Damian Sendler: COVID-19 has disproportionately affected vulnerable populations as a result of the pandemic and its associated restrictions. To better understand how COVID-19 interacts with mental health and substance use disorders, this review summarizes the most recent evidence, emphasizing acute as well as long-term dangers, as well as pharmacotherapy interactions and implications for the use of evidence-based treatment.
Damian Jacob Sendler: This study shows that psychiatric and substance abuse disorders are linked with COVID-19 in a complex way. The COVID-19 virus has the potential to be harmful to people with a variety of psychiatric and substance use disorders. Infection with COVID-19 has been linked to both short-term and long-term effects on mental health and substance use disorders. Restrictions imposed to stop the spread of disease have also been linked to an increase in the occurrence of new disorders and the recurrence and worsening of existing ones.
Dr. Sendler: Chronic disability caused by mental health and substance use disorders, as well as their co-occurrence, can be prevented with early detection and intervention. It is critical that those most in need of services do not fall through the cracks of our healthcare systems. To ensure that digital health interventions are widely available to everyone, especially those who are most at risk, the pandemic has expedited the timetable for their widespread implementation.
The coronavirus disease 19 (COVID-19) has been wreaking havoc around the world for more than a year, putting healthcare systems to the limit. 104 million cases had been reported in over 190 countries, with nearly 2.3 million deaths, just 13 months after COVID-19 was first discovered [1,2]. Since the beginning of the pandemic, there have been concerns about the virus’s potential impact on people who are particularly at risk [3]. Psychiatric and substance-abusing patients are particularly vulnerable to the side effects of COVID-19, as evidenced by an uptick in recent months in both the amount of commentary and the amount of new data. Coexisting health conditions like diabetes, asthma, and heart disease are all associated with a wide range of risk factors for the COVID-19 virus infection [4]. These issues are likely to be exacerbated for those who suffer from both conditions. Since the emergence of COVID-19, a search of the PsycINFO database in January 2021 was conducted to identify studies published in English that dealt with the relationship between substance use, mental disorders, and the disease. Searches for relevant research studies and reviews were conducted in both directions. COVID-19’s unique impact on psychiatric and substance use disorders, including acute and long-term risks, multimorbidity, pharmacotherapy interactions, and challenges and opportunities regarding access to, and the provision of, appropriate and timely evidence-based treatment, is summarized in this review, which synthesizes these findings.
COVID-19 is a multi-system disease that requires a multi-faceted approach. A growing body of evidence suggests that COVID-19 has negative effects on multiple organ systems in addition to the respiratory system [5]. Following a bout of acute infection, there is increasing evidence of long-term consequences [6,7]. COVID-19’s acute and long-term effects on psychiatric and substance use disorders, such as suicidal ideation, psychosis, anxiety, and depression [8], have received increasing attention in the literature.
Acute COVID-19 survivors are more likely to suffer from anxiety and depression, as well as post-traumatic stress disorder (PTSD) [4–9]. About one in five (18.1%) of COVID-19 survivors had a psychiatric diagnosis within three months of their diagnosis, including 5.8% who had new-onset conditions, according to a recent US cohort analysis. A new diagnosis of a mental illness was associated with a risk more than twice as high as any other health event [4]. Early detection and intervention are essential to prevent a significant increase in the number of people with mental health issues, which can lead to other health problems, such as substance abuse disorders.
COVID-19 was found to be 65 and 80 percent more likely to be diagnosed with a psychiatric disorder in those with a recent 12-month or 3-year history of psychiatric diagnoses, respectively [4]. Having a mental illness may increase one’s risk of getting sick in the short term, but it may also have long-term consequences down the road. As to why these groups have a greater risk, it is unclear, but factors such as noncompliance with COVID-19 restrictions, physical health comorbidities, and smoking have been suggested [4].
In addition to the immediate effects of COVID-19 infection on individuals, the response to the pandemic itself may have long-term consequences. To slow the spread of the disease and lessen the strain on already overburdened healthcare systems, more than 180 countries have put in place a variety of restrictions [10,11]. It has included physical separation, partial or complete lockdown, closure of schools and offices, cancellation of public events and social occasions as well as requiring the use of protective gear such as face masks, restricting both domestic and international travel [10,11]. Despite their importance in slowing the spread of the virus and saving many lives, restrictions have had significant financial and social ramifications [4–12–13–14–15]. For those already suffering from mental health issues, the significant social upheaval has made them more vulnerable to isolation, with evidence showing that existing mental health issues have been amplified.
