Impact de la pandemie COVID-19 sur la mortalite hospitaliere des patients schizophrenes pris en charge pour une affection autre que le COVID-19.

Introduction: L'impact de la priorisation des ressources lors de la pandemie COVID 19 sur la prise en charge des populations les plus vulnerables (non atteintes de COVID-19) comme les patients atteints de schizophrenie a ete peu documentee alors que des disparites de prise en charge de cette population avaient deja ete demontrees avant meme la pandemie. L'objectif de l'etude etait d'etablir si l'impact de la pandemie de COVID-19 sur la mortalite hospitaliere non-COVID-19 et l'acces aux soins hospitaliers differait entre les patients atteints de schizophrenie et ceux sans trouble mental severe. Methodes: A partir des donnees nationales du PMSI, nous avons selectionne toutes les hospitalisations aigues (MCO) non liees a la COVID-19 dans la periode pre-COVID-19 (du 15r mars 2019 au 31 decembre 2019) et COVID-19 (du 15r mars 2020 au 31 decembre 2020) et inclus les patients atteints de schizophrenie pour les apparier a des patients sans trouble mental severe (ratio 1:10) sur l'age et le sexe. En utilisant une approche de difference de la difference, nous avons realise des modeles de regression logistique multivaries avec ajustement sur differents facteurs. Resultats: Au total, 198 186 patients atteints de schizophrenie ont ete apparies avec 1 981 860 temoins. La mortalite hospitaliere a 90 jours chez les patients atteints de schizophrenie a augmente significativement plus par rapport aux temoins (+0,47 % versus +0,21 %;OR ajuste=1,18;p<0,001);le taux d'admission en reanimation a stagne pour les patients schizophrenes alors qu'il a augmente pour les temoins (0,00 % versus +,.85 %;ORajuste=0,93, p<0,001). Discussion/Conclusion: Ces resultats suggerent une plus grande deterioration de l'acces, de l'efficacite et de la securite des soins aigus non COVID-19 chez les patients atteints de schizophrenie par rapport aux patients sans troubles mentaux severes et soulignent l'importance de developper des strategies specifiques pour les patients vulnerables en prevision des futures urgences de sante publique. Mot-cles: Schizophrenia, Mental disorders, Psychiatry, Health services research, Public health, COVID-19 disparities. Declaration de liens d'interets: LB has received honoraria/has been a consultant for Lundbeck. P-ML has been a consultant and/or advisor to or has received honoraria from from Eli-Lilly, Janssen, Lundbeck, Otsuka and Teva, GF has received honoraria/has been a consultant for Lundbeck and Eisai. The other authors declare no competing interests.Copyright © 2023

Impact de la pandémie COVID-19 sur la mortalité hospitalière des patients schizophrènes pris en charge pour une affection autre que le COVID-19

Introduction L'impact de la priorisation des ressources lors de la pandémie COVID 19 sur la prise en charge des populations les plus vulnérables (non atteintes de COVID-19) comme les patients atteints de schizophrénie a été peu documentée alors que des disparités de prise en charge de cette population avaient déjà été démontrées avant même la pandémie. L'objectif de l'étude était d'établir si l'impact de la pandémie de COVID-19 sur la mortalité hospitalière non-COVID-19 et l'accès aux soins hospitaliers différait entre les patients atteints de schizophrénie et ceux sans trouble mental sévère. Méthodes A partir des données nationales du PMSI, nous avons sélectionné toutes les hospitalisations aiguës (MCO) non liées à la COVID-19 dans la période pré-COVID-19 (du 15r mars 2019 au 31 décembre 2019) et COVID-19 (du 15r mars 2020 au 31 décembre 2020) et inclus les patients atteints de schizophrénie pour les apparier à des patients sans trouble mental sévère (ratio 1:10) sur l'âge et le sexe. En utilisant une approche de différence de la différence, nous avons réalisé des modèles de régression logistique multivariés avec ajustement sur différents facteurs. Résultats Au total, 198 186 patients atteints de schizophrénie ont été appariés avec 1 981 860 témoins. La mortalité hospitalière à 90 jours chez les patients atteints de schizophrénie a augmenté significativement plus par rapport aux témoins (+0,47 % versus +0,21 %;OR ajusté=1,18;p<0,001);le taux d'admission en réanimation a stagné pour les patients schizophrènes alors qu'il a augmenté pour les témoins (0,00 % versus +,.85 %;ORajusté=0,93, p<0,001). Discussion/Conclusion Ces résultats suggèrent une plus grande détérioration de l'accès, de l'efficacité et de la sécurité des soins aigus non COVID-19 chez les patients atteints de schizophrénie par rapport aux patients sans troubles mentaux sévères et soulignent l'importance de développer des stratégies spécifiques pour les patients vulnérables en prévision des futures urgences de santé publique. Mot-clés Schizophrenia, Mental disorders, Psychiatry, Health services research, Public health, COVID-19 disparities. Déclaration de liens d'intérêts LB has received honoraria/has been a consultant for Lundbeck. P-ML has been a consultant and/or advisor to or has received honoraria from from Eli-Lilly, Janssen, Lundbeck, Otsuka and Teva, GF has received honoraria/has been a consultant for Lundbeck and Eisai. The other authors declare no competing interests.

