Impact of COVID-19 pandemic on pre-existing mental health problems.

Sir,

Starting from a seafood market in Wuhan, COVID-19 is now an apocalyptic threat to public health and society, worldwide (Bai et al., 2020). Individuals in general have difficulty dealing with uncertainty and this generates anxiety. COVID-19 in its scope has taken uncertainty to a different level (Bhat et al., 2020). As it is sprawling its grip on India, its impact on persons with mental illness is expected to be significant, as most of the psychiatric disorders have an intricate association with stress leading to increase in incidence and relapse rates. Research is sparse with regards to psychiatric disorders in viral pandemics. But most of the studies from this current COVID-19 and previous SARS epidemic in 2003 or corona influenza epidemic in 2009 have shown anxiety, panic, depression to be the predominant manifestation; hence accurate health information and specific precautionary measures are important (Banerjee, 2020).

COVID-19 pandemic and country-wide lockdown are likely to increase the new onset of Illness Anxiety Disorder and to cause exacerbation of symptoms in diagnosed cases. Any simple flu like symptom increases anxiety and under present circumstances, COVID-19 is expected to have a more severe impact. Obsessive Compulsive Disorder patients, especially who have checking, hoarding and washing compulsion, are at higher risk. Advice on improving personal hygiene measures might increase the contamination obsessions and washing compulsions. In the face of ongoing lockdown, patients are more likely to resort to panic buying and excessive hoarding of essential items, even though continuous supply of essential items is assured by the states (Qiu et al., 2020). For Recurrent Depressive Disorder patients, lockdown is a major stress jeopardizing normal daily routine, social rhythm and thereby increasing stress levels, which would further escalate the cortisol level, resulting in a vicious exacerbation of depressive symptoms. This is same for generalized anxiety disorder, chronic insomnia (Dong and Bouey, 2020) and even suicide (Goyal et al., 2020). Moreover, pandemics are not only a medical phenomenon. Inability to join work, dwindling finances and the long term impact on economy will have its effect on new and preexisting common mental health disorders (Zandifar and Badrfam, 2020).

Quarantine can lead to different kind of problems. It can precipitate feelings of fear, anger, anxiety and panic about worse possible outcome, boredom and loneliness and guilt about not being there for family. In a person with a previous psychiatric disorder, all these problems can surface with renewed severity and can lead to PTSD or even suicidal thoughts and attempts. Anxiety can be so overwhelming, that it can precipitate paranoia and nihilistic delusions (Brooks et al., 2020). Patients with bipolar disorder and schizophrenia are likely to have relapses due to jeopardy in both the availability of regular medication and medication compliance. For substance use disorder patients, this period could be lethal as non-availability of substance or medicines can precipitate severe withdrawal symptoms and medical emergencies like delirium or seizures, which can be life-threatening due to inadequate accessibility to dwindling emergency services (Xiang et al., 2020).

In this scenario, doctors involved in emergency services must be more aware about psychiatric emergencies so that appropriate and timely referrals can be done. There is need to bring in policy changes which will ensure continuous availability of healthcare services and essential drugs. E-dispensing rules should be relaxed, albeit under close monitoring. Telemedicine consultation should be practiced and policy makers should focus on making doctors more aware and comfortable using tele-consultation.

In the aftermath of COVID-19 outbreak, Medial Council of India has issued guidelines for practicing telemedicine on 25th March (MCI, 2020), which is a welcome step establishing the basic purpose, guideline and protocol of telemedicine. However, there is no mention of psychiatric management and use of psychotropic medications. A lot of common psychotropics which are essential, like SSRI's, atypical antipsychotics, sodium valproate can be prescribed without stringent monitoring and ought to be mentioned in the list ‘A’ and ‘B’ drugs. Further study and discussion should be planned on the tele-prescribing guidelines of other medications like lithium, clozapine, benzodiazepines etc., which warrant more strict regulation.

Author contribution

All the authors have contributed and approved the final manuscript.

Funding

This research has not received specific grant from any funding agency in the public, commercial or not for -profit sectors.

Declaration of Competing Interest

Nil.