Addictions and mental health in the trans- and post-COVID-19 era: are we prepared to teach and treat?

Dependências e saúde mental na era trans e pós-COVID-19: estamos preparados para ensinar e tratar?

INTRODUCTION

The COVID-19 pandemic has reached its second year, leaving a trail of more than 5,570,000 deaths worldwide, and more than 621,000 in Brazil only¹. Figures are probably underestimated, ranging from underreporting of data due to technical challenges to active blocking of scientific information in our country for political reasons. COVID-19 demonstrated that the typical crisis approach had to move beyond the health sphere to include the handling of active political neglect along with health efforts. Mental health has been widely affected by the pandemic due to direct losses of millions of individuals – suffered by families, friends and colleagues². Specifically, addiction psychiatry had to quickly adapt to the rapidly emerging techniques to assist trainees and patients³. We focus this editorial on how training and treatment in our specialty has been affected by the pandemic, capitalizing on our experience inside a large teaching hospital of southern Brazil.

CONTEXT

Recent studies have shown that addicted patients were largely affected by the pandemic due to the increase in economic and psychosocial stressors, which escalated drug consumption and relapse – along with a severe reduction of services available due to the social distancing needs of the pandemic³,⁴. Analyses made by our group with the Datasus database – comparing the expectation of clinical treatment due to drug use with the actual number of hospitalizations after the beginning of the pandemic – showed a reduction of 19% in admissions for treatment of alcohol use disorders, 37% for crack use disorders and 19% for treatment of other drugs. This scenario induced many “parallel pandemics”², where the quality of mental health services – generally lower than that other health services in the country⁵ was deeply affected; also, there are subgroups of patients which suffer great neglect in Brazil – crack users, homeless patients, women, transsexuals and other minority populations. These are marked by multiple clinical and psychosocial vulnerabilities that impose additional complexity – adding even more weight on the shoulders of practitioners and trainees.

TRAINING AND ADAPTATION OF RESOURCES

Residents under training in Addiction Psychiatry dealt with a load of challenges in order to adapt to the emerging techniques in record time: many were admitted for training already during the pandemic; hospitals were semi-closed; all the practical, face-to-face teaching had to be either suspended or adapted; and patients and staff were masked⁶. For example, facial expression and body language learning – part of the psychiatric examination – had to be transported into a small screen⁷. Particularly in public hospitals and clinics, addiction patients have poor access to technologies such as a phone with good connection – yielding an extra burden to a treatment process that already deals with resistance on a daily basis. Residents were trained to encourage motivational techniques and relapse prevention protocols towards a healthier way of life while patients were forced to stay at home and deal with increasing loads of financial problems, family conflicts and anxiety – certainly demanding a greater amount of flexibility and empathy from their therapists to avoid slips and relapse. While the distance between patient and therapist made it impossible to perform urine screening tests or to analyze alcoholic breath, therapists in training were supervised to help overcome this limitation by involving family members in therapy sessions in order to have more perspective of what was really happening. However – as much as family members can certainly contribute to the treatment in most cases, many patients were not able to find a place for on-line sessions where they could feel enough privacy. Also – as much as some institutions rapidly organized the possibility to provide prescriptions by e-mail, some controlled prescriptions used in withdrawal protocols were impossible to provide on-line. At the same time, the pressure to understand how addicted patients perform in moments of crisis was a unique opportunity to explore and learn about the behavioral patterns concerning the addictive disorders. It also allowed trainees to understand how the environment can affect the way patients deal with their addiction⁸. This adaptation had to be done at a high cost, since trainees and their supervisors were forced to move out of their comfort zone in a rapid transition. Residents’ own wellbeing and emotional balance – as well as technical training – was key to enable the learning and practice processes to occur. Residents had to deal with personal issues like distance from home while their relatives were getting sick, with increasing demands related to grief, depression and anxiety among patients, themselves and their families. They also had to rapidly adapt their agendas to cover for colleague’s shifts while they were in quarantine or on leave for psychological reasons such as burnout. In addition to all the content programmed for the residency period, they needed to quickly learn about uncertainty, resilience and empathy – while caring for their own health and emotional balance. This meant to develop a dedicated trust at the information provided by peers and professors in the face of chaos, anguish and lack of knowledge about the course of the pandemic – in an environment where COVID-19 vaccination, masking and social distancing were played at for political – not exclusively health-related reasons.

LESSONS TAKEN TOWARDS THE FUTURE

In the face of an ongoing process of adapting to the current pandemic, institutions should be very clear to their residents about strategies to overcome the aforementioned difficulties, as well as to provide the best data about the pandemic, and what to expect from the future in realistic terms⁹,¹⁰. Professors and preceptors should be flexible and attentive to the difficulties faced by their trainees, always taking into consideration their residents’ mental and health wellbeing. Efforts such as the rapid development of multidisciplinary teams to provide psychological first aid to staff – as occurred in our institution – proved to be effective in curtailing most of the psychological, social and health crises that occurred in these last two years. Unlike many areas of medicine that quickly adapted to online consultations, there are still many doubts as to whether this is a format that should be fully incorporated in the field of addictions in the post-pandemic. There are emerging issues in the trans- and post-pandemic era to be addressed, and the invaluable lessons learned in the process will help shape the future of training and treatment in our field.

REFERENCES

• ¹
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  Love S. How to Support Residents During the COVID-19 Pandemic. Acad Med. 2020;95(11):e3-e4.

Publication Dates

• Publication in this collection
  25 Mar 2022
• Date of issue
  Jan-Mar 2022

History

• Received
  26 Jan 2022
• Accepted
  07 Feb 2022