|Ahead of print publication
Managing a COVID-positive health-care worker with recent suicide attempt through telepsychiatry
Chandrima Naskar, Sandeep Grover, Swapnajeet Sahoo, Aseem Mehra
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||10-Jan-2021|
|Date of Decision||13-Jan-2021|
|Date of Acceptance||18-Jun-2021|
|Date of Web Publication||15-Mar-2021|
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
COVID-19 pandemic has emerged as a major problem for the health-care workers (HCWs). Many HCWs are facing adverse psychological outcomes, during the COVID pandemic. HCWs are not only expected to carry out duties in COVID areas but are also expected to stay in isolation during the period of quarantine. Various models have been proposed to address the psychological issues in HCWs using telepsychiatry. However, there are no clear-cut guidelines, for managing people with suicidal behavior. In this report we present a HCW, diagnosed with recurrent depressive disorder, current episode severe depression without psychotic symptoms, who attempted self-harm and was shortly diagnosed with COVID-19 infection leading her to getting admitted in the COVID-19 ward. She was managed with supportive psychotherapy during her COVID ward stay through telepsychiatry. We discuss the challenges faced and how these were handled.
Keywords: COVD-19, depression, health-care worker, telepsychiatry
|How to cite this URL:|
Naskar C, Grover S, Sahoo S, Mehra A. Managing a COVID-positive health-care worker with recent suicide attempt through telepsychiatry. Ann Indian Psychiatry [Epub ahead of print] [cited 2021 Apr 20]. Available from: https://www.anip.co.in/preprintarticle.asp?id=311206
| Introduction|| |
COVID-19 pandemic has emerged as a major psychological stressor for humankind, more so for the health-care workers (HCWs)., Available data suggest that there is an increase in the number of completed suicides and suicidal behavior during the ongoing pandemic,, including completed suicide among those admitted in COVID wards., There are reports of completed suicides in HCWs too during the ongoing pandemic. In the absence of regular outpatient psychiatric services, management of suicidal behavior has become more challenging.
Ongoing pandemic has led to expansion of telepsychiatry services,, due to notification of telemedicine guidelines by the Government of India. However, these guidelines are silent about management of suicidal behavior while practicing telepsychiatry. In general, it is recommended that patients with suicidal behavior are requested to attend the nearest health-care facility in a person. No information is available about management of a suicidal patient with telepsychiatry intervention, although there is some information about telephone-based psychosocial interventions, in managing people after suicide attempt. In this background, we present the case of a HCW, who attempted suicide and was shortly diagnosed with COVID-19 and resultantly admitted to the COVID-19 ward, and managed with telepsychiatry intervention, throughout her COVID ward stay. We also discuss the ethical aspects and the challenges faced while managing such a person.
| Case Report|| |
Ms. X, 27 years old, a HCW, diagnosed with recurrent depressive disorder and maintaining well for a period of about 6 months, on tablet escitalopram 15 mg/day, presented with a self-harm attempt, with overdose of medications. Exploration of history revealed that recently she had completed her COVID-19 ward duties and this was followed by a period of quarantine for 1 week. During the period of quarantine, she started to have relapse of depressive symptoms in the form of irritability, sadness of mood, anhedonia, lethargy, low self-esteem, hopelessness, ideas of self-harm, and disturbed biofunctions. These symptoms continued even after the end of quarantine, and she was not able to perform her duties. She started having repeated thoughts about suicide and would search on the Internet for various means of painless and definite methods of ending her own life. In her follow-up, tablet escitalopram was increased to 20 mg/day and supportive psychotherapy sessions were started, but her symptoms persisted. One day, she took 30–60 ml of wine to overcome her low mood, but under the influence of this, she felt disinhibited and consumed 20 tablets of tablet escitalopram 20 mg, with intent to end her life. She did not feel any distress in the following 1 h, but while having dinner, she disclosed about the same to her colleagues. She was brought to the emergency, gastric lavage was done, and she was given intravenous fluids. Investigations in the form of hemogram, serum electrolytes, renal function test, liver function test, coagulation profile, and electrocardiogram were found to be in the normal range. After the initial stabilization, she was seen by the psychiatry team and was considered for inpatient stay, in view of the diagnosis of recurrent depressive disorder, current episode being that of severe depression without psychotic symptoms. A verbal no-suicidal contract was executed and supportive sessions were started. Her colleagues were asked to supervise her, and the family was contacted. Unfortunately, 3 days after the self-harm attempt, her colleague with whom she was sharing her accommodation tested positive for