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      Implementation of a telemental health service for medical students during the COVID-19 pandemic Translated title: Implementação de teleatendimento em saúde mental para estudantes de Medicina durante a pandemia da Covid-19

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          Abstract

          Abstract: Introduction: The COVID-19 pandemic can be considered a severely stressful event and trigger negative repercussions on the mental health of medical students, such as psychological distress and the development or worsening of mental disorders, harming the academic, social and professional life of these students. As a result of the interruption of classes and the social distancing measures advocated by health agencies during the pandemic, the mental health care sector for medical students at the Federal University of Rio de Janeiro (UFRJ) needed to cancel the face-to-face care at the Clementino Fraga Filho University Hospital in early March 2020 and think of other forms of mental health care for these students. Experience report: This is an experience report about the implementation of telemental health care for medical students at UFRJ during the pandemic, for the continuity of mental health care program using remote assistance, started in late March 2020. The service is being offered by a team of five psychiatrists, a psychologist and a social worker, all university employees. Discussion: The teleservice has served as an important space for listening and embracement in face of these students’ psychosocial demands, whose challenge consists in overcoming some barriers that hinder the availability of and access to mental health services on the university campus, including the preservation of the doctor-patient relationship, the guarantee of confidentiality and quality, and the offer of a space for mental health care when the physical presence is not possible. Conclusion: Despite the difficulties inherent in the rapid process of implementing this service, the potential of technology to help the population at this critical moment is perceived, especially regarding the attention to the mental health of specific groups, such as medical students. The telehealth represents a potential for learning and change in the ways how the access to care is offered, with the perspective of bringing benefits to the students’ mental health, even after the current period of the pandemic, with the goal of expanding these services to other courses of the UFRJ.

          Translated abstract

          Resumo: Introdução: A pandemia provocada pela Covid-19 pode ser considerada um evento estressante grave e desencadear repercussões negativas na saúde mental dos estudantes de Medicina, como sofrimento psíquico e desenvolvimento ou agravamento de transtornos mentais, trazendo prejuízos à vida acadêmica, social e profissional desses alunos. Em consequência da interrupção das aulas e do distanciamento social preconizado pelos órgãos de saúde durante a pandemia, o Setor de Atendimento em Saúde Mental destinado aos alunos de Medicina da Universidade Federal do Rio de Janeiro (UFRJ) necessitou cancelar os atendimentos presenciais do Hospital Universitário Clementino Fraga Filho no início de março de 2020 e pensar em outras formas de cuidado em saúde mental para esses alunos. Relato de experiência: Trata-se de um relato de experiência acerca da implementação do teleatendimento em saúde mental destinado aos estudantes de Medicina da UFRJ durante a pandemia, para a continuidade do cuidado em saúde mental de forma remota, iniciado no final de março de 2020. O atendimento está sendo ofertado por uma equipe de cinco psiquiatras, uma psicóloga e uma assistente social, todos funcionários da universidade. Discussão: O teleatendimento tem servido como um espaço importante de escuta e acolhimento diante das demandas psicossociais desses alunos e tem como desafio ultrapassar algumas barreiras que dificultam o acesso e a disponibilidade de serviços de saúde mental no campus universitário, incluindo a preservação da relação médico-paciente, a garantia da confidencialidade e qualidade, e a oferta de um espaço de cuidado em saúde mental quando a presença física não é possível. Conclusão: Apesar das dificuldades inerentes ao rápido processo de implementação desse serviço, percebe-se o potencial da tecnologia em auxiliar a população nesse momento crítico, em especial na atenção à saúde mental de grupos específicos como os estudantes de Medicina. O teleatendimento representa um potencial de aprendizado e mudança nas formas de como o acesso ao cuidado é ofertado, com a perspectiva de trazer benefícios à saúde mental dos estudantes, mesmo após o período atual da pandemia, com a meta de expansão desses atendimentos para outros cursos da UFRJ.

