INTRODUCTION — Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is highly transmissible and the disease it causes, coronavirus disease 2019 (COVID-19), is often lethal and has reached pandemic scale worldwide in 2020 . Information about COVID-19 is evolving rapidly, and interim guidance by multiple organizations is constantly being updated and expanded.
COVID-19 is associated with multiple psychiatric problems in several groups, including patients with COVID-19 and in clinicians who care for patients with suspected or confirmed COVID-19 [2,3]. In addition, COVID-19 may adversely affect patients who have psychiatric disorders predating the pandemic and may be at increased risk of infection, due to difficulties adhering to frequent handwashing and physical distancing as well as poor insight and problems understanding the risk of infection [4-6].
This topic addresses the epidemiology, clinical features, course of illness, and management of psychiatric illness that is associated with the COVID-19 pandemic. Other topics discuss COVID-19 per se and related issues arising in different specialties, such as cardiology, obstetrics and gynecology, and oncology.
EPIDEMIOLOGY — A limited number of studies describe the prevalence of mental health sequelae associated with COVID-19.
Health care workers — Psychiatric symptoms and disorders can occur in clinicians exposed to COVID-19 [3,7]. As an example, cross-sectional studies used self-report instruments close to or during the peak of the pandemic to assess hospital-based physicians and nurses (total n >1200) in China  and frontline and second-line health care workers (n >1300) in Italy . The prevalence of moderate to severe psychiatric symptoms was as follows [2,8]:
●Anxiety – 12 to 20 percent
●Depression – 15 to 25 percent
●Insomnia – 8 percent
●Traumatic distress – 35 to 49 percent
Consistent with these results is the finding from an online survey of Canadian health care workers (n >500, 90 percent female) in April 2020, which reported that 47 percent needed psychological support .
Another cross-sectional study assessed nearly 300 hospital-based physicians and nurses caring for patients with COVID-19 in Singapore in February and March 2020, using self-report screening instruments . Relatively few clinicians screened positive for anxiety, depression, and posttraumatic stress disorder (PTSD; approximately 5 to 10 percent), which the authors attributed to better preparedness of the clinicians based upon their previous experience with the 2003 severe acute respiratory syndrome (SARS) epidemic.
A review of 59 studies of viral outbreaks such as the SARS epidemic and COVID-19 pandemic identified multiple risk factors and protective factors for psychiatric problems in health care workers :
●Risk factors – The most consistent risk factor across studies was increased contact with affected patients. Other consistent predictors were a prior history of psychiatric symptoms/disorders and/or general medical illnesses, spending a prolonged time in quarantine, perceived lack of organizational support, and perceived social stigma directed towards health care workers.
●Protective factors – Across studies, the factor that most consistently decreased the risk of adverse psychological outcomes in health care workers was access to personal protective equipment. Other consistent protective factors included having supportive peers, access to psychiatric interventions, and trust in the institution’s infection control measures, as well as receiving clear communication from supervisors and adequate time off from work.
Patients with COVID-19 — Patients who survive acute COVID-19 are at increased risk for psychiatric symptoms and disorders [12-14]. As an example, a one-year, retrospective study of administrative health care data examined the risk of incident psychiatric disorders in patients (n >150,000) who survived COVID-19 for 30 days and patients (n >5,600,000) without COVID-19 . After adjusting for potential confounding factors (eg, age, smoking status, and general medical comorbidities), the analyses found that infection with severe acute respiratory syndrome coronavirus 2 was associated with an increased risk of a psychiatric diagnosis (hazard ratio [HR] 1.46, 95% CI 1.40-1.52). Specific symptoms and disorders that were observed more often in patients with COVID-19 included:
●Substance use disorders
Following a diagnosis of COVID-19, the increased risk of psychopathology persists for varying lengths of time across different psychiatric symptoms and disorders. A two-year retrospective study identified patients with a diagnosis of COVID-19 (n >1.2 million) and an equal number of patients with other respiratory infections, and used propensity scoring to match the two groups on 82 potential confounders observed at baseline (eg, sociodemographic factors, comorbidities, and exposure to medications) . For the first six months of follow-up after onset of infection, patients with COVID-19 experienced more psychopathology than patients with other infections. However, the increased risk of anxiety disorders, insomnia, and mood disorders subsequently dissipated, such that the risk in the two groups was equal after further follow-up for one to three months, depending upon the specific symptom/disorder. By contrast, COVID-19 was associated with a greater risk of cognitive impairment and psychotic disorders during the entire two-year follow-up.
General population — The COVID-19 pandemic may be associated with psychiatric symptoms in the general population of adults and children .
●Adults – Cross-sectional, self-report surveys from January to April 2020 found that clinically significant psychiatric symptoms of anxiety, depression, distress, and PTSD were present in up to 36 percent of adults. In addition, the prevalence of psychiatric symptoms during the pandemic may exceed the baseline prevalence:
•Anxiety – One online survey, conducted in China in January and February 2020, included more than 1200 individuals (primarily adults) and found that moderate to severe anxiety was present in 29 percent .
•Depression – Two internet surveys of individuals from China (n >1200 and n >2400), in January and February 2020, found that moderate to severe depression was present in 9 to 17 percent [17,18].
•Distress – Psychological distress (eg, depression, hopelessness, and nervousness) was found in 8 to 36 percent of adults:
-Two online studies of individuals from China (n >1000 and n >1200), in January and February 2020, found that psychological distress was present in 8 and 12 percent [17,19].
-In a March 2020 online survey of a nationally representative sample in the United States (n >1000), 36 percent of Americans felt that the new coronavirus pandemic was having a serious impact on their mental health .
-In an internet survey of adults (n >1400) from the United States in April 2020, psychological distress was present in 14 percent . In addition, the prevalence of distress was greater compared with results from a similar survey conducted in 2018 (14 versus 4 percent).
•PTSD symptoms – Online surveys in China have found that the prevalence of PTSD symptoms varies widely, ranging from 3 to 7 percent of adults:
-An internet survey of nearly 300 adults from China in February 2020 found that symptoms of PTSD (intrusion symptoms, avoidance, negative alterations in mood and cognition, and hyperarousal) were present in 7 percent .
