Psychiatric Services and Teaching during the Covid-19 Pandemic in Romania

Abstract

The Covid-19 pandemic has been declared in Romania on the 16th March 2020.The medical system reacted promptly: chronic patients had to be discharged within 48 h and further scheduled admittances were postponed, adequate epidemiological measures and circuits were organized. Anxiety, insomnia, frustration, binge eating, domestic violence were reported. The majority respected the general advises but soon, persons selected their information sources rather from social media, being victims of the infodemia and peculiar conspirationist theories. A new disorder has been described: coronaphobia. The psychiatric hospitals and outpatient settings had to reduce or innactivate their activity, switch as much as possible to TelePsychiatry. Psychiatry admittances were: onsets of psychosis, relapses of schizophrenia and alcohol, other psychoactive substances abuses, intoxications, and withdrawal states. Later, there were depressions, bipolar disorders, suicide attempts, self-harm in borderline disorder, dementia and delirium. Due to the closure of outpatient units for several months, patients visited the Emergency rooms. Personnel experienced burnout and new psychiatric pathology developed in the aftermath of Covid-19 infection. A big relief occurred with the initial vaccination of the medical staff and seniors, chronically ill persons, psychiatric patients being again left behind. Medical teaching shifted entirely to online and in 2021 the hybrid teaching system has been employed.

1. Introduction

The outbreak of COVID-19 pandemic was officially declared by WHO on 11th March 2020, most of European countries applying different state specific measures of lockdown in order to limit the spread of SARS-Cov 2 virus, mass contamination, and the consequences of the illness.

The characteristics of this pandemic were: ubiquity (in spite of its onset in a country, soon it affected almost all countries), severity, uncertainty, so far limited etiopathogesis and treatment knowledge, misinformation, and social isolation, economic restraint. These conditions are all stressful and might have huge consequences on mental health [1].

2. Brief history of one year Covid-19 pandemic in Romania

The first case was officially recorded on the 26^th of February 2020, even before the official declaration of the pandemic in Romania, and the re-organization of the Romanian health system in order to assist adequately the Covid-19 patients. A strange phenomenon occurred during the first months of pandemic in Europe: repatriation of thousands of Romanian citizens living and working in European countries, affected already by the first wave of Covid-19 pandemic, either due to suspended work places or due to fear of contamination. The borders were assaulted by these people, which were briefly checked by an epidemiological triage, but not tested and quarantined in the indicated domicile, contributing probably to the supplementary spread of the disease [2]. As a consequence, initially positive but asymptomatic persons were admitted to hospitals but soon the hospitals were assaulted by problematic and critical cases and the hospitals especially the Intensive Care Units (ICUs) were exceeded. March 2021 recorded 859709 infected persons and 21483 deaths. The general situation was managed by the department of Emergency Situations and by the Ministry of Health, supported by a mysterious committee of strategic communication, and local authorities. Since December 2020 health workers have been vaccinated, followed by seniors, and chronically ill persons, residents in centers, and disabled persons. The access for the general population has been launched since 15th March 2021. In spite the initial popularity of the vaccination campaign, mistrust especially to the Astra Zeneca vaccine led to a decrease of the vaccination rhythm; still elevated incidence rates of morbidity and mortality of Covid-19 characterize the third wave. Besides the initial electronic patform for vaccination appointments and call-centers, mobile teams, drive though vaccination centers and vaccination marathons aimed the increase of accessibility of the general population.

3. International challenges of psychiatric care during the Covid-19 pandemic

The hallmarks of this Covid-19 pandemic were the uncertainty, unpredictability of severity, duration and the unforeseen effects of several areas: personal, social, economical, triggering enourmous burden on health services, on other essential domains. Though the phenomenon had been experienced some months before by China, European countries seemed shocked and unprepared for this huge global turmoil, accessing simultaneous protection and medical equipment, leading early to a shortage of medical supplies and sometimes competiveness to access these. However, the Chinese experience represented an important pillar of guidance for organizing medical and social services and also treatment approaches. The fact that the disease might trigger life threatening evolution, may involve several individual or mass psychological reactions or worsen previous mental health problems.

A glimpse into the psychological reactions of the population to a global threat, evidenced fear/anxiety, insomnia, depression, anger, guilt, grief, loss at the beginning and frustration [3], PTSD, stigmatization later on, as well as the burnout, somatization of health care workers [4], the onset or aggravation of several psychological/psychiatric symptoms in some of the Covid patients, and the reactions of their family members, caregivers.

