|Year : 2020 | Volume
| Issue : 2 | Page : 163-166
Organizing Mental Health and Psychosocial Support Services for COVID-19 at a Tertiary Care Center in India
Rakesh Kumar Chadda
Department of Psychiatry and National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
|Date of Submission||16-May-2020|
|Date of Decision||29-May-2020|
|Date of Acceptance||01-Jun-2020|
|Date of Web Publication||14-Aug-2020|
Prof. Rakesh Kumar Chadda
Department of Psychiatry and National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
Coronavirus disease 2019 (COVID-19) pandemic is associated with mental health consequences in patients diagnosed as having the disease, their contacts, healthcare workers, and also in the general community because of fear of getting the infection. Organizing mental health services in a big general hospital, especially in the background of diversion of many services including the workforce for pandemic-related services is a big challenge. The paper discusses the personal experience of the author in organizing mental health and psychosocial support services at a tertiary care teaching medical institution in India in the background of the COVID-19 pandemic. The services were targeted at the population visiting the hospital, healthcare workers, persons being quarantined, caregivers of patients with COVID-19 and the community in general. Some guidance notes were also developed for the physicians dealing with persons with COVID-19-related concerns and for psychiatrists in dealing with their patients. The strategy employed has a scope of being used at other similar institutions and also in similar situations arising in the future.
Keywords: Coronavirus disease 2019, India, mental health, pandemic
|How to cite this article:|
Chadda RK. Organizing Mental Health and Psychosocial Support Services for COVID-19 at a Tertiary Care Center in India. World Soc Psychiatry 2020;2:163-6
| Introduction|| |
Coronavirus disease 2019 (COVID-19) pandemic has engulfed most of the world since January 2020, having begun as a sporadic infection in the end-December 2019 in Wuhan, China. It appears no less than the Spanish Flu of 1918, which was also associated with worldwide mortalities. Due to high mortality, absence of an effective treatment and vaccine, limited knowledge about the virus, large number of symptomatic carriers, and very high contagious nature of the virus, COVID-19 has led to a kind of panic in communities all across the world. COVID-19 pandemic has come out with a major challenge to the healthcare services, health planners, public health experts, local governments, the World Health Organization (WHO) and other international bodies, due to its impact on health infrastructure and the economy. There have been increasing reports of persons with COVID-19 and related deaths, with the WHO reporting 3,679,499 confirmed cases and 254,199 deaths till May 7, 2020. India with a population of about 1.38 billion has reported 56,342 cases with 1886 deaths till May 8, 2020. The low figures in India are a reflection of rapid control steps undertaken by the Government of India, such as social distancing, raising public awareness about respiratory hygiene, screening and quarantine of suspected contacts, followed by nationwide lockdown on March 24, 2020, which was extended in phases to May 31, 2020. COVID-19, by affecting all strata of population along with the lockdown, has got huge impact on the global economy, impacting the livelihood of large sections of the population. The illness is associated with a constant fear in the community of getting the illness along with economic hardships associated with the loss of livelihood. The pandemic has also been associated with a massive reverse migration of people back from urban to rural areas because of closure of many industries in urban sector.
| Challenge to Healthcare Services|| |
COVID-19 imposes a big challenge to the healthcare professionals with a very large number of asymptomatic carriers, high fatality, highly infectious nature of the virus, and absence of effective treatment and vaccine. The healthcare workers are also at a high risk of getting infected. The illness is associated with psychosocial stress reactions among the general public as well as the healthcare workers., The illness has also been associated with communitywide fear in the background of the deadly nature of illness and socioeconomic impact of the countrywide lockdowns. The audiovisual and print media as well as the social media such as Facebook and WhatsApp have been completely dominated by (mis) information related to COVID-19. This is also associated with multiple social phenomena, such as stigma for the affected persons and their contacts, social effects of lockdown, including marital or family conflicts due to many family members confined together at home over many days, loss of livelihood, withdrawal syndromes in the persons using psychoactive substances, not being able to get timely help in case of serious medical problems, and effects on academic careers of the school- or college-going population. Many healthcare settings also had to close down the general health services to divert resources for the COVID-affected population. The mental health professionals face a specific challenge in this scenario, especially to act on misconceptions and stigma among the public. The persons, who are detected COVID 19 positive, and their contacts have a number of mental health concerns including stress of being quarantined, which need to be tackled. Curtailment of general mental health services has adverse effects on persons with mental illness in the community. Similarly, concerns of healthcare professionals involved in the treatment of COVID-19 population due to their high risk of exposure need to be looked into.
