For 42-year old Neena* from Thiruvananthapuram, meeting with her psychiatrist has been a source of comfort in the past year. Diagnosed with bipolar disorder, Neena’s last appointment was supposed to be in the first week of March. However, her psychiatrist had suspended all sessions and consultations even ahead of the lockdown announced by the Kerala government last week.
"I spoke with my psychiatrist over the phone and he told me to double the dosage of my medication. But I am sceptical about doing so without meeting him in person," Neena tells TNM. "My anxiety has been really out of hand in the last couple of days. I don't know how long I will be able to handle this,” she added.
Neena, like many across the globe, is experiencing the mental health impact of the COVID-19 pandemic and the subsequent restrictions on movement and lockdowns. Those with pre-existing mental health issues have found themselves in a tough spot due to difficulties in accessing counselling, mental healthcare and psychiatric medication.
Bengaluru-based Sudha* started working from home around two weeks ago. She usually buys her psychiatric medication from a pharmacy near her workplace, which is around six kilometres away from her residence. “If I drive to my regular pharmacy, I fear the police may stop me and question me. It is not easy to get psychiatric medication from another pharmacy because the staff is often judgmental, suspicious or unwilling to give the medication unless they know you. Besides, many do not even stock psychiatric medication,” she tells TNM.
Dr Satish Ramaiah, a consultant psychiatrist with People Tree Maarga Hospital in Bengaluru, has been receiving frantic calls from his patients over the past week as they are unable to buy medications. Further, Gautam Saha, a psychiatrist and President-Elect of the Indian Psychiatric Society, explains, “A retail shop or a pharmacy cannot sell medication based on an old prescription.”
Further, Dr K Raju, former Secretary of Kerala Mental Health Authority, observes that where pharmacies could earlier give a month’s worth of medication to patients with a prescription, due to the lockdown and subsequent issues, pharmacies are now are only able to sell a week’s dose at a time.
Sudha finally managed to buy her medication from a nearby pharmacy, which, she says, will last for a few days. “Since my prescription has a week left on it, I was able to buy my medications. The pharmacist said that he may have more stock in a couple of days, but he is not sure for how long. This worried me as my parents, who are also on psychiatric drugs, will not be able to get their dose,” she says.
Dr Gautam warns that being unable to take medication can put psychiatric patients or those with serious mental health issues in jeopardy. “Even a few skipped doses can lead to a full-blown relapse.”
Many families in India are still unaware or unsupportive of a member’s mental health needs, compelling the latter to seek mental healthcare, including medication, furtively. The lockdown, however, has made this difficult.
For instance, Sudha's parents are unaware that she is on psychiatric medication. “Usually, my parents buy all supplies. So I had to use the excuse that I felt too cooped up and had to get out of the house to buy my medication,” Sudha says.
Dr Satish acknowledges that this is a problem for many patients. “In this time, when people have no option but to stay with families, we have been trying to get families on board with the patient’s consent. We counsel the families and usually, they understand. If they don’t, it becomes a sensitive situation.”
Despite the lockdown, people are allowed to step out in case of emergencies, including medical emergencies and for essential services. And while most of the Psychiatry Outpatient (OP) units in Kerala are functioning, they aren’t in many other places. The National Institute of Mental Health Sciences (NIMHANS) in Bengaluru, which sees patients from all over the country, has shut its outpatient services.
Further, many patients are unable to travel as all public transport and taxi services have been suspended. “A lot of patients from Tamil Nadu depend on centres in Kerala and now they have no option but to skip reviews and follow-ups. Some elderly patients are scared to step out due to the fear of contracting the infection,” says Dr K Raju.
“For those with anxiety disorders, it adds to their fears of being stuck or stranded. This is also a particularly difficult time for people who have separation anxiety or those who have addictions,” says Dr Anil Prabhakaran, head of the Psychiatry at Government Medical College Hospital in Thiruvananthapuram. Recently, seven people in Kerala took their lives due to the non-availability of alcohol due to the lockdown. Being unable to access mental health services at this time, makes them all the more vulnerable.
The Indian mental healthcare sector has been taking some steps to address some of the issues.
Gautam tells TNM that the Indian Psychiatric Society (IPS) will send a letter to the Union Ministry of Health and Family Welfare (MoHFW) to allow teleconsultation and telemedicine amid the lockdown and to prevent people in the near future from crowding hospitals and clinics, so as to keep up with social distancing protocols. “We are also pushing for online counselling or over the phone across the country,” he says.
IPS has also released guidelines for teleconsultation and telemedicine for mental health professionals based on existing MoHFW guidelines. The local medical councils have a say in the matter. The Karnataka Medical Council (KMC) for instance, on March 27, recommended that practitioners and patients follow a set of guidelines for consultation through video link, phone or internet if the practitioner thinks the patient need not be examined.
Both KMC and IPS have said that practitioners should not prescribe drugs that are under schedule X or are psychotropic substances listed in the Narcotic and Psychotropic Substances Act 1985, as they have high abuse value. Three prescriptions are required for schedule X medicines – one should be with the patient, one with the doctor and one with the chemist. The prescription should be dated, and bear a time (not just the month).
KMC’s guidelines also say that electronic prescriptions should be on a letterhead of the practitioner who has their KMC registration number.
The good news is that Schedule H drugs – commonly used in psychiatric medication – have now been allowed in e-prescriptions per IPS’s guidelines. Earlier, Schedule H drugs could only be sold on a physical prescription basis.
“The government should now direct chemists to give these medicines for a refill with an e-prescription of a doctor, which is the only possible way during the lockdown. Of course, the chemist can cross-check the prescription with the practitioner with the contact number provided,” Dr Anil says.