|Year : 2022 | Volume
| Issue : 1 | Page : 7-13
Mental health outcome among psychiatric patients due to COVID 19 lockdown induced disruption of access to psychiatric services: A cross-sectional study
Shanti Mohan Kethawath, Shagufta Rahman, Venkata Rahul, Aditya Kashyap, Harish Pinnoju, Rajshekhar Bipeta, Umashankar Molanguri
Department of Psychiatry, Institute of Mental Health, Osmania Medical College, Hyderabad, Telangana, India
|Date of Submission||09-Jan-2022|
|Date of Decision||30-Jan-2022|
|Date of Acceptance||07-Feb-2022|
|Date of Web Publication||30-May-2022|
Prof. Rajshekhar Bipeta
Department of Psychiatry, Institute of Mental Health, Osmania Medical College, Hyderabad - 500 038, Telangana
Source of Support: None, Conflict of Interest: None
Background: COVID 19 lockdown has an impact on the mental health of the general population, COVID patients, and health professionals. However, knowledge about its impact on psychiatric patients is limited.
Objectives: To assess the mental health outcomes among psychiatric patients due to disruption of access to psychiatric services caused by the COVID 19 lockdown.
Materials and Methods: It was a single-center, cross-sectional, observational, pragmatic study conducted at a tertiary care psychiatric hospital. All consecutive psychiatric patients presented to review in the outpatient department for 3 weeks following the relaxation of lockdown were screened, and a total of 305 eligible patients were enrolled. A semi-structured questionnaire was applied to capture the mental health status of the patients.
Results: More than three-fourths (78.3%) of patients were off medications during the lockdown. During lockdown, more than half (64.3%) of patients' mental health conditions worsened, and significantly more in those who were not on medications. More than half of patients who were doing well before lockdown showed re-emergence of symptoms, and it was more commonly seen in mood disorder patients, followed by schizophrenia and other psychotic disorder patients. Thirty-one (10.1%) patients reported self-harm ideas; six (1.9%) claimed to have made self-harm attempts during lockdown.
Conclusions: COVID-19 lockdown has worsened the mental health status of psychiatric patients. Strengthening community-based psychiatric care in tie-up with telepsychiatry services and adopting new innovative measures may help face such eventualities in the future.
Keywords: COVID-19, lockdown, outcome, psychiatric illness, re-emergence, worsening
|How to cite this article:|
Kethawath SM, Rahman S, Rahul V, Kashyap A, Pinnoju H, Bipeta R, Molanguri U. Mental health outcome among psychiatric patients due to COVID 19 lockdown induced disruption of access to psychiatric services: A cross-sectional study. Telangana J Psychiatry 2022;8:7-13
|How to cite this URL:|
Kethawath SM, Rahman S, Rahul V, Kashyap A, Pinnoju H, Bipeta R, Molanguri U. Mental health outcome among psychiatric patients due to COVID 19 lockdown induced disruption of access to psychiatric services: A cross-sectional study. Telangana J Psychiatry [serial online] 2022 [cited 2022 Jun 30];8:7-13. Available from: https://tjpipstsb.org/text.asp?2022/8/1/7/346236
| Introduction|| |
The coronavirus disease 2019 (COVID-19) was detected in December 2019, as a viral outbreak in Wuhan, China, and the World Health Organization declared it a pandemic on March 11, 2020. Since the first case of coronavirus was reported in India, i.e., on January 30, 2020, COVID-19 cases are increasing daily. The pandemic of COVID-19 has a sudden and significant effect on the infrastructure, transport, daily activity, free movement, and distribution of medical services worldwide. COVID-19 vaccinations have been shown to reduce infection severity.,, However, as there are currently no definitive treatment modalities, preventive strategies involving public lockdown, isolation, quarantine, and social distancing are the means of controlling COVID-19 transmission. In India, a nationwide lockdown and strict home confinement were enforced from March 25, 2020. Lockdown was a successful strategy in exponentially slowing the COVID-19 disease progression (infection rate and death). While this approach is an appropriate consideration for addressing the enormous increase in COVID cases, it has a widespread impact on the economy, psyche, and daily lives of the public. Implementation of lockdown might have also reduced psychiatric patients' access to psychiatric services. Reduced access to psychiatric care might worsen existing mental health conditions. As evident from previous disasters, there is a heightened risk of relapse of preexisting mental illness due to various factors, such as exacerbation of loneliness and despair under confinement measures, leading to increased rumination and overall reduced ability to cope with stress, low self-esteem, and nontreatment compliance, compared to the general population. Further, during a viral pandemic like in the current situation, worsening of existing mental health conditions may make them vulnerable to an increased risk of contracting the virus and may eventually impose the risk of transmitting COVID 19 infection to others by not following strict safety measures. A recent review found that a psychiatric diagnosis in the previous year was associated with a higher incidence of COVID-19 diagnosis. This may be more common for patients with severe mental illness, as cognitive impairment in this vulnerable population may pose a challenge to processing informational overload in times of crisis.