Psychotropics and COVID-19: An analysis of safety and prophylaxis.

The use of psychotropics during the COVID-19 pandemic has raised two questions, in order of importance: first, what changes should be made to pharmacological treatments prescribed to mental health patients? Secondly, are there any positive side effects of these substances against SARS-CoV-2? Our aim was to analyze usage safety of psychotropics during COVID-19; therefore, herein, we have studied: (i) the risk of symptomatic complications of COVID-19 associated with the use of these drugs, notably central nervous system activity depression, QTc interval enlargement and infectious and thromboembolic complications; (ii) the risk of mistaking the iatrogenic impact of psychotropics with COVID-19 symptoms, causing diagnostic error. Moreover, we provided a summary of the different information available today for these risks, categorized by mental health disorder, for the following: schizophrenia, bipolar disorder, anxiety disorder, ADHD, sleep disorders and suicidal risk. The matter of psychoactive substance use during the pandemic is also analyzed in this paper, and guideline websites and publications for psychotropic treatments in the context of COVID-19 are referenced during the text, so that changes on those guidelines and eventual interaction between psychotropics and COVID-19 treatment medication can be reported and studied. Finally, we also provide a literature review of the latest known antiviral properties of psychotropics against SARS-CoV-2 as complementary information.

[Challenges for psychotropics in the context of the SARS-Cov-2 pandemic]. / Enjeux de l'utilisation des psychotropes dans le cadre de la pandémie au SARS-Cov-2.

French recommendations have been proposed for psychotropics use and possible adaptations during the SARS-CoV-2 epidemic. Between uncertainties linked to the lack of data and speculations about possible benefits of psychotropics against the coronavirus, we propose here elements allowing to base the pharmacotherapeutic decisions potentially useful in Covid+ patients with psychiatric disorders.

[Informations on psychotropics and their adaptations for patients suffering from mental disorders in France during the SARS-CoV-2 epidemic]. / Informations relatives aux psychotropes et à leurs adaptations éventuelles pour les patients souffrant de troubles psychiques en France pendant l'épidémie à SARS-CoV-2.

