Decision No. 2057/QD-BYT dated May 14, 2020 on issuance of specialized document on “Guidelines for mental health care during Covid-19 epidemic”

DECISION

ISSUANCE OF SPECIALIZED DOCUMENT ON “GUIDELINES FOR MENTAL HEALTH CARE DURING COVID-19 EPIDEMIC”

MINISTER OF HEALTH

Pursuant to Law on prevention and control of infectious diseases dated 2007;

Pursuant to the Law on Medical Examination and Treatment in 2009;

Pursuant to Decree No. 75/2017/ND-CP dated June 20, 2017 of the Government on functions, tasks, powers, and organizational structure of the Ministry of Health;

Pursuant to Decision No. 170/QD-TTg dated January 30, 2020 of Prime Minister on establishment of Nation Steering Committee for management of pneumonia caused by novel Corona virus;

At the request of the Director General of the Vietnam Administration of Medical Services and Ministry of Health,

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Article 1.Attached to Decision is the document on “Guidelines for mental health care during Covid-19 epidemic”.

Article 2.The specialized document on “Guidelines for mental health care during Covid-19 epidemic” shall be applied at nationwide medical examination and treatment establishments

Article 3.This Decision comes into effect from the day of signing.

Article 4.Chief of the Ministry Office, Chief Ministry Inspectorate, Director General, Directors of General Departments, Departments affiliated to Ministry of Health, Directors of Departments of Health of provinces and central-affiliated cities, Chairpersons of Hospitals and Institutes affiliated to Ministry of Health, heads of medical sector shall implement this Decision./.

PP. MINISTER
DEPUTY MINISTER




Nguyen Truong Son
Heads of Treatment Sub-division – National Steering Committee for COVID-19 epidemic management

GUIDELINES

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LIST OF MEMBERS OF COUNCIL FOR COMPILATION AND APPRAISAL OF “GUIDELINES FOR MENTAL HEALTH CARE DURING COVID-19 EPIDEMIC”

Chief Editor

Assoc. Prof. Dr. Nguyen Truong Son

Associate chief editors

Assoc. Prof. Dr. Luong Ngoc Khue

Dr. Nguyen Doan Phuong

Participants in compilation and appraisal

Dr. Tran Thi Ha An

Dr. Vu Thy Cam

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Dr. Nguyen Van Dung

Dr. Vuong Anh Duong

Specialist Level 2 Dr. Vo Thanh Dong

Dr. Le Thi Thu Ha

Specialist Level 2 Dr. Do Huy Hung

Dr. Nguyen Manh Hung

M.S. Nguyen Trong Khoa

M.S. Nguyen Trong Khoa

Specialist Level 2 Dr. Ngo Hung Lam

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M.S. Duong Minh Tam

M.S. Dang Duy Thanh

Specialist Level 2 Dr. Lam Tu Trung

M.S. Lai Duc Tuong

M.S. Cao Van Tuan

Assoc. Prof. Nguyen Van Tuan

M.S. Dang Thanh Tung

Secretaries

M.S. Dang Thanh Tung

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BSc. Do Thi Thu

TABLE OF CONTENTS

Section I. Recommendations on prevention and of psychological trauma during COVID-19 epidemic.

1. For general public

2. For medical employees

3. Heads or managers of health facilities

4. Childcare workers

5. Senior care workers.

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7. Recommendations for individuals suffering from mental illnesses.

Section II. Detection and handling of primary mental disorders of individuals suspected to have been infected or infected with COVID-19.

Section III. Management and treatment of mental illnesses.

1. General guidelines.

2. Patients with severe developments or under emergency mental conditions requiring hospitalization.

3. Notice on treatment of individuals whose existing conditions are mental disorders

REFERENCE

GUIDELINES

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Section I. Recommendations on prevention and of psychological trauma during COVID-19 epidemic.

1. For general public

1.1. Do not discriminate but empathize with individuals influenced by the COVID-19, including those who are in Vietnam and those who are from other countries.  Infected persons do nothing wrong. Do not refer to infected persons as “victims” or “COVID-19 families”. They are “persons infected with COVID-19”, “persons receiving treatment for COVID-19” and “persons recovering from COVID-19” whose lives will proceed as normal with jobs, families and relatives after recovery.

