Unravelling potential severe psychiatric repercussions on healthcare professionals during the COVID-19 crisis

PRimary carE digital Support ToOl in mental health (PRESTO): Design, development and study protocols

BACKGROUND

About 30-50% of Primary Care (PC) users in Spain suffer mental health problems, mostly mild to moderate anxious and depressive symptoms, which account for 2% of Spain's total Gross domestic product and 50% of the costs associated to all mental disorders. Mobile health tools have demonstrated to cost-effectively reduce anxious and depressive symptoms while machine learning (ML) techniques have shown to accurately detect severe cases. The main aim of this project is to develop a comprehensive ML digital support platform (PRESTO) to cost-effectively screen, assess, triage, and provide personalized treatments for anxious and depressive symptoms in PC.

METHODS

The project will be carried out in 3 complementary phases: First, a ML predictive severity model will be built based on all the cases referred to the PC mental health support programme during the last 5 years in Catalonia. Simultaneously, a smartphone app to monitor and deliver psychological interventions for anxiety and depressive symptoms will be developed and tested in a clinical trial. Finally, the ML models and the app will be integrated in a comprehensive decision-support platform (PRESTO) which will triage and assign to each patient a specific intervention based on individual personal and clinical characteristics. The effectiveness of PRESTO to reduce waiting times in receiving mental healthcare will be tested in a stepped-wedge cluster randomized controlled trial in 5 PC centres.

DISCUSSION

PRESTO will offer timely and personalized cost-effective mental health treatment to people with mild to moderate anxious and depressive symptoms. This will result in a reduction of the burden of mental health problems in PC and on society as a whole.

TRIAL REGISTRATION

The project and their clinical trials were registered in Clinical Trials.gov: NCT04559360 (September 2020).

Burnout in residents during the first wave of the COVID-19 pandemic: a systematic review and meta-analysis

Introduction

The high prevalence of burnout in resident physicians is expected to have increased as a result of the expansion of the pandemic. We conducted a systematic review with a meta-analysis of studies conducted during the first wave of the COVID-19 pandemic on burnout in residents and potential associated risk factors.

Methods

The search was done in the Web of Science, MEDLINE, Scopus, and Lillac databases (April 2020-October 2021) using a priori protocol based on the PRISMA guidelines. The Newcastle Ottawa Scale was used to assess the risk of bias in the included studies. We estimated the pooled prevalence (95% CI) of burnout and the prevalence ratio (95% CI) of each risk factor associated.

Results

We included 23 studies from 451 potential initial articles and those written in the English language; all of the collected studies were cross-sectional with anonymous online surveys, involving 4,998 responders (34%), of which 53.2% were female responders, 51% were R1-2, and 71% were in direct contact with COVID-19 patients. Eighty-seven percent presented a low-to-moderate risk of bias. Publication bias was not shown. The estimated pooled prevalence of burnout was 40% (95% CI = 0.26 - 0.57). Burnout was associated with psychiatry history (PR = 4.60, 95% CI = 1.06 - 20.06). There were no differences by gender, civil status, children in-charge, year of residency, or time exposure to COVID-19.

Discussion

The overall prevalence of burnout in residents during the first wave of the pandemic was in line with the results described in this collective before the pandemic. The presence of a psychiatry history was a potential burnout risk factor, suggesting a high vulnerability during the peak of the stress period and the need to implement mental health surveillance for this subgroup.

Existing workloads among managers and healthcare workers during the COVID-19 pandemic: Meanings in the Amazon context

INTRODUCTION

The global COVID-19 pandemic has increased the concern and risks of health professionals exposed by acting on the front lines in combating and controlling the spread of the virus. This study aims at analyzing the workloads and their implications for the activities carried out by managers and health workers in the face of the COVID-19 pandemic in Manaus, Amazonas, Brazil.

METHOD

This is a qualitative study, of the case study type, that integrates a macro research that deals with the experiences built during the confrontation of the pandemic of COVID-19 in the capital of the state of Amazonas, Brazil, the epicenter of the pandemic in the country. Data production resorted to documentary analysis and semi-structured interviews with 56 managers or professionals from the Manaus Health Care Network. The analytical process was supported by the resources of the Atlas.ti 8.0 software and the precepts of Thematic Networks analysis.

RESULTS

The thematic network "workloads" brought together three topics related to the experience of psychological, physiological and biological loads. Psychological workloads were strongly present in the work routine, being referred to in a more significant way. The sources that increase them are strongly related to work stress, dealing with suffering and death and excess demand on the service. Physiological loads were related to excessive working hours, staff shortages and activity overload. "Biological burdens" include exposure to the SARS-CoV-2 virus, constant contact with infected individuals, and individual protection as key elements of this set.

CONCLUSION

The study showed that both managers and workers have work processes and environments with conditions that tend to generate workloads that harm their health and safety, as well as institutions and patient care. Therefore, there is a need for more effective organizational actions in workers' health surveillance, disease prevention, adequate working conditions, reducing workloads and promoting more resolute and less stressful work environments.

First-episode psychotic disorders in the wake of the COVID-19 pandemic: a descriptive review of casereports

OBJECTIVE

Since the onset of COVID-19 pandemic, many case reports and case series dealt with new-onset psychotic disorders in patients either infected with SARS-CoV-2 or thematically linked to the pandemic, but without an infection. Our aim was to provide a comprehensive collection of these reports to illustrate the nature of these psychoses.

