Guidelines For Covid19 PatientHaving Psychiatric Disorders   Presented By Dr. Md Imtiaz Hossain Bhuiyan HDU DOCTOR| IQARUS | Medical Treatment Facility / IQARUS - Cox’s Bazar - Bangladesh Mobile +8801324-404020| Mail: Imtiaz.Bhuiyan@iqarus.com

1. Guidelines For
Covid19 Patient
Having Psychiatric
Disorders
PRESENTED BY
DR. MD IMTIAZ HOSSAIN BHUIYAN
HDU DOCTOR| IQARUS | MEDICAL TREATMENT FACILITY /
IQARUS - COX’S BAZAR - BANGLADESH

2. COVID-19 AT A
GLANCE :
• Coronaviruses are a group of viruses belonging to the
family of Coronaviridae, which infect both animals and
humans. Human coronaviruses can cause mild disease
similar to a common cold, while others cause more
severe disease (such as MERS - Middle East Respiratory
Syndrome and SARS – Severe Acute Respiratory
Syndrome). A new coronavirus that previously has not
been identified in humans emerged in Wuhan, China in
December 2019.
• Signs and symptoms include respiratory symptoms and
include fever, cough and shortness of breath. In more
severe cases, infection can cause pneumonia, severe
acute respiratory syndrome and sometimes death.
• Standard recommendations to prevent the spread of
COVID-19 include frequent cleaning of hands using
alcohol-based hand rub or soap and water; covering the
nose and mouth with a flexed elbow or disposable tissue
when coughing and sneezing; and avoiding close
contact with anyone that has a fever and cough.

3. MENTAL HEALTH ISSUES OF QUARANTINE/ISOLATION
Common problems Possible management
Anxiety, Distress, confusion, frustration
and boredom 1. Clear information about duration of
quarantine
2. Restriction of news consumption, avoiding
multiple times news, news scroll, one or two
authenticate source of information, less social
media.
3. Simple relaxation Technique for worry and
anxiety like breathing exercise

4. MENTAL HEALTH ISSUES OF QUARANTINE/ISOLATION
Common problems Possible management
Fear of infection:
Health anxiety.
Fear of infecting others.
Losing contact with family
members,.
1. Information, reassurance about the
disease,
2. Ensure regular contact with family
members by phone or online
3. Provide facilities to the individual to
remain physically active, continue or
develop hobbies to be mentally active and
ensure a balanced diet to keep themselves
fit and calm

5. MENTAL HEALTH ISSUES OF QUARANTINE/ISOLATION
Common problems Possible management
Facing Social Stigma with COVID-19 1. DO talk about the disease (COVID-19), But
DO NOT use terms such as 'Wuhan virus/
Chinese virus etc'.
2. Social distancing is not to be confused with
social discrimination. Its okay to stay safe by
keeping 1-2 meters. Treat everyone as human
with equal status and opportunity.
3. Correct misconceptions and do not
encourage false propagation

6. MENTAL HEALTH
ISSUES IN
PATIENTS WITH
COVID-19
Stress.
Delirium
Anxiety
Sleep disturbance
Depression
Communication problems
Pain
Fear of being dependent on the machine for breathing
Delirium (also called ICU psychosis)

7. ACUTE BEHAVIORAL CHANGES IN COVID-19
PATIENT:
Delirium
Acute
psychosis/
Mania
Anxiety
Depressive
Disorder
Insomnia Dementia

8. TREATMENT OF ACUTE ONSET BEHAVIORAL
DISTURBANCES WITH PSYCHOTROPICS
Delirium Haloperidol 2.5 - 5 mg / Risperidone (1mg in divided doses) /
**Do not use Olanzapine for delirium
**Addition of Inj. Haloperidol for patients can not take oral medication.
Acute psychosis/ Mania *Risperidone 4-8 mg/ day. / Olanzapine 10-20 mg / day.
* Add Procyclidine 5-10 mg daily if there is Extra pyramidal side effects
Anxiety For acute anxiety: Lorazepam 1-2 mg daily and 5-7 days.
For chronic anxiety : Escitalopram 10 mg daily
Depressive Disorder Escitalopram 10-20 mg daily/ Sertraline 50 mg daily.
Insomnia Lorazepam 1-2 mg daily if no contraindications to Benzodiazepines
Quetiapine 25 mg/ day if Benzodiazepines is contraindicated.
Dementia No data..

