Psychosomatic Medicine and Covid-19 Pandemic.

Healthcare systems are currently threatened by the Covid-19 pandemic in a way not known after the Second World War. In Germany, in particular, large hospitals have implemented psychosomatic departments with consultation/liaison services over the last 20 years. Foci are inpatient psychotherapeutic treatment for severe somatoform disorders usually with comorbid depressive and anxiety disorders (or the latter by their own) and eating disorders as well as treating patients on somatic wards with comorbid mental disorders or somatoform disorders. Support of medical staff by supervision and psychoeducational themes are further tasks.

In the region of “the Ortenau” in Southwest Germany at the border to France, 425,000 inhabitants are served by two large teaching hospitals with more than 1,200 beds (and few local small hospitals in addition). Each of the two academic hospitals has one psychosomatic inpatient unit of about 20 beds each (with additional day clinic facilities), both headed by the author. As there is no psychiatric unit within these hospitals, psychiatric as well as psychosomatic consultations are carried out by the head of the department and the senior registrar, both being psychiatrists in addition to qualifications as psychosomatic specialists. Furthermore, there is a psychiatric hospital with >100 inpatient facilities within a few kilometers distance.

Under the current assumption of a large increase of severely ill patients, the hospital administration decided to close inpatient psychosomatic treatment and allocate psychological resources to strained somatic health care personnel. Major issues are the following:

1 Psychosomatic patients had to be discharged within a time frame of 10 days. Usually these patients have biographies with disturbed and disrupted relationship experiences. We used the time to plan discharge to outpatient psychotherapeutic institutions and psychopharmacological intervention as needed. We tried to make therapeutic use of the situation in coping with the sudden termination of the relationship in a most therapeutic way as possible. On the other side, it had become clear soon that inpatient treatment, which uses many group interventions, was not feasible in face of a pandemic anymore. Consultation liaison services focus on phone and on somatic personnel being supported when dealing with distressed patients.

2 Healthcare personnel are extremely strained during the course of a pandemic [1, 2, 3]: using a somatic perspective, long hours with masks and gowns are a substantial burden, in particular for the older personnel. Psychologically there are many facets of distress: there is uncertainty about the risk of infecting oneself, which is a real one. Many patients will have bad outcomes; even so everything possible is done medically. Ethical decisions put much emotional strain on healthcare personnel, which had not been experienced before or anticipated and which involves existential questions; instead of the best treatment for most patients in a traditional framework of medical ethics, more utilitarian and a population-based ethical framework come into play [4]. This situation likely leads to a difficult situation with patients' relatives. All these factors might lead to vicarious traumatization. From a social perspective, there is often considerably less recreation at home: Children have to stay at home during a pandemic; relatives, in particularly elderly, might become ill, which puts on further stress on personnel. In addition, spouses might have economic and work-related worries. In effect, this distress may lead to psychic disorders like depression and anxiety, and in the context of severe strain post-traumatic stress disorders. Apart from personal suffering this might lead to work disability of healthcare personnel and therefore less human resources in the hospital-which is usually already limited [5].

Therefore we created a hotline with an offer for personal psychological support (direct or via telephone) 7 days a week. In addition, team leaders are offered supervision for difficult team situations and high levels of tension. All offers are provided with low-threshold access. If necessary, the intervention includes psychopharmacologic medication for a few days (like anxiolytics or low-potent neuroleptics). In case of more prolonged and severe mental disturbances, we set up a network with local outpatient psychotherapists. When announcing our offer we wrote a brief letter including some prophylactic and psychoeducational issues (importance of relationships, communicating emotions, leisure time, sleep, dreams, fluid intake etc.).

3 In view of limited material (ventilation, intensive care facilities) and human resources, we anticipate the use of triage, which represents a new phenomenon in this extent in post-war Europe/Western countries [5, 6]. This issue is of some debate (for more in-depth discussion see, e.g., [7]); in Germany, the very dark history 80 years ago of the Nazi regime might impact additionally (i.e., which lives are worth living, and acting on these grounds). The Department of Psychosomatic Medicine was asked to work closely with local ethics committees. These scenarios will put an enormous emotional strain on health care personnel [4, 5], e.g., situations with reverse triage [5, 7].

In sum, we emphasize that psychosomatic departments can be valuable in the phase of natural catastrophes like a severe pandemic like currently with Covid-19. In particular, the biopsychosocial perspective [8] is of much value in considering all its three components for health care personnel, patients, and relatives. In the context of an earlier pandemic Matsuishi et al. [2] described the value a psychiatric liaison service. Further sociocultural aspects like health care systems, politics, and ontological themes in phases of pandemics were not foci and out of the scope of these more pragmatic considerations of this letter. It will be of interest to evaluate these procedures when this pandemic is over, as well as longer lasting impacts on somatic and psychosomatic/psychiatric departments, their staff, and their interactions, which might also contain chances of increased interdisciplinary care.