key: cord-0858673-94xjt1vi
authors: Maoz, Zeev; Huet, Isabelle; Sudres, Jean-Luc; Bouchard, Jean-Pierre
title: Clinical condition, Resuscitation and Medical-Psychological Care of Severe COVID-19 patients (part 2)
date: 2022-01-13
journal: Ann Med Psychol (Paris)
DOI: 10.1016/j.amp.2022.01.002
sha: 6f22f4c2dc9838d42f06fb177ee07b077d88032f
doc_id: 858673
cord_uid: 94xjt1vi

Respiratory rehabilitation is the penultimate step in the medical management of patients with severe COPD-19. It is an essential step before patients’ returning home, and is usually carried out in specialised Follow-up and Rehabilitation Clinics. When discharged from hospital, patients with post-severe COVID-19 usually progress in their medical condition. However, they may remain frail and have a constant fear of possible deterioration leading to (re)hospitalisation and a return to baseline. Psychological support in this phase can reduce patients’ anxiety and increase their motivation to carry out daily rehabilitation activities. This support provides a stable and consistent basis for patients to focus on their progress, leaving the difficulties behind. Being aware of the improvements in their physical condition allows them to maintain their motivation to continue to be physically active. Psychological support during respiratory rehabilitation aims at preparing patients to return to the normal life they had before the disease. It is usually based on brief psychotherapies that focus on strengthening the patient's abilities through behavioural changes and through reducing risk behaviours. Only after this phase is it sometimes possible to deal with complex issues and to cope with personality mechanisms and maladaptive behaviour patterns.

Medical knowledge about the management of patients treated for COVID-19 has been steadily developing since the beginning of the epidemics, accumulating into a substantial structure [6, 19, 20, 26, 30, 32, 39, 45, 50] . It covers the various treatments of the disease in its different phases, from prevention to resuscitation and towards community care [5, 7, 9, 28] .

Pulmonary rehabilitation is the penultimate phase of medical expertise in the management of post-severe COVID-19 patients. For a large part of these people, it is an essential step before returning to daily life. Pulmonary rehabilitation in France is most often carried out in specialised Follow-up and Rehabilitation Clinics (SSR) where patients are hospitalised on a full ward or outpatient basis for three to five weeks. Psychological support plays an important role in this stage.

This interview with Jean-Pierre Bouchard is the second in a series of two [27] in which Zeev Maoz, Isabelle Huet and Jean Luc Sudres discuss the somatic and mental condition and rehabilitation of severe COVID-19 patients who have undergone resuscitation. This part discusses the condition of these patients after discharge from hospital, during which phase some of them will return directly to their life in the community, while others may benefit from hospitalisation in pulmonary rehabilitation.

Rehabilitation center (near Toulouse), where he provides psychological support to COVID-19 patients undergoing rehabilitation at the clinic. He is also an associate research professor at the Jean-Jaurès University in Toulouse. Isabelle Huet is a pneumologist at the Saint-Orens Rehabilitation center. She also has an independent medical practice and provides consultations at her office in Foix. Jean-Luc Sudres is a hospital psychologist. He is also a Professor of psychology at the University of Toulouse Jean-Jaurès. of danger and can hypothetically resume their daily lives. Nevertheless, a large proportion of them will continue to experience various symptoms for some time, sometimes for months after their hospitalisation. Most of these symptoms are physiological, such as breathing difficulties and fatigue, or pain, but others are cognitive, such as memory problems, mood disorders and concentration problems.

The long duration of illness has challenged the modern medical system. In terms of patient-health providers encounters. It required building up as complete a picture as possible of the patient's condition, going beyond the usual one-off look of the health care professional.

The medical history has to be defined in terms of a therapeutic trajectory in which dots where the health professionals meet the patient are connected to a complete path taken by the patient before and after the crisis points [49] . Each encounter between the health caregiver and the patient constitutes a milestone in the patient's medical trajectory.

This enables a comprehensive anamnesis, i.e. knowledge of the development of the patient's disease and the history of his symptoms prior to the medical collapse, which allows for a correct diagnosis, not only of a specific problem but of a whole range of problems and risks, thus quantifying the therapeutic needs much better. It is thus possible to identify the origin of risks arising from the patient's other problems, whether medical or not [17, 37, 40, 44] .

One of the important therapeutic consequences deriving from this systematic perspective is the attempt to link the end of one phase of medical care with the beginning of another, avoiding the patient experiencing 'abrupt transitions' that interrupt his or her medical trajectory. Such abrupt transitions can be, of course, the emergency situations, but also the transition from hospitalization in a closed environment to a full discharge into community.

