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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Self-reported Medication Adherence in Schizophrenia and Bipolar Disorder Patients during COVID-19 Pandemic in a COVID Care Hospital: A Cross-sectional Study
Correspondence Address :
Dr. Sajal Sathiadevan,
Assistant Professor, Department of Psychiatry, Government Medical College, Palakkad-678013, Kerala, India.
E-mail: sajalsathiadevan@gmail.com
Introduction: The Coronavirus Disease 2019 (COVID-19) pandemic has made it difficult for patients with Schizophrenia and Bipolar Affective Disorder (BPAD) to receive ongoing care, which has led to nonadherence to medication and undesirable health outcomes. Lower treatment adherence in severe mental illness might lead to symptom exacerbation and relapses and might cause a strain on the health system during the COVID-19 pandemic.
Aim: To assess treatment adherence in Schizophrenia and BPAD patients during the prevailing COVID-19 situation in India.
Materials and Methods: This cross-sectional study was conducted among 92 patients with Schizophrenia and BPAD through a questionnaire between January and September 2021 in a COVID-19 care hospital at Government Medical College Palakkad/District Hospital Palakkad, Kerala, India. Demographic and clinical data, adherence to treatment, along with Brief Psychiatric Rating Scale (BPRS), Young Mania Rating Scale (YMRS), Hamilton Rating Scale for Depression (HAM-D), Clinical Global impression (CGI S&I), Work and Social Adjustment Scale (WSAS), Modified COVID Threat Scale (CTS), and Medication Adherence Rating Scale (MARS) were collected. The outcomes included adherence to medication, deterioration of psychopathology, improvement in severity, and social functioning. Descriptive statistics were used to define the sample characteristics, presented as mean and standard deviation, and frequency and percentages. Spearman’s Correlation coefficient was used to find the correlation between MARS and other variables: CTS, BPRS, YMRS, HAM-D, CGI, and WSAS.
Results: A total of 92 patients were interviewed, which comprised 43 patients with Schizophrenia and 49 patients with Bipolar disorder. As assessed by the MARS rating scale, 19 patients (20.65%) had a MARS score less than six, suggesting poor adherence, and 73 (79.35%) had a MARS score of six or greater, suggesting better adherence to treatment. This was supported by negative correlation with BPRS, YMRS, HAM-D, and CGI-S and CGI-I scales, which implies that the COVID-19 pandemic did not hinder the patients from taking medication. The mean MARS score was 7.31±2.11. A total of 37 (40.2%) patients had acute exacerbation of the illness during the COVID-19 related lockdown, and 37 (40.2%) had exacerbation during the six months prior to the COVID-19 lockdown. There was a negative correlation between MARS scores and the CTS but was not statistically significant.
Conclusion: Despite the COVID-19 pandemic-related restrictions, patients with Schizophrenia and BPAD were adherent to medication, and the number of relapses during the COVID-19 pandemic was similar to the period before the pandemic. COVID-19-related anxiety did not have an impact on medication adherence and relapse in this study.
Bipolar affective disorder, Coronavirus disease-2019, Medication non adherence
The entire world is grappling with the COVID-19 outbreak, which is thought to have been caused by the virus Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), which developed in Wuhan, China. Although COVID-19 primarily affects the respiratory system, it has also been shown to damage other organs, including the brain. Moreover, COVID-19-related neurological and psychiatric problems have recently been observed (1). Apart from the physical consequences of the virus, the quarantine, limitations, and the millions of people who died throughout the world as a result of the outbreak produced major mental health issues. Furthermore, this pandemic has generated major complications for individuals with mental illness (2). Adherence to treatments involves attending outpatient clinics on a regular basis, taking prescribed medications on time and in sufficient quantities (3).
Non adherence to treatment is a major obstacle in the successful treatment of Schizophrenia and BPAD (4). Nearly 50% of Schizophreniaand BPAD patients are nonadherent to treatment, leading to symptom exacerbation and relapses [5-7]. Relapses in severe mental illness can lead to noncompliance with COVID-19 norms like physical distancing, wearing masks, etc., and can lead to an increased risk of getting COVID-19 infection and higher a risk of spreading (8). Due to the COVID-19 pandemic-related restrictions on movement to prevent the spread of COVID-19, patients with severe mental illness had difficulty maintaining regular psychiatry follow-up visits, which led to nonadherence in medications, leading to symptom exacerbation (9). Psychological stress due to COVID-19 pandemic restrictions and health anxiety related to COVID-19 can also precipitate symptoms in patients with severe mental disorders (10),(11),(12).
