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Case Reports
. 2020 Sep 1:274:1062-1067.
doi: 10.1016/j.jad.2020.05.149. Epub 2020 Jun 1.

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

G Anmella  1 , N Arbelo  2 , G Fico  3 , A Murru  3 , C D Llach  2 , S Madero  2 , S Gomes-da-Costa  1 , M L Imaz  2 , H López-Pelayo  4 , E Vieta  3 , L Pintor  5
Affiliations
Case Reports

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

G Anmella et al. J Affect Disord. .

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.

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Conflict of interest statement

Declaration of Competing Interest Dr. Anmella has received CME-related honoraria, or consulting fees from Janssen-Cilag, Lundbeck and Angelini and reports no financial or other relationship relevant to the subject of this article. Dr. Arbelo has received CME-related financing and travel grants from Janssen-Cilag and Lundbeck and reports no financial or other relationship relevant to the subject of this article. Dr. Fico has received CME-related honoraria, or consulting fees from Janssen-Cilag and Lundbeck. Dr. Llach has received CME-related financing and travel grants from Janssen-Cilag and reports no financial or other relationship relevant to the subject of this article. Dr. Madero has received travel grants and CME-related honoraria from Janssen-Cilag, Lundbeck, Pfizer and Angelini and reports no financial or other relationship relevant to the subject of this article. Dr. Gomes-da-Costa has received CME-related honoraria, or consulting fees from Janssen-Cilag, Lundbeck, Italfarmaco and Angelini and reports no financial or other relationship relevant to the subject of this article. Dr. López-Pelayo has received travel grants from the laboratories honoraria and travel grants from Janssen and Lundbeck. None of them has relationship with this research. Prof. Vieta has received research support from or served as consultant, adviser or speaker for AB-Biotics, Abbott, Actavis, Allergan, Angelini, AstraZeneca, Bristol-Myers Squibb, Dainippon Sumitomo Pharma, Ferrer, Forest Research Institute, Gedeon Richter, Glaxo-Smith-Kline, Janssen, Lundbeck, Otsuka, Pfizer, Roche, Sage pharmaceuticals, Sanofi-Aventis, Servier, Shire, Sunovion, Takeda, Telefónica, the Brain and Behaviour Foundation, the Spanish Ministry of Science and Innovation (CIBERSAM), the Seventh European Framework Programme (ENBREC), and the Stanley Medical Research Institute. All other authors declare no conflict of interests.

Figures

Fig. 1
Fig. 1
Personalized treatment recommendations for each presented real-case scenario. (A) Delirium in elderly population. (B) Severe mental illness in median aged patients with few medical comorbidities. (C) Non-SMI with depressive and/or anxiety symptoms. † Respiratory depression effects of antipsychotics and benzodiazepines need to be monitored, especially in delirium. ‡ Psychopharmacological treatments with risk of cardiotoxic interactions (most antipsychotics and antidepressants, lithium and methadone) should include an ECG evaluation with special attention to QTc interval and consider the presence of drug-inherent cardiac risks and co-existing cardiac risk factors. Abbreviations: ECG: electrocardiogram; IM: intramuscular; LAI: Long-acting injectable; LPV/r: lopinavir/ritonavir; PP1M: once-monthly LAI paliperidone palmitate; PP3M: once-every-3-months LAI paliperidone palmitate; SMI: severe mental illness; SSRI: Selective serotonin reuptake inhibitors.
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