Damian Sendler: Due of the pandemic produced by the SARS CoV-2 virus, a large portion of the world’s population is in partial or total lockdown at the time of writing this article. This health emergency, which has wreaked havoc on our country of Spain, has changed and will continue to change our social traditions, economy, and, of course, our health-care system in unpredictable ways. This article seeks to foresee some of the changes that will occur in the field of mental health and mental illness care, as well as the specialty that deals with it: psychiatry. In its broadest definition, psychiatry encompasses components of medical psychology, as well as preventive and health promotion, which are unquestionably part of the specialty’s theory.
Damian Jacob Sendler: Many psychiatrists have returned to practice as general practitioners and are bolstering COVID-19 patient care teams. At this time, the importance of basic medical training and the early years of residency, when practical training in medicine and neurology is needed for excellent psychiatric practice, is recognized. The current health crisis has reminded us once again that psychiatry is a medical specialty, and that psychiatrists can and should act as doctors, both in the field of our specialty and when, as in the current crisis or other circumstances (accidents, disasters), our most basic medical knowledge is required. Without lessening the importance of psychological and social determinants in the practice of psychiatry, the current crisis has emphasized and will continue to emphasize the medical paradigm that underpins the specialty’s practice and the importance of excellent public health.
Dr. Sendler: Medicine, like psychiatry, cannot be separated from the psychological aspects of medical treatment that are critical to the practice of any discipline that cares for the sick, including, obviously, psychiatry. Hospitals have been forced to adopt standards for the psychological care of patients, their relatives, and professionals in the middle of a health crisis. Patients require this because COVID-19’s infectious characteristics require them to spend long days and weeks in social isolation, separated from their loved ones and comforted only by professionals wearing masks and gowns that make them virtually unrecognizable and who do much of their observing from a distance. Families, on the other hand, are in more need of information and support because they are unable to be with their hospitalized loved ones. Health professionals, on the other hand, are working longer hours than ever before, in often precarious conditions due to a lack of equipment and resources, caring for patients with health problems that are different from those they usually see and that pose an unpredictable risk of sudden deterioration and death, all while watching their own strength eroded by the wear and tear of so much professional dedication,1 as we will discuss in greater depth below.
Damian Sendler
This pandemic will highlight psychological support as a health tool for the three aforementioned categories, and it will promote collaboration in the practice of health psychology between psychiatrists and clinical psychologists, as well as nursing and social work teams.
Liaison psychiatry has risen to prominence during the COVID-19 epidemic, despite its reputation as a “small” discipline of psychiatry that is subordinate to medical and surgical specialties and underfunded in healthcare systems depending on income produced. Once it is proven that a patient has COVID-19 in addition to their psychiatric condition, several hospitals have chosen to transfer them to different specialist wards, leaving the administration of these patients to the consultation and liaison psychiatry personnel. In several institutions, employees assigned to consultation and liaison psychiatry have taken over psychological support for patients who have been isolated owing to infection, relying on clinical psychologists and nursing personnel in addition to psychiatrists. Liaison psychiatrists have also had to learn and recognize the side effects and interactions of a variety of drugs (chloroquine and hydroxychloroquine, tocilizumab, remdesivir, atazanavir, lopinavir/ritonavir, favipiravir, azithromycin, and many others) that are currently being used against SARS CoV-2, in addition to well-known drugs like corticosteroids and interferon beta When given as a bolus, corticosteroids can generate manic symptoms,2 and interferon (particularly alpha, but also beta) can cause depressive symptoms. 3 & 4 Hydroxychloroquine can cause anxiety and, in rare cases, psychosis, and it can interact with antipsychotics, raising phenothiazines levels. 5 Quetiapine, lurasidone, ziprasidone, and pimozide, as well as some benzodiazepines like midazolam and triazolam, can all be significantly increased by atazanavir and liponavir/ritonavir. 6 Atazanavir, remdesivir, chloroquine, and hydroxychloroquine levels are all reduced by carbamazepine. In patients with alcoholism, disulfiram and nalmefene should be stopped. SARS CoV-2 infection may diminish the white blood cell count in clozapine-treated individuals, necessitating a dose reduction. 7 Although there is a link between antipsychotic use and an increased risk of pneumonia (not proven in the case of coronavirus infection), there are multiple confounding variables, and the benefit–risk balance for psychopharmacological treatment is generally positive. 8
When the pandemic is over, it is hoped that the vital work of consultation and liaison psychiatric teams would be more recognized, if not increased.
