Management of mental health issues in Persons with Acute COVID-19 infection and during the post-COVID phase.

INTRODUCTION

The COVID-19 pandemic has emerged as a crisis for humans all across the globe. One of the most important impacts of the pandemic has been an upsurge of mental health issues in the general population of all age groups. Available data from different parts of the world has confirmed an upsurge in mental morbidity in the general population. The initial months of the pandemic and subsequent lockdown[1] worldwide gave rise to significant anxiety, nervousness, and fear in all strata of the public. Those who had to undergo isolation and quarantine following exposure to COVID-19-positive patients or travel to foreign countries reported horrifying experiences of stress, anger, anxiety, irritability, and loneliness.[2] Available data also suggests a high prevalence of common mental health disorders in patients with active COVID-19 infection and high psychiatric morbidity in persons who have recovered from COVID-19 infection.[345] Besides the mental morbidity, other negative emotional consequences of developing COVID-19 infection include loneliness, social isolation, and social disconnectedness.[6] Further, several studies have reported significant mental health issues in patients during hospitalization which might have long-standing consequences.[789] Recent meta-analysis of 16 observational studies from 7 countries (n = 19,086) revealed that mental health disorders were associated with increased COVID-19 related mortality (odds ratio: 1.67) when compared to those without any mental health disorders.[10] In addition, studies have reported a neurological or psychiatric diagnosis incidence by 6 months’ period in patients admitted to COVID wards and COVID intensive care units (ICU) to be around 34% and 46%, respectively,[11] suggesting that survivors had significant psychiatric morbidity in the recovery period. The data regarding post-COVID fatigue, stigma, and cognitive deficits are also being reported across the globe,[1213] which is likely to add more psychological burden to the survivors.

Patients with psychiatric disorders have suffered significantly due to lockdown and subsequent closure of in-person mental health services. Many patients had exacerbation of previously stabilized symptoms or had a relapse of symptoms during the lockdown period. Studies have revealed higher mortality due to COVID-19 in patients with psychiatric illness.[1011121314] Further, studies have reported excessive worries about physical health, anger, impulsivity, and intense suicidal ideations to be higher in patients with psychiatric disorders during acute COVID infection.[15] Therefore, more care and prompt identification of exacerbation of mental health issues in these patients should be done to prevent any adverse outcome.

Data also suggest that patients with various mental disorders have a higher risk of developing COVID-19 infection, are discriminated against for hospitalization, and experience higher levels of mortality.[14] Several studies have also pointed out the issues of psychiatric disorders related to the medications used to manage COVID-19 infection (e.g., steroid-associated psychiatric disorders), and drug interactions between the psychotropic medications and medications used for management COVID-19 infection.[16]

All these facts suggest a need for proper mental health assessment of persons with acute COVID-19 infection and after recovery from the COVID-19 infection. In addition, the data also suggest that there is a need to monitor all the patients diagnosed with various mental disorders, especially, severe mental disorders to be closely monitored during the acute phase of COVID-19 infection and during the post-COVID-19 phase.

This guideline provides a broad framework for assessing and managing mental health issues in persons with acute COVID-19 infection and during the post-COVID phase. In addition, the guidelines also provide a framework for the assessment and management of patients with mental disorders, when they develop COVID-19 infection.

MENTAL HEALTH ISSUES IN PATIENTS WITH COVID-19 IN THE ACUTE PHASE

Since the beginning of the pandemic, World Health Organization had declared that mental health considerations should be an important part of COVID-19 pandemic management.[17] Many studies have reported several common mental health issues in patients with acute COVID-19 infection.[35] Acute stress reaction, panic attacks, depressive symptoms/disorders, suicidal ideations and attempts, acute psychosis, delirium are the commonly reported new-onset mental health problems in patients with COVID-19 during the hospital stay or during home isolation. In terms of patients with preexisting mental disorders, available data suggests an acute exacerbation of previously well-controlled obsessive–compulsive disorder, psychosis, anxiety disorder, depression, etc. It is also expected that patients using various substances are going to experience withdrawal symptoms while they are admitted to the COVID ward, where they do not have access to substitution therapy or detoxification regimens.

