key: cord-0947896-z5tuw5d0 authors: Cabrera, Maximilliam A.; Karamsetty, Lakshmipriya; Simpson, Scott A. title: Coronavirus and its implications for psychiatry: a rapid review of the early literature date: 2020-05-27 journal: Psychosomatics DOI: 10.1016/j.psym.2020.05.018 sha: 41ef830104d9b701642532f226521ee10b1e68d5 doc_id: 947896 cord_uid: z5tuw5d0 BACKGROUND: The novel coronavirus pandemic has changed healthcare rapidly and dramatically. We provide a critical synthesis of the scientific literature on the pandemic’s implications for psychiatric practice. METHODS: A rapid literature review was undertaken to identify scientific literature linking psychiatric outcomes and practice changes due to coronavirus and the disease it causes (COVID-19). A structured quality assessment was used to assess those articles reporting quantitative data. RESULTS: Fifty articles were identified for inclusion, but only 12 contained original data. Eleven of those twelve were rated as poor quality. The literature described psychiatric sequelae of the coronavirus and related public health interventions through cross-sectional surveys among different populations; no studies include diagnostic or functional impairment data. Populations at risk include COVID-19 survivors, healthcare workers, the elderly, and those with pre-existing psychiatric disease. Impacts on psychiatric practice were described, again without data on changes to quality or access of care. CONCLUSIONS: There is a quickly accumulating body of evidence on the psychiatric implications of coronavirus including psychological effects on the general public and at-risk subgroups. Similarly, psychiatric practice has witnessed substantial adaptation to the pandemic. However, these reports are largely anecdotal at this point. Few data characterize these trends, and the early scientific findings are of generally poor quality. On March 11, 2020, the World Health Organization recognized novel coronavirus (SARS-CoV-2) infection as a global pandemic. 1 Although a large emphasis has rightfully been placed on the high transmissibility and lethality of this disease, the pandemic has also wrought psychiatric sequelae and rapid change to the delivery of mental health care. 1, 2 What is currently known about the coronavirus' impact on psychiatric care? Popular media has spoken to anxiety, stress, grief, and depression associated with coronavirus, its resultant disease , and the public health response to the pandemic. This review aims to provide a critical synthesis of the scientific literature on coronavirus and its relationship to psychiatric practice. We identified literature describing the psychiatric implications of coronavirus and COVID-19. Our approach was consistent with a rapid review of a quickly evolving topic. 3 A rapid review is "a type of knowledge synthesis in which components of the systematic review process are simplified or omitted to produce information in a short period of time." 4 The search terms and strategy using a single database, PubMed, is described in Table 1 . That database was chosen for its high scientific standard and global reach. Inclusion criteria were publications in English from December 2019 to April 13, 2020 . Articles were screened for content by the authors independently and included in the review by consensus. References from included articles were reviewed to identify additional literature. The quality of original quantitative research was assessed using the Quality Assessment Tool. 5 The heterogeneous nature of these studies precluded a meta-analytic approach. Seventy-one articles were identified in an initial search, from which fifty full-text articles were included. The PRISMA flow diagram for article selection is shown in Figure 1 . 6 Most articles (38/50, 76%) were narrative reports without original data ( Figure 2 ). A quality assessment on articles with original data is shown in Table 2 . All but one (11/12) of the papers were rated as poor quality. Articles were found from 9 countries, largely from China (19/50, 38%) and the United States (US; 14/50, 28%)( Figure 3 ). There were two major categories of literature: 1) the risk of psychiatric symptoms and 2) changes in psychiatric practice consequent of coronavirus, COVI19, and their related public health responses. Population-based surveys in China have demonstrated increases in distress and posttraumatic stress, anxiety, and depression symptoms over the course of the pandemic. 7, 8 In addition, posttraumatic stress symptoms (PTSS) were prevalent in 7% of Wuhan residents and visitors to Wuhan during the initial outbreak; these rates were higher than in surrounding cities and did not correlative with a history of infection. 9 A nationwide survey in China with 52,730 citizens from 36 provinces and three large cities showed 35% of respondents having mild psychological distress from the coronavirus pandemic; 5% reported more severe distress. 10 These findings were consistent with data from the United States. A month prior to the peak of the outbreak in the US, a national survey found that 40% of Americans were anxious about contracting or dying from COVID-19; psychiatric symptoms included more frequent insomnia (among 19% of respondents), alcohol consumption (8%), and interpersonal conflict (12%). 11 The long-term impact of chronic stress due to the pandemic is widely feared in the literature, if yet unproven. "Pandemic adjustment disorder" has been proposed to describe the totality of these persisting symptoms. 