Home care, including its more intensive version, home hospitalization, is playing an important role in avoiding hospital admissions for mental disorders (which would put patients at higher risk of contracting COVID-19) and ensuring good care for patients who are not candidates for telemedicine care for a variety of reasons. COVID-19 must be checked for, and the home care workers must be suitably protected, keeping a safe distance at all times. 9 Although not all patients are candidates for this type of care, the COVID-19 pandemic has demonstrated that home care can often replace admission to a psychiatric hospitalization unit, especially in situations like the current one, where many psychiatric wards have had to be converted into COVID-19 wards, and it allows for certain treatments such as long-term injectables9, white blood cell counts to be monitored in patients treated with clozapine,7 and an increase in the number
Damien Jacob Markiewicz Sendler: People with intellectual disabilities and/or autism, as well as patients with severe mental problems and limited functionality who live with older carers, require this type of home care. During a pandemic, it is advisable to phone all such patients’ homes and, if there is no answer, to perform a home visit, as the caregiver may have died and the individual with a mental disease may require care. Home care is a misnomer in the situation of homeless persons, many of whom have mental illnesses, but it has a similar meaning when caring for this group in shelters and other secure locations. An increase in this population, which is so sensitive to diseases and economic crises, is projected in nations without a strong public health system.
Finally, nursing homes, which have been hit hard by the disease, have been candidates for home care, reducing unnecessary hospitalizations. In brief, after the acute phase of the pandemic, home care, including in-home hospitalization, should be pushed.
Damian Jacob Sendler
Transitioning to remote care via outpatient televisits by telephone, chat, or video contact was one of the first strategies generally embraced in all countries. Physical examination is less important in mental health than it is in other disorders, thus it is undoubtedly the field that is best suited to this transition. 10 Even yet, the psychopathological evaluation is limited, particularly when using an audio-only telephone route without visual information. Although it is likely that face-to-face visits will resume after the epidemic, this crisis has demonstrated that many unnecessary journeys can be avoided and that remote communication can, at least in part, replace or supplement in-person encounters. After the COVID-19 epidemic, this is surely one of the lessons we should have learned.
As has been done in other nations such as China and South Korea, big data approaches will likely be used to combat the virus. Those with a technologically savvy populace and smartphone access will use these tools to negotiate the return to social normalcy. As a result, mHealth, or mobile health, will play an increasingly important role in the future, and it can also be utilized to promote mental health11, 12 if the issues of anonymity and data protection are effectively addressed. 13 In Spain, the Spanish Society of Psychiatry has issued a number of recommendations. 14 Post-COVID-16 Psychiatry will increasingly leverage digital resources, such as apps, to provide mental health care, as a case management and empowerment tool. 15
During the pandemic, billions of people have been confined to their homes around the world. Some countries have been tighter than others, but in general, very strict measures have been created, such as Spain’s proclamation of a state of emergency, which has kept the majority of the people at home for weeks (save for vital services). Lockdown can cause tension and worry, and some patients may experience decompensation as a result. The Spanish Society of Psychiatry has issued suggestions for mental health care for the general public. 14 It can be especially difficult for children16, 17, especially those with neurodevelopmental issues, who are stressed by routine changes (e.g., autism spectrum disorders or intellectual disability). The Spanish Royal Decree of State of Emergency allows people with disabilities to get out and walk, though the greater complexity of treating these patients if they become infected, the requirement that they be accompanied by a family member, which creates many opportunities for infection, and the fact that, in the context of such a health emergency, they may not be candidates for a critical care bed due to a so-called “therapy ceiling,” make it less desirable. Therapeutic adherence may be jeopardized in some circumstances. People with Alzheimer’s disease or intellectual disabilities may struggle to comprehend the importance of staying at home. Patients with schizophrenia and other serious mental illnesses, who have their own demands, may be more vulnerable.18 Due to the difficulties in acquiring drugs, addicts may experience withdrawal symptoms, and other addictions, such as drinking, smoking, and online gambling (other than sports betting, which may worsen due to game cancellations), may worsen. The lockdown situation might be especially dangerous for women and children who have been victims of domestic violence. COVID-19 patients, like families whose loved ones are admitted to the hospital, feel lonely and miss out on communication with their relatives. During lockdown, feelings of hatred, indignation, frustration, and guilt are prevalent, and they can make living together difficult. According to studies done during the lockdown, it is recommended that individuals and families restrict their consumption of pandemic news, exercise, eat a nutritious diet, and participate in a variety of leisure activities. 19 In addition to relaxation and mindfulness approaches, reducing screen time before bed can help prevent insomnia. 20 Some of these emotional abnormalities will fade away when the lockdown relaxes (depending on the pandemic’s positive outcome), while some people may experience long-term repercussions such as anxiety disorders and despair.