POSSIBLE FACTORS WHICH HAVE BEEN PROPOSED TO POOR MENTAL ISSUES IN PATIENTS WITH COVID-19 INFECTION

In addition to the fear of staying alone/away from family in COVID isolation center/hospitals and fear of death, lockdown related psychological distress, continuous media exposure to COVID-related news, unemployment, economical/financial burden, grief due to loss of relatives/family members due to COVID, etc.[18] contribute to the development of mental health problems in the patients when they get infected with SARS-2-CoV. Other factors which have been reported to be associated with poor mental health outcomes include feelings of not being cared for by the treating team and perceived lack of empathy by the patients from the health care professionals. Other factors that have been associated with higher mental morbidity include the COVID wards not being patient-friendly, poor or maladaptive coping on the part of the patient and seeing the co-patients die due to the COVID-19 infection.

MENTAL HEALTH ASSESSMENT AT THE TIME OF DIAGNOSIS OF COVID-19

It is suggested that wherever feasible, all the patients should undergo a psychiatric assessment prior to initiation of treatment for COVID-19 infection. This assessment can be done by a mental health professional (MHP) and should cover assessment of preexisting mental disorders if any, use of psychotropic medications in the past, current use of psychotropic medications, history of substance use (type, quantity, last intake, past complications), cognitive functioning, sleep duration and sleep-related problems, coping mechanisms, frustration tolerance, personality traits, suicidal behavior in the lifetime and current suicidal ideations/planning and recent attempts, and current mental status examination [Table 1]. These baseline assessments can guide the decision whether to admit the patient to COVID ward and consider home isolation. Additionally, these assessments can also help in deciding the mental health monitoring, monitoring physical health parameters (e.g., QTc prolongation in patients on antipsychotics), and selection of medications to be used for management of COVID-19 infection.

Table 1

Basic baseline mental health assessment in patients with COVID-19

• History taking

• Preexisting mental disorders if any

• Current mental morbidity - Onset of mental health issues - Anxiety, depressive symptoms

• History of use of psychotropic medications in the past

• Current use of psychotropic medications - Type of medications, doses, adherence, etc.

• History of substance use (type, quantity, last intake, past complications), signs and symptoms of withdrawal

• Cognitive functioning including past history of delirium

• Sleep duration and sleep related problems

• Coping mechanisms

• Frustration tolerance

• Personality traits

• Suicidal behaviour in the lifetime

• Current assessment

• Screening for depression - Can use instruments like PHQ-9, PHQ-4, PHQ-2, etc., for quantifying the problems at the baseline

• Screening for anxiety - Can use instruments like GAD-7

• Questionnaire to quantify the problems at the baseline

• Cognitive functioning

• Screen for delirium: Delirium is occasionally a presenting compliant in patients with severe COVID-19 infection

• Recent sleep pattern

• Current suicidal ideations/planning and recent attempts

• Mental status examination: Affect including irritability, psychomotor activity including agitation, speech, thought, perception, cognition, judgment, etc.

• Expectations from the treatment and admission

• Physical examination

• Look for any signs of anxiety - Looking nervous, sweating, restlessness, tremors etc., monitor vitals - Pulse, blood pressure, check for palpitations, fluctuating blood pressure

• Look for signs and symptoms of withdrawal

• Look for signs and symptoms of drug toxicity, especially if the patient is antipsychotics like clozapine

• Look for any signs of agitation, irritability and take steps to promptly predict imminent violence

PHQ – Patient health questionnaire; GAD – Generalized anxiety disorder

If the MHPs are called to assess new-onset mental health issue in a patient with COVID-19 infection, already admitted in the ward or the ICU, then besides the basic assessment listed in Table 1, the MHPs should focus on evaluating issues more pertinent for a new-onset mental disorder [Table 2 and Figure 1]. As delirium is a common manifestation in patients with severe COVID-19 infection, especially among those admitted to the COVID-ICU, all the patients should be screened for delirium. It also must be remembered that many patients may not report their pre-existing mental health issues at the baseline assessment and hence, while reassessing or assessing for the first time, it is recommended to review all the issues to be considered at the baseline assessment. An important aspect to be kept in mind, while evaluating the patients with COVID-19 infection includes assessing the doctor–patient relationship and relationship with other treating team members [Table 2].

Table 2

Assessment of patients already admitted in the COVID ward

• Signs and symptoms

• Screen for delirium: CAM, CAM-ICU

• Sensorium, sedation and motor activity: Richmond Assessment Scale for Sedation

• Evaluate cognition: Check for attention, concentration, recent memory deficits and other cognitive symptoms briefly; can use MMSE, HMSE or MoCA for assessing current cognitive profile

• Sleep: Duration, quality

• Pain

• Contextual issues

• Doctor patient relationship

•Relationship with other treating team members

• Factors contributing to distress: Food, cleanliness, lack of internet connection, access to the electronic devices, functioning of the electronic devices, ambient temperature and sound, worsening of health of co-patients, death of other patients in the ward, able to communicate with family members or not

• Establish the etiology of symptoms

• Try to establish the temporal association of onset of psychiatric symptoms with starting of anti-COVID medications/therapy (hydroxycholoroquine, remdesivir, favipiravir, dexamethasone, prednisolone, tocilizumab, convalescent plasma, etc.)