-An internet survey of home-quarantined college students (n >2400) in February 2020 suggested that PTSD was probably present in 3 percent .
In addition, the risk for PTSD may be elevated among family members of patients admitted to an intensive care unit with acute respiratory distress [23,24].
No consistent predictors of psychiatric illness in adults have been identified.
●Children – Chinese students in grades 2 through 6, who were quarantined at home for an average of 34 days, completed a cross-sectional, online, self-report survey in February and March 2020 . Anxiety symptoms and depressive symptoms were each reported by approximately 20 percent and almost two-thirds were worried about becoming infected.
Older individuals (eg, ≥70 years), immunocompromised patients, and patients with chronic disease may also experience increased anxiety, depression, and worry [26,27]. In addition, individuals living in settings with armed conflicts and humanitarian crises (eg, refugees and internally displaced people) are at risk for psychiatric symptoms and disorders related to COVID-19 .
Although these data provide useful perspectives on the burden of illness and can generate hypotheses, they are compromised by the convenience sampling methods necessary to rapidly generate and publish data .
PATHOGENESIS — The pathogenesis of psychiatric symptoms and disorders that arise during the COVID-19 pandemic may include biologic and psychosocial factors.
COVID-19 can affect central nervous system function. One cross-sectional study identified patients (n = 125) who were hospitalized with COVID-19 and had new-onset neuropsychiatric symptoms, including cerebrovascular events (62 percent); acute alterations in behavior, cognition, consciousness, or personality (31 percent); and neurologic problems (9 percent) .
Retrospective studies also suggest that COVID-19 may affect the brain:
●A chart review of hospitalized patients with COVID-19 (n = 214) found that central nervous system manifestations (eg, dizziness, headache, or impaired consciousness) occurred in 25 percent .
●A study of patients hospitalized with acute respiratory distress syndrome due to COVID-19 (n = 58) found multiple neurologic and psychiatric features, such as agitation (69 percent), confusion (65 percent), corticospinal tract signs (67 percent), and neuropsychological impairment (33 percent) . However, analysis of cerebrospinal fluid in seven patients was negative for the virus, which suggests that the neuropsychiatric features may have resulted from encephalopathy secondary to the massive inflammatory response and associated physiologic derangements of critical illness, cytokines, or medications, rather than the direct effect of viral infection.
●A study of hospitalized patients with COVID-19 (n = 841) found that nearly 60 percent manifested neuropsychiatric symptoms, including anxiety, delirium, depression, dizziness, dysgeusia, headache, insomnia, and myalgias . Tests for the virus in the cerebrospinal fluid of two patients were negative, suggesting that the virus may not directly infect the central nervous system and that the symptoms might be due to inflammation (eg, via cytokines) or the adverse effects of treatment.
In addition, a literature review that found past viral epidemics were associated with neuropsychiatric symptoms such as demyelination, encephalopathy, and neuromuscular dysfunction, as well as mood changes and psychosis . The symptoms occurred during infection or following recovery from the infection in the ensuing weeks, months, or longer.
Multiple studies suggest that COVID-19 may indirectly affect the central nervous system through the associated inflammatory immune response and medical interventions that are administered [14,32,33]. Immunologic findings in patients with COVID-19 include elevated serum C-reactive protein and pro-inflammatory cytokines (eg, interleukin-6) and decreased total blood lymphocyte counts .
Additional information about the neurologic complications of COVID-19 is discussed separately. (See "COVID-19: Neurologic complications and management of neurologic conditions".)
Critical illness and resultant intensive care unit stays commonly expose patients to extreme physiological and psychological stressors that are life-threatening and traumatic, and frequently precipitate persistent psychiatric illness [14,35]. (See 'Patients critically ill with COVID-19' below.)
In addition, psychiatric illnesses that occur during the pandemic may stem from psychosocial factors such as [3,12,26,36,37]:
●Frequency and extent of exposure to individuals infected with the virus
●Fear of infecting family members
●Lack of access to testing and medical care for COVID-19
●Physical distancing, home confinement, quarantining, and loneliness
●Inconsistent messages and directives regarding public health measures such as wearing face masks
●Economic hardships and insecurity
●Shortages of available resources (eg, foods, paper products, and personal protective equipment)
●Diminished personal freedoms
●Continuous media reporting about the pandemic and the uncertainty surrounding its eventual outcome
Among outpatients with pre-existing psychiatric illnesses (ie, onset prior to the pandemic), deterioration may occur because routine visits with clinicians are not available . Consequently, patients who are unable to obtain refills may be forced to reduce the dose of their medications or stop them altogether, and some patients may not have the opportunity to adjust the dose or switch medications if they are ineffective or causing adverse effects.
CLINICAL FEATURES — The COVID-19 pandemic may give rise to psychiatric symptoms and disorders.
Overview — Based upon studies of the COVID-19 pandemic and previous epidemics that are discussed in the subsections immediately below, the COVID-19 pandemic may be associated with psychiatric symptoms that do not necessarily rise to the level of a psychiatric disorder, as well as full-blown anxiety disorders, depressive disorders, insomnia disorder, and posttraumatic stress disorder (PTSD). The clinical features of these disorders are discussed separately:
In addition, the COVID-19 pandemic may be associated with exacerbation of substance use behaviors and disorders [13,39-41]. An online, self-report survey of Chinese adults in March 2020 found that during the pandemic, use of alcohol and tobacco increased . Among:
●Regular drinkers (n = 137) – 32 percent increased the amount of alcohol consumed.
●Ex-drinkers (n = 331) – Recurrence of alcohol use disorder occurred in 19 percent.
●Regular smokers (n = 412) – 20 percent increased the amount of tobacco consumed.
●Ex-smokers (n = 190) – Recurrence of tobacco use disorder occurred 25 percent.
Separate topics discuss substance-related and addictive disorders.
