Lockdown during the early phase of Covid-19 – effects on specialized mental health services and vocational activities for patients with psychotic disorders

Abstract Purpose People with psychotic disorders may be particularly vulnerable to adverse effects from restrictions implemented to limit the COVID-19 pandemic. Mental health professionals may also be at risk of adverse effects. The aim of this study was to investigate the impact of potential changes in accessibility, quality of care and vocational activity on people with psychotic disorders and the impact on clinicians working in these conditions. Materials and methods Patients and clinicians in specialized mental health services for psychotic disorders answered questionnaires regarding changes in treatment, quality of treatment, vocational activity, and well-being. Data was analyzed with nonparametric tests. Results Inpatients appeared more influenced by the restrictions than outpatients, however, quality of treatment was regarded relatively unaffected. Clinicians seemed satisfied working under these conditions, though a larger portion of clinicians reported changes in treatment compared to patients. The patients who reported being affected by changes in vocational activity tended to report negative effects, but the majority reported being unaffected. Conclusion Overall, patients and clinicians appeared to cope well with the changes they experienced in accessibility, quality of care and vocational activity during the early phases of the pandemic.


Introduction
The coronavirus disease-19 (COVID-19) pandemic has caused major disruptions to the lives of people around the world.In order to limit the spread of the virus many countries implemented comprehensive measures [1], commonly referred to as 'lockdown' .On 12 March 2020, the Norwegian government implemented restrictions constituting 'the first lockdown' in Norway.The measures to prevent the spreading of infection were the most severe restrictions in the country during peacetime and included mandatory physical distancing from others, quarantine and isolation for people potentially exposed to infection, who showed symptoms or had tested positive for COVID-19.In addition, educational institutions and businesses in various industries were required to close [2].Several outpatient mental health services were closedexempting services deemed necessary to prevent severe worsening of mental illness or life-threatening behaviourand access to mental health facilities was limited [3].At inpatient clinics, visitation and leaves of absence were ceased or limited, social distancing measures were implemented and group-based activities altered or cancelled [4] (personal communication).National restrictions were gradually lifted starting 20 April 2020.However, they were not completely removed by October 2020 when several restrictions were implemented again due to a second wave of infection [5].
Various studies carried out during the pandemic indicate that the pandemic itself and consequent restrictions have negatively affected peoples' mental health [6].People with psychotic disorders may be particularly vulnerable [7], with some studies indicating adverse mental health effects for this population [8,9].In an effort to reduce the risk of infection while also assuring continuity of care, there has been an increase in the use of technologies such as videoconferencing in mental health services during the pandemic [10].However, there is little knowledge about how changes in service delivery in specialized mental health services influenced the quality of treatment during early stages of lockdown.
There are indications of reduced accessibility of treatment and organized activities for people with psychotic disorders during early phases of the pandemic.For example, an online survey assessed how family members of people with psychotic disorders experienced treatment and availability of mental health services during the first lockdown in Norway.The majority of the participants reported perceiving their family members' mental health as worsened [11], in addition to reports of reduced access to mental health treatment and decreases in organized daily activities [3].The latter is in concordance with an American study on a sample of people with first episode psychosis.In this study, participants experienced what Szmulewicz and colleagues [12] categorized as 'major job losses and educational disruption' during early stages of the pandemic.In addition to the negative consequences from reduced accessibility and/or quality of treatment, loss of vocational activity may be unfortunate as employment/vocational rehabilitation may reduce psychiatric symptoms and improve quality of life [13,14].
The aim of this paper was to explore how restrictions during lockdown influenced individuals receiving and providing specialized mental health services for psychotic disorders in Norway.We wanted to examine how restrictions influenced ongoing treatment and the potential impact of changes in vocational activities based on the hypotheses that treatment included less physical interaction and more use of technologies, that quality of treatment worsened during early phases of lockdown, and that patients engaged in less vocational activity affecting them negatively.We further hypothesised that potential difficulties providing treatment, combined with ongoing restrictions and possible exposure to disease, could negatively influence clinicians working in specialized mental health services.We consequently investigated how clinicians experienced lockdown working conditions.