12 Editorialists have expressed concern about the potential for incident mental illness perhaps in part due to inflammatory dysregulation in the context of increased stress and decreased social connection. 13, 14 While survey studies have pointed to an increase in anxiety, one analysis of electronic medical records found decreasing mention of anxiety and depressive systems across multi-site health systems compared to before the pandemic. 15 These contrasting findings suggest that surveillance of coronavirus' mental health impacts may be nuanced and dependent on methodology Other articles suggest the psychiatric risks of coronavirus among at-risk populations: Some cases of coronavirus and COVID-19 appear to be correlated with neurological symptoms such as anosmia and delirium. 16 It is thus reasonable to hypothesize that coronavirus may put patients at risk for other psychiatric syndromes. A survey among stabilized COVID-19 patients prior to discharge from quarantine facilities found that 96% of survivors endorsed PTSS. 17 The extreme environmental modifications of hospital environments for infection control may increase the risk of delirium among at-risk patients. 18 The mental health consequences of coronavirus have been most studied among healthcare clinicians and administrators. 1, [19] [20] [21] [22] In a cross-sectional survey of 5,062 healthcare workers in Wuhan, China, providers who were female, had more than 10 years of experience, or worked with acutely ill patients (emergency, intensive care, respiratory care, and infectious disease clinicians) were at heightened risk of stress, depression, and anxiety. 23 Other studies describe increased rates of insomnia (up to 38%), anxiety (13%), depression (49%), somatization (2%), and obsessive-compulsive (5%) symptoms among providers. 24, 25 A survey of clinical staff found that 71% felt significant fear working with coronavirus patients. 26 Staff with direct patient care responsibilities experienced significantly higher psychological sequelae than staff who did not. 27 Specific components exacerbating these responses from healthcare staff were suggested: concerns included fear of infecting family, limited amounts of personal protective equipment (PPE) and other resources, exhaustion from longer working hours, and dealing with patients who do not want to cooperate with current guidelines. 28, 29 Supportive interventions have been described to ameliorate these negative effects among healthcare staff. One Chinese hospital provided medical staff supplementary space to rest outside of their homes, prepared meals, pre-job training on how to address psychological problems in patients suffering from COVID-19, and explicit rules on the management of limited PPE. 29 This intervention builds on factors described as protective against psychological stress, feelings of preparedness and institutional support, but was not rigorously evaluated for effectiveness. 28 Anecdotally, persons who have pre-existing mental health conditions may be at risk for worse outcomes as a result of the pandemic. These risks derive from barriers in accessing timely health services and being more emotionally susceptible to stressors. 30 These patients' limited access to care may result in relapse of disease. 31 Access to care may be particularly problematic for individuals in substance treatment programs, such as on medication-assisted treatments. 32 Psychiatrists have been asked to proactively engage patients who might not seek care out of fear of infection. 14 No evidence described specific risks by psychiatric diagnosis. Elderly persons were postulated to be among the groups at highest risk for mental health sequelae of coronavirus. 33 This population was predicted to not only suffer from a greater physical risk due to coronavirus, but also be more susceptible to the negative psychological impacts of social isolation. 14, 33 An increased incidence of death by suicide was observed among elder persons during the 2003 severe acute respiratory syndrome epidemic; elder persons may be at similar risk yet again. 33 A narrative report from China portrayed elders as disproportionately struggling with technological utilization and decreased access to public transportation. 34 Patients with dementia who struggle to follow infection control guidelines increase the risk of burnout among nursing facility staff while also increasing patients' risk of Interventions to mitigate potential psychological effects among the elder population were not described. 33 Less literature described psychiatric risks of coronavirus among other populations. Correctional facilities reported difficulty maintaining social distance regulations among inmates and promoting adequate hygiene. 36 Students, adolescents, and children experienced disruptions to daily routines and academic schedules. 37 International Chinese college students reported experiencing discrimination given the coronavirus' origins and anxiety related to family members contracting this disease in their home country. 38 Patients involved in research studies were suggested to be negatively impacted by unexpected study discontinuations or protocol changes. 