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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 4  |  Issue : 3  |  Page : 202-210

A Study on Impact of COVID-19 Pandemic on Persons with Preexisting Psychotic Disorder, their Coping Strategies, and Compliance with Preventive Measures


1 Department of 1Psychiatry, All India Institute of Medical Sciences, New Delhi, India
2 Warwick Medical School, University of Warwick Medical, Coventry CV4 7AL, UK

Date of Submission19-Dec-2020
Date of Decision07-Jul-2022
Date of Acceptance27-Jul-2022
Date of Web Publication21-Dec-2022

Correspondence Address:
Prof. Mamta Sood
Department of Psychiatry, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/wsp.wsp_88_20

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  Abstract 


Background: Coronavirus disease 2019 (COVID-19) pandemic has impacted persons with preexisting psychiatric disorders negatively. There is a lack of studies on the impact on people with preexisting psychotic disorder. Aims: We studied the impact of the COVID-19 pandemic and lockdown on patients with a preexisting psychotic disorder and whether they were following the recommended preventive measures for COVID-19. We also studied coping strategies used by them and their caregivers. We compared persons with first-episode psychosis (FEP) and chronic psychotic disorders (CPD). Methodology: The study sample was a part of the National Institute of Health Research Psychosis Research Group cohort. The subjects belonged to two groups: FEP consisted of patients with the first episode of psychosis, with the duration of illness ≥3 months and ≤2 years, and CPD group consisted of patients with psychosis, with the duration of illness ≥2 years. They were interviewed telephonically on a semistructured questionnaire. Thematic analysis was done to identify coping strategies. Results: Fifty patients were interviewed: 24 in the FEP (26·12 ± 8·0 years) and 26 in the CPD group (34 ± 7.5 years). Forty-six (92%) patients reported difficulty in access to hospitals and 32 (64%) had difficulty in contacting a doctor. Eight (16%) of them reported worsening of symptoms and 12 (24%) reported irregular adherence to treatment. The two groups differed significantly on doing household chores, occupational functioning, and financial issues. The majority of them used emotion-focused coping strategies. Three-fourth (79.1%) of the patients in the FEP group were following all four recommended preventive measures, whereas, in the CPD group, three-fourths (73.1%) were able to follow only one measure. Conclusion: The COVID-19 pandemic had impacted FEP and CPD groups differently. CPD group could follow recommended preventive measures less frequently than FEP.

Keywords: Chronic psychosis, coronavirus disease 2019, first-episode psychosis, India, preexisting


How to cite this article:
Sood M, Chadda RK, Shukla T, Patel R, Ratra D, Mohan M, Singh SP. A Study on Impact of COVID-19 Pandemic on Persons with Preexisting Psychotic Disorder, their Coping Strategies, and Compliance with Preventive Measures. World Soc Psychiatry 2022;4:202-10

How to cite this URL:
Sood M, Chadda RK, Shukla T, Patel R, Ratra D, Mohan M, Singh SP. A Study on Impact of COVID-19 Pandemic on Persons with Preexisting Psychotic Disorder, their Coping Strategies, and Compliance with Preventive Measures. World Soc Psychiatry [serial online] 2022 [cited 2023 Feb 1];4:202-10. Available from: https://www.worldsocpsychiatry.org/text.asp?2022/4/3/202/364589




  Introduction Top


Globally, coronavirus disease 2019 (COVID-19) pandemic has overwhelmed the health systems and raised concerns regarding its psychological impact on patients with mental illness. Evolving insights into its presentation and pathophysiology, lack of definitive treatment, and presence of mutants along with high contagion capacity caused difficulties in dealing with it.[1] Many countries implemented complete to partial lockdown to deal with the COVID-19 pandemic.

