Journal Article Annotations
2020, 1st Quarter
Annotations by Paula C Zimbrean, MD. O. Joseph Bienvenu, MD, PhD. Aum A Pathare MD, Franklin King IV, MD, Sahil Munjal, MD
April 1st, 2020
Psychol Med. 2020Mar 27:1-7. doi: 10.1017/S0033291720000999. [Epub ahead of print]
Abstract: not available.
Unstructured annotation (Paula Zimbrean, MD):
This is the first report on systematic evaluation of patients treated for COVID 19 respiratory disease. Severn hundred thirty patients who had been hospitalized for COVID 19 and were now in stable conditions were asked to complete online psychological assessments prior to discharge form the hospital. They completed 17 item self-reported PTSD check list and one additional unstructured question about need for mental health services. Almost all patients 96.2% (95%CI: 94.8%-97. 6%),reported significant PTSD symptoms (>50 score on the PTSD checklist).
This study suggests that prevalence, course and potential interventions for Posttraumatic Stress Disorder need to be considered and further studied in patients hospitalized with COVID 19.
Type of study:
cross sectional cohort
This study had most of the respondents rate themselves as healthy, and without perceived exposure to infection. Around half of them reported moderate-severe feelings of distress, but less than a third reported significant anxiety, and fewer still noted more than mild depressive symptoms. Females and students had greater anxiety, depression and stress scores. Lower educational status was associated with higher depression scores. The presence of respiratory symptoms, pre-existing medical illness, or perception of poor health was linked to a greater impact on all psychological domains. Greater satisfaction with health information had the opposite effect, while wearing nonspecific masks lowered anxiety scores.
Strength and weaknesses:
This is a timely survey for the COVID-19 pandemic. It provides baseline data for potential interventions, and its conclusions are supported by previous studies during the SARS epidemic. Limitations include the possibility of oversampling populations due to a snowball sampling design, which could limit generalizability, along with increasing potential social desirability bias. We must remain mindful of the obvious limitations of cross-sectional surveys, and that increased scores on the IES-R and DASS-21 do not necessarily reflect any specific diagnosis.
As the COVID-19 pandemic unfolds, the field of healthcare shall be faced with a population in increasing distress. It is useful to understand the factors which could expose individuals to elevated symptom burdens of anxiety, depression, and disruption in their lives. C-L psychiatrists are uniquely positioned to keep themselves updated about the evolving nature of the threat and the healthcare system’s response. Helping the community with satisfactory health information, provided either at an individual patient level, or by aiding larger institutions communicate better could also have a large impact in alleviating distress.
Type of Study:
In this fast-tracked report, the authors report on 799 moderately to severely (including critically) ill patients transferred to Tongji Hospital in Wuhan, China, which the Chinese government rapidly renovated to take care of severely ill patients with COVID-19. The authors examined clinical and laboratory correlates of mortality, which was 14% in this sample, and they noted that disorders of consciousness were significantly more common in patients who died (22%) than in those who survived (1%).
Strengths and weaknesses:
The authors completed data collection for this study between January and February of 2020 (1 month), and they published it in BMJ online March 26th; time is of the essence here! Note that the authors relied on chart information regarding acute brain dysfunction, and it is unclear whether the hospital employed routine screening methods to assess delirium and coma.
Despite limitations, the study reinforces the prognostic importance of acute brain dysfunction in the context of acute illness for mortality. No doubt, we are all interested in learning more about the encephalopathy associated with COVID-19 (including any experimental treatments). I hope that we will see more reports about this in the coming months.
Type of study:
Retrospective case series
Annotation (Franklin King IV, MD):
The authors describe psychological interventions devised to help medical staff dealing with the COVID-19 crisis in a Hunan (adjacent to Hubei province) hospital during the height of the coronavirus epidemic. They describe a trio of interventional tactics that was initially debuted but met with required adjustment given staff resistance. Specifically, minimization of psychological stress, reluctance to participate in group and individual psychological treatments offered by the crisis team and focus of staff on external issues such as lack of protective equipment and need for housing apart from their at-risk families was noted. Additionally, hospital staff reported difficulty managing the psychological and emotional issues arising from admitted patients with COVID-19. Interventions were adjusted to target these concerns and included counseling regarding safe use of protective equipment, provision of temporary housing accommodations for staff unable or unwilling to return home due to fear of infecting others, training for staff on how to manage psychological issues arising in infected patients, and ‘decompression’ sessions arranged for staff through on-the-floor counselors.
Strengths & Weaknesses:
As this is only a brief communication describing the strategy for one hospital, there are significant limitations given the absence of randomization, or in fact of any follow up data, to report on the efficacy of the interventions. However, given the unprecedented nature of the COVID-19 pandemic and strain placed on hospitals, this article describes a unique set of circumstances and needs of hospital staff during the height of the pandemic in China.
Relevance to Consultation-Liaison Psychiatrists:
Consultation questions do not arise in a vacuum, with issues related to floor acuity, unit morale, and overall team dynamics often playing a significant role in the generation of the consult question and requisite needs. The unique set of circumstances of the current COVID-19 pandemic and the needs of hospital staff will be likely to influence the consultant-consultee interaction. As such, it is important for consulting psychiatrists to be aware of these issues and, when possible, to collaborate with hospital leadership, social services, and staff to assist where appropriate in addressing staff needs. The present paper describes interventions that among other things helped staff feel more at ease regarding concerns from their own families, as well as providing psychoeducation to staff on how to manage psychological issues arising in patients a pandemic situation.
Annotation (Sahil Munjal, MD)
The paper is a review written to address the unique challenges of the current COVID-19 outbreak at psychiatric hospitals in China citing various state guidelines and local articles (in Chinese). It highlights the vulnerability of psychiatric inpatients and the strategies to improve mental health services during the COVID-19 outbreak in China specifically addressing the shortage in personnel, infection risk and disruption of service due to logistics.
Strength and weaknesses:
As more information is gathered in this quickly evolving pandemic and reaches the scientific community, it is one of the few review articles that addresses the subject of psychiatric inpatients at the epicentre of the pandemic.
They have mainly cited state guidelines and articles published in the Chinese literature geared towards mental health resources in China. Some of this may not apply to other countries.
As we grapple with the COVID-19 pandemic, CL psychiatrists already are or will be asked to cover inpatient psychiatric units depending on the workforce. It is important to have some guidance from countries that are ahead of us in the curve. This may include provision of adequate medical supplies and protective equipment, public education, restricting family visits, maintaining good personal hygiene, measurement of body temperature daily, group activities avoided, admission criteria tightened, and the length of hospitalization shortened. China has already suffered from another epidemic SARS in 2003 after which it started one of the largest community mental health projects globally. They have used various strategies including creating an infectious disease hospital for psychiatric patients, isolation wards in psychiatric hospitals and establishing specific quarantine facilities for clinically stable psychiatric patients. The paper has a very helpful figure summarizing the strategies to improve mental health services during the COVID-19 outbreak in China, some of which can be readily incorporated in our inpatient units as we advocate for the safety of our patients and staff.
Type of study: