Problems shared in psychiatry helpline of a teaching hospital in eastern Nepal during COVID-19 pandemic lockdown

Novel Coronavirus 2019-nCoV, irst identi ied in December 31, 2019 in Wuhan city of Hubei in China causes the disease called COVID-19. It soon spread rapidly worldwide and WHO has to declare it a Public Health Emergency of International Concern in January 30, 2020 and a worldwide pandemic in March 11, 2020. It affected almost all countries with a great morbidity and death toll. Majority of the infected people manifest with simple symptoms of fever, cough and short of breath; some develop severe pneumonia, renal and multiorgan failure requiring ICU management [1,2]. The pandemic has brought a wide range of effects, e.g. shutdown of business and transport, lockdown and mental stress. General public have continuously been bombarded with confusing, and often divergent, messages about COVID-19 leading to panicky situation [3]. Abstract

It is an institute based period observation noted for all psychiatry helpline calls during 1 week of lockdown days of COVID-19. Their concerns and problems were listened and symptoms clarifi ed by a consultant psychiatrist to help them as far as possible through the telephonic conversation. Maintaining the confi dentiality, basic information were noted down in a semistructured proforma to record certain socio-demographic and clinical information (including mood and other emotional symptoms).
We received 102 helpline calls of 60 clients for psychiatry in 1 week, from 14 districts. More patients being discussed were males (35/60), average age being 34.15 (15 -70) years. More patients were regular follow-up cases with some new issues (24/60) and 18/60 each were new clients and regular follow-up cases. Majority had exacerbated symptoms in the wake of COVID-19 as: emotional (47/60; mood 24/60, anxiety/worry 23/60) symptoms along with disturbed sleep (32/60); treatment/service issues (31/60) and changed routines. Most common mental problems were Bipolar aff ective disorder, Psychosis, Anxiety and Depression and advices included Antipsychotics, Benzodiazepines, Antidepressants, along with some Psycho-education. Most common concerns were about OPD service, worsening symptoms and local unavailability of medicines. Many had mood and emotional symptoms in this stressful time, both simple amenable to telephonic advices and severe requiring to be called to emergency service.

Nepal situation
The irst case was detected positive in Nepal in January 23, 2020 in a person who had returned from Hubei of China [4]. There has been constant news of ever increasing morbidity and mortality by the pandemic affecting China and India, all other SAARC countries along with almost all nations. This country with one of the poorest development index status has been panic stricken due to certain realities and challenges e.g. test facility, resource de iciencies for Isolation, Quarantine, hospital service, Ventilators, PPE, masks, sanitation measures etc. Many Nepalese abroad workers returned home and apparently they are less health literate, making them threat for other people. Almost together with its bordering country India, Nepal government also declared for nationwide lockdown in March 24, 2020 which was later extended in phased manner.

Stress and eff orts during lockdown
During lockdown; boarders were sealed, all public and other vehicles were prohibited, of ices and facilities were closed except certain 18 listed essential emergency services and people were made to stay inside home. It was necessary strategy which has been pointed out to have been late by many public health experts, considering the nature of the pandemic. It needs to be backed up with other strategies of WHO guidance/ recommendation [5]. Though there have been some meager efforts in some places by local government, the government support packages seem inadequate in such a havoc situation. Even health service providers were panic stricken due to grossly inadequate safety measures and facilities to provide essential health care. For health service provider institutes and system, it was other great challenge to pursue essential health service in such a pestilence time. The government demanded all health professionals to be in duty. Emergency services were in great threat and risky business for health service providers. Health institutes best put efforts to help needy people by various strategies including: information displays, media coverage about the changed service patterns, and starting up helplines facilitating physical distancing.

Helpline: a useful strategy
Health Institutes started up with helplines for needy clients. Public soon accepted and started utilizing this easy, accessible and ready medium of seeking help for their health problems. It does not involve infection risk though the caller has to bear the cost of call. B. P. Koirala Institute of Health Sciences (BPKIHS), a multi-specialty tertiary teaching institute with daily OPD loads reaching 3500-4000 cases and with 850 bed capacity [6] has to con ine its service to dire essential and emergency services during the lockdown period. This article is being prepared while we are still in the continued lock down.

Methodology
The institute had 15 helplines (later others added) from 8 AM to 5 PM for various specialties; including Psychiatry, particularly intended for this COVID-19 period. This author was scheduled in rotation in Department of Psychiatry for 1 week (March 20 -April 4, 2020) as a consultant psychiatrist in direct advising position in the helpline. In the calls, their concerns were clari ied and addressed as far as possible in telephonic conversation. Maintaining their anonymity and con identiality, basic information were noted down in a semistructured proforma to record certain socio-demographic and clinical information including reason for call and symptoms for all the calls during 1week of lockdown days.

Our clients
In this institute based period observation; we had 102 helpline calls of 60 clients from 14 districts including 2 Indian residents for psychiatry in 1 week. More callers were self (16/60), fathers (11/60) and brothers (8/60) of patients. More patients being discussed were males (35/60), average age being 34.15 (15 -70) years. Out of them, 18/60 were new clients, 18/60 regular follow-ups and 24/60 old with some new issues.

Their problems
Many had exacerbated symptoms in the wake of COVID-19 in the form of: emotional symptoms 47/60 including mood (24/60) and worry/ anxiety (23/60), disturbed sleep (32/60), treatment/service issues (31/60) and changed routines. Most common mental problems (we use ICD-10 criteria here) were Bipolar affective disorders, Psychosis, Anxiety and Depression. This diagnostic pro ile with preponderance of Bipolar picture and presentation patterns were similar to one reported from same institute during stressful situation of armed con lict [7] ( Table 1).
Most common call concerns were about OPD service, increased/worsening symptoms, and inquiry of services and local unavailability of medicines (Table 2).
Advices included: Antipsychotics, Benzodiazepines, and Antidepressants, along with some Psycho-education.

Lessons learned
During stress and disaster period, different mental problems emerge, both recurrent and new ones, mainly including mood and anxiety disorders. The emotional/ psychological symptoms were because of the impact of severe life/stress on the psychological defences or exacerbation of previous symptoms in stressful times [8]. In 2015 [9], it was natural disaster earthquake in Nepal, this time, a worldwide pandemic. Both are stressful with emotional problems and we are struggling hard to tackle.
Many of the suffering people had simple issues and mild mood and emotional symptoms amenable to telephone helpline advice whereas many severe ones (13/60) needed to be called in emergency service.

Recommendations
Though this is a single centre short period single service provider observation, this might be useful for further planning and policy making. The helpline should be continued till there is need, along with coordination for transfer to emergency service for needy severe cases. In such a needy period, client friendly and need based packages need to be offered to facilitate helpline calls.