Summarising how NGOs providing mental health outreach services to marginalised and vulnerable populations in India adapted care services during the ‘new normal’, Dr Sapna Nair, Research Fellow – Health, LEAD at Krea University and Dr R Padmavati, Director, Schizophrenia Research Foundation (SCARF, India) make critical recommendations, including the importance of framing care policies and programmes for the mentally ill population within administrative and disaster planning strategies, particularly the need to integrate housing, transportation and medication for people with mental illnesses
COVID-19 caused disruptions in services to the mentally ill in several countries across the globe. While these disruptions have been well-documented, few studies have looked at the service provider perspective. Mental health outreach services to marginalised and vulnerable populations in India have been pioneered by NGOs and it is important to understand how these organisations adapted care services during the ‘new normal’. A recent study by LEAD at Krea University and the Schizophrenia Research Foundation explored care dynamics from the perspective of the service providers at SCARF, based in Chennai, Tamil Nadu. The organisation provides mental health care services for a range of mental disorders.
The two initial ‘lockdown’ weeks
Services were disrupted with the nationwide lockdown in March 2020, and guidelines were released by the Government to transition to tele-medicine, to ensure continuity of care. The practice of tele-psychiatry has raised concerns involving patient dynamics, proper diagnosis and legal issues but has been successful in some contexts. Services to the rural and older population, which was always problematic, worsened during the pandemic.
In the two weeks of complete lockdown, all services were affected, after which essential services related to care could be resumed. Non-essential services like outreach, training, research and mass awareness programmes were partially resumed on digital platforms. From the service provider perspective, two areas of concern were the discontinuation of the medications dispensed from the centre and the change in circumstances of the patients. Moreover, the service providers faced additional barriers in navigating the changed routines and managing their care responsibilities.
Accessibility, availability and personal challenges
Access to all mental health care services was affected during the early lockdown because patients could not physically access the centre’s services due to restrictions. Obtaining psychotropic medications, a standard of care for those with chronic mental illness, was challenging for most patients, as not all neighbourhood pharmacies stocked these medications, and if they did, some pharmacists were reluctant to dispense them. For some patients, especially in rural and district borders, restrictions on movement were particularly challenging.
The non-availability of medication resulted in worsened outcomes, especially in conditions like schizophrenia or mood disorders, often necessitating in-patient care. However, the pandemic restricted admissions because of concerns of possible spreading of COVID-19.
The service providers had to also respond to multiple contextual issues faced by the families. Discharged and rehabilitated clients spoke about their concerns regarding absence of vocational activities and a social life at the centre. For the caregivers at home, the closure of the vocational centre and day-care led to an increased burden of care apart from intersecting issues such as job losses, pay cuts and rise in debt.
In addition, the providers faced challenges in maintaining work-life balance, and providing appropriate quality of care while implementing the adaptations. Their personal time was also affected with extended work hours, care fatigue, decreased time with the family and reduced formal and informal interaction with colleagues. There was also the perception of the risk of contracting COVID-19 during travel or patient interactions.
3 Rs of adaptation were key
The main objective of service delivery was to maintain continuity of care and at the same time minimise the risk of infection. We find that three elements of service provision were key: established relationships with communities, responsiveness to the patient needs, and resilience in ensuring continuity.
System adaptations included the use of telecommunication platforms, electronic prescriptions and the continued use of expired prescriptions as well as facility-level strategies such as isolation and liaison psychiatry for patients diagnosed with COVID-19.
Every service department – operations, pharma/clinical services and non-pharma/counselling services, worked towards a set of adaptations and tackled challenges through informal communication channels like WhatsApp groups, which proved useful for decision making, emotional support and load sharing.
The operations and management adaptations were intended for the following ongoing purposes:
- Establishing standard safety protocols on the premises
- Ensuring that staff and patients had requisite documentation to travel
- Introducing a judicious rostering system that linked patients and the providers effectively, either physically or through tele-consultation, and ensuring services to a 24-hours helpline for the general public and existing patients
Safety protocols included streamlining movement of the patients, standard precautions like sanitisation, temperature checks, masks and social distancing guidelines, which were adopted early and enforced. The documents required by staff and patients for movement demanded personnel to be constantly available to authenticate to the authorities.
Lessons from the past
Lessons from past calamities such as floods, tsunami and cyclones in Tamil Nadu were found to be useful in helping adapt service delivery during the crisis. Providers’ prior experience in implementing tele-psychiatry made implementation during the pandemic somewhat easier. The importance of framing care policies and programmes for the mentally ill population within administrative and disaster planning strategies, particularly the need to integrate housing, transportation and medication for people with mental illnesses is critical. It is also important to sensitise enforcing authorities on the diverse needs of the mentally ill. Finally, it is imperative to have training programmes for health workers to build their capacity to handle isolation, infection and relocation, and similar engagement for caregivers and families.