The COVID-19 pandemic may also increase the risk of suicidal ideation and behavior, based upon studies that found previous viral epidemics were associated with increased rates of suicide deaths , including suicides that were reported as an adverse effect of quarantine . Among individuals aged 65 years or older, the 2003 severe acute respiratory syndrome (SARS) epidemic was associated with a 30 percent increase in suicide .
Suicidality related to COVID-19 may be due to the hardships imposed by the pandemic, including economic privation, social isolation, reduced access to general medical and mental health care, and the stigma of having COVID-19 [26,36,38,43,45]. The spike in gun purchases in the United States during the pandemic represents another risk factor for suicides . In addition, the deaths caused by the pandemic may leave health care workers vulnerable to suicide [47-49]. General information about suicidality is discussed separately. (See "Suicidal ideation and behavior in adults".)
Health care workers — Studies of emerging viral outbreaks suggest that psychiatric symptoms and disorders are more likely to occur in health care workers who are at relatively high risk of exposure, compared with workers who are at low risk of exposure. As an example, a meta-analysis identified 25 studies (sample size not reported) of viral epidemics that examined psychiatric problems in health care workers who had direct contact with affected patients and health care workers who had little or no contact (controls) . The analysis included 16 studies of the 2003 SARS epidemic and 5 studies of the COVID-19 pandemic. The primary findings included the following:
●Clinically significant psychological stress was more likely to occur in health care workers exposed to the virus than controls (odds ratio 1.7, 95% CI 1.5-2.0).
●Clinically significant acute and/or posttraumatic distress was more likely to occur in workers exposed to the virus than controls (odds ratio 1.7, 95% CI 1.3-2.3).
However, health care workers may also experience positive psychological outcomes as a result of their efforts during the COVID-19 pandemic. A cross-sectional, online survey of clinicians (n >600) at a medical center in New York City during April 2020 found that an increased sense purpose and meaning occurred in more than 60 percent and nearly 50 percent remained optimistic .
Patients with COVID-19 — COVID-19 appears to be frequently associated with a neuropsychiatric syndrome in the acute phase of the illness. In a systematic review of 12 studies that examined psychiatric symptoms in patients acutely infected with COVID-19 (n >900), confusion and impaired consciousness were observed in nine of the studies . One of the studies, which included 144 patients with COVID-19, found that anxiety occurred in 35 percent and depressive symptoms in 28 percent.
A subsequent cross-sectional study included patients (n = 39) with a median age of 71 years, who were hospitalized with COVID-19 and had acute alterations in behavior, cognition, consciousness, or personality :
●Encephalopathy (n = 16, 41 percent)
●Psychosis (n = 10, 26 percent)
●Dementia-like syndrome (n = 6, 15 percent)
●Other (eg, mood disorder; n = 7, 18 percent)
Among the 23 cases of psychosis, dementia-like syndrome, or other disorders, only 2 (9 percent) represented an exacerbation of a pre-existing disorder.
Studies of previous coronavirus (non-COVID-19) epidemics suggest that COVID-19 is likely to be associated with a wide variety of psychiatric symptoms and disorders. A systematic review examined psychiatric symptoms in patients who were hospitalized for SARS or Middle East respiratory syndrome (25 studies, n >2400 cases) . During acute infection, each of the following symptoms occurred in at least 5 percent of patients:
●Attention or concentration impaired
However, many patients who survived the 2003 SARS and 2012 Middle East respiratory syndrome (MERS) epidemics reported positive psychological outcomes such as gratitude for their interpersonal relationships and health . Despite limitations in role functioning, more than 75 percent resumed employment.
Patients with pre-existing psychiatric illness — Among patients with pre-existing psychiatric illness, infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may exacerbate the pre-existing illness . In patients with schizophrenia, for example, COVID-19 and medications used to treat the infection may be associated with psychotic relapses, and patients may incorporate the virus and COVID-19 into their delusions (eg, "The staff are trying to infect me") [50,51]. In addition, psychotic symptoms, cognitive deficits, disorganized thinking and behavior, poor insight, and marginalized social status (congregate living or homelessness) may impair their ability to follow public infection control measures such as physical distancing, hand washing, and wearing masks.
In addition, patients with pre-existing psychiatric illness who become infected with SARS-CoV-2 may develop new, comorbid psychiatric symptoms and disorders. (See 'Patients with COVID-19' above.)
Individuals in quarantine — Individuals in quarantine during the COVID-19 pandemic may develop a wide range of psychiatric symptoms, based upon studies of previous epidemics. As an example, a review of 24 studies examined the psychological impact of quarantine in 10 countries during infectious disease outbreaks such as the 2003 severe acute respiratory syndrome epidemic and the 2014 Ebola outbreak . Adverse psychological outcomes included anger, anxiety, boredom, confusion, fear, depression, emotional exhaustion, frustration, irritability, and stress. Other adverse outcomes included avoidance behaviors (eg, avoiding crowded or public places), detachment from others, subthreshold symptoms of alcohol use disorder and PTSD, excessive preoccupation with distressing somatic symptoms, and stigma, as well as domestic violence and suicidal ideation and behavior [26,37].
COURSE OF ILLNESS — Few data are available regarding the course of psychiatric illness that occurs in patients with COVID-19. However, based upon studies of previous coronavirus epidemics, we anticipate that many patients who are hospitalized and recover from COVID-19 will manifest persistent psychiatric symptoms and disorders [12,13]. As an example, a systematic review examined psychiatric disorders in patients who were hospitalized for severe acute respiratory syndrome (SARS) or Middle East respiratory syndrome (MERS) and assessed 3 to 46 months after recovery (six studies, n >500 cases) . The point prevalence of psychiatric disorders was as follows:
●Anxiety disorders – 15 percent
●Depressive disorders – 15 percent
●Posttraumatic stress disorder (PTSD) – 32 percent
The systematic review also examined psychiatric symptoms in survivors of the 2003 SARS and 2012 MERS epidemics (40 studies, n >1300 hospitalized cases); follow-up occurred 2 months to 12 years after recovery from the acute infection . The most common symptom was frequent recall of traumatic memories, which occurred in 30 percent of patients. Other relatively common symptoms included anxiety, depressed mood, fatigue, irritability, and insomnia, as well as impairment of attention, concentration, and memory. In addition, social functioning and role functioning were each impaired among survivors, compared with the general population. Longer-term psychiatric outcomes also included stigma from health care professionals, families and friends, and the general public.