METHODS

We conducted a literature search in MEDLINE, Embase, PsycINFO, using search terms regarding first-episode psychotic disorders in the context of corona.

RESULTS

96 case reports or case series covering 146 patients (62 without and 84 with SARS-CoV-2 infection) were found. Compared to patients without infection, patients with infection showed significantly more often visual hallucinations (28.6% vs 8.1%), confusion (36.9% vs 11.3%), an acute onset of illness (88.5% vs 59.6%) and less often depression (13.1% vs 35.5%) and a delusional content related to the pandemic (29.5% vs 78.3%). Both groups had an equally favourable outcome with a duration of psychosis ≤2 weeks in half and full remission in two-thirds of patients. In patients with infection, signs of inflammation were reported in 78.3% and increased CRP in 58.6%. While reports on patients with infection are continuously published, no report about patients without infection was found after July 2020.

CONCLUSION

Cases without infection were considered reactive and originated all from the first wave of the corona pandemic. In cases with infection, inflammation was considered as the main pathogenetic factor but was not found in all patients. Diagnosis was impeded by the overlap of psychosis with delirium.

Psychological Impact and Risk of Suicide in Hospitalized COVID-19 Patients, During the Initial Stage of the Pandemic: A Cross-Sectional Study

OBJECTIVES

This study aimed to assess the psychological impact and risk of suicide in patients hospitalized for COVID-19.

METHODS

A cross-sectional study was conducted on a representative sample of patients hospitalized for COVID-19 at the "San Cecilio" University Hospital (Granada, Spain) between March and May 2020. Sociodemographic and clinical variables were collected. All participants were evaluated using the Gijon's Social-Familial Evaluation Scale to assess social problems, the Impact of Event Scale-6 and the Hospital Anxiety-Depression Scale to assess psychological impact, the Columbia Suicide Severity and Beck Hopelessness scales to assess risk of suicide, and the List of Threatening Experiences questionnaire to control for confounding bias.

RESULTS

Thirty-six COVID-19 patients were evaluated. Of them, 33.3% had a significant psychological impact; 13.9% showed symptoms of anxiety, 13.9% showed symptoms of depression, and 47.2% showed symptoms of anxiety-depression. Moderate and severe risk of suicide were found in 75% and 2.8% of the patients, respectively. Suicidal ideation was observed in 16.7% and suicide behaviors in 5.6% of the patients. Psychological impact was associated with previous psychological treatment, a greater degree of functional dependency, and increased social-familial risk. In addition, the risk of suicide was mainly associated with active treatment of a psychiatric illness and active smoking. No significant correlation was found between psychological impact and risk of suicide.

CONCLUSIONS

Psychological impact and risk of suicide were significant in patients admitted for COVID-19. Although the risk of suicide was not associated with increased psychological impact, both should be assessed, especially in patients at higher risk based on significantly associated factors.

Survey on Anxiety and Post-Traumatic Stress Disorder in Intensive Care Personnel during the COVID-19 Pandemic in a Medically Under-Resourced Country

The COVID-19 pandemic has increased the need for intensive care personnel. Romania has a low number of physicians per inhabitant. The stress of pandemics upon an already weak medical health system triggered some psychological effects upon burnt-out personnel. The main objective is to provide an insight into the psychological status of Romanian ICU personnel by evaluating their level of anxiety. The secondary objectives aim to identify the level of post-traumatic stress disorder and anxiety in different groups and to identify the personnel most affected psychologically. This study enrolled adult responders from the ICU of Târgu Mureș Emergency Clinical County Hospital, Romania, participating voluntarily. The evaluation tests were the State-Trait Anxiety Inventory and Post-Traumatic Stress Test. Out of the 126 eligible participants, 87 adult employees were enrolled—with a 69% response rate. The study comprised three groups: doctors, nurses, and auxiliary personnel. All three groups scored for moderate anxiety symptoms. COVID-19-related anxiety was strongly correlated with age and number of working years in all groups. Increased PTSD scores were observed in doctors and nurses. All ICU personnel who dealt with COVID-19 patients presented with moderate anxiety and post-traumatic stress disorder symptoms. The years of ICU experience had a positive impact on anxiety symptoms.

The emotional impact of COVID-19 on Spanish nurses and potential strategies to reduce it

BACKGROUND

Although the emotional and psychological impact of nurses' work had been identified before the COVID-19 pandemic, the pandemic aggravated risk indicators for their mental health.

AIM

The objective of this study was to analyse the levels of anxiety, depression, post-traumatic stress and burnout of nurses in the Balearic Islands (Spain) during the pandemic to identify possible sociodemographic and related occupational factors.

DESIGN

A cross-sectional study of 892 nurses was conducted during four weeks from February to March 2021.

METHODS

Sociodemographic data related to the pandemic were collected and anxiety, depression, burnout and post-traumatic stress were measured with validated scales. A multivariate and predictive analysis was carried out with risk estimates.

FINDINGS

About 75.6% of the nurses had experience in COVID-19 units, and 49.1% had worked for more than 10 months in a COVID-19 unit. Nurses in COVID-19 units (hospital ward or ICU) were more likely to report emotional fatigue (OR 1.9, p < 0.001) and anxiety (OR 1.5, p = 0.021). In general, moderate post-traumatic stress was evident in general nurses (p = 0.027), and severe post-traumatic stress was evident in ICU nurses (p = 0.027). A 1.24-month reduction in COVID-19 patient care predicted reduced levels of emotional fatigue (5.45 points), depersonalisation (1.87 points) and post-traumatic stress (4.65 points) in nurses.

