Brigham and Women's Hospitals

Psychiatry

Updated: April 13, 2020

Psychiatry Consultation

  1. Clinical scenarios that should prompt psychiatry consultation:
  1. Suicidal ideation or risk of self harm
  2. Agitation in the setting of delirium or neurocognitive disorder
  3. New onset psychosis or assistance with management of antipsychotics
  4. Assistance with management of mood symptoms
  5. Severe alcohol or opioid withdrawal
  6. Assistance with management of psychotropic medications in the setting of other QTc prolonging agents (i.e. hydroxychloroquine and azithromycin)
  7. Transfer of patient from psychiatric facility for COVID rule out
  1. Pro-active psychiatry consultation on select COVID units:
  1. Brigham Medical Psychiatry Service is offering consultation by fellows to COVID ICU units with goal to:
  1. Provide a designated psychiatrist to a assist with clinical care and
  2. Provide support to individual medical team members to discuss emotional/psychological responses to difficult cases.
  1. These consults are virtual, via telephone with either the patient directly or the primary team
  2. These services will be available roughly 9am-3pm Monday - Friday, with some exceptions. This team is also the psychiatry consult service for the rest of the hospital. If a COVID provider is interested in consulting the psychiatry service, please place an order in Epic and contact the Psychiatry service.

General Management of Anxiety/PTSD

  1. Preliminary data from China found that 96.2% of patients hospitalized for COVID-19 reported significant PTSD symptoms prior to discharge from the hospital (Bo et al, Psychol Med, 2020)
  2. For management of anxiety related to dyspnea and at the end of life, please refer to the Palliative Care section.
  3. Non-pharmacologic
  1. Feelings of uncertainty and fear can fuel anxiety
  1. Important to first acknowledge and normalize distress reactions
  2. Correct misinformation. Provide accurate information (regarding patient’s current medical condition and next steps, regarding hospital protocols and measures being taken for safety)
  3. Encourage limiting media exposure
  1. Counseling (Spiritual, Psychocological, SW)
  2. Reiki
  3. Strategies for reducing distress
  1. Restful sleep, eating regular meals, exercising
  2. Talking to loved ones (via telephone or video chat)
  3. Diaphragmatic breathing
  4. Muscle relaxation
  1. Pharmacologic
  1. Continue home psychotropic medication regimen if possible
  2. For patient with evidence of delirium
  1. Quetiapine 12.5-25mg TID PRN
  1. For patient without evidence of delirium
  1. Quetiapine 12.5-25mg TID PRN
  2. Lorazepam 0.5-2 mg PO/SL TID PRN; 0.5-2 mg IV TID PRN
  1. For patient with risk of respiratory depression or history of respiratory illness
  1. Buspirone 5-15mg PO TID

Affective Disorders

Depression

  1. Symptoms: Dysphoric mood, withdrawn, difficulty concentrating, disrupted sleep, decreased appetite, fatigue, tearfulness, worthlessness, hopelessness, helplessness
  2. Non-Pharmacologic
  1. Physical distancing can worsen depression given increase in isolation.
  1. Using safe communication channels between patients and families such as smartphone communication should be encouraged to decrease isolation
  1. Feelings of guilt and stigma surrounding COVID positivity may also increase symptoms of depression
  1. Bring focus to what the patient and family can control going forward and that the appropriate steps to ensure safety are being taken
  1. Pharmacologic
  1. Continue home psychotropic medication regimen if possible
  2. SSRI: Sertraline 50mg daily. If tolerated, can uptitration of 50mg every 5-7 days to target symptoms. Max dose 200mg daily.
  3. Depression with sleep disruption and low appetite: mirtazapine 7.5mg qhs. Can uptitrate to 30mg qhs as tolerated.
  4. Consider consulting Psychiatry if depressive symptoms persist after non-pharmacologic interventions have been attempted or patient reports suicidal ideation

Bipolar Disorder

  1. Symptoms of Mania/Hypomania: sleeping very little BUT feeling extremely energetic, racing thoughts, rapid speech, flight of ideas, elevated or irritable mood, grandiose beliefs, highly distractible, impulsivity/recklessness. Psychotic symptoms can be present in severe cases (delusions/hallucinations).
  2. Pharmacologic
  1. Continue home psychotropic medication regimen if possible
  2. Consider consulting Psychiatry if patient appears to have decompensated hypomania or mania that is affecting ability to engage in patient care