The primary objective of this study was to assess treatment adherence in Schizophrenia and BPAD patients during the prevailing COVID-19 pandemic in a COVID-19 care hospital in Kerala, India, and the secondary objective was to find the correlation between MARS and other variables: CTS, BPRS, YMRS, HAM-D, CGI, and WSAS.
The study was a cross-sectional hospital-based study and consisted of 92 patients with BPAD and Schizophrenia who were regularly followed-up in District Hospital Palakkad, Kerala, India. After obtaining approval from the Institutional Ethical Committee: IEC/GMCPKD/31/20/85 dated 21/12/2020, patients with diagnosis of Schizophrenia and BPAD as per the ICD 10 criteria (13) were recruited for the study and convenience sampling method was used. The study was conducted at Department of Psychiatry at District Hospital Palakkad/Government Medical College, Palakkad at outpatient and inpatient department between January to September 2021 during the COVID-19 pandemic.
Sample size calculation: Based on the percentage of low medical adherence in bipolar patients of 54.7% observed in a study done in AIIMS Delhi in 2019 (7), using the below equation and with 95% confidence and 20% precision, the minimum required sample size was 82.
n=4pq/ d2 where p=54.7%, q=100-p, d=precision=20% of 54.7.
In this study 92 patients with severe mental illness comprising of Schizophrenia and BPAD were recruited.
Inclusion criteria:
1. Patients over 18 years of age with Schizophrenia (F20 ICD criteria) and patients with BPAD (F31 ICD criteria) (13) registered in District Hospital Palakkad before October 2019 and on follow-up;
2. Patients and family relatives who may be contacted (direct or telephone);
3. Informed consent of relative and patient.
Exclusion criteria: Patients not willing to participate in study were excluded from the study.
Study procedure: Once patient satisfied the inclusion criteria as assessed by Psychiatrist, clinical examination was done to assess psychotic symptoms, mood symptoms, illness severity, perceived threat due to COVID-19 and medication adherence. Education and family income was assessed using Modified Kuppuswamy scale (14). All the patients were assessed using BPRS, YMRS, HAM-D, CGI, Modified CTS, MARS and WSAS. The number of follow-up in the six months prior to COVID-19 related lockdown and the number of consultations during the first six months after the COVID-19 related lock-down was assessed to evaluate whether the patients had regular follow-up. Patients were considered as having regular follow-up if they used to come during the scheduled appointment week for consultation for the initial six months during the COVID-19 pandemic. Any exacerbation of symptoms during the initial six months of COVID-19 pandemic and six months prior to the COVID-19 pandemic was also assessed through the questionnaire evaluating the clinical characteristics of the sample. A written informed consent was obtained from all patients.
Assesment scales: The BPRS is a scale which assesses the severity of such as hostility, suspiciousness, hallucination, and grandiosity in patients. It is useful for assessing the effectiveness of treatment for individuals with mild to severe psychoses. It’s a clinician assessed scale where the clinician’s rates the patient behaviour based on his observations over the last 2-3 days. Inputs from the patient’s family on their behaviour was also taken into account. For each of the 24 symptom construct, the rater enters a number that ranges from 1 (not present) to 7 (extremely severe). BPRS scale was administered on all patients of Schizophrenia and Bipolar disorder in this study to assess symptom severity of the patients (15).
The YMRS is one of the most frequently utilised rating scales to assess mania symptoms. The scale has 11 items and each item is rated 0 to 4 and is based on the patient’s subjective report of his or her clinical condition over the previous 48 hours. Higher scores suggest worsening of Mania symptoms. Additional information is based upon clinical observations made during the course of the clinical interview. The items are selected based upon published descriptions of the core symptoms of mania (16).
The HDRS (also known as the HAM-D) is the most widely used clinician-administered depression assessment scale. The original version contains contains 21 items and scored 0 to 4 with higher scores suggesting to symptoms of depression over past one week (17).