Materials and methods
Individuals receiving or providing care for psychotic disorders in specialized mental health services at Oslo University Hospital during the first lockdown period were asked to fill out questionnaires developed for the study.This included patients who spoke sufficient Norwegian to fill out the questionnaires and were not considered too unwell for participation, as well as employees in full time clinical positions (i.e.treatment responsible personnel and nursing staff ).The participating units in the study were Nydalen Outpatient Clinic, South Oslo Outpatient Clinic, Section of Psychosis Treatment (inpatients) and Section of Early Psychosis Treatment (in-and outpatient clinic) at Gaustad Hospital.These units provide inand outpatient services designed for people with psychotic disorders, but acute inpatient service units were not included.Participants were recruited between June and July 2020.
Inpatients, outpatients and clinicians from the two settings filled out different questionnaires with similar content.The process of developing the questionnaires is described elsewhere [15].All the questionnaires asked participants to provide some sociodemographic information.Patients were asked to state age and gender.Clinicians were asked how many years of clinical experience they had and their educational background (with the response alternatives doctor/psychologist or other).Exposure to the virus was assessed with yes/no questions (e.g.'have you had symptoms of the corona virus?').Participants were asked to indicate which, if any, differences in treatment they had experienced after onset of restrictions from a list.Patients were asked to report whether they experienced changes in quality and accessibility of treatment, and to indicate their level of overall satisfaction with the offered treatment during lockdown.They were also asked whether they were engaged in various vocational activities, to indicate which changes they had experienced (if applicable) from a list, and how much changes in vocational activity had affected them (on a scale ranging from 'very negatively' to 'very positively').
Clinicians were asked to indicate how much they believed the quality of treatment was influenced by restrictions and level of agreement with various statements assessing COVID-19 related concerns and overall satisfaction during the early phases of lockdown.Translated versions of the full questionnaires are included as appendices (A-D).
In an effort to lessen the risk of misunderstandings, a research associate was present and available to answer questions while the participants were responding to the questionnaires.Written informed consent was obtained from all participants.The study was approved by the Regional Committee of Medical Research Ethics and the Norwegian Data Protection Authority.ClinicalTrials.gov Identifier: 137567.

Data analyses
SPSS version 28 was used for all statistical analyses [16].Due to the differing sample sizes and the distribution of answers, nonparametric alternatives were applied when analyzing the data.Levels of significance were set at p = .05.Effect sizes were interpreted according to guidelines by Cohen [17], indicating small, moderate and large effects at r = .01,.06 and .14.
Separate frequency analyses were conducted for patients and clinicians on descriptive variables and clinicians' degree of exposure to the virus and experience with quarantine due to symptoms of COVID-19.Patients' exposure to infection and sample characteristics separated by treatment setting (i.e.in-versus outpatient setting) are reported elsewhere (Seierstad et al. in prep).
How patients and clinicians believed lockdown influenced treatment, quality and accessibility of services was explored using frequency analyses.Fischer's Exact Probability Tests and Chi Square Tests (with yates' Correction for Continuity) were conducted to investigate whether patients and clinicians from the same treatment settings responded differently to questions about changes in treatment.Mann-Whitney U Tests were applied to assess if there were statistically significant differences in how patients from different treatment settings responded regarding accessibility and quality of treatment, and whether clinicians working in different settings answered differently to questions addressing these topics.
Frequency analyses were conducted to investigate how many patients were engaged in vocational activities, what differences in activity they reported and how affected they considered themselves by such changes.
Clinicians' answers to questions about COVID-19 related concerns and overall satisfaction during the first lockdown were assessed using frequency analyses (separately for the two treatment settings).Mann-Whitney U Tests were performed to investigate whether there were significant differences in how clinicians from the different treatment settings answered these questions.

Sample characteristics
Among the patients, 57.5% were male and 42.5% female.Age ranged from 18 to 60 years, with a mean of 32.12 years.Clinical experience among clinicians ranged from zero to 42 years (mean = 17.78 years), 32.1% were doctors or psychologists while the rest (67.9%) had other educational backgrounds.Table 1 displays clinicians' exposure to infection.

Changes in treatment
All participants from inpatient clinics answered that the treatment offered had been affected by lockdown.Regarding leaves of absence from the clinic, 26.7% of inpatients answered they experienced a reduction after onset of restrictions (clinicians were not asked).Results from frequency analyses regarding changes in treatment as reported by inpatients and clinicians at inpatient clinics are displayed in Figure 1.There were statistically significant differences regarding reduced number of visitors (p =.006) and activities (p =.008) in the clinic, as more clinicians reported these changes (i.e. agreed to statements indicating there had been fewer activities and visitors in the clinic during lockdown).There were no statistically significant differences in their reports regarding frequency of contact with therapists or other patients.
Figure 2 shows the results from frequency analyses of agreement with suggested changes in treatment, as reported by outpatients and clinicians working in outpatient clinics.It should be noted that the clinicians were asked whether they had increased phone contact, use of videoconferencing, home visits and appointments outside, while the outpatients were asked if they had these kinds of treatment.Outpatients were also asked whether there had been no changes in treatment (22.0%), and if contact with the outpatient clinic had been more seldom (15.4%) or more frequent (7.7%).Chi-Square Tests showed statistically significant differences between outpatients and clinicians' agreement with items suggesting increased contact by phone χ 2 (1) = 25.75, p < .001,phi = −.47 and increase in appointments outdoors χ 2 (1) = 23.22,p <.001, phi =-.44.These were moderate effects.Fischer's Exact Probability Tests showed significant differences regarding agreement with statements suggesting an increase in use of videoconferencing (p =.002) and home visits (p =.002).For all these items, a larger percentage of clinicians indicated that they experienced the suggested changes in treatment during early phases of the pandemic.

