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Rev Psiquiatr Salud Ment (Barc.). 2020;13(2):105---110 www.elsevier.es/saludmental SPECIAL ARTICLE Psychiatry in the aftermath of COVID-19 La psiquiatría post-COVID-19 Eduard Vieta a,∗ , Víctor Pérez b , Celso Arango c a Hospital Clínic, Neuroscience Institute, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain b Neuropsychiatry and Addiction Institute, Hospital del Mar, Barcelona. CIBERSAM. IMIM (Hospital del Mar Medical Research Institute). Psychiatry, Autonomous University of Barcelona, Barcelona, Spain c Psychiatry and Mental Health Institute, Hospital General Gregorio Marañón, Complutense University, CIBERSAM, Madrid, Spain Received 8 April 2020; accepted 16 April 2020 Available online 23 April 2020 At the time of the writing of this article, a substantial part that psychiatry is a medical specialty and that psychiatrists of the world population is in partial or total lockdown due can and should act as doctors, both in the field of our spe- to the pandemic caused by the SARS CoV-2 virus. This health cialty and when, as in the current crisis or due to other emergency, which has hit our country of Spain hard, has circumstances (accidents, disasters), our most fundamen- transformed and will continue to transform our social cus- tal medical knowledge is required. Without diminishing the toms, our economy, and, obviously, our health care system in complexity of the psychological and social determining fac- ways that are difficult to predict. This article aims to antic- tors that are so important to the practice of psychiatry, the ipate some of the changes that are coming in the field of present crisis does and will to continue to emphasize the mental health and care for people with mental disorders, medical model that underlies the practice of the specialty as well as the specialty that deals with it: psychiatry. Psy- and the value of good public health. chiatry, in its broad sense, also includes aspects of medical psychology and prevention and health promotion that are undoubtedly part of the specialty’s doctrine. The psychological aspects of medical practice Psychiatry as a medical specialty Just as psychiatry is a medical specialty, medicine cannot be dissociated from the psychological aspects of medical practice that are so important for the practice of any Many psychiatrists have returned to serve as general practi- specialty that cares for the sick, including, obviously, psy- tioners and are reinforcing patient care teams dealing with chiatry. In the midst of a health crisis, hospitals have been COVID-19. At this time, there is recognition of the value of compelled to develop protocols for the psychological care basic medical training and the initial stages of residency, of patients, their families, and professionals themselves. during which the practical training in medicine and neurol- Patients need this because the infectious characteristics ogy essential for the good practice of psychiatry takes place. of COVID-19 require they spend long days and weeks in The current health emergency has once again reminded us social isolation, separated from their loved ones and com- forted only by professionals completely shrouded in masks ∗ and gowns that make them practically unrecognizable and Corresponding author. who do much of their observing from a distance. For the E-mail address: evieta@clinic.cat (E. Vieta). same reason, families are more in need of information and https://doi.org/10.1016/j.rpsm.2020.04.004 1888-9891/© 2020 SEP y SEPB. Published by Elsevier España, S.L.U. All rights reserved. 106 E. Vieta et al. support, since they cannot be with their hospitalized loved When the pandemic recedes, it is to be hoped that the ones. Health professionals, for their part, are working longer important work of consultation and liaison psychiatry teams hours than ever, under often precarious conditions due to will be better recognized and even heightened. lack of equipment and resources, caring for patients with health problems that are different from those they usually Mental health home care see and that comprise a less than predictable risk of sud- den deterioration and death, while they watch their own Home care, including its more intensive version, hospital- strength undermined by the wear and tear of so much pro- ization at home, is playing a key role in avoiding hospital fessional dedication,1 as we will discuss in greater depth admissions for mental disorders (which would put patients at below. greater risk of contracting COVID-19) and ensuring good care This epidemic will showcase psychological support as a of patients who, for a variety of reasons, are not candidates health instrument for the three aforesaid groups, and it for telemedicine care. The home care staff must be tested will reinforce the collaboration between psychiatrists and for COVID-19 and must be adequately protected, keeping clinical psychologists, together with