CAM – Confusion assessment measure; ICU – Intensive care unit; MMSE – Mini-mental state examination; HMSE – Hindi mental state examination; MoCA – Montreal cognitive assessment

Figure 1

Algorithm for basic assessment of mental health issues in patients with COVID-19 infection

In addition, if feasible patients with COVID-19, who do not have any mental health issues at the baseline assessment, should undergo daily surveillance for mental health issues, including monitoring mood, anxiety, suicidality, and sleep. These can be done by using self-rated Likert scales or more structured scales [Table 3] by the patients themselves and transmitted to the MHPs electronically. The MHPs can review the findings of these scales and determine further detailed evaluation and management. The mental health surveillance can also be done by the nursing staff and other medical staff posed in the COVID ward and they can convey the findings to the MHPs.

Table 3

Daily monitoring of mental health status of patients with COVID-19

• Daily rating of mood, anxiety, stress, sleep by the patient

• Suicidality

• Fear of death

• These can be done by using PHQ-9, PHQ-4, PHQ-2, GAD-7, Perceived Stress Scale, etc.

• Worries about health of family members

• Grief of loosing family members

PHQ – Patient health questionnaire; GAD – Generalized anxiety disorder

Persons with COVID-19 infection, belonging to special population (i.e., children and adolescents, elderly and peripartum women) need to be evaluated further for specific issues pertinent to them [Table 4].

Table 4

Additional assessment of persons belonging to special population groups

Elderly

• Physical disabilities: May predispose to delirium, may not be able to go the toilet on their own in the COVID-ward

• Sensory deprivation: May predispose to delirium

• Physical comorbidities

• All the ongoing medications

Peripartum women

• Duration of pregnancy

• Worries related to unborn child: Transmission of infection, congenital malformations

• Issues related to delivery - Type of delivery (cesarean section, normal vaginal delivery), place of delivery, risk of transmission during delivery, etc.

• Worries related to breastfeeding: Transmission of infection through breast milk

• Worries related to infection in the newborn

• Domestic violence

• Self-blame, guilt, etc.

Children and adolescents

• Ability to stay alone

• Intellectual ability, developmental disorders

• Screen media use, gaming addiction, etc.

• Hobbies

• Couples/families getting admitted together to the COVID ward

• Interpersonal relationship

• Blaming other person for their suffering

• Guilt about infecting others

• Responsible for death of other family members

Based on findings of the assessment, provisional diagnosis should be considered at different time points and individualized management plans should be formulated. Depending on the level of involvement of MHPs (i.e., MHPs present in the COVID ward round the clock, MHPs available only for few fixed hours, MHPs available in-person on call, MHPs available only for Teleconsultation [audio calls only/audio-video calls]), the treatment plan should be discussed with the primary treating team.

Besides the mental health assessment, the psychiatrists should also liaise with the physicians to understand the severity of the COVID-19 infection, associated comorbidities, and the plan of management for the patient by the primary team. The MHPs should carefully give their inputs, especially for patients being considered for home isolations. At times, patient may be considered to have mild COVID-19 symptoms and suitable for home isolation, but their mental health status puts them at higher risk of self-harm or relapse of illness. In such a situation, the MHPs should inform the primary treating team about the risk and need for hospitalization. This issue becomes more pertinent at places where there are no separate COVID inpatient facilities for persons with mental disorders. If such facilities are available in nearby vicinity then the MHPs should facilitate the transfer of patients to such a facility, so that their mental health issues are addressed along with management of acute COVID-19 infection.

Persons with mental disorders are discriminated against while being considered for admission into the COVID wards, despite the lack of difference in the severity of COVID-19 infection. This usually happens because of scare in the mind of the treating physicians about the unpredictable behavior of the patients with mental disorders and eminent risk of suicidality. In such a situation the MHPs should act as advocates and facilitate the admission of patients with preexisting mental disorders to the COVID ward facilities.

