COVID-19 inpatients with psychiatric disorders: Real-world clinical recommendations from an expert team in consultation-liaison psychiatry

J Affect Disord. 2020 Sep 1:274:1062-1067. doi: 10.1016/j.jad.2020.05.149. Epub 2020 Jun 1.

Abstract

Background: The management of coronavirus disease 2019 (COVID-19) in patients with comorbid psychiatric disorders poses several challenges, especially regarding drug interactions.

Methods: We report three representative case-scenarios on patients with psychiatric disorders and COVID-19 to provide a practical approach based on the existing literature and the clinical experience of an expert team in consultation-liaison psychiatry.

Case-centered recommendations: Psychopharmacological ongoing treatments should be prioritized and most doses should be reduced 25-50% of original dose if the patient receives lopinavir/ritonavir, with some exceptions including quetiapine, asenapine, olanzapine, sertraline, lamotrigine, bupropion, and methadone. If the psychopharmacological usual doses are in the low-to-median range levels, a dose change during COVID-19 drugs co-administration is not recommended, but only ECG and clinical monitoring of adverse effects and drug levels if required. Furthermore, when introducing a psychopharmacological drug, dose titration should be progressive, with ECG monitoring if cardiotoxic interactions are present. (A) In agitated delirium, olanzapine is recommended as first-line antipsychotic and quetiapine should be avoided. (B) In severe mental illness (SMI), essential treatments should be maintained. (C) In non-SMI with depressive/anxiety symptoms, psychological support should be provided and symptoms identified and treated.

Limitations: Most recommendations on pharmacological interactions provide only a limited qualitative approach and quantitative recommendations are lacking.

Conclusions: Patients with psychiatric disorders and COVID-19 should be managed on a personalized basis considering several clinical criteria and, should not be excluded from receiving COVID-19 treatments. Risks of pharmacological interaction are not absolute and should be contextualized, and most psychopharmacological treatments should include an ECG with special attention to QTc interval.

Keywords: COVID-19; Consultation liaison psychiatry; Interactions; Psychiatry; Psychodrug; Psychopharmacology.

Publication types

  • Case Reports
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Anti-Anxiety Agents / therapeutic use
  • Antidepressive Agents / therapeutic use
  • Antipsychotic Agents / therapeutic use
  • Betacoronavirus*
  • COVID-19
  • Coronavirus Infections / complications*
  • Coronavirus Infections / psychology
  • Female
  • Humans
  • Inpatients / psychology*
  • Male
  • Mental Disorders / complications*
  • Mental Disorders / psychology
  • Mental Disorders / therapy*
  • Middle Aged
  • Pandemics
  • Pneumonia, Viral / complications*
  • Pneumonia, Viral / psychology
  • Psychiatry
  • Referral and Consultation*
  • SARS-CoV-2

Substances

  • Anti-Anxiety Agents
  • Antidepressive Agents
  • Antipsychotic Agents