Accessibility and quality of treatment
Results from frequency analyses regarding in-and outpatient reports of accessibility and quality of treatment are displayed in Table 2. Results from Mann-Whitney U Tests indicate a small statistically significant difference in responses to the question 'Would you say the treatment you have been offered by mental health services post March 12th 2020 has been: worse/unchanged/better?' .Outpatients (mean rank: 54.70) tended to respond more positively compared to inpatients (mean rank: 37.64), U = 422, z =-2.31, p =.021, r =.23.The tests did not suggest significant differences between the groups on the questions regarding accessibility and overall treatment satisfaction.
Clinicians' answers on questions related to quality of treatment and how it was affected by the restrictions are presented in Table 3. Mann-Whitney U Tests did not suggest any significant differences in how clinicians working at in-and outpatient clinics responded to these questions.Participants could indicate agreement with several proposed changes in activity, e.g.indicating that they received more support from their employment specialist and that support was provided by phone/videoconferencing.There is, however, missing data related to changes in vocational activity as not all participants engaged in vocational activities responded to the questions relating to potential changes.

Organized activities
In total, 58.5% of the participants receiving specialized mental health care reported being engaged in one or multiple of the aforementioned activities before lockdown.Most, 53.6%, reported no change when asked to what degree they were affected by changes in employment, studies and vocational rehabilitation.About 10% reported being positively affected ('positively' = 7.1%, 'very positively' = 3.6%), while about a third stated they had been either 'negatively' (32.1%) or 'very negatively' (3.6%) affected by the changes.Six of the participants did not respond.When including all participants that answered this question in these analyses (n = 82), the pattern of responses was similar, with a greater portion of the respondents answering 'no change' (65.9%).

Clinician satisfaction
Complete results from the frequency analyses of clinician reports of COVID-19 related concerns are included in Appendix E.
Overall, most clinicians indicated being content to a large or very large degree since onset of restrictions.Less than 5% of clinicians from each treatment setting indicated no-or only small agreement with the statement that they had been generally content since restrictions began.The majority reported no or low levels of fear of getting seriously ill -with somewhat higher concerns of infecting family members -and small or moderate agreement that they had been thinking about catching infection at work or fear that a family member would fall seriously ill.Respondents largely reported being 'not at all' worried or worried to a 'small degree' that a family member would lose their job due to the COVID-19 crisis.Most clinicians disagreed with statements regarding the decreased quality of sleep and difficulties with concentration due to the COVID-19 crisis (indicated by responding 'not at all').The majority of clinicians believed their family and friends were either unafraid or only slightly afraid of being infected by them.Most clinicians responded with no or little agreement to a statement that other people avoided contact with their family because they worked at a hospital.The majority indicated moderate to large agreement that they found it challenging not to be with other people, while about a fifth from both settings indicated small agreement.
The clinicians mostly felt they had gotten adequate information from management about how they were handling the COVID-19 situation, and responded with high agreement that measures to prevent spread of the disease was good at their unit.The majority responded not having talked to their leader about fear of infection and not wanting to avoid work due to fear of infection (over 70% from both treatment settings answered 'not at all' to this statement).Answers to whether they thought all patients should be tested before they were admitted varied.
Mann-Whitney U Tests revealed two statistically significant differences between the responses from clinicians working in different treatment settings.Clinicians from inpatient clinics tended to agree more (mean rank: 61.2) with the statement that they were afraid of bringing disease from work and infecting family members compared to clinicians from outpatient clinics (mean rank: 44.7), U = 958, z =-2.70, p =.007, r =.26.Clinicians from inpatient clinics also had a higher tendency to agree that all patients should be tested before they were admitted (mean rank: 59.0, clinicians from outpatient clinics: 45.9.), U = 994, z =-2.12, p =.034, r =.20.These were both small effects.Notes: chi square tests and fischer's Exact Probability tests suggested all differences between the groups were statistically significant.