ESTABLISHING A LIAISON WITH FAMILY MEMBERS OF PATIENTS WITH COVID-19 INFECTION

Besides carrying out the assessment of the person with COVID-19 infection, it is important for the MHPS to establish a baseline relationship with the family members of the person with COVID-19 infection. As at most of the COVID wards, family members are not allowed to stay with the patient, but they are in touch with patient telephonically (voice calls/video-calls), they can act as an important source of support for the patient, while being in the hospital or at home isolation. However, because of their own distress and lack of information about the patient the family members can also become very anxious and troublesome for the primary treating team. Hence, understanding their issues at the baseline and regularly updating them about the progress of the patient can be useful. Additionally, they can also be involved in the day to day monitoring/surveillance of the mental health status of the person with COVID-19 infection.

ESTABLISHING LIAISON WITH THE COVID TEAM

There are different models of involvement of MHPs in the care of persons with acute COVID-19 infection. Accordingly, the MHPs should develop a strong liaison with the primary team to provide mental health care to all the persons with COVID-19 infection, address the queries related to mental health issues of the physicians managing such patients, and address mental health issues among the health care workers. The nursing staff and the treating physician need to be informed about the patient’s mental state and risk assessment.

MENTAL HEALTH ASSESSMENT DURING THE POST-COVID-19 PHASE

Available data also suggest a high rate of mental morbidity in persons with COVID-19 after recovery from COVID-19 or as part of long COVID. During the post-COVID recovery period, persons can have new-onset mental health problems or can have prolongation of mental health issues that they experienced in the acute phase. Currently, there is sufficient evidence for depression, anxiety, posttraumatic stress disorder, mild cognitive impairment, and dementia during the recovery period.[121617] Prolonged fatigue and cognitive deficits are the new emerging issues often being reported during the recovery period up to 6 months.[121819] Besides these, studies have also reported a higher prevalence of psychosis, cognitive deficits, and dementia, and substance use disorders. Some of these symptoms have been regarded as symptoms of “Long COVID” and need periodic monitoring and early intervention during follow-up visits. Other symptoms of Long COVID which need due focus include persistent fatigue, confusion, loss of smell and taste, shortness of breath, chest pain, sleep problems, anxiety, and headache.

Going through the whole experience of COVID-19 infection from the time of diagnosis to discharge and facing the society after recovery can be very challenging and distressing. Getting admitted to ICUs, remaining on oxygen support for long, remains with various tubing’s in-situ for long, seeing others dying around you, going through delirium, having near-death experiences, etc., can be very distressing to the person with COVID-19 infection. Similarly, supporting a person with a COVID-19 infection can also be very distressing for the family members.

Hence, for all the patients presenting to the MHPs with a new-onset psychiatric disorder, the MHPs should always inquire about recent COVID-19 infection in self and any family member, and the death of any family member COVID-19 infection.

Patients being followed up in the post-COVID clinics/centers, should be routinely evaluated for mental health issues from time to time. Ideally, an MHP should be a part of the post-COVID care clinic. If not, then physicians should be trained or sensitized to enquire about mental health issues and refer the patient to MHPs for further care. Periodic follow-up of the patients with any suspected emerging mental health issue needs to be done to initiate early treatment.

Like, the baseline assessment, while carrying out the assessment of persons during the post-COVID infection phase, the clinicians should focus on evaluating the experience of going through the infection for everyone, and provide psychological support to everyone, irrespective of the presence or absence of diagnosable psychiatric morbidity. Certain general mental health issues which should be considered for assessment in all patients with long COVID [Table 5] and these should be repeated from time to time.

Table 5

General mental health issues for assessment of persons during the post-COVID period

• Assess for the experience of going through the COVID-19 infection

• Assess for loss of any family members

• Try to understand post-COVID symptoms involving other organs and patient’s reaction to the same

• Monitoring and exploring for symptoms suggestive of long COVID

• Screen for depression (PHQ-9, PHQ-4, PHQ-2), anxiety (GAD-7), PTSD (primary care screening for PTSD, DSM-5), cognitive functioning (MMSE, HMSE, MoCA, IQCODE), sleep disturbances (Pittsburgh Insomnia Scale), Fatigue (Fatigue Assessment Scale)

• Suicidality: CSSR-S, Beck Suicide Severity Intent Scale, Beck’s Scale for suicidal ideation

• Current level of functioning and disability

• Current level of coping

• Any relationship and financial issues

PHQ – Patient health questionnaire; GAD – Generalized anxiety disorder; MMSE – Mini mental state examination; HMSE – Hindi mental state examination; MoCA – Montreal cognitive assessment; PTSD – Posttraumatic stress disorder; DSM – Diagnostic and statistical manual of mental disorders; IQCODE – Informant questionnaire on cognitive decline in the elderly; CSSR-S – Columbia Suicide Severity Rating Scale

Detailed assessments for individual psychiatric disorders are discussed in the subsequent section on management.