Reintegration of patients into the community is nowadays a main goal of almost all medical care and its final step [15] . This is true for different diseases, especially for patients with major chronic diseases or psychiatric disorders. Returning to the community and reintegrating, as far as possible, into a normal life has many psychological and physical benefits, such as support from relatives, a familiar environment and incentives for activity.

However, some patients are too frail, and for others, solutions and adaptations to their living environment are needed.

As described in the first part of this interview, the evolution of patients with respiratory problems can be described through the model of the upward and downward spiral [36] . This image of the spiral is a systemic description [18] , which looks at the person from several points of view: physiological, psychological, behavioural, social and others. It emphasises the interdependence between the parts that make up the whole. The idea of spiral dynamics is that each system is an evolving whole and that for each system one can describe the evolution in terms of a spiral. The different spirals evolve in parallel, each influencing the other, pulling it in its direction of evolution. This systematic view considers that acting on one or other of the components of the system allows the whole system to evolve. Similarly, a risk in one or other of the components can weaken the whole system.

While in the intensive care unit, the patient is detached from the outside world, away from disturbances and pressures. He/she is in a passive, infantilised state, constantly monitored by a team about his condition and its dangers. On discharge from hospital, he or she must become as independent as possible, not only in terms of daily functioning, but also in terms of responsibility for his or her condition and actions in the world. The patient must be active, both physically and psychologically, otherwise he or she risks being drawn into a negative spiral. This abrupt transition of the patient's condition requires the creation of antechambers between discharge from the hospital and the return to everyday life.

Medical rehabilitation tries to create this safe environment that bridges the gap between emergency hospitalisation and the return home. It offers an antechamber for these patients, between their assisted and supervised position and a more or less independent life.

Whether it is psychiatric rehabilitation or functional rehabilitation for victims of physical trauma, they all aim to bring the person back into the community in a way that allows him or her to move forward and not to sink, to function and not to be sedentary, to find the strength to cope.

In general, the condition of patients with post-severe COVID-19, once out of danger, will usually improve. However, this description needs to be qualified, taking into account the pre-existing risk factors of the disease and its sequelae. In terms of psycho-social support, some of these patients suffered from social isolation before their hospitalisation, others had very little or no support in their usual living environment. These conditions are likely to negatively affect the physical and medical evolution of the patient, leading to a sedentary lifestyle and social isolation that may lead to a deterioration of physiological parameters, which could be the starting point for a downward spiral. For these frail, post-severe COVID-19 patients that carry significant physical after-effects and/or insufficient support at home, a stay in pulmonary rehabilitation helps to avoid the downward spiral. They can gradually and safely rebuild their physical strength while feeling psychologically protected, both by the medical and paramedical personnel as well as by the psychological follow-up offered, and thus stabilise their construction of the upward spiral.

The rehabilitation process aims to exploit the positive momentum of the medical recovery process, in a secure environment. Psychological support is provided by the whole health care team and is part of the group dynamics of the patients, each with their own history and pathology, but almost all facing the necessity to make behavioural changes that should be maintained at discharge.

One of the primary objectives of pulmonary rehabilitation is to reactivate the body, strengthening the muscles and preventing their deconditioning. In doing so, rehabilitation provides the physical basis for stabilising the respiratory condition and progressing towards recovery, despite some of the sequelae of the disease. It has been found that patients who are hospitalised or bedridden for a long period of time (more than a few weeks) show symptoms of physical deconditioning, including a significant loss of muscle mass and cardiovascular dysfunction. The absence of essential body movements triggers a progressive deterioration of the entire muscular system, which hinders recovery efforts. Fatigue, due to physical deconditioning, adds to the effects of the initial medical condition, due to the disease, to accelerate towards a negative process. This effect of physical deconditioning accelerates considerably with age.

But, as explained in the previous interview [27] , patients may feel that the demands of the medical team to activate their bodies are in contradiction with the natural tendency. The body's natural instinct, when it is frail or after going through a life-threatening situation, tends to save energy, to 'rest'. It was only in the 1980s that rest was no longer indicated as primary care after hospitalisation, surgery or a long illness. The current recommendations are clearly to mobilise the body and activate the muscles, even minimally, as soon as possible [22] .