Clinical Global Impression- Severity (CGI-S) and Improvement (CGI-I) scales: The CGI-S (18) is a 7-point scale that requires the clinician to rate the severity of the patient’s illness at the time of assessment, relative to the clinician’s past experience with patients who have the same diagnosis. The CGI-I (19) is a seven-point scale that requires the clinician to assess how much the patient’s illness has improved or worsened relative to a baseline state at the beginning of the intervention. CGI severity is scored as 0=Not assessed, 1=normal, not at all ill, 2=borderline mentally ill, 3=mildly ill, 4=moderately ill, 5=markedly ill, 6=severely ill, 7=among most extremely ill patients. CGI improvement is scored as 0=not assessed, 1=very much improved, 2=much improved, 3=minimally improved, 4=no change, 5=minimally worse, 6=much worse, 7=very much worse.
Higher scores CGI severity indicates worsening of symptoms and lower scores suggesting lesser severity of illness. Higher scores on global improvement suggest worsening of symptoms and lower scores suggests improvement in symptoms. The CGI severity and improvement scales offer a readily understood, practical measurement tool that can easily be administered by a clinician in a busy clinical practice setting.
The CTS is used to measure the degree of anxiety related to contracting or spreading COVID-19 (20). The scale was translated into five Indian languages (Kannada, Tamil, Telugu, Malayalam, and Hindi), following norms laid out by the World Health Organisation (WHO) (21). The scale has 10 item and is scored on a likert scale from 1 to 5 with higher scores indicating higher anxiety. The Malayalam translation of the scale was used for this study.
The WSAS (22) is an outcome measure assessing degree of functional impairment. Subjects would be provided instructions to rate how various aspects of their lives in five domains (work, home management, social leisure, and private leisure, and close relationships) were affected due to the pandemic. It is rated from 0 to 8 with higher scores indicating higher impairment. It was translated to Malayalam following norms laid by WHO (21). Its psychometric properties, validity and sensitivity to change have been supported in several studies.
The MARS (23) is a self-rated scale which determines an individual’s medication adherence. It determines adherence in three dimensions of medication adherence behaviour, attitude and negative side-effects along with attitudes to psychotropic medication. It is a self-report measure of medication adherence and patients give yes/no response to 10 questions and it is rated from 0 to 10. 10 is best adherence to medication and 0 is non adherence to medication. A MARS score of less than six was considered as poor adherence to medications in this study and a score of six and more considered as good adherence.
A specially designed socio-demographic and clinical data sheet was used to record the demographic and clinical variables.
Statistical Analysis
The statistical data analysis was done using Statistical Package for Social Sciences (IBM SPSS, version 20. Chicago, SPSS Inc.) Descriptive statistics was used to define the sample characteristics and presented as mean and SD and frequency and percentages. One sample Kolmogorov-Smirnov (KS) test was done for checking the normality. As the distribution was not normally distributed, non parametric, Spearman rank correlation was used for finding correlation between MARS and other variables (CTS, BPRS, YMRS, HAM-D, CGI- S&I, WSAS) p-value <05 was considered significant.
The sample comprised of 92 patients with severe mental illness comprising of 43 patients (46.74%) with diagnosis of Schizophrenia and 49 patients (53.26%) with diagnosis of BPAD and the total sample was analysed. However, subgroup analysis according to the diagnosis was not attempted. (Table/Fig 1) depicts the mean age (standard deviation) of participants was 38.4±13.3 years. The majority were female (n=52; 56.52%), with most having high school of formal education (n=41; 44.57%). Over half of the participants were married (n=49; 53.26%) and unemployed (n=61; 66.3%).
The mean age of getting illness was 25.34±8.81. The mean duration of illness was 156.63±100.4 months and mean duration of treatment was 134.63±100.9 months. Only 35 (38%) patients had regular follow-up during the COVID-19 lockdown but majority, 72 patients (78.3%) reported taking medicines regularly. In 66 (71.7%) patients medication intake was monitored by a caregiver. A total of 37 (40.2%) patients had acute exacerbation of the illness during the COVID-19 related lockdown. Eight patients (8.70%) had COVID-19 and 20 (21.74%) underwent COVID-19 related quarantine.
