|Year : 2021 | Volume
| Issue : 1 | Page : 1-3
COVID-19 and Psychopharmacology: Critical Issues
Avinash De Sousa1, E Mohandas2, Afzal Javed3
1 Department of Psychiatry, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
2 Sun Medical and Research Centre, Trichur, Kerala, India
3 Pakistan Psychiatric Research Centre, Lahore, Pakistan
|Date of Submission||10-May-2021|
|Date of Decision||10-May-2021|
|Date of Acceptance||12-May-2021|
|Date of Web Publication||18-Jun-2021|
Dr. Avinash De Sousa
Carmel, 18, St. Francis Road, Off SV Road, Santacruz West, Mumbai - 400 054, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sousa AD, Mohandas E, Javed A. COVID-19 and Psychopharmacology: Critical Issues. Ann Indian Psychiatry 2021;5:1-3
The emergence of the COVID-19 pandemic has resulted in new challenges for psychiatrists and mental health professionals. There are many instances where the psychiatrist shall be brought into manage COVID-19 professionals and there are intersections between psychiatry and COVID-19 where psychopharmacology and the agents used in the management of COVID-19 would have to be prescribed together. There are several critical issues that need to be considered when one considers the role of psychopharmacology in COVID-19 patients. The current editorial aims to highlight some of these issues from a psychiatric standpoint.
| Intersection of Psychopharmacology and COVID-19|| |
There are many situations where we may have an intersection of psychiatry, psychopharmacology, and COVID-19. These include:
- There may be patients with psychiatric diagnoses who are already maintained on psychiatric medication and then contract the COVID infection
- There may be patients that develop COVID and consequently need psychiatric treatment due to psychiatric issues that develop in COVID and post-COVID
- There may be patient that develop COVID and are in an intensive care unit and may get aggressive and violent and need psychiatric help or may develop delirium that may need psychiatric intervention
- There may be patients with dementia that develop COVID and may need management of behavioral and psychological symptoms in dementia with the management of COVID
- There may be patients with psychiatric disorders and comorbid medical conditions where we may have intersection of psychiatric management, non-COVID medical management, and the management of COVID
- There may be patients who develop psychiatric side effects of medications that are used in the management of COVID.
| Psychopharmacological Clinical Situations that May Arise|| |
One of the major issues that confound us is the lack of clinical studies of psychopharmacological agents in patients with COVID. There are number of specific psychopharmacological situations that may arise in patients with COVID and concomitant psychiatric medication. These situations are as follows:
- The need to prescribe antipsychotics in the management of delirium or psychosis that arises in patients with COVID in an intensive care and ward setting where there will be a choice to be made as to whether typical antipsychotics such as haloperidol or whether atypical antipsychotics should be prescribed. Even with the atypical antipsychotics, a choice between risperidone and olanzapine would have to be made. The role of quetiapine or amisulpride and weighing of the pros and cons and side effect of every drug would have to be considered and the decision would be based on a large number of clinical and medical factors
- There would be patients who are suffering from schizophrenia for many years and are well maintained on clozapine and doing very well and are rather symptom free. They then develop COVID infection and the issue and the need to reduce the dose of clozapine or removing the drug due to the ensuing agranulocytosis and neutropenia as well as the chances of it precipitating seizures. The decision to withdraw clozapine in a patient that is maintained is always a tough and a harsh one for both the patient and the clinician
- There are many patients with bipolar disorder that may well maintained on lithium and with the contracting of COVID, there may be need to reduce the dose of lithium or withdraw the drug due to its effects on electrolytes and renal function. There may also be side effects such as lithium-induced tremors and renal dysfunction that may be accentuated by COVID infection and the reduction and removal of lithium shall lead to a relapse of the bipolar disorder which shall cause further complications to the patient with COVID
- There are many patients with anxiety disorders and panic disorder that are well maintained on benzodiazepines such as clonazepam and alprazolam. Benzodiazepine usage may have to be restricted in patients with COVID due to their effects on respiratory depression. The choice to continue or withdraw these drugs would depend on factors such as lung infection, respiratory distress, presence of lung pathology, and levels of oxygen saturation. There is also a chance of sedation which would hamper the patient expressing what symptoms he is going through and may also alter sensorium coupled with fever and COVID infection. The choice of benzodiazepine would have to be clinical and prudent and there would also be a need for understanding that many patients feel secure that would not have panic attacks as they are on the medication. The stoppage of the same would either provoke rebound panic attacks or evoke anxiety of getting a panic attack. Substitution with the right benzodiazepine would be necessary in most cases
- One may also need to have a detailed of the cytochrome P450 system and the drug–drug interactions that may arise as a result of the effects on drug levels and metabolism and this would help both the COVID team and the psychiatrist to adjust drug dosages in view of drug–drug interactions
- There is also a need for COVID treating doctors to have a psychiatrist on their team as there are many psychiatric side effects that may be due to COVID medication that may need to be attended to and there may psychiatric patients with emergent symptoms that may arise due to both the presence and diagnosis of COVID.
