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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 9  |  Issue : 1  |  Page : 95-100

Assessment and comparison of the mental health status of patients seeking psychiatry facilities in prelockdown and postlockdown period of the COVID-19 Pandemic: An ambispective study in a tertiary care center in a Hilly Region of North India


1 Department of Psychiatry, Indira Gandhi Medical College and Hospital, Shimla, Himachal Pradesh, India
2 Department of Psychiatry, Bhagat Phool Singh Government Medical College for Women, Sonipat, Haryana, India
3 Department of Radio Diagnosis, Maharishi Markendeshwar Medical College and Hospital, Solan, Himachal Pradesh, India

Date of Submission19-Mar-2021
Date of Decision17-Apr-2021
Date of Acceptance21-Apr-2021
Date of Web Publication26-Jun-2021

Correspondence Address:
Dr. Sunny Garg
Department of Psychiatry, Bhagat Phool Singh Government Medical College For Women Khanpur Kalan, Sonipat, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_64_21

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  Abstract 


Background and Aim: The servicing and framework for mental health care accessible to population have been affected during the unprecedented times of the coronavirus disease (COVID-19) pandemic. The new and almost exclusive method to maintain a therapeutic alliance with these patients has been the recently evolving telepsychiatry services. The main aim of the study is to assess and compare the mental health status of patients seeking psychiatry facilities in prelockdown and postlockdown period during the COVID-19 pandemic. Materials and Methods: This was a ambirespective study which was conducted in a tertiary care hospital in a hilly region of North India in which the registered data were analyzed between January 1, 2020 and March 21, 2020 (prelockdown phase) and from May 3, 2020 to September 30, 2020 (postlockdown phase, after the resumption of outpatient department services in the institute), to gather the information of patients about sociodemographic profile and clinical diagnosis on the basis of International Classification of Diseases-10. A total sample size of 1000 patients was included. Chi-square test and Student's t-test were used to compare the patient presentation before and after the lockdown periods. Results: Majority of the patients were male (66%) and within 19–60 years of age (85%–90%). The average age of the patients (39.17 years, standard deviation = 14.37) was significantly higher in postlockdown phase. As compared to prelockdown period (499 patients), a significantly (P < 0.001) lower number of patients diagnosed with substance use disorders and a significantly (P < 0.001) higher number of patients diagnosed with psychotic disorders along with anxiety disorders, availed the available psychiatry services in the period of COVID-19 pandemic (501 patients). Conclusions: Sudden cessation of the psychiatry services further precipitated the deterioration of mental health of the patients. There is an urgent demand for services to adapt to changing scenarios with emphasis on practical approaches to help the mentally ill people, especially in geographically difficult hilly areas.

Keywords: Anxiety disorders, coronavirus disease-19 pandemic, postlockdown, prelockdown, tele psychiatry services


How to cite this article:
Sharma D, Garg S, Sharma A, Sharma DD, Sharma N, Gupta S, Sharma S. Assessment and comparison of the mental health status of patients seeking psychiatry facilities in prelockdown and postlockdown period of the COVID-19 Pandemic: An ambispective study in a tertiary care center in a Hilly Region of North India. Arch Med Health Sci 2021;9:95-100

How to cite this URL:
Sharma D, Garg S, Sharma A, Sharma DD, Sharma N, Gupta S, Sharma S. Assessment and comparison of the mental health status of patients seeking psychiatry facilities in prelockdown and postlockdown period of the COVID-19 Pandemic: An ambispective study in a tertiary care center in a Hilly Region of North India. Arch Med Health Sci [serial online] 2021 [cited 2021 Nov 30];9:95-100. Available from: https://www.amhsjournal.org/text.asp?2021/9/1/95/319401




  Introduction Top


Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. Most people infected with the coronavirus experiences mild-to-moderate respiratory problems and recover without requiring special treatment. Older people and those with underlying medical problems such as cardiovascular disease, diabetes, chronic respiratory disease, or cancer are more likely to develop serious illnesses. However, there are many ongoing clinical trials evaluating potential treatments.[1]

The world Health Organization and public health authorities around the world acted to contain the COVID-19 outbreak. In support of this on March 22, 2020, India observed a 14-h voluntary public curfew. It was followed by mandatory lockdowns in COVID-19 hotspots and all major cities from March 24, 2020, affecting the entire 1.3 billion population of India.[1] Due to closure of public transport, people faced many difficulties in attending the emergency and outpatient department (OPD) services. Health-care system except the emergency services became unreachable to the patients affected with other illnesses as most of the available resources were directed for managing the COVID-19 pandemic.[2] Along with other specialties, psychiatry facilities were also affected significantly. This led to inconvenience for patients as many with regular follow-up were left confused regarding renewal of their treatment prescription.[3]

