While experts had been discussing the effect of prolonged lockdowns on mental health for some time, we now have a survey that seems to confirm their fears. Dr Jugal Kishore, who heads the Department of Community Medicine at the Vardhaman Mahavir Medical College & Safdarjung Hospital, conducted an online survey titled ‘Depression and Corona’, and its results were unsurprising.
“From the responses we have received so far, over 30 per cent show signs of depression. This is a very high rate. The people reporting symptoms come from all walks of life,” he says.
The survey was in the form of a questionnaire set according to the working definition of depression by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). The team received over 400 responses from across the country.
While depression and other mental health issues affect an individual’s daily functioning, a spike in these cases amid the ongoing pandemic might go beyond personal harm — it could prove dangerous for an already strained public health infrastructure.
Dr Kishore explains: “People who are suffering from depression can behave hazardously. It can lead to suspension of self-care and other harmful behaviours. This becomes alarming, given the fact that they can put themselves and others at risk of catching the coronavirus infection.”
Life for those suffering from mental health problems has indeed become tougher. Ananya (name changed), a 25-year-old Delhi resident who is required to take anti-depressants, says: “My medicines are going to last another two days. I have no idea what I’ll do after they are exhausted.”
“Pharmacists won’t hand you the medicine unless you have a recent prescription to show. Getting a prescription these days is tough, as the private clinic I go to, like most others, is shut,” she adds.
The nationwide lockdown to prevent the spread of coronavirus has led to a peculiar situation for those suffering from severe mental health issues. Getting medication, as Ananya points out, is challenging. These patients often have to rely on sympathetic chemists, as sale of medicines on outdated prescription notes is unethical.
“Ideally pharmacists must ensure new prescriptions to dispense. Sale of medicines on old prescription is not uncommon outside of metro cities, but even rural pharmacists would refuse to sell if a prescription advising benzodiazepines (sleeping pills) is old,” says Dr Ajish Mangot, a psychiatrist based in Karad, Maharashtra.
While this uncertainty adds to the plight for people like Ananya, the problem faced by a vast majority of Indians living in rural areas is far worse. As one health official points out, not all psychiatric medicines are available at generic pharmacy stores, and availing of them in rural areas is particularly difficult. District hospitals, meanwhile, have been over-burdened with coronavirus cases and are finding it difficult to provide other health care services.
Can telemedicine save the day?
On March 25 the Ministry of Health and Family Welfare (MoHFW) published a set of guidelines for remote delivery of healthcare services, or telemedicine. Until that point, telemedicine was mostly used for training medical professionals. But the nationwide lockdown made the government push for a wider deployment of these services.
According to a list compiled by the Indian Psychiatric Society (IPS), there were 656 mental health professionals volunteering to provide tele-psychotherapy as on April 15, 2020.
Experts Business Standard spoke to pointed out some grave shortcomings. An official from National Institute of Mental Health and Neuro Sciences (NIMHANS), the apex centre for mental health research, set up in 1974 and run autonomously under the MoHFW, says: “Remote diagnosis and prescription presents serious ethical issues for psychiatrists. Telemedicine is not viable in all cases as all psychiatric tests cannot be performed remotely. Some require physical presence of patients. Physical examination of patient is a key factor for prescribing medication.” The official does not wish to be named.
Besides, an in-person evaluation of patients is strongly recommended for new clients according to NIMHANS guidelines for tele-psychotherapy.
“Problems of access also exist, especially for patients in rural areas. Arranging online appointments for them is not easy,” the official adds.
Accessibility, however, isn’t just limited to internet proliferation and literacy. Getting an online appointment has become quite a task, as one patient points out.
A resident of Lucknow, 24-year-old Sukanya (name changed), says: “My psychiatrist and therapist have both shut down on call appointments and you have to undergo an entire process to qualify for an online appointment.” She shared with Business Standard a checklist that a patient is required to go through for getting an appointment. One of the must-haves on the list that proves a big hindrance is ‘prescription’.
“I tried to get an online appointment but since I didn’t have my prescription with me, the psychiatrist refused to take up my case. I told the person I have a diagnosed disorder — Borderline Personality Disorder — and I shared all the requisite information, including the medication I was on. But he still didn’t give an appointment,” she says.
While Sukanya does not rely on a daily dose of medicines anymore, she is required to keep anti-anxiety medication for emergencies. But now she has run out of her SOS pills and is finding it difficult to buy.
An increase in isolation, loneliness, and the uncertainty of the lockdown, are weighing on many people. The looming threat of pay cuts and job losses are only adding to the pressure. Noting the consequences of the prolonged lockdown, Dr Kishore warns: “Depression leads to high instances of anxiety, panic attacks and suicidal tendencies. You are already seeing such cases — the suicide of a health care worker is one example.”
Realising the need for a proactive response to the crisis-in-waiting, countries have begun preparing. “UK’s Royal College of Psychiatry is aware that people will face overwhelming psychological issues after this pandemic. So, its team is already gathering data to address increased work load in the future. It's being called ‘preparedness for new normal’,” says Dr Pallavi, a UK-based psychiatrist who previously practised in India.
“In India, we have extremely small mental health units, hardly any registered nurse practitioners or psychiatric social workers, and few elaborate community mental health units,” she adds.
A 2015 WHO report corroborates Dr Pallavi’s concern. Its findings showed there were three psychiatrists and ‘even fewer psychologists’ per million people in India — even as 7.5 per cent of the Indian population suffers from some form of mental disorder.
India still has a long way to go in terms of mental health care services with a deep-rooted stigma against these issues working against progress. For Ananya, however, nothing is more important than life returning to normalcy.