Considered as vulnerable groups for mental health impact of Covid-19 were: older adults, the homeless, migrants, mentally ill patients, pregnant women, and students studying abroad [1].

A gender analysis has revealed that younger women are more prone to develop especially anxiety, despite family support and resilience [3], due to an increase of household responsibilities, decrease of physical activity, the emergence of domestic hostility (violence, psychological and/or sexual abuse), due to more time spent together in close proximity. Two peaks of these psychological disturbances could be recorded: at outbreak and more severe later on in a specially vulnerable population: younger, single women, exposed to the infection [3].

Regarding the different psychological reactions, they were not homogenous in different age groups. Children and parents had to adapt to confinement in a narrow space. Small children were deprived of social encounters, discovery and interactions of peers and other persons, institutional acquisition of knowledge and social skills. Predominant indoor seclusion might produce fear, loneliness, anxiety, depression, sleep disorders [5], restlessness [6] and even PTSD [7]. In school children, adolescents, the remote teaching promoted by e-learning developed attention and concentration difficulties [8], a peculiar friendship dynamics with isolation, frustration, and consecutive overuse of electronic devices, anger outbursts, proneness for alcohol and/or psychoactive misuse. The Flynn effect, that of constant increase of IQ by decades with at least 3 points, has recently registered a dramatic decrease [9] but probably not yet evidenced by the compensating Dunning-Krueger phenomenon. A better resilience seems to be in the case of families, peers, teachers’ involvement [8, 10], and a balance between intellectual and physical tasks [8].

On the other end, seniors were at risk and vulnerable due to multiple comorbidities, low social integration, and social disadvantages [11] even before the restrictions imposed by the lockdown and higher risk of poor evolution in case of contamination. The isolation raised great concerns of the possible consequences in the disruption of daily routine, difficulties in provision of basic personal needs, health care services, loneliness, and limited access to neutral information and entertainment. As a consequence, they felt abandoned, stressed by the news, with sedentary lifestyle, with limited access to medical services, anxiety aggravated, depression, poor sleep and huge cognitive impairments [12, 13]. Social isolation, various restrictions of movement, social interactions were perceived as stressful and sometimes less understood as protective. A vivid debate regarding the respect of human rights and marginalization of seniors arose [14]. Even painful separations, limited funeral rituals, grief and bereavement were experienced as frustration [15].

4. Role changes during the Covid-19 pandemic

Active persons experienced the general pattern of psychological reactions, in accordance to the degree of understanding of the threat, protecting measures, adherence to the official recommendations of protection or denial of the existence of the infectious disease, different involvement in social roles. A dramatic shift has occurred: while medical staff and other emergency personnel were highly implicated in the last year, working intensely and under pressure, others had to adapt to passivity or even suspend their professional activity with huge economical downshift and uncertainty. Therefore, some became very involved and active and others had to freeze their professional identity or reorient towards other means of subsistence. Beside the huge personal reactions, the financial breakdown, the postponing of real life habits put some jobs under question (musicians, actors, hospitality). The responsibility for social, individual, family, financial survival put those persons on supplementary pressure and existential uncertainty.

While the active group had to practice and act rapidly, lacking a very precise documentation or scientifically evidenced based guidelines, being permanently confronted with unexpected situations, unpredictability and task overload, the counterpart had to remain passive, in expectation, “hibernation”, sometimes forgotten by the governmental sustainable support and resilience programs. Special behaviors developed: hoarding and food stocking, a special personal or group survival selfishness, binge movies and internet consumption, binge eating, and isolation in bunker similar homes.

The Covid-19 pandemic has shaken deeply communication, personal and group liberties, adherence to norms, values, the social boundaries and equilibrium, optimum proportion between implication/passivity, personal, professional, family and recreational activities. If the initial official recommendations stated “social distance” as a protective measure, it became soon obvious that taken literally, this could lead to huge unintended detrimental effects: isolation, loneliness, exacerbation of own fears, limitation of social interaction, even stigmatization. So, the term “physical distance” seems to coin more precisely the real need of the respect for safety distance in order to avoid contamination. Moreover, special efforts should be addressed especially towards vulnerable populations to provide social closeness, inclusion, connection and special care [16].