There is growing literature on the effect of the COVID-19 pandemic on the mental health of the general population,, health professionals, and COVID 19 patients. Research pertaining to the effect of pandemics and lockdowns on the mental health of psychiatric patients is also increasing. Recently, the World Health Organization, reported that essential mental health services were disrupted in 93% of countries across the world during the period of social isolation. Consequently, it may have an impact on the mental health of psychiatric patients also. A recent study assessed the mental health condition of psychiatric patients during the lockdown and found that 30% of patients showed a relapse of symptoms. It was proposed that patients with bipolar disorder and schizophrenia are likely to have relapses due to jeopardy in both the availability of regular medication and medication compliance. Another study found that 11% of severely mentally ill patients had relapsed during the initial phase of the pandemic. Given the variable course of psychiatric illness and the requirement for continuous monitoring for psychiatric illness, it becomes necessary to understand mental health because of the COVID 19 pandemic lockdown. Assessment of mental health outcomes of these patients due to lockdown may help in understanding its impact and may help design policy for such future eventualities. The study aimed to assess the mental health outcomes among psychiatric patients due to the disruption of access to psychiatric services caused by the COVID-19 lockdown.
| Materials and Methods|| |
This pragmatic observational study was done in the outpatient (OP) setting of a 600 bedded tertiary care psychiatric teaching public hospital inTelangana, India. In the hospital's OP setting, the main OP and the review OP run parallelly. The main OP consists of newly registered patients. In review OP, already registered patients are reviewed for regular follow-up. The medication is dispensed from the hospital pharmacy. All the consecutive patients presenting to the review OP department for 3 weeks following the partial relaxation of lockdown in theTelangana. State, i.e., from May 20, 2020 to June 09, 2020, were recruited through consecutive sampling. By this time, transportation was still restricted except for emergency health situations. However, some relaxation was given in other domains such as shops, restaurants, taxis, and intrastate bus services in some areas of the State. Only those patients who mentioned that they missed their previous follow-up because of lockdown were included. Those who did not miss previous follow-ups during a lockdown or could not review for reasons other than a lockdown were excluded.
The procedure of the study
The Institutional Ethics Committee approved the current study. Review patients were screened from the OP setting, and prescriptions were checked for their continuity to follow-up during the lockdown. If they missed their follow-up during the lockdown, they were asked for reasons for the same. Those who mentioned lockdown as a reason were included, and after obtaining written informed consent from patients/caregivers, they were assessed by qualified psychiatrists. A semi-structured questionnaire was prepared to capture current sociodemographic and clinical details. All the clinical details, including diagnosis, were made using the International Classification of Diseases-10 (World Health Organization, 1992), was captured from the patients' medical records.
The mental health outcome of patients following their last visit to the hospital was assessed. As all the patients had at least one visit to the hospital, their old medical records were retrieved and all the relevant clinical details were recorded. The current clinical condition was rated as “maintaining the same,” “improved,” or “worsened” by a qualified psychiatrist based on a clinical interview that included patients' and caregivers' perceptions. For the purpose of the study, worsening was arbitrarily considered a “deterioration in the existing psychological symptoms” or “emergence of new psychological symptoms.” Similarly, maintaining the same was arbitrarily considered to be no change in psychopathology compared to the last visit. Current mental health status was assessed based on the clinician's judgment.
