Impact of lockdown and health anxiety during COVID 19 pandemic among inpatients of a psychiatric hospital: an observational study

Abstract

Sir, Among several strategies to fight against the current ongoing COVID-19 pandemic, India adopted lockdown on 23rd March 2020. Impact of mental health has been enormous during virus outbreaks or pandemics. Lockdown has a similarity with quarantine which has an unpleasant experience due to loss of freedom, restriction of movement, boredom. In addition to this, quarantine has negative effect on mental health like post-traumatic stress symptoms, confusion, and anger. Several factors like longer quarantine duration, infection fears, frustration, boredom, inadequate supplies, inadequate information, financial loss, and stigma played role as stressors (Brooks et al., 2020). During current ongoing COVID 19 pandemics too, people of this planet are facing “collateral damage” both due to the pandemic itself and responses to it like lockdown (Tandon, 2020). Research have found emerging adverse psychological outcomes, increased loneliness, depression, anxiety. Health anxiety, loneliness and reduced social support are among few others which could be directly or indirectly linked to this pandemic and lockdown (Courtet et al., 2020; Tull et al., 2020). Not surprisingly, few studies and review have shown that during COVID-19 pandemic and lockdown persons with pre-existing mental illness report worsening of psychiatric symptoms or development of anxiety, depression, stress, suicidal ideation, impulsivity, insomnia or post-traumatic stress disorder (Fernandez-Aranda et al., 2020; Zhou et al., 2020; Qiu et al., 2020; Vindegaard & Benros, 2020; Hao et al., 2020; Brooks et al., 2020). While most of them are on psychiatric treatment on out-patient basis, those who are on inpatient care might deserve special attention as they are far from their homes and families and their illnesses are presumably in symptomatic phase which further make them vulnerable to pandemic and lockdown. To our best of knowledge, no study has examined impact of COVID-19 pandemic and lockdown among admitted inpatients of a psychiatric hospital. Hence our study was aimed to examine impact of lockdown, health anxiety and depression among inpatients of a psychiatric hospital during lockdown in India. After approval from institute ethics committee, a hospital based cross-sectional study was conducted at a psychiatric hospital located in India. All inpatients were approached for the study. Data was collected during month of June and July in 2020. Those inpatients who were 1) having active psychotic symptoms in recent mental state examination as recorded in case record file of the inpatient and/or 2) were undergoing electroconvulsive therapy and/or 3) refused to give informed consent were excluded from the study. Thus, 60 inpatients were included in the study. Sociodemographic and clinical details were recorded with a pre-designed semi-structured data sheet. The Clinical Global Impression-severity (CGI-S) (Guy, 1976) was applied to measure severity of illness among participants. A predesigned questionnaire Impact of Lockdown questionnaire (IOLQ) which was adapted from the Impact of Event Scale -Revised (IES-R) (Weiss and Marmar, 1997) was used to assess impact of lockdown. The Impact of Event Scale (IES-R) is one of the most widely used self-report measures to assess subjective distress caused by traumatic events. IOLQ was developed for assessing PTSD like symptoms. After serial interviews with patients, a questionnaire was developed. The IOLQ had 16 items with 5-point Likert scoring with 0 = Not at all; 1 = A little bit; 2 = Moderately; 3 = Quite a bit; 4 = Extremely. The items were as follows – 1) How often you think about the lockdown? 2) Thoughts of it caused me to have physical reactions, such as sweating, trouble breathing, nausea, or a pounding heart, 3) Does it trouble your sleep? 4) Do you often think about the welfare of your family? 5) Often, I get weepy thinking about my family, 6) I felt irritated and angry when lockdown was being extended, 7) I avoided letting myself get upset when I thought about it or was reminded of it, 8) I tried not to think about it, 9) I had trouble concentrating, 10) I remain apprehensive about further extension of the lockdown, 11) I always try to reassure myself from the staff about the end of lockdown, 12) I keep updating myself from TV or newspapers about it, 13) I get angry upon my family members of not taking any initiative for discharging me, 14) I get overwhelmed when other fellow patients get discharged, 15) I keep on thinking about my future once I return home, and 16) I often wish that the lockdown would never had have happened. The Health Anxiety Inventory-18 (HAI-18) (Salkovskis et al., 2002) and Patient Health Questionnaire -9 (PHQ-9) (Spitzer et al., 1994) were administered to assess health anxiety and depression, respectively. Analysis was done with Statistical Packages of Social Science (SPSS) version 25 for Windows. Table 1 describes sociodemographic and clinical profiles of inpatients participated in the study. Comparison between male and female and among diagnoses have been shown. Table 1 Sociodemographic and clinical profile of inpatients (N = 60). Table 1 Characteristic n (%)/ Mean (SD) Age (years) 31.45 (9.34) Sex Male 35 (58.3) Female 25 (41.7) 

