James Paul Pandarakalam*
Consultant Psychiatrist, UK
*Corresponding author:James Paul Pandarakalam, Consultant Psychiatrist, UK
Submission: January 26, 2022; Published: February 04, 2022
ISSN 2578-0093Volume7 Issue4
Background:The COVID-19 pandemic has led to unprecedented disruptions to the normal way of life for people around the globe. Health services have been overburdened in both developed and developing countries. The impact of the ongoing pandemic on mental and physical health, jobs, and relationships could be catastrophic, warranting collective action.
Aim: To evaluate the magnitude of COVID-19’ impacting on psychiatric services and health professionals, as well as to gain useful insights into the potential health burden of similar pandemics and global disasters in the future.\
Materials and Methods: Published studies concerning mental health problems associated with the COVID-19 outbreak and other global infections were considered and reviewed. A selective survey of the literature, including narrative reviews, was then carried out to collect different interpretations, which helped form a framework to study the ongoing pandemic’s implications for psychiatric services.
Results: Covid-19 pandemic has resulted in a surge of mental health problems. During the pandemic, mental healthcare services have been reorganized in many parts of the world to seek help from modern technological facilities and offer speedier service input. Such a procedure may involve merits and demerits. Mental health professionals do not seem to have properly considered the global nature of the Internet, the associated risks and they should be urged to pay more attention to the limitations of web-based therapies, as well as ethical and legal problems, before popularizing distance treatment. However, virtual psychiatry in combination with face-to-face interactions are likely to continue in the future years.
The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was named COVID-19 by the Director-General of the World Health Organization . The origin of this respiratory infection was traced to a Chinese seafood wholesale market in the city of Wuhan. As in any new epidemic, a single person seeds the first infection, several links of which are fated to seed chains of their own and spark a viral Big Bang. In response to their awareness of grave global problems such as climate change, extremism, migration crises, xenophobia, the rise of authoritarian regimes, and societal polarization, Ladislav Kesner and Jiri Horacek recognized that this pandemic arrived when global communities and societies were already exhausted by negative emotions, fears, anxieties, and feelings of helplessness .They also advised psychiatric practitioners to prepare for the tangle of concerns and come up with new techniques to deal with them.COVID-19 has, in the end, added to the existential threat that the human society is already facing .
Although data collection on psychopathological characteristics in the post-illness phase is still growing, available evidence suggests that confusion and delirium are prevalent features in the acute stage of COVID-19 [4,5]. For a variety of reasons, patients with COVID-19 are at an increased risk of delirium . During the epidemic, numerous investigations have shown neurological problems, anxiety symptomatology, exacerbated OCD symptoms, depression, and suicidal ideation [7-9]. There has also been a rise in general alcohol and drug abuse . Mental sequelae or morbid psychological elements, such as psychological repercussions of this new severe and potentially fatal sickness, worries of infecting others, and stigma, can all induce psychiatric consequences . COVID-19's psychiatric consequences have been extensively documented [4-6;11-13]. All these psychiatric and neuropsychiatric problems have placed a significant strain on mental health care. The Covid epidemic has harmed the physical and emotional health of the population. Vaccinations are predicted to reduce the severity of these psychological consequences, but underdeveloped countries are lagging in implementing immunization regimens to combat the pandemic. Virtual psychiatry has been accelerated to suit the growing need for psychiatric services. In the last two decades, digital psychiatry has progressed slowly. It has been lurking in the shadows for a long time, and the COVID-19 pandemic has served as a catalyst for its complete integration into mainstream mental health care for the safety of patients and clinicians.
Healthcare professionals run a high risk of being infected with SARS-CoV-2. Feelings of being inadequately supported, concerns about their own health, fear of taking the infection home to family members or others, not having rapid access to testing through occupational health if needed, being isolated, feelings of uncertainty and social stigmatization, and overwhelming workload are daunting realities to many health workers . Frontline staff are under pressure to make morally challenging decisions while caring for the afflicted , which also makes them more vulnerable in developing moral trauma. Moral injury and the consequent development of mental illness are very real for the frontline staff working in these unprecedented and underprepared times . Administrative workers, who are now consumed by overcrowded clinic wards, settling on split-second choices under pressure, and double shifts, are additionally damaged by the various deaths they witness in a single day. Suicides have also been reported among healthcare staff. Further, they are prone to PTSD, like firefighters. One study positively correlated the perceived emotional and cognitive threat of COVID-19 contagion with physiological anxiety, depression, and emotional exhaustion, which led to agonistic behavior .