CONCLUSION

Given the occurrence of new waves of COVID-19, the need to establish preventive strategies that focus on the personal and occupational characteristics related to these indicators and to implement urgent psychological support strategies is demonstrated.

IMPACT

Given these findings, it is imperative solutions are urgently applied in order to prevent compounding risk to the health system.

PSYCHOTIC DEPRESSION IN HEALTHCARE WORKERS DURING THE COVID-19 HEALTHCARE CRISIS: A CASE SERIES

After the initial phases of the COVID-19 pandemic, new waves have occurred that have chronicled the epidemiological situation. This could especially affect the Mental Health of healthcare professionals with the appearance of serious conditions such as psychotic depression. The objective of this article is to describe a series of cases of psychotic depression in health professionals during the chronic phase of the sanitary crisis.

The collaborative outcomes study on health and functioning during infection times in adults (COH-FIT-Adults): Design and methods of an international online survey targeting physical and mental health effects of the COVID-19 pandemic

BACKGROUND

. High-quality comprehensive data on short-/long-term physical/mental health effects of the COVID-19 pandemic are needed.

METHODS

. The Collaborative Outcomes study on Health and Functioning during Infection Times (COH-FIT) is an international, multi-language (n=30) project involving >230 investigators from 49 countries/territories/regions, endorsed by national/international professional associations. COH-FIT is a multi-wave, on-line anonymous, cross-sectional survey [wave 1: 04/2020 until the end of the pandemic, 12 months waves 2/3 starting 6/24 months threreafter] for adults, adolescents (14-17), and children (6-13), utilizing non-probability/snowball and representative sampling. COH-FIT aims to identify non-modifiable/modifiable risk factors/treatment targets to inform prevention/intervention programs to improve social/health outcomes in the general population/vulnerable subgrous during/after COVID-19. In adults, co-primary outcomes are change from pre-COVID-19 to intra-COVID-19 in well-being (WHO-5) and a composite psychopathology P-Score. Key secondary outcomes are a P-extended score, global mental and physical health. Secondary outcomes include health-service utilization/functioning, treatment adherence, functioning, symptoms/behaviors/emotions, substance use, violence, among others.

RESULTS

. Starting 04/26/2020, up to 14/07/2021 >151,000 people from 155 countries/territories/regions and six continents have participated. Representative samples of ≥1,000 adults have been collected in 15 countries. Overall, 43.0% had prior physical disorders, 16.3% had prior mental disorders, 26.5% were health care workers, 8.2% were aged ≥65 years, 19.3% were exposed to someone infected with COVID-19, 76.1% had been in quarantine, and 2.1% had been COVID 19-positive.

LIMITATIONS

. Cross-sectional survey, preponderance of non-representative participants.

CONCLUSIONS

. Results from COH-FIT will comprehensively quantify the impact of COVID-19, seeking to identify high-risk groups in need for acute and long-term intervention, and inform evidence-based health policies/strategies during this/future pandemics.

Stress, coping and silver linings: How depressed perinatal women experienced the COVID-19 pandemic

BACKGROUND

Research on perinatal mental health during the COVID-19 pandemic has largely focused on data from community samples. This study sought to understand the experiences of pregnant and postpartum women with histories of clinically elevated symptoms of depression.

METHODS

Participants included 60 perinatal women who participated in wellness intervention trials for women with antenatal depression. We used a mixed methods approach, assessing depression, anxiety, stressors and coping behaviors, along with narrative responses to questions regarding COVID-specific effects on mental health.

RESULTS

Over three-fourths of the sample indicated a worsening of mental health during the pandemic, with 31.7% of women endorsing clinically elevated depression symptoms and 36.7% screening positive for anxiety. Women reported negative impacts on their emotional wellbeing, especially a resurgence of mental health symptoms. Participants also articulated positive experiences during the pandemic, including an appreciation for increased time with family, especially infants. Women detailed numerous, mostly adaptive, coping strategies they had used to mitigate stress; self-isolation and spending time outdoors were associated with having depression above or below the clinical cut off, respectively.

LIMITATIONS

The study had a small sample, and the generalizability of findings may be limited, given that participants were clinical trial completers.

CONCLUSIONS

Although the pandemic upended many aspects of life for perinatal women and raised mental health concerns, many also reported adaptive means of coping and positive experiences or 'silver linings' related to pandemic restrictions. Some coping strategies that were utilized, including wellness-based behaviors, may have helped to mitigate the impact of COVID-19 related stress.

Depression, anxiety and insomnia among frontline healthcare workers amid the coronavirus pandemic (COVID-19) in Jordan: a cross-sectional study

OBJECTIVE

This study aimed to explore the prevalence and factors associated with depression, anxiety and insomnia among frontline healthcare workers (HCWs) in Jordan.

METHODS

A cross-sectional design was conducted among 122 frontline HCWs who have dealt with suspected or confirmed cases of COVID-19. The study survey included standardised questionnaires of the 7-item Generalized Anxiety Disorder (GAD-7) Scale, 9-item Patient Health Questionnaire (PHQ-9) and the Insomnia Severity Index (ISI). Data were collected online during the active surge period of cases from 11 May 2020 to 13 June 2020. The statistical analysis included descriptive statistics, analysis of variance, bivariate correlation and multivariate linear regression analyses.