The COVID-19 pandemic has had a negative psychological impact such as increased anxiety, impulsivity, anger, insomnia, and depressive symptoms[2] in patients with neurotic disorders. There is also an increased risk of relapse[3] in persons with preexisting mental conditions. There is a scarcity of studies that systematically investigate the impact of COVID-19 in people with psychotic disorders.[4] People with psychotic disorders are particularly a vulnerable population. The underlying pathophysiology such as neuro-inflammation[5] along with the high prevalence of cardiometabolic disorders, sedentary habits, obesity, and poor nutrition[6],[7] puts them at a higher risk of contracting the virus and developing more severe COVID-19 complications. In addition, there are concerns about the deprivation of care in this population due to decreased access to health care during the pandemic.[8] Research also suggests that people with severe mental illness use maladaptive coping strategies in the postdisaster phase and these impact them negatively.[9] Persons with psychotic disorders may not adhere to recommended preventive measures such as wearing a mask, social distancing, and hand hygiene due to cognitive deficits, lack of insight, and impaired judgment.[10],[11],[12] A recent study conducted at a psychiatric inpatient facility in China reported poor practicing of recommended preventive measures among psychotic patients.[13] Adhering to preventive measures of infection especially in a population vulnerable to complications is very important.[4]

The current prevalence of psychotic disorders in India is 1.4% with a treatment gap of 75.5%.[14] Most of them receive treatment from outpatient services and continue to stay at their homes with families who take care of their needs.[15],[16] At our center, which is a tertiary care, public-funded general hospital psychiatric unit of a medical school, we have two ongoing research projects: the first one is on first episode psychoses (FEP) and the second on chronic psychotic disorders (CPD). The details of these projects are available elsewhere.[17] Due to the COVID-19 pandemic and our hospital policy, there was closure of outpatient services and limited inpatient care. Therefore, recruited for these research projects patients could not be examined in person. Phone follow-ups were conducted for the already recruited patients in these projects. This was as per the guidelines issued by the Indian Council of Medical Research.[18] A recent review highlighted that there is a lack of literature on the specific needs of people with severe mental illness during pandemics and proactive research is required in this area.[19] The effects of a pandemic on persons with psychotic disorders staying in low-and middle-income countries (LMIC) like India have not been studied. When interviewing patients, the impact of lockdown and ongoing COVID-19 pandemic on the mental health and functioning was quite apparent in the conversations. We also observed that the impact was different in patients with FEP and CPD. Therefore, we planned this study to assess the impact of COVID-19 pandemic and lockdown on persons with preexisting psychotic disorders: the difficulties experienced by them, and how they were coping with these difficulties. We also assessed whether they were following the recommended preventive measures for COVID-19 pandemic. We compared the FEP and the CPD groups on the impact of COVID-19 pandemic and adherence to recommended preventive measures.


  Methodology Top


This study was conducted at a tertiary care multidisciplinary teaching health-care institution in Northern India. The study sample was a part of the National Institute of Health Research Psychosis Research Group cohort.[17] The patients were registered in the outpatient services and were receiving regular follow-up care. The projects were approved by the Institute Ethics Committee: IEC-745/December 29, 2017, RP-19/2018, and IEC 252/May 05, 2017 and IEC-252/May 05, 2017, OP-21/July 02, 2021.