In a rapid review and meta-analysis, Kisely et al. , noted that the risk factors of psychological pain are being young, more junior, parents of dependent children, having members of the family already infected with COVID-19, lack of practical support, and COVID-19 stigma. They also observed that clear interaction and communication, availability and access to adequate personal protection, enough rest, and practical and psychological support are linked to lowered morbidity. A considerable portion of healthcare workers have also experienced mood and sleep disturbances during this outbreak, stressing the need to establish ways to mitigate mental health risks and adjust interventions under pandemic conditions .
Notably, Pappa et al. , found the anxiety symptoms among healthcare workers in 12 studies had a pooled prevalence of 23.2%, and depression in 10 studies yielded a prevalence of 22.8%. The researchers also demonstrated insomnia’s prevalence at 38.9% across 5 studies. Working in a COVID-19 ward can be mentally and physically exhausting . Staff burnout poses its own problems and is associated with poorer-quality care, higher patient dissatisfaction with their care and higher numbers of patients dying in acute settings.
Pandemics extend beyond pathophysiology and medical phenomena to associations with intense psychosocial impacts. Interruptions to school systems have befuddled youngsters, senior residents must isolate themselves, and caregivers and individuals recuperating from the disease and those with long-term clinical conditions will all face their own psychological issues. As for securing psychological wellness, remaining connected with friends and family, working out, and keeping busy are useful adapting procedures. Research has also reported long-term behavioral changes like vigilant handwashing, avoiding crowds, as well as a delayed return to normality even many months after the quarantine . The same scenario could repeat in the post-COVID-19 period, however. Thus, the quarantine period seems to have important and dysfunctional psychological consequences on individuals’ mental health not only in the short term, but even in the long term .
Hopefully, mass disasters can inspire unity to curb the situation, which will improve mental health. Individual mental wellbeing can be assisted by the big group energy effect. In health crises, the social environment is an important factor to be considered in maintaining mental health, but it is under constant threat. Feelings of insecurity creep in when we lose control of our environment, such as now, and anxiety has emerged because of the current medical crisis’s obscure end. Psycho-spiritual preparedness is important at this stage to face pandemic challenges. To effectively combat present and future pandemics, the psychiatric and psychological aspects of COVID-19 from the perspectives of public and global mental health must be studied .
The COVID-19 pandemic has caused widespread disruption in the delivery of mental health services in all countries, though particularly in developing countries. Community-based services and mental health prevention and promotion programs, already limited in availability, are reported to be compromised at a time when they are most needed due to the adverse mental health impacts of COVID-19. The WHO has seriously considered COVID-19’s impact on mental health and health services, initiating worldwide studies . All over, people are affected by substance misuse disorders at staggering rates. COVID-19-afflicted psychiatric patients are reluctant to seek medical help, and formal admissions have become unavoidable in such cases. In many contexts, appropriate and evidence-based treatment for mental health problems is deficient, notably in resource-limited settings, and the COVID-19 pandemic has worsened this situation. People with mental health disorders experience severe human rights violations, discrimination, and stigma everywhere in the world. Global studies have shown that despite the heavy workloads the pandemic has imposed on health staff, they have coped with the additional, uninvited stress of dedication and heroism. An Italian study revealed that despite having been subjected to intense work shifts and psychophysical stress, health service staff are confident in the work they have done and are available to continue bravely serving patients during these hard times with professionalism and dedication . There have been many unsung heroes everywhere and, overall, it has been a time of triumph for global health services.
Children have been under huge psychological pressures everywhere. They are scared about dying from the virus or worried about their family dying. During the lockdown, children in households where domestic and physical abuse is taking place have been helpless to seek refuge and support elsewhere. Globally, youngsters in low-income households have fallen behind their peers academically as a result of school closures. Children are also feared to be more vulnerable to online abuse as they are spending more time in front of the screen. There are hardly any psychological therapies for children in the underdeveloped countries. The young generation is going to need support not only survive this crisis, but to thrive beyond it. The real psychological victims of the pandemic have been the innocent children. There has been an increase in mobile addictive behavior among children. Change in the daily routines, distancing from the peer group due to the introduction of virtual learning have a negative impact on the young ones. Missing many significant life events such as celebrations have an adverse effect on both the social and emotional life of children and adolescent groups.