1.2. Do not watch, read or listen to news that evokes anxiety or sorrow; only search for information which suggests practical actions to protect yourself and relatives. Look up updated information at specific time in a day once or twice. Anyone will feel anxious when faced with unexpected and nearly continuous streams of information on the epidemic. Search for reliable and accurate information from Ministry of Health (https://ncov.moh.gov.vn/), World Health Organization (WHO), etc. for example, to best distinguish facts from fiction.

1.3. Protect yourself and assist others. Assist others when they need help which may benefit both helpers and beneficiaries.

1.4. Seek for opportunities to spread positive stories and images of locals who were infected with COVID-19 and recovered or persons who helped their relatives with recovery and are ready to share the experiences.

1.5. Honor care workers and medical personnel helping persons infected with COVID-19 in your community. Recognize their efforts in treating, preventing spreading infection and keeping your relatives safe.

2. For medical employees

2.1. Medical employees, you and your colleagues may experience tension which is relatively normal in current epidemic scenario. Tension and related emotions do not mean that you are incapable of performing your work or that you are weak. Controlling your tension and states of mind is as importance as managing your physical fitness.

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2.3. Some medical employees may unfortunately be alienated by their families or community due to discrimination or fear of infection which may further worsen an already deteriorated situation. Try to maintain contact with your relatives, including doing so via digital devices.  Seek assistance from your colleagues, manages or other reliable persons – colleagues who may also have similar experiences.

2.4. Use comprehensive methods to share messages with persons with psychological, recognition or intellectual disabilities. Utilize many different methods of communication.

3. Heads or managers of health facilities:

3.1. Regularly keeping all employees from anxiety and poor mental states while responding to COVID-19 epidemic means they will accomplish the task more successfully.

3.2. Ensure information and communication affairs to provide all employees with accurate and up-to-date information.  Transfer employees from positions with high tension to positions with lower tensions. Assign persons with less experience to work alongside colleagues with more experience. Install systems for assisting, monitoring tension and enforcing safety procedures. Provide assurance for employees working in community in groups. Initiate, encourage and supervise short breaks. Implement flexible working schedules for employees directly influenced or employees whose family members are influenced by traumatic events.

3.3. Enable and ensure that employees can access mental and psychological health services when necessary. Heads or managers may also face factors of tension similar to their employees and potentially more depending on their roles and responsibilities. Therefore, regulations and methods mentioned above are also applied to managers. Meanwhile, managers may also adopt self-care methods to reduce tension and enable everyone to follow.

3.4. Provide guidelines for persons participating in epidemic management including medical employees, ambulance drivers, volunteers, persons classifying cases of epidemic, leaders of local governments and employees in quarantine zones on provision of basic psychological assistance for affected individuals.

4. Childcare workers

4.1. Help children find positive ways to express disturbing emotions namely fear and sorrow. Each child has his/her own way of expressing emotions. Participation in an activity promoting creativity namely playing and drawing may occasionally help this process. Children will feel relief if they can express their anxiety and be understood in a safe and supportive environment.

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4.3. Maintain usual daily routines as much as possible, especially when children are kept at homes. Provide compelling activities according to ages. Encourage children to play and communicate with others as much as possible, permit communication within family even when social contact limitation is advised.

4.4. In times of tension and depression, children usually seek for bonding and demand more from their parents. Talk to your children on the COVID-19 epidemic with honest and age-appropriate information. If your children express confusion, working together to solve the confusion will reduce their anxiety. Children will seek hints for ways of controlling their emotions in behaviors and emotions of adults in difficult times.

5. Senior care workers.

5.1. Seniors, especially those who are isolated and those who are suffering from cognitive impairment and/or dementia may turn anxious, angry, tense, agitated and reserved even more in case of epidemic quarantined.  Provide practical physical and mental assistance via unofficial networks (family) and medical employees.

5.2. Simply tell them about what is going on and provide clear information on how to reduce risk of infection by using language comprehensible to the seniors and/or people with cognitive impairment. Repeat the information if necessary. Instructions given to the seniors must be delivered clearly, coherently, patiently and in a respectful manner; information displayed in text or images can be beneficial.  Encourage their families and other assistance networks to provide information and assist the seniors in adopting preventive measures (e.g. washing hands, etc.)

