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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 6  |  Issue : 1  |  Page : 44-48

Telecounseling and guided relaxation for addressing patient, student, and health-care worker distress: An experience


1 Department of Psychiatry, Pramukhswami Medical College, Bhaikaka University, Karamsad, Anand, Gujarat, India
2 Department of Microbiology, Pramukhswami Medical College, Bhaikaka University, Karamsad, Anand, Gujarat, India

Date of Submission11-Aug-2021
Date of Decision14-Dec-2021
Date of Acceptance19-Dec-2021
Date of Web Publication29-Apr-2022

Correspondence Address:
Dr. Jagdish Varma
Department of Psychiatry, Pramukhswami Medical College, Bhaikaka University, Karamsad, Anand - 388 325, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aip.aip_104_21

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  Abstract 


Introduction: In the face of the coronavirus disease 2019 (COVID-19) pandemic, the leadership of the institute felt a need for mental health interventions among patients admitted in COVID-19 isolation, university students, and health-care workers engaged in COVID-19 care. This article aims to share our experience in providing these services. Methodology: COVID-19 inpatients were telephonically counseled. Counseling protocol was based on national guidelines. Students of the university were assessed for emotional problems using a symptom checklist and Kessler 10-item Distress Scale. Subsequently, the faculty assigned as mentors were trained in providing telephonic psychological first aid (PFA) to the students. Psychosocial help was offered to health-care workers through daily guided relaxation sessions. Results: Forty-two of 69 COVID-19 inpatients were telephonically contacted. New-onset mental health problems were found in 40%. Half of the COVID-19 confirmed patients and half of the females had a higher prevalence of mental health problems. On the symptom checklist, 330 students were responded. Worry about the future, contagion, and boredom were reported by the majority of students. On the Kessler 10-item Distress Scale, 272 students were responded. Thirty-seven percent had likely mental disorders (22 males and 79 females). Twenty-two students contacted psychiatrists through mentors and were provided teleconsultation. Eighty health-care workers attended guided relaxation sessions. Twenty-nine responded on the feedback form. Most respondents felt guided relaxation was useful in reducing stress, with strongly agree (n = 12) and agree (n = 14) responses. Conclusions: Emotional problems were significantly prevalent among students and COVID-19 patients. Training faculty in PFA can help address students in distress. Guided relaxation may help frontline workers manage stress.

Keywords: COVID-19, frontline workers, mental health intervention, patients, students


How to cite this article:
Naik S, Prabhakaran A, Mahida A, Singh SP, Sharma H, Varma J. Telecounseling and guided relaxation for addressing patient, student, and health-care worker distress: An experience. Ann Indian Psychiatry 2022;6:44-8

How to cite this URL:
Naik S, Prabhakaran A, Mahida A, Singh SP, Sharma H, Varma J. Telecounseling and guided relaxation for addressing patient, student, and health-care worker distress: An experience. Ann Indian Psychiatry [serial online] 2022 [cited 2022 May 22];6:44-8. Available from: https://www.anip.co.in/text.asp?2022/6/1/44/344418




  Introduction Top


The global pandemic of 2020 is caused by the novel severe acute respiratory syndrome coronavirus 2. It causes a range of symptoms from mild upper respiratory tract symptoms to severe pneumonia and acute respiratory distress syndrome.[1] Keeping in mind the social distancing norms to prevent contraction of the virus, a lockdown was initiated in various parts of the world, including India, which also had an impact on mental health.[2] A literature review suggests that in a pandemic situation, survivors, caregivers, orphans, or health professionals working with infected patients are a vulnerable population and are more likely to experience psychological distress, sleep disorders, anxiety, and posttraumatic stress disorder. All these symptoms can lead to suicidal ideation, substance abuse, and reduced quality of life.[3]

COVID-19 patients face the challenges of isolation in a hospital with loss of social contact and uncertainty about life, perceived danger, physical discomfort, medication side effects, fear of virus transmission to others, and negative news on social media.[4]

Students, due to being quarantined in their homes, faced a loss of rhythm in the academic routine, uncertainty, and loss of purpose, trouble adjusting to online classes, and stress about contracting the virus to themselves and their loved ones.[5]

Health-care professionals, being the frontline workers, suffered from emotional stress due to fear of contagion to themselves and family members, helplessness because of the increasing death rate, stigmatization, and uncertainty, shortage of supplies.[3]

Therefore, the leadership of our institute felt the need for mental health interventions among these vulnerable populations, keeping in mind the regulations received from the government to support the population. The study aims to share the findings and experience gained in providing mental health support to COVID-19 inpatients, university students, and health-care workers.


