reread the paragraph, trying to figure

out what it’s saying.

It’s true that a paragraph should usually focus on a single idea—paragraphs are, after all, the bite-sized

chunks into which you break your argument so that your reader will be able to digest it easily. But keep in

mind that, to some degree, you can bring unity to a paragraph that seems to contain two or three ideas by

showing how those ideas really fit under the same umbrella. The way a paragraph conveys its claim, in

other words, dictates whether your reader will see it as a coherent idea or as a hodge-podge of different

points.

Evidence and Analysis

Evidence and analysis are a paragraph’s main course; they are what allow you to prove that your

paragraph’s main idea is plausible. Your evidence could be information from journal articles you’ve

found in the library; it could be data from research or interviews you’ve conducted yourself; it could be a

quotation or paraphrase from a work of literature; it could be an image; it could be a chain of logical

reasoning you have developed; in some types of papers, it might be an anecdote or personal experience.

However, evidence shouldn’t be plopped down in a paragraph and left to “speak for itself.” If you leave

your evidence unexplained, your reader may interpret it differently than you intended, and if that happens,

your main idea doesn’t get the support it needs. Therefore your paragraph should carefully analyze the

evidence it provides; it should, in other words, explain exactly how the evidence you’ve cited proves what

you think it proves. Often a paragraph’s “E” and “A” are hard to separate: you might provide some

evidence, analyze it, and then provide more evidence and analysis. Sometimes individual sentences will

contain both evidentiary and analytic elements. But in most academic writing, both evidence and analysis

are essential to a paragraph’s well being.

Duke Writing Studio 2

Link Back to the Larger Claim

A paragraph’s link back to the larger claim is often implicit—it can be awkward to wrap up a paragraph

with a really heavy-handed link (“This idea is important to my claim because of X, Y, and Z”).

Nevertheless your reader should get a good sense of how your paragraph fits into the larger scheme of

your paper’s argument. He or she shouldn’t finish reading the paragraph and think, “Why did the writer

put this paragraph in this paper? I don’t see how this idea is relevant!” An effective paragraph will clarify

its own place in the essay’s (or section’s) larger claim.

Here’s an example of a paragraph drawn from an essay in Deliberations: A Journal of First-Year Writing

at Duke University; the column on the left maps the parts of the paragraph’s “complete MEAL”:

M: Danielson here uses a

traditional “topic

sentence” that lays out

the paragraph’s overall

point.

E: His evidence is

indirect, drawn from a

work on Roman history.

A: His analysis links the

historical evidence to his

own assertion about the

United States by

outlining the two

cultures’ similarity.

L: He uses the central

terms of his paper’s

argument to remind his

reader of the paragraph’s

relevance.

It is here that indeed one may foresee a new union between Church

and State, one that the “religious right” may not completely predict:

the complete eradication of all forms of traditional religion from

government, to be replaced by the Worship of Government itself.

This seemingly far-fetched idea finds its historical roots in an obvious

and powerful reality: the ancient Roman Empire. According to early

twentieth century historian Louis Sweet, the “Worship of Roma” was

indeed quite common in the Roman Empire. This worship, which

Sweet refers to as the “Roma-cult,” started most clearly “immediately

after the entrance of the Romans into Asiatic affairs. The similarities

between such ancient, pagan patriotic worship and the current

American situation cannot be overlooked. Just as Rome developed

nation-worship after its conquest of Asian lands, so the United States

seems to be entering a similar stage of paganism during its conquest

of the Middle East. “The Roma-cult is interlocked from the beginning

with the imperial,” Sweet reminds his readers. Will the vague

patriotic monotheism of America, stripped of traditional religion,

become her vague patriotic paganism as she continues on her

imperialistic crusade? (14)

Source:

Danielson, Donald Kyle. “Imperium Dei: America’s New Religion.” Deliberations: A Journal of First-

Year Writing at Duke University. Fall 2006: 10-16.