| Meeting the Challenge|| |
This paper discusses the strategies used at a tertiary care teaching healthcare institute in India to deal with various mental health and psychosocial issues related to COVID-19. This could serve as a model for developing services and strategies at any healthcare institution in a pandemic situation across the world. Author works at a tertiary care multidisciplinary teaching hospital with bed strength of over 2500 beds. The institute hospital attends to around four million patients in its outpatient service and more than 250,000 inpatients annually.
A number of contingency measures were taken up by the institute to control the spread of infection inside its hospital and campus, and also to develop the strategies at providing COVID-19-related services. Both the outpatient and inpatient settings in the hospital are at risk of spreading infection because of close contact. The outpatient service is often overcrowded, further increasing the risk of spread. In addition, the hospital was expected to develop the contingency measures for patients presenting with COVID-19 symptoms. As initial steps, the institute decided to close its outpatient service from March 24, 2020, commensurate with the nationwide lockdown. In addition, attempts were made to discharge the admitted patients as they recovered. Three blocks in the hospital with a capacity of more than 500 (later increased to more than 1000) patients were reserved exclusively for COVID-19 services. Some percentage of clinical staff including from psychiatry was also diverted for the COVID-19-specific services.
| Development of Mental Health and Psychosocial Support Services|| |
Department of psychiatry at the institute was requested by the hospital administration to develop strategies at taking care of mental health issues related to COVID-19. The department also received a communication from the Ministry of Health and Family Welfare, Government of India, to develop public health education material on mental health issues related to the pandemic.
There were a number of issues to be dealt with including stress and worries communicated by the healthcare staff, stress levels in the general community secondary to the lockdown, patients with mental health problems in the community who were not able to access the services, and challenges faced by the mental health professionals and the physicians. COVID-19, because of its highly infectious nature, absence of an effective treatment or vaccine, high mortality, restriction on daily routines due to the lockdown, and other preventive measures such as social distancing, has a tremendous impact on mental well-being of the general population. Stress and fear are observed in healthcare workers posted for COVID-19-related services and in the persons who are advised isolation or quarantine due to coming in contact with a person detected COVID-19 positive. The person who tests COVID-19 positive suffers further emotional turmoil both as a result of getting a potentially fatal illness with no effective treatment and social stigma as a consequence of being kept under observation and isolation. All these issues needed to be considered while developing educational material for COVID-19.
| Development of Educational Material for Lay Public|| |
India is a multilingual and multicultural country with 22 official languages. The Government of India has developed educational material on COVID-19, focusing on the necessary precautions to be undertaken to protect oneself from getting the infection, concentrated mainly on respiratory and personal hygiene, consonant with various international guidelines. As already pointed out, COVID-19 has led to widespread anxiety, worries, and fears among the lay public of getting infected. This is also stigmatizing the persons who are detected COVID-19 positive even after they have recovered and also their family members. The lockdown, associated with restrictions on outdoor activities, loss of livelihood, difficulty in accessing essential services, loss of recreational activities, and a general loss of freedom, has been associated with lot of stress. For school- and college-going population, it is affecting their education, since all educational institutions are closed, some institutions have though started with online classes, which may, however, not be a satisfactory substitute. The WHO has recently come out with posters on “Coping with stress during the 2019-nCoV outbreak” and “Helping children cope with stress during 2019-nCov outbreak.” We translated these posters into various Indian languages (Hindi, Punjabi, Gujarati, Marathi, Bengali, Kannada, Telugu, Tamil, Malayalam, Odia, and Manipuri), after taking due permission from the WHO. The translated versions were circulated among various social groups and also uploaded on our institute's website. We also prepared many educational video clips targeting general public, children and adolescents, pregnant women, single men, single women and the elderly population, which were put on our institute's website. Some of our colleagues also participated in health education programs on national television channels. We also provided services on mental health issues on the national helpline created by our institute.