5. The dynamics of the public perception of medical personnel

At the beginning of the lockdown, as serious cases of Covid-19 patients applied for testing, diagnosis, and treatment, medical staff were idealized as “heroes”, sent to the frontline of the triage, hospitals designated for this purpose, invested with great hope and confidence of healing and rendering all safe as soon as possible, taking less into consideration that protection methods and special beds for ICU were scarce, and treatment options were not universally lifesaving, being a new disease, without yet a guaranteeing cure. This emotional investment of trust in medical personnel has been shown by encouraging messages, gratitude stickers, TV interviews, outlining the devotion, overwork, exhaustion. As soon as complications, or even death occurred, with limitations of family members to take direct contact to the personnel, limitation imposed by isolation, restricted funerals, the initial attitude began to fade. Less objective information about testing, quarantine, hospital procedures were explained by the government, local officials, by personnel. But a tremendous shift occurred as the conspirationists gained ground in convincing persons that higher “interests” would intervene and declare healthy persons as Covid-19 patients. A further cognitive bias “concluded” that ICU ventilated patients were incurable and condemned to death. As a consequence, a virtual loop produced an avoidance of hospital admittance and application for admittance in tardive stages of the disease, which were hard to manage. Media and the general public reconsidered common medical procedures in ICUs as punitive (i.e. oxygen masks, restraint of confused patients, ventilation, with the inherent side effects, like bacterial suprainfections). Therefore, a radical shift in attitude of the population towards medical staff took place, also nurtured massively by the nonmedical adherents: they were considered corrupt, sadistic, even criminal. Mistrust and adversity, stigmatization contributed to supplementary work hardship and status decline. As infection incidence rose, more restrictions were imposed, less understood as protective, frustration of limitation of liberties during the second and third wave were hardly accepted, calling the epidemiological methods as “medical dictatorship”, encouraging revolts, disobedience, promoting risky behaviors.

The prevalence of burnout among American nurses ranged up to 45%, being at double risk of depression than other health workers [17].

6. Infodemia versus scientific information

As soon as the infection with the new SARS-Cov 2 emerged in the Wuhan region of China, WHO launched an official evidenced based scientific information platform tailored to specific population groups-Information Network for Epidemics (EPI-WIN). The official general information delivered by media channels, according to the employment of the general safety measures, health professionals benefited of full access to free evidenced based studies, which were informative and valuable in exploring, adapting treatment plans according to the latest scientific achievements. But often the official information was overshadowed by more convincing false information, called infodemia (the rapid and massive spread of pseudoscientific information), with particular features: launching deep fake news, the misinformation had large channels of distributions, inducing an “illusory “truth by repetition, familiarity, promoted by influencers, by famous persons, relying partly on conspiracy theories, exploiting the general heightened level of fear, discouraging the medical approaches, along with intensive anti-vaccination campaigns [18]. Among the most popular “explanatory” theories can be cited: the pandemic has been planned by Big Pharma, companies, the virus is produced in laboratory, 5 G produce clinical signs of Covid-19 infection. There are several reasons which might explain the development of pseudoscientific information: subjective misinterpretation of some evidence, called cognitive biases, magical or irrational meanings, a hidden mercantile interest and the credible, persuasion reaching the fragile emotional ground of the receptor [19].

The conspirationist theories promote that certain events and phenomena are manipulations of occult forces, a plot of leading groups, offering some plausible believable simple explanations, but not reliable scientific sources, dividing irreconcilable adherents from contestants [20]. Why are some people more prone to accept false theories in spite the scientific proofs? Miclea advances the supposition that the emitter of the fake information launches an emotionally charged information that is in consonance with the own beliefs [21] that gives the impression of being special and having access to secret information; the person seems to have a cognitive bias, called by Mixich [22] “cognitive impermeability”, selecting within the available data only the convenient information, being insensitive to contra arguments, proofs of the false assumptions. These persons select within the news only convenient data, being nurtured in their convictions by peers, denying neutral facts, and evidenced based data, similar to cognitive impenetrability.

Some “messianic” characters invaded social media, promoting personal theories, calling population to disobedience of the official rules, pretending that conspirations aim the subjugating citizens and obliterating their rights and freedoms. Even the contamination or death of close adherents did not lead them to conclusions that the illness is serious and might be fatal. Strangely, some of the doctors promoted peculiar theories about the inexistence of the Covid-19 disease or claimed to have cured thousands of patients with primitive remedies, contesting vividly the official protocols, gaining acceptance and trust by a significant number of people.