In the FEP group, patients aged between 18 and 45 year and, of either gender who met International Classification Of Diseases–10th Edition (ICD-10)[20] criteria for schizophrenia (F20) or persistent delusional disorder (F22) or schizoaffective disorder (F25) or other nonorganic psychotic disorder (F28) or unspecified nonorganic psychosis (F29) or bipolar affective disorder-mania with psychotic symptoms (1st episode) (F 31.2) or depressive episode with psychotic symptoms (F 32.3 and F 33.3) with duration of illness ≥3 months but ≤2 years, no past history of psychotic or episodes, were included. Patients with peripartum onset, organic causes, affective neurodevelopmental disorders, or comorbid substance use disorder except tobacco were excluded. The CPD group comprised of the patients aged 18–65 years, of either gender, who met diagnostic criteria for F20, F22, F25, F28 and F29 on ICD-10, with a duration of illness of ≥2 years, having received adequate treatment for at least ≥6 months but having persistent symptoms and dysfunction (Clinical Global Impressions Scale-Severity of Illness score ≥4).[21] A semistructured questionnaire was developed by the investigators to collect information related to COVID-19 after focused group discussion comprising of authors (mental health professionals) based on themes identified in the literature related to the impact of a disaster, more specifically pandemic, on the mental health of people with preexisting mental illnesses.[4],[5],[6],[8],[9],[22],[23],[24],[25] This questionnaire was sent to two independent psychiatrists explaining the aim and background of our study. We requested them to look at the items of questionnaire and see whether the items would be able to capture the information that these are supposed to elicit. We modified the questionnaire according to their inputs. The questions were asked in Hindi and Hindi translation of the questionnaire was available with all the interviewers. However, we did not use any formal method to assess content validity like content validity index and contentment validity ratio and inter-rater reliability. The questionnaire was applied to 5 patients to assess the comprehensibility and feasibility for use on telephone and was modified accordingly. The questionnaire was answered by patients and supplemented by family/caregivers wherever needed. Research staff DR, RP, and TS applied the questionnaire. The questions were phrased in an open-ended manner and verbatims were also recorded along with the categorical responses.

Data entry and statistical analysis were performed using the Statistical Program for Social Sciences (IBM SPSS Corp, SPSS Statistics ver. 16, USA). Descriptive statistics (mean, standard deviation [SD], and frequency distribution) were calculated for all sociodemographic variables. The means between the two groups were compared using Mann–Whitney U-test. For comparing categorical variables between the two groups Chi-square test with Yates correction was used. Fisher's exact test was used if >50% of the cells contained values <5. In order to correct for multiple comparisons, P < 0.005 was considered significant. The verbatim obtained in response to the question “how do you handle these problems?” were analyzed based on thematic analysis[26] to identify themes reflecting coping strategies used by patients and their caregivers as per the cognitive-transactional theory of stress[27] as problem-focused or emotion-focused coping strategies. Problem-focused coping strategies are mainly directed at eliminating or reducing the stressor; on other hand emotion-focused coping strategies are mainly directed at the management of one's emotion to handle the stressful situations.


  Results Top


One hundred and thirteen persons-68 in the FEP group and 45 in the CPD group were contacted telephonically. A total of 50 participants were interviewed: 24 participants in the FEP group and 26 participants in the CPD group. We were unable to contact the remaining 63 participants because there was no answer after repeated attempts (n = 37) or the telephone was disconnected or was out of use (n = 26).

Baseline characteristics of study population

Baseline sociodemographic characteristics of study population with FEP and CPD are shown in [Table 1]. All the patients stayed at home with their families. Participants in the FEP group were younger than CPD group (mean ± SD = 26·12 ± 8·0 vs. 34·0 ± 7·5, P = 0.0007), and the duration of illness was higher in the CPD group (median [interquartile range = 0·4 [1·4] vs. 10,[10] P < 0.00001) but did not differ in terms of gender distribution, occupation, marital status or zone of residence. In the FEP group, half of the participants had unspecified psychosis, four of them had schizophrenia, seven had acute and transient psychotic disorder, and three had bipolar disorder (mania with psychotic features). All patients in the CPD group had schizophrenia.
Table 1: Baseline Characteristics of Patients

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Impact of the coronavirus disease 2019 pandemic

