|Year : 2022 | Volume
| Issue : 1 | Page : 37-45
The Impact of Coronavirus Disease 2019 on People with and without Severe Mental Illness in Tamil Nadu, India
Joseph Lam1, Sujit John2, Tessa Roberts1, Amaldoss Kulandesu2, Karthick Samikannu2, Kruthika Devanathan2, Triplicane Chakravarthy Ramesh Kumar2, Ramachandran Padmavati2, Jothy Ramadoss Aynkaran2, Georgina Miguel Esponda1, Craig Morgan1, Thara Rangawsamy2
1 Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, ESRC Centre for Society and Mental Health, King's College London, London, UK
2 Schizophrenia Research Foundation, Chennai, Tamil Nadu, India
|Date of Submission||26-Mar-2021|
|Date of Acceptance||04-Oct-2021|
|Date of Web Publication||27-Apr-2022|
Room 1.03 David Goldberg Centre, 18 De Crespigny Park, SE5 8AF, London
Source of Support: None, Conflict of Interest: None
Background/Objectives: People living with severe mental illness may be more susceptible to infection and stress, leading to relapses or worsening of their mental health. The experiences of people with severe mental illness during the coronavirus disease 2019 (COVID-19) pandemic have seldom been captured. This study set to describe the experience of people with severe mental illness in Tamil Nadu, India, during the COVID-19 pandemic. Methods: Between July and December 2020, 158 age-, gender-, neighborhood-matched case − control pairs from the INTREPID II study completed a survey regarding their experience, worries, and behavioral changes during the pandemic. Their responses were collected by phone during six-monthly check-ins, or in-person at 24-month follow-up appointments. Only the first response for each participant is included in this report. Results: None of our participants reported knowingly having been infected with COVID-19 by the time of the survey. There is no evidence that people with psychoses were disproportionately affected by the pandemic. Unemployment and financial hardship were highly prevalent in both cases and controls. Job-related anxiety and stress were the largest source of worry, followed by worries regarding government decisions and access to mobile phones. Conclusions: The pandemic placed great strain on participants both with and without severe mental illness. The impact of unemployment and financial hardship as a result of COVID-19 requires urgent attention.
Keywords: Coronavirus disease 2019, psychosis, rural India
|How to cite this article:|
Lam J, John S, Roberts T, Kulandesu A, Samikannu K, Devanathan K, Kumar TC, Padmavati R, Aynkaran JR, Esponda GM, Morgan C, Rangawsamy T. The Impact of Coronavirus Disease 2019 on People with and without Severe Mental Illness in Tamil Nadu, India. World Soc Psychiatry 2022;4:37-45
|How to cite this URL:|
Lam J, John S, Roberts T, Kulandesu A, Samikannu K, Devanathan K, Kumar TC, Padmavati R, Aynkaran JR, Esponda GM, Morgan C, Rangawsamy T. The Impact of Coronavirus Disease 2019 on People with and without Severe Mental Illness in Tamil Nadu, India. World Soc Psychiatry [serial online] 2022 [cited 2022 Dec 4];4:37-45. Available from: https://www.worldsocpsychiatry.org/text.asp?2022/4/1/37/344183
| Coronavirus Disease 2019 in India|| |
To date, India has recorded over 11 million cases of coronavirus disease 2019 (COVID-19). A nationwide lockdown was imposed in March 2020. People living with severe mental illness could be more susceptible to infection and stress, leading to relapses or worsening of their mental health. The experiences of people with severe mental illness during the pandemic have seldom been captured, and there is a particular dearth of information on this group's experiences from the outside of Western Europe and North America.