The Indian experiences are illustrative of the impact of the pandemic on mental health services. Because of the stigma attached to mental illness, the private sector is fast. Developing in India. An Indian study suggests that the mental health services in the private sector have been markedly impacted by the lockdown and the pandemic and the services which have been most affected include ECT services, inpatient services, and outpatient services. An Indian survey conducted by Grover et al suggests that more than two-fifths of the people are experiencing common mental disorders, due to lockdown and the prevailing COVID-19 pandemic . This finding suggests that there is a need for expanding mental health services to everyone in the society during this pandemic situation. Overall, there is also a significant compromise in the revenue generated by the mental health professionals in private practice. The pandemic and the lockdown have led to the expansion of the teleconsultation services in accordance with telemedicine guidelines by the Government of India. Attempts were also carried out to explode the several myths surrounding transmission of COVID-19 . It is feared that the ongoing wave of COVID-19 in India has generated a silent epidemic of psychiatric disorders.
In the last two decades, digital psychiatry has progressed slowly. It has been lurking in the shadows for a long time, and the COVID-19 pandemic has served as a catalyst for its complete integration into mainstream mental health care for the safety of patients and clinicians. Through a live video link from a remote location, the practitioner is connected to the service user [28,29]. Mental health practitioners have been attempting to perfect the skill of establishing therapeutic relationships across technology devices while integrating them with real-world contacts. This type of clinician-patient rapport is now known as the hybrid physician-patient connection . But research elucidating the underlying mechanisms and causal relationships between technology use and brain health, with a focus on both the positive and negative impact of digital technology use is lacking.
In densely populated countries, digital psychiatry is beneficial, as are developing digital care tools that aid early intervention and care. It improves existing treatment options by providing better predictive models. Social correspondence is made easier with the use of the internet, video, and telephone gatherings. Telepsychiatry eliminates geographical boundaries between patients and health care providers, resulting in higher-quality therapy. It is possible to treat a greater number of patients. It expands the number of patients who can be reached and diagnosed by psychiatrists. It is convenient and easy to use, and it eliminates the need for travel.
The advantage of digital psychiatry is that it reduces waiting times. Patients with physical restrictions may benefit from remote treatment, while those who are very sensitive to stigma attached to meeting mental health professionals may prefer telepsychiatry. It has the potential to improve client satisfaction with services and provide access to specialists who are not available in rural or underserved locations. It can help people feel less stressed and prevent appointment cancellations due to weather or health issues. It may turn out to be the best option for people who lead hectic lives. It has the potential to improve the quality of treatment and treatment adherence. A negative transference reaction is less likely. Telepsychiatry can help patients become more engaged in the treatment process. Patients would be more likely to disclose concerns as soon as they arise. It has the potential to enhance treatment access while also being cost-effective. Patients no longer need to feel lonely because of advances in digital technology. Patients with disabilities have the same access to digital technology as other patients. The Internet revolution has boosted amusement and cognitive distractions, as well as worldwide consultations and scientific knowledge exchange, which has provided a solution to language obstacles. Virtual psychiatric services would become a second choice for all service consumers in the post-pandemic period .
When it comes to evoking subjective symptoms, telepsychiatry is less effective. Digital psychiatry lacks personal touch and human connections since it reduces face-to-face encounters between service consumers and their treating providers. Clients need to be educated on technology. Hardware/Software Glitches and broadband connection interruptions are prevalent and might make delivering psychiatric treatments difficult. It has prescription restrictions. In the implementation of web-based mental health services, the age-old axiom that "one size does not fit all" is extremely apt.
Controlled substances cannot be prescribed unless patients are in authorized healthcare settings, and early diagnosis of psychotropic pharmaceutical adverse effects may be missed. There are some limits on employment: At the time of service, clinicians must be approved in the region where the patient is located. Broadband service is still scarce in many rural areas. Staff must be tech-savvy, which many aren't, necessitating further training. Equipment costs can be greater at first. With multiple healthcare professionals using the platform, care must be taken to maintain continuity of service. Users of digital psychiatry should have access to high-speed Internet and a smartphone or computer.