7. Coronaphobia

The spectrum of anxiety disorders is wide: it is usually indefinite in general anxiety or out of the blue in panic attacks, triggered by a phobic stimulus in specific phobias. At the beginning of the SARS-Cov2 outbreak, being limited to a faraway region, the concerns were vague and a certain conviction that the danger will never affect us prevailed. After the European and American widespread of this respiratory transmitted disease with high transmission rate and mortality, WHO declared the disease pandemic, imposing several protective restrictions and mobilizing huge medical resources in research and medical assistance of Covid-19 disease. As soon as the incidence rate of the disease and mortality due to complications of the disease raised dramatically in developed European countries with advanced health systems, the general population developed a rapid awareness of the real dimension of the threat. As more and closer acquaintances were positive or ill, the proximal danger became real. Therefore, a specific acute anxiety developed, having a clear object of fear, namely the threat of being contaminated/contaminating by the SARS-Cov2 virus and the possible consequences (i.e. economic, status), severe outcome, and death. The circumscribed phobia, developing specific cognitive distortions and specific behavior (either of exaggerated disinfection or avoidance of public places) entitles a precise name for the phobia, different from other contamination phobias, called coronaphobia [23]. Arora et al. [24] conceptualized the excessive fear of contracting the Covid-19 disease into three main components of coronarophobia, namely the physiological, cognitive and behavioral aspects. The fear is triggered by situations of meeting potentiallly infected people, exposure to crowded places, traveling, touching potentially infected surfaces, misinterpreting mild signs of flu. The physiological part implies palpitations, breathing difficulties, appetite, and sleep problems. The cognitive component meant absolutistic assumptions like: if I contract the disease, I will die, it might represent an economic, personal disaster and trigger worry sadness, sleep disorders. The fear of contamination included both senses: to contract the infection or infect close persons. The behavioral component is represented by avoidance of getting out, meeting friends, and attending public places. Other consequences of combining recommendations and personal fears of contaminations were the development of compulsive disinfections, cleaning and washing.

The analysis and comparison to other phobias reveals the following characteristic features of coronaphobia: intense, widespread, involving also socio-occupational and personal domains, with apprehension ranging beyond self and present time [24]. The majority of phobias are personal diverse fears occurring during different points in time of life and, with different intensities, depending on the degree of de exposure to the phobic stimulus. Coronaphobia represents beyond an individual experience, a mass fear, with a special dynamics, a vicious loop of hardships during quarantine, new habits (hoarding, binge eating, binge TV series watching and, seclusion), the unforeseen end of the danger, some hope related to vaccination, doubts after escalation of incidence rates due to mutations of the virus and its virulence, the revolt of some people faced with further restrictions and limitations.

8. Romanian psychiatric care during Covid-19 pandemic

8.1 Romanian legislation during Covid-19 pandemic

Soon after the WHO declaration of COVID-19 pandemic, the Emergency state has been declared by the Romanian President on the 16th March 2020 [25] with the lockdown measures for 30 days in Romania, which reduced the unnecessary workplaces, shops, social encounters, travel bans and shift towards remote working and/or online teaching, quarantine/isolation when requested. The Emergency state has been followed by successive alert states or local confinements in high infection incidence zones.

On the medical level, several immediate measures were stated by the common order 74527/2020 issued by the Department of Emergency Situations of the Internal Ministry and Health Ministry in Romania at 23.03.2020 [26] such as: the hospital facilities had to discharge within the following 48 h most patients, only emergency admissions being permitted; postponing the programing of public and private ambulatory assistance. Health services had to adapt their circuits and programs according to the epidemiological safety needs and structures, personnel programmed their activity in shifts. The supply with protection materials and disinfectants, necessary medication was provided in accordance with the management strategies of each hospital/service. Some Covid hospitals were designated (infectious disease, pneumonology, internal medicine) and support Covid hospitals, which had to assist milder cases. But each department, regardless of the speciality, organized its own circuits according to the local buildings, endowment and personnel in order to assist suspected or confirmed Covid patients at the same time to protect the other hospitalized patients against contaminations. Updated case definitions and treatment protocols were provided as systematic scientific knowledge evolved. The Law no.136/2020 [27], partly in consonance with international health regulations, offers precise definitions of specific terms such as personal, regional quarantine, isolation and measures of report, application of the above mentioned measures aimed to avoid the spread of the infections, as well as the sanctions in case of deliberately refusal to comply with or violate these measures, respecting personal rights and freedoms. The law expresses the right of the person to ask for the annulment of the imposed measures, if the persons fill injured by the restrictions, steps to challenge the decided methods [28, 29]. Based on this later paragraph, specialists encountered difficulties to convince patients to sign the informed consent, accept treatments, and being admitted in spite of the severity of the Covid-19 illness.

