How the COVID-19 Pandemic is Changing Mental Health Disease Management: The Growing Need of Telecounseling in Italy

Abstract

Coronavirus-19 (COVID-19) is a novel severe acute respiratory syndrome (SARS), which is caused by coronavirus-2 (CoV-2). The World Health Organization has declared COVID-19 to be a global pandemic. Standard public health measures, such as “stay-at-home” orders, quarantine, social distancing, and community containment, are being used to manage the pandemic, and these measures are changing social relationships, including those between doctors and patients. The mental health effects of this confinement can include feelings of isolation and stress-related fear of contamination and death, and psychiatric and/or psychotherapeutic help using telehealth could be beneficial. In Italy, psychological telecounseling has been an effective method of supporting the physical and psychosocial needs of all patients, regardless of their geographical locations. In this commentary, the authors promote the use of telehealth as an effective means of treating patients with mental health issues.

Coronavirus-19 (COVID-19) is a novel severe acute respiratory syndrome (SARS) that is caused by the coronavirus-2 (CoV-2) and has become a global health problem. COVID-19 is a single-stranded, enveloped, ribonucleic acid virus that can produce influenza-like symptoms in infected individuals.¹ The virus can be spread via droplets of saliva and mucus from infected individuals to other people, either through direct physical contact (e.g., a handshake) or by touching a surface contaminated by the virus (e.g., a doorknob). COVID-19 has an incubation period of 2 to 14 days, and its clinical presentation in humans can range from no symptoms to mild upper respiratory tract infections, fever, and/or cough, to severe acute respiratory distress syndrome, sepsis, and death.² The COVID-19 virus was first reported December 2019 in Wuhan, China. The World Health Organization (WHO) has since declared COVID-19 to be a global pandemic. As of May 13, 2020, the WHO has reported that, worldwide, there have been 4,170,424 cases of COVID-19, and 287,399 deaths due to COVID-19-related complications.³ The incidence and mortality of COVID-19 varies in different countries/territories, ranging from 61.44 per 1,000,000 people in Republic of Korea to 0.0002 per 1,000,000 people in India.⁴ On January 31, 2020, two Chinese tourists in Rome tested positive for COVID-19. One week later, an Italian man who had returned from Wuhan, China, became the third case in Italy. By February 21, the situation had worsened, and 16 cases were confirmed in Lombardy. Sixty new cases were confirmed a few days later. The epidemic in Italy⁵ has one the highest percentages of confirmed cases of COVID-19 in Western countries. Unfortunately, in Italy, data regarding the diffusion of COVID-19 confirmed its higher lethality compared to that observed in China and worldwide (9% vs 4.3%).⁶ Currently there is no vaccine for COVID-19, and the treatment is mainly symptomatic supportive therapy. Moreover, early diagnosis, quarantine, and supportive treatments are essential to patient recovery and prevention. Standard public health measures, including quarantine, social distancing, and community containment, are being used to curb the pandemic of this respiratory disease,⁷ and these new measures have changed the dynamics of social relationships, including relationships between doctors and patients. Doctors are at risk of experiencing psychological distress due long work hours and the high risk of exposure to COVID-19 when treating ill patients. This might also lead to stress, anxiety, depressive symptoms, and burnout in physicians, which can negatively impact the healthcare system’s ability to provide adequate services during the COVID-19 crisis.⁸

Globally, we all have had to quickly adapt to living with an invisible enemy and trying to understand how to defend ourselves through altered lifestyles and altered daily habits. We also have had to face a “psychological pandemic,” which has caused an “internal explosion” of negative emotions: fear of dying and fear of staying home alone without any familiar/social contact. COVID-19 has changed the lifestyles of every person in the world. We have all become misfits; we have lost our habits completely and have had to build new ones. This can lead to feeling more vulnerable and less tolerant of stress, which can result in less inhibitory control, dysfunctional communication, and inadequate coping strategies. In fact, anxiety and depression symptoms have increased in prevalence and frequency, increasing risk of panic attacks and suicidality, especially in people with chronic mental health conditions.^8,9 But few patients with mental disorders have access to psychiatric services or emergency departments.

We have had to deal with the mental health effects of confinement and stress-related fear of contamination and death, along with acute episodes of mental disorders, such as psychotic events, emotional disorders, behavioral and mood alterations (especially in children), suicide attempts, and violence at home.⁹ Moreover, economic problems should also be taken into account. It is estimated that COVID-19 could cost the world more than $10 trillion, although considerable uncertainty exists in regard to how far the virus has reached and the efficacy of the social distancing protocols.¹⁰ For each percentage point reduction in the global economy, more than 10 million people plunge into poverty worldwide, mainly those with pre-existing conditions with higher risk of COVID-19-associated mortality.

Because the pandemic has perpetuated an economic crisis, unemployment rates will rise substantially and weakened welfare safety nets will further threaten public health and social security.¹⁰ COVID-19 pandemic has changed mental health disease management in that patients are not able to go out of their home and cannot easily access mental health services. Consequently, during this pandemic, there is a growing need for telecounseling and telepsychiatry.^11,12

Telecounseling refers to any type of psychological service performed over the internet, including emails, chat rooms, and web cameras. It ranges from individual, couple, and group psychotherapy, with qualified therapists providing psychological first aid to those who need it. In February 2018, the American Psychiatry Association (APA) updated its Policy on telepsychiatry, stating that telemedicine in psychiatry, using video conferencing, is a valid and effective practice of medicine that increases access to care. In fact, the APA “supports the use of telemedicine as a legitimate component of a mental health delivery system to the extent that its use is for the benefit of the patient, protects patient autonomy, confidentiality, and privacy; and when used consistent with APA policies on medical ethics and applicable governing law.”¹¹ In such a critical period, these validated tools should be utilized globally.

China was the first country to actively provide telemedicine mental health services during the outbreak of COVID-19. These services were provided by the government and academic agencies and included counseling, supervision, and training, as well as psychoeducation through online platforms. Notably, telemedicine mental health services have been prioritized for people who are at higher risk for developing severe health complications related to COVID-19, including clinicians on the frontline, patients who are COVID-19 positive and their families, policemen, and security guards.¹¹

In Paris, Corruble and colleagues implemented an interesting experiment using a dedicated hotline for psychiatric cases and consultations and organizing virtual visits with qualified psychiatrists and psychologists.¹³ Utilizing telepsychiatry and teleworking was a necessary step for this French psychiatry department to face this crisis, and the Corruble and colleagues reported that telemedicine was well accepted by staff and patients.

Hollander et al described the potential use of telemedicine in disaster situations or public health emergencies. The communication between patients and medical personal was maintained via smartphones and web-cam enabled computers.¹⁴

In the psychiatric department of Siena (Italy), Fagiolini et al rapidly switched almost all (more than 90%) of outpatient visits to telemedicine sessions, promoting the simplest method of virtual communication (a phone), as well as apps such as Whatsapp or Face Time, concluding the visits via video calls.¹⁵

Following these promising experiences, we support the idea that, during this COVID-19 era, there is a need for constant psychological support, which is possible if we all use telemedicine. China and Australia have provided their populations with telehealth support, which also covers the rural areas; however, this method of treating patients virtually is lacking in Italy, with few exceptions in the central Northern areas.¹⁵ Communication of all health needs, including psychological well-being, is important during times when patients are isolated due to stay-at-home orders. We support the use of psychological telecounseling as a valuable way to support both physical and psychosocial needs of all patients, regardless of their geographical location.