Lockdown and this COVID-19 pandemic generated stress throughout the population like other outbreaks in the past.[4] These uprisings contribute to long-term mental health effects in not only victims/survivors but also other members of the community (the “Spill-over” effect).[5] The stress experiences can range from anxiety to clinical depression, psychosis, substance use disorders (SUDs), and a wide range of other psychological issues in the population and previously affected patients.[4],[5] In a study, conducted in 2004 during Severe Acute Respiratory Syndromes outbreak in Canada, it was found that there was a high prevalence of psychological distress including symptoms of depression and posttraumatic stress disorder among quarantined persons.[6]

The Ministry of Health and Family Welfare, in collaboration with Board of Governors started the telemedicine services in India, as one of the promising approaches to dispense the medical facilities to the people without risking the COVID-19 infection.[7],[8] During the lockdown period, telepsychiatry services other than emergency services, augmented the availability of health-care system to the people with mental health problems.[9] Accordingly, there is a need to understand the impact of the COVID-19 pandemic on the psychiatry services which has been studied poorly in Indian context as per our knowledge.[9] There are only few studies[10],[11] in India which revealed the impact of the COVID-19 pandemic on emergency services only, but none of the study has been conducted to assess and compare the impact of lockdown on OPD, emergency and telepsychiatry services. Thus, the present study was conducted in one of the tertiary care centers in a hilly region of North India, to analyze the pattern of patient presentation seeking available psychiatry services including telepsychiatry services during the COVID-19 pandemic and to compare the same attending the available (OPD and emergency) services before the lockdown period.


  Materials And Methods Top


Study design and settings

The present study was ambirespective in nature, conducted in the Department of Psychiatry, Indira Gandhi Medical College and Hospital, Shimla, which is a tertiary care hospital located in hilly areas of Himachal Pradesh in North India. The department caters to the mental health-care needs of around 30,000 patients per year. Before the COVID-19 pandemic, psychiatry services were provided to all types of patients including self-referred, referred from other departments/hospitals and emergencies. During the lockdown period, patients were attended only in emergency department. Simultaneously, tele psychiatry services were being given by the department of psychiatry during this period.[12] During the first phase of the postlockdown period (i.e., on May 3, 2020) the OPD services were resumed along with already ongoing emergency and telepsychiatry services. The patient coming to the hospital were first screened in the emergency and then referred to avail the psychiatry services. These patients were evaluated by the trainee doctor under the supervision of senior residents and consultants. All the psychiatric diagnoses were made as per the International Classification of Diseases-10[13] and registered by the data operator. This study was carried out after getting Ethical approval from the Institutional Ethical Committee Board and in accordance with Ethical Committee standards and the Helsinki declaration. During the study, the data of the patients who sought psychiatry services released while ensuring the personal information was kept confidential, and anonymity was maintained.

Study sample and size

This study used the administrative database information about the patients availing psychiatry facilities (OPD, emergency, and telepsychiatry services) during the study period (prelockdown and postlockdown phase). A total sample size of 1000 patients was studied during the survey.

Data collection

The study was started in postlockdown phase (i.e., on May 3, 2020; after 6 weeks of lockdown). For the purpose of this study, initially, data of the new patients (around 499) who have attended psychiatry OPD and emergency services before the implementation of the lockdown period i.e., January 1, 2020–March 21, 2020 (81 days) were retrieved from the case record files or the registered data. Then, to compare and collect the same sample size (501 new patients), data were collected in postlockdown periods after the resumption of OPD services along with ongoing emergency services and telepsychiatry consultations, i.e., from May 3, 2020 to September 30, 2020. Data regarding the sociodemographic profile (age and gender) and clinical profile (diagnosis and treatment) of the registered patients were gathered from the database information.

Statistical analysis

The data were entered, coded, and analyzed using the Statistical Package for the Social Sciences (SPSS) software version 25.0 (IBM corp., Armonk, New York, USA). Descriptive statistics for the continuous variables were calculated as mean and standard deviation (SD). Categorical variables were calculated as frequencies and percentages. Chi-square test for categorical variables and Student's t-test were used for continuous variables, to compare the patient presentation before and after the lockdown periods. Statistical significance of all two-tailed tests was set at P < 0.05.