Journal of Clinical and Diagnostic Research. 2020 Dec, Vol-14(12): YE01-YE04 11

DOI: 10.7860/JCDR/2020/45839.14298

P
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ys
io

th
e

ra
p

y

S

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ti
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n COVID-19 Pandemic: Mental
Health and Coping Strategies

Review Article

Original Article

Miscellaneous

Postgraduate Education

Letter to Editor

Short Communication

Images in Medicine
Experimental Research

Clinician’s corner

Case Report

Case Series

Research Protocol

INTRODUCTION
A major health crisis that has affected around 213 nations across
the world is the COVID-19 pandemic. A cluster of pneumonia cases
of unknown aetiology that was first reported from Wuhan, Hubei
Province, China on 31 December 2019 has spread globally [1]. It
has become a pandemic because of its zoonotic nature. Since the
past few months a significant increase in the mortality and morbidity
rates have occurred due to this pandemic [2]. In the wake of this
global health crisis, stringent public health measures have been
implemented to curtail the spread of COVID-19 [3]. Widespread
outbreak such diseases are associated with psychological distress
and symptoms of mental illness [4,5]. Presently, the World Health
Organisation (WHO) laid the major objectives about the prevention
of human-to-human transmission in order to limit the spread of this
disease to other person and medical HCW. WHO has also given
guidelines regarding the isolation and 14 day quarantine period,
prevention of complications in infected persons and research to
produce vaccine and to minimise the spread of this disease [6].
The main aim of this review was to create awareness about the
mental health effects of to COVID-19 and various coping strategies
because it has been reported in various studies that due to this
pandemic, mental health of a person has been hindered.

Effects on Mental Health during the COVID-19 Pandemic
The diagnosis of specific diseases needs specific time period, which
is the main constraint for measuring and quantifying mental health
issues in the population. Long terms effects may develop in survivors.
Brooks SK et al., have written a review which revealed the presence
of emotional disturbances including frustration, stress, depression,
anger, insomnia, fear, confusion and boredom in quarantined
people and health care professionals. Specific stressors included
greater duration of confinement, having inadequate supplies,
difficulty securing medical care and medications, and resulting
financial losses [7]. In the current pandemic, the home confinement
of large swathes of the population for indefinite periods, differences
among the stay-at-home orders issued by various jurisdictions, and
conflicting messages from government and public health authorities
will most likely intensify distress [8]. It has been noted that there is a
need to enhance mental health support because there is an increase
in mental health burden. In China, the National Health Commission
[9] issued its first comprehensive guidelines for emergency
psychological crisis intervention for people affected by COVID-19
on 27 January 2020 which emphasis the need for multidisciplinary

mental health teams to deliver mental health support to patients
and HCW.

Impact on Normal Population
Spreading of COVID-19 rapidly across the globe has resulted in the
development of mental health issues like stress and anxiety in the
general population [10]. As reported by many studies inadequate
knowledge and awareness regarding spread of the virus, routes
of transmission, the incubation period of virus and precautionary
measures leads to the development of myths, fear and increased
level of stress and anxiety [11-13]. During the lockdown period,
people became homebound and this is the main source of creating
negative mental health issues. They are worried about the insecurity
regarding their future [12]. Because of the lockdown, people have
reported feeling of disappointment, irritability, tension or stress.
It was also reported that this event can give rise to new mental
disorders or even worsen the symptoms of previous mental disease
[11,13]. It was reported that when an outbreak occurs, it produces
fear in the normal population. The Kikwit Ebola outbreak already
provided beneficial psychological insight into how the general
community responds to this biological crisis [14]. Research has
shown that misinformation and fictitious reports about the COVID-
19 can aggravate anxiety and exacerbate depressive symptoms
in the general population [13]. A study found that although more
than half of the participants (52.1%) reported that they felt horrified
and apprehensive due to the COVID-19 pandemic, they did not feel
helpless due to the pandemic when measured on impact of event
scale [15].

