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 Table of Contents  
ORIGINAL ARTICLES
Year : 2021  |  Volume : 9  |  Issue : 3  |  Page : 77-81

Psychiatric morbidities in inpatients of COVID-19 in dedicated COVID hospitals


1 Seven Hills Dedicated Covid Hospital, Mumbai, India
2 Department of Community Medicine, HBTMC and Dr RN Cooper Hospital, Mumbai, Maharashtra, India

Date of Submission06-Aug-2021
Date of Acceptance11-Oct-2021
Date of Web Publication11-May-2022

Correspondence Address:
Smita S Chavhan
Department of Community Medicine, HBTMC and Dr RN Cooper Hospital Mumbai, U 15, Bhaktivedanta Swami Road, JVPD Scheme, Juhu, Mumbai, Maharashtra 400056
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/dypj.dypj_50_21

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  Abstract 

Objectives: We aimed to assess (a) the prevalence of psychiatric illness in inpatients of COVID-19 and (b) different types of psychiatric morbidities. Materials and Methods: This hospital-based cross-sectional study was done in a dedicated COVID hospital after an Institutional Ethics Committee approval. It was a cross-sectional observational study of all patients admitted from December 2020 to May 2020 after ethical committee clearance. A total of 1535 patients were referred, and 1452 (8.2%) were diagnosed with psychiatric illnesses by using clinical interview and diagnostic questionnaire based on Diagnostic and Statistical Manual for Mental Disorders Fifth Edition criteria. Results: Out of the 17,676 patients admitted during this period, 1,452 (8.2%) patients were diagnosed with psychiatric illness, out of them 1,233 (6.9%) had new onset psychiatric illness. The age (mean±SD) of the patients was 59.75±16.46 years. The majority [959 (66.1%)] of the patients were males and 493 (33.9%) were females. Psychopharmacotherapy and psychological interventions were done to help patients through this crisis. Duration of stay (mean±SD) was 16.86±10.4 days and 636 (43.8%) patients had comorbidities. Conclusion: The prevalence of psychiatric illness was 8.2% in inpatients of COVID-19. Common psychiatric morbidities in COVID-19 inpatients are depression, anxiety disorders, adjustment disorders, and delirium.

Keywords: Anxiety, COVID-19, depression, psychiatric morbidity


How to cite this article:
Joshi R, Chavhan SS, Dhikale PT, Adsul B, Kumbhar M, Gokhale CN, Ingale AR, Pawar P. Psychiatric morbidities in inpatients of COVID-19 in dedicated COVID hospitals. D Y Patil J Health Sci 2021;9:77-81

How to cite this URL:
Joshi R, Chavhan SS, Dhikale PT, Adsul B, Kumbhar M, Gokhale CN, Ingale AR, Pawar P. Psychiatric morbidities in inpatients of COVID-19 in dedicated COVID hospitals. D Y Patil J Health Sci [serial online] 2021 [cited 2022 May 27];9:77-81. Available from: http://www.dypatiljhs.com/text.asp?2021/9/3/77/345104




  Background Top


The world has been going through an unprecedented crisis over the past one and half years. When the outlook is all bloom and doom, even most optimistic among us find it difficult to remain cheerful. Due to uncertain nature of COVID-19 infection, people are vulnerable to develop mental health problems. The pandemic has created a state of feeling on edge and an apprehension about future in the people’s mind. Various reasons are cited for an individual to get predisposed for developing mental turmoil during this crisis period. The safety factors of the pandemic such as strict adherence with lockdown, social distancing, quarantine, excessive cleanliness, and its secondary effects have caused a major impact on mental health.[1]

Consultation-liaison psychiatry has been one of the most requested services in the face of this pandemic. We aimed to assess (a) the prevalence of psychiatric illness in inpatients of COVID-19 and (b) different types of psychiatric morbidities.


  Materials and Methods Top


Study setting

The study was done in a dedicated Covid hospital.

Study design and population

It was a cross-sectional observational study of all patients admitted from December 2020 to May 2020 after ethical committee clearance. A total of 1535 patients were referred, and 1452 (8.2%) were diagnosed with psychiatric illnesses by using clinical interview and diagnostic questionnaire based on Diagnostic and Statistical Manual for Mental Disorders Fifth Edition criteria. Patients were assessed in blocks and intensive care units by face-to-face interaction using personal protective equipments. Detailed evaluation in collaboration with family members was done using teleconsultation services available in hospital settings. Delirium (21.9%) was the commonest diagnosis, followed by depression (20.19%), anxiety (16.8%), and adjustment disorder (13.86%), respectively.

Statistical analysis

Data entry was done by using Microsoft Excel version 2010, and statistical analysis was done using descriptive statistical methods.