8.2 Psychiatric services in Romania during the Covid-19 pandemic

The re-organization of psychiatric services varied depending of the type of service (ambulatory, hospital, state/private), location, type of buildings, proximity to a Covid hospital and specialized examinations, resources, local management. The general lines of the provision of medical services were stipulated by the Government Decision (HG 252/2020) [30], pointing the maximum protection of patients and medical personnel, recommending the provision for stable chronic patients remote consultations, treatments, the annulment of the mandatory use of the medical assurance card. The types of distance consultations were not clearly specified, since telemedicine systems were not yet officially employed. So GP’s, ambulatory specialists decided to offer teleconference facilities to their patients WhatsApp, Skype or other smart phone applications, with great concerns of security of data protection, accessibility. If these communication facilities might be familiar to the Z-generation (born in the mid-nineties), they could encounter technical difficulties for both doctors and patients, partly due to some digital illiteracy or to the lack of availability of the device or the internet network by the later. In spite of older recommendations to apply TelePsychiatry emphasized by various Psychiatric Associations, these became imminent during the Covid-19 pandemic. But various components of this methods (secured electronic health record, synchronicity, teleconference, teleconsultation, monitoring of vital signs, psychological testing) lacked entirely, being in fact a videoconference, followed by an electronic recipe, send to the patient via e-mail or to the indicated Pharmacy, being reimbursed by The National Health Insurance system. Above the general depicted advantages (portability, cost-efficiency, accessibility, continuity) [31], the major advantage was to overcome the reluctance of patients to apply to direct medical services, to guarantee the safe and quick follow-up; more barriers were recorded: the lack of personal psychological authenticity, missing clear juridical framework, problematic technical set ups, modest training. If the initial consultation seems the most problematic, the achievements could be employed later after the extinction of the current epidemiological risk in the aftercare, follow-up [32, 33].

The Romanian psychiatric hospitals organized their circuits and activities according to the local settings, profile, management decisions and epidemiological advisors. The case of huge, independent emergency psychiatric hospitals such those in Bucharest, Iaşi, Sibiu, Cluj-Napoca, built on a pavilionar style permitted the designation of special isolated Covid suspect and confirmed departments. Within the Covid pavilions, suspect cases and confirmed positive cases were totally separated and personnel respected strictly the protective rules, circuits, equipments. Face to face briefings were canceled and switched to online meetings. The suspect cases were monitored until negative RT-PCR test arrived and directed towards the designed sections. Positive cases, either asymptomatic or symptomatic were monitored or treated both for the Covid-19 signs and for the psychiatric illness, until negativation of RT-PCR, when transferred or discharged. Even Infectious disease hospitals or other Covid-19 hospitals and Covid-19 support Covid hospitals asked for psychiatric support or transfer when psychiatric symptomatology exceeded their capacity of specialized care, but guaranteed the somatic stability for a psychiatric ward that does not possess the adequate technical equipment for possible severe somatic outcomes. Each department could decide after a careful epidemiological triage to admit patients in buffer zones until the results of RT-PCR test oriented the patient within the ward or towards the special pavilion. Personnel and negative tested patients were also monitored for signs of a possible suspect case, according to the updated case definition provided by the Ministry of Health.

For acute patients brought by ambulance, Police, only direct consultations were possible and admittance often required special supplementary safety measures, being kept in a buffer zone until negative RT-PCR results were confirmed. Similar procedures were reported by colleagues in other countries, with the same difficulties, partly due to understaffing, less specialized training [34, 35].

For chronic hospitals, there were no new admittances. Psychiatric hospitals, part of a general hospital, could hardly organize safety circuits according to the imposed regulations. One major concern regarded the continuity of delivery of psychiatric treatments to the chronic patients, which could have been at risk of relapses, triggered by medication discontinuation. This led to the initiation of several programs and facilities that provided safe medication supplies after safe Tele-Psychiatry consultations. Due to the fact that the majority of ambulatory psychiatric services interrupted their onsite activity the first two months of pandemic, clients with psychiatric problems requested either online consultations or visited the emergency rooms. If oral medication reached easily the patient, either accustomed with the administration or in case of changes, a short explicative schema had been attached, more problematic seemed the administration of long acting injectable antipsychotics, which supposed the administration by a trained nurse.

Speaking about admitted psychiatric patients, the quarantine measures interrupted the periodical visits into the hospital of family members or friends, the contact being possible by telephone. In order to overcome this emotional deprivation, especially in those patients and carers who did not afford a smart phone with videocalls, the Cluj emergency hospital initiated the technical support for this gap by offering two tablets to the patient and the carer in the proximity of the hospital, providing also technical assistance.

