This is an Accepted Manuscript for BJPsych as part of the Cambridge Coronavirus

Collection. Subject to change during the editing and production process.

Accepted date: 11 Apr 2020

Editorial:

Covid-19 (Coronavirus): Challenges for Psychiatry

Brendan D. Kelly

Summary
Covid-19 (coronavirus) presents two urgent health problems: the illness caused by the virus
itself and the anxiety, panic and psychological problems associated with the pandemic. Both
problems present substantial challenges for our patients, their families, our multi-disciplinary
teams and our psychiatrist colleagues. We need good psychiatry, now more than ever.

Editorial

In late December 2019, a patient in Wuhan Jinyintan Hospital in Hubei province in China
was diagnosed with pneumonia.1 The illness was caused by a novel coronavirus, Covid-19.
By 20 February 2020, there were over 75,000 cases of Covid-19 in China. The median age of
those infected was 51 years, but ranged from just two days to 100 years. Over three quarters
of cases were aged between 30 and 69 years. Just over half were male.
Covid-19 was quick to spread beyond China’s borders. On 11 March, the World Health
Organization (WHO) declared a pandemic. By early April, the WHO reported that there were
1.25 million confirmed cases worldwide and over 69,000 deaths.
It is now clear that Covid-19 presents two major health problems. The first problem is
the illness caused by the virus itself which is usually self-limiting but can be fatal, especially
in the vulnerable, the elderly and people with underlying health conditions. The second
problem is the anxiety and panic that the virus triggers in the minds of virtually everyone who
hears about it. Both problems present substantial challenges to psychiatry.
Regarding the first problem, the illness itself, much of the solution lies in the hands of
public health authorities, the governments that fund them, and citizens all around the world
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who adhere to public health advice about hand washing, coughing etiquette, not touching our
faces, physical distancing and staying at home when advised to do so. These methods work to
reduce community transmission of the virus.
In addition, medical staff around the globe are using established methods of infection
control and treatment that were developed during previous outbreaks and are being adapted to
this new challenge. Ultimately, coronavirus will be controlled, albeit at very considerable
cost to health, mental health and economies around the world.
The physical illness caused by Covid-19 is an urgent concern for psychiatry. We
already know that people with mental illness have a lower life expectancy and poorer
physical health outcomes than the general population.2 This means that our patients appear
less likely to access public health advice about Covid-19, more likely to contract the virus,
and less likely to receive prompt diagnostic and treatment services.
Vulnerable populations are at particular risk: the homeless, people with disabilities, the
chronically ill, prisoners and all who live in institutional settings. People in these groups often
have accumulations of risk factors including poor physical and mental health, impaired
access to services and diminished control over their day-to-day lives.
As a result, there is a clear need for greater focus on providing care to the mentally ill
and other vulnerable groups at this time and a clear need to question any proposed re-
deployment of mental health staff to other duties during the crisis, unless absolutely
necessary.3 Our patients need us now more than ever. This is a mental health emergency as
well as a physical health crisis.
One of the challenges with providing enhanced psychiatric care during the pandemic is
the high risk of infection among psychiatrists and other mental health workers. Careful
awareness of risk, judicious rostering and remote working where possible can help reduce
this risk. This concern applies not only to fully trained psychiatrists and other mental health
professionals, but also to trainees and students, whose education needs to progress as best as
possible in the current, radically altered circumstances. They, too, need our assistance.
Fortunately, the website of the Royal College of Psychiatrists provides excellent information,
advice and support (www.rcpsych.ac.uk). It is important that this continues and that we
support the College’s tireless work on Covid-19.
The second problem with the Covid-19 pandemic is the anxiety, panic and other mental
health issues that are attributable to, or worsened by, Covid-19 among the public, health
professionals, our patients, people with the infection, and their families. Many of these
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problems are understandable in the context of a pandemic, but they still require careful
consideration, accurate diagnosis and active management where necessary.
Among the public, free-floating anxiety can be helped by advising people to manage
their use of media, especially social media, and focus on reliable sources of information, such
as the WHO (www.who.int). This will help combat false information and conspiracy theories
that simply stoke anxiety and cause enormous distress to many. Good diet, exercise and sleep
are also important at times of heightened emotion, along with practices such as mindfulness
and reaching out to others for mutual support.
Ironically, some of the public health measures required to control this infection can
have negative effects on mental health. Quarantine, for example, can be associated with fear
of infection, frustration, boredom and anxiety owing to lack of information.4 There can also
be problems with stigma and finances afterwards. These problems can be mitigated by
terminating these public health measures when they are no longer necessary, providing
adequate information and basic supplies, reducing boredom and improving communication,
using technology where possible. Children require particular attention to maintaining
structure in their day and providing schooling as best as feasible. Children respond to
honesty, practical suggestions (such as hand washing) and their parents setting a good
example.
For people infected with Covid-19, there can be feelings of guilt, anxiety and despair,
compounded by the physical effects of infection (cough, fever, hypoxia) and prolonged
hospital stays. For the families of those affected, there can be feelings of guilt, remorse and
loss. Following bereavement, grief is likely to be complex owing to limits on visiting the sick
or dying in hospitals, uncertainties about the spread of infection, and complications about the
conduct of funerals. In this emotionally charged setting, psychological support is vital both at
the time of death and into the future. The best strategy is to give people the time and space to
rely on their informal networks to cope, but also ensure they know that the door is open to
mental health services if they need them at any point, now or in the future.
Regrettably, there is already evidence that, in China at least, psychological and
psychiatric care have been neglected in the context of Covid-19.5 While this is partially
understandable in the white heat at the epicentre of a pandemic, it would be deeply unwise to
neglect mental health care at this time. Never before has there been greater need for multi-
disciplinary mental health teams, clear communication about psychological supports, and use
of new technologies to provide diagnostic and therapeutic services where and when they are
needed.