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          Most cited references38

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          Public responses to the novel 2019 coronavirus (2019‐nCoV) in Japan: Mental health consequences and target populations

          In December 2019, cases of life‐threatening pneumonia were reported in Wuhan, China. A novel coronavirus (2019‐nCoV) was identified as the source of infection. The number of reported cases has rapidly increased in Wuhan as well as other Chinese cities. The virus has also been identified in other parts of the world. On 30 January 2020, the World Health Organization (WHO) declared this disease a ‘public health emergency of international concern.’ As of 3 February 2020, the Chinese government had reported 17 205 confirmed cases in Mainland China, and the WHO had reported 146 confirmed cases in 23 countries outside China.1 The virus has not been contained within Wuhan, and other major cities in China are likely to experience localized outbreaks. Foreign cities with close transport links to China could also become outbreak epicenters without careful public health interventions.2 In Japan, economic impacts and social disruptions have been reported. Several Japanese individuals who were on Japanese‐government‐chartered airplanes from Wuhan to Japan were reported as coronavirus‐positive. Also, human‐to‐human transmission was confirmed in Nara Prefecture on 28 January 2020. Since then, the public has shown anxiety‐related behaviors and there has been a significant shortage of masks and antiseptics in drug stores.3 The economic impact has been substantial. Stock prices have dropped in China and Japan, and other parts of the world are also showing some synchronous decline. As of 3 February 2020, no one had died directly from coronavirus infection in Japan. Tragically, however, a 37‐year‐old government worker who had been in charge of isolated returnees died from apparent suicide.4 This is not the first time that the Japanese people have experienced imperceptible‐agent emergencies – often dubbed as ‘CBRNE’ (i.e., chemical, biological, radiological, nuclear, and high‐yield explosives). Japan has endured two atomic bombings in 1945, the sarin gas attacks in 1995, the H1N1 influenza pandemic in 2009, and the Fukushima nuclear accident in 2011: all of which carried fear and risk associated with unseen agents. All of these events provoked social disruption.5, 6 Overwhelming and sensational news headlines and images added anxiety and fear to these situations and fostered rumors and hyped information as individuals filled in the absence of information with rumors. The affected people were subject to societal rejection, discrimination, and stigmatization. Fukushima survivors tend to attribute physical changes to the event (regardless of actual exposure) and have decreased perceived health, which is associated with decreased life expectancy.7, 8 Fear of the unknown raises anxiety levels in healthy individuals as well as those with preexisting mental health conditions. For example, studies of the 2001 anthrax letter attacks in the USA showed long‐term mental health adversities as well as lowered health perception of the infected employees and responders.9 Public fear manifests as discrimination, stigmatization, and scapegoating of specific populations, authorities, and scientists.10 As we write this letter, the coronavirus emergency is rapidly evolving. Nonetheless, we can more or less predict expected mental/physical health consequences and the most vulnerable populations. First, peoples' emotional responses will likely include extreme fear and uncertainty. Moreover, negative societal behaviors will be often driven by fear and distorted perceptions of risk. These experiences might evolve to include a broad range of public mental health concerns, including distress reactions (insomnia, anger, extreme fear of illness even in those not exposed), health risk behaviors (increased use of alcohol and tobacco, social isolation), mental health disorders (post‐traumatic stress disorder, anxiety disorders, depression, somatization), and lowered perceived health. It is essential for mental health professionals to provide necessary support to those exposed and to those who deliver care. Second, particular effort must be directed to vulnerable populations, which include: (i) the infected and ill patients, their families, and colleagues; (ii) Chinese individuals and communities; (iii) individuals with pre‐existing mental/physical conditions; and, last but not least, (iv) health‐care and aid workers, especially nurses and physicians working directly with ill or quarantined persons. If nothing else, the death of the government quarantine worker must remind us to recognize the extent of psychological stress associated with imperceptible agent emergencies and to give paramount weight to the integrity and rights of vulnerable populations. Disclosure statement The authors declare no conflicts of interest. Supporting information File S1 Online health information sources for the novel coronavirus (2019‐nCoV). Click here for additional data file.
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            Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation Among Medical Students: A Systematic Review and Meta-Analysis.