5.3. Encourage seniors with specialties, experience and health to volunteer for community activities responding to COVID-19 epidemic (e.g. healthy retired seniors may provide assistance, watch over neighbors and look after children of medical employees who must stay in hospitals during the war against COVID-19.)

6. Quarantined persons

6.1. Keep contact and maintain your social relations. Even when quarantined, try your best to maintain your daily routine. If health authorities recommend limited social interaction to prevent epidemic spread, you can maintain connection via phone, e-mail, social networks and online conferences.

6.2. In times of tension, pay attention to your own needs and emotions. Participate in healthy activities that you enjoy and find relaxing. Regularly exercise, keep good sleep habits and use food healthily.  Look at things in the picture. Public health authorities and medical experts in all countries are trying to control the epidemic outbreak to ensure the best care for affected people.

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7. Recommendations for individuals suffering from mental illnesses.

In order to assist prevention of COVID-19 epidemic effectively, in addition to measures recommended by Ministry of Health to prevent the epidemic, individuals suffering from mental illnesses must:

7.1. prepare everything necessary in case infected with COVID-19 or quarantined, especially medication for your mental illnesses for 1 to 3 months of treatment as per the law.

7.2. do not deliberately suspend or cease medication for chronic mental illnesses. If periodic follow-up examinations are delayed due to the epidemic, participate in remote medical consultancy with medical employees according to appointment and ensure maintenance of current treatment regimen until the next estimated follow-up examinations.   Cooperate with medical employees in providing adequate information on illness development and receiving treatment during remote consultancy to receive appropriate adjustment.

7.3. learn simple physical exercises that can be performed at home or in quarantine to maintain mobility and reduce boredom.

7.4. maintain daily routines and habits as much as possible or create new habits in new environment, including regular exercise, hygiene, daily activities/work, recreational activities or other activities. Maintain regular contact with relative (e.g. via phone, e-mail, social media or video calls).

7.5. provide adequate address and phone number to contact when necessary (of hospitals, pharmacies, doctors, relatives, groceries, etc.).

7.6. provide adequate information on current mental illness treatment regimen upon infected with COVID-19 or other illnesses to avoid disadvantageous drug interactions and appropriately adjust doses of medication for mental illnesses when medication for COVID-19 or other illnesses is required.

7.7. stringently comply with guidelines for preventing spread of COVID-19 in provinces and health facilities to protect yourself, people around you and medical employees from infection.

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1. Provide basic social psychological assistance for individuals potentially infected with COVID-19 by asking about their needs and concerns and try to solve them. Ask people about their needs and concerns attentively in addition to diagnosis, estimation, other social affairs and/or professions.  Listen carefully in order to understand what the most important thing is for them at the time and help them discover their priorities. Provide accurate information on conditions and treatment plans of the individuals using comprehensible and common languages. Help people solve their emergency needs and concerns and make decisions if necessary. Help individuals connect with their relatives and social assistance, including via phones or internet if necessary.

2. Individuals diagnosed with COVID-19 who may display anxiety and depression, especially those who must be hospitalized, due to acute stress from worrying for their health or health of others must be intervened and assisted. Factors leading to acute stress may trigger new symptoms or worsen current mental conditions or hidden mental conditions. Actions:

a) Consider popularity of anxiety and symptoms of depression during the COVID-19 epidemic, timely assessment and identification must be performed. Social assistance strategies are initial intervention for short-term control of new-found anxiety and symptoms of depression during the COVID-19 epidemic.

b) With respect to individuals displaying symptoms of anxiety, consider social psychological assistance strategies namely psychological support or stress control (including relaxing techniques and mindfulness)^i,ii,iii. If their anxiety includes great grief which cannot be eased by social psychological assistance strategies, especially in hospitals, consider the use of medication. Benzodiazepines may be used for a short period to reduce anxiety caused by great grief but with extreme care due to risk of confusion and hypoventilation during the COVID-19 epidemic, as well as risk of drug tolerance and dependence. If benzodiazepines are used, prioritize drugs with short half-life^iv. Prioritize the lowest dose over the shortest period possible.  Avoid injection and use of benzodiazepines in high dose or over prolonged period.

c) With respect to individuals suffering from depression, consider short psychological interventions based on cognitive behavioral therapy, problem-solving therapy and relax if possible^v.  If their symptoms cannot be controlled or become overwhelmed (e.g. prolonged or very severe), they may suffer from hidden depression disorders and must be physically examined by doctors specialized in psychology.

d) If an individual previously diagnosed with anxiety or depression disorders and has taken psychotropic drugs, carefully consider whether or not the use (or ceasing of use) of these medications will influence symptoms of COVID-19. Decisions on ceasing, adjusting the dose or readministering any new psychotropic drugs by individuals infected with COVID-19 must be analyzed in terms of benefits and risks carefully and consulted doctors specialized in psychology (if possible).