The 2019-20 coronavirus pandemic (SARS-CoV-2; severe acute respiratory syndrome coronavirus 2) has dramatic consequences on populations in terms of morbidity and mortality and in social terms, the general confinement of almost half of the world's population being a situation unprecedented in history, which is difficult today to measure the impact at the individual and collective levels. More specifically, it affects people with various risk factors, which are more frequent in patients suffering from psychiatric disorders. Psychiatrists need to know: (i) how to identify, the risks associated with the prescription of psychotropic drugs and which can prove to be counterproductive in their association with COVID-19 (coronavirus disease 2019), (ii) how to assess in terms of benefit/risk ratio, the implication of any hasty and brutal modification on psychotropic drugs that can induce confusion for a differential diagnosis with the evolution of COVID-19. We carried out a review of the literature aimed at assessing the specific benefit/risk ratio of psychotropic treatments in patients suffering from COVID-19. Clinically, symptoms suggestive of COVID-19 (fever, cough, dyspnea, digestive signs) can be caused by various psychotropic drugs and require vigilance to avoid false negatives and false positives. In infected patients, psychotropic drugs should be used with caution, especially in the elderly, considering the pulmonary risk. Lithium and Clozapine, which are the reference drugs in bipolar disorder and resistant schizophrenia, warrant specific attention. For these two treatments the possibility of a reduction in the dosage - in case of minimal infectious signs and in a situation, which does not allow rapid control - should ideally be considered taking into account the clinical response (even biological; plasma concentrations) observed in the face of previous dose reductions. Tobacco is well identified for its effects as an inducer of CYP1A2 enzyme. In a COVID+ patient, the consequences of an abrupt cessation of smoking, particularly related with the appearance of respiratory symptoms (cough, dyspnea), must therefore be anticipated for patients receiving psychotropics metabolized by CYP1A2. Plasma concentrations of these drugs are expected to decrease and can be related to an increase risk of relapse. The symptomatic treatments used in COVID-19 have frequent interactions with the most used psychotropics. If there is no curative treatment for infection to SARS-CoV-2, the interactions of the various molecules currently tested with several classes of psychotropic drugs (antidepressants, antipsychotics) are important to consider because of the risk of changes in cardiac conduction. Specific knowledge on COVID-19 remains poor today, but we must recommend rigor in this context in the use of psychotropic drugs, to avoid adding, in patients suffering from psychiatric disorders, potentially vulnerable in the epidemic context, an iatrogenic risk or loss of efficiency.

[Ensuring mental health care during the SARS-CoV-2 epidemic in France: A narrative review]. / Assurer les soins aux patients souffrant de troubles psychiques en France pendant l'épidémie à SARS-CoV-2.

OBJECTIVE: The lack of ressources and coordination to face the epidemic of coronavirus raises concerns for the health of patients with mental disorders in a country where we keep in memory the dramatic experience of famine in psychiatric hospitals during the Second World War. This article aims at proposing guidance to ensure mental health care during the SARS-CoV epidemy in France. METHODS: Authors performed a narrative review identifying relevant results in the scientific and medical literature and local initiatives in France. RESULTS: We identified four types of major vulnerabilities in patients suffering from mental disorders during this pandemic: (1) medical comorbidities that are more frequently found in patients suffering from mental disorders (cardiovascular and pulmonary pathologies, diabetes, obesity, etc.) which represent risk factors for severe infections with Covid-19; (2) age (the elderly constituting the population most vulnerable to coronavirus); (3) cognitive and behavioral troubles which can hamper compliance with confinement and hygiene measures and finally and (4) psychosocial vulnerability due to stigmatization and/or socio-economic difficulties. Furthermore, the mental health healthcare system is more vulnerable than other healthcare systems. Current government plans are poorly adapted to psychiatric establishments in a context of major shortage of organizational, material and human resources. In addition, a certain number of structural aspects make the psychiatric institution particularly vulnerable: many beds are closed, wards have a high density of patients, mental health community facilities are closed, medical teams are understaffed and poorly trained to face infectious diseases. We could also face major issues in referring patients with acute mental disorders to intensive care units. To maintain continuity of psychiatric care in this pandemic situation, several directions can be considered, in particular with the creation of Covid+ units. These units are under the dual supervision of a psychiatrist and of an internist/infectious disease specialist; all new entrants should be placed in quarantine for 14 days; the nurse staff should benefit from specific training, from daily medical check-ups and from close psychological support. Family visits would be prohibited and replaced by videoconference. At the end of hospitalization, in particular for the population of patients in compulsory ambulatory care situations, specific case-management should be organized with the possibility of home visits, in order to support them when they get back home and to help them to cope with the experience of confinement, which is at risk to induce recurrences of mental disorders. The total or partial closure of mental health community facilities is particularly disturbing for patients but a regular follow-up is possible with telemedicine and should include the monitoring of the suicide risk and psychoeducation strategies; developing support platforms could also be very helpful in this context. Private psychiatrists have also a crucial role of information with their patients on confinement and barrier measures, but also on measures to prevent the psychological risks inherent to confinement: maintenance of sleep regularity, physical exercise, social interactions, stress management and coping strategies, prevention of addictions, etc. They should also be trained to prevent, detect and treat early warning symptoms of post-traumatic stress disorder, because their prevalence was high in the regions of China most affected by the pandemic. DISCUSSION: French mental healthcare is now in a great and urgent need for reorganization and must also prepare in the coming days and weeks to face an epidemic of emotional disorders due to the containment of the general population.