We studied how the ongoing pandemic was impacting medical care and functioning during the period when full to partial lockdown was implemented [Table 2]. In all the persons with psychoses, current clinical status had worsened in one-sixth (16%) of them. The symptoms reported were increased irritability, suspiciousness, aggression, muttering to self, or becoming more inactive. One-fourth (24%) of them had issues related to medication adherence. Three patients in the FEP group reported that they had completely stopped medications. Reasons for nonadherence were reported as lack of availability of medication and in some cases lack of knowledge regarding the need to continue treatment (as the patient was not experiencing symptoms when medications were stopped). A large number of patients reported difficulty in access to hospitals (92%) and in contacting a doctor (64%). One-sixth (16%) and one-fourth (26%) of the patients reported issues related to nonavailability of medicine stock and access to medical stores respectively. One-third (30%) of them reported facing problems in their daily routine and 6 (12%) reported interpersonal issues with their family members; one-fourth (26%) of them reported difficulties related to household chores and one-third (32%) reported job related issues. Twenty-two (44%) reported experiencing financial difficulties. Only 4 (8%) of them had utilized telepsychiatry services of the hospital that had started within a week of the lockdown.
Table 2: Comparison of Impact of COVID-19 between FEP and CPD groups

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The patients in FEP group were performing household chores significantly more than before as compared to CPD group. However, they experienced significant difficulties in occupational functioning and financial issues.

Coping strategies used by patients and caregivers

We also studied the coping strategies used by the patients and their family caregivers to handle difficulties arising out of the pandemic and restrictions due to lockdown [Table 3]a and [Table 3]b.
Table 3:

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For dealing with medical care issues, most (n= 22) of the participants in the FEP group used emotion-focused coping strategies. It typically involved denial towards the situation, taking no action or using an avoidant approach.

In the CPD group, the majority (69.2%) of patients and caregivers reported using problem-focused or task-oriented coping strategies for dealing with medical care issues such as information seeking by contacting doctors telephonically or accessing local doctors and, searching and accessing online medical stores. Some of them had used a coping strategy of anticipation as they had purchased medicines in advance prior to lockdown and some took help from their relatives for procuring medicines.

Eight participants in the CPD group had kept medicine stock for a long duration as they had been on the same medications for a long period, and so they did not face any difficulty.

For the difficulties related to functioning in terms of personal care and interpersonal interactions, all the participants in the FEP group n = 24 reported using mostly emotion-focused strategies to handle their stressors related to disruption in their routine which included distraction to distance themselves from the situation, talking and sharing their distress with their family, while some used an avoidant approach.

In the CPD group, majority (n = 22) of the participants reported using emotion-focused coping strategies in the form of avoidance of triggers by not bringing up discussion about the patient's routine and not asking them to participate in household activities.

Only 4 participants in the CPD group reported using problem-focused coping like making a structured routine and engaging in leisure activities or physical exercise.

For handling their financial difficulties, in the FEP group, 17 participants were using emotion-focused coping.

Seven participants were using problem-focused coping to manage their financial issues. It mainly included seeking financial support from their relatives and neighbors, using their past savings, and applying for jobs to start working.

In the CPD group, majority of the participants (n = 22) reported using emotion-focused coping by trying to accept the situation for what it was. Four participants reported using problem-focused coping by seeking financial support from their relatives.

Compliance with recommended preventive measures for coronavirus disease 2019

We also noted compliance of the persons with FEP and CPD were compliant with the recommended preventive measures for COVID-19 [Table 4].[22] All the participants were following one or the other preventive measures. Three-fourth (79.1%) of the patients in the FEP group were following all four recommended preventive measures. About one sixth of them (16.6%) followed only one measure and only one person followed two measures. Conversely, in the CPD group, three-fourths (73.1%) were able to follow one measure, 15.4% followed all the recommended preventive measures and 11.5% followed two measures.
Table 4: Comparison of Compliance with Recommended Preventive Measures for COVID-19 between FEP and CPD groups

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  Discussion Top


We studied the impact of COVID-19 in fifty persons with preexisting psychotic disorders under regular follow-up prior to the COVID-19 pandemic by interviewing them telephonically to assess the impact of COVID-19 pandemic. Twenty-four of them had FEP and 26 had CPD. Both the groups were comparable on most of the sociodemographic characteristics. As per the selection criteria, persons with FEP had a lesser duration of illness and were younger.