nursing and social work a safe distance at all times.9 Although not all patients are teams, in the practice of health psychology. candidates for this type of care, the COVID-19 pandemic has shown that home care can, in many cases, substitute for admission to a psychiatric hospitalization unit, especially in Consultation and liaison psychiatry situations such as the current one where many psychiatric wards have had to be converted into COVID-19 wards, and it Sometimes viewed as a ‘‘minor’’ subspecialty of psychi- allows certain treatments such as long-term injectables9 to atry, or one that is subordinate to medical and surgical be given, white blood cell counts to be monitored in patients specialties, underfunded in healthcare systems based on treated with clozapine,7 and lithium levels to be checked. revenue generated, liaison psychiatry has gained promi- This home care is also important for people with intel- nence during the COVID-19 epidemic. Many hospitals have lectual disabilities and/or autism and patients with severe elected to move patients hospitalized in inpatient psychi- mental disorders and poor functionality who live with older atric wards to other specialty wards once it is confirmed caregivers. During the pandemic, it is advisable to call the that they have COVID-19 in addition to their psychiatric homes of all such patients and, if there is no answer, to pro- disorder, leaving the management of these patients to the vide a home visit, since the caregiver may have died and consultation and liaison psychiatry staff. In many hospi- the person with a mental disorder may be in need of care. tals, staff assigned to consultation and liaison psychiatry In the case of homeless people, many of whom have mental have also taken over psychological support for patients disorders, home care is a misnomer but takes on a similar isolated due to the infection, counting on clinical psy- meaning when caring for this group in shelters and spaces chologists and nursing personnel for that purpose along used for their lockdown. In countries without a powerful with the psychiatrists themselves. Liaison psychiatrists public health system, an upswing is expected in this group have also faced the challenge of learning and recognizing so vulnerable to diseases and economic crises. the adverse effects and interactions of a series of drugs Finally, nursing homes, severely penalized by the whose use was previously much more anecdotal (chloro- infectious disease, have also been candidates for home quine and hydroxychloroquine, tocilizumab, remdesivir, treatment, avoiding unnecessary transfers to hospitals. In atazanavir, lopinavir/ritonavir, favipiravir, azithromycin, short, home care, including hospitalization at home, is also and many more) that are currently being used against a resource to be promoted after the acute phase of the SARS CoV-2, in addition to others that are already well pandemic. known such as corticosteroids and interferon beta. Corti- costeroids can cause manic symptoms when administered as a bolus,2 and interferon (especially alpha, but also Telepsychiatry: online community mental beta) can produce depressive symptoms.3,4 Hydroxychloro- health care quine can cause anxiety and, less frequently, psychosis, and can interact with some antipsychotics, increasing the lev- One of the first measures universally adopted in all countries els of phenothiazines.5 Atazanavir and liponavir/ritonavir is a transition to remote care through outpatient televisits can substantially increase the levels of quetiapine, lurasi- via telephone, chat, or video call. Undoubtedly, the field of done, ziprasidone, and pimozide, as well as those of mental health is one that is best suited to this change since certain benzodiazepines, such as midazolam and triazolam.6 physical examination is generally less crucial than in other Carbamazepine, meanwhile, reduces levels of atazanavir, conditions.10 Even so, the psychopathological examination is remdesivir, chloroquine, and hydroxychloroquine. Disulfiram more limited, especially if the audio-only telephone route and nalmefene should be discontinued in patients with alco- is used without visual information. Although it is foresee- hol addiction. In patients treated with clozapine, SARS CoV-2 able that after the pandemic there will be a return to the infection may lower the white blood cell count and a dose format of face-to-face visits, this crisis has made it clear reduction is advisable.7 In general, there is an association that many unnecessary trips can be saved and that remote between administration of antipsychotics and an increased communication can, at least in part, replace or complement risk of pneumonia (not demonstrated in the specific case the in-person visit. This is undoubtedly one of the lessons we of coronavirus infection), but there are several confounding would do well to learn after the COVID-19 outbreak. variables and the benefit---risk balance is