A psychiatrist’s experience treating hospitalized patients in New York City during Covid-19
My first memory that something was changing was around March 15th, 2020. This was just a few weeks before New York went into lockdown, but Covid-19 cases were already increasing and causing a lot of illness and beginning to cause deaths as well. I work at both Bellevue Hospital and a VA hospital and remember coming to work in the ER that Sunday and feeling the fear in the air. It was palpable and it was coming from both the patients and the staff.
Outside of the hospital people were not yet wearing masks.
The change struck me the most when I walked into the medical ER entrance and saw that some staff were wearing masks in areas of the hospital where no one ever wore masks. At that time, masks were only used for very specific circumstances and were not readily available, especially not N-95 masks.
The psychiatric ward during the pandemic
As I walked into the psychiatric ward that day, there was that same sense of fear – no one knew what was going on. Even just trying to test people at that time wasn't possible so we did what we could do to screen people by taking their temperature and asking them about their contact with sick people.
People were scared. We were all scared, but we tried to do our best to put aside our fears and focus on treating our patients the best we could throughout the crisis.
A “perfect storm” for psychiatric patients
The coronavirus created a trifecta of challenges for people already struggling with mental health challenges. The body’s immune response often aggravated existing issues. Anxiety around the virus exacerbated mental health challenges. Difficulty connecting with patients while following social distancing protocols and wearing personal protective equipment.
Anxiety around the coronavirus tended to exacerbate mental health challenges
One of the tricky parts of treating people during Covid-19 was this: in general, people often come to the hospital because they are feeling depressed, suicidal, or having increased anxiety. However, once Covid-19 began, once in the hospital, if the patient discovered that they had the coronavirus, their fearful thoughts would increase, which in turn exacerbated their depression and distraught feelings.
I remember one patient in particular, who came to see me because he was feeling depressed and distraught. When he found out he was Covid positive, his degree of fear skyrocketed. He was scared of how this was going to affect his lifespan, if he would get severe symptoms, what would he need to do when he left the hospital, and if he would need to self-isolate.
Fortunately, he didn’t have severe Covid symptoms and he spent enough days in the hospital that when he left he wasn't required to remain in quarantine. In addition to working on the reasons he developed his depression in the first place, part of the treatment was providing him with reassurance and information regarding his Covid symptoms.
Providing information and reassurance for people who tested positive was key for patients who came in for a mental health crisis and discovered they had Covid. Can you imagine the shock of coming to a hospital for depression and then being told you have a disease that no one knows much about?
Covid-19 infection can exacerbate mental health symptoms
For outpatients who tested positive for Covid, getting accurate information was also crucial in their mental health treatment plan. Inflammation and other immune responses that occur following Covid can make underlying symptoms worse. ADHD symptoms, for example, tended to increase with Covid.
As part of the care, I might suggest interventions they could do at home to manage their mental health challenges, in addition to providing a referral to an infectious disease specialist and to specfic medical support they might need to address the virus.
Social distancing and protection protocols can interfere with treatment
It was very bizarre and posed quite a challenge to treat patients while suited up in a gown, gloves, an N-95 mask, and either goggles or a face shield. It’s more than a little off-putting, especially when the patient is coming in for psychiatric treatment rather than medical attention.
A mental status examination (MSE) is a routine assessment of psychiatric patients. The MSE relies on appearance, behavior, and mannerisms to help assess an individual's state of mind. For example, avoiding eye contact may suggest a degree of anxiety. PPE can make it more difficult to observe facial expressions and create eye contact.
In medical school and when I was a resident, I was fitted for an N-95 mask for protection against tuberculosis. I remember thinking that I probably would never need this and if I did, it would be an exceedingly rare situation (such as where someone was hospitalized for tuberculosis and became depressed). So I knew what the mask was but I never imagined I would ever have to use this kind of protection on a daily basis to see my patients.
PPE can make it more difficult to establish rapport with patients. Important non-verbal cues, such as the patient noticing the clinician's empathy and non-judgment by facial expressions and tone of voice, can be obstructed when I wear a facemask. Blocking the clinician's facial expressions has been shown to increase fear and paranoia in certain individuals.
Since the garb was quite alarming for many patients, I started every session by introducing myself and letting the patient know that seeing me in this suit can be a bit upsetting. We talked about that in the beginning and went on from there. Having to treat patients under such odd circumstances forced me to creatively adapt the way I engage with them, despite having a literal physical barrier between us. It pushed me to communicate more consciously using my body language, gestures, and tone of voice.
Four positive takeaways from the pandemic for this psychiatrist
Although I wouldn’t wish this year back, when there are such extreme shifts in the world, individually and globally, it forces change. There are some silver linings that came from this year.
One is that many people started seeking ongoing treatment for their mental health struggles. Some of the patients that came to the hospital were not getting regular mental health treatment in the community before they came to the hospital. The pandemic tipped them into a crisis but facing the crisis underscored the need for the patient (and for all of us) to be proactive and seek regular maintenance and treatment of mental health challenges.
A second silver lining emerged for patients that came to the hospital for a mental health challenge and then were diagnosed as Covid positive. The experience of being isolated and needing treatment for mental health problems brought to the forefront the need to continue treatment even after leaving the hospital. Many of these patients have become more engaged in preventive treatment and ongoing care.
Paradoxically, a third silver lining is that Covid made psychiatric problems worse for many people (either directly through infection or indirectly through loss of coping mechanisms and isolation). Many of these patients were suffering difficult symptoms for long periods without getting help. The pandemic brought some people in for psychiatric treatment that might have otherwise just tried to put up with their symptoms. A lot of these patients have continued ongoing maintenance treatment. They got scared after being in the hospital and realized they need to take care of themselves in a more consistent way and not wait for an emergency – and they are generally doing better.
The fourth silver lining is the increased acceptability of video visits. Patients that may have missed appointments or had trouble physically getting to the clinic or the hospital can now attend appointments from home. While there is something that’s lost via video, and some people still prefer coming in person, overall video appointments have made it easier and more convenient for people to schedule an appointment and actually show up.
As the spread and effects of Covid slow, I hope that we can continue to provide much-needed support to heal from the trauma of this pandemic last year but to build healthier and stronger communities for generations to come.