3. Persons infected with COVID-19 have a high risk of facing sleep-related problems due to acute stress reactions and other reasons for hospitalized persons namely environmental factors, infiltration techniques (e.g. mechanical ventilation) and regular combination of multiple types of medication which may cause sleep disorders^vi,vii. Actions:

a) Social psychological assistance strategies are initial interventions to control sleep-related problems in case of acute stress^viii. In case of hospitalized individuals, deal with environmental factors that potentially cause sleep disorders (e.g. reduce excessive lighting and noise at night). Patients may receive guidance on sleep hygiene (including avoidance of stimulants such as caffeine, nicotine or alcohol) and stress control (including relaxing techniques and mindfulness) to reduce stress disorders. May consider psychological intervention based on principles of cognitive behavioral therapy if possible. If social psychological assistance strategies are ineffective and patients suffer from severe sleep disorders and/or sleep-related problems influence medical care, may consider use of sleep aids such as trazodone but with great care due to ability to cause hypoventilation of most sedatives^ix.

b) If sleep aids are used, use the minimum dose that takes effect in the shortest time possible and does not combine with other sedatives.

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a) Delirium is considered a medical emergency since it is related to hidden severe illnesses thus doctors should immediate assess persons infected with COVID-19 who are suffering from delirium. With respect to persons hospitalized due to COVID-19, adopt measures to prevent and deal with all hidden causes leading to delirium.

b) Provide adequate measures to prevent delirium including monitoring oxidation and epidemic development, adjusting any irregularities regarding metabolites or endocrine activities, dealing with coinfection, reducing use of medications that potentially cause or worsen delirium (namely analgesics, anticholinergic drugs or opioid analgesics), maintaining sleep cycle as much as possible, regularly helping patients with reorientation and explaining medical techniques whenever possible.

c) In case of delirium and the patient is agitated (defined to be visibly anxious or hyperactive, usually accompanied by nervous), adopt comforting communicating strategies and try to reorient the patient. Beware that acute pain due to bodily illnesses or dyspnea is the cause of agitation thus must be dealt with immediately. If the patient remains agitated and suffers serious difficulty, utilize psychotropic drugs to prevent further harms^x.

d) When using psychotropic drugs, consider side effects that potentially worsen symptoms of COVID-19 including overly-calm, respiratory functions, cardiac functions, risks of fever, other immunity irregularities or coagulation irregularities and irregular drug interaction. In case of severe agitation, may consider use of low-dose antipsychotics including haloperidol via oral administration or intramuscular injection, or risperidone via oral administration. Use the minimum dose that is effective at the lowest frequency and takes effect in the shortest time possible; the dose shall be adjusted based on age, comorbidity of bodily illnesses and severity^xi. If the patient remains severely agitated despite administering antipsychotics, consider use of benzodiazepines, prioritize those with short half-life^xii. Prioritize the lowest dose over the shortest period possible.

Section III. Management and treatment of mental illnesses.

1. General guidelines.

a) Comply with general provisions on COVID-19 epidemic management in health facilities prescribed by Ministry of Health

b) Medical examination and treatment establishments must publicize their hotlines and other methods of remote communication to ensure that patients can access mental health care services.

c) In case of recent exposure to mental disorders:

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- In case patients must be examined at the establishments, the medical examination and treatment establishments shall instruct the patients to visit the nearest psychiatric medical examination and treatment establishments.  If the case exceeds their capacity, medical employees may consult expertise of higher tier hospitals via phones, e-mail, online medical consultation, etc.