Descriptive statistics were primarily used to represent the sociodemographic and clinical characteristics of the participants. The Chi-square test was applied to compare mental health outcomes between various psychiatric illnesses and participants' sociodemographic characteristics. The level of statistical significance was kept at P < 0.05, and all the tests were two-tailed. SPSS version 26 (SPSS Inc, Armonk, New York, USA) was used to analyze the data.
| Results|| |
A total of 1509 patients attended the review outpatient department during the study period. The flow chart of patients screened for the study is depicted in [Figure 1]. A total of 305 patients could not be followed up because of lockdown, which comprised the final study sample. [Table 1] shows their sociodemographic characteristics, whereas [Table 2] shows the diagnosis-wise distribution. More than three-fourths of the patients (n = 236, 77.7%) were registered in our hospital for more than 1 year, and 55.1% (n = 168) were compliant with treatment for more than 1 year before lockdown, as noted from their medical records. A total of 24 (7.8%) patients were on depot antipsychotic medications before lockdown. Most of them are in the schizophrenia and other psychotic disorders group (n = 18, 75%). During the lockdown, 66 (21.6%) patients consumed medication on a regular basis, either through “direct purchase from local pharmacy” (n = 61, 92.4%) or through “consultation with another psychiatrist” (n = 5, 7.5%). However, 78.3% (n = 239) of patients were off medications during the lockdown.
|Table 1: Sociodemographic characteristics of the study participants (n=305)|
Click here to view
The mental health status of patients following lockdown
The mental health condition of patients following lockdown is given in [Table 3]. During lockdown, mental health conditions worsened in more than half (64.3%) of the patients. Before lockdown, 101 (33.1%) patients were maintained well with no active psychopathology; however, only 46 (15%) participants were maintained well during the lockdown. Moreover, among those who maintained well before the lockdown, 55 (54.4%) patients showed a re-emergence of symptoms during the lockdown. Re-emergence of symptoms was more commonly seen in mood disorder patients (n = 25, 56.8%), followed by schizophrenia and other psychotic disorder patients (n = 22, 50%). Similarly, ten patients (40%) required admission among the patients who showed re-emergence of symptoms.
|Table 3: Comparison of mental health outcome of psychiatric patients between various demographic and clinical variables|
Click here to view
A comparison of mental health outcomes among various sociodemographic and clinical variables is given in [Table 3]. Before lockdown, 204 (66.9%) patients were symptomatic, whereas, after lockdown, 259 (84.9%) patients became symptomatic, and the difference is significant (P < 0.001). No particular disorder had a significant worsening (P = 0.378). However, when compared to those who took medications during lockdown (n = 66, 21.6%), mental health conditions significantly worsened (P = 0.001) for those who did not take medications (n = 239, 78.3%). In patients with schizophrenia and other psychotic disorders, worsening of symptoms (P = 0.029) occurred in patients who were not on depot preparation (n = 96, 65.3%) compared to those who were on depot antipsychotic medications (n = 7, 38.8%).
During the lockdown, a total of 69 (22.6%) patients showed physical aggression towards family members or neighbors and aggression was significantly more (P = 0.001) among those “worsened” compared to those who “maintained well” or “improved.” Similarly, 31 (10.1%) patients reported self-harm ideas during the lockdown; 6 (1.9%) claimed to have made self-harm attempts during the lockdown, and suicidal ideas were significantly more prevalent in those patients who worsened compared to those who did not (P = 0.016).
| Discussion|| |
Mental health conditions worsened in more than half of the patients during the lockdown, and more than three-fourths of the study population were off medications because of a lack of access to psychiatric services during the lockdown. Further, compared to those taking medications during the lockdown, those who did not take medications significantly worsened (P = 0.001). In an online survey regarding mental health services at various training centers in India, more than half of the patients could not obtain prescribed benzodiazepines (56.9%), followed by antipsychotics (41.3%), antidepressants (38.5%), and mood stabilizers (32.1%). Thus, the unprepared lockdown has adversely affected psychiatric patients' access to mental health services.