RESULTS

A total of 122 HCWs participated in the study (response rate=64.2%). Among the participants, 44.3% were physicians, 32.8% were nurses and 17.2% were paramedics. The mean age of participants was 32.1 (±5.8) years, and the majority were males (80.3%). The mean scores for GAD-7, PHQ-9 and ISI were 8.5 (±5.2), 9.5 (±5.7) and 11.2 (±6.4), respectively. Results showed that the participants reported severe symptoms of anxiety (29.5%), depression (34.5%) and insomnia (31.9%), with no observed differences based on gender, job title, marital status or educational level. Moreover, in the multivariate linear regression, none of the independent factors were associated with GAD-7, PHQ-9 or ISI scores, and the only exception was increased severity of insomnia among paramedics.

CONCLUSION

The COVID-19 pandemic has exerted strenuous emotional, psychological and physical pressures on the health of frontline HCWs.

Diagnosis, prognosis, and treatment of brief psychotic episodes: a review and research agenda

Brief psychotic episodes represent an intriguing paradox in clinical psychiatry because they elude the standard knowledge that applies to the persisting psychotic disorders such as schizophrenia. This Review describes key diagnostic considerations such as conceptual foundations, current psychiatric classification versus research-based operationalisations, epidemiology, and sociocultural variations; prognostic aspects including the risk of psychosis recurrence, types of psychotic recurrences, other clinical outcomes, prognostic factors; and therapeutic issues such as treatment guidelines and unmet need of care. The advances and challenges associated with the scientific evidence are used to set a research agenda in this area. We conclude that brief psychotic episodes can be reconceptualised within a clinical staging model to promote innovative translational research and improve our understanding and treatment of psychotic disorders.

COVID-19 and the occupational stress experienced by health professionals in the hospital context: integrative review

ABSTRACT Objective: To analyze Brazilian and international scientific publications about the stress experienced by health professionals in the hospital context during the COVID-19 pandemic. Methods: Integrative literature review carried out on the SciELO, ScienceDirect, and LILACS databases, and sources of official Brazilian institutions, with documents published by May 2020. Results: Of the 26 selected references, 19 (73.08%) were indexed articles, and 7 (26.92 %) were obtained from official institutions. The study found that stress is mainly due to the overload of hospital services, the removal of professionals, the insufficiency of personal protective equipment and strict biosecurity measures, challenges in the allocation of available resources, and the risk of contamination by COVID-19. Final considerations: The stress experienced by health professionals in hospital institutions during the pandemic can trigger occupational and psychological problems.

Development of the Stress and Anxiety to Viral Epidemics-9 (SAVE-9) Scale for Assessing Work-related Stress and Anxiety in Healthcare Workers in Response to Viral Epidemics

BACKGROUND

The coronavirus disease 2019, or COVID-19, has had a major psychological impact on healthcare workers. However, very few scales are available to specifically assess work-related stress and anxiety in healthcare workers responding to a viral epidemic. This study developed a new assessment tool, the Stress and Anxiety to Viral Epidemics-9 (SAVE-9) and aimed to validate it among healthcare workers directly affected by COVID-19 in Korea.

METHODS

A total of 1,019 healthcare workers responded through anonymous questionnaires during April 20-30, 2020. Exploratory factor analysis (EFA) was conducted to explore the construct validity, and the reliability was assessed using internal consistency measures of Cronbach's alpha coefficients. Receiver operating characteristic analysis was conducted to define the most appropriate cut-off point of SAVE-9 using the Generalized Anxiety Disorder-7 scale (GAD-7; ≥ 5). Second, Spearman's rank correlation coefficient was used to establish convergent validity for the SAVE-9 questionnaire with GAD-7 and the Patient Health Questionnaire-9.

RESULTS

The nine-item scale had satisfactory internal consistency (Cronbach's α = 0.795). It adopted a two-factor structure: 1) anxiety regarding viral epidemics and 2) work-related stress associated with viral epidemics. A cut-off score of 22 for the SAVE-9 ascertained levels of stress and anxiety in response to a viral epidemic in healthcare workers that warranted clinical attention. Correlations between the SAVE-9 and the other scales were statistically significant (P < 0.05).

CONCLUSION

The results suggest that the SAVE-9 is a useful, reliable, and valid tool to evaluate stress and anxiety responses in healthcare workers during viral epidemics.

Prevalence of Burnout Syndrome and other psychiatric disorders among health professionals during the COVID-19 pandemic: A systematic review and meta-analysis protocol

INTRODUCTION

Studies carried out during previous pandemics revealed an increase in the prevalence of Burnout Syndrome and other psychiatric disorders among health professionals. A high prevalence of psychiatric disorders is also observed in some health categories, during the COVID-19 pandemic.

OBJECTIVE

This systematic review/meta-analysis study aims to assess the prevalence of Burnout Syndrome and other psychiatric disorders (depression, anxiety, stress, and insomnia) among health care professionals and other support professionals during the COVID-19 pandemic.

INCLUSION CRITERIA

Observational studies published from December 2019, without language restrictions in which the prevalence of Burnout Syndrome and other psychiatric disorders among health professionals during the COVID-19 pandemic will be assessed.