Medical support during the stay in rehabilitation reassures patients that despite the natural 'resistance' of the body, the prescribed activities are necessary for recovery. At the same time, the team listens to the patients and to their concerns and adapts the activities to their rhythm.

They can gradually and safely rebuild their physical strength while feeling psychologically protected by the medical team as well as by the psychological follow-up offered, and thus stabilise the building of the upward spiral.

Resuscitation is a psychologically complex experience, which confronts the person with old memories and destabilizes certain deep symbols. The physical pains and life threatening dangers are the elements that evoke the weakness of the body as an envelope supposed to protect one's ego [9, 16, 47, 53] . The intrusion of the virus inside through the respiratory tract evokes the penetrability of the body, and leaves deep anxiety at each moment when one carries out the most common activity, that of breathing.

Psychological support for patients during rehabilitation covers two aspects. The first refers to the patient's immediate past, including the psychological impact of the illness, Psychological work with them aims to reassure them that their psychological fragility is only a temporary condition and not a real pathology (like depression or even psychosis). It helps them to express these conflicting feelings, including memories and images of the state they were in a few days before, and then to reassure them of their normality. During the psychological sessions, patients may be encouraged to describe their condition, their emotions and the sensations they are experiencing, thus preventing negative psychological feelings from invading their whole world. The psychologist may suggest that they explain some of the images and hallucinations they experienced during and after the resuscitation. Giving meaning to these memories reduces the emotional and anxiety-provoking charge they can induce. Patients can appropriate them, thus avoiding the formation of 'black holes' that they cannot integrate into their memory system. However, during the rehabilitation phase post-severe COVID-19 patients cannot be considered as suffering from a Post-Traumatic Stress Disorder (PTSD). PTSD should only be diagnosed at least one month after the traumatic situation (symptoms occurring less than one month after the trauma can be diagnosed as Acute Stress Disorder) [8] . Post-severe COVID-19 patients usually approach their rehabilitation stay very soon after their painful experiences have taken place. In fact, for these patients, even the acute stress disorder cannot yet be diagnosed, as the traumatic event is still ongoing. They still suffer from physical pain and have a constant sense of life-threatening danger.

Thus, total desensitisation work, as proposed for PTSD patients, and re-exposure to trauma stressors are generally not part of the psychological support during the rehabilitation of post-severe COVID-19 patients. However, work on memories related to traumatic events can already be initiated [10] . The aim at this early stage is to prevent these memories from becoming threatening and thus to prevent the patient from developing PTSD later on. For example, Eye Movement Desensitization and Reprocessing (EMDR) [31, 42, 43, 48] motivations enhances their progress. The psychological perception of physical progress is important to encourage activation and effort, and to reduce patient anxiety. This is particularly true when progress is small, from day to day, sometimes inconsistent and not in all expected areas. Thus, the perception of progress often requires defining micro-goals that make microprogress perceptible. As rehabilitation structures are multidisciplinary, the psychologist can collaborate with other professionals in the team and has access to certain parameters that allow this progress to be quantified.

For example, one of the most common indicators of progress in patients with postsevere COVID-19 is the therapeutic oxygen requirement, both during activity and at rest. The decrease in oxygen dependency is a very palpable physical parameter for the patient that indicates the recovery of his or her lungs. It is also one of the parameters that distinguish the most post-severe COVID-19 patients from chronic respiratory diseases such as Chronic Obstructive Pulmonary Disease (COPD) patients. While the latter experience a gradual decline in the condition of their lungs, usually with increased dependence on oxygen, post-COVID-19 patients can see a real improvement in their dependence on oxygen, with most achieving full oxygen independence within a month or two after discharge. This is a very encouraging sign for them, as oxygen, for many, is a symbol of the disease, and being free of it represents healing.

Other notable positive evolutions for this population during the rehabilitation relate to physical capacities, measured during activities by force applied (in Watts), distances (e.g. for walking on a treadmill or walking outdoors). Other indicators are the results of different physiological tests, for example the six-minute walk test (6MWT) [14] , an easy test to perform by the physiotherapy team, which quickly quantifies the person's physical capacity.

Achieving objectives and micro-objectives and being able to quantify one's progress is a source of motivation and pleasure, especially for this population of post COVID-19 patients who were in a serious condition only a few days ago.