  Results Top


The age (mean±SD) of the patients was 59.75±16.46 years (as shown in [Table 1]). The majority [959 (66.1%)] of the patients were males and 493 (33.9%) were females. Out of the 17,676 patients admitted during this period, 1,452 (8.2%) patients were diagnosed with psychiatric illness (as shown in [Table 2] and [Figure 1]). Psychopharmacotherapy and psychological interventions were done to help patients through this crisis. The duration of stay (mean±SD) was 16.86±10.4 days. About 636 (43.8%) patients had comorbidities.
Table 1: Age distribution of patients with psychiatric morbidities

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Table 2: Types of psychiatric morbidities

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Figure 1: Types of psychiatric morbidities

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  Discussion Top


The common psychiatric morbidities in COVID-19 inpatients are depression, anxiety disorders, adjustment disorders, and delirium. In our study, we found many of the patients had delirium. Etiology of delirium is multifactorial. The inflammatory response to critical illness includes release of cytokines, prothrombotic state, reduced cerebral blood flow, direct central nervous system invasion, induction of CNS inflammatory mediators, secondary effect of other organ system failures.[2],[3] Effect of sedative strategies, prolonged mechanical ventilation time, immobilization, and unfortunate environmental factors including social isolation and quarantine without family are known factors.[4],[5]

In our setting, the majority of the patients referred for complaints of irrelevant talks and behavioral problems were old age having problems with hearing and vision. Also they were presented late to seek medical help leading to more O2 requirement, with deranged blood parameters and also with co-morbidities such as diabetes mellitus, hypertension, ischemic heart disease, and chronic kidney disease. During the initial phase, there were no orientation protocols in intensive care units. Nursing staff were inadequately trained to follow the orientation protocols because of a sudden surge in cases. In intensive care unit settings, it was difficult to follow sleep hygiene methods as frequent blood investigation and continuous monitoring were required. This may have led to an increase in the number of delirium cases.

One of the common psychological disturbances reported was depression and the prevalence was found to be 20.19%. Deprivation in basic needs, financial crisis, uncertainty of the current situation, away from home, lack of emotional support, and aging have put many individuals at risk of developing the core depressive cognition of hopelessness and helplessness. Most of them were having guilt feeling after contracting illness and they were asking for reason why they landed up in this situation in spite of following all the protocols as per guidelines. Cancellation of functions, vacations, and business plans also added misery in the situation. Emotional exhaustion, low mood, fatigue, worries about future and family, restlessness, loss of interest, irritability, and disturbed sleep are common symptoms being reported, which on continuation for a prolonged period has led to suicidality.[6]

People were having anxious preoccupations about precautions they failed to take in the past, there was worry regarding getting infected again, they were preoccupied with thought of family members getting affected by COVID-19, and concerns about personal belongings acting as fomites for spread in home or locality were there. People were worried about walking in corridors and interaction with people due to fear of contagion. Intense fears of open spaces, crowd, and any gatherings were also observed. We reported 16.8% of anxiety cases, 4.1% of panic attack cases, phobia of 0.3% of the total cases.

As frequent handwashing and cleanliness is advised as an important measure to prevent coronavirus, there is a raising concern that it may worsen and cause a new surge in the prevalence of obsessive compulsive disorders. We diagnosed five (0.9%) people with diagnosis of obsessive compulsive disorder.

When compared with other disaster situations such as earthquake and cyclone, this disaster is different as enemy is invisible. The impact of pandemic is continuous when compared with other disasters in which impact is single time. The invisibility of enemy also multiplies the fears irrationally, thereby causing scary images and catastrophic consequences in mind. This has caused a surge in trauma and stress-related disorders and hence adjustment disorder was the third most common psychiatry diagnosis with prevalence being 13.86%; we also found acute stress reaction in 1.1% and post-traumatic stress disorder in 0.9% of the cases.

Psychosis was found to be linked to viral exposure, treatments used to manage the infection, and psychosocial stress. Prevalence of psychosis has shown a marginal increase. We reported 4.75% of total cases of schizophrenia and related psychosis. There is moderate (if low quality) evidence to suggest that a small but important number of patients will develop coronavirus-related psychosis.[7]

We noted illness anxiety disorder (1.6%) growing rapidly with COVID-19 in which fear of having acquired already or will develop the illness led to experience of intense fear associated with constantly searching for symptoms of illness, repeated doctor’s visits, and request for corona testing to rule out the illness. It can be inferred that symptoms of somatic symptom disorders rise as people come in close proximity with COVID-19 patients.[8]

Because of isolation and separation, it was difficult for people to go through process of grief reaction. Many were cremated immediately even without the presence of loved ones and later with few relatives. The farewell is muted largely. There is no complete closure and grief reaction (2.9%) was associated with intense pain and guilt.

