Impact of COVID-19 pandemic and lockdown on the state of mental health services in the private sector in India.

BACKGROUND: No information is available about the impact of lockdown and COVID-19 pandemic on the mental health services in the private practice in India. AIM: The current study is aimed to assess the impact of the COVID-19 pandemic and lockdown on the state of Mental Health Services in the Private Sector in India.
MATERIALS AND METHODS: An online survey was carried out using the Survey Monkey platform during the period of 1st to 15th May 2020 among the members of the Indian Psychiatric Society.
RESULTS: Three hundred and ninety six responses were analysed. There was a reduction in revenue generation by about 70%. All kinds of services, including outpatient services, inpatient services, psychotherapy services, consultation-liaison, and electroconvulsive therapy (ECT) services, were severely affected. One-third of the participants were using the teleservices during the pandemic. The most common problem faced in running the services included modifying the psychological treatment to maintain social distancing, and managing the staff. Besides providing clinical care to the patients, the majority of the mental health professionals reported that they were involved in increasing awareness about the mental health consequences of pandemic and the lockdown and addressing myths related to the spread of infection.
CONCLUSION: The pandemic and the lockdown have markedly impacted mental health services in the private sector. ECT services, inpatient services, psychotherapy services and outpatient services are the most affected. However, the COVID-19 pandemic and lockdown have led to the expansion of teleconsultation services. Copyright:

INTRODUCTION

The COVID-19 pandemic has led to a significant negative impact on the provision of mental health services globally. Available data from China suggest that during the COVID-19 pandemic patients with psychiatric ailments faced more barriers and problems, compared to patients in other departments.[1] It is also suggested that patients with psychiatric ailments are more vulnerable to COVID-19 contamination, even in relatively isolated places.[1] Data from Wuhan Mental Health Centre suggested that about 50 patients with psychiatric disorders and 30 medical staff developed COVID-19 infection. It is also documented that many psychiatric hospitals refused to take new inpatients.[1] Similarly, data from the United States suggest that pandemic has had a significant impact on access to care, quality of care provided, and modality of delivery of care. It is reported that continuity of care in a different environment had been maintained, at the cost of bypassing the legal provisions and privacy rules.[2] In some countries like Italy, the mental health services were also compromised initially, with some of the psychiatry inpatient facilities being converted to COVID intensive or subintensive units.[3]

It is also reported that psychiatric outpatient services have evolved and have incorporated various teleservices or virtual services to provide mental health care.[2] Data from other countries such as Australia, Italy, etc., also suggest the expansion of remote location teleservices for providing mental health-care services.[4] However, the teleservices have not been universally accepted, and some patients have expressed that they still would prefer in-person consultations,[2] whereas, at other places, patients have been reported to accept the telephone consultation, given the fear of getting infected.[4] Many new patients are apprehensive of starting medications just based on teleconsultation.[2] In other countries like Italy, telephonic reviews are encouraged, and outpatients' services have been restricted.[3] Data also suggest that patients on psychiatric treatments are facing challenges such as difficulty in getting the medications and difficulty in getting the necessary investigations done to continue the psychotropics.[2]

The pandemic has also brought forth the need to change in the functioning of psychiatry inpatient facilities.[5] In countries like Italy, for the inpatient setting, various recommendations have been made in the form of a reduction in staff on duty, providing information and training the inpatients about the symptoms of COVID-19 and hygiene measures, maintaining constant vigil to prevent the spread of infection, suspension of group activities in the ward, revision of discharge mechanism to minimize the contact of old patients with the new patients, develop isolation procedures in the ward, and online video-conferencing for all staff meeting activities.[3] At some places, such as Massachusetts, considering the increase in the need for more inpatient care, the acute inpatient units have been opened to cater patients who have psychiatric ailments and have additionally got infected with COVID-19, which is medically not serious to the extent of admitting the person in infectious disease units.[2]