generally favorable Big data approaches will undoubtedly be incorporated as for psychopharmacological treatment.8 a tool to fight the virus, as has been done in other coun- Psychiatry in the aftermath of COVID-19 107 tries such as China and South Korea. All those that have a appear, but some people may also show delayed effects in digitally literate population and access to smartphones will the form of anxiety disorders and depression. use these resources to navigate the return to social normal- ity. Therefore, mHealth or mobile health is going to play an Grief increasingly important role and can also be used to benefit mental health,11,12 provided that the aspects of confidential- COVID-19 has caused extremely high mortality, since the ity and data protection are properly taken into account.13 In world population is not immunized against the virus. The Spain, the Spanish Society of Psychiatry has made a series of elderly and people with underlying conditions or immun- recommendations in this regard.14 Post-COVID-16 Psychiatry odeficiencies have been particularly vulnerable, but also will use digital resources, such as apps, much more to pro- health professionals, exposed to a higher viral load. Death vide mental health services, as an instrument of both case by COVID-19 carries the added cruelty of isolation. Death management and empowerment.15 in solitude not only causes suffering to those who die, but it can leave sequelae in the form of pathological mourning for those close to them and also for health professionals, Lockdown and its impact on mental health who are sometimes the only ones there to provide support for the terminally ill patient. To prevent the aftereffects of Billions of people worldwide have been confined to their these deaths in solitude, health professionals in charge of homes during this pandemic. Some countries have been managing communication with the patient and the family stricter than others, but in general very hard and fast can be advised by experts in end-of-life and palliative care. rules have been established, such as Spain’s declaration Once again, the role of health psychology is fundamental. of a state of emergency, which has kept most of the A serene, empathetic attitude, active listening, and sup- population (except essential services) at home for weeks. portive care for those in pain are of great help. Symbolic Lockdown is a source of stress and anxiety and certain and spiritual aspects are also important. Some patients with patients may decompensate. The Spanish Society of Psychi- severe mental disorders may be at the mercy of their ill- atry has made mental health care recommendations for the ness if their caregiver dies. We address the issue of grief general population.14 It can be particularly challenging for and guilt in healthcare professionals in the next section. children,16,17 especially for those with neurodevelopmen- When the health emergency ends, we will be aware of the tal disorders in whom routine changes cause great stress importance of hospitals having teams and professionals who (e.g., autism spectrum disorders or intellectual disabil- are experts in supporting terminally ill patients and their ity). The Spanish Royal Decree of the state of emergency families, as well as their most exposed colleagues, such as allows people with disabilities to get out and walk, although intensivists, oncologists, hematologists, etc., and all those the greater complexity of treating these patients if they who have been on the front lines during this crisis. We must become infected, the need for them to be accompanied by be able to anticipate the expected high prevalence of com- a family member resulting in many possibilities for becom- plicated grief that will surely ensue by setting up preventive ing infected, and the fact that, in the context of such a plans that identify high-risk subjects in the early stages. The health emergency, they might not be candidates for a criti- often marginalized practice of prevention in mental health cal care bed due to a so-called ‘‘ceiling of therapy’’ make it should emerge strengthened by a crisis like this.21 more inadvisable for them than other populations to leave home and increase their risk of infection. In some cases, therapeutic adherence may be compromised. People with Health care professionals and their mental Alzheimer’s disease or intellectual disability may have dif- health ficulty understanding the need to stay home. Patients with schizophrenia and severe mental disorders, who have their As we have discussed in the sections on the psychological own needs,18 may also be more vulnerable. Addicted individ- aspects of medical practice and grief, health professionals uals may experience withdrawal syndrome due to difficulty have endured this crisis with an overload of work, gen- obtaining drugs, while other addictions, such as alcoholism, erally precarious safety conditions, anxiety at the risk of smoking, and online