Reports from Australia’s First Nations’ response may be an exception to the general rule that COVID-19 and other restrictions have disproportionately affected marginalized populations. COVID-19-related complications are more likely to occur in First Nations people because they have higher rates of smoking and multiple chronic diseases compared to non-Indigenous Australians [17–20]. Only 149 cases of COVID-19 were reported among First Nation Australians in Australia’s COVID-19 epidemiology report (which included data up to 14 February 2021) despite these risk factors and the fact that First Nations people comprise 3.3 percent of the Australian population [17,21]. The rapid, collective response led by First Nations health leaders in the very early days of the pandemic is thought to be responsible for preventing widespread illness and death. This included the lobbying of all levels of government to close remote communities, help with protective equipment, testing, and contact tracing; the provision of staff training, accommodation for homeless people, and information via social media; and the establishment of partnerships with government and nongovernmental organizations to ensure culturally appropriate services were implemented [18].
Damian Jacob Markiewicz Sendler: Mental and substance abuse disorders are strongly linked to poor physical health across a wide range of domains, all of which increase the risk of contracting COVID-19 and developing more severe COVID-19-related complications if infected. In addition to confinement in a forensic, residential, or in-patient facility, people who smoke, are overweight, or have metabolic syndrome, hypertension, or cardiovascular disease are at an increased risk of infection or disease [28,29]. People with preexisting psychiatric symptoms may be exacerbated by fear and worry about being infected with the virus, social isolation and the lack of connectivity with others, distressing medical symptoms, and death.
Comorbid conditions present a special challenge for clinicians managing and treating COVID-19 in patients with mental health or addiction issues, especially those with well-tolerated prescriptions of pharmacotherapies. A recent review found that COVID-19 treatments may interact with psychiatric medications and pharmacotherapies for substance use disorders, such as SSRIs, SNRIs, tricyclic antidepressants, antipsychotics, mood stabilizers, benzodiazepines, methadone, and bupropion, posing potential safety risks. Respiratory distress, cardiovascular events, infections, coagulation, and delirium are all possible side effects of this medication [30]. The lack of data makes it difficult to draw conclusions about the magnitude of the risk associated with interactions between medications [30]. However, despite this uncertainty, general guidance on well-tolerated prescribing includes close monitoring of any risk interactions, assessment of psychotropic-related risk of respiratory depression, and provision of psychosocial interventions Additional information on possible interactions between COVID-19 experimental agents and pharmacotherapies has been compiled in an online ‘Interaction Checker’ [32].
The prevalence of homelessness, unstable or higher density housing, incarceration, and social disadvantage among people with substance use disorders is higher than the general population’s [22–27,33], all of which can increase the risk of COVID-19 transmission. Since many needle and syringe exchange programs have had difficulty providing the services they were designed to provide [34–35], some injectors have been forced to reuse or share their injecting equipment [33].
Damian Sendler
While the global public health response to COVID-19 places physical distance at the top of the priority list, it may inadvertently increase the risk of drug-related harms. People who use drugs should never do so alone, and someone else should be available to respond and call emergency services in the event of an overdose or other adverse event [34,36,37]. Conflicting guidance may force a choice between avoiding COVID-19 exposure, adhering to government orders, and using drugs safely [34,36].
Damien Sendler: Loneliness, self-isolation, financial stress, and suicidal ideation are all common in people with substance use disorders, and all of these factors can exacerbate their mental health problems [38]. Risk factors for someone who had previously stopped using substances to return or relapse, or increase their current use to “self-medicate” for mental health issues may also be present in these situations. [39–41]. Reduced access to drugs may exacerbate preexisting mental health issues. People may be tempted to purchase illicit substances from unrecognized and untrustworthy suppliers due to supply shortages caused in part by international travel restrictions [34,41,42]. It’s possible that COVID-19 and withdrawal symptoms (such as high body temperature and sweating and aches and pains) are interchangeable [23].