Impact on Children
Children are well attuned to adult’s emotional states; exposure to
unexplained and unpredictable behaviour is perceived by children
as a threat, resulting in a state of anxiety. For children quarantined
at home with their parents or relatives, the stress caused by such a
sharp change in their environment might be eased to some extent.
However, children separated from their caregivers require special
attention, including children infected with or suspected of being
infected with Severe Acute Respiratory Syndrome Coronavirus-2
(SARS-CoV-2), who are quarantined in local hospitals or collective
medical observation centres and children whose caregivers are
infected with SARS-CoV-2 [16]. Companionship is essential for a
child’s normal psychological development and well-being [17].
Quarantined children are more expected to develop acute stress

Sajjan Pal1, Sheetal kalra2, ShilPa jain3

Keywords: Awareness, Health issues, Outbreak, Psychological health

ABSTRACT
The world has been facing a global threat from the past few months from Coronavirus Disease 2019 (COVID-19). There has been a
significant increase in morbidity and mortality due to this ongoing pandemic which is creating a global challenge. This pandemic is
having a profound effect on all aspects of society especially the physical and mental health of the people. There has been a rising
concern about the mental health of normal population, COVID-19 patients, Healthcare Workers (HCW) or doctors, children and the
elderly population. Recent research has reported symptoms of anxiety, depression and other symptoms of psychological distress
among these populations. The main purpose of this review was to focus on various mental health issues and the coping strategies
during the COVID-19 pandemic period.

Sajjan Pal et al., COVID-19 Pandemic: Mental Health and Coping Strategies-A Review www.jcdr.net

Journal of Clinical and Diagnostic Research. 2020 Dec, Vol-14(12): YE01-YE0422

Impact on Elderly Population
Aging is the main cause of increasing psychological, social and
environmental vulnerabilities in the elderly population. It increases
the risk of various infectious diseases and leads to a decrease in
their body immunity. Additionally, they also have co-morbidities (like
diabetes mellitus, hypertension, Parkinson’s disease, dementia,
etc.,) which also increase the risk of getting infection during a
pandemic [29]. Because of their increased risk of health problems,
the “social isolation” is a serious health concern among the elderly
population [30]. A recent study by Santini ZI et al., demonstrated
that social isolation or disconnection puts older adults at a greater
risk of stress, anxiety and depression [31]. It was found that the
elderly individuals, whose only social contact is like places of
worship and community centers, are affected more due to social
isolation. People who do not have close family or friends, could be
placed at additional risk, along with those who are already lonely
and isolated [32]. Besides, older people might have cognitive and
sensory deficits which makes it difficult for them to comprehend
and follow precautions. Mental health is the cornerstone of public
health, more so in the elderly. As the need for a ‘viral cure’ eclipses
importance of mental health, the global panic only aids in increasing
the spread. Lessons learnt from earlier pandemics like SARS
have proved that regular telephonic counseling sessions, healthy
contact with family, relevant and updated information, caring for
the general medical and psychological needs and respecting their
personal space and dignity are important components of mental
health care in the elderly [33]. This warrants sensitisation at all
levels for early detection of mental health care needs and plan
appropriate interventions, especially for the vulnerable old-age
population [29].

Coping Strategies for Mental Health Issues
Early identification of community and healthcare groups which are
at a high risk of developing psychological morbidities is needed
by health authorities for targeted early psychological interventions.
Furthermore, there is increased risk of psychiatric issues among
people under quarantine or in isolation in hospitals because
they are deprived of their social supports, thereby practical and
emotional support is necessary for them. In this pandemic, online
psychotherapy has been adopted by many hospitals for psychiatric
patients through video conferencing platforms (like Zoom) [12]. It also
minimises virus transmission from face-to-face therapy. The online
and smartphone-based psycho-education about the viral outbreak,
promote mental wellness and initiate psychological intervention
like Cognitive Behavioural Therapy (CBT) and Mindfulness-Based
Therapy (MBT) [12]. All HCW need to be prepared for the moral
dilemmas they are going to face during the COVID-19 pandemic. It
is known that properly preparing staff for the job and the associated
challenges reduces the risk of mental health problems [34]. Routine
support processes (such as peer support programmes) available
to healthcare staff should include a briefing on moral injuries, as
well as an awareness of other causes of mental illness and what to
look out for. Once the crisis is over, supervisors should ensure that
time is made to reflect on and learn from the extraordinarily difficult
experiences to create a meaningful rather than traumatic narrative
[27]. Mental health support and follow-up should be provided even
6 months after the release from isolation for those individuals with
prior vulnerable mental health status. Appropriate supplies of food,
clothes and accommodation to the individual, if needed should
be provided [35]. For children to ensure that they have access to
regular programmed work, require access to online and advanced
technologies, that would enable remote connectivity. Relevant
steps are needed for ensuring better infrastructure for continuity of
learning and socialisation to mitigate the short and long-term effects
of COVID-19 [36]. A new form of intervention can be implemented
to cope up with mental stress. Psychological First Aid (PFA) is a
form of psychological support that teaches individuals how to care

