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      COVID-19-negative psychiatric units: Mitigating sequelae of pandemic isolation

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      a , * , a , b
      General Hospital Psychiatry
      Elsevier Inc.

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          Abstract

          Research Letter to the Editor: We are writing to call attention to the profound psychological/physiological stress caused by the ongoing coronavirus disease 2019 (COVID-19) pandemic. As second waves are on the rise, U.S. total death rates related to COVID-19 are greater than 270,000, and above 1.5 million worldwide [1]. While public health guidelines continue to advise social distancing to prevent further spread of the virus, this very distancing increases pandemic-induced isolation, fear of infection, and fear of death [[2], [3], [4], [5], [6], [7], [8]]. Extended periods of social isolation have led to disruption of daily routines, separation from loved ones, and perceived loss of autonomy. The subsequent distress has been labeled a “parallel epidemic,” [8] and an unprecedented “shock to humanity's fabric,” [7] rife with anxiety, depression, post-traumatic stress symptoms, and suicidal ideations [[2], [3], [4], [5], [6], [7], [8]]. Although medical literature has focused on COVID-19-positive individuals, there has been sparse discussion regarding COVID-19-negative individuals, specifically in the inpatient psychiatric setting. While the effects of isolation for COVID-infected patients are devastating, COVID-negative patients, too, require consideration regarding access to treatment. Given the decrease of in-person outpatient treatment, patients may be lost to follow up, leading to psychiatric decompensation requiring hospital admission [7]. We propose four different practices, indications, and key features (Table 1 ), through which we encourage COVID-19-negative psychiatric units to implement social support, trauma-guided principles, review of current events, and psychoeducation on telemedicine. The unique setting of COVID-negative psychiatric units may serve as a way to mitigate pandemic-associated psychopathology during a time of crisis, and help prepare patients for outpatient follow up care in the ongoing uncertainty of the COVID-19 pandemic. Table 1 Recommendations for COVID-19-negative psychiatric units. Table 1 Recommendations for COVID-19-negative psychiatric units: mitigating sequelae of pandemic isolation Practice Indication Key features Socially distanced support Social support is a protective factor • Frequent COVID-19 symptom screening & masks required for patients & staff • Group dining w/ physically-distanced seating • More patient group times (eg. AM / PM groups) to allow for maximum participation with physical distancing Trauma-guided principles COVID-19 pandemic may be experienced as a trauma • Directly ask patients about COVID-19-related loss • Psychoeducation on adaptive coping mechanisms • Trauma-focused therapy: exposure-based, cognitive restructuring ⟶ reduce post-traumatic stress severity COVID-19 current events groups Plethora of COVID-19 pandemic (mis)information • Facilitate structured groups to discuss & synthesize COVID-19 news • Review pathophysiology basics & public health guidelines • Address ethnic, racial, socioeconomic disparities of COVID-19 Link to virtual support Patients may be ambivalent about telehealth • Education about benefits of telemedicine • Technical assistance w/ virtual resources • Tablets/computers w/ HIPAA-compliant video capabilities for family meetings/visits 1 Socially-distanced support From community dining, to group therapy, and milieu intermingling, psychiatric units foster socialization, which mediates negative effects of isolation. However, COVID-negative units must cultivate socially-distanced support in accordance with current public health guidelines. Patients and staff should wear masks, adhere to hand hygiene, and undergo frequent COVID-19 symptom screening [9]. Patients should be placed in single rather than shared bedrooms whenever possible. Meanwhile, patient groups, which are a vital component of inpatient treatment, should be continued. Physical distancing can be maintained by limiting group attendance, or double-scheduling, to allow different patients to attend on different days/times. Group dining, in lieu of patients eating alone in their rooms, can continue by staggering meal times, and urging masks-on immediately whenever not eating/drinking. We acknowledge that group settings during a pandemic, and hospitalization itself, are not zero-risk. However, if risk is minimized with masks, physically-distanced seating, and symptom screening, we argue the benefits of socialization on COVID-negative units outweigh the risks of isolation, which may have precipitated psychiatric decompensation leading to admission in the first place. 2 Trauma-guided principles The COVID-19 pandemic and the “parallel epidemic” of psychological stress may be experienced as a trauma, especially for patients with pre-existing psychiatric comorbidities. In the face of trauma, patients may develop maladaptive coping mechanisms such as increased substance use, and may be at increased risk for self-harm [3]. Providers should be attuned to pandemic-related trauma, and should directly ask patients about their exposure and/or loss related to COVID-19. Trauma-focused therapy, which uses exposure-based interventions and cognitive restructuring, may be effective in reducing post-traumatic stress, especially if used as an early intervention [3]. Inpatient units can utilize trauma-guided principles in individual therapy and in dedicated groups. 3 COVID-19 current events groups The influx of information from public health authorities, news broadcasting, and social media, is in itself a significant stressor, especially for individuals with serious mental illness [4,5]. Patients would benefit from current events groups to review COVID-19 basics including symptoms, spread and prevention, and public health guidelines. Ethnic, racial, and socioeconomic disparities of COVID-19 should also be addressed. These groups would provide patients the opportunity to ask questions and correct potential misconceptions about the COVID-19 pandemic. 4 Link to virtual support In the COVID-19 era of social distancing, virtual communication is critical, and telemedicine has become an indispensable method of care. Given strict limitations on hospital visitors [4], HIPAA-compliant video devices should be available to patients for virtual visits with loved ones and for family meetings, often a crucial component of discharge planning. Furthermore, regarding telemedicine, we have heard numerous patients say, “that's not my thing.” Providers should prepare patients for the reality of virtual treatment during the pandemic and potentially beyond. By working through and addressing ambivalence about telemedicine, individuals who might otherwise be lost to follow up in the absence of in-person appointments may more readily pursue care through telehealth after discharge. As governments and healthcare systems navigate the impact of this unprecedented pandemic, epidemiological research and evaluation of mental health interventions are essential for patients and their providers, whose relationships will continue by necessity to exist, even and especially in the face of pandemics as devastating as COVID-19. Declaration of Competing Interest None.

