Psychiatry and COVID-19

The coronavirus disease 2019 (COVID-19) pandemic has caused major disruptions in all aspects of daily life, from school and work to interactions with friends and families. Mitigation measures also substantially altered the economic environment, with tens of millions of people in the US losing their jobs, and many more experiencing income reductions (through furloughs) or uncertainty about the future of employment and health insurance. In addition, major changes took place almost overnight in the landscape of medicine and medical care, including new policies to reduce social/physical interaction and cessation of many in-person medical visits.

Within the field of psychiatry, a rapidly growing literature is addressing the disruption and transformation experienced during the pandemic; more than 1000 publications have already appeared. This Viewpoint describes some of these developments to date and discusses important themes relevant to clinical psychiatry, care delivery challenges, and public health considerations.

In the early stages of the pandemic, major changes took place in clinical psychiatry quite rapidly. Routine in-person visits were stopped, inpatient and residential facilities adopted new measures such as polymerase chain reaction testing for all new admissions, and concern arose about COVID-19–related morbidity and mortality among people with major psychiatric disorders. Psychiatrists needed to establish protocols to provide ongoing care to their patients who developed COVID-19. Patients with psychiatric disorders are particularly vulnerable to COVID-19 due to high rates of overweight, tobacco smoking, medical comorbidities, and poor self-care.¹ In addition to patients with preexisting psychiatric illness, psychiatrists were asked to treat clinicians and other frontline workers who developed high rates of depression, anxiety, and trauma-related problems associated with providing care during the pandemic.² The well-publicized case of an emergency physician who committed suicide following her own COVID-19 infection, and her exposure to deaths among patients with COVID-19 who were treated in the emergency department in which she worked, has drawn attention to the mental health challenges for physicians, nurses, technicians, paramedics, and other health care personnel in the pandemic.³

Routine psychiatric care has also become more difficult. Many psychiatrists work in group homes, community-based programs, and emergency departments where they engage in extensive in-person interaction with patients. This has become challenging during the pandemic; many psychiatrists transitioned to telehealth to provide routine treatment across these levels of care. Another challenge has been protecting inpatient psychiatric units from contagion. Unlike most inpatient medical services, communal areas in psychiatric units are used extensively by patients who are ambulatory, eat meals together, and participate in group therapy sessions. For these reasons, concern was raised that psychiatric units could become a major source of COVID-19 outbreaks, much like prisons and nursing homes. Although this has been reported in isolated situations,⁴ extensive efforts to contain infection risk appear to have limited extensive infection from occurring in these units. For example, some inpatient units exclusively admitted psychiatric patients with psychiatric illness and COVID-19 so they could be cared for in separate physical spaces from patients who were not infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

Emerging evidence indicates that acute COVID-19–related medical concerns and lockdown measures are leading to delays in patients seeking psychiatric care, just as has been reported for patients who have delayed seeking care for cardiac and neurologic conditions. Emergency department visits and hospitalizations for psychiatric disorders were significantly reduced in states that experienced peak numbers of COVID-19 cases,⁵ which are only now starting to abate. It is unknown whether there will be a rebound in hospitalizations as reopening progresses and patients become more comfortable seeking care or as COVID-19 resurges in some areas. The delay in accessing care is likely to have adverse effects on a range of outcomes, for example, by extending the duration of untreated psychosis among young people with emerging psychotic disorders.

The effects of COVID-19 and mitigation measures on psychiatric care delivery have been significant because in-person care was abandoned in favor of telehealth. Regulatory and reimbursement issues and privacy/confidentiality of internet-based care were addressed rapidly: most psychiatric outpatients went from in-person to online visits almost overnight. Psychiatry is unusual among medical specialties in that most outpatient psychiatric services can be delivered virtually without in-person interaction, with the notable exceptions of ketamine infusions, electroconvulsive therapy, and transcranial magnetic stimulation. Early experience suggests that virtual care functions well, and many are predicting that this transformation will become permanent.⁶ Long-term prospects for telehealth in psychiatry, however, will depend on reimbursement patterns, in particular, whether payers revert to providing minimal reimbursement for such care. Most psychiatry clinics operate on narrow financial margins and cannot continue telehealth services if reimbursement is much lower than that for in-person care.