disorder and unhappiness. Only 30% of the children who were isolated
or quarantined met the clinical criteria for Post-Traumatic Stress
Disorder (PTSD) [18]. Recently, the National Health Commission of
China issued guidelines and listed specific intervention strategies
for children who are quarantined in collective medical observation
centres [19]. For example, these measures seek to increase children’s
communication time with their parents; increase children’s access
to disease information via comic books and videos; guide children
to establish a regular activity schedule; provide night lights and small
gifts; and provide timely referrals to psychiatrists when children feel
mental discomfort, such as worry, anxiety, difficulty sleeping, and
loss of appetite [19,20].

Impact on the COVID-19 Patients
It has been found that the quarantined people were more likely to
feel lonely, anger, depressed, anxious, a feeling of boredom, denial,
sleeplessness or even suicidal thoughts [10,11,21]. The suspected
or confirmed COVID-19 persons largely experience fear and anxiety
regarding the high contagiousness and fatality [11,21]. Survivors of
COVID-19 are at a higher risk of developing several mental disorders
such as depression, anxiety and PTSD [6]. Li W et al., reported
that patients may develop Obsessive-Compulsive Disorder (OCD)
during their quarantine period [11]. The COVID-19 not only brings in
the illness but also the anxiety or panic among the patients [22].

Impact on Healthcare Workers
Healthcare workers are facing increased workload and fear of being
infected. They too have to undergo quarantine for the specified
duration. Ho CS et al., found that increased workload causes
physical exhaustion and emotional disturbance such as fear, stress,
anxiety and insomnia in their study on 1563 health professionals
which reported that more than half (50.7%) of the participants
reported depressive symptoms, 44.7% anxiety and 36.1% sleep
disturbance [12]. Paramedical staff, ambulance personnel and
HCWs have also reported stress and emotional difficulties with
increased levels of depression and anxiety. It was reported that
rates of anxiety and depression were higher for female HCW. It was
found that a considerable proportion of HCWs experienced mood
and sleep disturbances during this outbreak [23]. For a healthcare
provider, the novel nature of SARS-CoV-2, lack or limited laboratory
testing, insufficient treatment options, lack of Personal Protection
Equipment (PPE) and the high workload lead to stress. Self-care
is very important for health care providers (which includes being
informed about the illness, looking after and monitoring body’s
own reactions and looking for appropriate assistance) and also
implementation of mental health intervention if needed [8]. Jones
NM et al., found that exposure to social media rumors can also
create mental health problems like stress, anxiety, depression,
restlessness, denial and fear [24]. Mental health problems also affect
attention, decision-making capacity of medical workers that will
hinder the fight against COVID-19. It has been observed that there is
a long-lasting effect on overall well-being of healthcare professionals
[25,26]. The COVID-19 pandemic has put healthcare professionals
across the world in an unprecedented situation, who are compelled
to take unprecedented decisions and work under extreme pressure.
These decisions may include how to allocate scanty resources to
equally needy patients, to balance their own physical and mental
healthcare needs with those of patients, to align their desire and duty
to patients with those to family and friends and to provide care for all
severely unwell patients with constrained or inadequate resources
[27]. The health care workers may suffer from the so-called moral
injury. The term “moral injury” is defined as the psychological distress
that results from actions which violate someone’s moral or ethical
code and those who develop moral injuries are likely to experience
negative thoughts about themselves or others as well as intense
feelings of shame, guilt, or disgust. These symptoms can contribute
to the development of mental health difficulties [28].