In the future, information poisoning could increase patient stress and lead to greater psychological issues. It is extremely dangerous to use telepsychiatry to respond to mental emergencies in a timely manner. Identity theft would be a legal issue. Telepsychiatry will make it more difficult for social services to enable formal admissions. Medical issues may go unnoticed. Without a physical examination, some of the side effects of psychiatric medicines that necessitate immediate medical attention and investigations might go undetected. Because of the lack of oversight, there is a larger danger of negligence on the part of the practitioners. The risk of practitioners engaging in fraudulent activities could be a problem. Telepsychiatry is insufficient to facilitate the interactions that occur during comprehensive case-taking and documenting, which itself may serve indirectly as a form of psychotherapy. More legal issues would arise because of digital psychiatry. Practitioners may become less alert and foster laziness if they are out of position. Digital psychiatry would be unable to establish a complete understanding of crisis conditions, thus leading to a false sense of denial.
The youthful personnel will require a personal touch from senior staff as well as the knowledge that comes with experience, which may not be available in the zoom world. People will quickly get uneasy in the virtual environment and distrustful. The overcrowding in the zoom workplace is detrimental to the less articulate employees, while extraverts thrive and dominate. If the epidemic and attendant quarantines last longer, these new technology interventions will become ingrained in psychiatry's day-to-day practice . In reality, virtual psychiatry advisers and believers are anticipating and supporting these adjustments in therapeutic practice to remain in the post-pandemic period [33,34]. Human connection is at the heart of psychiatric treatment, and only time will tell whether telepsychiatry can help or hinder it. For the time being, virtual psychotherapy is required to weather the current storm. As a result of the pandemic's urgency, there have never been more possibilities to study, teach, invent, and assess telepsychiatry solutions .
Digital psychiatry poses several ethical issues. In a review study by Julia S et al. , they found altogether 24 ethical arguments in favor of cyber- psychotherapy and 32 against . The top five ethical arguments in support of online psychotherapy were (a) increased access to psychotherapy and service availability and flexibility that could be gained by virtual psychotherapy; (b) web-based therapy offers its own therapy benefits and enhanced communication; (c) Certain clients may benefit depending upon specific client characteristics; (d) convenience, satisfaction, acceptance, and increased demand; and (e) digital psychotherapy has economic advantages. The top five ethical arguments against engagement in online psychotherapy were (a) loss of privacy, confidentiality, and security issues; (b) questionable therapist competence and need for special training; (c) communication issues specific to technology; (d) research gaps; and (e) helplessness to tackle emergency issues .
Psychotherapists have started practicing distance psychotherapy. Many authors have expressed concerns about privacy, confidentiality, security, and safety in web-based psychotherapy [36,37]. There are apprehensions about to the use of unsecured websites or unencrypted communication tools, like commercially available software that is easily hacked. Data security may also be compromised when technology fails, with potential breaches of confidentiality that might extend beyond the therapist's control. When employing Internet programs, patient confidentiality may be jeopardized. There is a significant risk to one's privacy. When there is terrible weather or other interference, the connection may be disrupted. Clients with dementia, younger children, and individuals with particular learning or other disabilities may find that digital psychiatry is ineffective. The therapeutic energy exchange that takes place in one-on-one interactions would be absent. The clinician's voice may be indistinguishable from the client and lack an empathetic tone. Electronic equipment could be misinterpreted as electronic trackers by paranoid patients. Overfeeding may cause patients with impaired abstract thinking to misinterpret information.
Mental health practitioners, like any other human being, have psychological needs of their own. The workplace is a social environment, and any sort of interaction with peers is a social phenomenon. Face-to-face interaction will be lost, as will informal interactions by the coffee machine or in the cafeteria. Workgroups will soon lose focus in the realm of virtual communications, as will their sense of belonging and dedication to an organization. Even before the COVID pandemic, everyone in industrialized countries was suffering from a loneliness epidemic. Newcomers to psychiatry will be more affected than those with more experience. Face-to-face meetings are not replaced by the digital world of Zoom and Skype .
