Oliver Freudenreich, MD, FACLP Co-Director, MGH Schizophrenia Clinical and Research Program Associate Professor of Psychiatry Massachusetts General Hospital Harvard Medical School Boston, Massachusetts
Nicholas Kontos, MD, FACLP Director, Fellowship in Consultation-Liaison Psychiatry Assistant Professor of Psychiatry Massachusetts General Hospital Harvard Medical School Boston, Massachusetts
John Querques, MD Vice Chairman for Hospital Services Department of Psychiatry Tufts Medical Center Associate Professor of Psychiatry Tufts University School of Medicine Boston, Massachusetts
Disclosures Dr. Freudenreich has received grant or research support from Alkermes, Avanir, Janssen, and Otsuka, and has served as a consultant to American Psychiatric Association, Alkermes, Janssen, Neurocrine, Novartis, and Roche. Dr. Kontos and Dr. Querques report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
Caregivers are always important to SMI patients, but they may assume an even bigger role during this pandemic. Some patients may have moved in with a relative, after years of living on their own. In other cases, stable caregiver relationships may be disrupted due to COVID-19–related sickness in the caregiver; if not addressed, this can result in a patient’s clinical decompensation. Clinicians should take the opportunity to understand who a patient’s caregivers are (group home staff, families) and rekindle clinical contact with them. Relationships with caregivers that may have been on “autopilot” during normal times are opportunities for welcome support and guidance, to the benefit of both patients and caregivers.
Table 1 summarizes clinical tasks that need to be kept in mind when conducting clinic visits during COVID-19 in order to achieve the high-priority treatment goals of infection control, relapse prevention, and psychosocial support.
Differential diagnosis.Neuropsychiatric syndromes have long been observed in influenza pandemics,23 due both to direct viral effects and to the effects of critical illness on the brain. Two core symptoms of COVID-19—anosmia and ageusia—suggest that COVID-19 can directly affect the brain. While neurologic manifestations are common,24 it remains unclear to what extent COVID-19 can directly “cause” psychiatric symptoms, or if such symptoms are the result of cytokines25 or other medical processes (eg, thromboembolism).26 Psychosis due to COVID-19 may, in some cases, represent a stress-related brief psychotic disorder.27
Hospitalized patients who have recovered from COVID-19 may have experienced prolonged sedation and severe delirium in an ICU.28 Complications such as posttraumatic stress disorder,29 hypoperfusion-related brain injuries, or other long-term cognitive difficulties may result. In previous flu epidemics, patients developed serious neurologic complications such as post-encephalitic Parkinson’s disease.30
Any person subjected to isolation or quarantine is at risk for psychiatric complications.31 Patients with SMI who live in group homes may be particularly susceptible to new rules, including no-visitor policies.
Continue to: Outpatients whose primary disorder...