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          Most cited references9

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          The psychological impact of quarantine and how to reduce it: rapid review of the evidence

          Summary The December, 2019 coronavirus disease outbreak has seen many countries ask people who have potentially come into contact with the infection to isolate themselves at home or in a dedicated quarantine facility. Decisions on how to apply quarantine should be based on the best available evidence. We did a Review of the psychological impact of quarantine using three electronic databases. Of 3166 papers found, 24 are included in this Review. Most reviewed studies reported negative psychological effects including post-traumatic stress symptoms, confusion, and anger. Stressors included longer quarantine duration, infection fears, frustration, boredom, inadequate supplies, inadequate information, financial loss, and stigma. Some researchers have suggested long-lasting effects. In situations where quarantine is deemed necessary, officials should quarantine individuals for no longer than required, provide clear rationale for quarantine and information about protocols, and ensure sufficient supplies are provided. Appeals to altruism by reminding the public about the benefits of quarantine to wider society can be favourable.
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            How mental health care should change as a consequence of the COVID-19 pandemic

            Summary The unpredictability and uncertainty of the COVID-19 pandemic; the associated lockdowns, physical distancing, and other containment strategies; and the resulting economic breakdown could increase the risk of mental health problems and exacerbate health inequalities. Preliminary findings suggest adverse mental health effects in previously healthy people and especially in people with pre-existing mental health disorders. Despite the heterogeneity of worldwide health systems, efforts have been made to adapt the delivery of mental health care to the demands of COVID-19. Mental health concerns have been addressed via the public mental health response and by adapting mental health services, mostly focusing on infection control, modifying access to diagnosis and treatment, ensuring continuity of care for mental health service users, and paying attention to new cases of mental ill health and populations at high risk of mental health problems. Sustainable adaptations of delivery systems for mental health care should be developed by experts, clinicians, and service users, and should be specifically designed to mitigate disparities in health-care provision. Thorough and continuous assessment of health and service-use outcomes in mental health clinical practice will be crucial for defining which practices should be further developed and which discontinued. For this Position Paper, an international group of clinicians, mental health experts, and users of mental health services has come together to reflect on the challenges for mental health that COVID-19 poses. The interconnectedness of the world made society vulnerable to this infection, but it also provides the infrastructure to address previous system failings by disseminating good practices that can result in sustained, efficient, and equitable delivery of mental health-care delivery. Thus, the COVID-19 pandemic could be an opportunity to improve mental health services.
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              The psychological impact of COVID-19 on the mental health in the general population

              Abstract As a result of the emergence of coronavirus disease 2019 (COVID-19) outbreak caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in the Chinese city of Wuhan, a situation of socio-economic crisis and profound psychological distress rapidly occurred worldwide. Various psychological problems and important consequences in terms of mental health including stress, anxiety, depression, frustration, uncertainty during COVID-19 outbreak emerged progressively. This work aimed to comprehensively review the current literature about the impact of COVID-19 infection on the mental health in the general population. The psychological impact of quarantine related to COVID-19 infection has been additionally documented together with the most relevant psychological reactions in the general population related to COVID-19 outbreak. The role of risk and protective factors against the potential to develop psychiatric disorders in vulnerable individuals has been addressed as well. The main implications of the present findings have been discussed.
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                Author and article information

                Journal
                Gen Hosp Psychiatry
                Gen Hosp Psychiatry
                General Hospital Psychiatry
                Elsevier Inc.
                0163-8343
                1873-7714
                14 December 2020
                January-February 2021
                14 December 2020
                : 68
                : 100-101
                Affiliations
                [a ]New York University School of Medicine, 550 First Ave., New York, NY 10016, USA
                [b ]New York Harbor Veteran Affairs Hospital, 423 East 23rd St., New York, NY 10010, USA
                Author notes
                [* ]Corresponding author.
                Article
                S0163-8343(20)30170-5
                10.1016/j.genhosppsych.2020.12.002
                7834021
                33349463
                90c4e0c9-d184-4a79-8d59-c8b61b910b20
                © 2020 Elsevier Inc. All rights reserved.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

                History
                : 19 November 2020
                : 4 December 2020
                : 8 December 2020
                Categories
                Letter to the Editor

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