The prevalence of long-term psychiatric illness secondary to COVID-19 may be higher than that observed after the SARS and MERS epidemics due to differences in treating the viral diseases and the social context of the epidemics . As an example, the economic crisis caused by the COVID-19 pandemic surpasses the economic adversity imposed by the prior coronavirus epidemics and the social disruption appears greater due to the much wider geographical reach.
Patients critically ill with COVID-19 — Clinical studies have established the association between critical illness and the subsequent manifestation of psychiatric symptoms [14,35,53]. Patients who are critically ill with COVID-19 appear to be at risk for persistent psychiatric illness. In a meta-analysis of 13 observational studies including 1093 individuals with severe COVID-19 infection, the pooled prevalence of PTSD at between 4 and 16 weeks postdiagnosis was estimated to be 16 percent (95% CI 9-23) . Generalizability of the findings is limited by low quality of most of the studies included.
Additional information about critical illness and subsequent psychiatric symptoms and disorders is discussed separately. (See "Post-intensive care syndrome (PICS)".)
Patients with pre-existing psychiatric illness — It appears that the psychological effects of the COVID-19 pandemic are adversely affecting many patients with pre-existing mental disorders (ie, onset of the disorder occurred prior to the pandemic). In some cross-sectional studies, approximately 20 to 25 percent of patients with various disorders think they are coping poorly and deteriorating:
●A self-report, online survey of outpatients with pre-existing psychiatric disorders (n >1400), which was conducted in China from February to March 2020, found that deterioration related to the pandemic was reported by 21 percent . New or worsening mental health problems included anxiety, depression, and insomnia, which were attributed to fear of infection, restrictions on transportation, and isolating at home.
●In a self-report, online survey of individuals who self-identified as having a mental illness such as an anxiety disorder, unipolar major depression, or bipolar disorder (total n = 193), approximately twice as many were coping poorly compared with coping well (23 and 12 percent) . The majority had specific concerns about the potential effects of the pandemic upon their mental health, such as worsening of their illness (64 percent), inability to receive treatment (39 percent), and running out of medication (38 percent).
The psychological effects of the pandemic upon patients with eating disorders also appear substantial. In a systematic review of studies examining the impact of COVID-19 on eating disorders, the percentage of participants who reported a worsening of their eating disorders ranged as high as 78 percent . In another national survey of 88 individuals who identified as having anorexia nervosa, 66 percent of individuals reported increased restriction of food intake, and nearly 50 percent reported increased exercise . Changes to daily routine, level of physical activity, and difficulty regulating emotions appear to be the most important contributing factors .
Patients with serious mental illness such as schizophrenia are especially likely to suffer from the pandemic, being at risk not only for COVID-19 based upon their mental illness and social circumstances (eg, homelessness), but also are more likely to smoke and suffer from chronic illnesses that put them at risk for poorer health outcomes once infected [4,50,59,60].
Patients with psychiatric disorders that precede infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are at increased risk for severe COVID-19 [61,62] For example, a meta-analysis of 23 observational studies examined outcomes in nearly 1.5 million patients with COVID-19, including patients with pre-existing psychiatric disorders (n >40,000) . In analyses that controlled for potential confounding factors such as age, sex, and general medical comorbidities, the primary findings were as follows:
●Hospitalization – Hospitalization for COVID-19 was more likely to occur in patients with pre-existing psychiatric disorders than those without psychiatric disorders (odds ratio 1.8, 95% CI 1.3-2.4).
●Mortality – The risk of death from COVID-19 was increased in patients with pre-existing psychiatric disorders (odds ratio 1.3, 95% CI 1.1-1.5). Specifically:
•Mood disorders – Mood disorders (unipolar depressive and bipolar) were associated with increased mortality (odds ratio 1.4, 95% CI 1.1-1.8)
•Psychotic disorders – Psychotic disorders (eg, schizophrenia) were associated with increased mortality (odds ratio 1.7, 95% CI 1.3-2.2)
These results indicate that patients with pre-existing psychiatric disorders, especially psychotic and mood disorders, should be included with other patients prioritized for vaccination .
ASSESSMENT AND DIAGNOSIS — Assessment and diagnosis of anxiety disorders, depressive disorders, insomnia disorder, and posttraumatic stress disorder are discussed separately:
Individuals with moderate to severe distress, anxiety, or depression should be screened for suicidal thoughts and behavior; one can use a screening tool or directly ask. (See "Suicidal ideation and behavior in adults", section on 'Screening'.)
MANAGEMENT — Psychiatric illnesses related to the COVID-19 pandemic can occur in multiple populations, including clinicians treating patients with COVID-19 or suspected illness, patients with COVID-19, and patients with psychiatric disorders predating COVID-19. In addition, family members of clinicians and patients may develop psychiatric symptoms or disorders. However, use of mental health services during the pandemic may have decreased, consistent with decreases in the use of other medical services for conditions other than COVID-19 [63,64].
General approach — For individuals who experience symptoms of anxiety, depression, insomnia, or posttraumatic stress disorder (PTSD) during the COVID-19 pandemic, stepped care may be an efficacious and cost-effective approach to treatment [65,66]. According to this approach, monitoring mental health problems is paramount. Surveillance for domestic violence and child abuse, both of which are predicted to increase during mandated stay-at-home orders, is also critical .
Individuals with low levels of symptoms are provided with self-help materials pertinent to their symptoms and concerns and are eligible to speak with a mental health professional if they have additional or persistent concerns . Online, clinician-guided self-help or pure self-help cognitive-behavioral therapy may also be beneficial . Other interventions that may help individuals cope with mild psychiatric symptoms related to the COVID-19 pandemic include limiting one’s intake of print and broadcast news about the pandemic, as well as maintaining routines for sleep, work, and getting dressed; maintaining structured activities such as exercise, engaging in pleasurable and relaxing activities; and staying connected to family and friends via phone and computer [26,66,67]. Individuals with moderate to severe symptoms can be treated by their primary care provider or referred to a mental health specialist.