This sea change poses both challenges and opportunities for psychiatry. For example, the shift to telehealth may be associated with greater accessibility for patients. Anecdotal reports and early analyses indicate that no-show rates for appointments are lower for telehealth visits compared with in-person visits. This may ultimately translate to improved outcomes. On the other hand, transition to telehealth may also exacerbate preexisting disparities in patient access to care. Many patients with psychiatric conditions, especially those with low socioeconomic status, do not have access to a computer in a private location with proper internet connectivity. The extent to which telephone calls can substitute for video in these patients remains to be seen.

Mental health has featured prominently in discussions of how the pandemic is affecting society. The pandemic, mitigation efforts, and economic downturn all raise the risk of homelessness, substance use, depression, anxiety, and suicide. Pandemic-induced distress is unusual in that individuals are experiencing it in isolation without the daily structure of work or school and repeated over many months via exposure to the news and social media. In addition, there is great uncertainty about the longer-term outcomes for those infected with SARS-CoV-2 and for society in general. Daily news of large-scale COVID-19–related disease and death in the community over months or years is almost certain to elevate psychiatric burden in the population.⁷ As such, the pattern of stress resembles that experienced by refugees or others exposed to chronic violence, rather than acute disasters like the September 11 terror attacks. Some have suggested the potential for a tsunami of psychiatric disorders brought about by the pandemic along with a second wave of COVID-19.² A sustained increase in demand for psychiatric services may well exceed the existing capacity of the system over time and may last for years, depending on the course the pandemic takes. Whatever the pattern, COVID-19 has focused attention on gaps in knowledge about how to prevent the effects of traumatic stress.

Beyond the consequences of quarantine, a key open question is whether COVID-19 infection results in psychiatric sequelae and by what mechanisms. Individuals who have survived intensive care unit stays and intubation (and their families) may experience acute and longer-term consequences of trauma. Survivors often require rehabilitation after hospitalization during which psychiatric and cognitive symptoms are commonly observed. The extent to which COVID-related coagulopathies, hypoxia, neuroinflammation, or direct viral infection of the brain may contribute to psychiatric morbidity remains to be defined.

Despite these areas of uncertainty, future demand for psychiatric services will be greater than current demand and it is good policy to prepare for this circumstance. Around the country, such services are poorly resourced and inadequate even for normal times. Thus, a series of measures are needed to increase capacity for mental health care. First, existing psychiatric services must be adequately funded and must institute measures to counteract staff turnover, burnout, and low morale. Community mental health centers provide an especially important safety net in this regard. Second, collaboration between psychiatrists and other medical professionals must be enhanced through collaborative care and support primary care and other physicians to provide mental health care services. Third, availability of internet-based self-help should be expanded along with other scalable mental health interventions for prevalent and milder cases of mental distress, while acknowledging that these applications can at best complement rather than replace careful psychiatric assessment and care. Fourth, longer-term solutions must be implemented by expanding psychiatry training in medical school curricula and ensuring acceptance and integration of mental health services in all clinical settings.

Psychiatry has encountered unique challenges during the COVID-19 pandemic but has been able to continue much routine care virtually when many other medical specialties ground to a halt. The pandemic is causing great distress in society and this is translating into increasing rates of depression, anxiety, and other psychiatric disorders. This trend is likely to continue. Psychiatry has been called on to lead efforts to treat these disorders and alleviate psychiatric disorders and distress, but this will necessitate close collaboration with primary care physicians and those in other specialties as well as renewed support and investment from society.

Corresponding Author: Dost Öngür, MD, PhD, Harvard Medical School, McLean Hospital, 115 Mill St, Mailstop 108, Room AB320, Belmont, MA 02478 (dongur@partners.org).

Conflict of Interest Disclosures: Dr Perlis reported receiving personal fees from Outermost Therapeutics, Psy Therapeutics, Genomind, RID Ventures, Burrage Capital, and Takeda outside the submitted work. No other disclosures were reported.