Course Authors
Roger Ho M.D., F.R.C.Psych., F.R.C.P.C., and Cyrus Ho M.B.B.S., M.R.C.Psych.
Dr. Roger Ho is Associate Professor and Dr. Cyrus Ho is Consultant Psychiatrist, Department of Psychological Medicine, National University of Singapore and National University Health System.
Within the past 12 months, Dr. R. Ho has been on the Speakers Bureau for Johnson and Johnson and Eisai Pharmaceuticals. Dr. C. Ho has nothing to disclose relevant to this activity.
Albert Einstein College of Medicine, CCME staff and interMDnet staff have nothing to disclose relevant to this activity.
Estimated course time: 1 hour(s).
Albert Einstein College of Medicine – Montefiore Medical Center designates this enduring material activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
In support of improving patient care, this activity has been planned and implemented by Albert Einstein College of Medicine-Montefiore Medical Center and InterMDnet. Albert Einstein College of Medicine – Montefiore Medical Center is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Upon completion of this Cyberounds®, you should be able to:
Delineate the psychiatric comorbidity of the general public during the COVID-19 pandemic;
Describe the impact on mental health of healthcare workers during the COVID-19 pandemic;
Assess the impact on mental health of psychiatric patients during the COVID-19 pandemic;
Assess the impact on mental health of the general workforce during the COVID-19 pandemic;
Describe the psychiatric comorbidity of COVID-19 infection and management.
The coronavirus disease 2019 (COVID-19) was declared a pandemic by the World Health Organization (W.H.O.) on March 11, 2020.(1) China was the first country that identified the novel coronavirus as the cause of the pandemic. Globally, as of May 25, 2020, the number of confirmed cases was 5,525,299, the number of deaths was 347,110 and the number of recovered cases was 2,316,127.(2)
The challenges of COVID-19 pandemic include the following issues: modified lifestyle due to lockdown and social distancing, misinformation about the origin of COVID-19, global socioeconomic crisis, travel restrictions, prolonged home stay, cancellation of public and private events, panic buying, discrimination, overwhelmed hospital services and burnout among health professionals.(3) All the above factors affect mental health of most people in the society. There is an urgent research need to understand the impact on mental health during the COVID-19 pandemic, with special focus on patients with a psychiatric condition, general workforce and healthcare workers.(4)
The Impact of COVID-19 Pandemic on Mental Health in the General Population
Wang et al. surveyed the initial psychological responses of the general public (1210 respondents from 194 cities) from 31 January to 2 February 2020, just two weeks into the China's outbreak of COVID-19 and one day after the W.H.O. declared a public health emergency of international concern.(5)The most common psychological problems mentioned were symptoms of post-traumatic stress disorder (PTSD). About 53.8% of respondents rated moderate or severe PTSD symptoms. The second most common problem is depression. About 16.5% of respondents reported moderate to severe depressive symptoms. The third most frequently cited issue was anxiety. About 28.8% of respondents reported moderate to severe anxiety symptoms.
The prevalence of moderate or severe psychological impact of PTSD symptoms, as measured by the Impact Event Scale-Revised (IES-R), was higher than the prevalence of depression, anxiety and stress, as measured by the Depression, Anxiety, Stress Scale-21 (DASS-21). The difference between IES-R and DASS-2 results from the fact that the IES-R is more sensitive in assessing the psychological impact after an event. In this study, respondents attributed the traumatic events to the COVID-19 outbreak, while the DASS-21 did not link to any specific event.(5)
Wang et al. conducted a longitudinal study four weeks after the COVID-19 outbreak. They found that there was no clinically significant reduction in the levels of PTSD symptoms, anxiety and depression.(6) About one-third of respondents experienced social discrimination because of the COVID-19 epidemic. People who had contact history and were under a stay-at-home order had greater anxiety, financial concern and loneliness.(7) At the outbreak and peak of the COVID-19 pandemic, physical symptoms resembling COVID-19 infection, such as fever, chills, headache, myalgia, cough, difficulty in breathing, dizziness, coryza, sore throat, persistent fever, poor self-rating of health status and history of chronic illness, were significantly associated with higher IES-R scores, DASS-21 stress, anxiety or depression subscale scores.