The pandemic has also brought forth many ethical challenges for mental health professionals. The issues which concern mental health professionals include personal protection, personal treatment needs in case they get infected, impact on others if they get infected, economic crisis, ethical issues for self and others, and training. The training of residents has also been compromised in the wake of the pandemic.[2] It is also possibly changing the ways of learning for the medical students and residents and has led to an opportunity to innovate.[2]

In India too, the lockdown was declared after about 2 weeks of the declaration of a pandemic. This led to the closure of the majority of the health-care services, especially in the private sector. Because of the sudden declaration of the lockdown, the patients with mental disorders are not able to seek consultations for their ailments. In addition, the pandemic has also led to severe psychological distress in the general public at large, and the need for mental health services has expanded.[6] Pandemic has also brought forth many myths, which are influencing the mental health, behavior, and practices of people at large.[7]

Although there are some data from various parts of the globe, little is understood about the impact of a pandemic on the mental health services in India. A previous survey showed that the pandemic has severely impacted the mental health services in the teaching institutes.[8] In India, a major proportion of the patients pay for their health care out of their pocket, and a significant proportion of the mental health care is catered by the private sector,[9] which includes people with single chamber outpatient practice, mental health inpatient setting owned by professionals, mental health services provided through the corporate hospitals or multispecialty hospitals. At some places the services are provided through the charitable organization. Most of these places work on the principle of charging the majority of the patients of the services utilized. Such kinds of private mental health services are in a way unique to India. In this background, this study aimed to evaluate the impact of lockdown and pandemic on the mental health services in the private sector, change in the practice of psychiatry, the role played by mental health professionals during the pandemic besides providing the routine clinical care, profile of patients and problems faced by the patients in procuring medications.

MATERIALS AND METHODS

This study was carried out under the aegis of the Research, Education, and Training Foundation sub-committee of the Indian Psychiatric Society. The study was approved by the Ethics Committee of the Indian Psychiatry Society for Research. This online survey was carried out by using the Survey Monkey platform during the period of 1st to 15th May 2020. Using the E-mail addresses from the directory of the Indian Psychiatric Society, E-mails were sent to all the members of the society with a valid E-mail address to respond to the survey. In addition, the link for the survey was also circulated by WhatsApp among the members of the society to complete the survey. Participation in the survey was voluntary and periodic reminders were sent to the members to complete the survey. The survey questionnaire was designed to keep the COVID-19 pandemic and the associated lockdown situation in mind.

RESULTS

Out of the 6269 E-mail addresses to which the survey was sent, the survey bounced back for 822 (13.1%) E-mail addresses. Only about half (n = 3106; 49.5%) of the peoples opened the survey and 2038 (32.5%) of the members did not open the mail. Out of the total 489 (7.8%) responses, 428 responses were received by E-mail links, and 61 responses were received by WhatsApp link. Out of these responses, 396 (81%) responses were found to be complete on most of the aspects and were considered for further analysis. The majority (n = 161; 40.7%) of the participants were running their single-chamber outpatient clinic and this was followed by those working in corporate hospitals (n = 78; 19.7%), those running their hospital with inpatient facility (n = 69; 17.4%), those running their hospital with the only outpatient facility (n = 54; 13.6%), and those working in other set-up formed 8.6% (n = 34) of the total participants. The mean number of years of being in private practice (information provided by 351 participants) was 14.6 (standard deviation: 11.9) years.

As is evident from Table 1 and Figure 1, mental health services were significantly affected for all kinds of services, with the most affected being the outpatient services, psychotherapy services, consultation-liaison psychiatry services, inpatient services and electroconvulsive therapy (ECT) services. However, there was the expansion of the teleservices, with the use of the same almost doubled during the lockdown period.

