key: cord-0891068-yc79q0no
authors: Veluri, Nikhila
title: Are masks impacting psychiatric inpatients’ treatment?
date: 2020-09-17
journal: Psychiatry Res
DOI: 10.1016/j.psychres.2020.113459
sha: 7fa96029fab6e4d79e3edc10ca607ab89efb2673
doc_id: 891068
cord_uid: yc79q0no

nan

Since the 2009 influenza pandemic, many healthcare providers in Asia have utilized facemasks (Wong et al., 2013) . Pamungkasih et al. (2019) and Wong et al. (2013) assessed patients' reception of physicians who employed facemasks in primary care clinics. The patients' acceptance of facemasks during these encounters was influenced by their age, gender, educational level, and background. For example, in the study, patients from low educational backgrounds believed that physicians use masks to prevent odor and dust. By contrast, those from higher educational backgrounds stated that the masks are used to prevent disease transmission (Pamungkasih et al., 2019) . Wong et al. (2013) compared patient satisfaction between the "mask" and "no mask" usage among physicians, applying the Consultation and Relational Empathy (CARE) measure score. The mean CARE score was lower in the "mask" group, which was statistically significant (p = 0.04) (Wong et al., 2013) . Routine assessment of psychiatric patients involves mental status examination (MSE). The MSE is dependent on appearance, behavior, and mannerisms. An individual's state of mind directly reflects his/her MSE. For example, an increase in paranoia can manifest through lesser eye contact, volunteering of less information, and a guarded appearance with a restricted affect. Patients' reluctancy produces difficulties for clinicians during their treatment. This resistance can further increase if clinicians are unable to develop a good rapport with the patients. Establishing a therapeutic alliance involves non-verbal cues, such as the patient noticing the clinician's empathy and non-judgment by facial expressions and tone of voice (Blanch-Hartigan et al., 2018; Mistry et al., 2009 ). These cues are obstructed from the patient's view when the clinician wears a facemask. Barriers to viewing the clinician's facial expressions can increase fear and paranoia in individuals with severe mental illness (Pal et al., 2020) . These emotions can be heightened in psychiatric inpatients due to their acute episodes or their illness' chronicity. For example: A man suffering from an acute episode of psychosis and auditory hallucinations admitted into the inpatient psychiatry facility demonstrated significant paranoia and anxiousness during his initial assessment, pointing to the facemask worn by the students and residents, asking, "Is this real? Is this a movie?" Another issue with facemasks is the limitations they cause on speech perception and comprehension (Pal et al., 2020) . Individuals with hearing impairment or endorsing auditory hallucinations could become distressed if they cannot read their clinician's lips. There is also a possibility of misinterpreting the perception of speech. To illustrate, wearing a mask can cause a clinician to raise his/her voice volume, which patients can infer as anger. While a therapeutic alliance entails a broad range of emotions, patients' misconceptions of anger can trigger and accentuate their current stress, fear, and anxiety, hindering the clinician-patient relationship. Analogous to the patients studied by Pamungkasih et al. (2019), the psychiatric inpatients may also believe that clinicians' usage of facemasks is due to their odor, resulting in self-consciousness, discomfort, and feelings of being judged. Additionally, facemasks and gloves may not be distributed to psychiatric patients due to an increased risk of self-injurious behaviors, leading to feelings of discrimination. This preconceived notion of prejudice and judgement toward the patient poses a challenge in building a good therapeutic relationship. To remove this barrier, we recommend educating patients at their level of competence. Metha et al. (2020) suggested that clinicians use their eyes, eyebrows, hand gestures, and appropriate body postures to facilitate accurate comprehension among patients. Research also advised that providing training to clinicians on the correct usage of intonation and prosody to speak clearly through a mask can significantly help build rapport (Mehta et al., 2020) . Pamungkasih et al. (2019) listed similar suggestions to enhance clinician-patient communication, such as visual communication, head movements, and voice inflection. They also proposed that clinicians remove their masks during the initial encounters and provide lengthy consultations to strengthen the clinician-patient relationship (Pamungkasih et al., 2019) .

Due to the uncertainty in the transmission of COVID-19, it is understandable for clinicians to adopt preventative safety measures, especially when the patients who were admitted to the psychiatric facility came from congregate settings or the streets. However, consideration for these patients is paramount. During admission into the psychiatric unit, we recommend that clinicians consider (i) conducting prompt COVID-19 testing, (ii) placing the patients in a quarantine section until results are available, and (iii) finding rooms that are large enough to maintain social distancing without using masks during patient interviews. These practices can help decrease clinicians' anxiety during the conduct of their daily assessments, making them less inclined to wear facemasks.

Further, we support Pal et al. 's (2020) discussion in opting to create a transparent physical barrier between clinicians and patients. While face shields can also cause apprehension in the psychiatric population, we hypothesize that fearfulness will be less severe, as the patients will be able to view facial expressions. Empirical evidence regarding the impact of using facemasks in mental healthcare settings is limited, especially in inpatient psychiatric facilities. Future research on this subject should be explored by conducting observational or randomized clinical trials using facemasks and other PPE in psychiatric wards. The investigators should also explore the impact of PPE usage in different psychiatric conditions (e.g., affective disorders versus psychotic disorders) and groups (e.g., racial or ethnic groups, genders, and age groups). It is essential to study this impact quickly as psychiatric inpatient facilities may experience a rise in admission since previous reviews posited that depression, anxiety, and post-traumatic stress disorder could surge after experiencing disasters such as the current COVID-19 pandemic (Galea et al., 2020) .

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