Psychiatry in the COVID-19 Era

This month’s ANZJP depicts the pre-COVID-19 world. Life is very different now, and psychiatric training, practice and research are adapting to a new and rapidly changing environment.

This will be a difficult time for people with chronic mental illnesses. They have high rates of obesity, smoking, diabetes and cardiovascular disease, so are extremely vulnerable to COVID-19. Their network of supports is likely to dwindle. Community organisations that are usually available will most likely be closed. They may have problems accessing medical care and medications, leading to an increased rate of relapse. Several authors in this month’s ANZJP talk about adverse events with clozapine (Siskind et al., this issue; Nakajima et al., this issue; Hirakawa et al., this issue; Saito et al., this issue). In the COVID-19 era, the monthly blood tests and prescriptions for clozapine may be hard to maintain, as services, including primary care, adjust to new ways of working. Reliable provision of other medications is also at risk. Stopping clozapine can be associated with a severe psychotic episode, and cessation of many other medications, including mood stabilisers, antidepressants and benzodiazepines, may also have very negative consequences.

In the general community, there are high levels of fear and anxiety about COVID-19. Many people have lost their jobs and are under financial pressure. They have also lost the structure and social contacts provided by work. Living in isolation will be challenging for those who rely on regular social engagements, family gatherings, and group activities, such as sport or exercise, to maintain their mental health. Most likely there will also be psychiatric sequelae from getting the virus and being ill. Mak et al. (2009) found that one third of 90 survivors of the SARS outbreak in Hong Kong in 2003 had a psychiatric disorder 30 months post-SARS, most commonly PTSD and depression.

The Chinese experience with COVID-19 has highlighted the need for increased online mental health services during the pandemic (Liu et al., 2020). Stepping up these services needs to be properly coordinated, on a national level. Hospital staff are under enormous stress and Chen et al. (2020) provide a helpful blueprint for effectively supporting these workers.

The psychiatric interview and mental state examination are essential to clinical practice. Whilst psychiatrists working in rural and remote services are skilled in video consultations, telepsychiatry has not usually been part of urban practice. Over the last couple of weeks, many more public and private psychiatrists have begun using tele-consultations, by phone or video. This change to remote psychiatric care has taken place very quickly and the effects have yet to be evaluated. Perhaps this will be one of those changes, made in a time of crisis, which alters practice in the long term. Similarly, we will find many meetings that involve participants flying in from interstate or overseas can take place using video conferencing, saving travel, accommodation and catering costs, so perhaps this will be one of the changes that continues after the pandemic has ended.

COVID-19 has had a huge impact on education and research. The Royal Australian and New Zealand College of Psychiatrists Objective Structured Clinical Exam (RANZCP OSCE) and the College Congress have been cancelled. Future exams may need to be delivered online as candidates cannot gather together in a room with an invigilator. The RANZCP has moved quickly to modify training requirements so training can continue despite challenges such as social distancing. Supervised psychotherapy may need to continue by phone or video during periods of social isolation or lock-down.

University campuses and research facilities are closing down and moving to work-from-home, so higher degrees and research involving laboratory work or patient contact have been interrupted indefinitely. Similarly, clinical trials have been abruptly discontinued. Many studies funded by the National Health and Medical Research Council (NHMRC), Australian Research Council (ARC), Medical Research Future Fund (MRFF) and other bodies cannot continue while the pandemic is ongoing and, even when it’s over, research may be slow to recover.

Looking at this month’s ANZJP, most of these studies could not be carried out in the COVID era. Falkov et al. (this issue) describe a brief intervention for families; such interventions would now be delivered remotely. Data collection involving interviews and assessments is no longer possible (Pandey et al., this issue; Zhang et al., this issue). The imaging studies investigating ultra-high risk and early psychosis populations (Park et al., this issue; Cen et al., this issue; Oh et al., this issue) could not take place.

Amongst these many diverse offerings the commentary by Scott Henderson (this issue) stands out. There is a massive amount of data already collected in large studies around the world. In the rush to obtain grants and undertake new studies, the richness of the existing data is often not fully appreciated or utilised. Henderson focusses on the high rates of comorbidity in psychiatric disorders. Plana-Ripoll et al. (2019) used the Danish Psychiatric Central Research Register to investigate comorbidity in almost six million patients. They found that psychiatric comorbidity is pervasive and the risk of developing comorbid disorders persists over time. Given that so much of our research takes place within narrow diagnostic boundaries, comorbidity is generally seen as a potential confound rather than worthy of study in its own right. However, as Henderson notes, comorbidity indicates shared risk architectures, which could include genetic, environmental, and developmental factors. An example would be the numerous disorders resulting from childhood exploitation, described by Pandey et al. (this issue). A focus on comorbidity may lead to new strategies in treatment and prevention.

The world after the COVID-19 pandemic will be very different. It is likely there will be more people in need of psychiatric care. Most research will have taken a forced pause - but maybe some good will come from this as researchers learn new ways of working, and take stock of existing resources. Transitions to telepsychiatry and online learning, whilst rushed and stressful now, may lead to more flexible access to education and to treatment in the long term.