  Results Top


Around 499 patients were assessed in the prelockdown period (83 days), but the similar number of patients (501) was assessed over a longer period of 151 days (postlockdown phase). During the COVID-19 pandemic, the average number of patients seen per day fell to 3.31, which was nearly double (6.02 patients) during the prelockdown phase. In the present study, majority of the patients were male (66%) and the remaining were female patients. Around 85%–90% of patients were within 19–60 years of age as shown in [Table 1]. The mean age (39.17 years, SD = 14.37) was significantly (P < 0.001) higher for the patients assessed in postlockdown period as compared to the mean age (38.32 years, SD = 15.58) of the patients evaluated in prelockdown phase. In the postlockdown phase, there was a significant decrease in the number of adolescent patients (<18 years of age), while there was no significant change in proportions of elderly and adult patients utilizing the psychiatry services as shown in [Table 1].
Table 1: Sociodemographic characteristics of the patients attending psychiatry services

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Before the lockdown, the most common diagnoses were anxiety disorders (neurotic/stress related/somatoform disorders) (41%), followed by SUDs (34%), mood disorders (20%), and schizophrenia with ATPD or other psychotic disorders (5%). [Table 2] shows that, in the postlockdown phase, the most common diagnoses were neurotic/stress related/somatoform disorders (56%), followed by mood disorders (25%), SUDs (11%), and schizophrenia with ATPD or other psychotic disorders (9%). As compared to prelockdown period, a significantly (P < 0.001) lower number of patients diagnosed with alcohol dependence syndrome, opioid dependence syndrome and other substance dependence syndromes (cannabis, tobacco, benzodiazepines, sedatives, cocaine, or multiple substances) attended the available psychiatry services in the period of the COVID-19 pandemic. In postlockdown period, patients attending the services increased significantly in proportions who had a diagnosis of bipolar affective disorder/manic episode (P < 0.001), schizophrenia/ATPD/other psychotic disorders (P < 0.001), and anxiety disorders (neurotic/stress related/somatoform disorders) (P < 0.001). In the postlockdown period, no significant difference (P = 0.834) was revealed in the proportions of patients diagnosed with depressive disorders as showed in [Table 2].
Table 2: Clinical diagnosis of the patients attending psychiatry services

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  Discussion Top


The unexpected closure of routine psychiatry OPDs of the main institution of Himachal Pradesh had left thousands of patients without mental health services around the catchment area of the institution, which provides these services to around 5–6 adjoining districts (Shimla, Kinnaur, Lahaul and Spiti, Kullu, Solan). The only way left for the patients was to apply for COVID 19 curfew passes on health grounds to visit the hospital where only major emergency services (acute psychosis, suicidal patients, complicated substance withdrawal, etc.,) were being provided, which also was subject to approval by local authorities on referral from the nearest government health facilities. Moreover, there was a gap of around 4–5 weeks between the stoppage of OPD services and establishment of telepsychiatry services by the department of psychiatry.[12] However, neither of the services were fully apt to address the need of the masses as before the lockdown. Meanwhile, many patients started developing new-onset behavioral problems and relapse of severe symptoms along with suicidal behavior. As the department had a long-standing commitment to the welfare of these patients, they were worried and curious to know the effect of sudden closure of OPDs on mental status of the people. Therefore, the index study was conducted to compare the presentation of the patients attending available psychiatry services (OPD, emergency, and telepsychiatry) in the COVID-19 pandemic and in prelockdown period.

In the present study, the average number of patients seen per day reduced significantly to half in the postlockdown period as expected due to restriction in the movement. This finding was in coherence with the observation made by Grover et al. at PGIMER Chandigarh.[10] Unlike other studies,[10],[14] no significant difference was observed in the presentation of male and female patients in the index study as nearly equal number of male and female patients availed the psychiatric help during both the phases. Although few studies[10],[11] revealed that a larger number of female patients attended psychiatry emergency services allegedly due to increased domestic violence and workload stress at home during the lockdown phase.[14]

The mean age of patients had significantly increased in the postlockdown phase which is inconsistent with other studies, in which mean age of the patients decreased significantly.[10],[11] It was observed that proportion of adolescent patients decreased significantly similar to other studies done by Dopfer et al.[15] in Germany and Tartari et al.[16] in Italy. Although there were limited possibilities of severe cases of COVID-19 infection in children,[17] the fear of getting infection while availing the services in hospitals may have influenced parental decision-making during this period.[15] This can also be explained in the background of few other reasons such as the lockdown strategies themselves, rigorous social-distancing, and parents may have inclined to “wait and watch” when their children fell ill as opposed to immediately presenting to the hospitals.[15] Contrary to other studies where proportion of elderly patients had decreased,[18] the number of elderly patients were nearly the same during both the observation periods of the present study.

Similar to another study done in India,[10] the proportion of adult patients had increased insignificantly. A KFF Health Tracking Poll from US also reported that about 50% of adults reported negative impacts on their mental well-being.[19] The reason for increased presentation of adult patients could be less fear of movement somewhat indicated by regularly running OPDs. During the pandemic, younger people were the most affected population and more apprehensive about acquiring the infection,[20] leading to more attendance of these patients in psychiatry OPDs in the postlockdown phase.