General Delirium

Incidence

  1. Disorders of consciousness were significantly more common in patients who died from complications of COVID-19 (22%) than in those who survived (1%). Chen et al, BMJ, 2020
  2. From anecdotal clinical experience across the US, COVID-19 patients seem to be experiencing very high rates of delirium with associated symptoms including agitation, aggressive behaviors, and disinhibition

Diagnosis

  1. Use the Confusion Assessment Method (CAM)
  1. CAM is positive if (1) AND (2) and EITHER (3) or (4) are present
  2. Acute often fluctuating change in mental status (vs dementia)
  3. Difficulty focusing attention
  4. Disorganized thinking (rambling, illogical flow of ideas)
  5. Altered level of consciousness (too sedated or too hyperactive)

Management

  1. Non-pharmacologic:
  1. Frequent reorientation when appropriate
  2. Early mobilization
  3. Promotion of sleep-wake cycles via use of room lighting and stimulation
  4. Timely removal of unnecessary restraints, catheters, lines, and other devices
  5. Ensure use of glasses/hearing aids once patient is sufficiently alert
  6. Reverse contributing medical conditions as able.
  7. Consult Psychiatry; for terminal delirium, see section in Palliative Care
  8. Additional information available at: Guidelines for Acute Hospital Acquired Delirium (Partners login required)
  1. Pharmacologic
  1. Avoid deliriogenic medications (anticholinergics, benzodiazepines, opioids) as possible
  2. Treat comorbid symptoms and underlying medical illness
  3. For agitation/aggression
  1. Antipsychotics
  1. Haloperidol: Mild agitation:0.5-1.0 mg IV or 1 to 2 mg PO q6h and 1-2 mg q2h PRN.; Moderate agitation: 2-4 mg IV; Severe agitation: 4-10 mg Maximum dose: 20 mg / 24 hours
  2. If refractory, olanzapine (Zyprexa), 2.5 to 5 mg (PO, SL, or IV) q12 hr and 2.5 mg q4h PRN; Maximum dose: 30mg / 24 hours. **do not combine with parenteral benzodiazepines due to increased risk of respiratory depression**
  3. If haloperidol/olanzapine not effective or contraindicated, could try:
  1. Quetiapine (Seroquel) 12.5-50 mg qHS
  2. aripiprazole (Abilify) 5 mg PO daily; maximum dose 30 mg daily
  1. Alpha 2 agonists - helpful for patients for vent weaning; also good option if prolonged QTc (Link for further information)
  1. dexmedetomidine (Precedex) IV - easily titratability given short half-life
  2. Consider use of clonidine 0.1 mg BID (can uptitrate) - available as a transdermal patch as well.
  1. Mood Stabilizers
  1. Valproic Acid (good option if prolonged QTc): Start at 125-250mg IV q8h TID, however, COVID patients are seeming to need escalations in doses (up to anti-manic dosing of 15-25 mg/kg) in combination with antipsychotics (i.e. haloperidol or olanzapine as above).
  1. Others
  1. For regulation of sleep/wake cycle: Mirtazapine (Remeron): 7.5 mg (can uptitrate, but it is more sedating at lower doses)
  1. Considerations for Geriatrics Patients
  1. High risk for delirium given no-visitors policy, disorienting effect of PPE use by staff, difficulty hearing/identifying caregivers through masks
  2. Avoid deliriogenic medications such as anticholinergics and benzodiazepines (See here for a comprehensive list, Beers Criteria)
  3. If acutely agitated, not redirectable by non-pharmacologic means, trial 12.5 mg trazodone x 1 prn, repeat dose x 30 min if no effect
  4. Use of antipsychotics (e.g. haloperidol, olanzapine, quetiapine) as last resort only, and only if QTc is < 500

Assessment of Capacity

General Capacity Assessment

  1. Capacity is an essential component of consent and deals with the process of decision-making. The evaluation of capacity is decision-specific and time-specific and involves a need to balance autonomy and beneficence. A capacity assessment can be completed by any physician. There are four decision-making abilities that patient require to be able to demonstrate capacity
  1. Ability to understand relevant information
  1. Patient must be able to comprehend basic information about the current condition, potential options, and risks/benefits associated with these options
  1. Ability to appreciate the situation and its consequences
  1. This is the ability to recognize how the above information pertains to one’s own situation
  1. Ability to reason
  1. Ask patient to describe how they reached their decision and what factors influenced this.
  1. Ability to communicate and express a consistent choice