More than half (54.4%) of the patients who maintained well before lockdown showed re-emergence of symptoms, which is higher than the study by Muruganandam et al., who reported 29.5% of their subjects having re-emergence of symptoms. The higher rate in our study could be because, in our study, more than three-fourths (78.3%) of the patients were off medications during lockdown because they were unable to access healthcare services, whereas, in a study by Muruganandam et al., it was 22%. Another study, found a relapse rate of 11%, but it only included patients with severe mental illnesses, as opposed to our study, which included all types of psychiatric patients. Our findings have implications, as the re-emergence of symptoms in otherwise “maintaining-well” patients lead to an increase in the morbidity of the illness and familial and financial burden. Worsening or re-emergence of the symptoms may sometimes require hospitalization, as in our study, wherein 40% of patients who had a re-emergence of symptoms required in-patient management. Similarly, in our study, re-emergence of symptoms was most commonly seen in mood disorders, followed by schizophrenia and other psychotic spectrum disorders. It could be explained that the use of depot preparation antipsychotic medications was higher in patients with schizophrenia and other psychotic disorders, which may have resulted in better illness maintenance in this population compared to mood disorders. It has significant implications because long-acting injectable antipsychotic preparations, as in our study, may help maintain a stable course of psychotic illness and reduce hospitalizations, which is critical, especially during unprecedented situations like lockdown, where access to health care facilities is difficult. Similarly, a recent study at the community level, under the assertive community psychiatry program, made a few adaptations during lockdown, such as switching their patients' medications from oral antipsychotics to long-acting injection (LAI) formulations or changing LAIs to longer-acting counterparts to enhance mediation adherence and convenience, which are otherwise disrupted during lock-down, and were found to be helpful. Thus, this kind of adaptation and innovation is recommended at all levels of psychiatric care, especially during lockdown periods.
The origin of the current pandemic remains controversial, but it worsened all psychiatric illnesses, as we did not find any specific diagnosis to be significantly worsened compared to other psychiatric illnesses. Our findings are in line with a recent study by Muruganandam et al. Lack of access to psychiatric services due to lockdown resulted in a clinical worsening of their psychiatric illness, which included increased suicidal ideas, physical aggression, and these are unwanted consequences because of the lock-down. Apart from lack of access to psychiatric services, increased alcohol consumption, perceived stress due to COVID 19, confinement because of lock-down, financial downfall due to restricted mobility, social support, and high negative expressed emotions during lockdown, all these can be contributing factors to increasing suicidality and aggression.,,
Globally, attention is predominantly focused on the containment of COVID-19. However, concerns about patients with mental illness are left unaddressed. To combat the needs of mentally ill patients, telepsychiatry aftercare services have been established at the National Institute of Mental Health and Neuro Sciences, Bangalore, India; these were feasible and acceptable for psychiatric patients. Moreover, in India, the Government is implementing mental health helplines, empowering digital communication platforms to disseminate mental health training and intervention in remote settings, and revising telemedicine guidelines to combat mental health issues. In India, telepsychiatry services increased by 45.9% during the lock-down, compared to 19.3% before the lockdown. However, most of them were being provided to those who were in quarantine and infected with COVID-19. Some of the apex institutions in India, such as NIMHANS and the All India Institute of Medical Sciences, were able to provide telepsychiatry services to the psychiatric patients during the lockdown. However, providing telepsychiatry services to the people in communities is a challenging task as accessing the requisite technology (and the knowledge to use this technology), internet access, data allowance costs, and privacy and data security are all possible issues. However, continuing the mental health needs of psychiatric patients should be of utmost importance to the Government. In India, though initiated, the District Mental Health Programme is currently yet to be implemented in all the districts. Given unexpected pandemics like COVID-19, there is a need to strengthen community-based psychiatric treatment further, thus minimizing the need to travel during the pandemic. Further, there is a need to implement telepsychiatry services in tie-up with tertiary care psychiatric hospitals, which would help in maintaining the continuity of treatment for psychiatric patients during unexpected situations such as pandemics and resultant lock-down.
