Management of Schizophrenia in COVID-19 Pandemic via Telepsychiatry

Introduction

Globally mental, neurological and substance abuse disorders (MNSUD) are a major public health problem accounting for the great burden of disease and disability. About 10-20% of adolescents are suffering from mental health disorders worldwide [1]. Schizophrenia is a severe mental disease affecting 20 million people globally [2]. About 69% of people suffering from schizophrenia are not receiving treatment and 89% of them are residing in lower-middle-income countries [3]. In India, mental disorders are the leading cause of the non-fatal disease burden. One in seven Indians were suffering from mental disorders of varying severity in 2017 [4]. The lifetime prevalence of schizophrenia and other psychotic disorders in the Indian population is 1.4% [5]. Urban adolescents have higher mental morbidity than their rural counterparts [5]. The symptoms of half of the mental disorders appear among teenagers by fourteen years of age [6]. The usual age of onset of schizophrenia is 15-35 years [7]. It affects the ability of adolescents to learn and reach their full potential. It causes disability and affects both educational and occupational performance. They are at risk for many other health problems and are 2-3 times more likely to die early [8]. These adolescents face discrimination, marginalization and social exclusion.

Mental disorders are often hidden by society due to stigma which hampers the person with ill mental health to seek care. In India, a wide treatment gap exists for various mental disorders, e.g., tobacco use - 91.8%, common mental disorders - 85% and psychotic disorders including schizophrenia -75.5% [5]. The majority of the patients with schizophrenia go to government facilities (60.9%) for treatment [5]. The median duration for seeking care from the onset of symptoms for schizophrenia is 4 months and patients may travel up to 30 km for consultation [5]. The long distance from the health facility and associated travelling costs put a burden on the family. A study reported that patients with schizophrenia who live far away from the medical facility were more likely to have longer hospital stays than those living closer [9]. The family bears the social, economic and emotional burden of treatment and caring for the adolescent with a mental disorder. The COVID-19 pandemic has widened the gaps and increased the barriers. Telehealth can address the unique challenges posed by the pandemic [10]. Teleconsultation services may help to bridge the treatment gap and improve adherence.

Study setting

The department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India has a rural health post at a village in Haryana to provide ambulatory promotive, preventive and curative health services The multipurpose health workers (MPHW) provide domiciliary care through home visits and organisation of health post based and community based activities. The junior resident doctors pursuing their postgraduate course in Community Medicine and senior resident doctors (those who have joined after passing their MD Community Medicine) visit the problem families as identified by the health worker to assess and provide solutions to improve the health problem under discussion with the concerned faculty. During one problem house visit, the resident doctors came across an adult female with a history of mental illness having symptoms of disoriented behaviour, muttering and smiling to herself.

Introduction of the Case

A 22 years old female, Shankari (name changed) was apparently alright 5 years ago. She was studying in 12^th standard at a government school. She was good at studies and was preparing for board exams. She liked singing devotional songs (bhajan). Suddenly, she developed sleep disturbances and began smiling to herself without any reason. She appeared indifferent to her family and surroundings. Her interest in studies declined. Her friends in the school avoided talking to her. She stopped showing interest in going to school and skipped classes. Within a few weeks, her symptoms worsened. She became suspicious about her family members and that they would harm her. She had a low appetite and skipped meals. She stopped interacting with her family and appeared aloof. On asking the reason, she did not reply with any low mood or negative thoughts. She spoke very little but irrelevant stuff. The symptoms continued for two months.

Family History

She lived in a seven-membered joint family. Her Grandfather was a priest (purohit) and her father is a farmer. The grandmother and mother were homemakers. She had two younger brothers who attended school with her. Her 15-year-old brother was rude, short-tempered and used to quarrel with the neighbours. He fought with a local man and caused grievous bodily injuries to him. He was arrested by the police and sent to a juvenile home. Within a few days, Shankari developed the symptoms of her illness.

Her youngest brother was suffering from epilepsy since the age of 6 years. He was on treatment from Civil Hospital and was taking a tablet of phenytoin and folic acid daily. Her grandmother was a known patient of coronary artery disease and was on follow-up in the non-communicable disease (NCD) OPD of our rural health post. The mother was diagnosed with extrapulmonary tuberculosis and was taking treatment at the Civil Hospital, Panchkula.

Birth and development history

There was no history of any prenatal exposures or obstetrics complications. She was born via normal vaginal delivery in a government hospital. She received breastfeeding for 6 months and was completely immunized. Her growth and developmental milestones were on par with her peers.

