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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 108-110

Challenges in geriatric mental health delivery during the COVID-19 lockdown in India: Illustration using a case report


Department of Psychiatry, Geriatric Psychiatry Unit, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India

Date of Submission25-Jun-2020
Date of Decision04-Jul-2020
Date of Acceptance22-Jul-2020
Date of Web Publication21-Jan-2021

Correspondence Address:
Dr. Migita M D’cruz
Department of Psychiatry, Geriatric Psychiatry Unit, National Institute of Mental Health and Neurosciences, Bengaluru - 560 029, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jgmh.jgmh_28_20

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  Abstract 


The COVID-19 pandemic and the global/local response to it have placed the mental health of older adults disproportionately at risk. We illustrate the challenges in geriatric mental health care during the COVID-19 lockdown in India using a case report. Mr. S, a 65-year-old man, developed very late-onset schizophrenia-like psychoses in January 2020. While his illness is not novel, the pandemic accentuated his distress and led to barriers in accessing elective mental health care. Social inequity including economic disparity and digital literacy amplified barriers in accessing care. In the meantime, he developed suicidal ideation and attempted self-harm, which was averted. Mr. S was finally able to access subsidized government mental health care in June 2020 and is recovering. However, we argue that the barriers to treatment and consequent delay in care in the context of the pandemic are worth addressing.

Keywords: COVID-19, geriatric mental health, health-care barriers, SARS-CoV2, social inequity


How to cite this article:
D’cruz MM. Challenges in geriatric mental health delivery during the COVID-19 lockdown in India: Illustration using a case report. J Geriatr Ment Health 2020;7:108-10

How to cite this URL:
D’cruz MM. Challenges in geriatric mental health delivery during the COVID-19 lockdown in India: Illustration using a case report. J Geriatr Ment Health [serial online] 2020 [cited 2021 Mar 3];7:108-10. Available from: https://www.jgmh.org/text.asp?2020/7/2/108/307586




  Introduction Top


Older adults are disproportionately at risk due to the COVID-19 infection. The physical distancing and shelter in place directives as part of the global response to the pandemic is also more stringent in their regard. The cessation of nonessential health-care services during the lockdown also disproportionately affects older adults, who represent 45.2' of the top 10' of health-care utilizers in the USA, despite making up only 13.5' of the population. In India, older adults make up 8' of the population, and 10' of state expenditure is on health care for older adults.[1],[2] These factors act together to impact geriatric mental health adversely while also pose challenges in the delivery of mental health services. We illustrate these challenges in India using a case report.


  Case Report Top


Mr. S, a 65-year-old man, married, with high school education is employed as a supervisor in government-run agricultural industries. He has nil significant past, personal, or family history with the exception of long-standing marital discord. In January 2020, he first developed delusions of persecution and reference, with second- and third-person auditory hallucinations with derogatory content (people commenting adversely upon his character and work). These symptoms worsened over January and February in the context of uncertainty and anxiety over the pandemic and reported feeling worried about how COVID-19 may affect his life and became withdrawn.

In March 2020, he was placed on unpaid leave, along with other employees, as per government instructions during the lockdown in India. This unpaid leave was part of the state response to the COVID-19 pandemic and was neither part of his delusion nor due to his mental health condition. There was a worsening of psychotic symptoms associated with worry over potential unemployment, the loss of income, isolation from his social and occupational circle, loneliness, worry about his vulnerability to the coronavirus infection, and boredom at home. Increased contact with his wife also meant that there was a flare of marital discord. He interpreted physical distancing while using public transport and in shops as people avoiding him due to the derogatory rumors spread about by his persecutors. During this period, he began acting out and often approached neighbors to ask them why they were avoiding him and spreading unsavory rumors. There was also a decline in sleep, appetite, and self-care.

He confided about his distress in his nephew, who decided to help him seek mental health consultation. However, outpatient psychiatric services were closed in the city he lived in by the end of March 2020 due to the lockdown. Telepsychiatry services were available as an alternative to in-person consultations during the lockdown, but the family had limited digital literacy, rendering them unable to utilize this alternative. Private in-person psychiatry services were resumed in May 2020, but the family was unable to afford this and waited for government inpatient psychiatry services to resume in June 2020.

