Mental health care for hospitalized COVID-19 patients; an experience from Iran.

↑ What is “already known” in this topic:

Patients with COVID-19 may experience psychological problems during hospitalizations.

→ What this article adds:

Using simple and small adjustments in addressing psychological distress in COVID-19 patients may help their mental health during hospitalization.

Up to May, 2020, the new coronavirus (COVID-19) has infected 6057853, with 371166 deaths worldwide (1). High contagiousness of the disease, shortage of medical facilities, lack of definitive treatment, and self-quarantine have all caused confusion, anxiety, and depression among COVID-19 patients. These patients are being admitted to hospitals without any companion and may face complex psychological issues (2). Moreover, psychiatric complications of COVID-19 have been reported in 59% of patients in a recent study (3). Such obstacles and their psychological consequences may be overlooked due to the heavy workload of health care professionals and communication barriers due to use of protective equipment. Based on our experience in Rasoul Akram hospital, Iran, with at least 25 psychiatric consultations per month for COVID-19 patients, addressing the following items would be beneficial for the mental health care of hospitalized patients with COVID-19.

Mental healthcare in a hospital ward

(1) Provide leisure activities in wards

Physicians reveal how the patients usually spend their leisure time. We routinely asked these questions from the patient or the family after taking medical history. Based on the answers, we offered some feasible hobbies to patients during hospitalization.

(2) Establish a phone/video line between the patients and their family

We provided a mobile phone for COVID-19 wards to establish a video/phone call between patients and their family, if requested.

(3) Pay attention to walk-out time

If a hospital ward has a separated exit, short term walk-out can be of help.

(4) Use more verbal communication

Due to restricted non-verbal communication, more verbal communication is recommended.

(5) Address the anxiety and depression with direct questions

Physicians should regularly ask questions about symptoms of anxiety, depression, and insomnia along with other COVID-19 symptoms (4).

(6) Provide professional care for psychological distress

Low doses of antianxiety medications, such as lorazepam (5) and gabapentin, which do not interfere with current medications, may be prescribed for COVID-19 patients. Online psychological interventions such as relaxation techniques can also help COVID-19 patients to deal with their anxiety (6).

(7) Do not forget to inform families

In our hospital, to minimize the risk of transmission, medical students were exempted from going to COVID-19 wards. Instead, they were asked to operate telephone follow-up service to provide information on the patient's medical situation. In addition to helping families, it was a valuable educational experience for the trainees. Families reported this service reduced their worries and they were more prepared for hearing bad news.

(8) Address families’ concerns

In our hospital, some of the families were in denial. Several studies provided evidence for the effectiveness of telehealth, especially in the context of depression (7), anxiety(8) and PTSD (9). Therefore, online psychological counseling with the patients’ family members could help them cope with stress and its psychological consequences.

Mental health care in the Intensive care unit (ICU)

(1) Empathic communication could prevent PTSD

Empathy, reassurance, and listening to the concerns of the COVID-19 patients encountering a life-threatening condition can play a protective role against PTSD (10).

(2) Address the patient anxiety or depression with direct questions

Physicians should ask about anxiety and depression in patients, as they can worsen the underlying breathing problem and their management may prevent PTSD.

(3) Provide professional care for psychological distresses

The use of help line or video call for psychological interventions in patients with COVID-19 (such as relaxation technique) can reduce the risk of PTSD, particularly if started in ICU (11). If patients are unable to speak, the written call can be used.

If not effective, pharmacological treatments can also be offered based on the etiology of anxiety. Consider antianxiety medication in a low dose with limited duration.

(4) Implement preventive measure for delirium

Implementing preventive measures for delirium, such as early ambulation, a daily reminder of time and place, talking to the family members or friends on a video call, regulation of sleep-wake cycle, respiratory physiotherapy, the regulation of water and electrolyte level, avoiding overuse of the sedative-hypnotics and neuromuscular blockers, should be taken into consideration (12,13). The latter is especially important given the early anecdotal report of advantages of prone position in COVID-19 patients, which usually leads to requiring higher doses of sedatives (14).

(5) Palliative care should be in mind

All patients with COVID-19 who are on the verge of death should receive palliative care (for symptoms such as anxiety, pain, shortness of breath, and nausea); thus, requests for palliative care should be examined before the illness worsens (15)

(6) Follow-up families of deceased

We dealt with a lot of pathological grieves in survivors who did not have the chance of proper bereavement. Therefore, we arranged for a follow-up of bereaved families by trained medical students in our hospital. Let the family members say their last goodbyes to the dying patients using virtual contact (15,16)

Conclusion

Hospitalization services for COVID-19 patients may be initially poor-coordinated. A multidisciplinary team of experts alongside psychiatrists could tackle challenging mental health conditions to provide a coordinated care program. Using simple and small adjustments in addressing psychological distress in COVID-19 patients may help their mental health during hospitalization. Therapists can help their patients only if they themselves are in good physical and mental health conditions.

Acknowledgment

The authors wish to thank Rasoul Akram Hospital Clinical Research Development Center (RCRDC), Iran University of Medical Sciences for its editorial assistance.

Conflict of Interests

The authors declare that they have no competing interests.