Table 1

Services provided before and during the lockdown period

Variables	Before lockdown, n (%)	During the lockdown period
Outpatient services	396 (100.0)	233 (58.8)
Inpatient services	153 (38.6)	64 (16.2)
ECT services	122 (30.8)	31 (7.8)
Brain stimulation services (rTMS, tDCS)	36 (9.1)	12 (3.0)
Psychiatry emergency services	189 (47.7)	149 (37.6)
Psychiatry consultation-liaison services	256 (64.6)	110 (27.8)
Opioid substitution therapy services	68 (17.2)	27 (6.8)
Psychotherapy services	244 (61.6)	66 (16.7)
Telecommunication (telemedicine/telepsychiatry) services	104 (26.3)	206 (52.0)
Psychological investigations	164 (41.4)	27 (6.8)
Other (please specify)	32 (8.1)	44 (11.1)

ECT – Electroconvulsive therapy; rTMS – Repetitive transcranial magnetic stimulation, tDCS – Transcranial direct current stimulation

Figure 1

Services provided before and during lockdown

When specifically the proportionate reduction in particular services was evaluated, ECT services were the most affected with nearly 90.7% reduction in initiation of ECT, this was followed by a reduction in the number of patients admitted to the inpatient reduced by 76.7% [Table 2 and Figure 2]. When a similar analysis was done for places where the services were still running, it was evident that at these places too, there was a significant reduction [Table 2]. Overall, there was about 70% of the revenue generated by psychiatrists [Table 2].

Table 2

Impact of pandemic and lockdown on the specific services

Variable	Mean (SD) (n=396)	Mean (SD)@
Percentage reduction in the patients that have been admitted in your inpatient facility	76.7 (28.9)	67.1 (22.2)
Percentage reduction in the patients that have been initiated on ECT	90.7 (10.8)	61.4 (34.4)
Percentage reduction in the patients that have been initiated on brain stimulation treatments, after the declaration of Lockdown	63.8 (46.7)	63.2 (42.1)
Percentage reduction in the patients that have been started on oral substitution therapy	60.8 (39.3)	41.6 (31.6)
Percentage reduction in the patients that have been seen in Emergency	65.9 (27.7)	57.5 (25.3)
Percentage reduction in the patients that have been seen in the outpatient	71.6 (20.5)	65.4 (18.3)
Percentage reduction in providing consultation to the medically ill patients of your colleagues	68.3 (28.3)	65.5 (21.0)
Percentage reduction in monthly income	69.8 (23.9)	-

@The mean was calculated for places, where the services were still running. SD – Standard deviation; ECT – Electroconvulsive therapy

Figure 2

Impact of pandemic and lockdown on the specific service

In terms of modalities used for providing the services during the lockdown period, only two-fifth (42.7%) were running the regular outpatient services, and only one-fifth (18.7%) were providing consultation-liaison psychiatry services. In terms of providing teleservices, about one-third were using both voice and video calls, with some proportions being paid and some being free of cost. Overall, about one-third of the mental health professionals were providing services free of charge. In terms of professional satisfaction, the participants rated their satisfaction with a mean figure of 45.8% [Table 3].

Table 3

Modalities of providing mental health services during the lockdown period

Variables	Frequency (%)
Total shut down	25 (6.3)
Only voice calls (free of charge)	108 (27.3)
Only voice calls (paid services)	12 (3.0)
Only voice calls (a combination of free and paid services)	31 (7.8)
Only video calls (free of charge)	11 (2.8)
Only video calls (paid services)	13 (3.3)
Only video calls (a combination of free and paid services)	22 (5.6)
Both voice and video calls (free of charge)	61 (15.4)
Both voice and video calls (paid services)	26 (6.6)
Both voice and video calls (a combination of free and paid services)	132 (33.3)
Regular outpatient services	169 (42.7)
Regular consultations to medically ill patients	72 (18.7)
How much are you satisfied with the kind of services which you are currently providing to your patients (Likert score 0-100)	45.8 (28.6)

In terms of challenges faced in running the practice, in case the participants were seeing patients, either in person or through the teleconsultations, the most common problem identified was a reduction in revenue collection (n = 234; 59.1%), and this was followed by the need for modifying the psychological treatments to suit the teleconsultations (n = 206; 52%), modifying the psychological treatments to maintain social distancing (n = 173; 43.7%), and managing the staff (n = 185; 46.7%). Other factors, which were identified by about one-fourth of the people, included lack of empathy (n = 61; 15.4%), probable legal issues (n = 106; 26.8%), and difficulty in diagnosing the problems (n = 96; 26.8%), while providing care through teleconsultations.