MANAGEMENT OF MENTAL HEALTH ISSUES IN PATIENTS WITH COVID-19

As mental health morbidity is considered to be highly prevalent in patients with acute COVID-19, there is a need to provide basic psychological first aid to all the patients diagnosed with COVID-19 infection, whether considered for admission to the hospital or home isolation. This should be provided to all the patients irrespective of the psychiatric morbidity and distress, either in-person, telephonically, or through video-conferencing [Table 6]. The psychological first aid can also be extended to the family members in distress.

Table 6

Psychological first aid to all patients with COVID-19 infection

• Reassure the patient after being diagnosed with COVID-19 infection, emphasize the fact that the mortality rate for COVID-19 is not very high

• Allow the patient to ventilate his/her fears, anxiety/distress, and anger

• Allay all kind of anxiety, and distress

• Answer to the queries raised (with a reassuring tone) such as duration of stay, testing, the possibility of meeting family members, location and medical status of previously admitted family members (if any) etc.

• Ask them to use of more adaptive coping (such as praying to god and other mindfulness-based techniques, talking to near and dear ones, sleeping adequately, exercises, following their hobbies, developing some new interest, or follow their pursuits which they were not able to do due to lack of time, count your blessings, etc.) and avoid use of maladaptive coping (following new updates, spending too much time on the screens, avoid substance use, focusing on negative aspects of COVID-19, frequently check their vital parameters despite lack of any respiratory distress)

• Teaching relaxation exercises if the patient is willing for the same

• Encouraging the patient to do yoga, meditation depending on the severity of the COVID-19 infection

ADDRESSING THE ISSUE OF CONTINUATION OF PSYCHOTROPIC MEDICATIONS IN PATIENTS WITH DIAGNOSED MENTAL DISORDERS

A thorough and quick assessment of previous mental health conditions and ongoing/past medications needs to be done in patients with diagnosed mental disorders. The decision to continue or discontinue the psychotropic medications should be based on the current severity of COVID-19 infection (oxygen saturation, laboratory findings, severe symptoms of COVID-19), the severity of psychiatric symptoms, type of psychotropic medications, and the medications being considered for the management of COVID-19 infection. As clozapine is reported to be associated with a higher risk of developing aspiration pneumonia, it is generally recommended to reduce the dose of clozapine to half.[1920] If the COVID-19 infection is mild and the patient is not being considered for any specific medications for the management of COVID-19 infection, then the ongoing psychotropic medications can be continued with close monitoring of both mental and physical health status of the person with COVID-19 infection.

As discussed earlier, assessment should be a continual process and MHPs should not hurry in starting of psychotropics in patients found to have mental health issues for the first time and when there is no immediate threat to the life of the patient. In many cases, the acute anxiety and depressive symptoms reduce after reassurance and as the acute respiratory symptoms subside. However, if there is an imminent risk of self-harm, agitation, delirium, and significant worsening of symptoms, then immediate use of psychotropic medications is warranted. High-risk management protocol should be initiated at the earliest and all safety and security measures need to be followed/activated. The patient at high risk should be monitored 24 × 7 all round the clock. Pharmacological treatment should be initiated and family members should be explained about the mental state and subsequent need for treatment (consent to taken from patient/family member depending on the mental capacity of the patient).

The basic principles of management of various psychiatric disorders in persons with COVID-19 infection are not different from those without the COVID-19 infection. However, certain issues may be more pertinent in persons with COVID-19, especially those with severe COVID-19 infection, receiving various medications for COVID-19 infection. A brief management plan of commonly encountered mental health issues in patients with acute COVID-19 infection is listed in Table 7.

