COVID-19 and people with pre-existing mental illness

The outbreak of COVID-19 is concerning for patients with pre-existing psychiatric diagnoses owing to disruptions to community services, decreased social contact, worsening of pre-existing symptoms (Holmes et al. Reference Holmes, O’Connor, Perry, Tracey, Wessely and Arseneault2020) and the possibility of redeployment of healthcare staff (HSE, 2020). Risk of contracting the virus itself is another significant concern. Patients with chronic and enduring psychiatric illness are more vulnerable to medical illness than members of the general public, with particularly increased risk of diabetes, respiratory and liver disease (Sokal et al. Reference Sokal, Messias, Dickerson, Kreyenbuhl, Brown, Goldberg and Dixon2004). This might also apply to their susceptibility to COVID-19 (Yao et al. Reference Yao, Chen and Xu2020).

These wider health consequences of contracting COVID-19 are starting to become apparent with emerging research reporting kidney and liver injury as well as thrombotic events (Rismanbaf & Zarei, Reference Rismanbaf and Zarei2020, Klok et al. Reference Klok, Kruip, van der Meer, Arbous, Gommers, Kant, Kaptein, van Paassen, Stals, Huisman and Endeman2020). These findings are particularly worrying for patients with psychiatric illness due to their increased risks of both underlying medical conditions and thrombosis, if prescribed anti-psychotics (Thomassen et al. Reference Thomassen, Vandenbroucke and Rosendaal2001). Inpatients in psychiatric units are thought to be especially vulnerable to contracting COVID-19, compared to medical inpatients, as a result of the layout of inpatient beds and shared dining and social spaces (Xiang et al. Reference Xiang, Zhao, Liu, Li, Zhao, Cheung and Ng2020b). Certain countries have suggested specific inpatient units for patients with psychiatric diagnoses and COVID-19 because the suggested guidelines are not always appropriate for patients with psychiatric diagnoses (Chevance et al. Reference Chevance, Gourion, Hoertel, Llorca, Thomas, Bocher, Moro, Laprévote, Benyamina, Fossati, Masson, Leaune, Leboyer and Gaillard2020).

Some countries have also published comprehensive protocols for the use of phone contact, conducting outpatient appointments and organising inpatient admissions in psychiatric services during the pandemic (Starace & Ferrera Reference Starace and Ferrara2020; Xiang et al. Reference Xiang, Zhao, Liu, Li, Zhao, Cheung and Ng2020b). The imperative to continue providing multidisciplinary care has been noted (Kelly Reference Kelly2020). Investing in online interventions for patients who require support during this time has been suggested as one method for maintaining services while minimising face-to-face contact between patients and healthcare professionals (Holmes et al. Reference Holmes, O’Connor, Perry, Tracey, Wessely and Arseneault2020). Patients’ increased access to the Internet and ownership of smartphones during the current pandemic, compared to the SARS epidemic, has been noted (Liu et al. Reference Liu, Yang, Zhang, Xiang, Liu, Hu and Zhang2020).

Despite these measures and advances, however, there are still several challenges associated with remote treatment (Gunnell et al. Reference Gunnell, Appleby, Arensman, Hawton, John, Kapur and Khan2020) including persisting issues about access to online interventions (Li et al. Reference Li, Yang, Liu, Zhao, Zhang, Zhang, Cheung and Xiang2020). Significant investment is likely needed to improve availability of Internet throughout Ireland, with nearly 60% of the Irish public reporting dissatisfaction in the quality of their Internet (Burke-Kennedy Reference Burke-Kennedy2019). The provision of online resources also needs to consider previous reports of social media having a negative impact on patients with depressive, anxiety and psychotic disorders (Primack et al. Reference Primack, Shensa, Escobar-Viera, Barrett, Sidani, Colditz and James2017). All services provided to existing patients need to simultaneously meet patients’ psychiatric needs and reiterate the importance of public health recommendations. Additionally, there is a need for psychiatrists to engage in prospective, high-quality research in relation to the broader consequences of this pandemic, with particular emphasis on mental health (Holmes et al. Reference Holmes, O’Connor, Perry, Tracey, Wessely and Arseneault2020).

