From the Editor
As we consider the psychiatric needs arising from COVID-19, are there lessons to be drawn from past severe coronavirus infections?
The first selection seeks to answer that question.
In The Lancet Psychiatry, Dr. Jonathan P. Rogers (of the University College London) and his co-authors do a systematic review and meta-analysis of severe coronavirus infections with a focus on psychiatric presentations. They included papers covering SARS and MERS. “This review suggests, first, that most people do not suffer from a psychiatric disorder following coronavirus infection, and second, that so far there is little to suggest that common neuropsychiatric complications beyond short-term delirium are a feature.”
Should mental health notes be shared with patients? In the second selection, we look at paper from The Lancet Psychiatry. Charlotte R. Blease (of Harvard Medical School) and her co-authors champion the idea. “Sharing clinical notes in mental health settings will be more complex than in other clinical specialties; however, for most patients it will be feasible and, if carefully implemented, an empowering tool that could improve care.”
Finally, we consider an essay from The Globe and Mail. Dr. Saadia Sediqzadah (of the University of Toronto), who is graduating from her psychiatry residency this month, discusses her training and the expectation that patients “present to the clinic.” Now practicing in a COVID-19 world, she writes about psychotherapy and her patients. “What would Freud say? I care less about that as we now contend with a very different world than his. The question I ask now is, how will we go back?”
Selection 1: “Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic”
Jonathan P. Rogers, Edward Chesney, Dominic Oliver, Thomas A. Pollak, Philip McGuire, Paolo Fusar-Poli, Michael S. Zandi, Glyn Lewis, Anthony S. David
The Lancet Psychiatry, 18 May 2020 Online First
Viral infections are common and some are known to infect the CNS, causing neuropsychiatric syndromes affecting cognitive, affective, behavioural, and perceptual Domains. Severe illness of diverse aetiologies is associated with subsequent psychiatric morbidity, at least some of which is attributable to its psychological impact of trauma.
So begins a paper by Rogers et al.
Here’s what they did:
- They did a search of major databases including MEDLINE.
- They included papers on the psychiatric and neuropsychiatric presentations of individuals with suspected or laboratory-confirmed coronavirus infection.
- Outcomes included psychiatric signs or symptoms and symptom severity.
Here’s what they found:
- “1963 studies and 87 preprints were identified by the systematic search, of which 65 peer-reviewed studies and seven preprints met inclusion criteria.”
- Studies covered China, Canada, France, Hong Kong, Saudi Arabia, South Korea, Japan, Singapore, the UK, and the USA.
- Systematic review: most patients with SARS or MERS do not develop psychiatric disorders.
- A significant minority exhibited confusion (27.9%), depressed mood (32.6%), anxiety (35.7%), impaired memory (34.1%), and insomnia (41.0%).
- Meta-analysis: the point prevalence in the post-illness stage was 32.2% for post-traumatic stress disorder, 14.9% for depression, and 14.8% for anxiety.
Our main findings are that signs suggestive of delirium are common in the acute stage of SARS, MERS, and COVID-19; there is evidence of depression, anxiety, fatigue, and post-traumatic stress disorder in the post-illness stage of previous coronavirus epidemics, but there are few data yet on COVID-19.
This is a good and detailed paper. Frankly, the above summary is superficial.
While there are clear psychiatric disorders associated with SARS and MERS, it’s also true that the majority of patients didn’t have mental health diagnoses. How to apply such learnings to COVID-19? Given that many people are only mildly or moderately ill with the virus, it seems reasonable to assume that – as with SARS and MERS – most infected people will not need mental health care. Thus, with much unknown about COVID-19, this paper provides us with good historical information and a possible way forward in terms of thinking about population needs (that is, a stepped-care approach with more resources for those with more needs).
But do past coronavirus infections really provide us with relevant information? Yes, there is a microbiological similarity, but COVID-19 is very different in terms of the illness experience.
In an accompanying commentary, Iris E. Sommer and P. Roberto Bakker pick up on this point: “Patients with COVID-19 who are admitted to hospital might be older than patients admitted for SARS (although not all studies show this), and the mean duration of their stay in the intensive care unit (ICU) is longer. In the COVID-19 era, unlike the previous SARS and MERS outbreaks, fear for shortage of medical facilities such as ventilators can further increase stress.” The length of stay in the ICU is particularly important, given the strong connection between ICU admissions and PTSD.
Further, Sommer and Bakker note differences in the world situation: “COVID-19 survivors, unlike SARS and MERS survivors, return to a society in deep economic crisis, with shortage of basic needs such as food in some countries and other countries still in lockdown and enforcing physical isolation. These social adversities will keep stress levels after somatic recovery high, and further increase patients’ risk for long-term psychiatric complications such as anxiety and depression.”
These are good points. So, while the Rogers et al. paper is reassuring, the mental health challenges of COVID-19 may prove to be greater than with SARS and MERS.
Selection 2: “Sharing notes with mental health patients: balancing risks with respect”
Charlotte R. Blease, Stephen O’Neill, Jan Walker, Maria Hägglund, John Torous
The Lancet Psychiatry, 11 February 2020 Online First
In the past decade, health institutions in over ten countries – including Australia, Canada, Sweden, and the USA – a have begun to provide patients with access to their clinical records via secure online portals. So far, however, few health organisations have chosen to share clinical notes written by mental health professionals. Clinicians, especially those working in psychiatric settings, remain concerned that patients could become anxious, confused, or offended by what they read, and that sharing notes will create an extra work burden for mental health professionals.
