COVID-19-negative psychiatric units: Mitigating sequelae of pandemic isolation.

Research Letter to the Editor:

We are writing to call attention to the profound psychological/physiological stress caused by the ongoing coronavirus disease 2019 (COVID-19) pandemic. As second waves are on the rise, U.S. total death rates related to COVID-19 are greater than 270,000, and above 1.5 million worldwide [1]. While public health guidelines continue to advise social distancing to prevent further spread of the virus, this very distancing increases pandemic-induced isolation, fear of infection, and fear of death [[2], [3], [4], [5], [6], [7], [8]]. Extended periods of social isolation have led to disruption of daily routines, separation from loved ones, and perceived loss of autonomy. The subsequent distress has been labeled a “parallel epidemic,” [8] and an unprecedented “shock to humanity's fabric,” [7] rife with anxiety, depression, post-traumatic stress symptoms, and suicidal ideations [[2], [3], [4], [5], [6], [7], [8]].

Although medical literature has focused on COVID-19-positive individuals, there has been sparse discussion regarding COVID-19-negative individuals, specifically in the inpatient psychiatric setting. While the effects of isolation for COVID-infected patients are devastating, COVID-negative patients, too, require consideration regarding access to treatment. Given the decrease of in-person outpatient treatment, patients may be lost to follow up, leading to psychiatric decompensation requiring hospital admission [7]. We propose four different practices, indications, and key features (Table 1 ), through which we encourage COVID-19-negative psychiatric units to implement social support, trauma-guided principles, review of current events, and psychoeducation on telemedicine. The unique setting of COVID-negative psychiatric units may serve as a way to mitigate pandemic-associated psychopathology during a time of crisis, and help prepare patients for outpatient follow up care in the ongoing uncertainty of the COVID-19 pandemic.

Table 1

Recommendations for COVID-19-negative psychiatric units.

Recommendations for COVID-19-negative psychiatric units: mitigating sequelae of pandemic isolation
Practice	Indication	Key features
Socially distanced support	Social support is a protective factor	• Frequent COVID-19 symptom screening & masks required for patients & staff • Group dining w/ physically-distanced seating • More patient group times (eg. AM / PM groups) to allow for maximum participation with physical distancing
Trauma-guided principles	COVID-19 pandemic may be experienced as a trauma	• Directly ask patients about COVID-19-related loss • Psychoeducation on adaptive coping mechanisms • Trauma-focused therapy: exposure-based, cognitive restructuring ⟶ reduce post-traumatic stress severity
COVID-19 current events groups	Plethora of COVID-19 pandemic (mis)information	• Facilitate structured groups to discuss & synthesize COVID-19 news • Review pathophysiology basics & public health guidelines • Address ethnic, racial, socioeconomic disparities of COVID-19
Link to virtual support	Patients may be ambivalent about telehealth	• Education about benefits of telemedicine • Technical assistance w/ virtual resources • Tablets/computers w/ HIPAA-compliant video capabilities for family meetings/visits

Socially-distanced support

From community dining, to group therapy, and milieu intermingling, psychiatric units foster socialization, which mediates negative effects of isolation. However, COVID-negative units must cultivate socially-distanced support in accordance with current public health guidelines. Patients and staff should wear masks, adhere to hand hygiene, and undergo frequent COVID-19 symptom screening [9]. Patients should be placed in single rather than shared bedrooms whenever possible. Meanwhile, patient groups, which are a vital component of inpatient treatment, should be continued. Physical distancing can be maintained by limiting group attendance, or double-scheduling, to allow different patients to attend on different days/times. Group dining, in lieu of patients eating alone in their rooms, can continue by staggering meal times, and urging masks-on immediately whenever not eating/drinking. We acknowledge that group settings during a pandemic, and hospitalization itself, are not zero-risk. However, if risk is minimized with masks, physically-distanced seating, and symptom screening, we argue the benefits of socialization on COVID-negative units outweigh the risks of isolation, which may have precipitated psychiatric decompensation leading to admission in the first place.

Trauma-guided principles

The COVID-19 pandemic and the “parallel epidemic” of psychological stress may be experienced as a trauma, especially for patients with pre-existing psychiatric comorbidities. In the face of trauma, patients may develop maladaptive coping mechanisms such as increased substance use, and may be at increased risk for self-harm [3]. Providers should be attuned to pandemic-related trauma, and should directly ask patients about their exposure and/or loss related to COVID-19. Trauma-focused therapy, which uses exposure-based interventions and cognitive restructuring, may be effective in reducing post-traumatic stress, especially if used as an early intervention [3]. Inpatient units can utilize trauma-guided principles in individual therapy and in dedicated groups.

COVID-19 current events groups

The influx of information from public health authorities, news broadcasting, and social media, is in itself a significant stressor, especially for individuals with serious mental illness [4,5]. Patients would benefit from current events groups to review COVID-19 basics including symptoms, spread and prevention, and public health guidelines. Ethnic, racial, and socioeconomic disparities of COVID-19 should also be addressed. These groups would provide patients the opportunity to ask questions and correct potential misconceptions about the COVID-19 pandemic.

Link to virtual support

In the COVID-19 era of social distancing, virtual communication is critical, and telemedicine has become an indispensable method of care. Given strict limitations on hospital visitors [4], HIPAA-compliant video devices should be available to patients for virtual visits with loved ones and for family meetings, often a crucial component of discharge planning. Furthermore, regarding telemedicine, we have heard numerous patients say, “that's not my thing.” Providers should prepare patients for the reality of virtual treatment during the pandemic and potentially beyond. By working through and addressing ambivalence about telemedicine, individuals who might otherwise be lost to follow up in the absence of in-person appointments may more readily pursue care through telehealth after discharge.

As governments and healthcare systems navigate the impact of this unprecedented pandemic, epidemiological research and evaluation of mental health interventions are essential for patients and their providers, whose relationships will continue by necessity to exist, even and especially in the face of pandemics as devastating as COVID-19.

Declaration of Competing Interest

None.