Home Infections A Case of Mixed Anxiety Depression in the COVID-19 Lockdown

A Case of Mixed Anxiety Depression in the COVID-19 Lockdown

Clinical History
Examination
Investigations
Diagnosis
Treatment
Discussion
References

A 43 year old male patient from rural area, educated up to Pre-university, electronic technician by profession, married and living with his wife and two children, reported to the psychiatry outpatient department complaints of tiredness for 3-4 weeks, feeling worried, fearful about having a corona infection even without any contact or symptoms.

The patient expressed that he would feel like sanitizing his hands often since the news of corona virus emerged.
He also reported that watching the news would increase thoughts with sweating, shiver and racing heartbeat. These episodes would last for five to ten minutes and would occur once or twice a day.

The patient had visited a local ayurvedic practitioner twice to get investigated and treated as acidity for these complaints but symptoms did not reduce. The patient complained of feeling sad, off and on due to this, along with a decreased interest, loss of libido and could not carry day to day activities.
He also complained of disturbed sleep, with a delay in initiation of sleep by more than an hour and decreased appetite. There was no significant past history, and no history of psychiatric illness in the family.

General Physical Examination:

Moderately built and adequately nourished. General physical andsystemic examination was unremarkable.

Mental Status Examination:

The patient was adequately groomed, cooperative and well oriented to time, place and person. He maintained eye contact throughout the interview and rapport was established with ease. The patient appeared uneasy and was occasionally fidgeting in his seat. 

The patient’s speech was normal. His thoughts mainly revolved around the fear that he might somehow contract COVID-19. He was preoccupied “what if I get” and expressed apprehension and worry about his own health and the safety and well being of his family members.

The patient expressed concern regarding lack of earnings in this period of lockdown and was worried about financial troubles in the future. He reported negative thoughts about his health, and would often wonder what would happen to his wife and children if something were to happen to him.His mood was anxious and depressed.

There were no history suggestive obsessive compulsive disorder or delusions or any perceptual disturbances in the patient, and there were no other positive findings. 

Assesments:

The Hamilton Depression rating Scale (HDRS) and Generalised Anxiety Disorder-7 (GAD-7) rating scale were applied.

The patient scored 12 on the HDRS, indicating mild depression,and 13 on the GAD-7 denoting moderate anxiety.

Mixed Anxiety Depression  based on WHO ICD 10 (International Classification of Disorders) Criteria : Low or Sad mood, loss of interest or pleasure with prominent anxiety or worry.

Symptoms are present most number of days for at least 2 weeks

Non-Pharmacological:

The patient was educated regarding COVID-19 infection. He was advised to reduce the amount of news exposure as per WHO guidelines and reduce the discussions regarding the same. He was taught breathing exercises, and Jacobson Progressive Muscular Relaxation JPMR techniques. He was also advised to inculcate a routine during lockdown, a healthy lifestyle, with a good diet and regular exercise. 

Pharmacological:

Tablet Clonazepam  (Benzodiazepine) 0.25mg 1-0-1 and SOS for 1 week.

Tablet Escitalopram (SSRI)  5mg 1-0-0 for 1 week & review. Increase to optimal dosage for at least 3-6months

The patient was educated about the possible side effects of the medications and was advised to come for follow up to the psychiatry OPD after one week.

It is important to screen patients for psychiatric conditions during the COVID19 crisis and aftermath of the disaster.
General Health Questionnaire with five questions (GHQ5) is simple tool for health care professionals, validated in India. 2


Mental disorders are among the leading causes of non-fatal disease burden in India.
One in seven Indians is affected by mental disorders of varying severity according to National Mental Survey 2015-16, Govt of India.
The Global burden of disease survey 2017 reported nearly 200 million Indians have a psychiatric condition that needs treatment. 45 million have depressive disorder and 44 million have anxiety disorder1 (ICMR Collaborated study published in Lancet 2019)


The proportional contribution of mental disorders to the total disease burden in India has almost doubled since 1990. Amongst these, the prevalence of anxiety disorders in India in both the sexes was 3.3% in 2017.2
It is important to consider the high existing morbidity in India, when whole population is affected by the novel coronavirus disease 2019 pandemic, specific sections of the population will be more affected.
They may be affected by issues including isolation or quarantine, loneliness, socio-economic adversities.


People with existing mental health issues, including those with severe mental illnesses, might be particularly affected by relapse, disruptions to services, the possible exacerbation of symptoms in response to pandemic-related information, increased discrimination and crime against minorities, against women, and other trauma. Rural communities might also be affected differently to urban communities. Also, people on low incomes, or ones who have a hand-to-mouth existence especially in a country like India, face job and financial insecurity, cramped housing, and poor access to basic services and healthcare.3,4,5,6 These are strongly associated with anxiety, depression, self-harm, and suicide attempts across the lifespan.7,8


Reports of infectious diseases in the media often use risk-elevating messages, which can amplify public anxiety.9 Social media too can lead to a lot of misinformation.10
Repeated viewing of the media coverage of the disease can exacerbate stress responses, amplify worry, and impair functioning.11

  1. Shamasunder C. Indian Journal of Psychiatry.1986;28(3):217-219.)
  2. Sagar R, Dandona R, Gururaj G, Dhaliwal R, Singh A, Ferrari A et al. The burden of mental disorders across the states of India: the Global Burden of Disease Study 1990–2017. The Lancet Psychiatry. 2020;7(2):148-161.
  3. Holmes E, O’Connor R, Perry V, Tracey I, Wessely S, Arseneault L et al. Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science. The Lancet Psychiatry. 2020;
  4. Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet 2020; 395: 912–20
  5. Rubin GJ, Potts HWW, Michie S. The impact of communications about swine flu (influenza A H1N1v) on public responses to the outbreak: results from 36 national telephone surveys in the UK. Health Technol Assess 2010; 14: 183–266.
  6. Lau JTF, Griffiths S, Choi KC, Tsui HY. Avoidance behaviors and negative psychological responses in the general population in the initial stage of the H1N1 pandemic in Hong Kong. BMC Infect Dis2010; 10: 139
  7. Elovainio M, Hakulinen C, Pulkki-Råback L, et al. Contribution of risk factors to excess mortality in isolated and lonely individuals: an analysis of data from the UK Biobank cohort study. Lancet Public Health 2017; 2: e260–66.
  8. Matthews T, Danese A, Caspi A, et al. Lonely young adults in modern Britain: findings from an epidemiological cohort study. Psychol Med 2019; 49: 268–77.
  9. Sell TK, Boddie C, McGinty EE, et al. Media messages and perception of risk for Ebola virus infection, United States. Emerg Infect Dis 2017; 23: 108–11
  10. Wang Y, McKee M, Torbica A, Stuckler D. Systematic literature review on the spread of health-related misinformation on social media. Soc Sci Med 2019; 240: 112552.
  11. Thompson RR, Garfin DR, Holman EA, Silver RC. Distress, worry, and functioning following a global health crisis: a national study of Americans’ responses to Ebola. Clin Psychol Sci 2017; 5: 513–21.

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