The rehabilitation process in sheltered pulmonary rehabilitation centres helps patients to mentally accept the physical efforts required and gives them more time to digest the physical process they are engaged in. In this dynamic of progress, post-severe COVID-19

patients are surrounded during their pulmonary rehabilitation by other patients, some of whom have emerged from similar conditions and are equally motivated to progress. They do not feel alone with their disease, as they probably would if they were at home. This motivating environment creates a real group support dynamic that can protect patients psychologically and reduce the risk of PTSD.

Zeev MAOZ: Psychological support in respiratory rehabilitation aims to prepare patients to return to their pre-fractured life. In the idea of getting back to the 'old life' are embodied, of course, its pleasures, and the psychological work of accentuating these moments of pleasure as much as possible to increase motivation. However, life before the disease also includes stresses, conflicts and worries, whether for financial or relational issues, either in the family or in the workplace. their disease, must also be integrated, so as not to stress the person further but rather to reassure them that these are not 'time bombs' that would explode upon return to daily life.

Indeed, the management of stressful situations was part of the patients' life before their hospitalisation and led to more or less adaptive behaviours. Some maladaptive behaviours can have consequences on patients' health, and cannot be ignored in the psychological work during rehabilitation. These include risk behaviours such as smoking, eating disorders, use of other substances (especially alcohol) and sedentary inactivity or sometimes hyperactivity. The way a person copes with daily life and handles stressful situations is an integral part of their personality, expressing their coping mechanisms and defences. Hence, once again, the need, even in a specialised rehabilitation setting, to engage in comprehensive psychological work with patients.

However, the limited number of psychological sessions during patients' stay in pulmonary rehabilitation centres (on average three to six sessions) tends to favour work focusing on rapid behavioural changes (Cognitive Behavioural Therapy) before addressing deeper psychological mechanisms. Psychological support can trigger a broad effect on personality through a sequence of small and successful behavioural changes, including increasing the person's self-esteem and confidence in their ability to change [29, 51] .

Patients' motivation to change is intensified in rehabilitation by the medical setting and their illness. Their painful experience during intensive care and the fact that they have survived a life-threatening situation facilitate behaviour change. Physical suffering, which for some is related to previous risk behaviours, prepares them to make decisions and commit to changes, which often require a significant motivational investment [34] .

This process of behaviour change can be viewed through the model of Prochaska and Di Clemente [25, 33] , which portrays six phases: Precontemplation, no intention to change behaviour; Contemplation, awareness of the problem but no commitment to change;

Preparation, intention to act; Action, active modification of the behaviour; Maintenance, new behaviour(s) replaces old ones, and Relapse, in case of possible failure to maintain the changes. Patients who have survived respiratory decompensation may have already approached the Action, or even the Maintenance phase, due to their 'forced weaning' from risky behaviours (or substances) during resuscitation.

After discharge from the rehabilitation clinic, how is the continuity of health care in post-severe COVID-19 patients maintained in the community?

The patient is discharged from the clinic when the medical team is reassured that the upward spiral has been steadily established. When the patient returns home, further care in the community can build on the foundations laid during his/her stay in rehabilitation.

Internal satisfaction surveys conducted at the clinic show that around 95% of patients are generally satisfied with their stay at the clinic. Thus, thanks to their pulmonary rehabilitation, patients can turn the page of their illness gently. They leave this (too) long period of their life in hospital with some positive memories and feelings, and above all they can remember some of the treatment instructions and retain some of the new physiological and psychological understanding. This softens the memory of these interludes in their lives and makes it easier to integrate the illness into the person's story, thus preventing them from developing post-traumatic stress disorder.

Medical follow-up and care in the community is then entrusted to general practitioners, specialists, paramedics such as nurses [11, 46] , social workers, psychologists [4, 52] , as well as associations and other social actors. They continue the work started during the rehabilitation stay, avoiding any interruption and generally with a low risk of relapse. This concern is particularly relevant for physical activities, where a high degree of continuity is required and follow-up is provided by physiotherapists and community health associations.

Community health care providers play an important role in both post-hospital care and secondary prevention [13] , i.e. prevention of relapse and re-hospitalisation. To ensure this continuity after leaving the rehabilitation environment, the Saint-Orens clinic maintains care relationships with several associations, including two in particular. The association of former patients of the clinic, offering them the opportunity to train several times a week for short sessions under the supervision of the clinic's physiotherapists, who are familiar with their initial problems; and a regional association specialises in ongoing respiratory rehabilitation work in the community. This association offers follow-up at home or group activities with the support of various professional care partners who follow the patients: doctors, physiotherapists, dieticians and psychologists.

The authors declare that they have no conflicts of interest regarding this article.