39 The pandemic's impact extends to the delivery of psychiatric care as well. Psychiatrists have been asked to adopt several roles in response to the pandemic. Psychiatrists have skills in general practice and may be required to refresh their medical knowledge in order to support their patients, collaborate with primary providers, and direct patients to appropriate treatment. 12, 40 Mental health professionals are positioned to support resilience among medical providers and volunteer for crisis support hotlines. These contributions have been compared to fighting a war against the pandemic, with psychiatrists' role being to not only direct clinical care, but also engage in research on the pandemic's effects. 41 Public health interventions have altered the standard of care in both hospital and outpatient settings. Psychiatric hospitals have accommodated enhanced infection control by reducing patient visitors and shortening inpatient stays. 42, 43 Published protocols provide specific guidance to enhance infection control in inpatient behavioral health units. 44 The rapid and widespread adoption of telepsychiatry has been the most appreciable change in psychiatric practice during the pandemic, a change predicted to have lasting implications on the accessibility and quality of mental health care after the pandemic. 43, 45, 46 Telepsychiatry is being used not only between physicians and patients, but also between consulting psychiatrists and primary teams. 47 A physician in France detailed the quick implementation of telepsychiatry in her hospital, which was necessary to accommodate increased patient volumes 10 days after social isolation orders were implemented. 48 Limitations of telepsychiatry have also been described. Electroconvulsive therapy is a life-saving procedure that cannot be performed remotely and places practitioners at high risk of contracting coronavirus. 49 Some opioid assisted therapy, particularly with methadone, requires in-person treatment, and patients who cannot remain in treatment are at risk of relapse. 32 Additionally, telepsychiatry may not be accessible for all patients, including those who are homeless, severely cognitively impaired, technologically uncomfortable (e.g., the elderly), or young children. 45 12 The pandemic has implications for psychiatric prescribing. Several psychiatric drugs impact the efficacy and tolerability of antiviral therapy through P450 metabolism interactions; agents with fewer drug-drug interactions should be used preferentially (e.g. citalopram, olanzapine, or valproic acid). 50 New guidelines have been published for assessing clozapine patients who presented with flu-like illness or suspected COVID-19 given those patients' risk for neutropenia. 51 These systemic changes emphasize the advantages of building adaptable healthcare delivery models and strong community support for mental health service prior to a crisis. 52, 53 The global nature of the pandemic has prompted international collaboration, in spite of prior conflicts. 54 The common challenges of the pandemic proffer opportunity for unified global advocacy that can lay the groundwork for improving access to and quality of mental health care. While much literature is being produced on coronavirus, even at this early stage, most papers are editorials and narrative descriptions devoid of original research. The long-term sequelae of coronavirus on psychiatric symptoms remain uncertain, and the data reported so far of the impact of coronavirus on psychiatric care is of generally poor quality. The initial pandemic has induced widespread psychological unease, but no epidemiological studies apply diagnostic or functional impairment criteria to populations of interest. Indeed, the ubiquity of distress calls into question whether an individualized psychiatric treatment approach is preferable to a broader public health and political interventions. No studies have demonstrated biological relationships between coronavirus and psychiatric symptoms. The rapid expansion of telepsychiatry has been widely noted but largely unstudied. There were no descriptions of adapting telepsychiatry to at-risk populations, including for the use of highly agitated patients or providing access to those without internet or phone access. The effectiveness of telepsychiatry among these populations remains untested. No quality measures to assess the effectiveness of this new modality have been proposed. This review is limited by the novelty of its subject; while the search was limited to English-language peer-reviewed scientific literature, many of these findings are yet to be fully vetted by the medical community. This rapid review was limited to one medical database which may limit access to articles published ahead of print or in the gray literature. As COVID-19 and its related public health responses transform life around the globe, the psychiatric sequelae of the pandemic among individuals and societies remain uncertain. At this early stage of the pandemic, original research remains scarce and of poor quality. High levels of distress and potentially revolutionary changes in psychiatric practice are being described, but there remains a poor understanding of the pandemic's impact on the incidence, prevalence, and prognosis of psychiatric disease and implications for access to and quality of care. Several small interventions on reducing psychological symptoms among at-risk populations suggest the potential for psychiatry to adopt an assertive and positive response equal to a monumental task. 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