INTREPID II is a longitudinal cohort study of psychotic disorders (affective and nonaffective) in urban and rural areas in India, Nigeria, and Trinidad. In India, our catchment area consists of four taluks in Tamil Nadu; Chengalpattu, Thiruporur, Uthiramerur, and Maduranthakam. People aged 18–64 years with ICD-10 psychotic disorders that have not been treated with antipsychotic medication for more than 1 month before case identification are included. A detailed research protocol for INTREPID II has been published elsewhere. Out of 225 recruited participants, 158 cases and their respective controls completed the COVID-19 survey between July 26 and December 11. These were the total number of participants that we were able to contact during this period. These responses were collected by phone during six-monthly check-ins or in-person at 24-month follow-up appointments. For participants who completed the survey more than once, only the first response for each participant is included in this report. Items in the COVID-19 survey were selected from existing national surveys that were used to capture the general impact of the pandemic on people's livelihood [Appendix 1]. Our sample demographic is described in [Table 1].
| Coronavirus Disease 2019 Experience and Diagnosis|| |
None of our 158 cases and 158 controls reported knowingly having been infected with COVID-19 by the time of the survey. One case and 12 controls (7.6%) reported someone close to them having been diagnosed or strongly suspected to have COVID-19. Zero cases and 7 controls (4.4%) reported someone close to them having been hospitalized with COVID-19. Zero cases and 5 controls (3.2%) reported that someone close to them died from COVID-19.
| Impact of Coronavirus Disease 2019|| |
Loss of job (N = 311)
Five participants did not respond to the question regarding their employment. Unemployment or the inability to do paid work was commonly experienced (73 [46.5%] cases and 83 [53.9%] controls). Among participants who were employed at baseline (N = 139), loss of paid work affected 22 of 41 cases (53.7%), and 62 of 98 controls (63.3%). From conditional regression of 60 discordant pairs (in this case, a discordant pair mean that either case or control had reported losing their job, whilst the other group had not), there is weak evidence that controls experienced an increased risk of losing their job compared to cases (odds ratio [OR] =1.50, 95% confidence interval [CI] 0.89–2.51).
Major cut in household income (N = 293)
Twenty-three participants refused to answer the question regarding their household income. Most people in our sample experienced a major cut in household income (75 cases [51.4%] and 105 controls [71.4%]). From 56 discordant pairs, there is evidence that controls experienced an increased risk of experiencing a major cut in household income compared to cases (OR = 3.00, 95% CI 1.64–5.49).
Unable to pay bills (N = 316)
Twenty cases (12.7%) and 32 controls (20.3%) reported the inability to pay bills. From 36 discordant pairs, there is weak evidence that controls were more likely to be unable to pay bills than cases (OR = 2.00, 95% CI 1.00–4.00).
Unable to access sufficient food (N = 316)
Forty-seven cases (29.8%) and 37 controls (23.4%) reported the inability to access sufficient food. From 50 discordant pairs, there is no evidence that controls were more likely to be unable access sufficient food than cases (OR = 0.67, 95% CI 0.38–1.17).
Access to health care and care avoidance due to coronavirus disease 2019 (N = 316)
One hundred and eight cases (31.7%) and 47 controls (29.8%) reported being unable to access health-care services during the COVID-19 pandemic. Fourteen cases (8.9%) and 19 controls (12.0%) avoided approaching health facilities because of fear of COVID-19 infection.
| Worry and Anxiety related to Coronavirus Disease 2019|| |
Overall difficulties with mood (N = 316)
Over half of the participants in our sample reported worsening difficulties with mood, worry, or anxiety since the COVID-19 pandemic started. Eighty-seven cases (55.1%) and 93 controls (58.9%) reported such difficulties since the beginning of the pandemic. From 26 discordant pairs, there is weak evidence that controls had more difficulties with mood than cases (OR 1.60, 95% CI 0.73–3.53).
Causes of significant stress and worries
Participants were asked to rate on a 5-point Likert scale (0–4) the extent of stress or worry they felt regarding issues related to the COVID-19 pandemic. Responses were subsequently grouped, with 0–1 classified as “Little or No Worry,” and 2–4 as “Moderate to Significant Worry.”
Worries related to contracting or infecting others with coronavirus disease 2019 (N = 316)
Three cases (1.9%) and 20 controls (12.7%) reported moderate to significant worry about becoming seriously ill from COVID-19. Two cases (1.3%) and 25 controls (15.8%) reported moderate to significant worry about infecting others with COVID-19. One case and 18 controls (11.4%) reported moderate to significant worry about people they know contracting COVID-19.
Other sources of worries
The most common source of significant worry among both cases and controls is the possibility of unemployment. Sixty-two cases (39.5%) and 78 controls (50.0%) reported moderate to significant worry of losing their jobs. From 70 discordant pairs, there is weak evidence that controls worried about unemployment more than cases (OR = 1.59, 95% CI 0.98–2.58).