Some peculiar event occurred since the personnel had to wear protective kilts, masks, making daily visits and consultation difficult regarding the identification of the persons, the establishment of confident relationships, limited face expression and changing personnel, producing gaps in adequate monitoring, coherent therapeutic plans. Some of the activities were canceled: morning conference, periodic meetings with shifts via online meetings, briefings, group messages.

During the first ten months of the pandemic, personnel had also been contaminated, ill, isolated and a shortage of personnel occurred besides reorganizations of other sections, where personnel had to be transferred. A great relief arrived with the vaccination of the personnel at the beginning of 2021.

8.3 Interhospital collaboration, onsite psychiatric care

The current situation imposed some flexible approaches: since some psychiatric patients suffered of symptomatic Covid-19 illness and were admitted into a dedicated hospital with special care needs and manifested psychiatric symptoms as well, the general strategy demonstrated that consultation and treatment plan in the initial hospital was the optimal attitude. In the case of serial contamination of senior residents that were assessed for various comorbidities, the common decision of the Cluj Emergency hospital was to temporarily detach a psychiatric nurse and a registrar to act onsite for the psychiatric decompensations (delirium, insomnia, agitation). But a better approach should be in case of senior stable residents to assist them in their familiar surrounding and transfer to a hospital only in the case of more complex investigations and medical assistance. Outbreaks, especially during the third wave posed special challenges, partly to the bigger contagion strength and the lack of available adequate suitable clinical facilities. Therefore, flexible designation of special wards, rapid transfer of patients into other hospitals should have been more functional and practical if we would have benefited of the efficient support and coherent coordination of the executive structures. In order to assess professional active Covid-19 ill psychiatric patients, psychiatrists employed the adequate explorations, beneficiated from guided and suitable treatment plans by the hospital infectionist.

Psychological hotlines were provided both for hospitals employees and for the academics, and recently by the Ministry of Health after the suicide of an anaesthesiologist, but which proved to be rather formal and modestly accessed.

8.4 Psychiatric ambulatory services within a psychiatric hospital

Respecting the strategy to avoid relapses due to medication discontinuation, the closure of the majority of ambulatory psychiatric services at least during the first two months, the difficulties to reach the ambulatory services and the centers for mental health, integrated ambulatories tried to provide consultations in both ways: remote and direct, adapted to the needs and preferences of the patients, and the confidence of the specialists in the authenticity and reliability of the newer method. But the direct consultation implied supplementary protection and safety measures due to the higher risk derived from the low reliable triage. As mentioned before, the TelePsychiatry approaches were preferred rather by young patients, for other patients hesitant to apply direct to the onsite consultations, intermediate caregivers facilitated the remote consultation but with lack of the adequate confidentiality.

8.5 Dynamics of psychiatric pathology: emergency hospitals, outpatients units

It has to be stated from the very beginning that data regarding admissions, psychiatric consultations, psychiatric patients infected with SARS-Cov 2 virus and their evolution have been requested in advance from the National Institute of Mental Health, National School of Public Health, National Institute of Statistics but feedback has not been sent or data are not available yet. Therefore, we will present data recorded at the Emergency Cluj County hospital, Psychiatry Clinic with a capacity of 150 beds, during the first months of Covid-19 outbreak. It is to be stated that the general trend of the analysis refers to the admittances, consultations, emergency room presentations during the lockdown (15th March-15 the May 2020) compared to the same period of the previous year 2019. There was a dramatic drop in admittances by 49% (i.e. 555 vs. 283) [36] but also in presentations to the emergency room, applying for psychiatric problems that usually were addressed to the closed ambulatory offices or to the GP’s (as insomnia, anxiety, mild depressions). The integrated ambulatory aimed at assuring continuity of treatment, had also their activity decreased, partly due to distrust of the safety sanitary measures and the fear of contamination or to the mobility restrictions; the decrease was by 37% regarding direct consultations, replaced whenever possible by Tele Psychiatry. The gender distribution revealed more men than women in all services described above [36]. The demographic profile of the hospitalized patients during the confinement was: man, from urban area, in the mid-forties, benefiting from a similar hospitalization duration-13.2 days [36].