If feasible, psychiatric care should be administered by computer or telephone rather than face-to-face [38,59,68,69]. Patient contact through voice or voice plus video may be superior to text messages and emails . Multiple studies suggest that outpatients and their psychiatrists are generally satisfied with the transition to telemedicine with video visits and/or phone visits [64,70-72]. Patient preference usually dictates whether visits are conducted by video or phone. Advantages of telepsychiatry include improved access for patients and the opportunity to see the patient's home (although there are patients who find this intrusive). While some patients may feel more relaxed and be more forthcoming, others may find it harder to effectively "connect" and establish trust with the clinician. Other disadvantages include difficulty observing nonverbal patient cues and hearing patients, technical disruptions such as frozen screens, as well as patients lacking privacy and problems with distractions. In addition, clinicians may feel isolated from colleagues or detached from patients.
Techniques that improve telepsychiatry include starting each visit by asking whether patients have enough privacy; if not, suggestions are offered such as using headphones or a car (not driving) or rescheduling the visit . For video visits, it may be helpful for clinicians to use the same place in the office or home to provide consistency and reassurance for patients. Other strategies to address common barriers to successful conversations over telephone or video are presented in the table (table 1). In addition, guidelines for telepsychiatry are available from the American Psychiatric Association.
Online psychotherapy can work well. For patients who view telehealth psychotherapy as inferior to in-person treatment, it may help to suggest that they experiment and try it anyways . They can always pursue face-to-face treatment later if they do not get better, and they will get better sooner if online treatment is successful. Some software platforms permit more than two people to meet and enable family involvement and group therapy. Therapists may find it helpful to scan and email written materials as part of virtual treatment with psychotherapies such as cognitive-behavioral therapy. Larger devices such as laptop or desktop computers are typically preferable to tablets or phones. Guidelines for administering online psychotherapy are available from the American Psychological Association.
The US Food and Drug Administration offered guidance on April 14, 2020 regarding the COVID-19 public health emergency and use of digital health devices to help treat psychiatric disorders such as generalized anxiety disorder, insomnia disorder, PTSD, and unipolar major depression . The guidelines recommend that the devices be used only as adjunctive treatment. Functions that these devices may perform include reminders about physical activities, mindfulness activities, and behavioral techniques that patients can use when experiencing increased anxiety.
When face-to-face visits are necessary, personal protective equipment (eg, masks) should be used. In-person visits with masks may be experienced as less personal and leave patients feeling less connected to the clinician, compared with voice plus video meetings. Face-to-face care should ideally be administered to individuals rather than groups. However, if the demand for mental health services is high, then a group format is acceptable.
Psychiatrists may be asked to consult on patients receiving pharmacotherapy for COVID-19 and should therefore be familiar with the medications that are currently being used. As an example, dexamethasone, which is a steroid undergoing clinical trials for COVID-19, is associated with psychiatric side effects such depression, emotional lability, euphoria, insomnia, malaise, personality changes, and psychosis. Patients should be asked about any other prescribed medications or supplements they may be taking in the belief they might reduce vulnerability to COVID-19 infection. Specific medications that are being evaluated for COVID-19 are described separately. (See "COVID-19: Management in hospitalized adults", section on 'Specific treatments'.)
In many cases, it appears that psychotropic drugs can be safely prescribed to patients receiving pharmacotherapy for COVID-19. As an example, antidepressants (eg, escitalopram), antipsychotics (eg, olanzapine), benzodiazepines (lorazepam), and valproate do not seem to interact with antiviral agents such as interferon, lopinavir-ritonavir, and ribavirin . Nevertheless, psychiatrists should be aware of potential drug-drug interactions before suggesting psychotropic drugs. Specific interactions of psychiatric medications with other medications may be determined using the Lexicomp drug interactions tool (Lexi-Interact Online) included in UpToDate.
Physical distancing, which is widely encouraged to decelerate the rate of COVID-19 transmission within the general public and “flatten the curve” of COVID-19 cases, will result in loneliness for some individuals, particularly those living alone, including the elderly. This is likely to exacerbate the high rates of loneliness already experienced by the elderly, especially those who rely on social services rather than family for human contact and connection . Digital technology may serve as a bridge for social connections and should be encouraged [12,76]. However, many individuals may lack access or the ability to take advantage of this.
One resource that provides examples of how one can respond to patients or family members with different concerns or reactions to the pandemic is the COVID Ready Communication Playbook. This document guides clinicians on a range of topics specific to COVID-19, including helping patients and family members cope with a dire situation, as well as how clinicians can manage their own emotions.
To promote physical distancing for psychiatric outpatients who are stable, it may be possible to safely increase the length of prescriptions .
However, psychiatric outpatients may decompensate to the point that they require evaluation for hospitalization, which can compromise physical distancing and expose patients to infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (see 'Hospitalized psychiatric patients' below) . The decision to admit an outpatient rests in part upon judging whether the morbidity of the psychiatric illness outweighs the possibility of acquiring COVID-19 and the morbidity that may follow.
Family members of COVID-19 patients — To maintain physical distancing, most inpatient facilities have limited or suspended visits by families and friends . Installing videoconferencing systems can connect patients with family members and allay anxiety .
Family members of a loved one who is severely ill and dying will respond with grief. Immediately or soon after the patient’s death, the treatment team should provide condolences to the family in a compassionate manner that includes expressing sorrow for the loss, acknowledging their pain, and answering questions about their loved one’s final days . In addition, it can help to ask the family about thoughts, feelings, and behaviors related to their loss, as well as provide grief counseling as warranted. The American Psychiatric Association website provides access to material to help clinicians with these discussions, such as “Guidance Document on COVID-19 Death and Dying Exposures: Considerations for Family and Other Personal Losses Due to COVID-19-Related Death.”