Interestingly, the clinical condition had remained the same as before the pandemic in most of the patients in both FEP (87.5%) and CPD (80.8%) groups. Only 16% of them had worsened and there was no significant difference between the groups. In an earlier telephonic survey in patients with severe mental illness that included bipolar disorder, depressive disorder, schizophrenia, and schizoaffective disorder, 29.5% of them reported worsening.[28] In another study from China, deterioration was reported in 20.9% of the patients with preexisting psychiatric disorders related to the pandemic.[29] Clinical stability in our patients could be due to the fact that even prior to lockdown they were receiving regular follow-up care from outpatient services. Therefore, majority of them had adequate stock of medications. One-fourth (24%) of our patients reported nonadherence to medications during the lockdown. Three patients in the FEP group had completely stopped medications. Rates of nonadherence to medications in our patients are comparable to the rates of 22% reported by Shultz et al.[24] and 17.2% reported by Zhou et al.[29]

A large number of patients reported difficulty in access to a hospital (92%) and in contacting a doctor (64%). In India, to limit the spread of COVID-19, cities were divided into three containment zones based on the risk profiling of the areas. Green zones were those which had 0 confirmed cases in the last 21 days. Red zones (hotspots) were defined by total number of active cases, doubling rate of confirmed cases, extent of testing and surveillance feedback. The areas which were neither in the red nor in the green zone were classified as orange zones. Many of our patients were residing in red (27) and orange zones (18) which meant more restriction of movement that resulted in difficulty in accessing hospitals and doctors. Teleconsultation services at our hospital had started within a week of closure of outpatient services in line with guidelines for practicing telemedicine issued by Medical Council of India.[30] However, only four patients (8%) had utilized telepsychiatry services of the hospital. This could be due to low internet literacy, digital divide and low awareness of tele-consultation services. The online mental health services utilization in China has also been reported quite low (3.7%) by the general population.[31] This highlights the need for increasing awareness about such services. All the patients contacted for this study were facilitated to connect with the telepsychiatry services in the hospital by providing contact numbers. Disruption of access to care can have serious negative consequences in patients with severe mental illness.[8] This is especially relevant as even though the lockdown has been lifted, it would still take time to reinstate regular services.[32] Majority of our patients had either adequate stock of medications (84%) or could access a medical store for purchase of medications (74%). There was no significant difference between the two groups. This could be because during the lockdown, medical stores being an essential service were permitted to remain open for a limited period of time every day.

We assessed functioning in different domains and asked how they were functioning as compared to pre-COVID-19 pandemic and lockdown. Personal care routine activities and interpersonal relationships with family members had remained the same in most of the patients and no significant difference was found between the two groups. Interestingly, half of the patients in the FEP group had started doing household chores whereas there was no such change in patients in the CPD group. Similarly, many patients in the FEP group reported occupational (58.3%) and financial difficulties (70.8%), whereas no such change was reported in the CPD group. These differences could be because of long duration of illness[28] and persistent dysfunction in the CPD group even prior to the lockdown, and they were financially supported by thefamilies.[33] The patients in the FEP group were younger in age, had a lesser duration of illness and were more functional than the CPD group to begin with. For dealing with the difficulties in all the domains of functioning, most of the patients in FEP and CPD groups were using emotion-focused coping strategies like denial, taking no action or using an avoidant approach. Emotion-focused coping strategies are mainly directed at the management of one's emotion to handle the stressful situations.[34] However, only for dealing with medical care issues, CPD group used problem-focused strategies like information seeking, taking help from their support networks and anticipation. Problem-focused coping strategies are mainly directed at eliminating or reducing the stressors. It could be because of the long duration of illness and knowledge about need for continued medications, the patients and relatives in CPD group were familiar with how to procure and stock medications. It has been reported that persons with severe mental illness may find it difficult to cope with additional stress of disasters like pandemics.[9] It has also been seen that people with psychotic illnesses utilise more avoidant strategies and less problem-focused coping.[34] This finding of coping difficulties in various domains of functioning and use of emotion-focused coping strategies suggests that the patients with psychotic disorders may benefit by specific and brief psychosocial interventions to address the same.