Lockdown due to COVID-19 has impacted the mental health of psychiatric patients. Lockdown has resulted in difficulty in transportation and resulted in poor access to even the health-care system. Through our study, we highlighted that disrupted access to mental health services due to lockdown has a negative impact on the mental health of psychiatric patients. Our study is unique in the sense that only those patients who missed their follow-up because of lockdown were considered. Thus, the actual impact of poor access to health-care services due to lockdown was understood.
This study has a few limitations worth noting. A validated questionnaire was not used for the study. The mental health outcomes of only those who could not follow-up due to lock-down were studied. A comparative group of psychiatric patients who were followed during the lockdown may help better understand the mental health outcome due to the lockdown. Similarly, some of the review patients who were due for follow-up during lockdown were not traced; hence, mental health outcomes assessed in the current study population might have resulted in overrepresentation by those who had clinically worsened and hence were brought. The current study was done at a tertiary care mental hospital where primarily severe mental illness patients come for treatment. Thus, our study findings cannot be generalized to patients who seek treatment in other settings, such as private practice, general hospital psychiatric units, and community-dwelling individuals. As ours was a pragmatic study, we did not calculate formal sample size.
Despite the limitations mentioned above, the current study attempted to look for mental health outcomes induced among psychiatric patients as a result of the lockdown disruption of access to psychiatric services. We are currently not adequately prepared to handle the aftermath of such a pandemic and issues, such as a lockdown. Nevertheless, it has given us valuable insight that such pandemics and the resultant lockdown may worsen the mental health status of psychiatric patients. Strengthening community-based psychiatric care in tie-up with telepsychiatry services (with proper regulatory guidelines) and adopting new innovative measures may help us face such eventualities in future.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Holshue ML, DeBolt C, Lindquist S, Lofy KH, Wiesman J, Bruce H, et al
. First case of 2019 novel coronavirus in the United States. N Engl J Med 2020;382:929-36.
Cucinotta D, Vanelli M. WHO declares COVID-19 a pandemic. Acta Biomed 2020;91:157-60.
Simpson RJ, Katsanis E. The immunological case for staying active during the COVID-19 pandemic. Brain Behav Immun 2020;87:6-7.
Lopez Bernal J, Andrews N, Gower C, Gallagher E, Simmons R, Thelwall S, et al.
Effectiveness of COVID-19 Vaccines against the B.1.617.2 (Delta) Variant. N Engl J Med 2021;385:585-94.
Pritchard E, Matthews PC, Stoesser N, Eyre DW, Gethings O, Vihta KD, et al.
Impact of vaccination on new SARS-CoV-2 infections in the United Kingdom. Nat Med 2021;27:1370-8.
Pouwels KB, Pritchard E, Matthews PC, Stoesser N, Eyre DW, Vihta KD, et al
. Effect of Delta variant on viral burden and vaccine effectiveness against new SARS-CoV-2 infections in the UK. Nat Med 2021;27:2127-35.
Ghosal S, Sinha B, Majumder M, Misra A. Estimation of effects of nationwide lockdown for containing coronavirus infection on worsening of glycosylated haemoglobin and increase in diabetes-related complications: A simulation model using multivariate regression analysis. Diabetes Metab Syndr 2020;14:319-23.
Ministry of Health and Family Welfare | GOI [WWW Document], n.d. Available from: https://main.mohfw.gov.in/
. [Last accessed on 2020 Aug 17].
Grover S, Sahoo S, Mehra A, Avasthi A, Tripathi A, Subramanyan A, et al
. Psychological impact of COVID-19 lockdown: An online survey from India. Indian J Psychiatry 2020;62:354-62. [Full text]
Montemurro N. The emotional impact of COVID-19: From medical staff to common people. Brain Behav Immun 2020;87:23-4.