In terms of problems being encountered by the patients, more than half of the participants reported that patients were having difficulty in purchasing benzodiazepines (n = 222; 56.1%), and this was followed by difficulties associated with the purchase of antipsychotics (n = 174; 43.9%), antidepressants (n = 146; 36.9%), mood stabilizers (n = 126; 31.8%), stimulants (n = 110; 27.8%), and opioid substitution therapy (n = 84; 21.2%) and other medications (n = 91; 23%).

In terms of mental health professionals providing services to people in quarantine and health-care workers (HCWs), it was seen that the most common problem encountered among people in quarantine, who were non-HCWs, HCWs in quarantine, and HCWs working with people with COVID-19 infection, was anxiety, and this was followed by insomnia, depression, irritability, boredom, and fear of death. Overall these symptoms were more often in people in quarantine who were not HCWs, followed by HCWs in quarantine and those on duty working with COVID-19 patients [Table 4].

Table 4

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

Variables	Frequency (%)
	People in quarantine (non-HCWs)	People in quarantine (HCWs)	HCWs working with patients with COVID-19 infection
Not applicable	127 (32.1)	141 (35.6)	198 (50.0)
Anxiety	243 (61.4)	204 (51.5)	134 (33.8)
Depression	176 (44.4)	136 (34.3)	102 (25.8)
Anger	119 (30.1)	92 (23.2)	69 (17.4)
Irritability	170 (42.9)	138 (34.8)	84 (21.2)
Insomnia	195 (49.2)	149 (37.6)	98 (24.7)
Fatigue	79 (19.9)	91 (23.0)	58 (14.6)
Guilt	46 (11.6)	54 (13.6)	41 (10.4)
Perception of stigma and discrimination	130 (32.8)	98 (24.7)	74 (18.7)
Boredom	167 (42.2)	90 (22.7)	46 (11.6)
Fear of death	150 (37.9)	102 (25.8)	90 (22.7)
Substance withdrawal and craving	119 (30.1)	39 (9.8)	24 (6.1)
Worries related to family members	184 (46.5)	153 (38.6)	99 (25.0)
Dissatisfaction with the services	83 (21.0)	79 (19.9)	53 (13.4)
Other (please specify)	13 (3.3)	11 (2.8)	9 (2.3)

HCWs – Health-care workers

When the participants were asked to describe their role as a mental health professional, in response to the pandemic and the lockdown, besides their routine clinical care, about three-fourth of the professionals reported involvement in increasing awareness about the mental health consequences of the pandemic and the lockdown and about half were providing free teleconsultation to the general public, free of cost. About two-third were also involved in providing free teleconsultations to their patients and about two-fifth of them donated funds for the government response to the pandemic. About half reported indulging in addressing the myths related to the pandemic and the lockdown and involved in providing free teleconsultations to the general public. A small proportion of the participants also reported that they were involved in increasing mental health awareness through social sites, involved in social activities, research, and conducting webinars [Table 5].

Table 5

Role played as a mental health professional

Variables	Frequency (%)
Increasing awareness about the mental health consequences of the pandemic and the lockdown	295 (74.5)
Addressing the myths about the pandemic and the Lockdown	208 (52.5)
Providing free Tele-consultation to the general public	186 (47.0)
Providing free Tele-consultation to your patients	269 (67.9)
Donated funds for the Governmental response to the pandemic	166 (41.9)
Others
Awareness through social sites/WhatsApp/you tubes/media	21 (5.3)
Social activities like distributing food, drugs, money, etc.	34 (8.6)
Research and webinar activities	11 (2.8)