Psychotraumatologie : prendre en charge les traumatismes psychiques

Les traumatismes psychologiques de l'adulte (1/2)

Les traumatismes psychologiques de l'adulte (2/2)

Covid-19: les dispositifs de soutien psychologique

COVID-19, les effets psychopathologiques de la pandémie

PSYCOVID-19, dispositif de soutien psychologique dans les champs de la santé mentale, du somatique et du médico-social

COVID-19 en Espagne : l'impact psychologique de la pandémie sur les infirmiers

Diagnostic and Statistical Manual of Mental Disorders

Le moi-peau, Nouvelle édition revue et augmentée

Treatment of post-traumatic psychiatric disorders: A continuum of immediate, post-immediate and follow-up care mediated by specific psychotherapeutic principles. Clinical experience in French-speaking countries

COVID-19: les soignants entre héroïsation et ostracisation

Mindfulness-based treatments for posttraumatic stress disorder: a review of the treatment literature and neurobiological evidence

La psychologie dans l'éducation thérapeutique du patient

Two-, six-, and 12-minute walking tests in respiratory disease

Les accidents vasculaires cérébraux et la prise en charge psychologique à domicile des personnes qui en sont victimes

Corps, cultures et thérapies [journées]. Toulouse: Presses universitaires du Mirail

A shared decision-making primary care intervention for type 2 diabetes

Le macroscope vers une vision globale

Méthode d'élaboration des réponses rapides dans le cadre du COVID-19

Prévention en soins primaires des situations à risques pour les personnes vulnérables

A meta-analytic investigation of the impact of mindfulnessbased interventions on post traumatic stress

Physical activity: contexts and effects on health. Short version

Post traumatic Stress Disorder in Patients After Severe COVID-19 Infection

Mindfulness as a mediator between trauma exposure and mental health outcomes: Results from the National Health and Resilience in Veterans Study

Stages of change and psychotherapy outcomes: A review and meta-analysis

Epidemiology of COVID-19: A systematic review and meta-analysis of clinical characteristics, risk factors, and outcomes

Clinical condition, Resuscitation and Medical-Psychological Care of Severe COVID-19 patients (part 1)

Tri-infection: tuberculosis, HIV, COVID-19 and the already strained South African health system

Physical activity, selfesteem, and self-efficacy relationships in older adults: a randomized controlled trial

A serial model of the interrelationship between perceived vulnerability to disease, fear of COVID-19, and psychological distress among teachers in South Africa

Empirically supported psychological treatments for adult acute stress disorder and posttraumatic stress disorder: a review

Validation of the fear of COVID-19 scale in South Africa: Three complementary analyses

In search of how people change. Applications to addictive behaviors

Stages of change and decisional balance for 12 problem behaviors

COVID-19 : risques de traumatismes psychologiques pour les malades en réanimation et leurs proches

The PAC-COPD Study Group. The dyspnoea-inactivity vicious circle in COPD: development and external validation of a conceptual model

Rethinking how we understand individual healthcare needs for people living with long-term conditions: a qualitative study

Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic

Risk Factors Associated with in Hospital Mortality in a US National Sample of Patients With COVID-19

Setting goals with patients living with multimorbidity: qualitative analysis of general practice consultations

Risk of Developing Post-traumatic Stress Disorder in Severe COVID-19 Survivors, Their Families and Frontline Healthcare Workers: What Should Mental Health Specialists Prepare For?

Eye Movement Desensitization and Reprocessing (EMDR): information processing in the treatment of trauma

The role of eye movement desensitization and reprocessing (EMDR) therapy in medicine: addressing the psychological and physical symptoms stemming from adverse life experiences

Cumulative complexity: a functional, patient-centered model of patient complexity can improve research and practice

South Africa: Challenges and successes of the COVID-19 lockdown

COVID-19 en Afrique du Sud : les soignants impliqués

Hommes Et Perspectives

Psychologues et psychothérapies : innovation dans la recherche académique, la formation et la consultation

A qualitative systematic review of internal and external influences on shared decision-making in all health care settings

Objective evaluation of anosmia and ageusia in COVID-19 patients: single-center experience on 72 cases

The Association Between Depressive Symptomology, Psychological Burden Related to COVID-19, and Engagement in Physical Exercise Among College Students

Collaboration entre médecins généralistes et psychologues en libéral

The Skin is the Cradle of the Soul: Didier Anzieu on the Skin-Ego, Boundaries, and Boundlessness