gambling (other than sports betting, due contagion, and a higher level of selflessness when having to to cancelation of games) may worsen. For women and chil- perform tasks for which many were not prepared.1 Further- dren who are victims of domestic violence, the lockdown more, knowing that they are at risk, many have restricted situation can be especially serious. People with COVID-19 their contact with their families or have confined themselves are also isolated and miss contact with their relatives, as to hotels or to their own health facilities. Although many do families when a loved one is admitted to the hospital. psychiatrists have continued to work remotely with patients, Feelings of rage, anger, frustration, and guilt are common it is likely that they will encounter a significant volume of during lockdown and can complicate living together. Based consultations, patients with exacerbations, and health pro- on surveys conducted during lockdown, it is recommended fessionals with burnout or post-traumatic stress disorder in to self-limit consumption of pandemic news, get exercise, the near future. Burnout is already a diagnosis recognized maintain a healthy diet, and engage in a variety of leisure by the WHO, and it would not be surprising that, if work activities, both as a family and individually.19 Relaxation overload persists, there will be an increase in cases among and mindfulness techniques can also be helpful, and avoid- healthcare workers, including especially those who work in ing screen time before bed can prevent insomnia.20 As the nursing homes, where mortality has been extremely high. lockdown relaxes (depending on the positive outcome of the This epidemic has several variables prejudicial to the men- pandemic), some of these emotional disturbances will dis- tal health of professionals.22 Firstly, the etiological agent is 108 E. Vieta et al. not well known, there is no proven effective treatment, and intensive care units and procedures to avoid post-traumatic it is not easy to predict who will experience the most serious disorders. complications that require critical care. Secondly, the mas- sive demand means that specialists working in specialties Relapses and late decompensation that do not usually treat patients of this nature (we have seen pediatricians administering sedation to dying 80-year- It is obvious that people with mental disorders are also old patients) have to do so in this situation. Thirdly, health going to be direct and indirect victims of the pandemic.25---27 professionals are neither prepared nor trained to let people Although the number of emergency room visits and hospital die whom they could save under normal circumstances; the admissions for patients with psychiatric disorders decreased shortage of critical care beds has meant they must deny significantly at the height of the health emergency, allowing intensive care beds when doctors request them because many hospitals to use psychiatric beds for infected patients their patients are not a priority due to age, comorbidity, etc. without mental disorders, a rebound effect is expected (the ‘‘ceiling of therapy’’). This denial generates a great in the medium term. In fact, this is also happening with emotional load on doctors who see how people who could other non-psychiatric medical conditions, such as strokes have been saved a few weeks ago cannot now be saved. The and heart attacks, which are seen in the emergency room decision to prioritize critical beds also generates a heavy much later than usual and with more serious symptoms. responsibility and in many cases guilt. The moral injury Fear of infection and confinement are undoubtedly part of caused by many of these decisions will certainly take its toll the reasons for the drop in demand. What telepsychiatry, in the future.23 Fourthly, workload and the need to make home care, and psychiatric consultation fail to resolve will non-consensus decisions make many professionals work in be reflected in a probable increase in acute crises and exac- a dissociated way, since not blocking their emotional side erbations of psychotic and affective disorders in the near would cause them to collapse. Fifthly, there is a challenge term. The temporary closure of day hospitals and rehabilita- that wears out professionals, consisting of fear of contagion tion centers may also be a source of problems in the medium (for themselves, which also implies having to stop working term. Adherence difficulties may also have an impact. As and helping colleagues, and for infecting their family, espe- soon as possible after the pandemic, it will be necessary to cially the elderly), and of guilt at not doing more due to the reopen the resources that have been closed or reduced to a limitations imposed by fear. Sixthly, there is often a sense of minimum and to reinforce inpatient and outpatient mental learned helplessness and hopelessness. A patchwork where health and primary care