State of mental health services in various training centers in India during the lockdown and COVID-19 pandemic.

BACKGROUND: There is some information from different developed coutries that mental health services have been badly affected by the COVID-19 pandemic. Little information is available from India. AIM: The aim of this study was to evaluate the impact of lockdown and COVID-19 pandemic on mental health services in India's various training centers.
MATERIALS AND METHODS: In an online survey, information was collected from various training centers of India through E-mail or WhatsApp.
RESULTS: Responses were received from 109 institutes. The majority of the responses were received from state-funded government medical colleges and private medical colleges. Since the lockdown and COVID-19 pandemic, brain stimulation treatments have completed stopped. Other, most affected services included electroconvulsive therapy, inpatient services, outpatient services, and psychotherapy services. However, there was an expansion of teleconsultations services because of the lockdown and the COVID-19 pandemic. In three-fourth of the centers mental health services were being provided to the patients with COVID-19 infection. In most of the institutes, mental health professionals were involved at different levels in the COVID-19 responsibilities. These included providing helpline services to the general public, screening people in quarantine for mental health issues, providing clinical care to COVID-19 patients, screening health care workers (HCWs) for mental health issues, and training the HCWs.
CONCLUSION: COVID-19 pandemic and lockdown have led to the collapse of regular mental health services. The present study also shows that mental health professionals are playing a significant role in addressing the prevailing psychiatric morbidity, specifically related to the COVID-19 related issues, and taking care of the HCWs. Copyright:

INTRODUCTION

COVID-19 was declared as a pandemic on March 11, 2020, and within 2 weeks, the Government of India imposed a nationwide lockdown. COVID-19 pandemic and the lockdown affected various service sectors badly, with health-care services being one of the same. Immediately after the lockdown, the outpatient services were closed at many places, and the health-care services were limited to emergency services or those dedicated to patients with COVID-19 infection. At many places, some of the wards were converted to COVID-19 wards, and new COVID-19 hospitals were commissioned at other places. In addition, quarantine centers were made functional. Many health-care professionals were involved in managing the people and in contact tracing of cases.

All these have led to a reorganization of the health-care services with people from different specialties working together to address the COVID-19 pandemic. The COVID-19 wards and hospitals are being managed by multidisciplinary teams, in which people from different departments are looking after the various issues. These include administrative matters, issues related to the procurement of personal-protective equipment, contact tracing, increasing awareness of general public and health-care professionals about the COVID-19 infection, training of health-care workers (HCWs), and managing patients with COVID-19 disease.[1] Sudden reorganization of services and the formation of multidisciplinary teams are posing their challenges in the functioning and smooth running of the services. At places, mental health professionals are involved in some of these services, but the exact level of participation is unknown. Understanding the level of involvement of the mental health professionals can help in formulating policy at the level of a professional organization.

As with other specialties, the mental health services have also been badly impacted by the lockdown and the pandemic across the globe, and India is no exception. Data from different parts of the world suggest that in many countries the inpatient care has been severely hit, with a reduction in the number of patients in the inpatient setting, restriction in the admission of new patients, and reorganization of the existing inpatient services. Similarly, outpatient services have also been restricted to only a few patients, and patients requiring acute care are seen at the emergency services. Consultation-liaison psychiatry (CLP) services have also been curtailed; electroconvulsive therapy (ECT) and brain stimulation services (such as repetitive transcranial magnetic stimulation [rTMS] and transcranial direct stimulation [tDCS]) have also been affected.[2345] The pandemic has also led to an increase in the number of patients visiting the emergency services, need to get the rapid COVID-19 test before psychiatric hospitalization, reorganization of inpatient care, and services.[2] At many places, the CLP services have also adapted to the telecommunication, rather than continuing with the face-to-face contact, as a preventive measure to the spread of infection.[2345]

In India, various medical colleges and central government-funded institutes provide psychiatric services to a large proportion of the patients. Further, response to the COVID-19 pandemic mainly involves government set-ups or institutional set-ups, it is important to understand the state of mental health services and the role of mental health professionals in these settings. In this background, this survey aimed at evaluating the impact of COVID-19 pandemic and the lockdown on the mental health services, the involvement of mental health professionals in the institutional response to the COIVD-19 pandemic, kind of mental health problems encountered in people in quarantine and HCWs, problems encountered in running the mental health services and difficulties faced by the patients in getting the medications.

