Emotional and Psychological Impact of COVID-19 Induced Delay in Treatment of Medical Conditions

1. Introduction

Covid-19 pandemic caused by SARS-CoV-2 virus hit the world in December 2019 [1, 2]. Because of rapid rise in the cases worldwide it was declared as an international emergency by WHO on 30th January 2020. Social distancing, face mask, hand hygiene became the new norms. Public transport & travel restriction were implemented in most of the countries.

While all the efforts were made to curtail the transmission of the virus and management of those affected by the virus, a lot of routine procedures, treatment appointments were put on halt. Most of the hospitals both public and private were either managing COVID-19 patients or only those with emergency conditions. As a result, lot of patients suffering from diseases other then COVID-19 had to cancel their scheduled appointments indefinitely. Due to the uncertainty neither the doctor nor the patients were sure when will the routine care start again which leads to anxiety, frustration, fear of progression of disease or development of complications related to diseases and depression in many of the patients and health care providers as well. According to a report published by WHO in June 2020, 94% of the member countries reported that all or some of the ministry of health staff with responsibility for non-communicable diseases were reassigned the duty for management of Covid-19. As per this report around 53% of the countries disrupted their medical services for hypertension, 49% for diabetes, 63% for rehabilitation services, 42% for cancer and nearly 31% for cardiovascular diseases [3]. Due to the delay in treatment many patients develop anxiety which also manifested as physical symptoms like palpitation, gastrointestinal disturbances, depression, substances abuse. Mental health of such patients waiting for procedures and treatment worsened.

2. Non-communicable disease

Nearly 70% of deaths in the developed nations and 80% in low & middle-income countries occur due to non-communicable disease every year [4].

Non-communicable disease include disease like hypertension, diabetes, coronary artery disease, cancers etc. Patient suffering from such conditions need repeated appointments to adjust their drug dose, check compliance to the drugs, follow improvement in the symptoms and to check for any further progression of the disease. Due to the closing of all non-emergency services during the pandemic resulted all routine appointments were postponed resulting in delayed treatment. Due to this sudden disruption in the existing health care system patients and health care professionals did not get time to discuss and plan their further management. This caused lot of anxiety and distress in many patients suffering from the any of the disease. Many patients experienced mental health problems, sleep disturbances, anxiety, mood disorders to add on to the existing symptoms but had no clue whom to seek clue from.

3. Cancer management

Being diagnosed to have cancer in itself is distressing for a patient and family. The anxiety levels are higher in newly diagnosed cases and new stressor can be difficult to manage for such patients [5, 6, 7]. Treatment delay due to COVID-19 pandemic and the fear associated with higher chances of acquiring infection due to week immune system lead to increased psychological issues in many cancer patients [8, 9, 10]. Many patients could not travel to hospitals on the scheduled appointments due to travel restriction and many of the hospitals temporarily suspended their services causing delay in treatment. Delayed treatment lead to progression of the disease and raised the mortality rate. A study done by Yingjun ye et al. found that psychological distress was significantly higher in the patient with cancer during COVID 19 as compared to the healthy volunteers [11].

4. Fertility treatments

Infertility i.e. not able to conceive is one of the most distressing diagnosis for a couple and is associated with lot of anxiety, depression and feeling of guilt.

Due to the advancement in the fertility services now many couple see ray of hope. Ovulation induction, intrauterine insemination, in-vitro fertilisation are some of the options which can be opted by the couple as per their medical needs decided after meticulous fertility workup. The whole work-up is itself time demanding and cycle dependent. Cycle cancellation of any reason can be distressing for a couple who is waiting to conceive for long [12, 13]. During the pandemic due to the restrictions and fear of contracting the disease lot of cycles needed to be cancelled and several couples kept waiting for their treatment. Due to the risk of exposure and conservation of resources on March 2020 American Society of reproductive Medicine (ASRM) and many other international societies recommended to suspend all kind of fertility treatments [14]. In a study published in 2020 by Kaur H et al. shows that 50% of the fertility treatment cycles were cancelled due to COVID-19 pandemic and 16.4% of the couples found it extremely upsetting. Around 10.9% experienced sleep disturbances, 14.15 were anxious, 18.4% had mood disturbances and 17.4 had disturbed thoughts [15].

5. Pregnancy and childbirth

Pregnancy and childbirth is one of the most joyful news for a couple. Lot of physical and hormonal changes takes place in the body to prepare for a growing baby and childbirth. Many women may experience mood swings, irritability and psychological issues like sleep disturbances, anxiety, fear and depression along with the other physical symptoms of pregnancy. These changes also make women more prone to infections due to decreased immunity. During the pandemic though the emergency obstetrics care were functional but routine ante-natal care were suspended. Routine antenatal care involves inquiry regarding any high-risk factor posing present pregnancy at higher risk of any adverse outcome, routine examination for maternal and fetal well-being, immunisation during pregnancy, investigations, ultrasound and childbirth preparedness. Due to the limited knowledge and evidence about the COVID-19 and its impact on pregnancy it was assumed that COVID-19 can cause a threat to the pregnant women and baby. Many pregnant women suffered anxiety because of the fear of contracting the disease. Antenatal women also suffered psychological issues in the absence of routine antenatal checkup and medical reassurance that everything is going fine. Women with early pregnancy were unsure about the risk of COVID-19 to the baby and experienced more psychological issues. Some even terminated the pregnancy. Women in advanced pregnancy were distressed because of the uncertainty of the place of delivery and limited options for transport in odd hours, fear of contracting COVID-19 on hospital admission for delivery. Many women even chose to deliver at home by female relatives and suffered complications like.