| Persons With Mental Health Problems in the Community|| |
Because of the lockdown, a large number of patients with mental health problems are unable to access mental health services. Those who are already on treatment are also facing difficulty in attending follow-up with the treatment facilities and are at risk of getting relapse, if they are not able to fill up their prescription. We started tele-consultation service for our follow-up patients. The service was offered to the patients who had earlier taken appointments for follow-up with us. We dedicated three phones for tele-consultation. All the patients who had taken appointment for follow-up at our hospital were called by a psychiatrist to confirm about their current mental health status and need for a fresh prescription. In patients needing any modification, the patient was asked to send the old prescription electronically, and a fresh prescription was issued and sent electronically. During the month of April 2020, 1955 patients had taken follow-up appointments, but contact number was available for 1658 cases. We were able to provide service to 910 patients. Others could not be contacted for various reasons, such as call not picked up or the number not accessible. Thus, we were able to contact 46.5% of the patients who had taken a prior appointment and were able to deliver service. This experience serves as an example to introduce tele-consultation services in routine follow-up care in India and similar such settings in other places, wherever follow-up visits to the hospital can be avoided, especially in situ ations like a pandemic, or when travel may not be feasible due to weather conditions. This can save time of travel as well as reduce overcrowding in hospitals, a very common problem in India and many other places. There is one limitation that tele-consultation may not be an advisable option in new patients.
| Taking Care of Healthcare Workers|| |
The healthcare workers including doctors, nursing professionals and supportive staff, both those who are posted on COVID-19-related services as well as in other healthcare areas, face lot of stress and worries due to increased risk exposure. This was further accentuated with the reports of many healthcare workers developing the infection as well as succumbing to it coming from different parts of the world. In India, there were also a few reports of the healthcare workers including the doctors being stigmatized, and facing stray events of violence in the community out of fear that they may spread the infection in the community due to being exposed to the virus during their clinical duties. This shows the kind of phobia the COVID-19 has spread in the community. Immediate curative steps had to be taken by the law enforcing agencies to prevent recurrence of such incidents.
We developed guidance notes for healthcare workers at our hospital giving general instructions about how to identify stress in them and to cope with it. In addition, the hospital administration also conducted periodic workshops on personal protection as well other precautions to be taken in care of patients and suspects of COVID-19, and for those being kept on quarantine. The healthcare workers also needed to be counseled about the precautions to be followed during clinical duties and while they were at home. Worries about spreading infection to the immediate family members further added to the stress. Our guidelines covered these areas. Focus was on basics of stress management and lifestyle modification. We also prepared short video clips on the subject which were put on social media and the institute's website. A tele-helpline was also created for the in-house employees.
| Mental Health Issues in the Persons Quarantined or Put in Isolation|| |
Individuals, who are put on isolation, go thorough lot of stress and anxiety for various reasons. This includes persons who are COVID-19 positive and also their contacts, who have been put under quarantine. Considering that a small percentage of individuals may develop serious complications with risk of death, a positive report of COVID-19 is associated with lot of anxiety, worries, and despair. Similarly, the contacts also suffer similar type of predicament while waiting for the report. The phase of complete isolation with no face-to-face contact is very anxiety provoking, the only contact being with a person serving food for the day, who also comes with full protection kit. There have also been reports of suicides in few persons waiting for the report of the test. In this background, we developed guidance notes both in English and Hindi using resource materials from the relevant literature, adapting it to local needs.
| Guidance for Physicians Dealing With Patients/suspects With Coronavirus Disease-19|| |
During COVID-19 pandemic, physicians are likely to encounter patients who are experiencing various levels of emotional distress about the risk of infection and its impact on them, their families, and the community. The physicians need to acknowledge this uncertainty and help patients understand the emotional component to their potential health concerns. The physicians can also take a lead in educating their clientele about the standard precautions such as respiratory hygiene, hand hygiene, and social distancing, and need to report to the relevant health services in case of development of the first warning signs of COVID19 in their patients.