MATERIALS AND METHODS

This survey was conducted under the aegis of the Research, Education, and Training Foundation subcommittee of the Indian Psychiatric Society (IPS) after obtaining necessary approval from the Ethics Committee of the Indian Psychiatry Society for Research.

As no specific questionnaire was available, a study specific questionnaire was designed to evaluate the impact of the pandemic on the various service areas, percentage reduction in the services after the lockdown, involvement of the mental health professionals in the COVID response at the institutional level, services provided to people in quarantine and those with COVID-19 infection, common type of mental health conditions encountered by the clinicians in different group of people, and problems faced while running the mental health services.

For this, a survey link was generated by using the Survey Monkey platform. The list of medical institutions providing MBBS courses was obtained from the website of Medical Council of India,[6] and the list of institutes providing Diplomate of National Board was generated. Based on the institutes' names, efforts were made to identify at least one faculty member from each institute. These faculty members were sent the survey link during the period of 1st to May 18th, 2020. Regular reminders were sent, and in case, even after repeated reminders, the response was not received, then the survey was sent to additional faculty members from the particular institute. Faculty members were identified for some of the institutes, and they were sent the survey link using the WhatsApp.

RESULTS

Valid information was received from 109 institutes, of which majority were state-funded government medical colleges (n = 53; 48.6%), and this was followed by the private medical colleges (n = 30; 27.5%), central government-funded institutes (n = 19; 17.4%) and others (n = 7; 6.4%). Out of the 109 institutes, 12 (11.0%) were mental hospital setting, and the majority were general hospital psychiatry units (GHPUs) (89.0%). The majority of the responders were working at the level of professors (n = 47; 42.9%), and 50 (45.9%) responders were head of the department.

As is evident from Table 1, >90% of the institutes were providing outpatient services, inpatient services, CLP services, and psychiatry emergency services (PES) before the pandemic and the lockdown. However, with the lockdown, there was a significant reduction in the institutes continuing with ECT, inpatient services, outpatient services, and psychotherapy services. However, at the majority of the places, the CLP and PES services were continued. However, the telecommunication (telemedicine/telepsychiatry) services showed expansion, in the form of starting of services, in about one-fourth of the institutes [Table 1 and Figure 1].

Table 1

Impact of lockdown and pandemic on the mental health services

Variable	Frequency (%)
	Services provided before lockdown	Services continued during the lockdown
Outpatient services (OPD)	109 (100.0)	74 (67.9)
Inpatient services (IPD)	103 (94.5)	63 (57.8)
ECT services (ECT)	82 (75.2)	23 (21.1)
BSS (rTMS, tDCS)	16 (14.7)	1 (0.9)
Psychiatry emergency services (EMG)	100 (91.7)	90 (82.6)
Psychiatry CL services	102 (93.6)	82 (75.6)
OST services	34 (31.2)	24 (22.0)
Psychotherapy services (PSYT)	87 (79.8)	36 (33.0)
Telecommunication (telemedicine/telepsychiatry) services (TELE)	21 (19.3)	50 (45.9)
Psychological investigations (PSYCHOL)	82 (75.2)	28 (25.7)
Other Services	31 (28.4)	16 (14.3)

ECT – Electroconvulsive therapy; OPD – Outpatient department; IPD – Inpatient department; BSS – Brain stimulation services; tDCS – Transcranial direct stimulation; rTMS – Repetitive transcranial magnetic stimulation; CL – Consultation-liaison; OST – Opioid substitution therapy

Figure 1

Impact of lockdown and pandemic on the mental health services

However, although some of the services were continued, the brain stimulation (such as rTMS and tDCS) services have entirely shut down, and there was a significant reduction in number of patients started on ECT. Other service areas were also significantly affected [Table 2 and Figure 2].