METHODS

PubMed, Web of Science, Embase, CINAHAL, PsycINFO, LILACS, SCOPUS, and The Cochrane Library will be searched for eligible studies. Two reviewers will independently screen and select studies, assess methodological quality, and extract data. A meta-analysis will be performed, if possible, and the Grading of Recommendations Assessment Development and Evaluation (GRADE).

ETHICS AND DISCLOSURE

This study will use secondary data. Thus, there is no need for submission to the ethics committee. The results of this systematic review will be published in a journal after a peer-review process.

TRIAL REGISTRATION

Systematic review registration number: CRD42020212036.

COVID-19 Infection: A Neuropsychiatric Perspective

As a potentially life-threatening disease with no definitive treatment and without fully implemented population-wide vaccination, COVID-19 has created unprecedented turmoil in socioeconomic life worldwide. In addition to physical signs from the respiratory and many other systems, the SARS-CoV-2 virus produces a broad range of neurological and neuropsychiatric problems, including olfactory and gustatory impairments, encephalopathy and delirium, stroke and neuromuscular complications, stress reactions, and psychoses. Moreover, the psychosocial impact of the pandemic and its indirect effects on neuropsychiatric health in noninfected individuals in the general public and among health care workers are similarly far-ranging. In addition to acute neuropsychiatric manifestations, COVID-19 may also produce late neuropsychiatric sequelae as a function of the psychoneuroimmunological cascade that it provokes. The present article presents a state-of-the-science review of these issues through an integrative review and synthesis of case series, large-cohort studies, and relevant meta-analyses. Heuristics for evaluation and further study of the neuropsychiatric manifestations of SARS-CoV-2 infection are offered.

Trastornos del sueño en emergencias y desastres

Los trastornos del sueño son frecuentes en la población y una causa importante de morbilidad. El objetivo de esta revisión es evaluar las alteraciones del sueño en periodos de emergencia y desastres. A lo largo de la historia, la esfera biopsicosocial y el sueño de las personas ha sido abrumada por múltiples eventos a gran escala, tales como desastres naturales, tragedias provocadas por el hombre, conflictos bélicos, crisis sociales y pandemias, cuya experiencia puede derivar en problemas de salud a corto, mediano y/o largo plazo. En los estudios analizados, se ha observado el impacto negativo de las emergencias y desastres en el sueño, por lo que ha cobrado gran relevancia la difusión y promoción de medidas que incentiven el buen dormir. Debido a la llegada del COVID-19 y a la situación de confinamiento por periodos prolongados en el hogar para prevenir su propagación, han surgido importantes consecuencias a nivel social. Ciertos factores ocupacionales y características de los desastres se asocian a mayor comorbilidad, un alto riesgo de experimentar agotamiento físico, trastornos psicológicos e insomnio en grupos altamente vulnerables, como lo son los profesionales de la salud, rescatistas y socorristas. El insomnio es el trastorno de sueño más frecuente en la población general y su empeoramiento en el contexto de pandemia por COVID-19 representa un nuevo problema en salud pública. Es por ello, que es indispensable promover campañas de prevención de salud física y mental orientados a la pesquisa precoz y manejo de patologías de la esfera psicosocial, dentro de las posibilidades socioeconómicas.

Psychiatric Clinical Profiles and Pharmacological Interactions in COVID-19 Inpatients Referred to a Consultation Liaison Psychiatry Unit: a Cross-Sectional Study

The Coronavirus Disease 2019 (COVID-19) can affect mental health in different ways. There is little research about psychiatric complications in hospitalized patients with COVID-19. The aim of the study was to describe the psychiatric clinical profile and pharmacological interactions in COVID-19 inpatients referred to a Consultation-Liaison Psychiatry (CLP) unit. This is a cross-sectional study, carried out at a tertiary hospital in Spain, in inpatients admitted because of COVID-19 and referred to our CLP Unit from March 17,2020 to April 28,2020. Clinical data were extracted from electronic medical records. The patients were divided in three groups depending on psychiatric diagnosis: delirium, severe mental illness (SMI) and non-severe mental illness (NSMI). Of 71 patients included (median [ICR] age 64 [54-73] years; 70.4% male), 35.2% had a delirium, 18.3% had a SMI, and 46.5% had a NSMI. Compared to patients with delirium and NSMI, patients with SMI were younger, more likely to be institutionalized and were administered less anti-COVID19 drugs. Mortality was higher among patients with delirium (21.7%) than those with SMI (0%) or NSMI (9.45%). The rate of side effects due to interactions between anti-COVID19 and psychiatric drugs was low, mainly drowsiness (4.3%) and borderline QTc prolongation (1.5%). Patients affected by SMI were more often undertreated for COVID-19. However, the rate of interactions was very low, and avoidable with a proper evaluation and drug-dose adjustment. Half of the patients with SMI were institutionalized, suggesting that living conditions in residential facilities could make them more vulnerable to infection.