www.jcdr.net Sajjan Pal et al., COVID-19 Pandemic: Mental Health and Coping Strategies-A Review

Journal of Clinical and Diagnostic Research. 2020 Dec, Vol-14(12): YE01-YE04 33

for themselves and to provide basic psychological support for family,
friends, and neighbours. It is a community-based intervention which
is a low-cost, sustainable model and appropriate for populations
with special needs, and can be present wherever and whenever it is
needed. In this intervention mental health professionals don’t “heal”
clients in therapy; they merely give them the tools to make repairs to
their psyche and their coping skills [37]. Raphael B in her pioneering
book on disaster mental health, described PFA in the context of
services provided in the first hours after a disaster which included
11 components [38]:

• Comforting and consoling

• Protecting from further threat

• Immediate care for physical necessities

• Helping affected individuals to become involved in goal-directed
behaviour

• Promoting reunion with loved ones separated in the event

• Supporting individuals while they identify the body of a loved
one is a process that merits its own category

• Accepting the ventilation of feelings (listening when someone
feels the need to talk)

• Structuring the routine of the individual to give a sense of order
in the aftermath of the event

• Promoting group support networks

• Identifying and referring individuals who need more traditional
mental health care

• Ensuring that the individual is linked to an ongoing system of
care and support

Walker G wrote about PFA in a more general manner for
understanding the event and significant stressors [39].

• Assess the participant’s response

• Educate the participant about stress and grief reactions

• Provide the participant with realistic coping responses

• Develop a response plan that mobilises the individual.

• Encourage good physical self-care

• Encourage use of the participant’s social support network

• Make appropriate referrals

• Provide follow-up

This model of PFA is intended for the general population to be
educated about stress and responses to stress (including traumatic
stress), active listening, resilience and coping skills, and when and
how to make referrals to mental health professionals. PFA is an
intervention that focuses on mental health of the individual [37,40].
Ornell F et al., has suggested some individual recommendations
for coping with stress. Maintenance of adequate sleep, nutrition
and exercises are the best way to cope with stress. Adequate
awareness about the COVID-19, avoid fake news of social media
and establish a support network like involving in leisure activities,
share your thoughts with someone will be helpful in reducing the
stress and anxiety related to COVID-19 [41].

CONCLUSION(S)
The COVID-19 pandemic has led to significant mental health issues
and has drawn attention to these issues. Because of this pandemic,
financial crisis has ensued, along with decreased recreational
activities, as a result of which mental health issues are likely to grow
exponentially. That is why, it is important to understand the mental
health implications of the COVID-19 pandemic including measures
to cope with this unprecedented situation for effective management
of these mental disorders.

More studies are needed to investigate the long-term psychiatric
sequelae arising from the COVID-19 pandemic such as impact of

the global economic recession on mental health. More research
should be done on psychotherapeutic interventions.

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PartiCUlarS OF COntriBUtOrS:
1. Assistant Professor, Faculty of Physiotherapy, SGT University, Gurgoan, Haryana, India.
2. Associate Professor, School of Physiotherapy, DIPSRU, Delhi, India.
3. Associate Professor, School of Physiotherapy, DIPSRU, Delhi, India.

PlaGiariSM CheCkinG MethODS: [Jain H et al.]

• Plagiarism X-checker: Jul 11, 2020
• Manual Googling: Oct 10, 2020
• iThenticate Software: Nov 20, 2020 (12%)

etyMOlOGy: Author OriginnaMe, aDDreSS, e-Mail iD OF the COrreSPOnDinG aUthOr:
Sajjan Pal,
SGT University, Gurgoan, Haryana, India.
E-mail: palsajjan14@gmail.com

Date of Submission: jul 10, 2020
Date of Peer Review: Sep 19, 2020
Date of Acceptance: Oct 22, 2020

Date of Publishing: Dec 15, 2020

aUthOr DeClaratiOn:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? NA
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

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