The mean MARS score was 7.32±2.11. The scores ranged between 0 and 10; the median score was 8, while the interquartile range was between 2 and 6. There were no differences in mean MARS scores across gender (p=0.146) or whether patient had Schizophrenia or BPAD (p=0.43). More details regarding the correlation with MARS score are shown in (Table/Fig 2),(Table/Fig 3). In this study’s sample, 19 patients (20.65%) had MARS score less than six implying poor adherence to medications, 24 patients (26.09%) had MARS score of six and seven suggesting medium adherence, and 49 patients (53.26%) had MARS score of eight and higher indicating high adherence to medications. For the purpose of analysis medium and high adherence were considered as good adherence group and compared with poor adherence group as risk of relapse are higher in poor adherence group.
There was no correlation between The MARS scores and The CTS as shown in the (Table/Fig 4).
As shown in (Table/Fig 5), MARS was negatively correlated with BPRS, YMRS, HAM-D, which means that patients did not have any significant symptoms either in symptoms of Schizophrenia or BPAD (Mania and Depression). The CGI Severity and Improvement had negative correlation with MARS score implying that patients were doing well and improving in terms of the symptomology as MARS scores are higher. All these, BPRS, YMRS, HAM-D and CGI-S&I were statistically significant. The WSAS which measure outcome of functional impairment, was also negatively correlated but it was not statistically significant.
The present study was done to evaluate medication adherence in patients with severe mental illness during the COVID-19 pandemic in India and had direct interview with patients as compared to other studies which relied on telephonic interview during the pandemic. The purpose of this study was to find out how the COVID-19 pandemic and its restrictions impacted the treatment adherence of patients who had Schizophrenia or BPAD who had been taking their medications as prescribed and had come for a follow-up. The treatment adherence was assessed using the self-reported MARS. The study had adequate representation from male and female gender, comprised of patients mostly coming from rural background 94.6% and lower income group.
Present study observed that only 38% of the patients had regular follow-ups but 78.3% said that they took the medicines regularly. In this study’s, sample as per MARS score of six and greater 73 patients (79.35%) had good adherence to treatment during the COVID-19 pandemic. Only 19 patients (20.65%) of them had their adherence affected. Patient adherence to medicines and follow-ups is a major issue in clinical practise across all medical specialities. In a study assessing medication adherence in a Lithium maintained cohort of 76 patients with Bipolar disorder conducted in AIIMS Delhi in 2019, medication non adherence was reported as 54.7% when MARS score for lower adherence was considered as seven and lesser (7). In the present study, MARS score of less than six was considered as poor adherence. On comparison present study observed that 43 patients (46.74%) in the present study had MARS score of seven and lesser which suggest that medication adherence during pre pandemic time and that during the COVID-19 pandemic time was similar. In a study done in JIPMER, Puduchery between 2015 and 2016 in 160 patients with Bipolar disorder, 97 patients (60.6%) had lower than 6 score on Morisky MARS suggesting poor adherence (6). In the present study during the COVID-19 pandemic the poor adherence to medication was found only in 19 patients (20.65%) of sample (MARS score less than 6), medium adherence was found in 24 patients (26.09%) of sample (MARS score of 6 and 7) might be due to the measures taken by the Government and patient’s caregivers to ensure medication adherence to prevent risk of relapse and subsequent hospital admission. In a study conducted in DY Patil Medical College, Maharashtra in 2016 in 50 Schizophrenia patients, 26 patients (52%) were found to have poor adherence to medications (5) which was comparable to this study having 43 patient (46.74%) having poor adherence and medium adherence to medication. In a study done in Turkey in 2020 during the COVID-19 pandemic, it was found that 59% of the 396 patients with Schizophrenia interviewed through telephone reported that they were able to continue their medications (24). These findings suggest that medication adherence was not significantly affected during the COVID-19 pandemic. In a study done in China in 800 Schizophrenia patients in 2021 during the COVID-19 pandemic it was found that only 332 patients (41.5%) had regular medication (25) intake during the pandemic which was significantly lower compared to this study’s sample’s medication adherence of 79.35% during the COVID-19 pandemic.
In a study, it was reported that 28.4% of the patients dropped out after first visit with a psychiatrist. A 61.5% patients had 1-3 follow-up and 10% had more than 4 follow-ups in a 2-year period (26). This issue was amplified by COVID-19 pandemic. It impacted both patients’ compliance with clinical follow-up and adherence to treatment. A prior study revealed that 40% of readmissions to hospitals within a year after being discharged from a psychiatry clinic were caused by non adherence with treatment (27). Another study reported that the rate of missed follow-up was reported as high as 48% (28). The present study shows that despite COVID-19 pandemic and associated lockdown, the adherence to the treatment was good as the mean MARS score of the sample was 7.32±2.11.
