Webinars

The COVID-19 outbreak has profoundly impacted population mental health because of exposure to substantial psychosocial stress. An increase in incident cases of psychosis may be predicted. Clinical advice on the management of psychosis during the outbreak needs to be based on the best available evidence. We undertook a rapid review of the impact of epidemic and pandemics on psychosis at the end of March 2020. Fourteen papers met inclusion criteria.

Our findings included studies reporting an incident cases of psychosis in people infected with a virus of a range of 0.9% to 4%. Psychosis diagnosis was associated with viral exposure, treatments used to manage the infection, and psychosocial stress. We also found that clinical management of these patients, where adherence with infection control procedures is paramount, was challenging. We suggested that increased vigilance for psychosis symptoms in patients with COVID-19 is warranted. In addition, clinicians need to carefully consider how to support adherence to physical distancing requirements and engagement with services in patients with existing psychosis.

Three months on, the experiences of managing these challenges at Orygen’s clinical services will be reflected on as well as an update on primary research papers that have been published on the impact of COVID-19 on psychosis since our rapid review was undertaken.

Biography

Dr Ellie Brown (B.Sc. (Hons), PG Cert (oxon), Prof Doc CounsPsych) is a Postdoctorate Research Fellow at University of Melbourne/Orygen, as well as a registered counselling psychologist. She has worked with people with severe mental illness in a clinical and research capacity for over 12 years, in the UK, Qatar and Australia. In her research fellow role at Orygen, Dr Brown leads a program of work aiming at improving the engagement of young people experiencing a first episode of psychosis in holistic treatments and services. Key to this has been engaging clinicians in research projects, supporting them to implement meaningful service evaluation throughout their work and publish in the field.

In March/April 2020, Dr Brown led a rapid review of the impact of pandemics on psychosis which attracted considerable international media attention. Following on from this review, she is coordinating a survey of the impact of COVID-19 on Orygen clients experiencing early psychosis (FEP and UHR) in Australia.

Mental health services have quickly moved to the provision of virtual therapy to support service users (SUs) during the covid-19 pandemic. The PICuP team never stopped offering therapy but moved straight to the provision of virtual therapy. At a wider level, this switch has been welcomed by many service providers. However, the impact of moving from face to face provision to virtual provision is unknown.

It is possible that the move to virtual therapy will exacerbate existing inequalities in the provision of services. While some service users are already tech savvy and in possession of appropriate technology, others have little confidence and/or access to technology. Those service users who already face the greatest barriers to receiving effective therapy may also be those who have the least access to virtual therapy. We anticipate that many services may face pressures to reduce therapy spaces and provide more virtual than face to face therapy.

In this talk I will provide preliminary data from a survey of our service’s users. We are collecting information about their access to technology, their willingness to try virtual therapy and their views on returning to face to face therapy with adaptations for preventing the transmission of covid-19.

While this data is necessarily preliminary, it will, together with data from other services, begin to help us to position our services so as to provide our users with the choice of therapy that works best for them.

Biography

Dr Fergus Kane is a clinical psychologist working for the PICuP outpatient psychosis service at the Maudsley hospital and the National Psychosis Unit at the Bethlem hospital. He completed his MSc in neuroscience (2004), PhD in neuroimaging (2008) and doctorate in clinical psychology (2012) at the Institute of Psychiatry (now IoPPN), King’s College London. Dr Kane’s PhD focused on cognition and brain function in people with a diagnosis of bipolar disorder and he maintains a keen interest in this area.

As a clinician, Dr Kane has worked in three different countries (UK, Ireland and Ecuador). He recently returned from working in Ecuador to work at the South London and Maudsley NHS Trust. Dr Kane has a specialist clinical interest in working with people with psychosis and diagnoses of bipolar disorder, as well as in providing trauma focused care.

Dr Kane also has an interest in how technology can be harnessed to make therapy more useful and efficient. He recently joined together with other psychologists, academics and health technologists to develop the online group support tool, helpers. This is specifically designed to support people during the covid pandemic. https://www.helpers.tools

More information can be found his website, which he tries, but often fails, to keep updated.
http://www.ferguskane.com. If you’re not careful, he will also do his best to convince you to start riding a bike. 

Background
Clozapine, an antipsychotic with unique efficacy in treatment resistant psychosis, is associated with increased susceptibility to infection, including pneumonia.

Aims
To investigate associations between clozapine treatment and increased risk of COVID-19 in patients with schizophrenia-spectrum disorders who are receiving antipsychotic medications, using electronic health records data, in a geographically defined population in London.

Method
Using information from South London and Maudsley NHS Foundation Trust (SLAM) clinical records, via the Clinical Record Interactive Search system, we identified 6,309 individuals who had an ICD-10 diagnosis of schizophrenia-spectrum disorders and were taking antipsychotics at the time of the COVID-19 pandemic onset in the UK. People who were on clozapine treatment were compared with those on any other antipsychotic treatment for risk of contracting COVID-19 between 1 March and 18 May 2020. We tested associations between clozapine treatment and COVID-19 infection, adjusting for gender, age, ethnicity, BMI, smoking status, and SLAM service use.