9. GENERAL
GUIDELINES
 The COVID-19 facility should have a facility for
consultation with a Psychiatrist either in person or by tele-
consultation, while admitting a person with mental illness.
 Wherever feasible, the primary treating Psychiatrist can be
contacted to collect treatment details of the individual
patients.
 Mental status examination within 24 hours of admission
either in-person or by tele- consultation.
 Simple risk assessment can be done by the consulting
psychiatrist to triage the patients.
 The bed allocated for the patient should be preferably close
to the nursing station. This will ensure that the person can be
observed round the clock.
 Steps must be taken to ensure that the windows are well
boarded and there is no access to instruments to harm
self/others.
 All medications must be supervised and medical care (eg:
wound care) reviewed.

10. SYSTEM- WISE MANIFESTATIONS OF COVID-19 AND POTENTIAL
COMPLICATIONS WITH PSYCHOTROPIC MEDICATIONS
System COVID-19
infection
Psychotropic
medications
Recommendation
Cardiovascular
system
A possible
arrhythmogenic effect
and heart failure.
Haloperidol, Quetiapine,
ziprasidone can prolong
QT interval. synergistic
effect with other
medications that cause
prolongation
(azithromycin,
hydroxychloroquine,
lopinavir/ritonavir)
ECG with baseline corrected QT (QTc interval)
for all patients on antipsychotic medications.
Frequent monitoring in case of QTc> 500ms
Safety of hydroxychloroquineis not well
established in elderly, especially with
concomitant psychotropic use.
Blood investigations including electrolytes as
hypokalemia and hypomagnesmia can worsen
it.
Risk- benefit decision to be done on a case-
by-case basis regarding continuation versus
switching to alternative medication.

11. SYSTEM- WISE MANIFESTATIONS OF COVID-19 AND POTENTIAL
COMPLICATIONS WITH PSYCHOTROPIC MEDICATIONS
System COVID-19
infection
Psychotropic
medications
Recommendation
Haematological
system
Lymphopenia,
increased
prothrombin
time,
thrombocytope
nia and
disseminated
intravascular
coagulation
Carbamazepine and
clozapine can cause
leukopenia,
neutropenia and
agranulocytosis.
SSRI increases
bleeding risk
Complete hemogram to be done.
Neutropenia can increase the risk of
secondary bacterial infections and
poorer prognosis.
In such case, the offending drug
must be stopped and alternate
medication to be considered

12. SYSTEM- WISE MANIFESTATIONS OF COVID-19 AND POTENTIAL
COMPLICATIONS WITH PSYCHOTROPIC MEDICATIONS
System COVID-19
infection
Psychotropic
medications
Recommendation
Renal
System
Acute kidney injury
has been observed
in patients with
COVID-19
particularly with
pre-existing chronic
kidney disease.
Psychotropic
medications that
are dependent
on renal
excretion
includes lithium,
topiramate,
pregabalin and
paliperidone
that
Renal function test and
creatinine clearance
calculation to be done and
dose adjustment accordingly.
Lithium levels to be done,
wherever feasible and dose
adjusted accordingly

13. SYSTEM- WISE MANIFESTATIONS OF COVID-19 AND POTENTIAL
COMPLICATIONS WITH PSYCHOTROPIC MEDICATIONS
System COVID-19
infection
Psychotropic
medications
Recommendation
Respiratory
system
The primary
organ of
damage is lungs
and respiratory
failure
Benzodiazepines
reduce respiratory
drive
Second generation
antipsychotics,
especially
clozapine can cause
pneumonia
Benzodiazepines in low dose
may be needed for panic or
anxiety.
Some patients on long term
benzodiazepines may need
gradual tapering