- In case the patients display severe or emergency mental conditions, their relatives or medical employees shall directly contact higher tier psychiatric hospitals to receive direct instructions on patient admission and transport.

d) With respect to persons suffering from mental illnesses and receiving outpatient treatment:

- Restrict physical examination and replace with remote monitor and consultancy and provide adequate medication according to treatment regimen for 1 to 3 months for stable patients (require relatives of the patients to commit to managing medication and enable the patients to take medicine according to prescription).

- Encourage the patients and their families to communicate with medical employees via phone to report on treatment effectiveness, symptoms, side effects of medication and issues for timely adjustment.

- If the case exceeds capacity of current tiers of the establishments, the medical examination and treatment establishments shall connect with higher tier psychiatric establishments for advice and medical consultation. Referral to higher tier hospitals is only required when the case is suspected to worsen. However, referral must not be delayed if patients display emergency mental conditions.

- In case hospitalization or referral is required, medical establishments shall perform referral according to applicable regulations and law while guaranteeing COVID-19 epidemic management.

- Patients who are addicted to opioids and receiving treatment with methadone or buprenophine must comply with guidelines of Ministry of Health under Official Dispatch No. 203/AIDS-DP dated April 9, 2020 on dispensing methadone/buprenorphine during the COVID-19 epidemic.

2. Patients with severe developments or under emergency mental conditions requiring hospitalization.

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b) Emergency mental conditions include: agitation, suicidal thoughts and/or behaviors, rejecting eating, withdrawal state, delirium, poisoning of medication or psychoactive substances. Patients displaying emergency mental conditions may harm themselves or people around them which require medical employees to interfere immediately with great care to ensure self safety.

c) Thus, persons with severe mental illnesses requiring hospitalization or displaying emergency mental conditions must be considered to have high risks of spreading COVID-19 to adopt early screening methods and strict personal protective measures to prevent spread during patient access and care.

d) Actions:

- Relatives or carers must immediately contact with doctors who are monitoring the patients or the nearest medical establishments, psychiatric establishments to inform about the conditions, the patients and request assistance. 

- All individuals make contact with the patients: employees receiving and transporting the patients, medical employees physically examining and taking care of the patients must adopt personal protective measures to prevent COVID-19 spread as per the law. Cooperate with competent individuals (security guards, policemen, self-defense forces, etc.) to constrain in case the patients resist or turn agitated.

- At psychiatric hospitals:

+ Transport the patients into quarantine areas designed with at least 3 compartments: transition compartment, patient compartment and sanitation compartment; equipped with personal protective gears; hand sanitizing equipment; separate equipment for physical examination; refuse collection equipment, surface cleaning equipment, etc. as per the law.

+ Perform tests on persons suspected with COVID-19 infection as per the law.

+ All medical employees making contact with the patients in these quarantine areas must wear all personal protective gears.

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+ Do not situate the patients in the same room as other patients without evidence confirming that they are not infected by COVID-19.

- When the patients’ mental conditions have stabilized, they may be discharged or referred; if patients have not been proven to be free from COVID-19 (due to time or test shortage), inform medical establishments of provinces about list of the patients where they are transferred to to enable continuous treatment or quarantine as per the law.

3. Notice on treatment of individuals whose existing conditions are mental disorders.

a) Persons with mental illnesses in case of quarantine

- Comply with regulations on quarantine and epidemic control zones according to plans of provinces.

- Cooperate with medical employees and employees of epidemic control centers to provide medications and periodic medical check-up at home for persons with mental illnesses in quarantine zones.

- Cooperate with central and local authorities in preparing plans to provide food and supplies for persons with mental illnesses in quarantine zones, especially families with seniors.

b) Persons with mental illnesses suspected to have been infected with COVID-19, post COVID-19 infection

- Persons with mental illnesses, especially cognitive impairment, pose a high risk of infection since they are not aware of the danger of COVID-19 and incapable of adopting self-protective measures. Thus, the most important measures are family publicizing for adoption of patient protective measures, especially patient management at home, using medication according to prescription and regularly communicating with medical employees.

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- Medical stations of wards and communes shall actively perform screening via physical examination at home, consultations, contact households via phones and report to local authorities upon suspecting infection.

- Supervise quarantine at home. Monitor health, motivate and provide psychological aid for patients and households with quarantined individuals.