COVID-19 and had to be shifted to COVID ward. The patient was considered to be a high-risk contact and advised to quarantine herself at home. In view of the suicidal risk, it was decided to shift the patient to the quarantine area in the hospital for observation and intervention. Although she had to be kept alone in a single room accommodation, it was ensured by the nursing staff that no sharp object/poisonous chemicals/ropes, etc., were there in the reach of the patient. Furthermore, she was provided with medicines for only 1–2 days at a time to minimize the risk of self-harm. While in the quarantine, she was managed with twice daily sessions through video conferencing. In addition, her colleagues, with whom she was close to, were also encouraged to be in contact with her. She was restarted on tablet escitalopram, and tablet clonazepam was added to manage the associated anxiety and insomnia. She underwent COVID testing, and while waiting for the results, she was monitored through video conferencing for the self-harm and was also prepared for being admitted to the COVID ward, in case she was found to be positive. Next day, she was found positive for COVID-19; she did not react adversely and was shifted to the COVID ward of the hospital. During her COVID ward stay, she was monitored through the video conferencing by the same treating team, with psychiatry resident in the COVID ward remaining as a standby in case of any emergency care. She could not be handed over for the clinical management to the COVID ward mental health team, as she wanted us to maintain confidentiality and did not want to disclose about her mental health issues to others. It was mutually agreed upon that we would be able to maintain the confidentiality, if she would not indulge in self-harm behavior. She was not given a single room, rather was made to share the room in the COVID ward with her colleague, with whom she was sharing her accommodation and had tested positive before patient being found positive.
In addition to the primary psychiatry team monitoring her, her close contacts were also encouraged to keep in touch telephonically and/or video conferencing. Throughout her stay of 1 week in the COVID ward, supportive sessions were continued by video conferencing. During the supportive sessions, ongoing stressors were discussed. Along with this, escitalopram 20 mg/day and tablet clonazepam 0.5 mg/day were continued. Mood charting and antecedent-consequence analysis for her periods of low mood with increased death wishes was started. During the sessions, she could identify that she would feel worst whenever she would not follow a daily routine and when she would remain without any specific work to complete. Thus, an activity schedule to keep her engaged throughout the day and a fixed sleep-wake cycle was planned. She was also monitored for symptoms of COVID-19. After 1 week of stay in the COVID ward stay, she was shifted to home for quarantine for another 1 week and supportive sessions were continued through video conferencing. She gradually improved and her suicidal ideations reduced in frequency and intensity. Later, her family members were also involved in the treatment through video conferencing, during which they were provided brief overview of her conditions without breaching patient's confidentiality. After completion of her home quarantine, she was allowed to go and meet her family members, and during her home stay, video conferencing sessions were continued. She resumed work after 1 week of home stay and has been maintaining well.
Throughout the treatment, during the video conferencing sessions, mood, depressive cognitions, and suicidal ideations were monitored closely. She was encouraged to contact the treating team, in case of any emergency, especially if there is intensification of suicidal ideations. Precautions were taken that the patient was assessable and reachable in-person, if she was not contactable telephonically because of any reason and all other contacts were told to contact the treating team in case of any perceived emergency. It was also ensured that the patient was at the reported address every time.
| Discussion|| |
This case description demonstrates successful management of a patient through video conferencing who recently attempted self-harm, and developed COVID-19 infection, which limited the in-person contact with the patient.
Suicidal behavior is a psychiatry emergency, which requires immediate clinical attention. Ideally, such patients should be monitored in-person, ideally in an inpatient setting, especially after suicide attempt. However, ongoing pandemic has led to a crisis for such patients, especially in places, which do not have special COVID ward for psychiatric patients. In such a situation, patients with suicidal behavior and ongoing psychiatric symptoms are admitted to the COVID ward with patients with other ailments. Although mental health professionals are posted in such a ward, patients with psychiatric illness, find it difficult to disclose their mental health issues and usually end up suffering or come to the clinical attention, when they face a crisis. In certain centers in the United States, in view of COVID-19, special wards have been started for persons with mental illnesses, who have COVID-19 infection, but are medically stable.