Table 7

Management of mental health issues in patients with acute COVID-19 infection

Diagnosis/mental health problem	Management plan
Acute stress reaction panic attack	• Reassurance and validation of patient’s worries/symptoms
	• Looking for ongoing psychosocial stressors - Being admitted alone, family members severely ill in a different hospital, family member admitted in ICU, death of family member in the recent past, financial stressors etc.
	• Try to establish the association of symptoms with the starting of medications for COVID-19 infection, and discuss with the physician about reduction or change of offending medications
	• Counsel the patient using positive affirmative statements
	• Explore if the cause of anxiety is related to the use of face masks, oxygenation or being on BiPAP devices; if the anxiety is related to these issues, explain the patient about the need for the same, how to appropriately breath through the same and reassure them
	• If the patient becomes more restless, short-acting benzodiazepines can be started (clonazepam, etizolam, alprazolam) as per the need
	• Deep breathing exercises and distraction techniques to be taught
	• Daily brief online/in person supportive ventilatory sessions to be taken
	• If symptoms do not subside and frequency of panic attacks increases, SSRIs can be started in addition to short acting benzodiazepines
	• Family members to be counseled to support the patient and to provide reassurance
Exacerbation of previously diagnosed anxiety disorder	• Review of previous medications
	• Look for or rule out benzodiazepine dependence and subsequent withdrawal/rebound anxiety due to sudden stoppage of benzodiazepines
	• Restart the previous medications (SSRIS/antidepressants) in low dose after taking due care of potential drug interactions with anti-COVID medications
	• Supportive sessions
	• Relaxation techniques
Depression	• Explore for any past history of similar episode and cognitive symptoms of depression
	• Review of ongoing medications
	• If patient is receiving steroids, interferons, hydroxycholoroquine, ritonavir etc., try to establish the association of symptoms with the starting of medications, and discuss with physician about reduction or change of offending drug
	• Mild depression - Supportive sessions, cognitive behavior therapy techniques
	• Moderate to severe depression - Antidepressants (SSRIs/SNRIs preferred) to be started keeping in mind potential drug interactions
	• Low dose benzodiazepines can be given for short time
	• If suicidal then high risk management and close surveillance to be carried out
	• In case of severe depression with psychotic symptoms, antipsychotics need to be added
Delirium	• Evaluate the onset of symptoms and fluctuating course
	• Monitor cognitive symptoms and sleep-wake cycle disturbances
	• Evaluate for underlying cause and address the same to the treating team
	• Try to establish the association of symptoms with the starting of medications for COVID-19 infection, and discuss with the physician about reduction or change of offending medications
	• Re-orientation cues
	• Pharmacological treatment - Melatonin, haloperidol/quetiapine (depending on/with monitoring of QTc interval), dexmetodimine
	• Lorazepam for alcohol-withdrawal delirium
	• High-risk management to be carried out
Sleep disturbances	• Reassurance
	• Sleep hygiene
	• Low dose melatonin, zolpidem, benzodiazepines
New onset psychosis	• Evaluate the association of new onset psychotic symptoms (delusions, hallucinations, thought disorder) with underlying medical illness and ongoing medications (steroids, hydroxychloroquine etc.)
	• Rule out delirium
	• Start second generation antipsychotics (check and monitor QTc interval and drug interactions)
	• If agitated, short acting benzodiazepines can be added
	• High risk management
	• Psychoeducation of family members and treating team
Substance withdrawal	• Explore for last intake of the substance (alcohol, tobacco, opioid, cannabis etc.) and the usual quantity consumed
	• Explore withdrawal signs and symptoms clinically and on a rating scale appropriate for the substance
	• Evaluate for craving
	• Look for signs of delirium
	• Take a proper history about withdrawal seizures and co-morbid psychiatric history
	• Management to be done taking care of clinical parameters and oxygen saturation with usual detoxification protocol for the specific substance
	• Benzodiazepines (mostly lorazepam) for alcohol withdrawal with monitoring for respiratory depression
	• Analgesics for opioid withdrawal and opioid substitution therapy (if needed) under supervision of psychiatrist
	• Nicotine replacement therapy (nicotine gums/patch) for tobacco related craving and withdrawal

ICU – Intensive care unit; BiPAP – Bilevel positive airway pressure; SSRIs – Selective serotonin reuptake inhibitors; SNRIs – Serotonin norepinephrine reuptake inhibitors

Once the patient improves from the acute COVID-19 infection, their apprehensions about facing the society need to be evaluated and the issues related to anticipated stigma need to be addressed.

MONITORING OF PATIENTS WITH MENTAL HEALTH ISSUES DURING THE ACUTE COVID-19 INFECTION

More stringent follow-up and adequate supportive support/sessions (Teleconsultation, videoconferencing, in-person consultation) must be conducted during the hospital stay or isolation phase, especially for those with mental health issues. Regular contact (Teleconsultation, videoconferencing, in-person consultation) with family members and treating MHPs also helps in stabilizing the patient’s acute symptoms. In case of agitation and violence, psychotropics needs to be used to calm down the patient, while taking care of oxygen saturation and other clinical parameters relevant for COVID infection.