services. a day when the professional has given his or her all is fol- lowed by a day of even greater load and greater stress. Good work is not rewarded --- or even the opposite --- and there is Education and research a feeling of lack of internal control with demands that one cannot act upon or modulate. As of today, there are thousands of teaching activities that Prevention of burnout and stress disorders requires rest have been canceled or postponed due to the pandemic, and disconnection. For this reason, it would be advisable including major events and conferences (the first and most for shifts and breaks to be scheduled after peak demand significant of which is the MWC, formerly the Mobile World and for the health system provide relaxation, workout, and Congress, which was scheduled to be held in Barcelona in reading areas in the facilities themselves, with mandatory February 2020), and, many dedicated to psychiatry, includ- time set aside for this. A mentally healthy professional is ing the congresses of the European Psychiatric Association a source of health. The post-COVID-19 era must take bet- and the American Psychiatric Association. Conferences that ter care of healthcare professionals, and particularly their were scheduled for after the summer are already being mental health. canceled. Since the start of the lockdown, many teaching activities have gone online, and most of them will proba- bly continue that way throughout the whole of 2020, since Humanism, deontology, and the effects of easing of the lockdown will not be quick, leaving the cele- difficult decisions bration of massive events for last. The first in-person events to recover will be clinical and scientific sessions at facilities This epidemic has tested the ethical principles of the medi- that are themselves small. Although the crisis is going to cal profession, forcing many professionals to make difficult spur distance learning, social interaction and face-to-face decisions. Many hospitals have revised their ‘‘ceiling of exchange of information have irreplaceable components; therapy’’ protocols to agree on the criteria for invasive conferences also fulfill a social function that helps us cope interventions, especially with regard to assisted breathing.24 with day-to-day healthcare efforts and promotes research The epidemic will also eventually entail certain privacy con- through collaboration that is often established after per- cessions (for example, requiring serological status to be sonal acquaintance. displayed in a mobile app). Psychiatrists will treat health- The writing of educational materials such as review arti- care colleagues, especially those on the front lines caring cles and books, for example, has however been reinforced for COVID-19 patients and unaccustomed to making life and by confinement. Many researchers have used this time to death decisions, experiencing symptoms of stress and possi- systematically review scientific topics, and journals do not ble feelings of guilt or frustration.23 When the saturation seem to have seen any drop in the submission rate of this of health services has declined, the capacity of the sys- type of scientific article. tem to deal with situations such as the present one should Furthermore, the training of residents in psychiatry, clin- be reevaluated, and measures should be taken to design ical psychology, and mental health nursing has been affected Psychiatry in the aftermath of COVID-19 109 by the health emergency and many have been drafted to tainty and economic crisis, such as those that lie ahead. This serve COVID-19 patients or to provide psychological support epidemic will showcase many of our specialty’s skills. to patients and their families, and professionals. Even medi- cal students have been participating in work to confront the crisis. It is likely that this will be a valuable learning experi- Conflicts of interest ence, and scheduled rotations and internships will probably be resumed soon, but some of these young people may feel EV has received funding unrelated to the present work the psychological impact of having been on the front lines. for research projects and/or honoraria as a consultant In research, the pandemic has remarkably enhanced sci- or speaker from the following entities: AB-Biotics, Aller- entific exchange. Although many researchers have had to gan, Angelini, Ferrer, Gedeon Richter, Janssen, Lundbeck, temporarily leave their jobs in order to shelter in place, Otsuka, Sage, Sanofi-Aventis, Sumitomo, Sunovion, Takeda, many journals, such as the New England Journal of Medicine, Instituto de Salud Carlos III, the EU Seventh Framework have begun offering open access to all articles on COVID- Program and Horizon 2020, the Brain & Behavior Research 19, and collaborative clinical trials have been designed, Foundation (NARSAD), and the Stanley Medical Research approved, and executed in record time. The scientific com- Institute. munity has broken