| Emerging Data on Antidepressants and COVID-19|| |
There is an emerging data that there is some of role of antidepressants in the management of COVID as it has been observed that patients with COVID on antidepressant treatment do not suffer from the effects of the cytokine storm in COVID. This may be due to the effects of selective serotonin reuptake inhibitors (SSRIs) on interleukin-6 (IL-6) and thereby helping in ameliorating high levels of cytokine that may be caused by COVID. There are recent reports of the role of fluvoxamine in managing COVID, but the reports are still in the preliminary stage and further confirmatory evidence is awaited. Among the SSRIs, sertraline is the preferred drug compared to fluoxetine and citalopram or escitalopram. There may be a need to reduce the dosage of tricyclic antidepressants due to their side effect profile and also due to the fact that may interact with various COVID agents. There is a need to be cautious when using bupropion in patients with COVID, especially with regard to its drug interactions with protease inhibitors and the seizure risk.
| Some General Points|| |
In general, across systematic reviews and meta-analyses, it has been found that almost all classes of psychotropic agents have some minor yet relevant safety issues when prescribed in patients suffering from COVID-19. The risk benefit analysis and clinical profile of the patient along with the individual properties of the molecule concerned have to be assessed on a case-by-case basis and data are unavailable in many cases. There is also a need for reporting new side effects that may be seen and discussing clinical dilemmas for the benefit for all. The side effect profile and presence of side effects may vary from patient to patient making it difficult to make rules in a one size fitting all mode. There are also a number of medical and psychosocial risk factors that shall have to be weighed. We cannot let either illness, i.e. COVID or the psychiatric illness suffer. It is clinically vexing to suggest recommendations based on single case observations or on a medication basis. There is an overlap of medical issues such as respiratory function being impaired by an additive effect of the sedative effect of medications as well as the risk of respiratory infections. It is also prudent that these are discussed with caregivers and they must be psychoeducated along with a brief training in psychotropics for the COVID unit medical and nursing staff. The multifactorial hepatic and kidney damage seen in patients with COVID-19 need close hepatic and renal function monitoring. Drugs that are possibly hepatotoxic such as sodium valproate, carbamazepine, and tricyclic antidepressants as well and nephrotoxic drugs such as lithium must be judiciously used. There is a need for hepatic monitoring as most psychotropic agents undergo first pass metabolism in the liver and are also extensively metabolized through the liver. Some other drugs such as gabapentin, topiramate, pregabalin, and paliperidone are eliminated through the renal pathway and must be used based on what system in a patient is more or less compromised. One must not hesitate to withdraw a drug if needed as management and recovery from COVID is far more paramount than managing psychiatric symptomatology that can always be managed in the post-COVID phase. In conclusion, physicians need to be vigilant when prescribing psychopharmacological agents in patients receiving medical attention for COVID-19 and when using medical drugs for COVID-19 in patients under long-term psychopharmacological treatment, one also needs to be careful as many treatments being used are new and experimental with debatable efficacies while their effects and psychiatric side effects are itself under-studied.
| References|| |
Luykx JJ, van Veen SM, Risselada A, Naarding P, Tijdink JK, Vinkers CH. Safe and informed prescribing of psychotropic medication during the COVID-19 pandemic. Br J Psychiatry 2020;217:471-4.
Javed A, Mohandas E, De Sousa A. The interface of psychiatry and COVID-19: Challenges for management of psychiatric patients. Pak J Med Sci 2020;36:1133-6.
Hoertel N, Sánchez-Rico M, Vernet R, Jannot AS, Neuraz A, Blanco C, et al.
Observational study of haloperidol in hospitalized patients with COVID-19. PLoS One 2021;16:e0247122.
Siskind D, Honer WG, Clark S, Correll CU, Hasan A, Howes O, et al
. Consensus statement on the use of clozapine during the COVID-19 pandemic. J Psychiatr Neurosci 2020;45:222-3.
Rajkumar RP. Lithium as a candidate treatment for COVID-19: Promises and pitfalls. Drug Developm Res 2020;81:782-5.
Bilbul M, Paparone P, Kim AM, Mutalik S, Ernst CL. Psychopharmacology of COVID-19. Psychosomatics 2020;61:411-27.
El-Ghiaty MA, Shoieb SM, El-Kadi AO. Cytochrome P450-mediated drug interactions in COVID-19 patients: Current findings and possible mechanisms. Med Hypotheses 2020;144:110033.
Armitage R. Antidepressants, primary care, and adult mental health services in England during COVID-19. Lancet Psychiatry 2021;8:e3.
Gatti M, De Ponti F, Pea F. Clinically significant drug interactions between psychotropic agents and repurposed COVID-19 therapies. CNS Drugs 2021;35:345-84.
De Sousa A, Mohandas E, Javed A. Psychological interventions during COVID-19: Challenges for low and middle income countries. Asian J Psychiatr 2020;51:102128.