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 Table of Contents  
INVITED COMMENTARY
Year : 2020  |  Volume : 36  |  Issue : 5  |  Page : 151-153

Embracing uncertainty during COVID-19 times: Psychiatry training, research, and practices in an institute


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

Date of Submission04-Aug-2020
Date of Acceptance04-Aug-2020
Date of Web Publication02-Oct-2020

Correspondence Address:
Prof. Santosh K Chaturvedi
Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_251_20

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How to cite this article:
Chaturvedi SK, Pai NM, Singh N, Jha A. Embracing uncertainty during COVID-19 times: Psychiatry training, research, and practices in an institute. Indian J Soc Psychiatry 2020;36, Suppl S1:151-3

How to cite this URL:
Chaturvedi SK, Pai NM, Singh N, Jha A. Embracing uncertainty during COVID-19 times: Psychiatry training, research, and practices in an institute. Indian J Soc Psychiatry [serial online] 2020 [cited 2020 Oct 28];36, Suppl S1:151-3. Available from: https://www.indjsp.org/text.asp?2020/36/5/151/297148



The COVID-19 pandemic and the consequent lockdown has been a major disruption in lifestyle in general, and medical training and practice in particular. Here, we discuss the impact of the viral infection and the lockdown on the training of postgraduates and clinical services in the National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore.


  Clinical Services: Remediation, Redemption, and Restitution Top


Health-care systems were not prepared for this outbreak or the lockdown, even less so about its impact on mental health and persons with mental illnesses. During the lockdown, routine clinical services were suspended and only emergency services continued functioning round the clock. One of the unintended consequences of restricted movement and curtailed business included the closure of alcohol shops, and there was a steep upsurge in cases of severe alcohol withdrawal syndrome. Delirium tremens with or without seizures was the most common presentation, followed by alcohol withdrawal seizures and withdrawal hallucinosis during the initial period of the lockdown.[1] In accordance with the guidelines to be followed on the detection of suspected/confirmed COVID-19 case in a non-COVID health facility issued by the Ministry of Health and Family Welfare, a staffing plan was put in place. The mental health-care professionals (MHPs) were divided into groups to work on a rotation basis every 14 days and these groups were assigned individual wards, thereby minimizing the exposure of chronic in-patients; a group of backup staff was pooled in case some high-risk exposure of an MHP with suspected COVID-19 infection was detected including a contingency plan for such an event to maintain continuity of operations.[2] Hospital admissions were reduced by postponing elective admissions and only those who had any emergency were admitted.

Individual psychotherapy and family therapy services were halted as clinical psychology and psychiatric social work were not considered as essential services. The psychiatric rehabilitation services (PRS) which provide the day-care facility for persons with chronic mental illnesses and intellectual disabilities was also considered a nonemergency service and suspended, leading to deprivation of these services.[3] However, the tailoring section of PRS started stitching masks and personal protective equipment (PPE) for hospital personnel with the help of family members of NIMHANS staff, former employees, housewives, and volunteers.

The challenges in these circumstances, and how these were addressed, are described using the following anecdote by one of the junior residents (NS).

”A 42-year-old gentleman from another state was admitted before the lockdown with complex mental health issues for the management of anxiety, titration of medications, treatment of substance dependence and addressing rehabilitation needs. Pharmacological and nonpharmacological treatments, including psychological intervention, yoga and rehabilitation were initiated. However, the lockdown caused temporary cessation of these nonessential services, bringing his treatment to a standstill. Incidentally, he developed fever with sore throat, and suspecting COVID-19 infection he was quarantined for two weeks and shifted to the designated isolation ward. Frequent rotation of resident doctors, however, created difficulties in establishing sustained rapport-a problem which was accentuated by his personality. During the quarantine period, clinical communications were through E-mails and phone calls. His routine care was also affected by fear among the nursing staff and the need for social distancing. In an unfortunate turn of events, his mother, who had multiple medical illnesses, needed medical attention from a general hospital, which was organised. Initially, psychological interventions, yoga and rehabilitation were stopped, but later on-line psychological interventions were provided. He could not be discharged because of the lockdown, sealing of state borders and non-availability of any means of transport.”