The dissemination of health information was important during the initial outbreak of COVID-19. Wang et al. found that the Internet was the primary health information channel for the general public during the initial stage of COVID-19 epidemic (>90%).(5) The general public requested regular updates on the latest information on the route of transmission, availability and effectiveness of medicines/vaccines, travel advice, overseas experience in handling COVID-19, number of cases and location, advice on prevention, information on outbreaks in the local area and details on COVID-19 symptoms.(5)
The Impact of COVID-19 on Mental Health of Healthcare Workers
An emerging issue is how best to understand the mental health of healthcare workers during the COVID-19 pandemic. Many healthcare workers are working outside of their area of expertise, without proper guidelines, with limited personal protective equipment (PPE) and facing greater numbers of seriously ill and dying patients.(8) A recent review suggested that adverse mental health scores, such as vicarious traumatization scores, are higher among non-frontline healthcare workers because they might feel guilt about having avoided frontline healthcare activities. This postulation requires further confirmation by research.(9)
In a multi-national study that surveyed 906 healthcare workers, the most common psychological problems reported included moderate to extremely-severe anxiety (8.7%); moderate to very-severe depression (5.3%); severe levels of PTSD symptoms (3.8%); and moderate to extremely-severe stress (2.2%). The most frequent physical symptoms mentioned were throat pain (33.6%), headache (32.3%), anxiety (26.7%), lethargy (26.6%) and insomnia (21.0%).(10) Psychological distress levels may also be exacerbated by the fear of being a carrier of the virus, causing transmission among fellow healthcare workers and their own families if they choose to continue to work but there is no quarantine facilities. The fear of transmission is especially high given multiple case reports of asymptomatic transmission of COVID-19.(11)
Tan et al. reported that non-medical health care workers had higher prevalence of anxiety than medical health care workers even after adjustment for potential confounders.(12) Reasons for this may include the fact that non-medical health care workers have reduced accessibility to formal psychological support, less first-hand medical information on the COVID-19 outbreak, less intensive training on personal protective equipment and infection control measures, as compared to the frontline healthcare workers.(12)
Targeted multidisciplinary interventions are needed to support healthcare workers by addressing both the psychological and physical symptoms. All efforts should be made to offer psychological support and interventions once an acute infection has been excluded. Dedicated counselling may be arranged to allay their fears of transmitting the infection to their family members, as well as to boost the confidence and morale of healthcare workers.
The Impact of COVID-19 Pandemic on Psychiatric Patients
Social isolation, home confinement, social distancing and poor social support pose more adverse threats to individuals with mental illness. These factors may lead to serious mental health issues and worse prognosis in this population.(13) Hao et al. compared the mental health status of psychiatric patients and healthy controls during COVID-19 pandemic.(14) There were significantly more psychiatric patients reporting PTSD-like symptoms, anxiety, depression, stress and insomnia as compared to healthy controls. Contributing factors to worsening mental health were likely delays in delivery of psychotropic medications, lack of access to primary care or outpatient clinics, increased financial difficulty, personal concern of contracting COVID-19, long duration of staying at home, as well as more impoverished living conditions due to shortage of supplies in the weeks following the outbreak.
The changes in society and economic recession as a consequence of the COVID-19 pandemic might lead to feelings of hopelessness and increased suicidal ideation among psychiatric patients.(14) During the COVID-19 pandemic, multiple factors caused a reduction in psychiatric service. First, immediate mental health care needs of psychiatric patients were a lower priority when the number of COVID- 19 cases rose sharply. Second, psychiatric patients were encouraged not to visit hospitals, as health services were devoted to managing terminally ill patients and suspected or confirmed cases of COVID-19. Third, the lockdown measures made it difficult for patients to see psychiatrists and other mental health care providers due to insufficient healthcare resources, along with fear of contracting COVID-19 in hospitals which managed patients infected by COVID-19.(14)
Telephone or online consultations became the new norm during the COVID-19 pandemic. Telephone or online consultations offer several advantages including flexibility in the appointment time and convenience for having the clinical interview in the home environment.(15) Diagnostic challenges, the effect of online or phone consultation on the therapeutic alliance, challenges associated with the use of technology for elderly people and ethical concerns (e.g., potential breach of confidentiality) were identified as negative aspects of telephone or online consultations.(15)
Insomnia is a common problem reported by psychiatric patients during the COVID-19 pandemic.(14) It is recommended that health care providers encourage these patients to consider cognitive behavior therapy (see further details below), avoid staying in bed in the day time, practice sleep hygiene (e.g., avoid heavy meals or strenuous exercise before sleep) and try to maintain the stability of the circadian regulatory system (e.g., avoid day and night reversal) to improve sleep quality during the COVID-19 pandemic.(16)
During the COVID-19 pandemic, psychiatric patients did not experience additional discrimination. One possible explanation was that society held more negative views towards COVID-19, as compared to psychiatric illnesses during an outbreak of a life-threatening infection.(14) Respondents with psychiatric illnesses did not show an increase in alcohol intake as compared to healthy people. This observation is different from a previous study, which reported the increase in alcohol intoxication and abuse after natural disasters (e.g., an earthquake).(17) As the government implemented lockdown restrictions for all citizens, people with and without psychiatric illnesses did not have frequent access to purchase alcohol from local markets. Also, entertainment venues, bars and restaurants were ordered to cease operation and these measures further reduced alcohol intake of psychiatric patients and healthy people.
The Impact of the COVID-19 Pandemic on Mental Health of Workers Who Returned to Work after Lockdown
Most of the COVID-19-related research has raised concerns regarding the mental health effect of the disease on patients with psychiatric disorders and the health-care workforce.(18) There is, also, a lack of research on the mental health of the general workforce, especially those who returned to work after extensive lockdown period.