 Religion Hindu 55 (91.7) Muslim 4 (6.7) Others 1 (1.7) 

 Residence Rural 42 (70.0) Urban 15 (25.0) Semi urban 3 (5.0) 

 Education Educated 46 (76.7) Uneducated 14 (23.3) 

 Occupation Employed 17 (28.3) Unemployed 43 (71.7) 

 Marital status Married 32 (53.3) Unmarried 22 (36.7) Divorced/ separated 6 (10.0) 

 Primary psychiatric diagnosis Affective psychosis 28 (46.7) Non affective psychosis 22 (36.7) Substance use disorder 10 (16.7) 

 History of psychiatricillness Present 20 (33.3) Absent 40 (66.7) 

 Family history of psychiatric illness Present 7 (11.7) Absent 53 (88.3) 

 Monthly income (INR) 10133.33 (8727.93) Distance of residence 319.60 (177.92) Duration of stay in hospital (months) 3.28 (0.74) Age of onset (years) 24.66 (9.44) Duration of illness (months) 59.1 (69.58) CGI-S 1.68 (0.83) IOLQ 33.53 (9.81) PHQ-9 6.71 (5.40) HAI -18 57.00 (27.05) Malen/Mean (SD) Femalen/Mean (SD) df/z χ2/t/U p Age (years) 30.31 (7.23) 33.04 (11.65) -0.33 415.00U 0.74 Religion Hindu 31 24 2 3.93f 0.07 Muslim 4 0 Others 0 1 

 Residence Rural 27 15 2 2.31f 0.33 Urban 7 8 Semi urban 1 2 

 Education Educated 27 19 1 0.01 1.00 Uneducated 8 6 

 Occupation Employed 15 2 1 7.09y 0.008** Unemployed 20 23 Marital status Married 18 14 2 2.42f 0.27 Unmarried 15 7 Divorced/ separated 2 4 

 Primary psychiatric diagnosis Affective psychosis 17 11 2 12.38f 0.002** Non affective psychosis 8 14 Substance use disorder 10 0 

 History of psychiatricillness Present 11 9 1 0.13 0.78 Absent 24 16 

 Family history of psychiatric illness Present 5 2 1 0.11y 0.73 Absent 30 23 

 Monthly Income (INR) 9957.14 (7394.72) 10380.00 (10473.45) -0.97 373.00U 0.33 Distance of residence (kms.) 350.17 (184.43) 276.80 (162.37) -1.90 311.50U 0.05 Duration of stay (months) 3.03 (0.68) 3.63 (0.69) -3.52 214.00U <0.001*** Age of onset (years) 21.88 (6.04) 28.56 (11.85) -2.02 302.50U 0.04* Duration of illness (months) 64.68 (78.89) 51.29 (54.53) -0.73 388.50U 0.46 CGI-S 1.45 (0.85) 2.00 (0.70) -3.23 241.00U 0.001** IOLQ 31.82 (10.08) 35.92 (9.09) 58 -1.61 0.11 PHQ-9 5.48 (5.60) 8.44 (4.70) -2.83 249.00U 0.004** HAI-18 47.65 (28.95) 70.08 (17.51) 58 -3.44 0.001 ** Affective Psychosis Non-affective Psychosis Substance Use Disorder Religion Hindu 25 22 8 4 5.41f 0.15 Muslim 2 0 2 Others 1 0 0 

 Residence Rural 19 16 7 2 0.93f 1.00 Urban 7 5 3 Semi urban 2 1 0 

 Education Educated 18 19 9 2 4.03f 0.16 Uneducated 10 3 1 

 Occupation Employed 9 0 8 2 22.95f <0.001*** Unemployed 19 22 2 

 Marital status Married 16 13 3 4 5.10f 0.24 Unmarried 11 6 5 Divorced/ separated 1 3 2 