Association between resilience and burnout of front-line nurses at the peak of the COVID-19 pandemic: Positive and negative affect as mediators in Wuhan

The outbreak of coronavirus disease 2019 (COVID-19) is having a dramatic effect on the mental health of healthcare workers (HCWs). Upon the emergence of the COVID-19 pandemic, the Chinese government dispatched about 42 000 HCWs to Wuhan City and Hubei Province to fight this pandemic. This study briefly examines front-line nurses who experienced burnout, with the main objective of investigating the mediating roles of positive and negative affect in the relationship between resilience and burnout in Wuhan hospitals at the peak of the COVID-19 pandemic. A total of 180 front-line nurses voluntarily participated via a social media group. They completed the online questionnaires, including the Maslach Burnout Inventory-General Survey (MBI-GS), the Positive and Negative Affect Schedule (PANAS), the Connor-Davidson Resilience Scale (CD-RISC), demographics, and work-related characteristics. Structural equation modelling (SEM) analysis was used to examine the mediating effect of positive and negative affect on the relationship between resilience and burnout. The total prevalence of burnout was 51.7%, of which 15.0% were severe burnout. These preliminary results revealed that positive and negative affect fully mediated the effects of resilience on burnout, emotional exhaustion, depersonalization, and reduced personal accomplishment of front-line nurses. It is necessary to know the impact of resilience on HCWs with burnout through the positive and negative affect of individual backgrounds and situations, and how policymakers can deploy resilience interventions to support front-line HCWs.

Changing trends in psychiatric emergency service admissions during the COVID-19 outbreak: Report from a worldwide epicentre

BACKGROUND

During the COVID-19 pandemic, a structural reorganization was imposed on public health systems. Psychiatry services were also affected with the imposed reduction of non-urgent consultations. We aim to explore the effect of these changes on a Psychiatry Emergency Service during COVID-19 lockdown in Spain.

METHODS

A retrospective analysis was performed on all patients admitted to our Psychiatric Emergency Service 90 days before and after March 14^th, 2020, the first day of lockdown in Spain. Extracted data were compared between the two periods. Poisson regression analysis was performed to analyze changes in admission rates.

RESULTS

1,958 psychiatric emergency admissions were analyzed. Although the number of admissions decreased by 37.9%, we observed a significant increase in the percentage of acute psychiatric hospitalization during the lockdown. Anxiety spectrum disorders accumulated the greatest significant decrease in admission rates during the lockdown. On the other hand, a significant increase in admissions rates was found in patients with dementia, autism spectrum disorders, and substance use disorders during the lockdown.

LIMITATIONS

This study was conducted in a single psychiatric emergency service, preventing a generalization of our results. The comparison time period might have biased our results due to the influence of external factors.

CONCLUSION

Mental health consequences of COVID-19 are becoming apparent. A reduction of admission rates for anxiety disorders might be related telepsychiatry implementation during the lockdown. Other conditions particularly vulnerable to the routine changes and lack of social support have suffered the most, and efforts should be placed to treat these situations.

Does Social Stigma and Neglect Post-COVID-19 Matter? A Case Report on Brief Psychotic Disorder Post-COVID-19 and Self-Quarantine

Social stigma and neglect post-coronavirus disease 2019 (COVID-19) and self-quarantine can be associated with a brief psychotic disorder (BPD). A 53-year-old African-American man with no significant past medical and psychiatric history was brought to the emergency department (ED) with symptoms of persecutory delusions post COVID-19 and self-quarantine. His symptoms included false beliefs that people were plotting to kill him which made him combative at work and home. As his symptoms worsened, his wife brought him to the hospital. He was given intramuscular haloperidol 5 mg one dose in the ED. The Clinical Health Psychology and Psychiatry team diagnosed the patient with BPD as per the Diagnostic and Statistical Method of Mental Disorder Fifth Edition (DSM-5). Over the next few days, his symptoms slowly improved. At follow-up visit in the outpatient clinic in a week, we found him back to his baseline without any delusional thoughts. Increased stressors post COVID-19, neglect at home, and social stigmata at work associated with COVID-19 along with his individual vulnerability appeared to be the cause of his delusions but various other mechanisms may exist. Our case raises the question: does social stigma and neglect post-COVID-19 and self-quarantine matter?

International experiences of the active period of COVID-19 - Mental health care

AIM

To summarise commonalities and variations in the mental health response to COVID-19 across different sites and countries, with a view to better understanding key steps not only in crisis management, but for future systemic reform of mental health care.

METHOD

We conducted a Rapid Synthesis and Translation Process of lessons learned from an international panel of experts, collecting on the ground experiences of the pandemic as it evolved in real time. Digital conferencing and individual interviews were used to rapidly acquire knowledge on the COVID-19 outbreak across 16 locations in Australia, Denmark, Italy, Spain, Taiwan, the UK, and the USA.

RESULTS

COVID-19 has had massive impacts on mental health care internationally. Most systems were under-resourced and under-prepared, struggling to manage both existing and new clients. There were significant differences between sites, depending on the explosivity the pandemic and the readiness of the mental health system. Integrated, community mental health systems exhibited greater adaptability in contrast to services which depended on face-to-face and hospital-based care. COVID-19 has demonstrated the need for a new approach to rapid response to crisis in mental health. New decision support system tools are necessary to ensure local decision-makers can effectively respond to the enormous practical challenges posed in these circumstances.

CONCLUSIONS

The process we have undertaken has generated clear lessons for mental health policymakers worldwide, beyond pandemic planning and response to guide next steps in systemic mental health reform. Key here is achieving some balance between national leadership and local context adaptation of evidence.