Andrade C. COVID-19 and lockdown: Delayed effects on health. Indian J Psychiatry 2020;62:247-9. [Full text]
Horan WP, Ventura J, Mintz J, Kopelowicz A, Wirshing D, Christian-Herman J, et al.
Stress and coping responses to a natural disaster in people with schizophrenia. Psychiatry Res 2007;151:77-86.
Taquet M, Luciano S, Geddes JR, Harrison PJ. Bidirectional associations between COVID-19 and psychiatric disorder: Retrospective cohort studies of 62 354 COVID-19 cases in the USA. Lancet Psychiatry 2021;8:130-40.
Guimond S, Keshavan MS, Torous JB. Towards remote digital phenotyping of cognition in schizophrenia. Schizophr Res 2019;208:36-8.
Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al
. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. Int J Environ Res Public Health 2020;17:E1729.
Temsah MH, Al-Sohime F, Alamro N, Al-Eyadhy A, Al-Hasan K, Jamal A, et al
. The psychological impact of COVID-19 pandemic on health care workers in a MERS-CoV endemic country. J Infect Public Health 2020;13:877-82.
Bo HX, Li W, Yang Y, Wang Y, Zhang Q, Cheung T, et al
. Posttraumatic stress symptoms and attitude toward crisis mental health services among clinically stable patients with COVID-19 in China. Psychol Med 2021;51:1052-3.
Muruganandam P, Neelamegam S, Menon V, Alexander J, Chaturvedi SK. COVID-19 and severe mental illness: Impact on patients and its relation with their awareness about COVID-19. Psychiatry Res 2020;291:113265.
Chatterjee SS, Barikar C M, Mukherjee A. Impact of COVID-19 pandemic on pre-existing mental health problems. Asian J Psychiatr 2020;51:102071.
Mutlu E, Anıl Yağcıoğlu AE. Relapse in patients with serious mental disorders during the COVID-19 outbreak: A retrospective chart review from a community mental health center. Eur Arch Psychiatry Clin Neurosci 2021;271:381-3.
World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organization; 1992.
Marcus SC, Zummo J, Pettit AR, Stoddard J, Doshi JA. Antipsychotic adherence and rehospitalization in schizophrenia patients receiving oral versus long-acting injectable antipsychotics following hospital discharge. J Manag Care Spec Pharm 2015;21:754-68.
Guan I, Kirwan N, Beder M, Levy M, Law S. Adaptations and innovations to minimize service disruption for patients with severe mental illness during COVID-19: Perspectives and reflections from an assertive community psychiatry program. Community Ment Health J 2021;57:10-7.
DeLisi LE, Cohen TH, Maurizio AM. Hospitalized psychiatric patients view the World Trade Centre disaster. Psychiatry Res 2004;129:201-7.
Caballero-Domínguez CC, Jiménez-Villamizar MP, Campo-Arias A. Suicide risk during the lockdown due to coronavirus disease (COVID-19) in Colombia. Death Stud 2020;46:885-90.
Nirmala BP, Vranda MN, Reddy S. Expressed emotion and caregiver burden in patients with schizophrenia. Indian J Psychol Med 2011;33:119-22.
] [Full text]
Das S, Manjunatha N, Kumar CN, Math SB, Thirthalli J. Tele-psychiatric after care clinic for the continuity of care: A pilot study from an academic hospital. Asian J Psychiatr 2020;48:101886.
Murty P, Preethi P, Reddy V, Muralidharan K. Mental health in the times of COVID-19 pandemic. In: Guidance for General Medical and Specialised Mental Health Care Settings. Bengaluru, India-560029: Department of Psychiatry, National Institute of Mental Health and Neurosciences; 2020. p. 03-7.
Grover S, Mehra A, Sahoo S, Avasthi A, Tripathi A, D'Souza A, et al
. State of mental health services in various training centers in India during the lockdown and COVID-19 pandemic. Indian J Psychiatry 2020;62:363-9. [Full text]
Chadda RK. Organizing mental health and psychosocial support services for COVID-19 at a tertiary care centre in India. World Soc Psychiatry 2020;2:163.
[Table 1], [Table 2], [Table 3]