down borders and is collaborating in VP has received funding unrelated to the present search of treatments and vaccines. Some of these projects work for research projects and/or honoraria as a consul- will investigate the effects of lockdown and many of the tant or speaker from the following entities: AB-Biotics, currently unresolved issues we discuss in this article regard- AstraZeneca, Bristol-Myers-Squibb, Janssen-Cilag, Lund- ing the relationship between COVID-19 and mental health. beck, Otsuka, Servier, Pfizer, and Esteve. Beyond the infectious disease itself, it is to be hoped that CA has received funding unrelated to the present work this tragedy will underscore the importance of biomedical for research projects and/or honoraria as a consultant research and, like public health, receive the recognition or speaker from the following entities: Acadia, Angelini, it deserves at the budgetary and social level. The hope is Gedeon Richter, Janssen Cilag, Lundbeck, Minerva, Otsuka, that governments will allocate much more of their budgets Roche, Sage, Servier, Shire, Schering Plough, Sumitomo to collaborative translational research, as Spain has done Dainippon Pharma, Sunovion, Takeda, Instituto de Salud Car- with the CIBER consortium,28 and to health registries.29,30 los III, the EU Seventh Framework Program and Horizon 2020, In short, virtual conferences and distance learning will be and Fundación Alicia Koplowitz. greatly enhanced after the pandemic, and this will spare a lot of travel, although not all. Collaborative research will be enhanced and the speed of knowledge advancement, includ- Acknowledgments ing in mental health, may be substantially increased. The opposite would be a very serious mistake. EV would like to thank the Ministry of Science and Research (PI15/00283, PI18/00805) integrated in the National R+D+I Plan and co-financed by the ISCIII-General Subdirectorate Conclusions of Evaluation and the European Regional Development Fund (ERDF), the Commission for Universities and Research, Venturing to predict the future is very risky, but reflecting on Department of Innovation, Universities, and Business (DIUE), the changes brought about by such an extraordinary event Government of Catalonia (2017 SGR 1365), and project as the COVID-19 pandemic and its impact on the practice SLT006/17/00357 of the Strategic Plan for Health Research of Psychiatry can help us turn a crisis into an opportunity. and Innovation (PERIS) 2016---2020 (Department of Health), Once the tragedy is behind us, we can quantify the social CERCA PROGRAM, Government of Catalonia. and health damage and look for solutions to the afteref- VP would like to thank the Ministry of Science and fects; it can be a good thing to celebrate the fact that values Research (PI19/00236) integrated in the National R+D+I such as solidarity, dedication to service, courage, adaptation Plan and co-financed by the ISCIII-General Subdirectorate to change, striving, and intelligence have guided most of of Evaluation and the European Regional Development Fund the actions of health professionals. Psychiatrists have again (ERDF), CIBERSAM G21. Commission for Universities and become general practitioners, psychologists, social work- Research, Department of Innovation, Universities, and Busi- ers, and caregivers, in harmony with others who have those ness (DIUE), Government of Catalonia (2017 SGR 134), CERCA specific duties as part of their profession. Teamwork has Program, Government of Catalonia. been accomplished. Solutions have been found to reduce the CA has received support from the Spanish Ministry impact of the health crisis on the most vulnerable among us, of Science and Innovation. Instituto de Salud Carlos III such as people with mental disorders. Some of those solu- (SAM16PE07CP1, PI16/02012, PI19/024), co-financed by tions will enrich our ability to meet the challenges of mental the European Commission’s ERDF Fund, ‘‘A way of mak- health in the near future. We must value psychopharmaco- ing Europe,’’ CIBERSAM. Madrid Regional Government logical treatments, especially the most innovative ones,31 (B2017/BMD-3740 AGES-CM-2), European Union Struc- and psychological interventions. Perhaps we will become a tural Funds. European Union Seventh Framework Program little more obsessive, especially with hygiene, and social under grant agreements FP7-HEALTH-2013-2.2.1-2-603196 customs may change. Let us hope that society as a whole (Project PSYSCAN) and FP7-HEALTH-2013-2.2.1-2-602478 and its representatives seize the opportunity to strengthen (Project METSY); and European Union H2020 Program under our public health and our research facilities and provide the Innovative Medicines Initiative 2 Joint Undertaking them with much-needed resources, even in times of uncer- (grant agreement No. 115916, Project PRISM, and grant 110 E. Vieta et al. agreement No. 777394, Project AIMS-2-TRIALS), Fundación 15. 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