The forced separation of family members from patients with COVID-19 who are close to dying disrupts the grieving process by denying all involved the opportunity to say final goodbyes [69,79,80]. In addition, the need for physical distancing can interfere with funerals and traditional mourning rituals, leaving the family socially isolated and lonely. Although most people adapt to bereavement, some families may be vulnerable to complications of bereavement, such as anxiety disorders, complicated grief, PTSD, and unipolar major depression, as well as stress-induced cardiomyopathy [79,80]. Risk factors for complications include sudden and unexpected death; especially close relationship to the deceased; previous history of anxiety, depression, insecure attachment, or trauma or loss; living alone; financial insecurity; primary caretaker for others; and fear of having been infected with SARS-CoV-2 .
At some point following the patient’s death (eg, four weeks), the treatment team should reach out to the family if feasible, and ask how they are coping and assess the risk for bereavement complications [79,80]. In deciding whether referral for further assessment and care is required, it is useful to ask the family if they feel overwhelmed by their loss and grief and if they have social support.
Additional information about the clinical features and management of grief and bereavement is discussed separately. (See "Bereavement and grief in adults: Clinical features" and "Bereavement and grief in adults: Management".)
Health care workers — A broad range of health care workers who directly or indirectly treat patients with COVID-19 are at risk for psychiatric symptoms and disorders (see 'Health care workers' above) . These clinicians and staff are likely to benefit from private, on-demand access to mental health professionals who can address sources of anxiety, distress, and other emotions related to caring for patients [11,48,82,83]. However, health care workers may be reluctant to engage in treatment because of concerns about stigma and problems with licensure, credentialing, and career advancement .
Mental health professionals treating psychiatric illness in frontline clinicians should address potential sources of anxiety, depression, distress, and trauma, including [7,11,43,47-49,69,82-84]:
●Access to personal protective equipment and concerns about reprimands for speaking about equipment shortages.
●High transmissibility of SARS-CoV-2 and risk of self-exposure and infection.
●Risk of transmitting the virus to family members, friends, colleagues, and patients.
●Physical distancing from family.
●Access to testing for oneself and family members.
●Enforcement of infection control procedures in the workplace.
●Uncertainty due to the lack of treatment guidelines for COVID-19.
●Undertaking unfamiliar clinical duties with insufficient preparation.
●Interventions for COVID-19 that are limited to supportive care rather than treatment per se.
●Unclear communication and perceived lack of support from supervisors.
●Access to childcare during school closures.
●Increased and taxing workloads.
●Moral dilemmas and moral injury arising from situations such as deciding how to allocate insufficient resources, inadvertently placing others in danger, and implementing clinical decisions by others that one thinks are contrary to best practices.
●Feeling disconnected from patients and their families due to personal protective equipment and physical distancing.
●Difficulties providing emotional support to patients.
●Loss of control, burnout, vulnerability, and making mistakes.
●Feelings of helplessness, worthlessness, and guilt for poor patient outcomes, becoming sick, not helping one’s colleagues, and infecting others.
●Physical distancing, loneliness, and isolation from colleagues and managers, as well as families and friends.
●Social stigma due to exposure to the disease.
●The large number of patient deaths, including those dying alone, and their grief-stricken family members – We encourage clinicians to speak with these families about their loved ones (see 'Family members of COVID-19 patients' above). In addition, the American Psychiatric Association website provides guidance for mental health clinicians in helping health care workers who directly treat patients dying with COVID-19: “Guidance Document on COVID-19 Death and Dying Exposures: Considerations for Healthcare Workers and Staff Exposed to COVID-19 Death and Dying.”
Coping behaviors and strategies — Health care workers use a variety of approaches for coping with stressors related to the COVID-19 pandemic. A cross-sectional, online survey of clinicians (n >600) working at a medical center in New York City during April 2020 found that coping behaviors included physical activity/exercise (59 percent), psychotherapy (26 percent), yoga (25 percent), religious or spiritual practices (23 percent), meditation (23 percent), and virtual support groups (16 percent) .
Other means of coping may be helpful as well, based upon a study of clinicians (n = 466) in public hospital emergency departments in Hong Kong during the 2003 severe acute respiratory syndrome (SARS) epidemic . The most frequent coping strategies included accepting the reality of the stressor, taking action to circumvent the stressor, and viewing the situation in a more positive light and attempting to grow from the situation.
A follow-up study of hospital employees who were exposed to the 2003 SARS epidemic in Beijing (n = 549) found that higher levels of altruistic acceptance of risk during the outbreak (eg, “I want to help the patients and accept the risk”) were associated with lower levels of self-reported depressive symptoms three years later .
Individuals in quarantine — We suggest the following steps to mitigate the adverse psychological impact of quarantine, based upon a review of 24 studies :
●Explain the purpose of quarantine and how to implement it.
●Voluntary quarantine is associated with less distress than mandatory quarantine.
●Emphasize the altruistic benefit of quarantine in keeping others safe.
●Facilitate acquisition of general supplies (eg, food and housing) and medical supplies (eg, prescriptions, thermometers, and face masks).
For those who are not at high risk for complications of COVID-19 and are not living with someone who is at high risk, we suggest going outside daily. Contact with others may be diminished early or late in the day.
Specific psychiatric disorders — Pharmacotherapy and psychotherapy for anxiety disorders, depressive disorders, insomnia disorder, and PTSD that are associated with COVID-19 should follow recommendations for treating the general population of patients with these disorders and are discussed separately:
Schizophrenia — Pharmacotherapy and psychosocial interventions for acute symptoms of schizophrenia that are associated with COVID-19 should follow recommendations for treating the general population of patients with schizophrenia and are discussed separately. (See "Schizophrenia in adults: Maintenance therapy and side effect management" and "Psychosocial interventions for schizophrenia".)