Other psychiatric diagnoses enlisted included sleep and related disorders (4.5%), bipolar disorder (1.1%), dementia (1.6%), alcohol use disorder (1.6%), and polysubstance use disorder (0.3%). Patients with known psychiatric illness are experiencing exacerbation of their symptoms. Feeling no control of the situation and reporting dissatisfaction with the response of the state during the COVID-19 pandemic and reduced interaction with family and friends increased the worsening of pre-existing psychiatric conditions.[9] One of the most important factors identified was non-availability of medication and inability to go for a regular follow-up due to quarantine. It is reported that the important reason for relapses in patients with bipolar disorder and schizophrenia is due to difficulty in both the availability of regular medications and medication compliance. The overwhelming anxiety due to quarantine can precipitate paranoia and nihilistic ideation in already affected individuals.[10] The impact of pandemic has increased the suicidal tendency particularly in patients with mood disorder and substance use disorder.[11]

Low mood, insomnia, and restlessness can be the initial transient emotional response to the stressful event of getting COVID-19 and admission to hospital for which the primary treating doctor might have referred them to the psychiatry liaison, but on detailed clinical evaluation and interviewing, we did not find persistent low mood, insomnia, or other symptoms amounting to psychiatric diagnosis and the symptoms had already been resolved, and hence there is difference between proportion of referred and diagnosed patients with. The primary treating doctors in COVID-19 ward are not trained enough for detailed psychiatric assessment. Forty-five patients among referred patients had no psychiatric diagnosis.

Pharmacotherapy and psychotherapy both were given to patients. General psychosocial measures such as sleep hygiene, removal of misconceptions related to COVID-19, and reassurance were advised to patients. Specific psychosocial intervention such as relaxation techniques, teaching distraction techniques, and supportive counselling to help alleviate anxiety, depression, and negative emotional responses was done. Family members of patients were given supportive counselling using smartphones. Telepsychiatry, which used to account for a small portion of psychiatric services, has become the new norm.[12] A similar transition to telemedicine is also underway for consultation-liaison services and even for inpatient psychiatry units.[13]


  Conclusion Top


The common psychiatric morbidities in COVID-19 inpatients are depression, anxiety disorders, adjustment disorders, and delirium. The COVID-19 pandemic is changing the face of psychiatry permanently. Upcoming challenges such as inadequate closure in case of grief reaction, interpersonal conflicts, slowing of economy, and catastrophic health expenditure will be significant. In order to serve the needs of our patients and of society, psychiatrists and researchers will need to remain active, forward-thinking, and ready to adapt to new situations. Telepsychiatry, which used to account for a small portion of psychiatric services, has become the new norm. A similar transition to telemedicine is also underway for consultation-liaison services and even for inpatient psychiatry units.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chakraborty N The COVID-19 pandemic and its impact on mental health. Prog Neurol Psychiatry 2020;24:21-4.  Back to cited text no. 1
    
2.
Xu J, Zhong S, Liu J, Li L, Li Y, Wu X, et al. Detection of severe acute respiratory syndrome coronavirus in the brain: Potential role of the chemokine mig in pathogenesis. Clin Infect Dis 2005;41:1089-96.  Back to cited text no. 2
    
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Lau KK, Yu WC, Chu CM, Lau ST, Sheng B, Yuen KY Possible central nervous system infection by SARS coronavirus. Emerg Infect Dis 2004;10:342-4.  Back to cited text no. 3
    
4.
Maldonado JR Delirium pathophysiology: An updated hypothesis of the etiology of acute brain failure. Int J Geriatr Psychiatry 2018;33:1428-57.  Back to cited text no. 4
    
5.
Vasilevskis E, Pandharipande P, Graves A, Shintani A, Tsuruta R, Ely EW, Girard TD Validation of a modified Sequential Organ Failure Assessment (SOFA) score incorporating the Richmond Agitation-Sedation Score (RASS) to assess neurologic end-organ function. Am J Respir Crit Care Med 2013;187:A1551.  Back to cited text no. 5
    
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.  Back to cited text no. 6
    
7.
Brown E, Gray R, Lo Monaco S, O’Donoghue B, Nelson B, Thompson A, et al. The potential impact of COVID-19 on psychosis: A rapid review of contemporary epidemic and pandemic research. Schizophr Res 2020;222:79-87.  Back to cited text no. 7
    
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Nicomedes CJ, Avila RM An analysis on the panic of Filipinos during COVID-19 pandemic in the Philippines.  Back to cited text no. 8
    
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Gobbi S, Plomecka MB, Ashraf Z, Radziński P, Neckels R, Lazzeri S, et al. Worsening of pre-existing psychiatric conditions during the COVID-19 pandemic. Front Psychiatry2020;11:1407.  Back to cited text no. 9
    
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Chatterjee SS, Barikar C M, Mukherjee A Impact of COVID-19 pandemic on pre-existing mental health problems. Asian J Psychiatr 2020;51:102071.  Back to cited text no. 10
    
11.
Sher L The impact of the COVID-19 pandemic on suicide rates. QJM 2020;113:707-12.  Back to cited text no. 11
    
12.
Spivak S, Spivak A, Cullen B, Meuchel J, Johnston D, Chernow R, et al. Telepsychiatry use in U.S. Mental Health Facilities, 2010–2017. Psychiatr Serv 2020;71:121-7.  Back to cited text no. 12
    
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Greenhalgh T, Wherton J, Shaw S, Morrison C Video consultations for covid-19. Br Med J 2020;368:m998.  Back to cited text no. 13
    


    Figures

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    Tables

  [Table 1], [Table 2]



 

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