  Methodology Top


Three different interventions were focused on the target groups, namely (1) COVID-19 inpatients, (2) university students, and (3) health-care workers.

COVID-19 inpatients

Participants

Counseling was provided by psychiatrist and psychologist to all confirmed and suspected COVID-19 inpatients isolated in the hospital from April 24, 2020, and continued for 2 months thereafter.

Procedure

Telephonic psychosocial counseling was provided, and the protocol was developed based on the guidelines released by NIMHANS and Pallium India.[6],[7] Telephonic counseling was preferred to avoid wastage of PPEs, which were in short supply at that time. Counseling was done in the local language (Gujarati or Hindi). The average call duration with each patient was 10–12 min, and follow-up calls were done after about 7 days or earlier if required or requested by the patient. Most of the patients were contacted on the 1st or 2nd day of admission. The counseling protocol is shown in [Box 1].



The protocol also included a set of questions to be asked based on which a diagnosis was made by the psychiatrists involved in the counseling as to whether there were new-onset mental health problems or exacerbation of any previous illnesses. A distress scale was used to rate current perceived distress by the patient in the first call and follow-up calls.

Students

Participants

As lockdown was enforced, students were sent back to their family homes. Students faced isolation, loss of academic rhythm, and added stress of transitioning to an online mode of education. To assess the impact of the same on the students, the provost requested the department of psychiatry to conduct a survey.

Procedure

Students of the university were asked to fill an online questionnaire sent to them through administrative WhatsApp groups. Students were asked to rate themselves on emotional problems and level of distress. Emotional problems were assessed using an emotional problem checklist, and the level of distress was measured using the Kessler 10-item Psychological Distress Scale (K-10). The K-10 scale is a 10-item Likert scale rated from 1 = none of the time to 5 = all of the time. Scores of the K-10 are rated as follows: <20 = likely to be well; 20–24 = likely mild mental disorder; 25–29 = likely moderate mental disorder; and >30 = likely severe mental disorder.[8]

After analysis of the data collected, the department of psychiatry in collaboration with the mentorship program trained the assigned mentors in providing remote psychological first aid (PFA) to the students.[9] PFA is a systemic approach of helping people in distress so they feel calm and supported to cope better with their challenges.[9] Mentors were trained to identify students in distress and helping them connect with clinicians from the department of psychiatry through teleconsultation.

Health-care workers

Daily guided relaxation sessions were arranged. Invitation to attend the session was sent to all staff members of using WhatsApp group messages. Sessions were conducted in small groups of 8–10, keeping in mind the social distancing norms. Passive progressive muscle relaxation is a technique introduced by Jacobson which involves conscious relaxing of muscle groups one by one to achieve a condition of deep relaxation.[10] Audio recordings were also provided to them to do the practice at home or the workplace. A month after the sessions, a single-item 5-point Likert scale rated from strongly agree to strongly disagree was used for getting anonymous feedback from the participants by sharing a Google Forms on their WhatsApp number.

Ethics

The study was approved by the Institutional Ethics Committee, vide reference number IEC/HMPCMCE/Ex. 60/284/20, dated 4/12/2020. Data for COVID-19 inpatients and university students were collected from records generated as part of routine work. Counseling of COVID-19 inpatients was done as per directives received from the Commissioner, Health Services, Govt. of Gujarat vide letter no Mehsel/Covid-19/Counselling/Seva/2020, dated 23/4/2020, and setting up of helplines and mentoring of university students was done as per directives received from the Secretary, University Grants Commission, New Delhi, vide letter no F. No 1-1/2020(Secy) dated April 5, 2020. Instruction sent to the students at the time of filling the survey included the following lines, “The data collected as part of the survey will be confidential, and your identity will not be disclosed. Completion of the survey will imply your consent to participate in this survey. You may choose not to fill this questionnaire, but if you feel that you need to talk to someone, please feel free to contact any one of us for counseling.” Waiver of consent was requested from the IEC for doing an anonymous survey among health-care workers.

Analysis

COVID-19 inpatients

Descriptive statistics were calculated for demography, symptoms and psychosocial issues faced, diagnosis, and distress level over time.

University students

Descriptive statistics were calculated for demography, emotional problems checklist, and K-10 scale.

Health-Care workers

The frequency of responses in each category was calculated for the single-item Likert scale. Data were analyzed using Microsoft Excel.