For dealing with COVID-19, four preventive measures have been recommended: regular hand washing, using a mask, social distancing and staying at home. All the patients were following at least one preventive measure. However, both groups differed in the type of measures they followed. The patients in the CPD group had restricted their movement and were staying at home. As part of their illness, the CPD group are less active physically and have poor volition which may explain that they could follow the “staying at home” preventive measure. However, they were practicing other measures like hand washing, using a mask and social distancing less frequently than the FEP group. It was clear that the CPD group followed those preventive measures less frequently that required new learning and active behavior change. This could be due to the presence of persistent cognitive and negative symptoms in this group.[35] This issue has been discussed in literature that the social isolation and restriction of the movement caused by the psychotic illness overlaps the behavior change required during the pandemic and the two should be differentiated.[36] Most of the patients in the FEP group were able to follow all the measures. This shows that a shorter duration of illness and better functioning[37] as in the FEP group was an indicator of how much a person would be able to follow the recommended preventive measures. It is also important to provide information to patients with chronic mental conditions like psychotic disorders in a short, clear and step-wise manner.[38] They may also require assistance in following these measures.

The study addresses an understudied area of research. The implications of the study are useful not only in the context of a pandemic but postdisaster preparedness in patients with psychotic disorders in LMIC countries. Classifying patients into FEP and CPD groups rather than taking psychotic disorders as a homogenous group is another strength of the study. Coping was assessed using a semiqualitative methodology rather than categorical responses as it is a complex process and persons do not use only one strategy at a time.[39] Some of the limitations of the study were a small sample size, the use of a semistructured questionnaire whose validity and inter-rater reliability of the questionnaire was not established before use, lack of a control group of healthy individuals, convenience sampling technique and lack of utilization of functional assessment, coping or psychopathology scales.


  Conclusion Top


In this study, we found many patients reported difficulty in access to hospitals and in contacting a doctor. Clinical condition and medication compliance were maintained in the majority of them. More difficulties in domains of doing household chores, occupation and finances were experienced in the FEP group. Most of the patients and their caregivers were using emotion-focused coping to deal with these difficulties. All the patients were following at least one recommended preventive measure. The findings of this study suggest three important actionable points for dealing with issues related to COVID-19 pandemic in patients with preexisting psychotic disorders: early initiation of telepsychiatry services and widespread information about these, specific and brief psychosocial interventions to enhance problem solving coping and providing assistance and information about preventive measures in a short, clear, and step-wise manner.

Financial support and sponsorship

This study was funded by the National Institute for Health Research, UK (Project number: 16/137/107) and was part of NIHR Global Health Research Group on Psychosis Outcomes: the Warwick-India-Canada (WIC) Network comprising of Warwick University, UK; McGill University, Canada, and All India Institute of Medical Sciences, New Delhi in North India and Schizophrenia Research Foundation in South India. SPS is part funded by the NIHR Global Health Group WIC and by the West Midlands Applied Research Collaboration (ARC). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care

Conflicts of interest

There are no conflicts of interest.

Questionnaire

  1. What is the present status of the illness?
  2. Tell us about the problems that you have faced due to the COVID-19 pandemic and lockdown?


    • Medical care-availability of medications, medication compliance, accessing facilities and doctors
    • Personal care and routine
    • Relationship with others
    • Participation in household chores and occupation
    • Financial difficulties.


  3. How do you handle these problems?
  4. 4. There are preventive measures that have been recommended to prevent covid infection.


    • Frequent hand washing
    • Using mask
    • Social distancing




 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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