Quality of treatment during early phases of lockdown
Most patients from both treatment settings reported quality of treatment to be unchanged, while the majority of clinicians stated quality was moderately influenced at most.In addition, more than half of the outpatients reported being satisfied (or very satisfied) with the offered treatment in this period.These findings are in contrast with results from an online survey conducted with people with psychotic and bipolar disorders in Norway during the same period.Barrett and colleagues [8] present findings indicating that more than a third of their sample reported receiving insufficient treatment during early phases of the pandemic, as well as reductions in quality treatment.One reason for the discrepancy in findings may be that participants in the studies received support from different mental health services, and some of the participants in Barrett and colleagues' study did not receive treatment from mental health services at all.If so, this suggests that the implemented restrictions differently influenced the quality of treatment in various health services.
To the extent that lockdown did influence quality of treatment, however, inpatients appear to have been more affected.There may be several reasons for this discrepancy.Firstly, inpatients may have been more vulnerable to reductions in treatment alternatives.Compared to inpatients, it is likely that outpatients had access to more alternate activities outside the clinics such as interaction with housemates or family members.Reduction in visitors in the inpatient clinics may be a second contributing factor.Family support helps coping in patients with schizophrenia [18], and a study conducted by Lau and colleagues [19] reported that participants cared more about family and friends during the pandemic.Although clinicians probably made their best efforts to facilitate inpatient family visitation, both inpatients and clinicians from inpatient clinics reported reductions in visitation in the early phases of lockdown.As such, inpatients may have experienced a reduction in family support.This is in line with findings suggesting family members of inpatients in the UK experienced challenges keeping in touch with their loved ones during the pandemic, partially because visitation was limited [20], and that Norwegian inpatients found lack of contact with their loved ones to be difficult during the beginning of lockdown [21].Finally, the preventative measures may have negatively impacted the atmosphere in the clinics, which has been linked to important treatment outcomes for inpatients [22][23][24].Open therapeutic settings positively influence important facets of perceived atmosphere at inpatient clinics [25].It can be argued that preventive measures such as restrictions on patients' leave of absence, physical social distancing, staff's use of facemasks, restrictions around common meals and area control restrictions (e.g.no one allowed in the game room) could negatively impact atmosphere in the inpatient clinics.The combination of limitations in treatment alternatives, reductions in family support, and a worsened atmosphere could explain the perceived negative effect on treatment quality of inpatients compared to outpatients.
Compared to outpatients, clinicians from outpatient clinics reported more changes in treatment during early phase lockdown and the majority agreed there had been increased contact with their patients by phone and more appointments outside.Less than half of the outpatients agreed that they had received treatment by phone and outside.Still, outpatients expressed markedly more agreement with these suggested changes compared to the other statements.Combined with the finding that the quality of treatment was not greatly affected at this time, these findings may suggest that the use of technology in treatment can somewhat compensate for lack of physical interaction (at least short term).Use of digital consultations is in accordance with current treatment guidelines as it has been explicitly encouraged by Norwegian health authorities, targeting at least 15% of all consultations to be conducted via telephone or video [26].Utilizing technology may increase the availability of mental health services [27], but is not without limitations [28,29].Such limitations may include logistical challenges, less engagement from clients and other clinical challenges [30][31][32].Potential long-term effects of phone consultations should also be considered.One possibility is that conducting a portion of the appointments by phone freed up clinicians' time and provided more flexibility for the in-person appointments.A large portion of clinicians reported agreement that they conducted more appointments outside.This might indicate that clinicians were able to meet their patients closer to their homes and/or in more therapeutic environments than the therapists' offices.Having to make changes in their routines and habits may also have facilitated clinicians' ingenuity and furthered individual adaption of treatment for each patient.

The impact of changes in vocational activities
More than half of the patients were engaged in some form of vocational activity before the onset of lockdown.Even though several patients expressed they had not experienced changes, a larger portion reported reductions in daily activities after the lockdown.The exceptions being students (where the majority reported partaking in internet-based studies) and patients receiving support from employment specialists.
Most of the patients who were engaged in vocational activity prior to lockdown reported that changes in vocational activities had not affected them.Among the patients who reported being affected, however, more than three times as many people reported being 'negatively' or 'very negatively' affected (a third in total) as compared to 'positively' or 'very positively' .About a quarter of the patients included in the study reported having received support from employment specialists prior to lockdown.Wittlund and colleagues [33] investigated Individual Placement and Support services in Northern Norway during lockdown.They found that the COVID-19 pandemic negatively affected these services, reporting that employment specialists were given additional work tasks or reassigned to other roles, resulting in less time for clients, as well as negative impacts on collaboration with potential employers and clinicians.If similar effects influenced our sample, this may partially account for why patients reported negative effects from changes in vocational activity.In addition, reductions in vocational activity may have had a negative impact on social functioning, structure of daily life and self-efficacy [34][35][36].Perceived decrease in exposure to stressful situations outside the home and increased flexibility when working from home may contribute to the positive effects reported by a minority of patients.