Machine mediated talks and listening deprive us of our faculty to listen and empathize with others. Only 25% of what we hear in zoom meeting are retained. It is high time that we all set up a few minutes of silence to reset our ears and re-calibrate so that we can hear the quiet again. We should use honesty, authenticity, integrity, love in all our communication and listening. Metaphorically, we are given two ears and one mouth with a purpose to listen twice as much as we talk. It builds rapport and shows that we are compassionate and care. Listening is the golden key that opens the door to human relationships. Genuine listening has its implications in all walks of our lives like a doctor –patient relationship. Empathetic listening without any bias should be the primary duty of a caring mental health professional. Unfortunately, computers have taken the role of patients and empathetic listening and compassion is becoming a thing of the past. It should not be forgotten that good listening also plays a big role in taking the history of an illness and history taking itself is a piece of psychotherapy. In genuine listening, the focus moves to the other person, and we put ourselves in their shoes, we tune into their wavelength. Let listening become the norm rather than exception. Listening should become a chain reaction and be contagious so that we can transform the world to a better place. What everyone values most in life is the gift of being heard. Empathy is seeing with the eyes of another, listening with ears of another and feeling with the heart of another; computers cannot replace human ears, mouth, and heart.
According to many reviews, there is insufficient research to warrant online psychiatric services. Pointing out such a view, there are just too many gaps in knowledge, particularly in terms of effectiveness, efficacy, and long-term effects. There is not much research that compares in-person treatment to online treatment. This is especially true in the case of digital psychotherapy . There is a clear lack of regulatory norms and practice standards. Web-based healthcare practice may intrude on global zones, necessitating global or international cross-border regulation. However, there are no legal or regulatory guidelines or oversight of this practice. The lack of defined ethical principles or codes of conduct for digital psychotherapy raises several vexing ethical issues . Online counselling has the potential to develop internet abuse and addiction in the long run . Loneliness and social isolation may be exacerbated by web-based therapy .
Smartphones do not make mental health practitioners necessarily smarter. We have only started exploring the positive and negative effects of digital technology on brain health and it is too early to jump into the waters of digital psychiatry without studying the long-term consequences of such newer measures of psychiatric interventions. These are days when internet is becoming more powerful than the pulpits. Digital tool explosion is taking place in an unstoppable pace and developments in digital technology are outpacing the evaluation of rigorous digital health interventions warranting more advanced methodologies to keep up with the pace of digital technology development before the digital revolution goes out of hand . Digital revolutions in mental health service should be toned-down as digital evolution. Exposure to unregulated and distorted health-related or other information may also occur as a result of digital psychiatry .
Technology has always been unsafe in the hands of businessmen who exploit them for financial gains, and they are in the lookout for new avenues to expand their business empire and psychiatry could become just another continent. Digital media may be like sugar; in small doses sugar is beneficial and high doses is detrimental to health. Focusing only on the negative aspects of them may be like highlighting the accidents and deaths motor vehicles may cause and ignoring the beneficial effects of them . By incorporating digital media into psychiatry, we are giving the wrong message to our clients that it is all great, but everything that glitters is not gold. Since the beginning of the pandemic, there has been an unprecedented shift in the medical landscape as a whole and these changes need close watching. The digital Big Bang proposed by Dave et al.  may turn into a Big Crunch unless prompt and proper guidelines are implemented.
The pandemic has given shock to health professionals as well as new insights into the impact of unruly globalization that has contributed to the rapid spread of the virus. We ponder what is going to happen next in all the unexpected crisis. The truth may be that the future is conditional, yet we do all our divination tricks into the future. The immediate questions are about the future course of the pandemic. Telenti et al.  has made three proposals of the future of COVID-19. (1) There may not be a rapid control of this pandemic and thus will face a future with ongoing manifestations of severe disease combined with high levels of infection that, in turn, could foster further evolution of the virus. (2) Transition to an epidemic seasonal disease such as influenza. (3) Transition to an endemic disease similar to other human coronavirus infections that have a much lower disease impact than influenza or SARS-CoV-2. It is too early to predict with confidence whether further adaptations of SARS-CoV-2 to humans will increase or decrease its intrinsic virulence .
The pandemic has slowed down the global community, something many people particularly in the technological societies were silently craving. The pandemic has also shown the interconnectedness of the world community, but also has highlighted the current inadequacies in the healthcare delivery systems and access to new biomedical interventions . Only a limited number of countries have contributed to the biomedical discoveries that have assisted to suspend the surge of the proliferation of the virus . Yet, there has been a lack of international cooperation to coordinate the implementation of these tools globally and such a scenario has showed the inequalities between advantaged and disadvantaged groups both within countries and between countries .
