COVID‐19 and psychiatrists’ responsibilities: an update of the WPA position paper

The increased awareness by mental health professionals of the effects of the COVID-19 pandemic and of post-COVID-19 conditions, and of the consequent need for augmenting and increasing access to mental health services, requires an update of the WPA Position Paper on this topic published in this journal in 20201. Most international evidence suggests that the COVID-19 pandemic has generated an increased incidence of mental health problems, especially anxiety and depression2. Elevated symptoms of depression are particularly prevalent among people with low household income, unmarried, and experiencing multiple stressors. Females, adolescents and younger adults are most affected. Poor coping skills, previous trauma exposure, deteriorating physical health, problems in family relationships, and lack of physical exercise are other risk factors. The impact of the pandemic has been greatest for people with serious mental illness, including schizophrenia and other psychotic disorders, bipolar disorder and major depression, with significantly higher rates of COVID-19 infection, hospitalization and death3. The disproportionate impact of the pandemic on people with serious mental illness is likely due to worse pre-existing health and poorer access to medical services. Even in the absence of infection, people with serious mental illness have experienced marked decreases in measures of well-being and mental health during the pandemic4. Overall, suicide rates have not increased or have even declined during the first year of the pandemic5. Nevertheless, increased suicide rates have been reported in certain groups. For example, suicide rates have increased among females and adolescents in Japan, males in India, females in Poland, adolescents in Spain and France, and ethnic minorities in the US5. Detecting at-risk groups requires continuing alertness and improved monitoring strategies, which will permit the development of targeted preventive measures. Health care workers have experienced very high levels of stress, as they were asked to respond rapidly to an unexpected crisis in situations of extreme work pressure. Meta-analyses estimated a 30-40% prevalence of anxiety and depressive symptoms among health care workers during the pandemic6. An even higher prevalence of post-traumatic stress symptoms and sleep disorders has been reported. The pandemic highlighted an already existing need for mental health resources for health care workers, that is now amplified. Effective approaches should address challenges such as the reluctance of health care workers to access psychological support, and the effects of racism and gender inequalities in these professions7. The COVID-19 pandemic has had many effects on family life, including job or income loss, working from home, quarantine, increased workloads, social isolation, food insecurity, school closures, and diminution of social supports, all of which have disproportionately affected marginalized populations8. Children have been among those hardest hit by the psychological impact of the pandemic. Being quarantined at home, facing school closures, virtual learning, masking, witnessing family distress, lack of outdoor activity, isolation from friends, overcrowding, changes in diet, and altered sleep arrangements have taken their toll9. A United Nations Women survey reports that one in four women feels less safe at home, and new and existing conflicts have increased within households since the pandemic started. Physical, psychological and sexual abuse have also increased. Psychiatrists should be alert for and prepared to inquire about family violence and intervene appropriately when needed10. Lingering symptoms following COVID-19 infection have been given various names. The World Health Organization has proposed the following definition: “Post COVID-19 condition occurs in individuals with a history of probable or confirmed SARS-CoV-2 infection, usually 3 months from the onset, with symptoms that last for at least 2 months and cannot be explained by an alternative diagnosis”11. Common symptoms include fatigue, shortness of breath, loss of smell, cognitive dysfunction, anxiety and depression12, 13. They can impact everyday functioning and may fluctuate or relapse over time. As the etiology of psychiatric/psychological symptoms of long COVID-19 remains unknown, psychiatrists should be familiar with strategies known to improve coping, such as self-management, mindfulness meditation, cognitive behavioural therapy, and supportive therapies. The burgeoning number of people needing psychiatric treatment because of the COVID-19 pandemic has strained already inadequate mental health services. Access to mental health care has become more difficult, due to restrictive measures and the shortage of staff and other resources. Digital technologies have offered an immediate solution to continue delivering mental health treatment. Nevertheless, the lack of legal and ethical regulation, standardization and preparation has posed several challenges to the large-scale application of telepsychiatry. Recognition of the opportunity to increase access to mental health care has led the WPA to develop global guidelines for telepsychiatry14. Public health agencies’ commitment to increasing mental health awareness and self-help during the pandemic has also enhanced interest in other digital mental health interventions, such as those based on mobile apps, sensor data, social media, and virtual reality. The integration of these interventions into real-world clinical practice requires ongoing progress15. Even as the pandemic fades, the psychological burdens of long COVID will create new needs for care. Furthermore, the easing of restrictions and the “return to the new normality” will require coping with new sources of stress. Governments, insurers and other funders should support increased resources for mental health services, commensurate with the growth in demand for treatment. Longer-term solutions, including a commitment to augmenting the mental health workforce, are also needed.

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