DISCUSSION

This survey aimed to evaluate the impact of a pandemic on the mental health services in the private sector in India. The findings of this survey reflect that the COVID-19 pandemic and the lockdown has led to significant compromise in providing mental health-care services to the general public at large. All kind of mental health services have got affected, but the services which have been most affected were the ECT services, inpatient services, and outpatient services. Further, at places where these services were continued, there was a significant reduction in the quantum of services provided. Although it can be said that the outpatient services have been somewhat replaced or compensated by the expansion of the teleservices, but these can be said to be at the early phase of expansion. The high level of compromise with the outpatient services suggests that a large proportion of the patients with various mental health problems are left to their resources and to the resources of their families in dealing with mental health problems.

The impact of the lockdown on the outpatient services is understandable considering the desired restriction in the morbidity, possible fear of getting infected in the mind of the patients, and also the mental health professionals. This level of compromise in the outpatient, inpatient, emergency services, consultation-liaison psychiatry services, ECT services, brain stimulation services suggests that mental health services have been badly hit by the lockdown. This also reflected by about 70% reductions in the revenue generated by mental health professionals. This finding is supported by the reports from the United States, which also suggests the COVID-19 pandemic has resulted in an economic crisis as an outcome for mental health professionals.[2] A survey from India, conducted among the ophthalmologists during the mid-April 2020, also suggests that lockdown and pandemic has led to financial difficulties, with slightly more than one-third (37%) reporting difficulty in meeting their living expenses.[10]

Although it is not clear from this survey, it is quite likely that this high level of disruption of mental health services has been mainly due to travel restrictions, rather than mental health professionals not making themselves available for the services.

In terms of governmental response to the COVID-19 pandemic, somehow, the mental health component is grossly missing except for mass media messages to stay back at home, maintain social distancing, use of masks and sanitizers, and recognizing signs and symptoms of COVID-19 infection. However, the COVID-19 pandemic and the associated lockdown is possibly associated with psychological issues, which are over and above the baseline prevalence reported in the general population.[6] There are mental health concerns of the general public at large, health-care workers, people in quarantine, those infected with COVID-19 infection, and those who have recovered from COVID-19 infection.[11] All these suggest that there is a need to reorganize the services to maintain the continuity of services and to expand the services to address the emergent mental health issues due to the pandemic.[12]

One such reorganization of the services has already begun, with the expansion of the teleconsultations, through voice calls and teleconferencing. The timely releases of telemedicine guidelines[13] have facilitated the same. However, as is evident from this survey, implementing of teleconsultation requires modifying the psychological treatments.

What can be learned from this experience is that in future, in such exigencies, the mental health services should be geared up to adapt to the emerging situation, and rather than closing the services, the services can be continued with the required modifications. It is true that possibly the teleconsultations cannot replace the in-person consultations, but in an exigency, clinicians should be prepared to adapt to more of teleconsultations, rather than continuing with the face to face consultations. For continuing with the in-person outpatient services, systems need to be developed to ensure the safety of the mental health professionals, all the other staff involved in managing the mental health set-ups, and also our patients.[12]

This survey has certain limitations. First, overall the participation rate was low. A stage sampling method could have led to the selection of a focused group of participants and a better response rate. However, this could be due to a lack of specific identification for those in private practice and those in institutional services. As a requirement of the survey, the participants were required to be in the private practice of some form. The impact on the mental health services as assessed by the survey was limited to the extent of coverage of the questionnaire, and some of the aspects may not have been covered.

CONCLUSIONS

To conclude, the present survey suggests that the mental health services in the private sector have been markedly impacted by the lockdown and the pandemic. The services which have been most affected include ECT services, inpatient services, and outpatient services. Overall, there is also a significant compromise in the revenue generated by the mental health professionals in private practice. However, the pandemic and the lockdown have led to the expansion of the teleconsultation services, which is possibly facilitated by the release of telemedicine guidelines by the Government of India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.