14. SYSTEM- WISE MANIFESTATIONS OF COVID-19 AND POTENTIAL
COMPLICATIONS WITH PSYCHOTROPIC MEDICATIONS
System COVID-19
infection
Psychotropic
medications
Recommendation
Neurological
system
Impaired
consciousness,
delirium (especially
in elderly), seizures,
memory
impairment
Azithromycin,
Hydroxychloroquin
e
, Corticosteroids
can cause delirium
Anticholinergic
agents such as
Trihexyphenidyl,
Tricyclic
antidepressants and
sedatives can
worsen confusion
Second Generation
Antipsychotics can
lower seizure
threshold
Use of benzodiazepines, opioids and
other anticholinergic agents must be
minimized.
Other contributing causes for
delirium such as electrolyte
imbalance, hypoxia has to be treated.
Haloperidol PO 2.5mg- 5mg or
Olanzapine PO 5-10 mg PRN can
be used for treatment of delirium

15. SYSTEM- WISE MANIFESTATIONS OF COVID-19 AND POTENTIAL
COMPLICATIONS WITH PSYCHOTROPIC MEDICATIONS
System COVID-19
infection
Psychotropic
medications
Recommendation
Hepatic
System
Acute liver
injury.
Use of
Remdesivir can
increase liver
enzymes
Valproate,
Carbamazepine,
Second Generation
Antipsychotics,
TCAs, SNRI can
have mild
hepatotoxicity with
modest increase in
liver enzymes
Baseline Liver function tests to be
done. Also, frequent monitoring
High risk drugs such as valproate,
carbamazepine, chlorpromazine to
be preferably avoided.

16. SPECIAL
CONSIDERATION
ABOUT DELIRIUM
• Delirium in patients with COVID-19 has many
possible etiologies, including metabolic,
respiratory, and coagulation alterations that are
consequences of the direct effects of SARS-CoV-2
on peripheral organs and systems. Additionally,
systemic inflammation that alters the blood-brain
barrier leads to a CNS immune response . The
virus produces a direct effect in the brain in a
minority of cases (encephalitis and meningitis),
such that delirium could result from a CNS
infection as well as brain inflammation.

17. PREVENTION OF
DELIRIUM USING NON-
PHARMACOLOGICAL
BEHAVIORAL
INTERVENTIONS
• Efforts to help in orientation
• Enhance sensory efficacy (e.g., encouraging patient to
use their glasses or hearing aids)
• Promote sleep
• Adequate and appropriate pain management
• Preventing complications of immobility (bed sores)
• Optimization of physiological parameters (e.g.,
electrolytes, hydration)
• Foster physical therapy/early mobilization.

18. MANAGEMENT
OF DELIRIUM/
PSYCHOSIS:
• Identification and resolution of the primary cause:
A When behavioral symptoms are disruptive or likely to
interfere with treatment, the use of low dose antipsychotic
medication is generally preferred for its short-term management.
Among the antipsychotic medications – a. If a patient is in a
position to take oral tablets, then oral haloperidol should be
preferred over parenteral administration. A low dose of haloperidol
(up to 2.5 to 5 mg up to twice a day) is generally adequate.
B. Alternately, Quetiapine 25mg to 50 mg in divided can be
administered orally
C. Hydroxychloroquine has a potential adverse effect of QTc
prolongation, cardiac arrhythmias there should be cautious about
concurrent use of hydroxychloroquine and parenteral haloperidol.
This necessitates regular cardiac monitoring

19. CAUTION :
• Respiratory distress and respiratory
failure are fatal manifestations of
COVID-19, hence administration of
benzodiazepines should be avoided.

20. INDICATIONS FOR REFERRAL FOR COVID-19
PATIENT:
Expressing suicidal
ideas
Violent/aggressive
behaviour
Uncontrolled use of
alcohol/drugs
Crying or expressing
uncontrollable distress
Unexplained bizarre
behavior like talking or
smiling to self
Significant deterioration
in occupational
functioning

21. REFERENCES:
• Guideline for Mental Health Issue-COVID-19- DGHS, Ministry
of Health. Bangladesh.
• QJM: An International Journal of Medicine, Volume 113,
Issue 8, August 2020, Pages 531–
537, https://doi.org/10.1093/qjmed/hcaa201.
• CSTS | Department of Psychiatry | Uniformed Services
University | 4301 Jones Bridge Road, Bethesda, MD 20814-
4799 | www.CSTSonline.org.
• Guidelines for Delivery of Mental Healthcare Services during
the Covid-19 Pandemic. Ministry of Health. India
https://www.mohfw.gov.in/pdf/GuidelinesforDeliveryofM
talHealthcareServicesduringtheCOVID19.pdf

22. THANK YOU
ALL