Damian Sendler on COVID-19 and the psychiatric aftermath
Damian Sendler: World-wide lockdown due to the SARS CoV-2 virus pandemic is at an all-time high at the time of this article's publication. It is impossible to predict how this health crisis, which has ravaged our country, will affect our social norms, our economy, and, of course, our health care system. Psychiatry, the medical specialty that deals with mental health and the treatment of those with mental disorders, is the focus of this article. Psychiatry encompasses not only the treatment of mental illness but also the prevention and improvement of one's overall health.
Damian Jacob Sendler: With COVID-19, many psychiatrists have returned to work as primary care physicians, reinforcing patient care teams. Basic medical training and residency training in medicine and neurology, both of which are necessary for good psychiatric practice, are now widely acknowledged for their value. Even though psychiatry is a medical specialty, the current crisis has once again reminded us of this fact. Psychiatrists can and should treat patients as doctors, both in the context of their specialty and in situations where our most fundamental medical knowledge is required. It is important to note that while the current crisis does and will continue to emphasize psychiatry's reliance on a medical model and the importance of public health, it does not diminish the complexity of the psychological and social determining factors.
Dr. Sendler: Mental health is an important part of the practice of medicine, and so is psychiatry, so it is impossible to separate psychiatry from other medical specialties, such as cardiology and neurology. Because of the current health crisis, hospitals have been forced to develop protocols for the psychological care of patients, their families and healthcare professionals. The infectious nature of COVID-19 requires patients to spend long periods of time in social isolation, separated from their loved ones, comforted by professionals who are completely shrouded in disguise and who do much of their observation from a distance. This is necessary for the health of the patients. Families are also more in need of information and assistance because they are unable to be present when a loved one is in the hospital. As we'll see in greater detail, health care providers are working longer hours than ever before, sometimes in dangerous conditions due to a lack of equipment and resources, and caring for patients with health issues that are different from those they are used to seeing and carrying a greater than normal risk of sudden deterioration and death.
As a result of this epidemic, mental health professionals, nurses, and social workers will work together more closely in the field of health psychology to provide psychological support to the aforementioned three groups.
Liaison psychiatry has risen to prominence in the wake of the COVID-19 outbreak, despite its status as a "minor" subspecialty of psychiatry or one that is subordinate to medical and surgical specialties. A growing number of hospitals are relocating patients with psychiatric disorders who have been diagnosed with COVID-19 to specialty wards, leaving the consultation and liaison psychiatry staff to handle the management of these patients. There are many hospitals now using clinical psychologists and nurses in addition to psychiatrists to provide psychological support for patients who are being quarantined because of an infection. There are a number of medications currently being used against SARS CoV-2 that were previously used only anecdotally, such as chloroquine and hydroxychlorophene; tocilizumab; tocilizumab; tocilizumab; remdesivir; lopinavir/ritonavir; favipiravir; azithromycin; and many more. Liaison psychiatrists have also had to learn and recognize the adverse effects and interactions of these medications. In the case of a bolus dose of corticosteroids or interferon (especially alpha, but also beta), manic and depressive symptoms can occur. 3 and 4 As well as anxiety and, in rare cases, psychosis, hydroxychloroquine has the potential to increase phenothiazines when taken with certain antipsychotics. 5 Quetiapine, lurasidone, ziprasidone, and pimozide, as well as certain benzodiazepines, such as midazolam and triazolam, can be significantly increased by atazanavir and liponavir/ritonavir. 6 For the most part, the atazanavir and remdesivir concentrations are reduced by Carbamazepine. The use of disulfiram and nalmefene should be discontinued in patients with a history of alcohol dependence. SARS CoV-2 infection may lower the white blood cell count in clozapine-treated patients, and a dose reduction is recommended. 7 As a general rule, antipsychotic use is associated with an increased risk of pneumonia, but there are numerous confounding variables, and the benefit–risk balance is generally favorable for psychopharmacological treatment.
Damian Sendler
We hope that when this pandemic is over, the critical role of consultation and liaison psychiatry teams will be better understood and even heightened.