Many patients with schizophrenia (and other chronic mental illnesses) who respond well to an oral antipsychotic but relapse due to nonadherence receive long-acting injectable (LAI) antipsychotic drugs. Some hospitals and other facilities consider administration of LAI antipsychotics as an elective procedure and have thus suspended their use during the COVID-19 pandemic to reduce transmission of SARS-CoV-2 virus infection, conserve personal protective equipment, and reserve clinical resources for managing patients with COVID-19. However, we view the use of these drugs as an essential procedure for some patients, consistent with the position of the American Psychiatric Association and other experts [50,87]. Switching patients from a LAI to an oral medication can be deeply destabilizing and increase the risk of psychiatric and general medical morbidity, as well as mortality. Indications for continued treatment with LAI antipsychotics include refusal to take oral antipsychotics and a prior history of deterioration (eg, arrest, relapse, or violence) when LAI antipsychotics were stopped. Additional information about long-acting injectable antipsychotic drugs is discussed separately. (See "Pharmacotherapy for schizophrenia: Long-acting injectable antipsychotic drugs".)
There is little evidence to guide use of outpatient telepsychiatry for patients with schizophrenia, who may be less likely to own the necessary equipment .
●Home visits – For patients with schizophrenia who are acutely ill with mild to moderate symptoms, daily home visits by clinicians and 24-hour coverage may be a reasonable alternative to inpatient hospitalization [68,88]. This allows patients to maintain physical distancing and home confinement, and thus avoid exposure to COVID-19. For patients with schizophrenia who are stable, home visits may be suitable to promote adherence to treatment and prevent relapse .
●Clozapine bloodwork – Patients receiving clozapine for schizophrenia or other serious mental illness typically require blood tests every one to four weeks to monitor absolute neutrophil counts. However, patients and clinicians need to decide whether the risks of COVID-19 outweigh the benefits of obtaining blood work. (See "Guidelines for prescribing clozapine in schizophrenia", section on 'Required bloodwork and COVID-19'.)
Hospitalized psychiatric patients — Patients who are hospitalized for psychiatric disorders are at high risk for acquiring and transmitting SARS-CoV-2 [4-6,50,77]. As an example, early in the pandemic, a state psychiatric hospital implemented guidelines from the United States Centers for Disease Control and Prevention, as well as other precautionary measures to forestall infections, at a point when none of the patients or staff were symptomatic or had tested positive . Subsequently, one patient became symptomatic for COVID-19 and tested positive; within two weeks, nearly 80 percent of the other patients who were housed in the same building (n = 65) tested positive. The large majority who tested positive were asymptomatic.
Psychiatric inpatients are at increased risk of COVID-19 because they reside in close quarters, are often free to move about open spaces on units and interact with other patients, are frequently in contact with nursing staff, and may be required to use shared bathrooms . In addition, patients may have difficulty following infection control measures such as physical distancing and hand washing because of psychotic symptoms, cognitive deficits, disorganized thinking, behavioral dysregulation, and poor insight. Despite these risks, some inpatient facilities have prevented infections among their patients.
We suggest that inpatient psychiatric programs follow general procedures for infection control in health care settings. These measures include screening all patients and health care workers prior to entry, limiting visitors, and universal masking. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Infection prevention in the health care setting'.)
In addition, other procedures specific for inpatient psychiatric facilities include the following if feasible [4,6,50,51,69,77,89-91]. These practices should be modified as detection and diagnostic certainty of COVID-19 improve:
●Maintaining a separate unit for patients who are suspected of having COVID-19 due to symptoms such as fever, cough, and sore throat (table 2), as well as a separate unit for patients who test positive for the virus and are medically stable, and a unit for patients who test negative. Voluntary staffing of units with suspected or positive cases is preferred.
If separate units are not available, it may be necessary to generally restrict patients with suspected or confirmed COVID-19 to their rooms and require all patients to wear a mask and gown if they leave their rooms. In addition, use of group therapy should be curtailed to enable physical distancing, and patients at high risk for adverse outcomes from COVID-19, such as elderly or immunocompromised individuals, should avoid group therapy.
Leadership representing different clinical disciplines, including psychiatry, nursing, and social work, should meet at least weekly to review and revise COVID-19 precautions and related issues regarding staffing and procedures. Any changes should then be communicated to the other staff.
●Establishing protocols for testing patients for infection, based upon availability of tests and accounting for problems such as false negatives and patient difficulties recalling potential exposures and onset of symptoms.
●Requiring negative tests for SARS-CoV-2 at two time points for patients who are hospitalized on a general medical unit for COVID-19 and now require transfer to a psychiatric unit dedicated to patients who test negative for the virus.
●Minimizing transport of patients off the unit to different parts of the hospital or to the community. Infection control during transport is described separately. (See "COVID-19: Perioperative risk assessment and anesthetic considerations, including airway management and infection control", section on 'Infection control during patient transport'.)
●Assigning health care workers who provide frontline, face-to-face care to work on the same unit rather than rotating among different units. In addition, staff at high risk for adverse outcomes from COVID-19, such as elderly or immunocompromised individuals, should avoid frontline care, and strategies implemented for creating a pool of back-up clinicians if frontline staff become ill or are quarantined.
●Installing the means for mental health specialists such as psychiatrists, psychologists, and social workers to administer routine care to patients by telepsychiatry. Typically, onsite, frontline nursing staff assist patients in using the equipment. Videoconferencing can also be used for communication with families, and between patients and families (table 1). Some facilities may choose to administer a combination of telepsychiatry and face-to-face care. Multiple inpatient programs report that uptake of telepsychiatry has been successful.
●Establishing protocols for using personal protective equipment and managing medical and psychiatric emergencies. As an example, acute, moderate to severe agitation or threatening behavior typically prompts a face-to-face evaluation and requisite treatment. Prior to interacting with the patient, clinicians should don the appropriate personal protective equipment (figure 1): gown, gloves, eye protection, a respirator such as an N95 (picture 1), and shoe covers. If the supply of respirators is limited, the United States Centers for Disease Control and Prevention acknowledges that facemasks are an acceptable alternative (in addition to contact precautions and eye protection). Donning and doffing personal protective equipment are illustrated in the following figures (figure 2 and figure 3).
●Dropping off food for patients outside the door to the unit and either staggering mealtimes in the dining area or delivering meals to patient bedrooms.
●Discouraging patients from sharing or trading food and other items.