Table 2

Percentage reduction in the mental health services compared to the prelockdown peior at different centers

Variable	Mean (SD) (n=109)	Mean (SD)@
Percentage reduction in the number of patients admitted to your ward	77.2 (17.7)	74.6 (15.4)
Percentage reduction in the number of patients initiated on ECT	91.9 (17.6)	74.1 (24.2)
Percentage reduction in the number of patients initiated on brain stimulation treatments	100	100
Percentage reduction in the number of patients started on opioid substitution therapy	57.9 (37.2)	40.0 (30.6)
Percentage reduction in the number of patients seen in the emergency services	66.3 (25.6)	57.1 (23.9)
Percentage reduction in the number of patients seen in the outpatient services	75.7 (20.1)	66.6 (16.2)
Percentage reduction in the number of patients seen in the consultation-liaison psychiatry services	70.1 (23.2)	66.9 (22.1)

@The percentage refers to the number of places, where these services were continued, i.e., centers where these services have not closed down completely. SD – Standard deviation; ECT – Electroconvulsive therapy

Figure 2

Percentage reduction in various services

In terms of involvement of mental health professionals in COVID-19 response at the institutional level, in about four-fifth (79.8%) of the institutes, mental health professionals were involved at different levels in the COVID-19 reaction of the institute. The most common level of involvement was at the level of providing helpline services to the general public. This was followed by screening people in quarantine for mental health issues, providing clinical care to COVID-19 patients, screening HCWs for mental health issues, and training the HCWs for behavioral change required while being on duty in the COVID-19 ward [Table 3].

Table 3

Involvement of mental health professionals in COVID-response at the institutional level

Variables	Frequency (%)
	Yes	No	Not aware	No response
Does your hospital has a COVID-19 ward, or has it been converted into a COVID-19 hospital	87 (79.8)	22 (20.2)	-	-
Not applicable – mental hospitals	20 (18.3)	15 (13.8)	1 (0.9)	73 (67.0)
Administrative roles	56 (51.4)	21 (19.3)	2 (1.8)	30 (27.5)
Policy making	32 (29.4)	36 (33.0)	3 (2.8)	38 (34.9)
Training the HCWs for using PPEs	30 (27.5)	42 (38.5)	3 (2.8)	34 (31.2)
Training the HCWs for behavioral change required while being on the COVID-19 ward	63 (57.8)	22 (20.2)	1 (0.9)	23 (21.1)
Providing clinical medical care (as part of a medical team) to COVID-19 patients	67 (61.5)	20 (18.3)	1 (0.9)	21 (19.3)
Screening and managing mental health issues among the HCWs	66 (60.6)	20 (18.3)	3 (2.8)	20 (18.3)
Preparing The HCWs for COVID-19 area duties	42 (38.5)	33 (30.3)	3 (2.8)	31 (28.4)
Screening and managing mental health issues among the persons in quarantine	72 (66.1)	21 (19.3)	3 (2.8)	13 (11.9)
Screening and managing mental health issues among patients with COVID-19 patients	65 (59.6)	24 (22.0)	2 (1.8)	18 (16.5)
Screening and managing mental health issues among the family members of patients with COVID-19 and those in quarantine	44 (40.4)	34 (31.2)	5 (4.6)	26 (23.9)
Providing helpline service to the general public	78 (71.6)	14 (12.8)	1 (0.9)	16 (14.7)
Publicity and mass media campaign	50 (45.9)	29 (26.6)	6 (5.5)	24 (22.0)

HCW – Health care workers, PPEs – Personal protective equipment

When asked explicitly about the modality of providing services, mental health services were being provided to people in quarantine and those with COVID-19 infection, mainly by telecommunication modes, with either the voice calls or video calls. However, in about half of the institutes, the mental health professionals were asked to provide services in-person [Table 4].