The exact cause of the COVID outbreak is still a debatable issue. One thing is certain that similar health crises could happen again, and measures should be undertaken in different spheres of human activity if we are to avert them in the future. Zoonotic diseases should be stopped at the source. With growing threat of global warming and climate breakdowns, viruses could jump out from animals to humans that may result in the increase of zoonotic diseases. The old dividing lines between the rich and poor no longer make sense as the pandemic did not discriminate the different sections of the population. The pandemic could result in the reorganization of a more robust health care service. A curious observation has been that certain nations were stepping away from each other rather than cooperating to tackle the unexpected health challenges. We have learned new lessons from the pandemic and measures to build a robust frontline defense against future outbreaks through the cooperative efforts of worldwide epidemiologists that would respond to future outbreaks more promptly and efficiently. World health services need to build a more equitable health care system that benefits everyone to combat future epidemics/pandemics
Remote learning has become more popular in the pandemic period. It has more advantages than disadvantages in the field of health education even though its impact on other areas of health profession are questionable or at least need stringent discernment. Remote learning is going to shrink distances and international lectures could pare air travels as they become accessible a few clicks away. This could have a favorable effect in sharing new health information and research activities. Considerable regulatory steps are required in the coming years to support the development and growth of distance learning, including privacy concerns.
The pandemic also poses challenging questions how human society could cope with global disasters like nuclear war, biological warfare, and even cybernetic viral issues when the world has struggled to cope with the aftermaths of a single virus. All wars have a psychopathology which may include abnormal psychodynamics and para-psychodynamics . Even during the pandemic crisis, we see that the world is full of political turmoil. One of the UK top military officials, Mr Andrew Woodcock  has cautioned that the world needs to learn from history and international mistakes that led to the previous world wars in the last century . The world community should unite and work together towards achieving multilateral nuclear disarmament and encourage peace-making endeavors. Nations should cooperate with each other by building up a peaceful society or would perish together. The post-pandemic worldview would be different from the pre-pandemic one.
There is an agreement in all the relevant studies that health care professionals are at an increased risk of getting infected with the virus, high levels of stress, anxiety, depression, burnout, addiction, and PTSD, which could have long-term professional and psychological consequences. A scientific monitoring of the ongoing pandemic is highly significant for mental health professionals. While Improving people's resilience and ability to cope with life's ups and downs, enhancing physical immunity to fight with pathogens is also a great concern. Cytokine storm in severe cases of COVID-19 leading to complications, which includes neurotoxic effects also illustrate how an abnormal autoimmune reaction, could lead to the formation of psychotic symptoms and strengthen the autoimmune etiology of psychotic disorders. These observations may pave the path to the establishment of immune psychiatry and immuno-neuropsychiatry. Such endeavors would promote investigating how the immune-inflammatory response translates into psychiatric illness shedding more light into the study of the etiopathogenesis of these disorders. Thus, the complications of cytokine storm, an autoimmune reaction could give a new impetus for the autoimmune etiological search for psychotic disorders. The neurotoxic effects of the COVID-19 might offer new conceptual models in cognitive sciences with regard to the causation of neurological and psychiatric disorders and could be routed to develop immune psychiatry.
Digital psychiatry carries more risks in the hands of poorly trained mental health professionals. It can also promote a mechanical outlook on life. Mental health organizations have to rethink their working arrangements in the digital era. A good percentage of mental health work force are currently working remotely from home. This re-calibration will eventually settle on a sustainable new normal consisting of a hybrid workforce and distributed clinic place. But, in the techno transformed world, technologically illiterate people are going to be at a loss. Very few places in the globe have been left untouched by the pandemic. There have been 4.4 million deaths reported as of August 2021. The pandemic has caused people to become more cognizant of the mortality of human existence. In these difficult circumstances, some discover comfort in faith traditions, and demonstration of kindness can bring about wide waves. Fear, frustration and futility are the emotions mental health workers are feeling when they face COVID cases. In all the apocalyptic films, mankind always came together to beat any obstacle and had the last laugh.
© 2022 James Paul Pandarakalam. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and build upon your work non-commercially.