Psychiatric inpatients with COVID-19 who are psychiatrically stable but continue to test positive for the virus may have difficulty qualifying for discharge to congregate living settings such as group homes . Positive tests may persist for weeks and prolong hospitalization. One possible solution is to discharge patients home to quarantine on an interim basis until they test negative and can then move to the group home [6,51].
Electroconvulsive therapy — Psychiatric inpatients with COVID-19 and severe psychopathology that does not respond to pharmacotherapy may require electroconvulsive therapy (ECT). Although elective procedures during the COVID-19 pandemic have been suspended to reduce transmission of SARS-CoV-2, conserve personal protective equipment, and reserve clinical resources for managing patients with COVID-19, we view ECT as an essential procedure for some patients, which is consistent with the position of the American Psychiatric Association . Indications for urgent treatment with ECT include incapacitating, treatment refractory catatonia, major depression, mania, and psychosis related to schizophrenia.
ECT treatments should be performed by the minimum number of clinicians required, which typically includes the treating psychiatrist, anesthesiologist to manage the airway, and a nurse. Each member of the team should don the appropriate personal protective equipment before entering the room and interacting with the patient. When feasible, a separate ECT machine should be dedicated for treating all patients with suspected or confirmed COVID-19, and disposable adhesive electrodes should be used rather than metal electrodes to minimize contamination. After each treatment, it is necessary to disinfect any equipment that has been in contact with the patient. Additional information about COVID-19 and infection control during ECT is discussed in the context anesthetic concerns. (See "Anesthesia for electroconvulsive therapy", section on 'Considerations for ECT during the COVID-19 pandemic' and "COVID-19: Perioperative risk assessment and anesthetic considerations, including airway management and infection control", section on 'Infection control for anesthesia'.)
Information about ECT is also discussed separately:
Suicidality — Interventions for managing suicidal ideation and behavior (suicidality) include the following :
●Treatments specific for suicidality (see "Suicidal ideation and behavior in adults", section on 'Management')
●Treating underlying psychiatric disorders by telehealth or in-person, depending upon the severity of suicidality
●Encouraging patients to maintain social contact by telephone or computer, as well as face-to-face encounters that maintain physical distancing
●Referring patients to social work for help in accessing financial safety nets (eg, food, housing, unemployment support, and loans)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately.
●Index of available COVID-19 guidance – (See "Society guideline links: COVID-19 – Index of guideline topics".)
●More detailed guidance for psychiatry – (See "Society guideline links: COVID-19 – Psychiatric care".)
●Resources for psychiatric patients and their families – (See "Society guideline links: COVID-19 – Psychiatric care", section on 'Resources for patients'.)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)
●Basics topic (see "Patient education: COVID-19 overview (The Basics)")
●Epidemiology of psychiatric symptoms – Many clinicians who treat patients with coronavirus disease 2019 (COVID-19) develop moderate to severe psychiatric symptoms, including:
•Anxiety – 12 to 20 percent of clinicians
•Depression – 15 to 25 percent
•Insomnia – 8 percent
•Distress – 35 to 49 percent
One estimate suggests that approximately 50 percent of health care workers need psychological support.
Patients who survive acute COVID-19 appear to be at risk for neuropsychiatric symptoms and disorders, including anxiety disorders, depressive disorders, and posttraumatic stress disorder (PTSD).
In addition, the COVID-19 pandemic may be associated with symptoms of anxiety, depression, distress, and PTSD in the general population. (See 'Epidemiology' above.)
●Clinical features – Among different groups, the COVID-19 pandemic may be associated with new onset or exacerbation of subsyndromal psychiatric symptoms as well as full-blown psychiatric disorders, including anxiety disorders, depressive disorders, PTSD, or substance use disorders. During viral epidemics, psychiatric symptoms and disorders are more likely to occur in health care workers who are at relatively high risk of exposure, compared with workers who are at low risk of exposure. In addition, acute infection and hospitalization during previous coronavirus (non-COVID-19) epidemics was associated with a wide range of neuropsychiatric symptoms. (See 'Clinical features' above.)
●Patients with pre-existing mental disorders – The psychological effects of the COVID-19 pandemic are adversely affecting many patients with pre-existing mental disorders, such that approximately 20 to 25 percent think they are coping poorly and deteriorating. (See 'Patients with pre-existing psychiatric illness' above.)
•General approach – For individuals who experience symptoms of anxiety, depression, insomnia, or PTSD, stepped care may be an efficacious and cost-effective approach; surveillance of mental health problems is paramount. Those with low levels of symptoms are provided with self-help materials and are eligible to speak with a mental health professional if they have additional or persistent concerns. Individuals with moderate to severe symptoms can be treated by their primary care provider or a mental health specialist. If feasible, psychiatric care should be administered by telehealth (table 1) rather than face-to-face, although there may be instances where face-to-face care is required. (See 'General approach' above.)
•Health care workers – Mental health professionals working with individuals who develop psychiatric issues related to COVID-19 should address potential sources of anxiety and distress, including access to personal protective equipment, risk of self-exposure and infection, risk of exposing others to infection, increased and taxing workloads, moral dilemmas, and patient deaths. (See 'Health care workers' above.)
•Individuals in quarantine – The adverse psychological impact of quarantine may be mitigated by taking steps such as explaining the purpose of quarantine and how to implement it, as well as emphasizing the altruistic benefit of quarantine in keeping others safe. (See 'Individuals in quarantine' above.)
•Hospitalized psychiatric patients – Patients who are hospitalized for psychiatric disorders are at high risk for COVID-19 because they reside in close quarters. We suggest that inpatient psychiatric programs follow general procedures for infection control in health care settings (eg, screening all patients and health care workers prior to entry), as well as other procedures specific for inpatient psychiatric facilities if feasible. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Infection prevention in the health care setting' and 'Hospitalized psychiatric patients' above.)
•Suicidality – The hardships imposed by the COVID-19 pandemic may give rise to suicidal ideation and behavior. Individuals with moderate to severe distress, anxiety, or depression should be screened for suicidal thoughts and behavior. Patients with COVID-19 and patients with psychiatric disorders predating the pandemic should be encouraged to maintain social contact and to access treatment through telehealth or in-person. (See 'Suicidality' above.)