On the Nature of Fear and Anxiety Triggered by COVID-19

Emergencies that occur during natural disasters, such as avalanches, earthquakes, and floods, tend to be sudden, unexpected, and ephemeral and recruit defensive responses, similar to the ones recruited when faced with dangerous animals. Defensive behaviors are triggered by activity in survival circuits that detects imminent threats and fear is the conscious emotion of that follows immediately. But this particular threat (COVID-19) is useable and mysterious, triggering anxieties much more than fear. We conducted a literature search on May 1, 2020 in Google Scholar, PsychInfo, and PubMed with search terms related to COVID-19 fears and found 28 relevant articles. We categorized the papers into six groups based on the content and implications: fear of the unknown, social isolation, hypochondriasis, disgust, information-driven fears, and compliance. Considering the nature of fear and anxiety, combined with the characteristics of the present COVID-19 situation, we contemplate that physicians and other health care workers of several specialties, as well as police officers, fire-fighters, and rescue personnel, and first responders might be more able to deal with COVID-19 if they have (a) some tolerance of the unknown, (b) low illness anxiety disorder, (c) tolerance to social isolation; (d) low levels of disgust sensitivity; (e) be granted financial support, (f) have priority if needed medical assistance (g) use caution relatively to the COVID-19 media coverage and (h) be trained to have high levels of efficacy. Possibilities for preventive and therapeutic interventions that can help both health care personnel and the general population are also discussed.

Impact of coronavirus syndromes on physical and mental health of health care workers: Systematic review and meta-analysis

BACKGROUND

Health care workers (HCW) are at high risk of developing physical/mental health outcomes related to coronavirus syndromes. Nature and frequency of these outcomes are undetermined.

METHODS

PRISMA/MOOSE-compliant (PROSPERO-CRD42020180205) systematic review of Web of Science/grey literature until 15th April 2020, to identify studies reporting physical/mental health outcomes in HCW infected/exposed to Severe Acute Respiratory Syndrome -SARS-, Middle East Respiratory Syndrome -MERS-, Novel coronavirus -COVID-19-. Proportion random effect meta-analyses, I² statistic, quality assessment and sensitivity analysis.

RESULTS

115 articles were included (n=60,458 HCW, age 36.1±7.1, 77.1% female). Physical health outcomes: 75.9% HCW infected by SARS/MERS/COVID-19 reported fever (95%CI=65.9-83.7%, k=12, n=949), 47.9% cough (95%CI=39.2-56.8%, k=14, n=970), 43.6% myalgias (95%CI=31.9-56.0%, k=13, n=898), 42.3% chills (95%CI=20.2-67.9%, k=7, n=716), 41.2% fatigue (95%CI=18.2-68.8%, k=6, n=386), 34.6% headaches (95%CI=23.1-48.2%, k=11, n=893), 31.2% dyspnoea (95%CI=23.2-40.5%, k=12, n=1003), 25.3% sore throat (95%CI=18.8-33.2%, k=8, n=747), 22.2% nausea/vomiting (95%CI=14.9-31.8%, k=6, n=662), 18.8% diarrhoea (95%CI=11.9-28.4%, k=9, n=824). Mental health outcomes: 62.5% HCW exposed to SARS/MERS/COVID-19 reported general health concerns (95%CI=57.0-67,8%, k=2, n=2254), 43.7% fear (95%CI=33.9-54.0%, k=4, n=584), 37.9% insomnia (95%CI=30.9-45.5%, k=6, n=5067), 37.8% psychological distress (95%CI=28.4-48.2%, k=15, n=24,346), 34.4% burnout (95%CI=19.3-53.5%, k=3, n=1337), 29.0% anxiety features (95%CI=14.2-50.3%, k=6, n=9191), 26.3% depressive symptoms (95%CI=12.5-47.1%, k=8, n=9893), 20.7% post-traumatic stress disorder features (95%CI=13.2-31%, k=11, n=3826), 16.1% somatisation (95%CI=0.2-96.0%, k=2, n=2184), 14.0% stigmatisation feelings (95%CI=6.4-28.1%, k=2, n=411).

LIMITATIONS

Limited amount of evidence for some outcomes and suboptimal design in several studies included.

CONCLUSIONS

SARS/MERS/COVID-19 have a substantial impact on the physical and mental health of HCW, which should become a priority for public health strategies.

A psychiatrist's perspective from a COVID-19 epicentre: a personal account

BACKGROUND

The COVID-19 pandemic has and will have a huge impact on mental health, especially in countries that have been significantly affected, such as Spain.

AIMS

Here we aim to provide the perspectives of a group of psychiatrists from Barcelona, one of the epicentres of the pandemic so far, to highlight the potential fatality of a virus that caught us unaware and unprepared, and hopefully this article will be of aid to countries about to face the pandemic.

RESULTS

The unprecedented situations that we have been faced with so far have included reconfiguring hospitals and the redeployment of healthcare professionals, with flexibility and adaptability key to managing the overload in demand. This has led to healthcare professionals being exposed to extremely stressful situations and they have had impossible decisions to make that may have mental health consequences, some of which may be severe and long lasting.

CONCLUSIONS

A rebound effect on mental health problems is to be expected in the medium and long term, especially for healthcare professionals and psychiatric patients, necessitating a strengthening of preventive approaches and policies for mental health along with a prompt reopening of mental health services. Ways to provide psychiatric healthcare in the immediate future need to be re-evaluated, and the development of telepsychiatry services is probably to be expected.

COVID-19 inpatients with psychiatric disorders: Real-world clinical recommendations from an expert team in consultation-liaison psychiatry

BACKGROUND

The management of coronavirus disease 2019 (COVID-19) in patients with comorbid psychiatric disorders poses several challenges, especially regarding drug interactions.