Regarding the diagnosis profile of admittances during the lockdown in comparison to the same period of the previous year, there were mostly onsets of first psychotic episodes, schizophrenia relapses, and alcohol and other psycho active substances acute intoxications or withdrawal states, in consonance with other international studies [37, 38, 39]. But quite surprising, there were less mood disorders of any polarity (either depressions of any severity or bipolar disorder spectrum), or suicide attempts despite frequent predictions. This trend changed in the following months, increasing the number of hospitalizations, adding to the former categories depressions, bipolar disorders, suicide attempts, self-harm in border-line personality disorder and newly diagnosed cases of dementia. Especially this cognitive decline has been noticed by carers soon after the lockdown and the physical distance and isolation, but they did not apply for evaluation immediately due to hesitancy and fear on contamination, they did so only months later. In the beginning of March 2021, the number of admittances reached the figures similar to the previous year, still maintaining the testing procedure and the Covid pavilion, with positive cases hospitalized at the extension of the buffer zones according to needs; the number of admitted patients exceeding for short periods the wards’ capacities. Due to the neurotropism of the Sars-Cov 2 virus, the environmental and psychosocial stressors, persons with Covid-19- illness, might be at risk for developing following psychiatric disorders in the aftermath of the infection: depression, bipolar disorder, PTSD, psychosis, OCD, cognitive disorders, epilepsia [40].

8.6 New kinds of delusions and behaviors

If there is no special specificity of the majority of the admittance diagnoses referring to alcohol and substance abuse, some particular trends could be noticed within the psychotic spectrum. The first case, a brief psychotic disorder was encountered in a young emergency doctor, who ran through the streets announcing an apocalyptic outcome of the Covid-19 pandemic and an overflow of severe cases exceeding the hospital facilities, trying to warn people, policemen of the imminent danger. The recovery was very fast within two weeks and returned after a month as an active doctor on a Covid-19 internal medicine ward. The majority of schizophrenia patients adapted their paranoid delusions to the actual social context, noticing the mimetics of the delusions: either delusion of contaminations or messianic mission of saving humanity, combined with mystic delusions. Worth mentioning is that the content of delusions changed: a man developed at the beginning of the outbreak of Cobid-19 pandemic a delusion of contamination, followed by isolation, compulsive exaggerate washing, disinfection, mistrust in all persons, even close family members. After some months of total isolation, the same person developed another paranoid delusion of the influence of 5G radiations, employing several protection methods: switching off of the internet router, isolating wires, culminating with the concealment in an aluminum box, aiming at blocking the damaging effects of 5G.

Another young obese women, with two family members deceased because of Covid-19 disease, being aware of the risks of this comorbidity for Covid-19 disease, employed a peculiar self-harm behavior, namely repetitive injections of insulin, in order to lose weight and therefore be protected.

8.7 Information kits

General information about SARS-COV-2, Covid-19 disease, safety measures were adequately distributed for the general public through various channels (TV, radio, and internet) but the avalanche of alarmist breaking news might have triggered exaggerated emotional reactions. In order to ensure that psychiatric patients correctly understood the recommendations regarding physical distance, disinfection, the hand washing rules and the adequate wearing of masks, special groups were organized twice weekly lead by nurses and registrars. Special booklets regarding the psychological resilience and short life style advices were provided to patients and their carers. Short video clips were provided by a specialist in public health. Another concern of the staff was related to the potential tension triggered by alarmist news, being either filtered or replaced rather by entertainment programs or by the broadcast of poetry, delivered every evening by a local actor.

8.8 New recreational activities

Being admitted to any quarantinated hospital, involved a huge limitation of the usual activities and social interactions. Therefore, the lack of family members, friends could be surpassed by compensatory networking: video calls, safe distanced groups activities run as much as possible outside in the inner garden (badminton, dancing, art therapy, interactive but safe activities such as gardening).

9. Vaccination and psychiatric disorders

The national vaccination campaign began for seniors (above 65 years old) and persons suffering from chronic diseases (diabetes, cardio-vascular diseases, cancers, immunosuppressive diseases, immobilized or disabled persons) on 15th January 2021. In spite the evidence of higher infection rates, morbidity, severe outcome [41], and mortality risk of severe mental ill patients [41, 42], several examples of Covid-19 outbreaks in psychiatric hospitals, the general recommendation of prioritizing of this vulnerable persons for the early vaccination [43], this group was not included in the Romanian vaccination program. The situation has not been remediated although several memoirs have been send to Ministry of Health, National Coordinator of the vaccination campaign, psychiatric associations. Therefore, psychiatric patients were left further at risk of contamination, being further discriminated. At present, due to the fact that most of them do not have access to internet, are digitally illiterate, have modest information to reliable sources, the access is even more difficult though the national vaccination campaign was launched on the 15th March 2021. Being frequently asked about opportunities, interactions with the medication, side effects, we decided to edit a short guide about the virus, contamination risk, vaccination dedicated to psychiatric patients and their caregivers [44].