To prevent the COVID-19 spread and related deaths, countries had implemented a variety of measures, including quarantine, social distance, and transportation restrictions. In India, these measures were also done in response to the pandemic (29). Due to the lack of evidence and uncertainty surrounding SARS-CoV-2 worldwide, these limitations became more stringent when the first case was discovered in India. Many felt that this will lead to a mental health pandemic and would create a chaos among those who are already on treatment especially those with Schizophrenia and BPAD (30). But the present study, suggested that high treatment adherence was negatively correlated with CTS but it was not statistically significant. In a study done in NIMHANS in OCD patients in 2020 during the early phase of COVID-19 pandemic in India it was found that relapse rate in Obsessive-Compulsive Disorder (OCD) during COVID-19 pandemic was 21% was almost similar to the pre pandemic relapse rate of 20% (21). In the present study sample of 92 patients, 37 patients (40.2%) had exacerbation of illness in the six months prior to COVID-19 related lockdown and 37 patients (40.2%) had exacerbation during the first six months of COVID-19 related lockdown. In a cross-sectional telephonic interview survey in patients with severe mental illness conducted during the initial phase of COVID-19 pandemic in Puducherry, South India in 132 patients it was found that 103 patients (78%) were able to continue their medications during the pandemic and 39 patients (29.5%) had symptoms of relapse (31). The present study had comparable medication adherence of 79.35% patients with medium and high adherence to medication but had slightly higher relapse of symptoms 40.2% but had comparable relapse to the pre pandemic relapse rate. In a retrospective chart review done during the initial months of COVID-19 pandemic in a community mental health centre in Ankara, it was found that 11% of patients had relapse out of the total sample of 155 patients comprising of Schizophrenia and Bipolar disorder and it was comparable to the pre pandemic relapse rate of 6.5% in the same sample (32). Relapse rate might have been lower than expected during the pandemic as caregivers might have been able to ensure medication adherence in patients despite not coming for regular follow-up visits during the time of pandemic. In a longitudinal cohort study done in UK in 356 patients with Bipolar disorder and mood symptoms assessed by an online monitoring tool it was found that mood symptoms during the COVID-19 pandemic in 2020 didn’t significantly differ from the pre pandemic period in 2019 even though higher rates of anxiety related to the pandemic was observed (33). The present study suggests that COVID-19 related pandemic control measures and COVID-19 related anxiety didn’t play a role to cause exacerbation in Schizophrenia and Bipolar patients and didn’t affect their medication adherence.
In this present study, MARS score was negatively correlated with the Scales of BPRS, YMRS and HAM-D which suggests that as medication adherence improves the psychopathology assessed using these scales had lower scores in Schizophrenia and Bipolar patients. In this study’s sample the mean MARS score was 7.32±2.11 implying better adherence to medication and hence lower scores on BPRS, YMRS, HAM-D. This suggests that there was reduction in psychopathology which may have occurred due to good adherence of the medications even though COVID-19 pandemic related restrictions were imposed.
Limitation(s)
1. Self-reported question of medication adherence has lower sensitivity, recall bias might be present.
2. Present study considered MARS score of 5 and lesser as poor adherence as this is the group with higher chance of relapse rather than medium adherence group. This might have impacted the study interpretation of lesser patients with poor adherence.
3. Patients who are non adherent might not be coming to COVID-19 hospital for follow-up due to fear of COVID-19.
4. Patients who are having good adherence might be continuing medications through prescription refills, teleconsultation, using e sanjeevani, obtaining medicines from District Mental health programme clinics or consulting non COVID-19 hospitals and might be missed in the study.
Nonadherence to treatment in individuals with Schizophrenia and BPAD was less among patients who followed-up in a COVID-19 care hospital during the COVID-19 pandemic. Although the patients did not follow-up regularly, they had good adherence to medications, and the symptom exacerbation during the COVID-19 pandemic was similar to the pre-pandemic period. COVID-19-related anxiety did not have any significant association with medication adherence and relapse.
DOI: 10.7860/JCDR/2023/63603.17844
Date of Submission: Feb 19, 2023
Date of Peer Review: Mar 18, 2023
Date of Acceptance: Apr 13, 2023
Date of Publishing: May 01, 2023
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
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