[Psychopharmacotherapeutic guidelines : a challenge during health crisis]

The construction of pharmacological guidelines is a complex endeavor, and this is all the truer amidst a health crisis such as the current SARS-CoV-2 pandemic. In psychiatric settings, guidelines have to consider the handling of other drugs (i.e., psychotropic medications), that have been suggested as potentially prophylactic for COVID-19. These dialectics are discussed here, and the methodological foundations used for the elaboration of guidelines are put forward.

Ensuring mental health care during the SARS-CoV-2 epidemic in France: A narrative review.

OBJECTIVE: The lack of resources and coordination to face the coronavirus epidemic raises concerns for the health of patients with mental disorders in a country where we still have memories of the dramatic experience of famine in psychiatric hospitals during the Second World War. This article aims to propose guidance to ensure mental health care during the SARS-CoV epidemic in France. METHODS: The authors performed a narrative review identifying relevant results in the scientific and medical literature and in local initiatives in France. RESULTS: We identified four types of major vulnerabilities among patients with mental disorders during this pandemic: (1) medical comorbidities that are more frequently found among patients with mental disorders (cardiovascular and pulmonary pathologies, diabetes, obesity, etc.) which are risk factors for severe covid-19 infection; (2) age (the elderly form the population most vulnerable to the coronavirus); (3) cognitive and behavioural disorders, which can hamper compliance with confinement and hygiene measures and finally and (4) psychosocial vulnerability as a result of stigmatization and/or socio-economic difficulties. Furthermore, the mental health healthcare system is more vulnerable than other healthcare systems. Current government plans are poorly suited to psychiatric establishments in a context of major shortages of organizational, material and human resources. In addition, a certain number of structural aspects make the psychiatric institution particularly vulnerable: many beds have been closed, wards have high densities of patients, mental health community facilities are closed, and medical teams are understaffed and poorly trained to face infectious diseases. There are also major issues when referring patients with acute mental disorders to intensive care units. To maintain the continuity of psychiatric care in this pandemic situation, several directions can be considered, in particular with the creation of "COVID+ units". These units are under the dual supervision of a psychiatrist and an internist/infectious disease specialist; all new entrants are placed in quarantine for 14 days; the nursing staff receives specific training, daily medical check-ups and close psychological support. Family visits are prohibited and replaced by videoconference. At the end of hospitalization, in particular for the population of patients in compulsory ambulatory care situations, specific case-management are organized with the possibility of home visits, in order to support patients when they get back home and to help them cope with the experience of confinement, which is liable to induce recurrences of mental disorders. The total or partial closure of community mental health facilities is particularly disturbing for patients, but a regular follow-up is possible with telemedicine and should include the monitoring of suicide risk and psycho-education strategies; developing support platforms could also be very helpful in this context. Private practice psychiatrists also have a crucial role of information towards their patients on confinement and barrier measures, and also on measures to prevent the psychological risks inherent in confinement: maintenance of regular sleep r, physical exercise, social interactions, stress management and coping strategies, prevention of addictions, etc. They should also be trained to prevent, detect and treat early warning symptoms of post-traumatic stress disorder, because their prevalence was high in the regions of China most affected by the pandemic. DISCUSSION: French mental healthcare is now facing a great and urgent need for reorganization and must also prepare in the coming days and weeks to face an epidemic of emotional disorders due to the confinement of the general population.