METHODS

We report three representative case-scenarios on patients with psychiatric disorders and COVID-19 to provide a practical approach based on the existing literature and the clinical experience of an expert team in consultation-liaison psychiatry.

CASE-CENTERED RECOMMENDATIONS

Psychopharmacological ongoing treatments should be prioritized and most doses should be reduced 25-50% of original dose if the patient receives lopinavir/ritonavir, with some exceptions including quetiapine, asenapine, olanzapine, sertraline, lamotrigine, bupropion, and methadone. If the psychopharmacological usual doses are in the low-to-median range levels, a dose change during COVID-19 drugs co-administration is not recommended, but only ECG and clinical monitoring of adverse effects and drug levels if required. Furthermore, when introducing a psychopharmacological drug, dose titration should be progressive, with ECG monitoring if cardiotoxic interactions are present. (A) In agitated delirium, olanzapine is recommended as first-line antipsychotic and quetiapine should be avoided. (B) In severe mental illness (SMI), essential treatments should be maintained. (C) In non-SMI with depressive/anxiety symptoms, psychological support should be provided and symptoms identified and treated.

LIMITATIONS

Most recommendations on pharmacological interactions provide only a limited qualitative approach and quantitative recommendations are lacking.

CONCLUSIONS

Patients with psychiatric disorders and COVID-19 should be managed on a personalized basis considering several clinical criteria and, should not be excluded from receiving COVID-19 treatments. Risks of pharmacological interaction are not absolute and should be contextualized, and most psychopharmacological treatments should include an ECG with special attention to QTc interval.

Symptoms of burnout in intensive care unit specialists facing the COVID-19 outbreak

BACKGROUND

The COVID-19 pandemic has resulted in an unprecedented healthcare crisis with a high prevalence of psychological distress in healthcare providers. We sought to document the prevalence of burnout syndrome amongst intensivists facing the COVID-19 outbreak.

METHODS

Cross-sectional survey among intensivists part of the European Society of Intensive Care Medicine. Symptoms of severe burnout, anxiety and depression were collected. Factors independently associated with severe burnout were assessed using Cox model.

RESULTS

Response rate was 20% (1001 completed questionnaires were returned, 45 years [39-53], 34% women, from 85 countries, 12 regions, 50% university-affiliated hospitals). The prevalence of symptoms of anxiety and depression or severe burnout was 46.5%, 30.2%, and 51%, respectively, and varied significantly across regions. Rating of the relationship between intensivists and other ICU stakeholders differed significantly according to the presence of anxiety, depression, or burnout. Similar figures were reported for their rating of the ethical climate or the quality of the decision-making. Factors independently associated with anxiety were female gender (HR 1.85 [1.33-2.55]), working in a university-affiliated hospital (HR 0.58 [0.42-0.80]), living in a city of > 1 million inhabitants (HR 1.40 [1.01-1.94]), and clinician's rating of the ethical climate (HR 0.83 [0.77-0.90]). Independent determinants of depression included female gender (HR 1.63 [1.15-2.31]) and clinician's rating of the ethical climate (HR 0.84 [0.78-0.92]). Factors independently associated with symptoms of severe burnout included age (HR 0.98/year [0.97-0.99]) and clinician's rating of the ethical climate (HR 0.76 [0.69-0.82]).

CONCLUSIONS

The COVID-19 pandemic has had an overwhelming psychological impact on intensivists. Follow-up, and management are warranted to assess long-term psychological outcomes and alleviate the psychological burden of the pandemic on frontline personnel.

Symptoms of Posttraumatic Stress, Anxiety, Depression, Levels of Resilience and Burnout in Spanish Health Personnel during the COVID-19 Pandemic

The number of health workers infected with COVID-19 in Spain is one of the highest in the world. The aim of this study is to analyse posttraumatic stress, anxiety and depression during the COVID-19 pandemic. Associations between burnout, resilience, demographic, work and COVID-19 variables are analysed. Cross-sectional data on 1422 health workers were analysed. A total of 56.6% of health workers present symptoms of posttraumatic stress disorder, 58.6% anxiety disorder, 46% depressive disorder and 41.1% feel emotionally drained. The profile of a health worker with greater posttraumatic stress symptoms would be a person who works in the Autonomous Community of Madrid, in a hospital, is a woman, is concerned that a person he/she lives with may be infected, and thinks that he/she is very likely to be infected. The risk variables for anxiety and depression would be a person that is a woman, working 12- or 24-h shifts, and being worried that a family member could be infected. High scores on emotional exhaustion and depersonalization are risk factors for mental health, with resilience and personal fulfilment being protective variables. Data are provided to improve preventive measures for occupational health workers.

Global Psychological Implications of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and Coronavirus Disease-2019 (COVID-19). What Can Be Learned From Italy. Reflections, Perspectives, Opportunities

On December 31, 2019, the Chinese authorities announced that in the city of Wuhan, Hubei Province, central-eastern China, a cluster of pneumonia cases of unknown etiology had developed. A new coronavirus (SARS-CoV-2) that causes serious problems like pneumonia and even death, has been discovered. This new disease (COVID-19) has spread also in Italy starting from the first recognized case on February 20. Beyond its biological implications, this coronavirus allows us many psychological reflections. A new virus is indeed a potentially serious problem for mankind, but it can also be an opportunity to bring the focus back to us, to observe what is happening, who we are and how we are reacting both as individuals and as a population. Even positive implication of this pandemic was discussed.