  Results Top


COVID-19 inpatients

Demography

Of 69 COVID-19 patients, 42 could be contacted for the first call, and the rest of the 27 were either on a ventilator or discharged/deceased at the time of the call. Of the 42 contacted, 22 were suspected COVID-19 patients and 20 were confirmed COVID-19 patients. The average age was 44.8 years and males (n = 28, 66%) outnumbered females (n = 14, 33%). Comorbid illnesses such as diabetes, hypertension, ischemic heart disease, and depression were found in 21% of patients (n = 9) and comorbid substance use was found in 21% of the patients (n = 9).

Symptoms and psychosocial issues

Anxious thoughts (n = 9, 21%), health anxiety (n = 8, 19%), boredom (n = 5, 11.9%), sleep disturbances (n = 4, 9.5%), fear (n = 2, 4.3%), and negative thoughts (n = 1, 2.3%) were the most common complaints reported.

Health anxiety (n = 5, 25%) and boredom (n = 5, 25%) were the most common complaints among confirmed COVID-19 patients and anxious thoughts (n = 7, 31.8%) were the most common complaint among suspected COVID-19 patients.

Psychosocial issues reported by patients included anxiety about family members and stigma from neighbors. Some patients reported a desire to run away from isolation (4.7%). None of the patients had suicidal ideation.

Gender-wise distribution of the symptoms

Females had more anxious thoughts (n = 6, 42.8%) than males (n = 3, 10.7%) and boredom was more common in males (n = 4, 14.2%) than females (n = 1, 7.1%). Health-related anxiety was found in 17.8% (n = 5) of the males and 21.4% (n = 3) of the females, whereas sleep disturbances were found in 7.1% (n = 2) of the males and 14.2% (n = 2) of the females.

Diagnosis

New-onset mental health problems were found in 50% (n = 10) of the confirmed patients and 32% (n = 7) of the suspected patients. Overall, new-onset mental health problems were found in 40% of the patients. None of the patients experienced an exacerbation of previous illnesses. New-onset mental health problems included health-related anxiety (n = 8, 47%), anxiety disorder (n = 6, 35.2%), boredom (n = 5, 29.4%), adjustment disorder (n = 3, 23.5%), and substance abuse (n = 1, 5.8%). Among the 17 patients diagnosed with a mental health problem, 10 were confirmed COVID-19 patients, and seven were suspected COVID-19 patients.

Health-related anxiety was the most common diagnosis among suspected COVID-19 patients (n = 3, 42%). Boredom (n = 5, 50%), health-related anxiety (n = 5, 50%), and anxiety disorder (n = 4, 40%) were the most common diagnosis among confirmed COVID-19 patients. 23.5% of all the patients were diagnosed with adjustment disorder.

Distress level over the time

Of the 20 confirmed patients, 15 patients received 1 follow-up call and one patient received 2 fol1ow-up calls. Of 22 suspected patients, eight patients received one follow-up call and one patient each received 2nd and 3rd follow-up calls. Among the patients contacted, distress level was in general low, ranging from 0 to 4 (on a scale of 0–10, 0 being least and 10 being worst) on the first call and showing a reduction to 0 or 1 on follow-up calls.

Students

Demography

Of approximately 1300 students at the university, 330 students were responded to the survey link, 237 were females and 93 were males.

Emotional problems checklist

Future worry (n = 97), concerns about contagion to oneself and family members (n = 93), and boredom due to being cutoff (n = 76) were the most frequent endorsed responses. Other emotional problems that were endorsed were feeling confused (n = 61), poor concentration (n = 55), feeling sad or low (n = 54), excessive concerns about health (n = 40), anger about feeling out of control (n = 39), poor sleep (n = 35), feeling helpless (n = 29), concerns about worsening of previous health conditions (n = 27), spiritual crisis (n = 15), poor appetite (n = 14), and excessive concerns about dying (n = 10).

Kessler 10-item Psychological Distress Scale

On the K-10 scale, 272 students responded to all the 10 questions, of which 77 were males and 195 were females. The mean score on the K-10 scale was 18.7 (standard deviation = 8.2). Of these 272 students, 171 (62.9%) students were likely to be well, while 22 (28.6%) males and 79 (40.5%) females (n = 101, 37.1%) had likely mental disorders. The gender distribution of the scores is as shown in [Table 1].
Table 1: Gender-wise distribution of psychological distress among university students using the Kessler 10-item (K-10) scale (n=272)

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Postpsychological first aid by mentors

After the remote PFA session was provided by mentors, 22 students were referred to the department of psychiatry. They were provided telepsychiatry consultations.