Clinician satisfaction
Perhaps surprisingly, clinicians appeared relatively satisfied working under early-phase lockdown conditions.Health workers reported low levels of fear of infection, and most responded that they were generally doing well during lockdown.These findings are in contrast to previous studies indicating increased symptoms of anxiety and depression among healthcare personnel during the pandemic [37,38].This discrepancy may be because the vast majority of clinicians in the current study were not infected with COVID-19, because they expressed a general agreement with the measures taken to restrict infection, and experienced being well informed about how the hospital management was handling the pandemic.Such explanations are in line with previous findings from studies of health care workers involved in the severe acute respiratory syndrome (SARS) crisis, suggesting that perceived lack of safety and/or control and being quarantined were associated with poor mental health for this group [39].The clinicians were also not working directly with COVID-19 patients, which may have made them less vulnerable to adverse effects on mental health [38].Importantly, these findings are from early stages of the pandemic, meaning that the long-term effects of living with such restrictions were not yet detectable.Notes: * the vocational activity in the rehabilitation programme had ended or been reduced, but economic benefit schemes were not affected.
It is worth noting that clinicians from inpatient clinics agreed more with two of the statements assessing COVID-19 related fears compared to clinicians from outpatient clinics.These statements assessed fear of bringing disease from work and an opinion that all patients should be tested before being admitted, suggesting clinicians working with inpatients were more concerned they would be infected at work.This may be due to a lesser degree of perceived control compared to clinicians working in outpatient clinics.For example, they may have experienced more difficulties keeping physical distance between themselves and the patients, and therefore felt they had less influence over the degree of exposure to the virus.It is also likely they had known their patients shorter and worked with patients in a more unstable phase of illness compared to clinicians in outpatient clinics.

Strengths and limitations
We would like to acknowledge strengths of the current study.The sample includes reports from both patients and clinicians from several different units.We believe this increases the generalizability of these findings as the sample likely includes patients in different phases of illness and with different support needs, as well as clinicians working in different environments and treatment cultures.The likelihood of including participants outside of the population we wanted to study is also low due to the targeted inclusion practice.
There are however also limitations to address.The number of respondents in the inpatient and outpatient groups is quite different which makes direct comparison somewhat challenging.The sample size of the inpatient group is small and more data is necessary to conclude on how lockdown affected this group.In addition, some discrepancies in the reports from clinicians and patients could be because clinicians also reported on patients that did not participate in the study.Participants may have been unable to remember their situation prior to lockdown adequately, creating potential for biased responses.However, as we wanted self-reported data from patients to provide information about their personal experience, we did not see any other alternatives rather than asking them directly about their experiences.Because we did not predict the implementation of lockdown before it happened, we could not collect this information in real time.The use of data from both patients and their clinicians may help corroborate the validity of the reports.We also note that restrictions differed between different countries [40,41] and measures implemented in Norway may not correspond with measures in other countries during the same period.When considered together, findings from various countries may give an indication of potentially differing effects associated with different restrictions and provide useful insight for similar situations in future.

Figure 1 .
Figure 1.Percentage of clinicians and patients from inpatient clinics that agreed to statements suggesting inpatients had less visitors, fewer activities in the clinic, less/more contact with their therapist and/or less/more contact with other patients during lockdown.Notes: *statistically significant difference in responses according to fischer's Exact Probability tests.

Figure 2 .
Figure 2. Percentage of clinicians and patients indicating that lockdown influenced treatment in outpatient clinics by increased phone contact, videoconferencing, home visits and/or increase in appointments outside.

Table 4
displays the results from frequency analyses investigating how many patients were engaged in various vocational activities prior to lockdown and what changes they reported.The percentages indicate the portion of respondents who answered affirmative or supported the statement.

Table 1 .
Percentage of clinicians that were tested and quarantined due to suspected coVid-19 infection, separated by treatment setting.

Table 2 .
distribution of answers given by patients to questions regarding accessibility and quality of treatment.responses are displayed separately for the two treatment settings.

Table 3 .
distribution of answers to questions regarding quality of treatment during lockdown by clinicians working at in-and outpatient clinics.

Table 4 .
Percentages of patients that were in various forms of vocational activities prior to lockdown and their agreement with statements about vocational changes after onset of restrictions.