key: cord-0864786-zldwyuhz
authors: John, John P.; Prasad, Krishna; Sadh, Kamaldeep; A.S., Bhaskaran; Lhamu, Tshering; Basavarajappa, Chethan; Dahale, Ajit; Senthil Kumar Reddi, V.; Murthy, Pratima
title: Issues related to testing for COVID-19 in a psychiatric emergency setting
date: 2020-08-04
journal: Asian J Psychiatr
DOI: 10.1016/j.ajp.2020.102338
sha: a5a192f18e0c4cb009713d71357f78da35b9144f
doc_id: 864786
cord_uid: zldwyuhz

nan

The ongoing novel Corona Virus Disease (COVID)-19 pandemic and the lockdown imposed to tackle its community spread raise several challenges in the management of mental health conditions in psychiatric hospitals.

Here, we present the challenges faced in the evaluation and management of a patient with acute psychosis at the Emergency Psychiatry and Acute Care (EPAC) services of the National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India. The management protocol described here may benefit psychiatrists working in emergency settings during this pandemic.

A 30-year-old migrant worker, Mr. L, was brought by the police and co-workers to the EPAC services with a report of him having climbed up a mobile phone signal tower fearing persecution by others. Mr. L.'s co-workers gave a history of him showing altered behavior, suspiciousness, irritability, sleep disturbance, disinhibition and causing disturbance to others during the preceding two weeks. He was initiated on involuntary treatment in view of his lack of capacity to consent and was administered intravenous Haloperidol 5mg and Lorazepam 4mg to reduce agitation. We decided to do a pre-emptive testing for Severe Acute Respiratory Syndrome-Corona Virus-2 (SARS-CoV-2) despite Mr. L. not showing any overt clinical symptoms of infection for the following reasons: his travel history-migration 3 months back; no reliable information regarding possible exposure to COVID-19; overcrowded living conditions; impaired judgement that may have limited his ability to take precautions to avoid exposure; and severity of symptoms warranting inpatient care, which necessitated a decision to be made regarding whether he can be admitted at NIMHANS or referred to a COVID-designated general hospital for further management.

The process of obtaining a nasopharyngeal and oropharyngeal swab for testing was explained in detail to the patient and his co-worker (who was unrelated to the patient) in their vernacular. Following this, both provided their signed consent for testing. However, in view of Mr. L's lack of full capacity to consent, the EPAC team took this as the patient's assent and proceeded with the swabbing procedure. The swabbing took more than one hour since the patient became suspicious and refused to co-operate with the procedure and needed repeated reassurances as well as demonstration of the harmless nature of the procedure on his co-worker. Mr. L was admitted to the inpatient unit of NIMHANS after the test results returned as negative. Following improvement in his condition, a reconsenting was done after 10 days. The Mental Health Review Board of the Department of Psychiatry at NIMHANS was intimated regarding the processes followed.

Testing for SARS-COV-2 and/or antibodies against the virus constitutes one of the cornerstones in limiting community spread (Hamzelou, 2020) . A conservative approach towards testing, limiting it to cases where there is a high index of suspicion may compromise efforts at early targeted isolation and prevention of potential exposure to a large number of vulnerable persons in inpatient mental health settings (Zitek, 2020) , especially when the exposure history is unreliable/insufficient, or when the patient's living condition does not permit adequate social distancing. Furthermore, psychiatric emergency services should formulate protocols and guidelines for testing that aim to prevent the spread of infection while optimally treating the underlying psychiatric disturbance, keeping in mind the challenges in collecting specimens in acute psychiatric emergencies as highlighted above. Other specialists in general hospitals may find the management of acute psychiatric emergencies challenging, and therefore it is important for psychiatrists in emergency settings to undergo training in swab collection.

A nasopharyngeal swab is preferred for SARS-CoV-2 testing in an asymptomatic patient (2019-nCoV| CDC). However, other alternatives include oropharyngeal swab, nasal middle turbinate swab from both the nares, or a swab from both the anterior nares. The Centre for Disease Control (CDC) recommends the latter two for symptomatic patients (2019-nCoV | CDC). Diagnosis requires the detection of viral RNA by RT-PCR (CDC). Alternatives to RT-PCR include antibody testing or imaging. However, even when serology or chest CT/radiography are suggestive, viral RNA testing is required for confirmation (CDC) . Acutely agitated patients may be calmed down by tranquilization before testing, but administration of short-acting anaesthesia is not recommended without the support of intensivists. The caregiver accompanying the patient in the hospital should also be tested prior to admission.

A substantial majority of HCWs who contract the infection, work in non-COVID-19 settings (Wockhardt Chairman). Swabbing and "holding" patients who scream, shout or spit in psychiatric emergency settings may involve heightened risk of HCWs coming in contact with their oral and upper respiratory secretions (Tandon, 2020a) . Moreover, the testing procedure itself may turn out to be lengthy. Therefore, it is recommended that all HCWs in psychiatric emergency services should take adequate precautions and don full PPEs throughout their duty shifts. The COVID-19 response teams of all hospitals should ensure availability of adequate personal protective equipments for HCWs, communicate with them on a regular basis, be open in their communications regarding the constraints that they work under and suggest protocols to ensure the safest environment possible within the existing limitations (Tandon, 2020b) .

Finally, all HCWs including psychiatrists working in psychiatric emergency settings should try and enhance their subjective well-being through adoption of positive mental health approaches and not hesitate to seek professional help when they experience symptoms of physical or psychological distress. 

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The Appropriate Use of Testing for COVID-19. The western journal of emergency medicine