A COVID-19 toll-free 24/7 national helpline for psychosocial support and mental health services was initiated to address the mental health and psychosocial needs of the general population. The institute initiated tracking of the patients through telephonic contact via the continuum of care program. This was in accordance with the telemedicine guidelines released by the Board of Governors (in supersession of the Medical Council of India) that enables the MHPs to provide services using technology.[4] A team of MHPs on a rotational basis called up patients from a dedicated telephone given for this specific purpose and did a brief follow-up and guided the patients to the nearest mental health services to enable them to procure medicines and avail other essential services. A message was sent across to all District Mental Health Psychiatrists (DMHP) in the state of Karnataka to provide medications to these patients who would contact them. Patients from outside the state were directed to the nearest mental health centers/DMHPs of their respective states based on the availability of these services.


  Training: the Journey of Transmutation Top


Educational and training activities including the didactic teaching and academic programs, both inter- and intradepartmental and scientific events such as CMEs and conferences, were suspended. The consultation-liaison services and external training of postgraduates which the department of psychiatry provided in liaison to the general hospitals in the vicinity of the institute were withdrawn. Departmental teaching programs were conducted via Zoom Video Communications or WebEx to ensure that the training needs continued to be met. Keeping in mind the role of telephonic follow-ups, simulated interviews and role-play for tele-objective structured clinical examination were conducted using the method of objective structured and clinical assessment and feedback.[5] However, due to restrictions on in-person group academics, we conducted this exercise through the Zoom Video Communications platform for the first time. Minor variations were needed, like the focus on paraverbal communication in place of nonverbal communication. Problem-based learning was also carried on by similar methods. We still need to work out how a mental state examination can be done on a patient with the mask on! How much masking happens in establishing rapport and doing psychological therapies would be newer challenges. In a lighter vein, we can now diagnose not only masked depression but also masked psychiatric disorders! Of course, there should be transparent masks, which will safely allow mental state examinations. Exit examinations for various postgraduation courses scheduled for April 2020 were postponed. Finally, residents seem to be already getting tired of the online classes, it's an acute burnout!


  Research: Turning on the Light Top


Data collection for all research studies was discontinued. Thesis and dissertation deadlines were extended. Research activities concerning retrospective chart reviews and those involving the use of several online survey platforms like SurveyMonkey.com and Google forms are on the rise. Investigators who were involved in national- or international-funded research projects asked for research pause from funders, which were, of course, granted.

Many research projects on the pandemic and impact of the lockdown on public and health-care workers have begun using online virtual methods or the use of telepsychiatry. The ethics committees are holding meetings through virtual methods and teleconsultations. The institute has circulated the National Guidelines for Ethics Committee reviewing Biomedical and Health Research during COVID-19 pandemic, prepared by the Indian Council of Medical Research.


  Administrative Tasks: Learning to Live With Pandemics Top


At the administrative level, all the faculty and residents were instructed to avoid travel and taking leave, except for emergency purposes. All important meetings including the faculty presentations and regular audit meets for the National Accreditation Board for Hospitals accreditation were held via online video communications. Students living outside the campus were permitted to work from home and departments ensured that at least 50% of their staff were available at work at all times. Face-recognition method was introduced to register attendance instead of contact-based finger biometric system as a precaution to prevent surface transmission.

For the safety and welfare of the trainees and the staff, every resident has been provided with suitable masks and hand sanitizers. Any resident or faculty who has come in contact with a suspected COVID-19 case has to go into self-quarantine for a period of 14 days, and if he/she shows any symptoms of COVID-19, he/she has to undergo testing for the same. For the purpose of quarantining the staff and residents, a designated area of the hospital and hostel were identified and facilities were provided. All the residents and staff underwent training in donning and doffing a PPE and handwashing and disinfection techniques. The nasal swab collection method was demonstrated and taught by an ear, nose, and throat specialist.

The Department of Psychiatry at NIMHANS has produced and released “Mental Health in Times of COVID-19: Guidelines for General Medical and Specialized Mental Health Care Setting.”[6] This publication comprehensively addresses the mental health concerns of the general public as well as those with psychiatric illness in these difficult times along with safety issues of psychiatrists and other mental health-care providers.

