How Did the Mental Health Care System in India Respond to COVID 19 Pandemic?

Abstract

India with a population of 1.3 billion has a unique health care system in its different states. Mental health care varies widely across the country and this became even more apparent after the COVID-19 pandemic set in. This paper examines the various strategies in response to COVID-19 adopted by the Government of India, the health departments of the individual states, and other private players such as on-government organizations and the civil society. The cessation of many services including outpatient and inpatient care and the scarcity of medicines were serious impacts of COVID-19. The prolonged lockdown in many parts of the country impeded access to mental health care services since public transport was unavailable. This led to many relapses in persons with serious mental disorders. The emergence of new cases of psychosis and an increase in suicides were also seen. Tele consultations came to the fore and many helplines were started offering counseling and guidance regarding the availability of mental health care facilities. While these helped the urban dwellers, those in remote and rural areas were unable to use these services effectively. Many mental health wards were used for COVID-19 patients and mental health professionals were deployed for COVID-19 related duty. The severely mentally ill, the homeless mentally ill, and the elderly were especially vulnerable. Based on our experience with COVID-19, we urge a strong call for action, in terms of strengthening the primary care facilities and increasing the manpower resources to deliver mental health care.

Introduction

India with a population of nearly 1.3 billion is a vast country with a wide variation in health care services. The mental health services are offered by State-run institutions such as mental hospitals, psychiatry departments in medical college hospitals, non-governmental organizations (NGOs), and private mental health practitioners. These services are largely urban-based providing predominant outpatient care, while the 40 odd mental hospitals and few other facilities offer inpatient care. Psychosocial rehabilitation services are seen in very few centers and most of the persons with severe mental illness (PSMi) live with their families.

The COVID-19 pandemic resulted in considerable burden on the health systems globally. The increased demands for mental health care imposed by COVID-19 intersect with the already fragile health systems, scarce resources, and workforce capacity, social unrest and violence in response to COVID-19 containment strategies, and overall scarce and inequitable access to intervention.¹ Disasters disproportionately affect poor and vulnerable populations, and the PSMi were among the hardest hit. The mental health issues in the context of the COVID-19 pandemic here are more complex due to a large proportion of socially and economically vulnerable populations like the children, the elderly, migrant laborers, and those with pre-existing mental illnesses.² The constrained health services infrastructure,³ less penetration of digital mental health solutions, and the scare created by the tremendous misinformation on social media compounded the problems.

The lockdown that happened at different times in different states was first declared in March 2020 and led to a great disruption in health care services. Many hospitals were turned into COVID-19 centers leading to the near depletion of beds for mental health care. Outpatient services came to a grinding halt in many states, and medicines were not available. The PSMi were unable to access centers/hospitals for both inpatient and outpatient care and procure medication and many consequently suffered relapses.

New patients were turned away from under-resourced hospitals for lack of beds, even as institutions were unable to discharge improved patients to live with their families.¹

Table 1.

Government and National Institutes Initiative

1.	Several guidelines/advisories by the Ministry of Health and Family Welfare, Government of India5 (MOHWF) were issued: • Management of mental health issues for different segments of the society. • The National Institute of Mental Health and Neurosciences (NIMHANS) released “Mental Health in the times of COVID-19 Pandemic-Guidance for general Medical and Specialized Mental Health Care Settings.” • Minding our minds during COVID-19. Document released by Ministry of Health and Family welfare, March 31, 2020. • Caring for Health Care Warriors-Mental Health Support During COVID-19. • Managing Mental Illness in Hospital Settings During COVID-19.
2.	Online capacity building of health workers in providing psychosocial support and training through (Igot)-Diksha platform.6
3.	The MOHFW-GOI issued a tollfree helpline number for “Behavioural Health,” a list of videos, advisories, and resource materials on coping with stress during COVID-19, yoga and meditation advice, was also put in place.5,7
4.	Multilingual Mental Health and Normalcy Augmentation System App. (MANAS), a digital well-being platform was endorsed as a national program to promote wellbeing among persons in the 15–35 years age groups by the Prime Minister’s Science, Technology, and Innovation Advisory Council (PM-STIAC). (https://pib.gov.in/PressReleaseIframePage.aspx?PRID=1711860)
5.	NIMHANS released Covid-19 guidelines for mental health care settings on behalf of the health ministry in April 2020. These included management and community care of at-home patients with severe mental disorders through existing community outreach programs, such as the District Mental Health Program (DMHP).8
6.	eSanjeevaniOPD, a patient-to-doctor telemedicine platform and provisions health services to the public in the confines of their homes was launched in April 2020.9 (https://pib.gov.in/PressReleasePage.aspx PRID = 1732524)
7.	Tele-Manas, the National Tele Mental Health Program was announced in 2022. This will include a network of 23 tele-mental health centers of excellence, with NIMHANS being the nodal centre.10
8.	Other institutions like the PGI, Chandigarh, All India Institute of Medical Sciences, Indian Psychiatric Society had all taken up independent responsibilities in the form of online and telemedicine services, etc.

Table 2.