Table 4

Services provided to the patients with COVID-19 or those in quarantine and with COVID-19 infection

Variables	Frequency (%)
Not aware	7 (6.4)
No mental health services being provided at my institute	14 (12.8)
Mental health professionals are providing or are expected to provide services in person	57 (52.3)
Mental health professionals are providing services through telephonic voice calls	62 (56.9)
Mental health professionals are providing services through video calls (Whatsapp, Skype, Wechat, etc.)	40 (36.7)
Others	8 (7.3)

The mental health problems encountered in different group of people, it was seen that the predominant problems encountered were categorized as anxiety, and this was followed by insomnia, depression, boredom, and stigma in people in quarantine and among the HCWs in quarantine or on duty in the COVID-19 wards [Table 5].

Table 5

Mental health problems encountered in people in quarantine and among health-care workers

Variables	Frequency (%)
	Non-HCWs in quarantine	HCWs in quarantine	HCWs on COVID-19 duty
Not applicable	22 (20.2)	24 (22.0)	36 (33.0)
Anxiety	84 (77.1)	71 (65.1)	59 (54.1)
Depression	59 (54.1)	40 (36.7)	41 (37.6)
Anger	41 (37.6)	32 (29.4)	32 (29.4)
Irritability	63 (57.8)	46 (42.2)	42 (38.5)
Insomnia	71 (65.1)	55 (50.5)	43 (39.4)
Fatigue	23 (21.1)	32 (29.4)	28 (25.7)
Guilt	15 (13.8)	14 (12.8)	19 (17.4)
Perception of stigma and discrimination	51 (46.8)	34 (31.2)	37 (33.9)
Boredom	63 (57.8)	42 (38.5)	23 (21.1)
Fear of death	48 (44.0)	32 (29.4)	39 (35.8)
Substance withdrawal and craving	31 (28.4)	9 (8.3)	11 (10.1)
Worries related to family members	63 (57.8)	49 (45.0)	47 (43.1)
Dissatisfaction with the services	33 (30.3)	27 (24.8)	23 (21.1)
Other (please specify)	4 (3.7)	7 (6.4)	8 (7.3)

HCW – Health-care workers

When asked about the problems faced in running the mental health services, the most common issues pointed out were the modification of psychological treatments to suit the teleconsultations (60.6%) and change required for psychological therapies to maintain social distancing (51.4%). Other issues identified included problems faced in managing staff (29.4%), lack of empathy with the patients (20.2%), poor rapport (41.3%), difficulty in diagnosing the problems (25.7%), legal issues (22%), and other issues (17.4%).

In terms of research, at more than half of the institutes' (n = 55; 50.5%), mental health professionals were involved in carrying out research related to COVID-19 infection, and the Institutional Ethical Committee was functional in less than half of the institutes (n = 49; 45.0%).

In terms of problems faced by the patients in procuring the medications, it was noted that more than half of the patients were facing challenges in purchasing benzodiazepines. This was followed by difficulty in obtaining antipsychotics, antidepressants, mood stabilizers, and stimulant medications [Table 6].

Table 6

Problems faced by the patients in procuring medications

Variables	Frequency (%)
Not able to get the required antidepressants	42 (38.5)
Not able to get the required antipsychotics	45 (41.3)
Not able to get the required mood stabilizers	35 (32.1)
Not able to get the required benzodiazepines	62 (56.9)
Not able to get the required cognitive enhancers	20 (18.3)
Not able to get the required opioid substitution therapy	28 (25.7)
Not able to get the required stimulants	35 (32.1)
Other (please specify)	34 (31.2)
Availability is not a problem	27 (24.8)
Injectables not available	3 (2.8)
Affordability is an issue	2 (1.8)
Rural area people are facing problems	2 (1.8)

When asked about overall satisfaction with the mental health services being catered, the participants rated their level of satisfaction as 46.6% (standard deviation: 27.6).