Personal history

She had good personal hygiene. She brushed her teeth and took bath daily. Self-care was adequate. As per 24 hours recall method, the patient was taking a vegetarian diet deficit in both calories (46%) and protein (30%), against the recommended calories and proteins for her age and weight.

Socio-economic status and environmental history

She belonged to a middle-class family according to the Udai Pareek Scale. They had a refrigerator, motorcycle and one-acre land. She lived in a kutcha pucca house with a sanitary latrine. There were three bedrooms with inadequate ventilation. The kitchen was separate. The cowshed was adjacent to their home. They had four cows and two buffaloes. Fly infestation was present in the environment.

Treatment seeking behaviour

She was taken to a local registered medical practitioner (RMP) who referred her to a psychiatrist in Civil Hospital. They went to Civil Hospital, Panchkula which is 35 km away from the village. The psychiatrist assessed her and told them that she was suffering from mental illness. She was diagnosed with schizophrenia and started on medication. The psychiatrist told them that the medicine needed to be continued for many months. After the initiation of treatment, her symptoms improved within a few weeks. She became interactive and went back to school. The teacher motivated her to appear for the 12^th standard board exams. She appeared for the exam but could not pass it.

Problems in follow-up

They went to the civil hospital for follow-up regularly for four months. Later they discontinued the follow-up visits as the hospital was far away and had a long waiting period. For the next 12-15 months, they bought medicine from the local pharmacy without a prescription and then discontinued it. At that time, she had no difficulty in sleep or loss of appetite.

Impact of discontinuation

Over the next few months, her interaction with the family members declined. She showed no interest in continuing school. She stayed at home and helped with household work. When MPHW, went to their house, the family said that Shankari was fine. Slowly she withdrew socially, spent most of the time in her room and spoke very little. She wandered away from the house 2-3 times and was brought back. She maintained this pattern till 2 months ago when she started having sleep disturbances. She developed symptoms of muttering and smiling to herself. She would appear aloof and stop interacting with family members. She did mistakes in the household work and threw utensils. She ran away from the home again and was brought back by her family members.

Examination

She was thin-built and had mild pallor. Her weight was 48 kg, height was 158 cm and body mass index was 19.2 kg/m². She was wearing clean clothes. In the mental status examination, eye contact was present. She was smiling for no reason. Anxiety and persecutory ideas towards the family members were present. Her speech was reduced. There was an abnormal flow of thought and the connection between statements was difficult to follow. Visual hallucinations were present. She had poor judgement and insight i.e.; she did not understand the outcome of her behaviour and was not aware of her illness. However, the cognitive functions were within normal limits.

Management

An appointment for teleconsultation was made in the department of Psychiatry at PGIMER with the help of resident doctors and MPHW. As the family was not comfortable using a smartphone, the MPHW assisted them during teleconsultation. A video call was conducted via WhatsApp. A detailed history was taken and a mental assessment was done by the psychiatrist at PGIMER Chandigarh. She was prescribed the atypical antipsychotic tablet risperidone 2mg/day. The family was counselled about the diagnosis and lifelong treatment. They were told about the side effects of the medicine. The resident doctors highlighted the importance of daily medication and regular follow-ups. They asked her grandmother to supervise the intake of medicine by Shankari. The family was asked to encourage and train her to do daily activities and household work.

Follow-up

After 3 weeks of treatment, Shankari’s interaction with the family members improved. She was taking medication on time and slowly started doing household work. She stopped running away from home. Over the next five months, three more teleconsultation appointments were arranged by the MPHW. But the family attended only one of them. The resident doctors of community medicine visited her home to assess her health status. She conversed with the resident doctors and maintained eye contact while talking. She was taking medicine regularly. The family was encouraged by resident doctors for psychiatry follow-up. After seven months, the family decided to visit a private psychiatrist in Yamunanagar. The psychiatrist started her on olanzapine 10 mg, trihexyphenidyl hydrochloride 2 mg and minocycline 100 mg. They visit the private clinic monthly for follow-up.

Discussion

Schizophrenia is a chronic mental illness. It has multiple risk factors viz. prenatal exposure to infection, stress, nutrition, obstetric complications, childhood trauma, urban birth, migrants, adolescent, cannabis use etc [11]. Certain events can trigger the development of schizophrenia in people at risk. Here, we are presenting the potential risk factors that may have contributed to the development of the illness.