            Medical students are at high risk for depression and suicidal ideation. However, the prevalence estimates of these disorders vary between studies.
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              “Pandemic fear” and COVID-19: mental health burden and strategies

              In the wake of the September 11 attack in the United States and the Kiss Nightclub fire in Brazil, psychological assistance task forces for victims and their families were quickly organized. However, during pandemics it is common for health professionals, scientists and managers to focus predominantly on the pathogen and the biological risk in an effort to understand the pathophysiological mechanisms involved and propose measures for preventing, containing and treating the disease. In such situations, the psychological and psychiatric implications secondary to the phenomenon, both on an individual and a collective level, tend to be underestimated and neglected, generating gaps in coping strategies and increasing the burden of associated diseases.1,2 Although infectious diseases have emerged at various times in history, in recent years, globalization has facilitated the spread of pathological agents, resulting in worldwide pandemics. This has added greater complexity to the containment of infections, which has had an important political, economic and psychosocial impact, leading to urgent public health challenges.2-6 HIV, Ebola, Zika and H1N1, among other diseases, are recent examples.1 The coronavirus (COVID-19), identified in China at the end of 2019, has a high contagion potential, and its incidence has increased exponentially. Its widespread transmission was recognized by the World Health Organization (WHO) as a pandemic. Dubious or even false information about factors related to virus transmission, the incubation period, its geographic reach, the number of infected, and the actual mortality rate has led to insecurity and fear in the population. The situation has been exacerbated due to the insufficient control measures and a lack of effective therapeutic mechanisms.5,7,8 These uncertainties have had consequences in a number of sectors, with direct implications for the population’s daily life and mental health. This scenario raises a number of questions: is there a fear/stress pandemic concomitant with the COVID-19 pandemic? How can we evaluate this phenomenon? To understand the psychological and psychiatric repercussions of a pandemic, the emotions involved in it, such as fear and anger, must be considered and observed. Fear is an adaptive animal defense mechanism that is fundamental for survival and involves several biological processes of preparation for a response to potentially threatening events. However, when it is chronic or disproportionate, it becomes harmful and can be a key component in the development of various psychiatric disorders.9,10 In a pandemic, fear increases anxiety and stress levels in healthy individuals and intensifies the symptoms of those with pre-existing psychiatric disorders.11 During epidemics, the number of people whose mental health is affected tends to be greater than the number of people affected by the infection.12 Past tragedies have shown that the mental health implications can last longer and have greater prevalence than the epidemic itself and that the psychosocial and economic impacts can be incalculable if we consider their resonance in different contexts.11,12 Since the economic costs associated with mental disorders is high, improving mental health treatment strategies can lead to gains in both physical health and the economic sector. In addition to a concrete fear of death, the COVID-19 pandemic has implications for other spheres: family organization, closings of schools, companies and public places, changes in work routines, isolation, leading to feelings of helplessness and abandonment. Moreover, it can heighten insecurity due to the economic and social repercussions of this large-scale tragedy. During the Ebola outbreak, for example, fear-related behaviors had an epidemiological impact both individually and collectively during all phases of the event, increasing the suffering and psychiatric symptom rates of the population, which contributed to increases in indirect mortality from causes other than Ebola.13 Currently, ease of access to communication technologies and the transmission of sensational, inaccurate or false information can increase harmful social reactions, such as anger and aggressive behavior.14 Diagnostic, tracking, monitoring and containment measures for COVID-19 have been established in several countries.6 However, there are still no accurate epidemiological data on disease-related psychiatric implications or their impact on public health. A Chinese study provided some insights in this regard. Approximately half of the interviewees classified the psychological impact of the epidemic as moderate to severe, and about a third reported moderate to severe anxiety.15 Similar data have been reported in Japan, where the economic impact has also been dramatic.11 Another study reported that patients infected with COVID-19 (or suspected of being infected) may experience intense emotional and behavioral reactions, such as fear, boredom, loneliness, anxiety, insomnia or anger,11 as has been reported about similar situations in the past.16 Such conditions can evolve into disorders, whether depressive, anxiety (including panic attacks and post-traumatic stress), psychotic or paranoid, and can even lead to suicide.17,18 These conditions can be especially prevalent