key: cord-0786603-ttir73l5
authors: Stefana, Alberto; Youngstrom, Eric A.; Jun, Chen; Hinshaw, Stephen; Maxwell, Victoria; Michalak, Erin; Vieta, Eduard
title: The COVID‐19 pandemic is a crisis and opportunity for bipolar disorder
date: 2020-06-08
journal: Bipolar Disord
DOI: 10.1111/bdi.12949
sha: 5126a901d72b3f50e24b0b3e3a0005c2f0afb57d
doc_id: 786603
cord_uid: ttir73l5

The ongoing COVID‐19 pandemic has to date infected more than one million people and led to tens of thousands of deaths across the globe. Thus, many governments have imposed regional or national mass shelters‐in‐place in an effort to slow its rapid spread. In this global health emergency, special attention should be paid to the potential impact of the measures taken to combat the pandemic on patients with bipolar disorders (BDs).

On top of public health and economic costs, the pandemic adds strain, disrupting daily routines and service delivery. Bipolar disorder can increase vulnerability, complicate treatment, and heighten interpersonal stigma. Yet there are successes when people proactively improve social connections, prioritize self-care, and we learn to use mobile and telehealth effectively.

Learning points:

(1) Bipolar disorder patients who move from situations with insecure housing to more structured (familiar or hospital) settings report more regular daily life than before, and their mood stays stable or improves.

(2) The use of current treatment options for SARS-CoV-2 with patients with bipolar disorder requires careful attention because of both interactions with the commonly recommended psychotropic medications.

(3) Informed and thoughtful use of technology may play a crucial positive role in providing costeffective and tailored interventions Key Words: Bipolar disorder, coronavirus, social distancing, quarantine, comorbidity, stigma, assessment, telehealth, resilience

This article is protected by copyright. All rights reserved

The ongoing COVID-19 pandemic has to date infected more than one million people and led to tens of thousands of deaths across the globe. Thus, many governments have imposed regional or national mass shelters-in-place in an effort to slow its rapid spread. In this global health emergency, special attention should be paid to the potential impact of the measures taken to combat the pandemic on patients with bipolar disorders (BDs).

Shelter-in-place and quarantine are key public health tools, yet they have high psychological and economic costs. They require sacrificing daily routines and public/personal social encounters that enhance health and quality of life and provide emotional support. Even in the general population, the length of social isolation and the constrained physical space in which isolation takes place can be associated with a wide range of adverse psychological effects, including depression, lowered selfesteem, alienation, and helplessness. 1 Anger, clinical anxiety, and posttraumatic stress disorder can persist years after the end of the isolation, as indicated by literature on quarantine. 1 We say this not to undermine the importance of these measures, but rather to underscore the potential consequences for vulnerable and marginalized populations.

The impact could be even more severe and long-lasting in persons with BD. The present emergency is disrupting both public and private mental health services, and most patients cannot access outpatient care. Under threat are treatment continuity, alliance and adherence, and patient-driven recovery progress -while the pandemic simultaneously escalates stress levels.

Alarming news reports about the economic and human costs add heightened stress at the same time as social distancing measures reduce opportunities for exercise, sunlight exposure, participation in meaningful activities and social engagement. Job loss and financial uncertainty add more strain, potentially triggering anxiety as well as mood symptoms-again, in a population already vulnerable.

This article is protected by copyright. All rights reserved

The regular rhythm of a healthy life becomes hard to maintain as classes are cancelled or moved online, and work-at-home policies are implemented. Sheltering-in-place can shave away the zeitgebers that help keep sleep and activity stable and promote engagement with community.

People with BD are likely to be especially susceptible. BD has high comorbidity with obesity, diabetes mellitus, coronary heart disease, and obstructive pulmonary disease, as well as smoking and substance use. 2 Moreover, current treatment protocols for COVID-19 are rapidly evolving, incurring risk for drug interactions, especially in patients being managed with complex regimens. Of course, BD itself frequently involves polypharmacy. Because no specific antiviral treatment has been developed, current treatment options include off-label use of azithromycin, lopinavir-ritonavir, and chloroquine/hydroxychloroquine. However, using these medications with patients with BD requires careful attention because of interactions between azithromycin/lopinavir-ritonavir and the commonly recommended medications for BD. Of real concern, the possible adverse psychiatric effects of chloroquine/hydroxychloroquine include psychosis, mood change, mania, and suicidal ideation. 3 Chloroquine may exacerbate BD.

Social stigma flares when societies are under stress, with a malign eye falling on people associated with high-risk groups as well as on anyone considered "different." BD is already prone to stigmatization and will undoubtedly take a second hit when people with BD also contract COVID-19.

People with COVID have been ostracized; the perceived stigma of having two burdens could not just aggravate a sense of isolation but provoke hostility instead of support.

Yet, crises are also times of opportunity. We can learn from examples of resilience and rethink and adapt our ways of working. Two months after the start of China's COVID-19 lockdown, Chinese

This article is protected by copyright. All rights reserved mental health clinicians are now seeing that if patients move from situations with insecure housing to more secure housing, they report more daily regulation and mood stability or improvement. These positive trends occur in patients returning to live with their families, as well as in hospital settings. 

This article is protected by copyright. All rights reserved it recedes, the landscape for the treatment of BD will have changed. There will be damage and loss, but also opportunities to learn-as well as changes in service delivery that could turn into significant advances in service delivery and outcomes.

The psychological impact of quarantine and how to reduce it: rapid review of the evidence

Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care

Psychiatric effects of malaria and anti-malarial drugs: historical and modern perspectives

The role of mental health home hospitalization care during the COVID-19 pandemic

mHealth in affective disorders: hype or hope? A focused narrative review