Resident Perspectives on COVID-19 in Psychiatric Decision-Making
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LETTER TO THE EDITOR
Resident Perspectives on COVID-19 in Psychiatric Decision-Making Amy Gallop 1
&
Matthew R. Graczyk 1
Received: 29 May 2020 / Accepted: 8 September 2020 # Academic Psychiatry 2020
To the Editor: As we left our shifts on the evening of Mr. L’s discharge, we began to worry. We wondered about the likelihood of him maintaining his sobriety and finding stable housing. How likely was it that he would be able to access and navigate the technology required to connect with mental health and substance use disorder treatment? Would the shelter he was discharged to eventually close due to viral spread? The challenges of ensuring safe disposition for patients have increased with COVID-19. Mr. L’s situation is not unique. As two first year psychiatry residents at a busy urban hospital, we have seen how the pathogenesis of COVID-19 has disproportionately targeted our patients with psychiatric illness. We have found ourselves at a crossroads, wondering how we can provide safe and thorough care in the age of social distancing. Mr. L was an elderly gentleman with a history of depression, who presented to our emergency department with acute suicidality in the setting of cocaine withdrawal. He was homeless and had been residing in various shelters and group homes with known positive coronavirus cases. Although he was clinically asymptomatic, his chronic substance use rendered him unable to confidently deny COVID-19 symptoms over the prior week. Triaging Mr. L in the pre-COVID era would have been rather unremarkable. He would have been admitted to inpatient psychiatry, and after time away from substance use, he could have reinitiated pharmacotherapy, participated in individual/group therapy, and ultimately would have been discharged armed with support to help him find housing and address his substance use. Rapidly changing testing guidelines, limited testing resources, and slow turnaround time for COVID-19 labs have
* Amy Gallop [email protected] 1
St. Louis University Hospital, St. Louis, MO, USA
resulted in long waits in the emergency department. Mr. L spent over twenty-four hours in the ED awaiting medical clearance prior to admission to inpatient psychiatry. Although we could help him comfortably get through the withdrawal period and initiate psychotropic medications, the environment was not therapeutic. He did not have daily social work meetings, family meetings, group therapy, or therapeutic interactions with other patients during this period. Oftentimes, patients with mental illness present to the emergency department during some of the lowest points of their lives, feeling isolated, hopeless, and worthless. Many of them have multiple risk factors for COVID, and screening results in an extended emergency department stay while awaiting test results. They spend sleepless hours listening to the buzz of the emergency department, where day and night are indistinguishable, and they wait in a small room alone without distraction from their thoughts. After a negative COVID-19 test, Mr. L was admitted
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