Initiatives by Civil Society and NGOs

1.	Firework, a video platform launched #sparkthejoy to address COVID-19-related mental health issues. This encouraged acts of kindness, spreading the message of love to spark positivity among people. These videos witnessed user engagement doubling during the lockdown period. A panel of doctors advised on treatment issues.11
2.	The NGO Schizophrenia Research Foundation (SCARF) launched a warmline Y4Y (Youth for Youth) for people aged 15–25 years who needed a peer to talk to, a place to vent or to share their problems. Youngsters could speak anonymously with a youth volunteer, who was well trained on mental health and in identifying needs of the caller, basic communication skills, and in supporting individuals.12
3.	Sangath, also an NGO addressed the psychological and social needs of different age groups by empowering communities, engaging on mental health issues and supporting people with counselling through digital platforms. Sangath has so far provided free online counselling to more than 260 unique clients and conducted more than 460 online sessions.13

Materials and Methods

A comprehensive search was conducted over several databases to identify relevant peer-reviewed studies, personal blogs, news reports, and personal narratives of the mental health care services provided during the COVID-19 pandemics. Expert opinions from informal sessions, talks, and interviews were compiled to make a narrative account of the mental health care system’s response to the pandemic.

Health System Response

To address the mental health needs of the population, the Government of India implemented multiple measures which are listed below along with the initiatives on NGOs and civil societies.⁴

Regional Responses.

Some regional responses preceded national plans. The Kerala State Government constituted a multidisciplinary team in February 2020, which integrated efforts by several sectors and established a state helpline.¹ Dedicated helplines were set up to supplement the regular District Mental Health Program activities, and involved mental health professionals and state nodal officers in the states of Andhra Pradesh, Assam, Delhi, Gujarat, Kerala, and Tripura.

Despite these efforts, mental health services were hit hard. The impact was manifold- on inpatient and outpatient care, availability of medication, patients on clozapine, homeless patients, Electro convulsive therapy (ECT), and emergency services. There were vaccine-related challenges as well as the emergence of new-onset psychosis related to COVID-19.

Impact on Treatments

A survey that included data from 109 institutes showed that lockdown led to the complete shutdown of brain stimulation treatments in all the centers providing these services. There was also a marked reduction in the use of ECTs, inpatient and outpatient services. However, the silver lining was the expansion of the telepsychiatry services.¹⁴ Another survey that included data from 396 private psychiatrists also suggested similar disruption of routine mental health services across the country and expansion of teleconsultation services.¹⁵

All this meant that even severely ill persons had to be managed at home by their families. The families of patients could not visit their relatives in the hospitals due to the lockdown restrictions and fear of COVID-19 infection.¹ Similarly, rehabilitation services also came to stand still at many centers.

State of Psychosis

The intensity of psychosis itself was aggravated by fear and stress caused by the pandemic, infection with the virus, distress, and isolation among those infected, and treatment with steroids and other agents.¹⁶ Psychosis precipitated by the fear of acquiring COVID-19, with a background of personal vulnerabilities and sociocultural issues was also observed.¹⁷ A large number of suicide cases have also been reported in India during the lockdown period due to COVID-19 pandemic.^18,19

Psychosis and COVID-19

A study done in PGIMER found the incidence of COVID-19 infection in patients with schizophrenia to be 5.6%, which appears to be higher than that seen in the general population. The incidence of COVID-19 did not differ between those receiving clozapine and those receiving other antipsychotic medications. Many patients did not require a change in the doses of psychotropic medications during the acute phase of COVID-19 infection.²⁰ This, however, contradicted the findings from other studies.^7,21

Impact on Services

Many out-patient services were replaced by the use of telephone check-ins and telepsychiatry visits. However, others such as daycare programs, sheltered workshops, and peer support groups came to a halt.^22,23

Raman et al. demonstrated a negative impact of COVID-19 on health care as part of the ongoing SMART study. A total of 2003 participants completed this multicenter survey.²⁴

The multivariable analyses showed that all 5 dimensions of healthcare provision were negatively affected: affordability, accessibility, adequacy, appropriateness, and continuity of care. Associated depression and social loneliness were pronounced.

Rehabilitation Services

A few publications from Karnataka have described the impact of COVID-19 on PSR services. Chaturvedi stressed the need to strike a balance between maintaining COVID-19-related safety and some alternative measures to continue rehabilitation services.²⁵ Richmond Fellowship, Bengaluru described the negative impact on its residential clients in terms of disruption of their activities requiring a change in the response of the management.²⁶ Pandemic-related challenges faced by a rural Community Based Rehabilitation (CBR) program in a Karnataka taluk were countered by stakeholder collaboration, task shifting of lay health workers, and the implementation of telepsychiatry.²⁷

The Rural Scenario

A great number of persons with psychosis live in rural areas where access to mental health services is difficult even in normal times. The lack of public transport during the lockdown period, lack of availability of medicines, and the misconceptions related to COVID-19 itself led to many staying away from health services. Some NGOs offering mental health services in rural areas also had to expand tele-enabled services.²⁸ While telemedicine enabled expansion of service as well as efficiency, there were issues of casualization of therapy and poor privacy. Ghosh and Sircar allude to the impact of the pandemic on maternal mental health and the health care services in rural India.²⁹