Psychiatry and people who recover from COVID-19

To date, over 23,000 cases of COVID-19 have been diagnosed in Ireland (Department of Health, 2020). Although it is not yet clear what proportion of these patients will develop a psychiatric illness in need of specialist care, there are some indicators from previous epidemics. Past research has reported quite strong links between acute infections and psychiatric illness, with an established association between influenza and psychosis (Kepińska et al. Reference Kępińska, Iyegbe, Vernon, Yolken, Murray and Pollak2020) and a correlation between disease severity in SARS and neuropsychiatric symptoms (Sheng et al. Reference Sheng, Wing Cheng, Lau, Li and Yiu Chan2005).

The SARS outbreak has been described as a mental health catastrophe for survivors, owing to the prolonged duration of threat, the infection’s unpredictable nature and the resulting social isolation. Contracting and surviving SARS resulted in an increased risk of both depressive and anxiety disorders (Mak et al. Reference Mak, Chu, Pan, Yiu and Chan2009). The psychiatric morbidity of SARS also appears to be long-lasting, with 64% of SARS survivors scoring above the threshold of the General Health Questionnaire (GHQ12) at 1-year follow-up (Lee et al. Reference Lee, Wong, McAlonan, Cheung, Cheung, Sham, Chu, Wong, Tsang and Chua2007). There were also significant rates of chronic fatigue and psychiatric disorders at 3-year follow-up (Wing & Leung, Reference Wing and Leung2012). These findings underline the importance of identifying, articulating and normalising the fears and stresses experienced by patients with these illnesses and placing particular emphasis on explaining anxiety as an appropriate response to an overwhelming event such as SARS (Maunder et al. Reference Maunder, Hunter, Vincent, Bennett, Peladeau, Leszcz, Sadavoy, Verhaeghe, Steinberg and Mazzulli2003).

Liaison psychiatry has several potential roles to play during this time, including aiding in the management of delirium, dysregulation and decompensation of patient’s mental state secondary to contracting COVID-19, managing drug interactions between psychotropic drugs and medications used in the treatment of the virus and advocating for patients with pre-morbid psychiatric diagnoses (Shalev & Shapiro, Reference Shalev and Shapiro2020; Vieta et al. Reference Vieta, Pérez and Arango2020).

In keeping with current models of mental healthcare, a stepped approach should be taken when managing the psychiatric sequelae of COVID-19. Care in general practice is the first step, involving psychological therapy or medication (if indicated) as the first-line treatment, depending on the clinical situation. Referral to specialist mental health services might be required if symptoms fail to improve or if severe, acute symptoms predominate, as is often seen in emergency departments (HSE Mental Health Division, 2017). Particular attention needs to be given to older adults who are most affected by COVID-19 (Yang et al. Reference Yang, Li, Zhang, Zhang, Cheung and Xiang2020). Specific training for psychiatrists to prevent and detect post-traumatic stress disorder has been suggested due to its prevalence in Wuhan, China (Chevance et al. Reference Chevance, Gourion, Hoertel, Llorca, Thomas, Bocher, Moro, Laprévote, Benyamina, Fossati, Masson, Leaune, Leboyer and Gaillard2020).

COVID-19 and healthcare colleagues

Past experience suggests that COVID-19 will likely result in significant psychiatric morbidity among healthcare professionals, based on the documented sequelae of the SARS, MERS and Ebola epidemics (Shah et al. Reference Shah, Chaudhari, Kamrai, Lail and Patel2020a). Such morbidity affects not only professionals’ own mental health but also their ability to provide effective care (Kang et al. Reference Kang, Li, Hu, Chen, Yang, Yang, Wang, Hu, Lai, Ma, Chen, Guan, Wang, Ma and Liu2020). Following the SARS outbreak, healthcare professionals in direct contact with infected patients had significantly higher levels of stress, anxiety and depression at 1-year follow-up compared to healthcare workers who were not in direct contact with affected patients (McAlonan et al. Reference McAlonan, Lee, Cheung, Cheung, Tsang, Sham, Chua and Wong2007).

The concept of resilience is important in this context. The development of psychiatric symptoms in the aftermath of treating patients with SARS was significantly associated with a history of mental illness and inversely associated with years working in healthcare. The rates, however, were similar to incidence rates in the community, suggesting a certain amount of resilience among healthcare workers, protecting their mental health (Lancee et al. Reference Lancee, Maunder and Goldbloom2008).