As a result of the classification of alcohol as a ‘essential’ commodity in many countries around the world, there has been an increase in its availability through home delivery and advertising, including targeted COVID-19 advertising [13,43,44]. Restrictions on COVID-19 and related alcohol consumption at home are likely to exacerbate financial, economic and social stressors, increasing the risk of experiencing or being exposed to domestic and family violence (including abuse of children), as well as underage consumption of alcohol and serious or traumatic injury and death.
Despite evidence that the COVID-19 pandemic has exacerbated mental health and substance use symptoms, public health responses introduced to reduce the transmission of COVID-19 have limited the ability of services and practitioners to provide and patients to access treatment. People with chronic co-occurring psychiatric and substance use disorders may be further marginalized by a healthcare system that prioritizes the urgency of COVID-19 patients when healthcare systems are under pressure and under-resourced [15,48]. In the event that symptoms recur or worsen, patients with these disorders may be unable to continue their current treatment plan, access medications, or attend new treatment sessions if their current provider does not accept new patients. Access to mental health services was reported to be a problem by Canadian youth in a cross-sectional study conducted in April 2020 [52]. Therapy/counselling, substance abuse, and psychiatric services were all listed as being unavailable. Among the US’s 18 opioid substitution therapy (buprenorphine) prescribers, one qualitative study found that many were reluctant to accept new patients or treat those who had no prior history with the service [50]. I However, those who require the most help are most likely to be overlooked by health care systems. Some patients refuse to attend appointments because they are afraid of being exposed to an infection because services and clinicians lack the capacity and resources to do so [31,53]. There were no studies or accounts of patients’ experiences using telehealth services that could be found in the literature.
Damian Jacob Sendler
Opioid substitution therapies have undergone rapid transformations around the world in an effort to maintain their availability. New regulations in North America allow pharmacists to adjust opioid substitution therapy doses, and restrictions on take-home doses have been relaxed in several countries, including Australia [23,53]. A coordinated approach is necessary for any changes to be implemented, even if they have to be made quickly in order to minimize the risk of treatment interruptions. When it comes to dosage adjustments, pharmacists should inform prescribing doctors and patients alike of any changes in dosages, as well as take the time to educate patients about possible side effects, such as possible drug interactions or contraindications.
Long-acting depot formulations of buprenorphine have been recommended in Australia to replace daily methadone/buprenorphine dosing and potentially be provided to those at risk of overdose or dose diversion, such as those stockpiling takeaway doses, using all doses quickly, and supplementing with other opioids [23,33]. The use of buprenorphine-naloxone in place of buprenorphine has also been recommended, along with take-home naloxone.
As a result of the outbreak, the potential for expanding the use of digital health interventions has increased dramatically. To help people with mental health and substance abuse issues, telehealth, which includes web, computer, and phone-based medicine can overcome many of the barriers that prevent them from receiving and receiving healthcare services. Access to those who are afraid of infection; those who live in rural or remote areas; those who are able to provide and access care wherever it is most convenient; and those who are able to reduce costs [42]. Many advantages come with using computers and telephones to identify high-risk situations (such as self-harm or suicidal ideation) where a person’s mental state and general behavior must be assessed. [54] Despite this, there has been some concern about this method. Some other logistical issues include the need for a smartphone and phone credit, a computer and stable internet coverage, and the ability of patients to engage in therapy in a well-tolerated and private therapeutic space. Equitable care is hampered by the inequity of technology availability and difficulties in locating it during the COVID-19 restrictions (e.g. in public libraries and other shared spaces) [51,54]. To ensure that digital health interventions are available to the most vulnerable members of our society will be a critical task for our future health systems and essential to the full utilization of digital technologies, the implementation of an e-mental health ecosystem will take some time.
As a result of the COVID-19 pandemic, healthcare systems around the world have undergone radical transformations. Additionally, as the pandemic and subsequent restrictions have progressed, there have been new opportunities to explore new models and think differently about how best to provide evidence-based care to those who are disproportionately affected by them. There is a general consensus that the virus will be with us for a long time, despite the development and current rollout of vaccines in many countries. Monitoring and modeling the effects of COVID-19 on substance use and psychiatric health at the national and local levels is essential. For the improvement of service capacity, linking and coordination, this type of evidence is essential.