Damien Sendler: COVID-19 has resulted in extraordinarily high mortality because the majority of the world’s population is not immune to the virus. The elderly and those with preexisting illnesses or immunodeficiencies have been particularly vulnerable, although health care workers have also been exposed to a greater virus load. COVID-19 death comes with the added cruelty of seclusion. Death in solitude not only causes pain to those who die, but it can also create pathological grief in others who are close to them, as well as health professionals, who are sometimes the only ones available to help the terminally ill patient. Experts in end-of-life and palliative care can advise health professionals in charge of managing communication with the patient and family to prevent the aftereffects of these deaths in solitude. Once again, the importance of health psychology cannot be overstated. A calm, understanding demeanor, active listening, and compassionate care for persons in suffering are all beneficial. Aspects of symbolism and spirituality are also essential. If their caretaker dies, certain people with serious mental illnesses may be at the mercy of their condition. In the next section, we’ll look at how grief and guilt affect healthcare practitioners. When the health emergency is over, we’ll realize how critical it is for hospitals to have teams and professionals who are experts in supporting terminally ill patients and their families, as well as their most vulnerable colleagues, such as intensivists, oncologists, hematologists, and others, and all those who have been on the front lines during this crisis. We must be prepared to foresee the high prevalence of difficult mourning that will almost certainly follow by putting in place preventive programs that identify high-risk people early on. A situation like this should boost the frequently marginalized practice of mental health prevention. 21
As we discussed in the sections on the psychological aspects of medical practice and grief, health professionals have been burdened by an abundance of work, generally precarious safety conditions, anxiety about the risk of infection, and a higher level of selflessness when forced to perform tasks for which they were unprepared.
1 Knowing they are under danger, several people have cut off communication with their family or confined themselves to hotels or their own medical facilities. Although many psychiatrists have continued to work remotely with patients, it is possible that in the near future they will be faced with a large number of consultations, patients with exacerbations, and health professionals suffering from burnout or post-traumatic stress disorder. Burnout is already a recognized diagnosis by the World Health Organization, and it’s not surprise that if work pressure continues, the number of cases among healthcare workers would rise, particularly among those who work in nursing homes, where mortality is exceptionally high. The mental health of professionals is jeopardized by various factors in this epidemic. 22 To begin with, the etiological agent is unknown, there is no proven effective treatment, and it is difficult to anticipate who would develop the most serious problems that will necessitate critical care. Second, because of the high demand, professionals in disciplines that do not typically treat patients of this sort are forced to do so in this situation (we’ve seen pediatricians apply sedative to dying 80-year-old patients). Third, health care providers are unprepared or trained to let people die who they could save in normal circumstances; a shortage of critical care beds has forced them to deny intensive care beds to doctors who request them because their patients are not a priority due to age, comorbidity, or other factors (the “therapy ceiling”). This denial puts a significant deal of emotional strain on doctors, who observe how people who may have been rescued just a few weeks ago are now unable to be saved. Prioritizing important beds comes with a lot of responsibility and, in many circumstances, guilt. Many of these judgments have resulted in moral harm, which will undoubtedly be felt in the future. 23 Fourth, because not limiting their emotional side would cause them to collapse if they did not operate in a detached manner, many professionals work in a dissociated manner due to workload and the need to make non-consensus judgments. Finally, there is a challenge that tires out professionals: fear of infection (for themselves, which also means having to stop working and aiding colleagues, and for infecting their family, particularly the elderly), as well as guilt at not doing more owing to fear’s constraints. Sixth, there is often a sense of powerlessness and hopelessness that has been learned. A patchwork where a day when the professional has given everything is followed by a day with considerably more work and stress. There is a sense of lack of internal control with demands that one cannot act upon or modulate, and good work is not rewarded – or perhaps the contrary – and there is a sense of lack of internal control with demands that one cannot act upon or adjust.