The COVID-19 pandemic has put the mental health institutes in an extraordinary situation, under extremes of pressures. MHPs face great ethical and moral dilemmas in terms of the decisions that need to be made including how to allocate available resources to equally needy patients, how to balance physical and mental health-care needs of MHPs with those of patients, and how to align one's desire and duty to patients with respect to those toward family and friends. There are chances of moral injury that has already been described in medical students who report great difficulty in coping with working in hospitals and emergency departments where they were exposed to risks that they felt unprepared for.[7] In Indian settings, the Sanskrit word “kim kartavya vimuda” describes the predicament of doctors – confusion about what is their duty and what they should do, save one at the cost of losing another!


  At Last, the Light Through the Crack Top


The well-being of the students and staff also needs to be addressed. Due to the lockdown, the common haunts of canteens, gyms, coffee shops, and cafes have closed down. There are hardly any physical or face-to-face interactions between professionals. The difficulties and the stigma faced by one of our residents who was quarantined has been well-documented through her (AJ) own account below.

”I had recently travelled back from another country and developed a sore throat and was referred for COVID-19 testing. This was back when people weren't on a never-ending lockdown and when the streets were bustling, flights were packed and business was as usual. Next thing I knew I was admitted, swabs were taken and my colleagues were being quarantined till my test results came back. Rumours were a resident with travel history has been admitted. People said “She was being irresponsible. She should have self-quarantined as soon as she had returned.” I remember being on a video call with my friends who were as confused and terrified as I was but were putting on a brave face to cajole me. The report came the same evening and much to my relief, it was negative. I was advised to hostel quarantine for 14 days. In the hospital, nurses were asking my friends to show them a picture of me; there was a circular handed over to the guard to check if I had fever periodically. My friends would drop my food at the door and I would eat my meals in solitude. Because of the looks that I got, I would often get up very early in the mornings to throw out my trash. When I returned to work, I was asked repeatedly if I had any symptoms, “Aren't you supposed to be in quarantine?” It wasn't what they said sometimes, it was how they said it, upset me. All the while, I knew that precaution is key and that in these situations, it is better to overreact than to be blissfully ignorant but if only they knew that a mental health care professional's mental health can also go for a toss in isolation.”

Institutions need to be prepared for any such events in future to be in a position to provide adequate and suitable training to students and clinical services to the patients. There have been unexpected gains from the situation, like holding online classes, seminars, and journal clubs. Telementoring can help take this forward. Tele follow-ups will reduce overcrowding in hospitals and clinics and save money and inconvenience for the patients and their caregivers, and a whole new area for qualitative and quantitative research opens up with these modifications. The future of psychiatry training, research, and practice has a novel excitement.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Narasimha VL, Shukla L, Mukherjee D, Menon J, Huddar S, Panda UK, et al. Complicated alcohol withdrawal-An unintended consequence of COVID-19 lockdown. Alcohol Alcohol 2020;55:350-3.  Back to cited text no. 1
    
2.
Guidelines to be Followed on Detection of Suspect/Confirmed COVID-19 Case in a non-COVID Health Facility. Available from: https://www.mohfw.gov.in/pdf/Guidelinestobefollowedond etectionofsuspectorconfirmedCOVID19 case.pdf 20. [Last accessed on 2020 April 29].  Back to cited text no. 2
    
3.
Chaturvedi SK. Covid-19, Coronavirus and mental health rehabilitation at times of Crisis. J Psychosoc Rehabil Ment Health 2020;7:1-2.  Back to cited text no. 3
    
4.
Board of Governors in Supersession of the Medical Council of India Telemedicine Practice Guidelines Enabling Registered Medical Practitioners to Provide Healthcare Using Telemedicine; 2020. Available from: https://www.mohfw.gov.in/pdf/Telemedicine.pdf 20. [Last accessed on 2020 April 29].  Back to cited text no. 4
    
5.
Chaturvedi SK, Chandra PS. Postgraduate trainees as simulated patients in psychiatric training: Role players and interviewers perceptions. Indian J Psychiatry 2010;52:350-4.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Mental Health in the Times of COVID-19 Pandemic: Guidance for General Medical and Specialised Mental Health Care Settings. Available from: http://nimhans.ac.in/wp-content/uploads/2020/04/MentalHealthIssuesCOVID-19NIMHANS.pdf 20. [Last accessed on 2020 April 29].  Back to cited text no. 6
    
7.
Greenberg N, Docherty M, Gnanapragasam S, Wessely S. Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ 2020;368:1-4.  Back to cited text no. 7
    




 

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