Patients Refusing Recommended Medical Intervention

  1. Considerations
  1. Assess urgency of intervention and consequences of refusal
  1. Embedded in a capacity assessment is a risk assessment
  2. The clinician needs to distinguish between tolerable risks and intolerable risks. Only intolerable risks require assessment of capacity. Intolerable risks might include behavior that is new and unprecedented (not consistent with past behavior) and behavior that is causing significant harm.
  1. Assess differential for refusal (i.e. delirium, anxiety, agitation, volitional, psychosocial stressors)
  2. Patients who refuse testing or airborne precautions will likely require a full capacity assessment. Given that symptomatic patients seem to have increased frequency of transmission to others, patients will likely have a higher threshold to demonstrate capacity in this setting.
  1. If patient lacks capacity, have low threshold for use of medications for agitation and/or restraints

Patients Requesting to Leave Against Medical Advice (AMA)

  1. Identify psychosocial stressors and address as able
  2. Patients who request to leave AMA will likely require a full capacity assessment. Given that symptomatic patients seem to have increased frequency of transmission to others, patients will likely have a higher threshold to demonstrate capacity in this setting.
  3. If patient is found to have capacity to leave AMA but poses significant infection risk to others, call legal and/or risk and consider involvement of security. Likely Boston Public Health Commission (BPHC)/Department of Public Health (DPH) will need to be alerted.
  1. At this time DPH has not invoked their authority to forcibly quarantine such patients
  1. For patients with unstable housing, DPH may be able to assist with shelter recommendations or placement.
  2. If patient lacks capacity, have low threshold for use of medications for agitation and/or restraints

Addictions Psychiatry

Alcohol Use Disorder

  1. Increased risk of relapse and escalation of alcohol use during this time due to isolation and increased stress
  2. Withdrawal
  1. Severe - Still requires inpatient management
  1. Options include:
  1. CIWA-driven benzodiazepine protocols (symptom-triggered)
  1. Contraindicated if patient has altered mental status due to lack of reliability of symptom reporting
  2. Less appropriate for higher-risk patients
  1. Scheduled/standing benzodiazepine taper
  2. Scheduled/standing phenobarbital load/taper
  1. BWH Drug Administration Guidelines for Phenobarbital (requires Partners login)
  2. If clinically appropriate for a COVID-19 positive patient, may be preferable to benzodiazepines/CIWA (which often require more frequent administration and is often more labor-intensive for nursing - requiring more PPE use and close patient contact for appropriate monitoring)
  1. For BWH Alcohol Withdrawal Protocol (Link)
  1. If concern for withdrawal symptoms despite using the above protocol, please consider addictions psychiatry consult for assistance in management
  1. Mild or Moderate
  1. For unsupervised withdrawal, consideration of anticonvulsant medications such as gabapentin, topiramate or carbamazepine (SAMHSA Guidelines) - advantage is lower abuse potential
  2. Could also consider short duration of benzodiazepines for taper

Opioid Use Disorder

  1. BWH Addictions Psychiatry is still available for suboxone inductions during business days
  2. Symptomatic management of withdrawal symptoms:
  1. Hypertension: Clonidine 0.1 mg q8h prn (hold for SBP < 90, HR < 55)
  2. Diarrhea: Loperamide 4mg po with 1st loose stool, then 2mg per loose stool. Max of 24 mg per day
  3. Nausea: Ondansetron 4-8 mg po/IV q8h prn
  4. Pain: Ibuprofen 600 mg or Acetaminophen 650 mg po q4-6h
  5. Abdominal cramping: Dicyclomine 20 mg po q4h
  6. Nasal congestion: Diphenhydramine 50 mg po q4h
  7. Muscle cramps: Methocarbamol 750 mg po q6h
  8. Insomnia: Trazodone 50-100 mg po qhs
  9. Anxiety: Diphenhydramine 50-100 mg po qhs or Hydroxyzine 25-50 mg qhs
  1. Pregnant women who are opioid dependent should NOT undergo symptomatic withdrawal management due to increased risk of miscarriage or preterm delivery. The recommended approach is methadone maintenance treatment. (WHO)

DEA Guidelines during COVID-19 (Link)