in quarantined patients, whose psychological distress tends to be higher.16 In some cases, uncertainty about infection and death or about infecting family and friends can potentiate dysphoric mental states.11,18 Even among patients with common flu symptoms, stress and fear due to the similarity of the conditions can generate mental distress and worsen psychiatric symptoms.15,19 Despite the fact that the rate of confirmed vs. suspected cases of COVID-19 is relatively low and that the majority of cases are considered asymptomatic or mild, as well as that the disease has a relatively low mortality rate,20,21 the psychiatric implications can be significantly high, overloading emergency services and the health system as a whole. In conjunction with actions to help infected and quarantined patients, strategies targeting the general population and specific groups must be developed, including health professionals who are directly exposed to the pathogen and have high stress rates.22 Although some protocols for clinicians have been established, most health professionals who work in isolation units and hospitals are neither trained to provide mental health assistance during pandemics1,17 nor receive specialized care. Previous studies have reported high rates of anxiety and stress symptoms, as well as mental disorders, such as post-traumatic stress, in this population (especially among nurses and doctors), which reinforces the need for care.22,23 Other specific groups are especially vulnerable in pandemics: older adults, the immunocompromised, patients with previous clinical and psychiatric conditions, family members of infected patients and residents of high-incidence areas. In these groups, social rejection, discrimination, and even xenophobia are frequent.17 Providing psychological first aid is an essential care component for populations that have been victims of emergencies and disasters, but there are no universal protocols or guidelines for the most effective psychosocial support practices.24 Although some reports on local mental health care strategies have been published, more comprehensive emergency guidelines for such scenarios are unknown,1,17,19 since previous evidence refers only to specific situations.24 In Brazil, a large developing country with pronounced social disparity, low education levels and humanitarian-cooperative culture, there are no parameters for estimating the impact of this phenomenon on the population’s mental health or behavior. Will it be possible to implement effective preventive and emergency actions aimed at the psychiatric implications of this biological pandemic in broad spheres of society? Specifically for this new COVID-19 scenario, Xiang et al., suggest that three main factors should be considered when developing mental health strategies: 1) multidisciplinary mental health teams (including psychiatrists, psychiatric nurses, clinical psychologists and other mental health professionals); 2) clear communication involving regular, accurate updates on the COVID-19 outbreak; and 3) establishing safe psychological counseling services (for example, via electronic devices or apps).17 Finally, it is extremely necessary to implement public mental health policies in conjunction with epidemic and pandemic response strategies before, during and after the event.13 Mental health professionals, such as psychologists, psychiatrists and social workers, must be on the front line and play a leading role in emergency planning and management teams.1 Assistance protocols, such as those used in disaster situations, should cover areas relevant to the individual and collective mental health of the population. Recently, the WHO25 and the U.S. Center for Disease Control and Prevention26 published a series of psychosocial and mental health recommendations, several of which are included in Box 1. This is in line with longitudinal data from the WHO demonstrating that psychological factors are directly related to the main causes of morbidity and mortality in the world.25 Thus, increased investment in research and strategic actions for mental health in parallel with infectious outbreaks is urgently needed worldwide.1 Disclosure The authors report no conflicts of interest.
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                Author and article information

                Journal
                rbem
                Revista Brasileira de Educação Médica
                Rev. bras. educ. med.
                Associação Brasileira de Educação Médica (Brasília, DF, Brazil )
                0100-5502
                1981-5271
                2021
                : 45
                : 4
                : e202
                Affiliations
                [1] Rio de Janeiro Rio de Janeiro orgnameUniversidade Federal do Rio de Janeiro Brazil
                Article
                S0100-55022021000400401 S0100-5502(21)04500400401
                10.1590/1981-5271v45.4-20200407.ing
                d127bdc0-8cbf-42d9-8ea4-8b1aa79eace2

                This work is licensed under a Creative Commons Attribution 4.0 International License.

                History
                : 29 August 2021
                : 13 September 2020
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 38, Pages: 0
                Product

                SciELO Brazil

                Categories
                Experience report

                Telemedicine,Estudantes de Medicina,Covid-19,Transtornos Mentais,Telemedicina,Medical Students,Coronavirus Infections,Mental Disorders

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