Results
Of 6,309 patients, 102 tested positive for COVID-19. Individuals who were on clozapine had increased risk of COVID-19 compared with those who were on other antipsychotic medication (unadjusted HR = 2.62 (95% CI 1.73 - 3.96), which was attenuated after adjusting for potential confounders, including clinical contact (adjusted hazard ratio HR=1.76, 95% CI 1.14 - 2.72).

Conclusions
These findings provide support for the hypothesis that clozapine treatment is associated with an increased risk of COVID-19. Further research will be needed in other samples to confirm this association. Potential clinical implications are discussed.

Biography

After an intercalated BSc in Psychology and Basic Medical Sciences, Professor MacCabe qualified in medicine at the University of London in 1995 and completed his basic and higher specialist training in Psychiatry at the Maudsley Hospital from 1997 to 2004. He obtained a joint MRC/Department of Health Special Training Fellowship in Health of the population research in 2004, in collaboration with the Department of Medical Epidemiology and Biostatistics at Karolinska Institute, Stockholm. He obtained an MSc in Epidemiology from the London School of Hygiene and Tropical Medicine in 2006 and a PhD in 2008. In 2009 he was awarded a Clinical Senior Lectureship by the Higher Education Funding Council for England. He was awarded a personal chair as Professor of Epidemiology and Therapeutics at King's College London in 2019.

Professor MacCabe has been honorary consultant psychiatrist at the National Psychosis Unit since 2005, where he is responsible for treating inpatients with severe psychosis and conducting clinical trials. Prof MacCabe serves on the Board of Trustees of the mental health charity, SANE.

Professor MacCabe's research in treatment refractory schizophrenia personalised medicine mirrors his clinical work, and is geared towards helping people whose psychosis has not responded to standard antipsychotic treatment. His research includes work on the epidemiology, genetics and neurochemistry underlying treatment refractory schizophrenia, and identifying biomarkers that may be used in personalised medicine. Much of his research is conducted in collaboration with UK and international partners.

The COVID-19 pandemic is a significant psychosocial stressor. Further, the virus itself (SARS-CoV-2), and the associated host immunologic response, can directly impact the brain. Therefore, understanding post-COVID-19 neuropsychiatric sequelae, such as psychosis, is an area of pressing concern.

We review currently available literature of COVID-19-associated neuropsychiatric syndromes, while also drawing parallels from past viral outbreaks. Potential etiopathogenic mechanisms are also discussed.

Heterogeneous neuropsychiatric symptoms are seen in patients with acute COVID-19, including new-onset psychosis. Past viral outbreaks have demonstrated that psychotic symptoms may accompany acute viral infection, or may be delayed post-viral manifestations. In utero exposure to viral infection has been associated with increased risk of schizophrenia, but neurodevelopmental outcomes following in utero exposure to COVID-19 remain unknown. Mechanisms by which SARS-CoV-2 could impact brain and behavior include viral entry to neural tissue leading to neuroinflammation, latent infection of peripheral and central immune cells, propagation of cytokine storm, or by acting as a stimulating antigen in processes of molecular mimicry. However, these remain to be established.

SARS-CoV-2-related neuropsychiatric outcomes are starting to be described, and are likely to have a significant public health burden. Prospective neuropsychiatric monitoring of survivors is needed to fully understand and mitigate the long-term burden of COVID-19.

Biography

Dr. Troyer is a general and child and adolescent psychiatrist, and also a NIMH T32 post-doctoral research fellow in the Department of Psychiatry at the University of California, San Diego (UCSD).

Dr. Troyer completed medical school at the University of Toledo in Ohio, and her general psychiatry residency training at the University of Illinois at Chicago, where she also served as chief resident. She then completed fellowship training in child and adolescent psychiatry at UCSD, where she also served as a chief fellow, before transitioning to her current position as a research fellow.

Dr. Troyer is a member of the Hong Laboratory at UCSD, where the group focuses on understanding cellular immune and neuroendocrine mechanisms as they relate to neuropsychiatric and neurocognitive outcomes. Under the supervision of Dr. Suzi Hong, Dr. David Rosenberg, and Dr. Rob Knight, Dr. Troyer’s primary research focus is on understanding gut-brain-immune axis function in pediatric obsessive compulsive disorder, and she was recently awarded a pilot grant from the American Academy of Child and Adolescent Psychiatry to further pursue this work.
Since the beginning of the current pandemic, the Hong Laboratory has also started to explore potential neuropsychiatric sequelae of COVID-19 infection, particularly as they relate to immune-mediated mechanisms.