In order to avoid hospitalizations for mental disorders (which would put patients at greater risk of contracting COVID-19), home care, including its more intensive version, hospitalization at home, is playing an important role. To ensure the safety of the home care workers, they must be tested for COVID-19 and properly protected at all times. 9 Home care can be a viable option for some patients, especially in situations like the current one where many psychiatric wards have been converted into COVID-19 wards, and it allows certain treatments such as long-term injectables9 and white blood cell counts to be monitored in patients on clozapine7 to be administered.8 However, not all patients are suitable for this type care.
Damian Jacob Markiewicz Sendler: Patients with severe mental disorders and poor functionality who live with elderly caregivers may also benefit from this type of home care. The caregiver may have died and the person with a mental illness may require care during the pandemic, so it's best to call the homes of all such patients and provide a home visit if there is no answer. Many homeless people, many of whom have mental disorders, are cared for in shelters and other places where they are kept in lockdown and are not allowed to leave, so the term "home care" is a misnomer. In countries where the public health system is weak, this vulnerable group is expected to rise in numbers.
As a final option, nursing homes, which have been severely impacted by the infectious disease, have also been considered for home treatment. In other words, after the pandemic's acute phase has passed, promoting home care and hospitalization at home should be a priority.
Outpatient televisits via telephone, chat, or video call are one of the first measures adopted in every country. The field of mental health is ideally suited to this new paradigm because physical examinations are less critical in this area than in other medical specialties. 10 Even so, the scope of a psychopathological examination is significantly reduced if only audio data is obtained via telephone, as opposed to visual data. This pandemic has made it clear that many unnecessary trips can be saved and that remote communication can at least partially replace or complement in-person visits, even though it is predictable that after the pandemic this format will be returned. After the COVID-19 outbreak, we should have learned this lesson the hard way.
Damien Sendler: As in other countries like China and South Korea, big data approaches will undoubtedly be used to combat the virus. Those who have a smartphone-wielding populace will be able to use these tools to get back to social norms. In light of these developments, mHealth, or mobile health, will play an increasingly significant role in improving mental health11, 12, as long as privacy and security concerns are addressed. 13 As a result, Spain's psychiatric society has issued a number of recommendations. 14 Post-COVID-16 Digital resources, such as mobile apps, will increasingly be used by psychiatry in the delivery of mental health services.
Since the beginning of this pandemic, millions of people around the world have been forced to stay at home. Spain's declaration of a state of emergency, which has kept most of the population (except for essential services) at home for weeks, is an example of a country that has imposed very strict rules. Anxiety and stress can cause patients to decompensate during a lockdown. Recommendations for general public mental health care were issued by the Spanish Society of Psychiatry. 14 Changes in routine can be especially stressful for children16, 17, especially those with neurodevelopmental disorders (e.g., autism spectrum disorders or intellectual disability). While it is possible for people with disabilities to leave their homes and walk under the authority of the Spanish Royal Decree of Emergency, the greater difficulty of treating these patients should they contract the disease, as well as the requirement that they be accompanied by an immediate family member, all lead to an increased risk of infection. Therapeutic adherence may be compromised in some cases. Staying at home may be a challenge for those with Alzheimer's disease or intellectual disabilities. Patients with severe mental illnesses, such as schizophrenia, may be particularly vulnerable. Addictions such as alcoholism, smoking, and online gambling (other than sports betting, due to the cancellation of games) may worsen as a result of a lack of access to drugs. The lockdown situation can be particularly dangerous for women and children who are the victims of domestic violence. Families who have a member with COVID-19 in the hospital face the same social isolation and loss of communication that everyone else does when a loved one is hospitalized. During a lockdown, it is common for people to feel enraged, angry, frustrated, and even guilty, which can make it difficult to live together. During the lockdown, researchers found that limiting one's exposure to pandemic news, exercising regularly, eating healthfully, and taking part in a wide range of recreational activities are all important ways to stay healthy. 19 Insomnia can be avoided by practicing relaxation and mindfulness techniques, as well as by avoiding screen time in the hours leading up to bedtime. 20 Emotional disturbances may fade as the lockdown is lifted (depending on the pandemic's positive outcome), but some people may show delayed effects in the form of anxiety disorders and depression.