Tan et al. conducted a mental health study of workers who returned to work after lockdown. They found that about 10.8% of the workforce met the diagnostic criteria for PTSD upon returning to work during the COVID-19 epidemic.(19) This workforce study also suggests that the experience of returning to work during the COVID-19 pandemic did not confer an increase in the prevalence of PTSD symptoms, depression, anxiety and stress when compared to results of a similar study which was conducted on the general population during the COVID-19 outbreak.(5) Factors that prevent negative mental health included personal prevention measures such as the frequent practice of hand hygiene and wearing face masks, as well as organizational initiatives including significant improvement of workplace hygiene and concerns from the employer about the health status of their employees.(19)
Psychiatric Comorbidity of COVID-19 Infection and Management
Patients infected with COVID-19 infection can present in delirious state with clouding of consciousness. Neurological symptoms include headache, loss of smell and taste and encephalitis.(20) The following psychotropic medications should be avoided in COVID-19 patients: clozapine (due to leukopenia and lymphopenia associated with COVID-19 infection), valproate (due to thrombocytopenia and liver injury associated with COVID-19 infection), lithium (because of renal injury associated with COVID-19 infection) and benzodiazepine (due to delirium and respiratory difficulty associated with COVID-19 infection).(21)
For medications that can be used to treat COVID-19, the psychiatric side effects are listed as follows: Anti-viral agents such as remdesivir (no neuropsychiatric symptoms), favipiravir (no neuropsychiatric symptoms), convalescent plasma therapy (no neuropsychiatric symptoms), corticosteroids (e.g., depression, mania, delirium and psychosis), chloroquine and hydroxychloroquine (e.g., psychosis, depression, delirium and change in personality).
Recommendations
Based on the above studies, there are several recommendations:
- Each country should conduct epidemiological research to identify high-risk groups for adverse mental health based on sociodemographic information. The health authorities need to offer early psychological interventions. Health authorities could consider providing online or smartphone-based psychoeducation and psychological interventions (e.g., cognitive behavior therapy, CBT, mindfulness therapy) to reduce risk of virus transmission by face-to-face therapy.(22)
- Education authorities need to monitor the mental health of students. Students were also found to experience a psychological impact of the outbreak and reported higher levels of stress, anxiety and depression.(5) During the COVID-19 pandemic, most schools were shut down indefinitely. The uncertainty and potential negative impact on academic progression could have an adverse effect on the mental health of students, especially those who were more academically competitive.
- Cognitive behavior therapy (CBT) can be helpful during the COVID-19 pandemic. Cognitive therapy can challenge cognitive bias when a person overestimates the risk of contracting and dying from COVID-19.(5) As most people were homebound for 20–24 hours per day during the COVID-19 pandemic, behavior therapy could focus on relaxation exercises to counteract anxiety and promote activity scheduling (e.g., home-based exercise and entertainment) to mitigate depression in the home environment.(5)
Due to the higher prevalence of PTSD symptoms, trauma-focused cognitive behavior therapy (TF-CBT) can be modified for the COVID-19 pandemic with emphasis on the following aspects: (1) psychoeducation on the mental health impact of the COVID-19 pandemic; (2) development of psychosocial skills to optimize psychological adjustment during quarantine and lockdown; (3) expression of feelings and problem solving to handle emotions and common problems (e.g., shortage of necessities) encountered during quarantine and lockdown; (4) cognitive formulation to illustrate the relationships among thoughts, emotions and behaviors; (5) cognitive challenge or modification of unhelpful thoughts about COVID-19 and perceived discrimination; (6) trauma narration, in which individuals describe their personal traumatic experiences during COVID-19 pandemic; (7) home-based relaxation techniques and stress management skills; (8) grief therapy to handle potential loss of family members or friends who died of COVID-19; (9) online peer support group sessions to allow ventilation about their trauma; (10) enhancing safety and precaution to reduce the risk of contracting COVID-19 and (11) exposure to trauma reminders to overcome avoidance of situations that are no longer risky when the COVID pandemic is over.(6)
- Strong association between physical symptoms and the psychological impact of the COVID-19 outbreak supports the importance of developing a rapid diagnostic test for COVID-19. There is a need for involving local health authorities as health gatekeepers, who are often the first health professionals to detect and report suspected COVID-19 cases. They are also a channel to which accurate information regarding COVID-19, protective equipment and intervention packages can be delivered. Having walk-in COVID-19 testing centers in the community is recommended.(23)
- The W.H.O. and governments from all countries should minimize the possibility of discrimination against certain groups of people or ethnicities regarding the origin of COVID-19. Our findings indicate an urgency to develop a more effective system to disseminate accurate health information related to the COVID-19 epidemic by the W.H.O. and governments.(24)
- Specific precautionary measures including hand hygiene and wearing a face mask could protect mental health. Universal face mask use, as a prevention method to reduce the transmission of COVID-19, was associated with lower levels of anxiety and depression, regardless of the presence of symptoms.(6) This is an interesting and important phenomenon due to the divided scientific opinion on protective effects of usual face masks, coupled with the scarce availability of face masks. Efforts are needed to impart an unbiased and clear guidelines on the use of face masks to allay the fears, confusions and sense of inferiority (for people with no access to the masks) among the public.(6)