STARTING PSYCHOTROPICS

While starting psychotropics the general principle of using psychotropics in medically ill, i.e., start with low dose and go slow should be followed. Other issues to be considered into the severity of COVID-19 infection, level of oxygen support required by the patient, ongoing medications for COVID-19 infection, other physical comorbidities (i.e., renal and hepatic functioning), complications of COVID-19 (coagulopathy, bleeding, stroke, etc), drug interaction (synergistic action of COVID-19 medications and antipsychotics on prolongation of QTc interval) and investigation findings (QTc interval, hyponatremia). In general, all the pros and cons of starting and not starting the psychotropic medications need to be discussed with the treating physicians, family members and if feasible with the patient. While using benzodiazepines the risk of respiratory depression must be kept in mind.

BREAKING BAD NEWS

Breaking bad news is an important component of the acute COVID-19 infection. The clinicians including the MHPs may have to break the bad news about the poor health status to the family members. The clinicians need to show compassion throughout the process and should be sensitive to the needs of the family members. Some of the commonly practiced models of breaking bad news includes the SPIKES (Setting, Perception, Invitation, Knowledge, Empathy, and Summary) model, ABCDE (Advance Preparation, Build a therapeutic environment/relationship, Communicate well, Deal with patient and family reactions and Encourage and validate emotions) model, BREAKS (B: Background, R: Rapport, E: Explore, A: Announce, K: Kindling and S: Summarize) Protocol. As during the ongoing pandemic, it is often not possible for the clinicians to meet the families in persons, breaking the bad news should preferably be done by videoconferencing so that clinicians are able to consider the nonverbal cues of the family members while they are given the bad news. The clinicians can follow the principles of one of the given models. It is important to remember that if the clinicians keep on providing updates to the families routinely, then it becomes easier to break the bad news and regular updates can themselves act as warning signs and prepare the family members for any kind of eventualities.

MANAGEMENT OF SPECIFIC MENTAL HEALTH ISSUES IN THE POST-COVID PHASE

During the post-COVID recovery period, patients can have new-onset mental health problems or can have prolongation of mental health issues that they experienced in the acute phase. The assessment and management of mental health issues in the post-COVID recovery period should be a continuous process and the mental morbidity should be treated as per the available guidelines. The basic assessment and management are listed in Table 8.

Table 8

Assessment and management of mental health issues in post-COVID recovery period

Mental health issue/condition	Assessment	Management
Anxiety/depression	• Evaluate for onset of anxiety and depressive symptoms - Either it is prolongation from acute phase or new onset during post-COVID period	• Based on severity and patient profile, the plan of management needs to be tailor made
	• Duration of symptoms and severity	• Psychotherapeutic interventions - Supportive psychotherapy, cognitive behavior therapy to be used in patients with mild to moderate symptoms (either alone or in combination with antidepressants in patients with mild symptoms)
	• Association with any ongoing medications (steroids) to be explored
	• Explore for any COVID related residual symptoms
	• Past history of self-harm
	• Any ongoing psychosocial stressors
	• Cognitive symptoms of depression - Ideas of hopelessness, helplessness, feeling burden etc.	• Antidepressants (SSRIs/SNRIs) for depression and anxiety
	• Rating of anxiety and depression on standardized rating scales like Hamilton Anxiety Rating Scale, Hamilton depression Rating Scale, Beck depression inventory etc.	• Low dose benzodiazepines for short term can be added
		• Relaxation exercises and yogic exercises
		• Activity scheduling
	• Assess for suicidal ideations and plans	• Thought diary and mood chart monitoring can be helpful
	• Family support	• Reassurance
Sleep disturbances	• Frequency and severity of the problem	• Sleep hygiene
		• Low dose melatonin, zolpidem, benzodiazepines
PTSD	• Explore for onset of symptoms - Anxiety, nightmares, hypervigilence, autonomic hyper arousal	• SSRIs
		• Benzodiazepines for short term
	• Explore for the association of symptoms with ICU stay, ventilator support, having seen anyone dying in ICU/hospital, any traumatic procedures experienced etc.	• Relaxation exercises
		• Trauma-focused psychotherapy
		• Supportive sessions
	• Explore for the severity of symptoms
	• Assess for concomitant depressive symptoms and suicidal ideations
	• Family support
	• Rating on Standard Scale - Impact of Life Events Scales - Revised
Cognitive deficits/dementia	• Explore for any residual symptoms of COVID-19	• Based on severity, treatment plan have to be tailor made
	• Any neurological event like stroke, transient ischemic attack during the acute phase or after the acute phase of COVID-19 infection	• Cognitive rehabilitation
		• Donepezil can be started
	• Explore for premorbid cognitive functions and ADL	• If co-morbid vascular risk factors are identified, memantine can be a good option
	• Estimate the impairment in cognitive functions (MMSE, HMSE, MoCA) and ADL
	• Laboratory investigations for dementia workup	• For behavioral problems, behavioral assessment and interventions to be planned
	• Neuroimaging - MRI
	• Detail neuropsychological assessment
	• Explore for behavioral and psychological symptoms
New onset psychosis	• Explore for onset of symptoms - During acute phase or during recovery period	• If all possibilities of organic psychosis are ruled out, then provisional diagnosis of acute psychosis can be considered
	• Thorough mental state examination - Delusions/hallucinations/cognitive functions/polymorphic picture - Fluctuating delusions
	• Assess for suicidal ideations	• Antipsychotics need to be started - Preferably second-generation antipsychotics
	• Relationship with any ongoing medication or physical ailment
	• Behavioral observation report of family members	• Benzodiazepines can be added for control of acute agitation
	• Take relevant family history and past history of similar episodes
	• Physical examination and vitals monitoring - Rule out fever
	• Laboratory investigations - To rule out any inflammatory conditions
	• Neuroimaging (if required)
	• Assess severity of symptoms and socio-occupational dysfunction