Damian Jacob Sendler
Because the global population has not been immunized against COVID-19, the virus has resulted in an extremely high death toll. In addition to the elderly and those with underlying conditions or immunodeficiencies, health care workers have also been exposed to a higher viral load due to their work in the field. Isolation is a cruel addition to death by COVID-19. Solitary demise not only causes pain and anguish for those who experience it, but it can also have long-term consequences, such as pathological mourning in those left behind, such as loved ones and health care providers who are often the only ones present to offer support to the dying patient. End-of-life and palliative care experts can be consulted by health care professionals in charge of facilitating communication between patients and their families. Mental health psychology is critical once more. A calm, empathetic attitude, active listening, and supportive care for those who are in pain can be extremely beneficial. Symbolic and spiritual aspects also play a significant role in the overall picture. If a patient with a severe mental illness loses a caregiver, they may be at the mercy of their condition. In the following section, we'll talk about grief and guilt in healthcare workers. Patients, families, and those on the front lines, like intensivists, oncologists, hematologists, and all those who have been on the front lines during this crisis, will be grateful when the health emergency is over for the teams and professionals that hospitals have assembled to assist terminally ill patients and their families. To avoid the inevitable high prevalence of complicated grief, we must devise preventative plans that identify high-risk individuals at an early stage. A crisis like this should strengthen the often-overlooked practice of mental health prevention.
Due to a combination of factors, such as increased workload, precarious working conditions and fear of spreading disease, health care workers have been forced to perform tasks for which they were not adequately trained, as we've discussed in our previous sections on mental health issues in medicine and bereavement.
1 Moreover, many have restricted their contact with their families or have confined themselves to hotels or their own health facilities because they are aware of the dangers. It is expected that a large number of consultations, patients who are experiencing exacerbations, and health care workers who are suffering from burnout or post-traumatic stress disorder will be encountered by remote psychiatrists in the near future. The WHO already recognizes burnout as a diagnosis, and it's not surprising that the number of cases among healthcare workers — particularly those who work in nursing homes, where mortality rates are notoriously high — will rise if work overload persists. Professionals' mental health is threatened by a number of factors in this epidemic. 22 The etiological agent is unknown, there has not been a treatment found to be effective, and it is difficult to predict who will have the most severe complications requiring critical medical care. First and foremost, Second, because of the high demand, specialists in fields such as pediatrics who would not ordinarily treat such patients (we've seen pediatricians sedate dying 80-year-old patients) are being forced to do so. Because of a lack of critical-care beds, health professionals are not prepared or trained to allow people to die who could have been saved under normal circumstances because of their age, comorbidity, etc. (the "ceiling of therapy"), a third issue. Seeing how people who could have been saved a few weeks ago can no longer be saved, doctors are put under a great deal of emotional stress as a result of this denial. As a result of the decision to prioritise critical beds, there is a heavy sense of responsibility and guilt. In the long run, many of these decisions will have a significant impact on our morale. 23 Professionals often work in a dissociated manner due to their heavy workload and the need to make non-consensus decisions, which can lead to emotional collapse if left unchecked. Professionals face a daunting obstacle in the form of the fear of infection (for themselves, which also implies having to stop working and helping colleagues, and for infecting their family, especially the elderly) and the guilt of not being able to do more due to the limitations imposed by fear. Sixth, there is often a sense of learned helplessness and hopelessness that permeates the atmosphere. There are days when the professional has given it all, and then there are days when the professional is under even more stress and pressure. There is a lack of internal control and a feeling of being unable to respond to demands that one can't control.
In order to avoid burnout and stress disorders, it is necessary to take time off and disconnect. The health care system should provide rest, exercise, reading, and relaxation areas in the facilities themselves with mandatory time set aside for these activities as a result of this. Shifts and breaks should be scheduled after the peak demand. Having a well-balanced mental state is a good thing. In the post-COVID-19 era, healthcare professionals' mental health must be prioritized.
Many medical professionals have been forced to make difficult choices as a result of this epidemic, which has put their ethical principles to the test. As a result, many hospitals have revised their "ceiling of therapy" protocols in order to agree on the criteria for invasive interventions, such as mechanical ventilation. 24 It is inevitable that the epidemic will require some compromises in privacy (for example, requiring serological status to be displayed in a mobile app). Mental health professionals, particularly those on the front lines of care for COVID-19 patients who aren't used to making life-or-death decisions, will be treated by psychiatrists if they show signs of stress or frustration or guilt. 23 When the health care system is no longer overburdened, it is time to reevaluate its ability to deal with current situations and to take steps to develop intensive care units and procedures that will help prevent post-traumatic disorders.