During this period, Mr. S's psychotic symptoms and emotional distress worsened. He developed death wishes and suicidal ideation and attempted to hang himself at the end of May 2020, in response to a command from his auditory hallucinations, which was fortunately averted by his family.

Outpatient psychiatry consultation was resumed on June 1, 2020, in our government hospital, and the patient was able to avail of care. He was evaluated and diagnosed with very late-onset schizophrenia-like psychoses, as per the consensus of the International Late-Onset Schizophrenia Group.[3] However, we would like to note that this consensus has not yet found its way to diagnostic manuals. Thus, our patient would qualify for a diagnosis of paranoid schizophrenia, continuous (F20.00), as per the tenth revision of the International Classification of Diseases and Related Health Problems (ICD-10). He would qualify for a diagnosis of schizophrenia, first episode, currently in acute episode (295.90) as per the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.

Neuro-imaging, hemogram, serum biochemistry, thyroid function tests, cyanocobalamin, folate levels, and electrocardiogram were unremarkable. He was started on risperidone 2 mg and clonazepam 0.5 mg with antisuicidal precautions and addressal of expressed emotions in the family. With these, there was a remarkable improvement in the patient's psychotic symptoms over the next 3 days as followed up over the phone, and he is no longer suicidal. W6e believe that the late age of onset, relatively short duration of untreated psychosis, and treatment naiveté of the patient may have been positive prognostic factors and mediated a relatively rapid response to psychotropic. Addressal of expressed emotions in the family, antisuicidal precautions, addressal of occupational stability, and phased emergence from the lockdown may also have been contributory toward mitigating the precipitating psychosocial factors.

At subsequent follow-up, through telepsychiatry (video conference) at 2 weeks, our patient had attained symptomatic remission while adherent to treatment. At another follow-up, also through telepsychiatry at 4 weeks, the patient continued to maintain remission while adherent but had not yet returned to work as he did not feel ready yet. However, he has been assured of employment security at his workplace.


  Discussion Top


While the presentation of our patient is not unremarkable, the barriers he and his family faced due to the COVID-19 lockdown in India are noteworthy.[4],[5] In addition, affordability, digital illiteracy, and expressed emotions played a role in accentuating barriers to care through social inequity. He may have developed a mental illness irrespective of COVID-19, but the pandemic and the national response to it Heightened his distress. Through this anecdotal report, we would like to make a case for targeted community outreach to underprivileged older adults with mental health vulnerabilities.[6]

Two decades after the release of the National Policy for Older Persons, 1999, and at the outset of the WHO Decade of Healthy Ageing 2020–2030, much of health care including mental health care for older adults remains on the article. The higher risk to older adults during the COVID-19 pandemic (especially in India, which is currently third in case count, worldwide), consequent social distancing, and their reverse quarantine may lead to greater vulnerability to mental illness when compared to younger and middle-aged adults. Older adults, as in our patient's case, also find it more difficult to access health care and face more barriers to care currently, with hospitals discouraging visits.

We would like to suggest that primary health care (PHC) and the District Mental Health Program (DMHP) be used effectively to reduce rather than increase barriers to health care during this turbulent period. Accredited social health activists and the psychiatric social worker under the DMHP may be engaged in screening for mental health during other community visits during the pandemic, particularly in older adults, and provide subsequent liaison with PHC centers and district hospitals. This would be of particular use in underprivileged areas or those with poor access to health care such as urban slums and rural areas. Households with older adults living alone may be identified as vulnerable, and neighbors and community leaders will be guided in checking in on them. State governments have identified vulnerable older adults to provide food security and other essential items to varying degrees. During such provision, a quick check on the health and well-being of older adults and earmarking those who may require medical care might be useful.