SSRIs – Selective serotonin reuptake inhibitors; SNRIs – Serotonin norepinephrine reuptake inhibitors; ICU – Intensive care unit; ADL – Activities of daily living; MMSE – Mini mental state examination; HMSE – Hindi mental state examination; MoCA – Montreal cognitive assessment; MRI – Magnetic resonance imaging; PTSD – Posttraumatic stress disorder

One of the important issues, which can be seen in the post-COVID phase, includes Grief Reaction, due to the loss of near and dear ones. This psychological intervention should facilitate adaptation to loss, must support spontaneous emotional outbursts and ventilation of emotions. There is a need to explore for if the patient was unable to do rituals of the deceased family member and provide psychological support, as this can be a significantly stressful event. The person going through the grief must remain connected with people, seek help from others, be encouraged to use adaptive coping, and develop new rituals in their daily life to remain connected with their loved ones and replace those who are no longer there. While carrying out grief work, the MHPs must be able to listen with empathy, convey warmth, acknowledge the emotions of the person and allow the person to express emotions and cry, without any interruption. While talking to the person, the MHPs should speak slowly and calmly and avoid speculations.

MENTAL HEALTH ISSUES IN HEALTHCARE WORKERS

Healthcare workers (HCWs) had been working an extra mile as frontline workers since the beginning of the COVID-19 pandemic. Initially, there was fear, apprehension, and anxiety among the HCWs, while dealing with patients with COVID-19 infection. However, HCWs have worked selflessly despite being subjected to difficulty in rendering patient care (due to PPEs), facing stigma from public and getting infected themselves and their family members. During the 1st wave and 2nd wave, the patient load increased significantly and HCWs had to deal with tremendous work pressure. All these have resulted in significant burnout, psychological issues (depression and anxiety), sleep disturbances, and substance use problems among the HCWs, that is evident from a number of studies conducted on mental health issues among the HCWs during the pandemic.[2122] Hence, it is pertinent that the health care organizations should take care of the mental health needs of the HCWs. These calls for conducting awareness programs to screen and identify psychological issues in HCWs. MHPs should evaluate for burnout, stress, and psychological morbidities in HCWs on COVID-19 duties. When any psychological morbidity is identified, the same should be managed in accordance with the existing guidelines for specific psychiatric disorders. Further, if the HCWs go through the COVID-19 infection, they should also be managed as per the recommendations.

PUBLIC HEALTH MEASURES TO REDUCE THE NEGATIVE MENTAL HEALTH CONSEQUENCES OF COVID-19

As COVID-19 infection is associated with significant stigma, there is a need to address the stigma associated with the COVID-19 infection. Stigma against COVID survivors needs to be addressed by the media campaigns and other public health measures.[20] Regular anti-stigma messages should be promoted to the general public so that people those who have recovered from COVID infection do not feel discriminated against.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.