 History of psychiatricillness Present 19 1 0 2 28.96f <0.001*** Absent 9 21 10 

 Family history of psychiatric illness Present 4 2 1 2 0.43f 0.86 Absent 24 20 9 

 Age (years) 32.67 (9.77) 31.09 (10.19) 28.80 (5.49) Monthly Income (INR) 9714.28 (9544.65) 9431.81 (6418.52) 12850.00 (10954.57) Distance of residence (kms.) 336.60 (192.15) 312.72 (166.25) 287.10 (173.46 Duration of stay (months) 3.23 (0.67) 3.58 (0.82) 2.76 (0.41) Age of onset (years) 26.25 (11.00) 25.00 (7.69) 19.50 (6.75) Duration of illness (months) 23.61 (49.27) 74.96 (63.50) 123.60 (76.74) CGI-S 1.64 (0.62) 2.00 (1.10) 1.10 (0.31 IOLQ 31.46 (8.43) 32.27 (10.68) 42.10 (7.30) PHQ-9 5.25 (4.91) 7.68 (4.95) 8.70 (6.97) HAI-18 49.78 (24.52) 60.31 (27.06) 69.90 (30.20) * Significant at 0.05 level. ** Significant at 0.01 level, CGI-S: Clinical Global Illness- severity of illness, IOL: Impact of Lockdown questionnaire, PHQ-9: Patient Health Questionnaire, HAI-18: Health Anxiety Inventory. f Fisher’s exact test. y Yate’s continuity correction. Spearman’s correlation revealed distance of home was negatively corelated with PHQ-9 (ρ = -0.26, p < 0.05). CGI-S score was positively corelated with HAI-18 scores (ρ = 0.27, p < 0.05). IOLQ score was positively corelated with both PHQ-9 (ρ = 0.49, p < 0.01) and HAI-18 (ρ = 0.38, p < 0.01). Participants of our study were young adults mostly hailing from rural area and affiliated to Hinduism which followed existing demographic pattern of India. Considering mean duration of illness of approximate 60 months, their illness could be termed ‘chronic’ one. Mean CGI-S score indicates that during time of data collection their severity of illness reduced to near ‘normal’ according to measure applied (Guy, 1976). Lower severity of illness presumably due to their mean duration of stay and treatment of approximate three months in the institute would have an advantage to speculate that effect of psychopathology on impact of lockdown and health anxiety might be minimal. Mean PHQ-9 score of 6.71 indicates presence of mild depression among the participants (Kroenke et al., 2001). High health anxiety was observed among inpatients (Salkovskis et al., 2002). Our findings that female inpatients suffered from depression and health anxiety more than males might be explained by their higher severity of illness. This is in accordance with earlier research during current and past epidemics where females were found to have greater psychological impact than males (Taylor et al., 2008; Qiu et al., 2020; Zhang et al., 2020b; Ozdin and Bayrak Ozdin, 2020). Though non-affective psychosis has significantly higher severity of illness, patients with substance use disorder diagnosis had experienced most impact of lockdown. As they were free from psychosis, we can speculate their functioning returned earlier than other group of inpatients and thus became aware of lockdown to much more extent than other groups of inpatients. Similarly, they had experienced highest health anxiety among all groups. Inpatients with higher severity of illness experienced higher health anxiety which might be explained by their more severe psychopathology. Those who had higher impact of lockdown were more likely to suffer from depression and higher health anxiety. Those having higher health anxiety also were more likely to suffer from depression. Inpatients who came from distant home address were less likely to suffer from depression which was against our presumption. This might be due to heterogeneity of inpatients having different diagnosis which might have a bearing on this. Our study suffered from limitations. We did not have any healthy control group which did not allow for comparison of findings. Where pandemic to this extent is uncommon in occurrence, a qualitative approach would have complemented the results of this study. Contributorship statement SK, SB and CRJK conceived the work. RRS, RK, SK and SB collected data. SK drafted the manuscript. SKM critically appraised the manuscript. All authors except CRJK approved the final manuscript. Financial disclosure Nil source of funding. Declaration of Competing Interest The authors report no declarations of interest.