  1. Decision tree for prescribing controlled substances during COVID-19 (Link)
  1. Buprenorphine
  1. Practitioners who prescribe buprenorphine are now able to prescribe buprenorphine to new patients with opioid use for maintenance treatment or detoxification treatment following an evaluation via telephone voice calls, without first performing an in-person or telemedicine evaluation, if deemed clinically appropriate and safe

Addictions Resources for Patients/Families

  1. Online Alcoholics Anonymous (AA) Groups (Link)
  2. Dharma Online Meetings (Link)
  3. In the Rooms Online Support (Link) - A global recovery online community
  4. Al-Anon Online Meetings (Link) - Al-Anon is an organization for anyone who is affected by alcoholism in a family member or friend. Utilizes Twelve Step principles.
  5. Virtual Narcotics Anonymous (NA) Groups: (Online) or (Phone)
  6. Marijuana Anonymouse Online Meetings (Link)
  7. Smart Recovery Online Meetings (Link)
  8. Tools for Smoking Cessation (Link)
  9. Herren Project (Link) - Meetings 7 nights per week at 7:30 PM EDT via Zoom platform for a peer support based live online recover meeting. Each meeting begins with a speaker, followed by fellowship and sharing.
  10. Connections - Free smartphone app for sobriety (Link) - features include sobriety tracking, access to e-therapy, messaging with trained counselors and peers, journaling, resource library including videos and testimonials

Psychological Effects of Quarantine

  1. The following is adapted from Brooks et al, Lancet, 2020
  2. Stressors during quarantine include:
  1. Frustration and boredom from isolation, loss of one’s usual routine, and limited social and physical contact with others
  2. Inadequate supplies and access to regular medical care
  3. Insufficient information
  4. Longer duration of quarantine (i.e. 10 days or longer) as well as extension of quarantine length
  5. Fears about becoming infected and/or infecting others which can manifest as increased attention to and worry about one’s health and physical symptoms
  1. Stressors following quarantine include:
  1. Financial loss (i.e. absence from work, healthcare costs, and other unanticipated financial burdens) leading to socioeconomic distress
  2. Stigmatization and rejection from family, neighbors, co-workers or friends
  3. Resuming one’s “normal” routine
  1. Promoting Psychological Well-being during quarantine
  1. Provide clear, understandable, and practical communication about the nature of disease, reason for quarantine and treatment, and other essential information. Information will often need to be repeated and developmentally/culturally appropriate.
  2. Facilitate communication with loved ones when possible with use of technology (e.g. phone and video calls, social media) when available
  3. Keep quarantine as short as possible and restrict to what is scientifically appropriate

Psychological First Aid and Supporting Well-Being

General Measures for Patients and Providers

  1. The following is adapted from WHO, Banerjee, Asian J Psychiatr, 2020
  2. Safety/Basic Needs
  1. Offer immediate assistance by looking for ways to make them feel safe and comfortable (blankets, water, somewhere to sit, etc).
  1. Good Communication
  1. Being calm and showing understanding can help people in distress feel more safe and secure, understood, respected and cared for appropriately
  2. Important not to pressure anyone to tell you what they’ve been through
  3. Allow for sharing silence - remember, some people are may not feel comfortable sharing, speaking, or asking for help
  4. Validate feelings and thoughts - allow them to talk as little or as much as they want to. Try not to push too hard to get them to talk about what happened or how they are feeling
  5. Avoid temptation to judge the rightness or wrongness of their reactions
  1. How to Help People Feel Calm
  1. Keep your tone of voice calm and soft
  2. Make eye contact
  3. Remind them you are there to help, remind them that they are safe, if it is true
  4. If feeling disconnected from their surroundings, it may help to make contact with the environment and themselves
  1. Place and feel feet on the floor
  2. Tap fingers or hands on lap
  3. Notice some non-distressing things in the environment, such as things you can see, hear, or feel.
  4. Focus on breathing, and to breathe slowly
  1. Education
  1. All reactions and emotions are “normal”
  2. Common stress responses include confusion, insomnia, panic attacks, health-anxiety, fear of illness, increase in substance use, irritability, guilt, shaken religious faith, loss of confidence in self or others, shock, grief, physical symptoms (GI distress, headaches, pain) and feelings of hopelessness or helplessness
  1. Coping
  1. Encouraging health-promoting behaviors
  1. Get enough rest
  2. Maintain routines
  3. Eat as regularly as possible and drink water
  4. Talk with family and friends (via phone or video)
  5. Discuss problems with someone you trust
  6. Do activities that help you relax (walk, sing, pray)
  7. Do physical exercise
  8. Find safe ways to help others in the crisis and get involved in community activities
  1. Minimizing negative coping activities
  1. Drugs, smoking, or drinking alcohol
  2. Sleeping all day
  3. Working all the time without any rest or relaxation
  4. Isolating yourself from friends and loved ones
  5. Neglecting basic personal hygiene
  6. Being violent
  1. Support Problem-Solving (re: pets, transportation, updating family)
  1. Connect individuals with support systems
  1. See therapy resources below
  2. Facilitate spiritual practices
  3. Help families to provide support and care for loved ones who are hospitalized as possible (including virtually).
  1. Emotional Re-Adjustment (after the crisis)
  1. Best helped by:
  1. Acceptance of the event and the losses
  2. Identification, labeling, and expression of emotions
  3. Regaining a sense of control and mastery over our lives