Persons With Psychosis in COVID Wards

PSMi who were infected with COVID-19 had a hard time getting admitted into COVID-19 wards, largely due to discrimination. This was endorsed by findings of a Delhi-based study that showed that patients with schizophrenia formed a minuscule of all the patients admitted to the COVID-19 ward.³⁰

In Emergency Services

On the contrary, the closure of regular mental health services resulted in PSMi thronging the emergency care services.^31,32

Homeless People With Mental Illnesses

Some of the initiatives to support this highly vulnerable group included the hiring of ceremony halls, community halls, and unoccupied residential facilities to house them.³³ Technology was used in some centers to integrate and manage these patients.³⁴

Incidence of COVID-19 in Patients With Psychosis

Data from different parts of the world suggest that patients with psychosis, especially those on clozapine, had a higher incidence of COVID-19 infection. These patients more often required admission and had more severe COVID-19 disease and higher mortality rates.^35–39

Only one Indian study on the incidence and outcome of COVID-19 in 567 patients with psychotic disorders found the incidence to be 5.64%, There was no significant difference in the incidence among 340 persons on clozapine and those on other antipsychotics.²¹

Patients on Clozapine

As the lockdown led to the closure of the laboratory services and the pharmacy, the patients on clozapine were impacted significantly. In some of the centers, telephonic monitoring of their treatment was done by educating them about the signs and symptoms of COVID-19 infection, the need for continuation of clozapine, blood monitoring, and ways of contacting the treating physician. One study reported that Clozapine was continued for 96.6% of the patients during this period, despite one-fourth of the patients facing difficulty in procuring clozapine. Grover et al. point out that over 75% of patients appeared to have followed the lockdown rules.²¹

COVID-19 Vaccine Prioritization for Person(s) With Mental Illness

In India, persons with mental illness were initially not included in the priority list for receiving COVID-19 vaccinations. This issue was also raised by individual psychiatrists and professional bodies in India.^40–42

Impact on Training and Teaching

In-person classes were replaced by online teaching. Many centers moved toward Objective Structured Clinical Examination (OSCE) formats as real patients were unavailable. Students and teachers needed to adapt to the new format. The online Training initiative for psychiatry postgraduate students (TIPPS) platform was well placed to continue its academic activities even during the lockdown phase and attempted to fill the gaps in residency training. The National Board of Examination also opted to use the unmanned OSCEs.⁴³ There was flurry of online CME activities, since conferences could not be held.

Discussion

Like elsewhere, the variety and extent of the implications of the COVID-19 pandemic for mental health are yet to be fully understood. However, the spotlight has shifted on mental health issues arising amid COVID-19 and some noteworthy guidelines for prevention activities have been drawn up in the last 1 to 2 years. These steps taken by the government and other stakeholders to reduce the risk of adverse mental health outcomes in the pandemic are certainly in the right direction for mental health in India.⁴⁴

There is little doubt that COVID-19 has brought into focus the stark reality of inadequate mental health services, especially in rural areas. This should be a call for action-fully integrating mental health in plans for universal health coverage, enhancing access to psychosocial interventions, and addressing the needs of neglected populations, such as children and people with substance use disorders in remote and rural regions.

Countering this hidden pandemic⁴⁵ requires collective effort by various stakeholders, including health professionals, community health workers, persons affected by mental illness, family members, school teachers, workplace managers, police, civil society organizations, community heads, and policymakers. Such a concerted effort needs to be directed toward the development of new institutional infrastructure around mental health care as well as towards the continuous expansion of existing resources.⁴⁶ Communities, including families of people with mental health conditions, local leadership, community health workers, and traditional and religious healers, must be empowered as active partners in delivering public health initiatives that are grounded in local realities and that recognize the interdependence of mental health, physical health, and social and economic context.⁴⁷ However, in most cases, these linkages have to be locally and contextually evolved depending on the specific need.⁴⁸

The central government should provide states more autonomy over their funding and decision-making. Attention needs to be paid to the health sector and recognize the importance of having strong public sector capacity, especially in primary care and at the district level. Our public health-care system is chronically underfunded (at just 1.28% of Gross Domestic Product [GDP]), leaving the primary care system ineffective. This pandemic could be the much-needed wake-up call to the necessity of long-term changes to India’s health system.

It is equally important for all sections of the population to be aware of the sources of help available for COVID 19. And this information is disseminated effectively through seminars and various awareness programs.

Some key recommendations are:

1. To strengthen effective leadership and governance for mental health.

2. To provide comprehensive, integrated, and responsive mental health and social care services in community-based settings.

3. To implement strategies for promotion and prevention in mental health.

4. To strengthen information systems, evidence, and research for mental health.

It can be hoped that the implementation of these would strengthen the response of our health care systems to future pandemics.

Conflict of Interest

The authors have declared that there are no conflicts of interest in relation to the subject of this study.