DISCUSSION

The present survey involved a collection of information from 109 teaching institutes across the country. At present, about 300 institutes are involved in psychiatry training in the country. Considering this, the level of participation was about one-third. Overall, it is estimated that there are 542 medical institutes in the country;[6] however, all the institutes do not have psychiatry residency training. If one takes this figure of 542 into account, the response rate was 19.2%. If one compares the level of response, with that seen in a previous survey, which evaluated the state of CLP services in the country,[7] it can be said that the response rate was higher for this survey.

The present study suggests that lockdown led to the marked disruption of services, involving brain stimulation, ECT, inpatient services, outpatient services, and psychotherapy services. However, at the majority of the places, the CLP and PES services were continued. Further, it is essential to note that, even though the services were continued, overall, there was a marked reduction in the proportion of patients seen in different institutes. This disruption of services is in line with the data emerging from other countries.[234589] However, data which have come from these countries are limited to particular institutes or area. In contrast, to this, data of this survey provides valuable insight into the whole country.

This high level of disruption in the outpatient and other mental health services across the country is understandable considering the restriction in movement due to lockdown, fear of getting infected, and concern in the mind of mental health professionals for seeing patients without proper PPEs. Disruption of the inpatient services can be understood from the perspective of the fact that in most places, inpatient care in these institutes is provided through the GHPUs, which have open wards. In the wake of the COVID-19 epidemic, it is difficult to control the movement of patients, caregivers, and other visitors. Some of the emerging data from China suggest that people with severe mental disorders are at higher risk of developing COVID-19 infection.[9] These factors have possibly contributed to the closure of inpatient units at various places. A brain stimulation therapy requires direct contact of the machine with the patient's body and the use of the same machine in different patients will require sanitization of the machine and other equipment. This possibly explains the closure of these services in most places. ECT despite involving general anesthesia and some level of aerosol generation has been continued at few places.

This high level of disruption of mental health services, when the general level of psychological distress in the general population has possibly increased,[1011] suggests that many people in need of mental health services are left to their resources or the resources of their family members. This high level of disruption of mental health services can lead to an increase in agitation, violence, and suicidal behavior due to a lack of proper and adequate treatment. These are reports of suicide attempts being made by people experiencing substance withdrawal.[1213] These factors suggest that, after the lockdown, when the mobility is going to increase, the mental health care set-ups may be flooded with cases, and the setups need to prepare themselves to take care of these patients. People working in the different institutions and the IPS as a professional organization should come up with certain guiding principles to cater to the needy patients.

One positive aspect of restriction of the movement and the fear of infection is the expansion of the telecommunication (telemedicine/telepsychiatry) services, in the form of starting of these services, in about one-fourth of the institutes. This has possibly been fuelled by the need for such services, in the absence of routine outpatient services, need to provide services by avoiding in-person contact, the convenience of use, and recent telemedicine guidelines from the Government of India. Further, these services are also being used for providing mental health services to people in quarantine and those with COVID-19 infection. Expansion of these services has possibly brought some respite to the needy patients and their family members.

When looks at the findings of this survey regarding the involvement of mental health professionals in the COVID-19 response at the institutional level, it is evident that mental health professionals are contributing to the COVID-19 response. The involvement of mental health professionals in providing helpline services to the general public, screening people in quarantine for mental health issues, providing clinical care to COVID-19 patients, screening HCWs for mental health issues, and training the HCWs at most places suggest active involvement of the profession. However, lack of such a role across all the institutes suggests that there is a need to increase the awareness among the administrators and the policy makers about the mental health issues arising out of the pandemic. Another important aspect in which mental health professionals were involved in only 50% institutes were the administrative roles and involvement in policy-making in only about one-fourth of the institutes.