Similar to the study done previously by Sidana et al.,[21] it was found that in present study, a large number of patients used the telepsychiatry services to continue with their treatment during the postlockdown period as compared to prelockdown period. A study by Arya and Gupta reported that initiatives such as telepsychiatry services were praiseworthy, in which patients felt safe and connected with doctors in their physical absence in the hospitals or clinics.[22]

In the present study, most of the patients availing psychiatry services were diagnosed with anxiety disorder which is in line with a study done in India by Sidana et al.,[21] while delirium was evaluated as the most common diagnosis during the COVID-19 pandemic in a study done in emergency setup.[10] Patients with anxiety disorders had a statistically significant increase in presentation in postlockdown phase in comparison to prelockdown period. This is in keeping with many other studies which also found the significant increase in patients with anxiety disorders during the pandemic.[21],[23] This could possibly be explained from the fact that the people experienced multiple problems related to the pandemic like loss of income or job, closure of school and colleges, concern about well-being of their families, social isolation, and loneliness due to lockdown that led to anxiety disorders in the population.[19] The prevalence of depression in both the study periods was nearly similar may be due to the fact that lockdown restrictions were relaxed earlier up to some extent in this state so the potential stressor had probably disappeared from the picture, thus the findings in patient presentation also support the same. These observations were dissimilar with findings of other study where a large number of the patients developed clinical depression and sought help from psychiatry settings.[24]

Most of the studies conducted during this period revealed that consumption of substance in the population had increased up to 10–15 times.[22],[25] However, in index study, it was found that there was a significant reduction in the proportion of the patients diagnosed with SUDs such as alcohol, opioid, or other multiple substances, implying that certain common variables had led to this decrease in patient footfall. First possible reason might be the closure of liquor shops, and difficulty in procuring illegal substances such as cannabis and opioids due to restricted movement of the people during the lockdown phase.[12] Another reason could be that most of the substance consuming patients were not so dependent so as to have significant withdrawal, requiring referral to higher centers or even a medical consultation. The ones having severe withdrawal might have recovered at home or peripheral health institutions during the initial weeks of complete lockdown.

Further, when patients diagnosed with other mental (psychotic) disorders were evaluated and compared, it was seen that there was a significant increase in the presentation of the patients diagnosed with bipolar affective disorders/manic episodes and schizophrenia/ATPD/other psychotic disorders in the postlockdown phase. Grover et al.[10] and Gonçalves-Pinho et al.[26] also reported a significant increase in the presentation of the patients diagnosed with these psychotic disorders, similar to the present study. These findings suggested that patients with psychotic features experienced the relapse of the symptoms in the absence of routine OPD services. There were few plausible reasons for relapse in these patients such as immediate stoppage of treatment due to difficulties in procuring the medicines without renewal of prescriptions and increase in the level of stress at their home.[9],[10],[11] Another possible reason might be that at the time of lockdown, taken into account these characteristics, adherence to the recommended protective measures, and compliance with social isolation, may be more difficult for the people with schizophrenia and other psychotic disorders, making this group particularly vulnerable to the limitations imposed by the current pandemic situation and more prone to decompensation.[27] Moreover, lockdown itself had decreased the movement of the patients to faith healers or other local sources of treatment including primary care. It is also important to consider the seasonal patterns of mood disorders, mainly the evidence for a significant seasonal trend for manic episodes with a peak in spring/summer, also coinciding with the study period during the pandemic.[28]

This study was conducted in an institute which was catering to routine OPDs, emergency, and telepsychiatry services during the postlockdown phase of the pandemic, thus having sufficient data to find any significant changes in the patient presentation seeking mental health services was one of the main strength of the present study as compared to the previous study conducted by Grover et al.[10] during this time period involved only emergencies services. The present study also reflects the change in presentation of voluntarily walk-in patients, while most other studies were reflective of general population was another strength of the present study.

The study has several limitations, mainly, the inclusion of only a few variables for evaluation. Second, the patient presentation cannot be considered representative of a routine OPD completely as the state wide lockdown was still persisting to some extent and the patient presentation is somewhat comprising emergency cases as well because the implied effort involved in movement. Third, this study was limited to a single center, so it is not possible to generalize the findings. The impact of the COVID-19 on psychology of patients and other population might be long term or changeable, which needs long-term evaluation.


  Conclusion Top


The COVID-19 pandemic has intense effect on the available mental health services globally. During the postlockdown phase, the proportion of the patients seeking psychiatry services had decreased as compared to prelockdown period. This study found that significant decrease in the presentation of patients diagnosed with SUDs, highlights the importance of administrative intervention in controlling SUD. There was a significant increase in anxiety disorders and psychotic disorders without much change in major depressive disorder during the postlockdown period. The clinical relevance lies in the fact that anxiety disorders require more extensive screening in OPDs during such pandemic situation contrary to prepandemic scenario. These periods have also warranted additional use of telepsychiatry services to address the problems faced by patients and their treating teams. Hence, there is a need to do some work on the feasibility and cost-effective usage of telepsychiatric services by the people.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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