In the index case, we thought of admitting her in psychiatry ward, but before that decision could be executed, she was found to be a high-risk contact and later was found to be COVID positive. These situations left us with no choice but to continue crisis intervention and supportive sessions through video conferencing. In contrast to the existing data, which provides information about managing the patients with suicide attempt with telephone-based, psychosocial interventions, we carried out the intervention using telepsychiatry (video conferencing) services.
We faced multiple challenges while managing the patient. These included, not being able to admit her in the psychiatry ward, send the patient to her parental house due to the travel restrictions and COVID-19 infection in the patient. The various factors [Table 1], which made the management challenging and also successful, were ensuring regular contact, having a verbal no-suicide contract, encouraging the patient to contact the treating team at any time in case of emergency, maintaining liaison with the mental health team in the COVID ward, maintained liaison with her colleagues and the family, and maintained confidentiality of the information. We were fortunate about the successful outcome. This outcome was possible because of the cooperation of the patient and a good therapeutic alliance with the patient.
|Table 1: Factors playing a role in adequate management of a patient with risk of self-harm during COVID-19 pandemic|
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Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Spoorthy MS, Pratapa SK, Mahant S. Mental health problems faced by healthcare workers due to the COVID-19 pandemic-A review. Asian J Psychiatr 2020;51:102119.
Wilson W, Raj JP, Rao S, Ghiya M, Nedungalaparambil NM, Mundra H, et al.
Prevalence and predictors of stress, anxiety, and depression among healthcare workers managing COVID-19 pandemic in India: A nationwide observational study. Indian J Psychol Med 2020;42:353-8.
Sher L. The impact of the COVID-19 pandemic on suicide rates. QJM 2020;113:707-12.
Sahoo S, Rani S, Parveen S, Pal Singh A, Mehra A, Chakrabarti S, et al
. Self-harm and COVID-19 pandemic: An emerging concern-A report of 2 cases from India. Asian J Psychiatr 2020;51:102104.
Thakur V, Jain A. COVID 2019-suicides: A global psychological pandemic. Brain Behav Immun 2020;88:952-3.
Rajkumar RP. Suicides related to the COVID-19 outbreak in India: A pilot study of media reports. Asian J Psychiatr 2020;53:102196.
Rahman A, Plummer V. COVID-19 related suicide among hospital nurses; case study evidence from worldwide media reports. Psychiatry Res 2020;291:113272.
Grover S, Mehra A, Sahoo S, Avasthi A, Tripathi A, D'Souza A, et al.
State of mental health services in various training centers in India during the lockdown and COVID-19 pandemic. Indian J Psychiatry 2020;62:363-9. [Full text]
Grover S, Chakrabarti S, Sahoo S, Mehra A. Bridging the emergency psychiatry and telepsychiatry care: Will COVID-19 lead to evolution of another model? Asian J Psychiatr 2020;53:102429.
Grover S, Mehra A, Sahoo S, Avasthi A, Tripathi A, D'Souza A, et al. Impact of COVID-19 pandemic and lockdown on the state of mental health services in the private sector in India. Indian J Psychiatry 2020;62:488-93. [Full text]
Enabling Registered Medical Practitioners to Provide Healthcare Using Telemedicine. Telemedicine Practice Guidelines. Medical Council of India, Niti Aayog; 2020.
Reinhardt I, Gouzoulis-Mayfrank E, Zielasek J. Use of telepsychiatry in emergency and crisis intervention: Current evidence. Curr Psychiatry Rep 2019;21:63.
Sreedaran P, Beniwal RP, Chari U, Smitha TS, Vidhya SSV, Gupta V, et al. A randomized controlled trial to assess feasibility and acceptability of telephone-based psychosocial interventions in individuals who attempted suicide. Indian J Psychol Med. 2020;42:1–6.
Grover S, Dua D, Sahoo S, Mehra A, Nehra R, Chakrabarti S. Why all COVID-19 hospitals should have mental health professionals: The importance of mental health in a worldwide crisis! Asian J Psychiatr 2020;51:102147.
Bartels SJ, Baggett TP, Freudenreich O, Bird BL. COVID-19 emergency reforms in massachusetts to support behavioral health care and reduce mortality of people with serious mental illness. Psychiatr Serv 2020;71:1078-81.