10. Psychiatric graduate and postgraduate psychiatric teaching

The first Medical University which decided to suspend the onsite courses on the 5th March 2020 even before the official national lockdown, switching on exclusively on line teaching was the University of Medicine & Pharmacy “Iuliu Haţieganu” Cluj-Napoca, followed soon by all medical universities. This quite abrupt switch, along with the telework of the administrative staff, implied the huge effort so send safe national and international students on demand at home. For the graduate preclinical teaching, courses and seminars could be easily adapted for the online teaching, beneficiating of adequate online platform Microsoft teams, with multiple interactive opportunities. As clinical courses did not encounter any problems, seminars had to rely on case vignettes, official didactical video clips or on life streams of surgical procedures, with the respect of the confidentiality of the patient. These didactical video clips were available and appreciated by the English, French line, applied also to the Romanian students. In order to make seminars more interactive and to develop interview skills, audio calls facilitated the direct but confidential access, or blurred videos were a compromise. But we have to confess our concerns regarding deficitary adequate acquisition of essential practical medical skills for medical students and nurses. The postgraduate Psychiatry beneficiated on the other hand of both: online courses, case presentations, scientific updates, and the onsite clinical work and training. But a quite peculiar phenomenon occurred, with the “misunderstanding” of the official recommendations during lockdown for the general population but not for medical staff to stay at home, leading to a shortage of medical personnel and the exhaustion of the older doctors. The prolongation of shifts until February 2021 of the registrars had as consequence a decline of the daily medical routine, the difficult follow up of patients with changing doctors for one patient. As a direct consequence were the modest theoretical and practical knowledge, with scarce assumed clinical decisions. The doctoral studies continued as online courses, literature search and meta-analysis but there was a hardship in exploring, testing the planned patients samples. Clinician teachers had to focus on the tremendous pressure of patients’ care and on teaching tasks as well, even though sometimes these tasks overlapped. The main problem faced by teachers and students as well, was the abrupt transfer of the educational system entirely towards online, with no previous planning philosophy of guidelines; the library did not offer the online resources of documentation. Teachers understood to transfer their orthodox teaching style online, not taking into consideration that students might have difficulties in understanding and acquiring information, tasks, skills. As seminars and practical clinical exams were canceled, innovative methods should be planned, the curricula overhauled, a steering committee point the general objectives and implement suitable pragmatic logistics, in order to diminish the gap of onsite training [45, 46].

11. Conclusions: lessons and future emphasis

The current pandemic was difficult to anticipate as magnitude, duration, health service organization and personal, social, economic burden. The three waves of Covid-19 pandemic exhausted the medical capacities, medical staff is in burn out and citizens are frustrated due to prolongation of restrictions, high number of victims, accept hardly to conform to the epidemiological rules. The vaccination campaign represented a tremendous hope to diminish the dramatic effects of this pandemic and has proven that countries that employed intensive vaccination strategies reached low mortality rates. But this enthusiasm has been overshadowed by the intense highlight of side effects of some of the vaccines by the media, conspirationists, leading to mistrust, hesitancy in sustained programming. Psychiatric patients, especially those suffering of serious mental illness were more prone to contract the infection, as outlined previously due to smoking, somatic comorbidities, overcrowded housing, difficulties to understand and respect restrictions, to recognize the contagious disease and to access medical services and adequately quarantine [47], and reached higher morbidity and mortality rates. The health care in a psychiatric hospital of Covid-19 psychiatric patients was difficult to organize, limited due to the inadequate endowment and the insufficient specialization of mental health providers in treating this particular infectious disease the understaff. But more difficult seemed the transfer to a more specialized hospital or back home for isolation. Another issue that is not yet solved, is the stigmatization of these patients even within the medical system, all efforts to include these serious mental ill patients into the priority group for vaccination failing in spite solid scientific argumentation [43], and the experience of several outbreaks, severe outcomes. The consequent tsunami of psychiatric cases, either as onsets or relapses or the new psychiatric pathology in the aftermath of Covid-19 infections put psychiatric services under pressure like a marathon race, with same or weaker human resources but with unpredictable endpoint. Apart from the great effort during this period, health workers felt that there were no coherent central or local health strategies and support, even though initiatives were proposed. The psychiatric and infectious disease control measures should be further continuous adapted upon needs and as rapidly adapted renegociated based on best practices and local availability, equity [48, 49]. The general aims for the next future would be a better awareness of the general population regarding the medical, psychological, social, financial consequences of this illness and better, coherent health policies, that encourage initiatives and multidisiplinarity, employment and adaptation of successful testing and treatment algorithms.