The physicians also need to keep themselves updated with the latest information about the pandemic so as to able to allay the fears and anxieties of their patients, as well as counsel them. It is also essential for physicians to follow full protection for themselves in clinical encounters, as being recommended by the local authorities.
| Guidance Notes for Mental Health Professionals|| |
Patients with mental health problems are at additional risk of developing exacerbation in their illness due to the stress related to the COVID-19 pandemic along with the consequences of the lockdown, such as inability to access the services, difficulty in filling up of their prescriptions, and general restrictions on outdoor activities. The new-onset cases are unable to access services. Patients with mental health problems would also have difficulty in following the social distancing and respiratory hygiene etiquettes such as use of mask. When admitted to a hospital, patients with mental health problems are likely to put themselves and their caregivers at extra risk of contracting infection because of their difficulty in following the usual safety precautions. If a person with psychotic disorder develops COVID-19 infection, maintaining isolation with the necessary precautions is a big challenge. Keeping all these issues, the guidelines were prepared for the mental health professionals. These included psychoeducating the patients with mental health problems, advising not to watch news on COVID-19 frequently, collecting information only from reliable sources such as websites of the Ministry of Health or the WHO, and to be regular in their medication. A strong emphasis was made on keeping a healthy lifestyle, stress management, and staying away from alcohol and drugs. It is believed that all these instructions would help in preventing relapse of an ongoing mental health problem.
| Conclusion|| |
COVID-19 pandemic is a major challenge to the healthcare professionals, considering its highly infectious nature and lack of an effective treatment and vaccine. There is a need to develop mental health and psychosocial support strategies aimed at general population as well as the healthcare workers. The strategies need to target multiple groups including the patients, their contacts, general population, healthcare workers, doctors and the mental health professionals. Author has shared his experiences at developing such services at a large tertiary care teaching hospital, which might be useful in developing similar services at other places in the face of similar crisis situations.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
WHO Coronavirus Disease (COVID-19) Dashboard. Available from: https://covid19.who.int
[Last accessed on 2020 May 08].
Hiremath P, Suhas Kowshik CS, Manjunath M, Shettar M. COVID 19: Impact of lock-down on mental health and tips to overcome. Asian J Psychiatr. 2020;51:102088. doi: 10.1016/j.ajp.2020.102088. Online ahead of print. PMID: 32302964.
Pfefferbaum B, North CS. Mental health and the COVID-19 pandemic. N
Engl J Med. 2020. doi: 10.1056/NEJMp2008017. Online ahead of print. PMID: 32283003.
Galbraith N, Boyda D, McFeeters D, Hassan T. The mental health of doctors during the Covid-19 pandemic. BJPsych Bull. 2020;1-4. doi: 10.1192/bjb.2020.44. Online ahead of print. PMID: 32340645.
Rajkumar RP. COVID-19 and mental health: A review of the existing literature. Asian J Psychiatr. 2020;52:102066. doi: 10.1016/j.ajp.2020.102066. Online ahead of print. PMID: 32302935.
Liu S, Yang L, Zhang C, Xiang YT, Liu Z, Hu S, et al
. Online mental health services in China during the COVID-19 outbreak. Lancet Psychiatry 2020;7:e17-8.
Chen Q, Liang M, Li Y, Guo J, Fei D, Wang L, et al
. Mental health care for medical staff in China during the COVID-19 outbreak. Lancet Psychiatry 2020;7:e15-6.
Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al
. The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet 2020;395:912-20.