6. Postpartum care

Period immediately after delivery is very crucial. Women requires a lot of support emotionally and physically to handle the changes that occurred with the birth of the baby. Initiating breastfeeding could be a real stressor for women. Reassurance and support from family members can help them adjust. Due to social distancing and to avoid overcrowding in the hospitals women did not get enough support postpartum and they were left at there own to manage. Feeling of loneliness and fear of contracting COVID-19 by mother or baby added to the anxiety. Even at home due to lockdown and travel restriction many women lack support post-delivery because of which many women experienced anxiety, sleep disturbance, mood swings and agitation.

7. Contraceptive needs

Many couple could not access contraceptive services during the pandemic due to closure of many of the hospitals and medical stores. Due to lockdown and restrictions also many could not visit the nearby medical stores as per their convenience. Those who could not get the contraceptive of their choice either practiced temporary abstinence, natural methods or did not use any method. Unintended pregnancies resulting as a result of non use of contraceptives needed abortion services and resulted in unsafe abortion services or continued with unwanted pregnancy and delivered. Many children born as a result of such unwanted pregnancies were abandoned. Many women suffered anxiety disorders, sleep disturbances and feeling of guilt because of this.

8. Abortion care

Since all the efforts were made to tackle COVID-19 and related emergency many routine family planning suffered. One of such important services was abortion care. Abortion services are usually used by a women/couple in cases of unintended pregnancy due to contraceptive failure or non use of contraceptives or rape. Unintended pregnancy can be a cause of psychological issue in a couple if they are not prepared to have a baby, due to financial or personal reasons. During the pandemic many couples with unintended pregnancy could not avail medical abortion services within time as the out-patient/family planning departments were closed, patient were themselves also scared to visit hospital, medical stores could not dispense MTP kits due to unavailability of the prescription. As a result many couples had to keep the pregnancy and deliver at term which adversely affected the mental health of the mother and couple.

9. Adolescents health

Adolescent means between childhood and adulthood from age 10–19 years. This is the time when a person experiences physical, cognitive and psychosocial growth. Most of the habits related to diet, exercise, substance use and sexual activity are formed during this period. For a healthier development adolescents need information, opportunities, safe and supportive environments.

Though considered to be the most healthy phase of life adolescent also struggle through lot of medical and psychological issues which needs to be addressed. Certain conditions like Polycystic ovarian disease, Abnormal uterine bleeding, sexual concerns, sexually transmitted diseases and contraception could not be addressed due to lockdown during COVID. Due to the uncertainty regarding future mental issue further deteriorated. Cases of eating disorders, obesity and body image disorders rise but due to unavailability of the routine health care services the issues could not be addressed.

10. Mental disease

Patients already suffering from psychiatric diseases like depressive disorders, anxiety disorders, schizophrenia etc. faced major challenges due to the changes in brought about due to pandemic. Many of them on long term treatment and follow -up could not plan there scheduled appointments and hence missed the necessary treatments. Some of them experienced worsening of the existing symptoms while others found difficult to cope with the new stressor along with their existing symptoms.

11. Substance abuse

Social distancing, quarantine, limited travels are the measures used to prevent COVID 19 transmission however these measures resulted in negative emotions, boredome, worthlessness in many and specially those trying to abstain from the substance abuse. Outbreak resulted in relapse in many long-term abstainers due to missing of counselling and treatment sessions. Many suffered intolerable and life-threatening withdrawal symptoms. Due to lack of medical services to address the issues or inability to reach the facilities many found it difficult to cope with the situation resulting in increased relapse, irritability, domestic violence and suicidal attempts [16].

12. Preventing health service

Health services aimed at prevention of certain non-communicable disease, cancer screening like screening for cervical cancers were suspended and hence most of the patients missed the opportunity to be diagnosed for treatable pre-cancerous lesion.

13. Minor ailments

Apart from the chronic and existing disease there are certain acute conditions which does not require emergency management but certainly require treatment as the symptoms can be boresome to the patient. In the absence of an appropriate diagnosis patient feel scared about the new onset symptoms. Certain such symptoms like abnormal uterine bleedings, acute abdominal pain, new onset headaches, ear infections, trauma remained untreated in the absence of routine care. Postponement of appointments for these non COVID or non-emergency conditions cause frustration and unrest to many.

14. Neuropsychiatric sequelae of COVID-19

None of the countries were prepared for such pandemic. Even the countries with best of health care system faced shortage of beds, ventilators during the first and second peak. Millions of people died due lack of effective management. Fear, anxiety about contracting the disease, uncertainty about future, disruption in work and social isolation affected psychological wellbeing of people. Since SARS-CO -V-2 also affects the central nervous system many studies have shown acute neuropsychiatric symptoms like cerebrovascular accidents/stroke and encephalopathies [16]. Patients presented with symptoms like headache, dizziness, myalgia, loss of smell and loss of taste. A lot of people experienced mood changes, anxiety disorders and sleep disturbances because of it. Those who contracted COVID-19 also suffered post-traumatic stress disorder (PTSD) [17, 18].

COVID 19 Pandemic had a significant impact on the existing health care system. As per WHO dashboard around 564,126,546 patients have been infected and around 6,371,354 died because of COVID- 19 virus till 22nd July 2022. Since Majority of the health care system was over-burdened due to the COVID 19 cases there was no place and arrangements which were made for non COVID patients. COVID-19 pandemic brought major challenges to the existing health care system through-out the world. Countries with underdeveloped digital healthcare system suffered the most. Due to the delay in treatment for new onset medical conditions and follow up and continued management of those on long term treatment adversely affected patients existing medical condition. As a lot of patients developed psychological issue and sleep disturbances. While a lot of effort was being made to curtail the transmission of COVID-19 and prevention and management of the complications because of it no separate arrangements were made to manage the longstanding disease and no effort was made to address the mental health issues of such patients [19].