It has been suggested that developing a culture of resilience at an organisation level reduces the stress levels of individual staff members (Maunder et al. Reference Maunder, Leszcz, Savage, Adam, Peladeau, Romano, Rose and Schulman2008). The provision of both practical and emotional support is recommended to increase such resilience, especially for individuals with a history of mental illness (Lancee et al. Reference Lancee, Maunder and Goldbloom2008). Investing in telepsychiatry has also been suggested to help avoid burnout in healthcare professionals (Shah et al. Reference Shah, Chaudhari, Kamrai, Lail and Patel2020a). Online interventions have also been discussed, although barriers include a lack of time and energy to engage with these supports (Li et al. Reference Li, Yang, Liu, Zhao, Zhang, Zhang, Cheung and Xiang2020). Crisis interventions for healthcare professionals were suggested by the National Health Committee in China in early 2020, informed by the SARS outbreak of 2003 (Xiang et al. Reference Xiang, Yang, Li, Zhang, Zhang, Cheung and Ng2020a).

There is also a risk of ‘moral injury’ when healthcare professionals have to make difficult treatment decisions with limited resources and high volumes of patients. This can result in negative cognitions and emotions which can, in turn, contribute to psychological and psychiatric symptoms (Greenberg et al. Reference Greenberg, Docherty, Gnanapragasam and Wessely2020). In clinical situations where healthcare professionals act in a manner that is not in keeping with their moral code, peer support rather than psychological debriefing should be prioritised (Brooks et al. Reference Brooks, Rubin and Greenberg2018; Greenberg et al. Reference Greenberg, Docherty, Gnanapragasam and Wessely2020).

COVID-19, psychiatry and the general public

Although most members of the general public will not meet the threshold for specialist psychiatric input, there are several ways in which psychiatry can assist the public during and after COVID-19. These include informing digital interventions to address psychological distress (Gunnell et al. Reference Gunnell, Appleby, Arensman, Hawton, John, Kapur and Khan2020), liaising with other agencies that provide support to people with low-grade symptoms and creating educational resources for general practitioners and other clinical colleagues who are addressing pandemic-specific psychological symptoms.

The MERS outbreak in Korea resulted in widespread anxiety concerning the lack of treatment, vaccination and the need for people to self-isolate (Jeong et al. Reference Jeong, Yim, Song, Ki, Min, Cho and Chae2016). Mandatory quarantine results in psychological effects that are not insignificant (Rubin & Wessely, Reference Rubin and Wessely2020), owing, not least, to the uncertainty and shifting parameters that characterise the early stages of most major public health emergencies (Johal, Reference Johal2009). Increased rates of suicide were found in the older adult population in Hong Kong during the SARS outbreak, with fear of burdening families, social isolation and anxiety associated with some of these deaths (Yip et al. Reference Yip, Cheung, Chau and Law2010). The normalisation of such fears can ameliorate the psychological impact of quarantine and other public health measures (Johal, Reference Johal2009). Engaging with reputable sources of information also assists with maintaining a positive outlook (Shah et al. Reference Shah, Kamrai, Mekala, Mann, Desai and Patel2020b).

The decrease in organisations providing supportive counselling is likely to have a knock-on effect for the psychiatric services, with some organisations moving from their usual services to the provision of online information and telephone support between March and July 2020 (Walsh, Reference Walsh2020).

The overwhelming amount of misinformation readily available online is another concern for the public, as high-speed Internet allows the dissemination of information – both reliable and unreliable – to large numbers of people. Various media channels are now being used to question the legitimacy of conspiracy theories that can undermine public health efforts (Ignatius, Reference Ignatius2020). The WHO has described the rapid spread of misinformation about COVID-19 as an ‘infodemic’ (Limaye et al. Reference Limaye, Sauer, Ali, Bernstein, Wahl, Barnhill and Labrique2020).

Although it is tempting simply to dismiss conspiracy theories, we should not underestimate their potential to cause harm. Decreased uptake of the mumps, measles and rubella vaccine owing to various unfounded concerns are just one example of this (Andrade, Reference Andrade2020). There is a need for all healthcare professionals to both provide accurate information and dismiss inaccurate information, especially among patients who are especially vulnerable to external influences.

The likelihood of an economic downturn as a consequence of COVID-19 also needs to be considered, with the previous recession in Ireland resulting in increased rates of suicide in males and increased rates of self-harm in both males and females (Corcoran et al. Reference Corcoran, Griffin, Arensman, Fitzgerald and Perry2015).