So opens a paper by Blease et al.
They argue that sharing notes comes down “ethical dilemma around patient autonomy balanced with harm prevention.”
“This dilemma might be avoided if two underlying assumptions are considered: first, that reading notes is harmful to mental health patients; and second, that record keeping cannot be adapted to avoid negative effects.”
With regard to the first assumption, preliminary studies show sharing notes may be beneficial.
- “A study done at a psychiatric outpatient clinic found that, after 20 months, most patients reported increased understanding of their mental health, better remembered their care plan, and had better awareness about the potential side-effects of medications.”
- “Qualitative research also shows that, as a result of reading their notes, many mental health patients describe feelings of validation, greater engagement, and enhanced trust in clinicians…”
- That said, while the majority found the notes “very important” to have access to in a study of those in psychotherapy, some found the notes to be “disrespectful, judgmental, or were surprised by perceived incongruencies with what was communicated face-to-face.”
Can record keeping be adapted? “Evidence indicates that some clinicians change how they write notes to protect patients from such risks. In a survey at a medical centre in the Veterans Health Administration – the nationwide health-care system that offers veterans portal access to mental health notes – early 63%… of clinician respondents reported being less detailed in their documentation and nearly one in two… admitted that they would be ‘pleased’ if the practice of open notes discontinued.” A Swedish study of clinical psychologists reported a similar finding.
The authors worry that modified notes may also undermine the purpose of releasing the notes in the first place. They favour a different approach. They suggest that patients could be allowed to incorporate feedback into the documentation. Also, “reconceiving access as an extension of the therapeutic clinical encounter means that patients should receive guidance on how to access their records, on the benefits and potential downsides of reading notes, and on how to constructively raise concerns with clinicians…” They also argue that clinicians could benefit from some training.
This is a well-argued commentary, and the authors make good points.
Mental health clinicians are often unsettled by the idea of sharing notes. But hospitals and clinics are more and more committed to the concept. Thus, instead of being opposed to sharing notes, a better strategy might be to consider the approach championed by Blease et al.
Selection 3: “Psychotherapy is now in the digital world. Should it ever go back?”
The Globe and Mail, 30 May 2020
‘What would Freud say?’
I ask myself this question regularly right now, as my training as a psychiatrist has been suddenly catapulted into the digital age by COVID-19. I am (for the first time ever) providing mental-health care over the phone and the internet. ‘Seeing’ my patients has taken on a whole new meaning in the era of physical distancing.
As a resident, I have completed hundreds of hours of supervised psychotherapy. Thus far, my training has been rooted in the expectation that the patient will ‘present to clinic’ in person.
So begins an essay by Dr. Sediqzadah.
She argues that there are a few reasons for wanting patients to present “to the clinic,” including compensation and the need for behavioural activation. She also notes the tie to tradition dating back to Freud and the psychoanalysts:
“We are taught that a significant portion of the work in psychotherapy is in analyzing the relationship between the therapist and the patient. In an interaction with a psychiatrist (or, I would argue, any physician), there is both transference and countertransference between patient and service provider. Transference is the redirection of the patient’s feelings about a person in their life (such as a parent) toward the psychiatrist. Countertransference is the psychiatrist’s feelings toward the patient. Analyzing these processes informs and guides our treatment, and the logic is that these dynamics are best played out in person.”
With COVID-19, she has changed her mind. “I am relieved to say that my consults and follow-ups through video conferencing and the phone have gone better than I expected.”
“My views on virtual and phone-based provision of mental-health care have changed significantly during the pandemic. I now see great value in it. Cynics may say that we are venturing too far away from tradition and that it may degrade the quality of psychotherapy over time – but only time will tell. For now, I would point to the evidence: We know that no matter what form psychotherapy takes or how it is provided, it is consistently the therapeutic alliance (the relationship between the therapist and patient) that matters the most. By reaching out to my patients and picking up new cases right now, I am indirectly telling my patients, ‘I am here for you during this difficult time.’ They have been more direct in telling me how much they appreciate having their appointments.”
She concludes: “So perhaps the better question is, should we ever go back entirely to the old way? What’s best for patients will likely be a mix of both old and new.”
This essay is excellent.
Mental health services have been profoundly changed by this pandemic, as telepsychiatry has become the safe alternative to in-person sessions. And so, Dr. Sediqzadah is using a digital platform – and so do many of us across this country.
She makes good points about the shift. And her concluding comments echo the questions raised by Dr. Jay H. Shore in a recent JAMA Psychiatry commentary: “What will the lessons of the COVID-19 pandemic be, in terms of what can vs should be done in person or through telepsychiatry or other technologies? How much virtual care is too much? Is there a virtual saturation point, at which the benefits of a virtual relationship decrease or patients request more in-person interactions?”
I’ll take a moment to congratulate Dr. Sediqzadah and all our other PGY5 resident colleagues on completing their training, and beginning their psychiatry careers.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.