I was attending to an old patient of mine when Sheila, the staff nurse, barged into my consulting room and said anxiously: “Doctor, we have an emergency; there is a 21-year-old who has recently recovered from Covid-19 and has now tried to kill himself. He is waiting in the emergency room.” I hurriedly finished the consultation and went to see the patient. As I began gathering the history from him and his parents, it became increasingly clear to me that his presentation was secondary to Covid-19, and that it was not a primary psychiatric disorder.
The youth had got Covid-19 eight weeks ago and was convalescing at home for the last two weeks. Around that time, he had started to hear strange buzzing sounds every once in a while. These had become more acute in the last one week. He had now started to hear his closest friend’s voice that commanded him to kill himself. And today he had tried to hang himself in response.
Psychiatrists are now routinely seeing clinical presentations that are secondary to Covid-19. Uncertain prognosis, an acute shortage of resources for testing, unprecedented public health measures that curtail personal freedom, economic recession, and uncertainty about the future are among the major stressors that are contributing to the widespread emotional distress, and increased risk for psychiatric illnesses associated with Covid-19. Those with an anxious temperament have found themselves being more prone to obsessive doubts about getting Covid-19. Many had developed the obsessive-compulsive disorder, too, in the face of this pandemic. Some of the commonly encountered obsessions include fear of getting Covid-19, obsessive thoughts about infecting loved ones, fear of being quarantined, not having access to timely treatment, and fear of death. I have had people compulsively checking the news to get a real-time update about Covid-19. I have also seen people getting repeatedly tested, and seeking reassurance from physicians at fever clinics.
Covid-19 has provided a fertile ground for the explosion of common mental health disorders such as depression and anxiety. Home-confinement directives, like quarantine, that are necessary to minimise viral spread, have had a negative psychological impact, such as causing post-traumatic stress disorder symptoms, depression and insomnia. Layoffs from work and economic recession have been associated with a long-lasting decline in mental health.
Chronic loneliness brought on by social isolation during the pandemic is another major concern. People who have been given the option to work from home routinely complain about not being productive at work. They also talk about missing office conversation over a cup of coffee. At the other end of the spectrum are people who have understandable fears of being unable to reconnect with their work colleagues once the pandemic subsides.
Covid-19 is also responsible for neuropsychiatric syndromes such as delirium and stroke. Increasingly, young people are arriving at the emergency room with unexplained strokes. I was called to attend to a 25-year-old woman who had been presented with progressive difficulty in speech, crying spells, emotional outbursts, and numbness and weakness in the left arm and leg. The attending physician had made a note of cough, headache and chills lasting one week before this hospitalisation. This patient had delayed seeking emergency care because of fear of Covid-19. A CT scan showed obstructed blood flow in a large brain artery, and a chest scan revealed typical features of Covid-19. Social distancing, isolation, and delayed decision-making to seek help result in poorer prognosis in such patients.
I have been increasingly seeing Covid-19 patients having delirium in the intensive care units of general hospitals. Fatima (name changed) was a 56-year-old primary school teacher who had got Covid-19 from her husband. She was progressively worsening with little improvement in her clinical status. One day I received a call from the doctor-on-call at a general hospital where I consult. “Fatima is speaking incoherently,” said the doctor. “She has been seeing ants and lizards on the walls of the ICU. She also complains of a foul odour. She is not recognising her family anymore.” We soon realised that she had slipped into delirium. Delirium is a psychiatric emergency characterised by an acute onset of confusion. An April 2020 study in France found that approximately 65 per cent of people who had a more severe form of Covid-19 had developed confusion—a defining and hallmark feature of delirium. The data of 2,000 Covid-19 patients presented at the annual meeting of chest physicians in America showed that a staggering 55 per cent had developed acute onset confusion and disorientation. These are unprecedented numbers and something that the medical fraternity is not routinely used to. A single episode of delirium can increase the risk of developing dementia years later. Conversely, people with underlying dementia are more prone to develop episodes of delirium. This becomes pertinent in the context of the elderly population with multi-morbidity, being more prone to develop severe Covid-19.
Health care workers are particularly vulnerable to emotional distress during this pandemic. Long working hours donning personal protective equipment, and being involved in emotionally fraught decisions, take a huge toll on the mental health of doctors.
Exercise, regular sleep, nutritious food and a strong mental health support system become imperative to deal with the psychological ramifications of Covid-19.
Kulkarni is a senior psychiatrist at Manas Institute of Mental Health, Hubli, Karnataka.