Rest and detachment are necessary for the prevention of burnout and stress problems. As a result, shifts and breaks should be scheduled after peak demand, and the health system should provide relaxation, gym, and reading places in the facilities itself, with mandated time made aside for these activities. A professional who is psychologically well is a source of health. Healthcare workers, particularly their mental health, must be better cared for in the post-COVID-19 era.
People with mental illnesses will, without a doubt, be direct and indirect victims of the epidemic.
25, 26, and 27. Although the number of emergency room visits and hospital admissions for patients with psychiatric disorders dropped dramatically during the health emergency, allowing many hospitals to use psychiatric beds for infected patients without mental illnesses, a rebound effect is expected in the medium term. At reality, other non-psychiatric medical problems, such as strokes and heart attacks, are being seen in the emergency room considerably later and with more significant symptoms than typical. Fears of infection and confinement are probably factors in the decrease in demand. In the near future, what telepsychiatry, home care, and psychiatric consultation fail to resolve will most likely be reflected in an increase in acute crises and exacerbations of psychotic and affective disorders. In the medium term, the temporary closure of day hospitals and rehabilitation centers may potentially be a source of concern. Adherence issues could also be a factor. It will be required to reopen resources that have been closed or reduced to a bare minimum as quickly as feasible after the pandemic, as well as to enhance inpatient and outpatient mental health and primary care services.
Thousands of teaching activities have been canceled or postponed as a result of the pandemic, including major events and conferences (the first and most important of which is the MWC, formerly the Mobile World Congress, which was scheduled to be held in Barcelona in February 2020) and many dedicated to psychiatry, such as the European Psychiatric Association and the American Psychiatric Association’s congresses. Conferences that had been planned for the fall have already been canceled. Many educational activities have gone online since the lockdown began, and the majority of them will most likely continue to do so throughout 2020, as the lockdown will not be eased quickly, leaving the celebration of major events to the end. Clinical and scientific sessions at facilities that are themselves modest will be the first in-person events to recover. Despite the fact that the crisis will encourage distance learning, social interaction and face-to-face information exchange are essential components; conferences also serve a social function by assisting us in coping with day-to-day healthcare efforts and promoting research through collaboration that is often established after personal acquaintance.
Confinement, on the other hand, has aided the creation of educational resources such as review articles and books. Many scholars have used this time to carefully review scientific issues, and the submission rate of this sort of scientific article does not appear to have decreased.
Furthermore, the health emergency has impacted resident training in psychiatry, clinical psychology, and mental health nursing, with many being drafted to serve COVID-19 patients or give psychological support to patients, their families, and professionals. Even medical students have gotten involved in the fight against the catastrophe. This will almost certainly be an useful learning experience, and scheduled rotations and internships will almost certainly resume soon, but some of these young people may be affected psychologically by their time on the front lines.
In terms of research, the epidemic has significantly increased scientific collaboration. Many journals, such as the New England Journal of Medicine, have begun offering open access to all articles on COVID-19, and collaborative clinical trials have been designed, approved, and executed in record time, despite the fact that many researchers have had to temporarily leave their jobs in order to shelter in place. The scientific community has shattered barriers and is working together to find therapies and vaccines. Some of these projects will look into the consequences of lockdown as well as many of the unanswered questions about COVID-19 and mental health that we explore in this post. Beyond the infectious disease, it is anticipated that this tragedy will highlight the importance of biomedical research and, like public health, will receive the fiscal and social support it deserves. The goal is that governments will devote a larger portion of their funding to collaborative translational research and health registries, as Spain has done with the CIBER consortium28. 30, 29 In summary, following the epidemic, virtual conferencing and distance learning will be considerably strengthened, allowing for the elimination of much, but not all, travel. Collaborative research will be improved, and the rate of knowledge growth, including in mental health, could be accelerated significantly. The polar opposite would be a huge blunder.