- Instruct and assist families to receive persons infected with COVID-19 after treatment for home quarantine according to regulations of Ministry of Health.

c) Persons with mental illnesses infected with COVID-19

- In order to take care and treat persons with mental illnesses infected with COVID-19 well, psychiatric hospitals must:

+ form groups of psychiatric medical employees (doctors, nurses, psychology employees) with specialties, adequate health and capacity for working for multiple days in quarantine conditions to assist medical examination and treatment establishments in treating COVID-19 patients with mental illnesses.

+ provide training on COVID-19 for medical employees to prepare them to assist medical examination and treatment establishments in case outbreak occurs and infectious disease hospitals or general hospitals are overloaded according to mobilization of Departments of Health and Ministry of Health.

- Upon receiving request for specialized assistance of establishments that are treating patients of COVID-19, rely on severity of mental disorders to determine treatment methods:

+ in case of mild or moderate mental illnesses: psychiatric doctors shall integrate remote treatment via phones, email or online medical consultation with COVID-19 doctors.

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- Cautions when using medication for COVID-19 in combination with psychotropic drugs:

+ despite unavailability of effective medication for COVID-19, many types of medicines have been used or tested clinically for treatment of COVID-19 (note that these medicines shall only be used when instructed by Ministry of Health): namely hydroxychloroquine and chloroquine; antibiotics such as azithromycin; antiviral drugs such as lopinavir/ritonavir. These medications may cause side effects such as long QT and torsades de pointes. Warnings on use of medications causing long QT in COVID-19 patients leading to high mortality rate especially when combined with other medications which also cause long QT have been issued. Thus, these COVID-19 medications must be used with care on persons with mental illnesses taking any of the psychotropic drugs that cause long QT such as tranquilizers (quetiapine, ziprasidone), antidepressants (citalopram) and anxiolytics (hydroxyzine).

+ hydroxychloroquine is metabolized by cytochrome P450 enzyme, which contains C P2D6, which should used carefully in combination with psychotropic drugs that inhibit C P2D6 such as fluoxetine or paroxetine since it may increase concentration of hydroxychloroquine.

+ with respect to patients exhibiting pneumonia or respiratory failure, restrict use of psychotropic drugs that cause respiratory center inhibition such as benzodiazepines.

REFERENCE

ⁱ WHO mhGAP Evidence Resource Center: Support based on psychological first aid principles in people recently exposed to a traumatic event. 2012.

https://www.who.int/mental_health/mhgap/evidence/other_disorders/g6/en/

ⁱⁱ Psychological support for pregnant women and for families with microphaly other neurological complications in the context fo Zika virus: Interim guidance for health-care providers. WHO. 2016.

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ⁱⁱⁱ WHO mhGAP Evidence Resource Center: Relaxation training in people woth anxiety symptoms. 2012.

https://www.who.int/mental_health/mhgap/evidence/other_disorders/g6/en/

^iv COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community. NICE Guideline [NG163]. Managing anxiety, delirium and agitation. Published 3 April, 2020.

^v WHO mhGAP Evidence Resource Center: Evidenc-based recommendations for management of depression in non-specialized health settings. 2012.

https://www.who.int/mental_health/mhgap/evidence/depression/en/

^vi Altman, M. T. Knauert, M. P. and Pisani, M. A. (2017). Sleep Disturbance after Hospitalization and Critical Illness: A Systematic Review. Ann Am Thorac Soc, 14, 1457-1468.

^vii Bourne, R. S. and Mills, G. H. (2004). Sleep disruption in critically ill patients—pharmacological considerations. Aneesthesia, 59, 374-384.

^viii Guidelines for the Management of Conditions Specifically Related to Stress. WHO. 2013.

https://apps.who.int/iris/bitstream/handle/10665/85119/9789241505406_eng.pdf?sequence=1

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^x WHO mhGAP Intervention Guide, version 2.0, Management of persons with agitated and/or aggressive behavior. 2016. https://www.who.int/publications-detail/mhgap-intervention-guide---version2.0

^xi WHO mhGAP Intervention Guide, version 2.0, Management of persons with agitated and/or aggressive behavior. 2016. https://www.who.int/publications-detail/mhgap-intervention-guide---version2.0

^xii COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community. NICE Guideline [NG163]. Managing anxiety, delirium and agitation. Published 3 April, 2020.