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 Table of Contents  
Year : 2022  |  Volume : 8  |  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

Department of Psychiatry, Institute of Mental Health, Osmania Medical College, Hyderabad, Telangana, India

Date of Submission09-Jan-2022
Date of Decision30-Jan-2022
Date of Acceptance07-Feb-2022
Date of Web Publication30-May-2022

Correspondence Address:
Prof. Rajshekhar Bipeta
Department of Psychiatry, Institute of Mental Health, Osmania Medical College, Hyderabad - 500 038, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjp.tjp_3_22

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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 Nov 28];8:7-13. Available from: https://tjpipstsb.org/text.asp?2022/8/1/7/346236

  Introduction Top

The coronavirus disease 2019 (COVID-19) was detected in December 2019, as a viral outbreak in Wuhan, China,[1] and the World Health Organization declared it a pandemic on March 11, 2020.[2] 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.[3] COVID-19 vaccinations have been shown to reduce infection severity.[4],[5],[6] 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.[7] In India, a nationwide lockdown and strict home confinement were enforced from March 25, 2020.[8] Lockdown was a successful strategy in exponentially slowing the COVID-19 disease progression (infection rate and death).[7] 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.[9] Implementation of lockdown might have also reduced psychiatric patients' access to psychiatric services.[10] Reduced access to psychiatric care might worsen existing mental health conditions.[11] 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.[12] 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.[10] A recent review found that a psychiatric diagnosis in the previous year was associated with a higher incidence of COVID-19 diagnosis.[13] 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.[14]

There is growing literature on the effect of the COVID-19 pandemic on the mental health of the general population,[9],[15] health professionals,[16] and COVID 19 patients.[17] 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.[18] 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.[19] 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.[20] Another study found that 11% of severely mentally ill patients had relapsed during the initial phase of the pandemic.[21] 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 Top

Eligibility criteria

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),[22] 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.

Statistical analysis

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 Top

Descriptive characteristics

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.
Figure 1: Flow chart of psychiatric patients screened for the study

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Table 1: Sociodemographic characteristics of the study participants (n=305)

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Table 2: Clinical diagnosis of psychiatric patients (n=305)

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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

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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 Top

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%).[23] 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.,[19] 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%.[19] Another study,[21] 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,[24] 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.[25] 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.[19] 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.[26],[27],[28]

Globally, attention is predominantly focused on the containment of COVID-19. However, concerns about patients with mental illness are left unaddressed.[19] 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.[29] 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.[30] In India, telepsychiatry services increased by 45.9% during the lock-down, compared to 19.3% before the lockdown.[23] 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,[31] 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.

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Conflicts of interest

There are no conflicts of interest.

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