Usually, mental health is often neglected, and the majority of the resources are directed to addressing the physical health issues. The mental health professionals should also look at the pandemic as an opportunity to emphasize the fact that there is “no health without mental health.” The mental health professionals and professional organizations like IPS can come up with suggestions, like, although COVID-19 infection per se has not affected everyone's physical health and if at all it affects everyone, everyone is not going to have severe symptoms to require intensive care unit care; but COVID-19 pandemic and the lockdown is affecting the mental health of everyone and hence, the mental health issues of the general public, HCWs, people in quarantine, people with COVID-19 infection and those who have recovered from COVID-19 infection require proper attention. The mental health professionals should actively get involved in emphasizing this fact, rather than waiting for being called for their services. In terms of administrative and policy-making role, the mental health professionals should take the initiative to emphasize the fact that our specialty is unique from the perspective of not only handling the clinical issues but also can contribute significantly in understanding the psyche of the general public and those suffering from the infection; additionally, mental health professionals can contribute significantly to the conflict and crisis resolution, which is seen at many places due to involvement of people from multiple disciplines, who are usually not accustomed to working with each other.

Another important aspect that comes out of this survey is the high prevalence of insomnia, anxiety, and depression in people in quarantine and HCWs. In addition, other important mental health issues emerging during the lockdown and pandemic include stigma, fear of death, boredom, and irritability. This fact suggests that mental health professionals have to address these clinical and psychosocial issues effectively. However, in dealing with these issues, it is becoming apparent that these emotional factors are manifesting in a slightly different way than the way the mental health professionals are used to seeing in their routine clinics. In many of the sufferers, these are mild and possibly require more psychosocial support, rather than the use of medications.[14] Accordingly, there is a need to develop interventions to address these mild mental health issues by developing manuals for psychological aid and providing services in a step cared manner, so that psychiatrists are involved in managing the severe end of the spectrum and those with mild symptoms are managed by those with a limited level of training. Mental health professionals need to suitably modify and utilize commonly used interventions such as activity scheduling, behavioral activation, anger management, relaxation techniques, yoga, etc., to address some of these mental health issues.

This survey also shows that the use of telecommunications services in clinical care is also coming up with problems such as issues related to empathy, rapport, making appropriate diagnoses, and specific legal issues. These findings suggest the need for continuing medical education programs and research this area to understand the best techniques to overcome some of these limitations of the technology and to understand the legal issues.

In terms of problems faced by the patients in getting the medications, the present study reflects issues in getting different classes of drugs. Accordingly, this issue should be taken up by the IPS and other professional organizations with the government to facilitate, proper availability of the medications to the patients to avoid relapse of symptoms.

This survey has certain limitations. Although people from different institutes across the country participated in this research, still the participation was low. The assessment of the functioning of mental health services and the role played by the mental health professionals in the pandemic may be limited by the assessment questionnaire, and many other aspects may not have been covered. The assessment of the expansion of telecommunications services was cursory, and this survey did not detail the exact modalities, quality of services, perception, and satisfaction of the mental health professionals and the patients about the teleservices. Similarly, the disorders reported in HCWs and persons in quarantine were based on recall and not on review of exact data.

CONCLUSIONS

To conclude, this survey suggests that the COVID-19 pandemic and lockdown have led to the collapse of regular mental health services to a large extent. However, there is an expansion of telemedicine services in the country. The present survey also suggests that mental health professionals have not been assigned/have not taken up different roles that they can be take up in the wake of COVID-19 pandemic to emphasize that there is “no health without mental health.” Further, this survey also suggests that mental health professionals have to play a major role in addressing the prevailing psychiatric morbidity, specifically related to the COVID-19 related issues, take care of the HCWs and act as advocates for their patients in terms of availability of proper psychotropic medications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.