Health-care workers

Eighty health-care workers voluntarily participated in the PMR sessions. Thirty-three participants responded to the feedback questionnaire. Most of them felt the sessions were useful in reducing stress, endorsing strongly agree (n = 12) and agree responses (n = 17).


  Discussion Top


Lockdown was imposed in India to fight against the COVID-19 pandemic, keeping in mind that social distancing is one of the main preventive measures. Several reviews report the detrimental effect of the pandemic on the mental health of vulnerable populations, suggesting the need for mental health interventions.[3],[11],[12],[13] Guided by policy directives interventions were done to address the mental health of COVID-19 inpatients, university students, and health-care workers.

COVID-19 inpatients

Our study concludes that new-onset mental health problems were found in 40% of the COVID-19 inpatients, which was in line with a study that showed doubled risk of being newly diagnosed with a psychiatric disorder in COVID-19 patients.[14] They also noted that there was an increased diagnosis of anxiety disorders, which was consistent with our findings showing 82.2% of the patients having anxiety disorder (health-related anxiety and anxiety disorder, NOS).[14] Other studies also noted similar psychiatric sequela are common in COVID-19 patients.[4],[15] A recent study has reported that females are at a higher risk to develop mental health problems which are in line with our study that demonstrated increased mental health problems among females infected with COVID-19.[12] Considering all aspects related to social distancing, shortage of PPE, and need for psychiatric care, telecounseling was preferred as the best intervention at that time. Protocol for the same was made based on NIMHANS and Pallium India guidelines and guidelines forwarded by the government of India to support COVID-19 patients.[6],[7] Telecounseling refers to any type of psychological service performed over the Internet including e-mail, chat rooms, and web cameras.[16] A tertiary hospital in China approached its COVID-19 inpatients through telecounseling to conclude that it was cost effective and helped in reducing the stress of the patients in quarantine.[17] This is commensurate with our experience that distress reduced over time, and telecounseling may have been beneficial to the patients.

University students

Students quarantined in their homes faced emotional problems due to boredom, concerns about contagion, and future worry as ascertained by a survey among university students. This was in line with a study that concluded that the students' main stressors were worries about one's health and family's health, followed by difficulty in concentrating.[5] A study from Jordan also reported online distance learning, social isolation, and worry about contagion were major concerns of the students.[18] The study also used the K-10 scale and noted that 92% of the students had a likely mental disorder as compared to our study showing 37% of the students with a mental disorder, which may be due to our study being restricted to students of one university.[18] Taking the help of the mentorship program, students were provided remote PFA.[19] PFA is an approach for assisting people in the immediate aftermath of a disaster and humanitarian crisis to reduce initial distress and to foster short-and long-term adaptive functioning. This can be used to provide remote services for the public during the time of a COVID-19 response. With the help of this, a small but significant number of students asked for further mental health and were provided the same thorough telepsychiatry consultation. With the benefit of no contact interaction provided by telepsychiatry, it has also proved to be cost effective with ease of accessibility and greater end-user satisfaction.[19]

Health-care workers

Health-care professionals, who are at a major risk of contracting the virus, are a more vulnerable group. Increased workload with a shortage of personal protective equipment and risk of contraction of the virus to themselves and their family are some major stressors.[20] They were offered progressive muscle relaxation exercises in line with a similar study where PMR was provided to health-care workers during the pandemic.[21] The literature review suggested that PMR helps reduce stress.[22],[23] Despite the limited response rate, feedback from health-care workers showed promise that it helped reduce stress.

Limitations

Since our study was restricted to one university, the sample size is small, and the generalizability of findings may be limited by this fact. Although telecounseling may be safe at these times of urgent need, we faced some technical issues such as poor Internet access and improper communication. Due to logistic issues faced in the COVID care center, telecounseling of COVID-19 patients could not be carried out beyond 2 months. Furthermore, the effectiveness of telecounseling could not be judged as most patients had low levels of distress on first contact. There was a low response rate on feedback taken from health-care workers and survey done among university students.


  Conclusions Top


Emotional problems were significantly prevalent among students and COVID-19 patients. Training faculty in PFA can help address students in distress. Guided relaxation may help frontline workers manage stress.

Financial support and sponsorship

Self-funded.

Conflicts of interest

There are no conflicts of interest.



 
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Bo HX, Li W, Yang Y, Wang Y, Zhang Q, Cheung T, et al. Posttraumatic stress symptoms and attitude toward crisis mental health services among clinically stable patients with COVID-19 in China. Psychol Med 2021;51:1052-3.  Back to cited text no. 4
    
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