<scp>COVID</scp>‐19 and psychiatrists' responsibilities: a <scp>WPA</scp> position paper
Authors: Donna E. Stewart, Paul S. Appelbaum
Journal: World Psychiatry (2020)

The SARS-CoV-2 virus has changed our world, endangering health, lives, social connections and economies1, with the likelihood and consequences of future waves of infection still unknown. In this context, the WPA Standing Committee on Ethics and Review has produced a position paper to provide ethical guidance to the profession on the issues raised by the pandemic2. This essay summarizes and builds on this position paper, adding more recent information. During the COVID-19 pandemic, psychiatrists must continue to care for their patients by all possible means, including telepsychiatry and other forms of virtual care3, 4. Their role, however, goes well beyond primary duties to prevent, diagnose, treat and keep safe individuals with mental disorders1, 3-5. To be effective, psychiatrists must have accurate information about COVID-19 and act accordingly. This includes appropriate knowledge of and adherence to physical distancing, frequent hand washing with soap and water or disinfectant, and proper protocols for masking, face shields and other protective equipment, which may vary over time and jurisdiction. Psychiatrists should also be prepared to debunk myths about the origin of the virus, unproven treatments, potential harms of vaccines, and protective measures. Of course, psychiatrists should safeguard their own health with proper nutrition, sleep, rest and exercise, and promptly seek professional help if they become physically or mentally unwell5. Some health care professionals, working long hours in life-threatening conditions, often without appropriate protective equipment, may develop anxiety, depression, post-traumatic stress disorder (PTSD), insomnia, and excessive irritability and an-ger3, 4, 6. Psychiatrists should assist in developing self-help, group or individual supports or treatments for distressed colleagues and their families. However, they should also support the resilience and pride in their roles experienced by many health care workers during the pandemic. As psychiatrists are physicians, they may volunteer or be redeployed to assume other duties in their institutions or communities, such as working in emergency departments, primary care, internal medicine, critical care or long-term care homes. They may also be called on to support medically ill patients or their families during illness or following bereavement3. This is especially critical as isolation often prevents the usual social supports. As leaders in their hospitals, health care agencies and communities, psychiatrists may also participate in COVID-19 decision-making committees (including triage), where they should safeguard the rights of persons with mental disorders. They may participate in educational and media activities for patients, health care workers, the public or policy makers about the mental health distress caused by physical distancing, home quarantine, shelter-in-place, isolation, and loss of social support, work and income3, 7. Psychiatrists should also advocate for interventions by governments and others to reduce distress and suicide in the general population. Social disadvantage and inability to follow public health advice places individuals with mental disorders at higher risk for COVID-19. In addition to older people, it is now clear that ethnic minorities, malnourished individuals and long-term care home residents, recent migrants and indigenous peoples also face higher risks of COVID-19 and adverse outcomes1. Mortality/morbidity data are missing for people with mental illness, who may not only share the above risk factors, but also be unable or unwilling to protect themselves against COVID-19 due to apathy, depression, paranoia or other psychiatric symptoms. They may also lose their ongoing social and psychiatric supports, including experiencing early discharge from care. Psychiatric inpatients should be screen-ed for COVID-19 symptoms before admission and carefully monitored thereafter3. Protective public health measures such as physical distancing, hand washing and masking should be enforced, and patients who are unable or unwilling to comply should be isolated to protect themselves, staff and other patients. When rates of in-fection in the community are high, inpatient units should prohibit visitors, but virtual visiting should be encouraged. Symptomatic patients should immedi-ately be retested for COVID-19 and, if posi-tive, promptly isolated either in an infection-controlled area of the unit or special unit for infected psychiatric patients or in an intensive care unit4. However, the need for isolation should never imply neglect of human rights, misuse of coercive measures, or disregard of treatment needs. Psychiatric patients should receive appropriate COVID-19 treatments and vaccines without discrimination now and in the future. Outpatients who require as-sess-ment or treatment for mental disorders should be seen virtually where possible but, if they must be seen in person, all public health protocols – including screening prior to visits – should be strictly followed as asymptomatic individuals may also be infected with the virus. It is becoming clearer, as with previous epidemics, that many individuals may experience anxiety, depression, PTSD and other neuropsychiatric disorders during and following COVID-19, whether or not they were infected. Stay-at-home quarantine has been shown to increase child abuse, intimate partner violence, excessive alcohol and drug use, and suicidal-ity1. Psychiatrists should alert policy makers and other authorities of the long-term consequences and likely increase in mental health service demand. Triaging of resources has now become necessary in several jurisdictions, as health care capacity is outstripped by demand. Triage may occur in emergency departments or any clinical unit (including intensive care units) or treatment allocation. The aim of triage is to use scarce resources for individuals most likely to survive, but mental disorders must never be used to exclude patients from medical resources or treatments. Comprehensive triage protocols should be established beforehand by a multidisciplinary expert committee that ranks medical comorbidities without reference to social position, disability, age, and cultural or religious affiliations. All individuals being triaged should be reviewed by this committee to ensure adherence to the protocols and avoidance of improper influence. The WPA position paper concludes: "While variations across countries will exist in responding to the COVID-19 pandemic, the human rights of individuals with mental disorders must be protected, and appropriate and safe services provided for their treatment. Moreover, the negative impact of the pandemic on government budgets should not be used as an excuse to reduce essential services for people with mental illness during or after the pandemic. Psychiatrists can play important roles in advocating for these measures and in supporting their patients, colleagues and the healthcare system's response to the pandemic"2.