Provision of contact details of the district mental health team and helplines for older adults (the NIMHANS helpline for older adults is one such service) prominently in public places, health announcements, and vernacular media would ensure that more underprivileged older adults are able to receive such information. Providing older adults priority in transportation, registration and queues would expedite their health care while minimizing their waiting time and hence (risk of exposure to infection). Digitization of health services may not benefit older adults with limited digital literacy, though telephones and other audiovisual media can be used as an alternative for outreach.

Mental health professionals may screen for depressive, anxiety, or psychotic symptoms, loneliness, social isolation, understimulation, death wishes, suicidal ideation, decline in mobility, orientation, and worsening of the behavioral and psychological symptoms of dementia. These are the mental health concerns which have been reported to be on the rise in older adults during the pandemic and lockdown, and a rapid check for these during a consultation may be cost-effective.

We recognize that the health-care system is struggling to cope with the pandemic but believe that it would be possible to incorporate some of our suggestions for older adults into public health care at minimal expenditure and human resource outlay, if integrated into disease control. Of course, any contact with older adults should be carried out with due precautions as recommended by the WHO and Government of India. However, we would wish to make a case for physical, rather than social distancing, so that older adults are effectively part of our response to the pandemic.

Guidelines and resource material from the WHO, International Psychogeriatric Association, Lancet Psychiatry, Government of India, and NIMHANS may be useful in tailoring mental health care to older adults during the pandemic in the Indian context.[7],[8],[9]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Andrade C. COVID-19 and lockdown: Delayed effects on health. Indian J Psychiatry 2020;62:247-9. Available from: http://www.indianjpsychiatry.org/text.asp?2020/62/3/247/284459. [Last cited on 2020 Jun 04].  Back to cited text no. 1
    
2.
Vahia IV, Blazer DG, Smith GS, Karp JF, Steffens DC, Forester BP, et al. COVID-19, mental health and aging: A need for new knowledge to bridge science and service. Am J Geriatr Psychiatry 2020; Available from: https://www.ajgponline.org/article/S1064-7481(20)30271-2/abstract. [Last cited on 2020 Jun 04].  Back to cited text no. 2
    
3.
Howard R, Rabins PV, Seeman MV, Jeste DV. Late-onset schizophrenia and very-late-onset schizophrenia-like psychosis: An international consensus. The International Late-Onset Schizophrenia Group. Am J Psychiatry 2000;157:172-8.  Back to cited text no. 3
    
4.
Armitage R, Nellums LB. COVID-19 and the consequences of isolating the elderly. Lancet Public Health 2020;5:e256. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7104160/. [Last cited on 2020 Jun 04].  Back to cited text no. 4
    
5.
Agarwal P. COVID-19: In urban India, the elderly are grappling with hunger and fears of dying alone. Scroll 2020;. Available from: https://scroll.in/article/961004/covid-19-in-urban-india-the-elderly-are-grappling-with-hunger-and-fears-of-dying-alone. [Last cited on 2020 Jun 04].  Back to cited text no. 5
    
6.
Morrow-Howell N, Galucia N, Swinford E. Recovering from the COVID-19 pandemic: A focus on older adults. J Aging Soc Policy 2020;26:1-9. Available from: https://www.tandfonline.com/doi/full/10.1080/08959420.2020.1759758. [Last cited on 2020 Jun 04].  Back to cited text no. 6
    
7.
WHO. COVID-19: Resources for Care for Older Persons; 2020. Available from: https://www.who.int/maternal_child_adolescent/links/covid-19-mncah-resources-care-for-older-persons/en/. [Last cited on 2020 Jul 07].  Back to cited text no. 7
    
8.
COVID-19 Resource Page. International Psychogeriatric Association; 2020 Available from: https://www.ipa-online.org/news-and-issues/covid-19-resources. [Last cited on 2020 Jun 17].  Back to cited text no. 8
    
9.
Department of Psychiatry. Mental Health in the times of the COVID-19 Pandemic. NIMHANS; 2020. Available from: https://nimhans.ac.in/wp-content/uploads/2020/04/MentalHealthIssuesCOVID-19NIMHANS.pdf. [Last cited on 2020 Jun 17].  Back to cited text no. 9
    




 

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