The second most common source of significant worry for cases related to the levels of government action, with 19 cases (12.0%) and 22 controls (13.9%) reporting concern about the government response. From 21 discordant pairs, there is no evidence that controls worried more about government action than cases (OR = 1.33, 95% CI 0.56–3.16).
The third most common source of significant worry for cases and second most common source for controls were other work-related worries even if they felt that their jobs were safe at present. Sixty cases (10.2%) and 28 controls (17.7%) reported moderate to significant work-related worries. From 36 discordant pairs, there is weak evidence that controls are more likely to report work-related worries than cases (OR = 2.00, 95% CI 1.00–4.00).
The third most common source of significant worry for controls related to mobile phone access. Fourteen cases (8.9%) and 24 controls (15.2%) reported moderate to significant worry of losing mobile phone access. From 24 discordant pairs, there is weak evidence that controls worried more about mobile access than cases (OR = 2.43, 95% CI 1.01–5.86).
Less than 5% of participants in our sample reported moderate to significant worry about shortage of essential supplies, lack of internet access, personal safety or security, education or exams, marriage or romantic relationships, separation from family members due to regulations, and being socially isolated.
Overall, COVID-19 did not affect the social connectedness of participants in our sample with their romantic partner, family, friends, neighbors, people in the same village, town or city, and country. The only exception regarded social connectedness to the people in their workplace or schools (N = 269), with 66 cases (47.8%) and 59 controls (45.0%) reporting feeling less connected to them since the pandemic.
Limitation and summary
A limitation of this study is that the questionnaire used for the data collection is not validated for the Chennai context; however, it was developed in consultation with researchers based there. A second limitation corresponds to the low number of discordant pairs in some of our analysis, such that the CI for our estimated effect was wide and should be interpreted conservatively.
In general, participants in our sample were not directly affected by COVID-19 infection at the time the survey was completed, although they were greatly impacted by the measures taken to control the pandemic.
From our data, there is no evidence that people with psychoses were disproportionately affected by the pandemic; in fact, people without psychosis were more likely to report negative impacts of COVID-19 across many measures. This might be because people with severe mental illness were more sheltered or had less to lose when the pandemic hit (being less likely to be employed and actively engaged with the community outside of their household). Alternatively, it could be explained by people without psychosis being more aware of the severity of the situation and of events unfolding around them, due to increased social participation and access to news updates.
It was clear from our data, however, that the pandemic placed great strain on participants both with and without severe mental illness. Unemployment and financial hardship were highly prevalent in our sample, with a quarter of our participants experiencing difficulties accessing sufficient food and accessing health-care services. Most respondents are daily-waged workers with jobs that require travel outside of their villages and do not own their own vehicles. They rely on their mobile phone access to communicate with their contractors regarding work opportunities. Downsizing of local businesses means that work opportunities are further limited. The imposed lockdown rules such as closure of nonessential industries and pauses of public transportation services are therefore likely to have contributed to these adverse experiences. The lockdown policies compound with the fear of infection of COVID-19 appeared to have led to the observed high unemployment rates, reduction of income, and prevalent worries of such consequences. The impact of unemployment and financial hardship as a result of COVID-19 require urgent attention.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
1. Have you had Covid.19 (coronavirus)?
If no, skip to q2
| References|| |
Dong E, Du H, Gardner L. An interactive web-based dashboard to track COVID-19 in real time. Lancet Infect Dis 2020;20:533-4.
Yao H, Chen JH, Xu YF. Patients with mental health disorders in the COVID-19 epidemic. Lancet Psychiatry 2020;7:e21.
Sheridan Rains L, Johnson S, Barnett P, Steare T, Needle JJ, Carr S, et al
. Early impacts of the COVID-19 pandemic on mental health care and on people with mental health conditions: Framework synthesis of international experiences and responses. Soc Psychiatry Psychiatr Epidemiol 2021;56:13-24.
Roberts T, Gureje O, Thara R, Hutchinson G, Cohen A, Weiss HA, et al
. INTREPID II: Protocol for a multistudy programme of research on untreated psychosis in India, Nigeria and Trinidad. BMJ Open 2020;10:e039004.