Third trigger - ill health of the mother

Her mother developed severe weakness, pain abdomen and low appetite two months ago. She was diagnosed with extra-pulmonary tuberculosis and hospitalized. This caused Shankari to worry about her mother and the subsequent deterioration of symptoms.

We have applied the Health Belief Model (HBM) to understand the perceptions of the family regarding her mental illness and mental healthcare services utilization behaviour (Figure 1) [12]. This model is based on a socio-cognitive perspective that proposes that people are likely to follow a health-related behaviour when they believe that disease will have serious consequences, the intervention will be effective and there are few barriers to taking action.

Acknowledgements

We would like to thank Mrs. Jagdeep Rana, Multipurpose Health Worker, Department of Community Medicine and School of Public Health, PGIMER, Chandigarh for her help in the teleconsultation services and follow-up with the patient.

References

1. World Health Organization. Adolescent mental health. WHO 2020:1. Available From: https://www.who.int/news-room/fact-sheets/detail/adolescent-mental-health (accessed July 5, 2021).
2. James SL, Abate D, Abate KH, Abay SM, Abbafati C, Abbasi N, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392:1789–858. [Google Scholar]
3. Lora A, Kohn R, Levav I, McBain R, Morris J, Saxena S. Service availability and utilization and treatment gap for schizophrenic disorders: a survey in 50 low- and middle-income countries. Bull World Health Organ 2012;90:47. [Google Scholar]
4. Sagar R, Dandona R, Gururaj G, Dhaliwal RS, Singh A, Ferrari A, et al. The burden of mental disorders across the states of India: the Global Burden of Disease Study 1990–2017. The Lancet Psychiatry 2020;7:148–61. [doi:10.1016/s2215-0366(19)30475-4]
5. Gururaj G, Varghese M, Benegal V, Rao G, Pathak K, Singh L, et al. National Mental Health Survey of India, 2015-16: Prevalence, patterns and outcomes. Bengaluru: 2016. [Google Scholar]
6. Kessler RC, Angermeyer M, Anthony JC, DE Graaf R, Demyttenaere K, Gasquet I, et al. Lifetime prevalence and age-of-onset distributions of mental disorders in the World Health Organization’s World Mental Health Survey Initiative. World Psychiatry 2007;6:168–76. [Google Scholar]
7. Sadock BJ, Ahmad S, Sadock VA. Kaplan & Sadock’s pocket handbook of clinical psychiatry. 6th ed. Philadelphia: Wolters Kluwer; 2019. [Google Scholar]
8. Laursen TM, Nordentoft M, Mortensen PB. Excess Early Mortality in Schizophrenia. Annu Rev Clin Psychol 2014;10:425–48. [doi:10.1146/annurev-clinpsy-032813-153657]
9. Tseng KC, Hemenway D, Kawachi I, Subramanian SV, Chen WJ. Travel distance and the use of inpatient care among patients with schizophrenia. Adm Policy Ment Health 2008;35:346–56. [doi:10.1007/s10488-008-0175-x]
10. Kasckow J, Felmet K, Appelt C, Thompson R, Rotondi A, Haas G. Telepsychiatry in the Assessment and Treatment of Schizophrenia. Clin Schizophr Relat Psychoses 2014;8:21. [doi:10.3371/csrp.kafe.021513]
11. Clarke MC, Kelleher I, Clancy M, Cannon M. Predicting Risk and the Emergence of Schizophrenia. Psychiatr Clin North Am 2012;35:585–612.. [doi:10.1016/j.psc.2012.06.003]
12. Henshaw EJ, Freedman-Doan CR. Conceptualizing mental health care utilization using the health belief model. Clin Psychol Sci Pract 2009;16:420–39. [doi:10.1111/j.1468-2850.2009.01181.x]
13. Ministry of Law and Justice. The Gazette of India Extraordinary. The Mental Healthcare Act 2017. New Delhi: 2017. [Google Scholar]
14. Ministry of Health and Family Welfare. eSanjeevaniOPD -SAFE HOME OPD National Teleconsultation Service-MoHFW 2020. https://esanjeevaniopd.in/ (accessed July 12, 2021).
15. Casares M, Wombles C, Skinner HJ, Westerveld M, Gireesh ED. Telehealth perceptions in patients with epilepsy and providers during the COVID-19 pandemic. Epilepsy Behav 2020;112:107394. [doi:10.1016/j.yebeh.2020.107394]