Supporting Family Members of COVID Hospitalized Patients

  1. The following is adapted from the Center for the Study of Traumatic Stress
  2. Managing Uncertainty and Elevated Distress
  1. Encourage health-promoting behaviors for family members at home
  2. Remind family that their loved one is receiving the necessary care to support their recovery and that the majority of hospitalized individuals are successfully treated and are able to return home
  3. Recommend obtaining ready access to the patient’s medical, legal, and financial documents during hospitalization should the need arise in his/her absence
  4. Set expectations for frequency of updates
  1. Staying Connected During Family Separations
  1. Remind family members that physical separation from loved ones is necessary to keep everyone safe and healthy and that keeping family members away from the hospital also allows healthcare teams to more effectively focus on caring for patients
  2. Create opportunities to communicate safely with the hospitalized family member via text, telephone, email, or video chat
  3. Encourage important conversations if health status deteriorates and prior to need for intubation
  1. To understand last wishes
  2. To provide opportunities to say goodbye
  1. Stigmatization from Others
  1. People are understandably concerned about the virus spreading to themselves and their loved ones
  2. Confirm with your health care provider when your loved one and other family members are no longer at risk of spreading the virus
  1. After all family members are cleared by healthcare providers, share this information with friends, family, and community members so they understand that the family is not at risk of spreading the virus
  1. Discussing Coronavirus with Children (Link)

Supportive Resources

Immediate Assistance

  1. Disaster Distress Helpline (SAMHSA)
    Call 1-800-985-5990 or text TalkWithUs to 66746
  2. National Suicide Prevention Lifeline (Link)
    Call 800-273-8255 or Chat with Lifeline
  3. Crisis Textline (Link)
    Text TALK to 741741
  4. Veterans Crisis Line (VA)
    Call 800-273-8255 or text 838255

Therapy Resources (for patients and/or providers)

  1. Therapy Matcher: free telephone referral service that connects to licensed clinical social workers. Phone: 617-720-2828 or email info@therapymatcher.org - provide name/phone number and a social worker will call back to learn about needs and recommend several potential therapists (based on requested location, gender, insurance)
  2. William James Interface Referral Service: Free telephone referral service that connects to licensed clinicians. Note: Only serves participating communities. Phone: 888-244-6843.
  3. Psychology Today: online directory of therapists

Helpful Tools

  1. Headspace (meditation/mindfulness app)
  1. available via iOS, Android or desktop, offers sets of guided meditations aimed at tackling problems related to anxiety, sleeplessness and relationships. For the rest of 2020, Headspace is offering a free subscription to all providers with NPI numbers
  1. 10% Happier (Free Coronavirus Sanity Guide)
  1. A stress/meditation/relaxation and sleep app free to all healthcare providers with code HEALTHCARE
  1. The Evermind app
  1. available via iOS and Android, can help you build resilience and handle stress using cognitive behavioral therapy techniques. In the app, you can access guided programs on improving sleep, disconnecting, challenging negative thought patterns and more.
  1. The Care Online: iCBT program
  1. available via iOS, Android or desktop, is an online self-directed cognitive behavioral therapy course offered to patients with anxiety or low-to-moderate levels of depression to help them self-manage symptoms of these conditions.
  1. Calm (free meditation/mindfulness app)
  2. Down Dog Yoga & Exercise Apps (HIIT, Barre, 7 Minute)
  1. Free for anyone with a .edu address and healthcare workers until July 1
  1. For more resources: MGH Guide to Mental Health Resources