COVID-19 and Psychosomatic Care in the Largest General and Academic Hospital in Iran

Dear Editor;
During the relatively short period of COVID-19 pandemic, we have witnessed numerous psychiatric and psychosomatic problems among patients with this disease and different groups of people and health care staff (1). Growing concerns about the uncertainty of the situation, along with fear and changes in biological rhythm, have played an important role in the formation of psychosomatic symptoms associated with this disease (2). In addition, increased depression and anxiety and decreased quality of life and well-being in different parts of the world, compared to the time before the recent pandemic, have been reported (3).
Concerns about the mental health of Iranians have been raised since the beginning of the recent pandemic (4). The high prevalence and severity of psychiatric disorders among patients with COVID-19 in Iran has also been reported since the beginning of the spread of the disease (5). In Iran, some hospitals, especially academic ones, have provided psychiatric and psychosomatic services to these patients during this period. Although psychosomatic medicine, in its modern form, is in its nascent stages in developing countries, it can lead to improve medical care, reduce length of hospital stay, and better treatment outcomes (6).
The largest general and academic hospital in Iran, in the city of Tehran, called Imam Khomeini Hospital, has more than 1300 hospital beds and a history of 80 years. This hospital has different inpatient wards including internal medicine, surgery, transplant, infectious, Intensive Care Unit (ICU), Coronary Care Unit (CCU) and other wards and outpatient clinics. It also has a psychosomatic inpatient unit with a related day clinic. This ward has 10 hospital beds and for about 11 years, psychiatric counseling services have been provided to patients admitted to the various wards by the psychiatrists of this ward. During the recent pandemic, while maintaining the capacity of the inpatient ward to provide psychosomatic services in various fields and psychiatric and psychosomatic counseling services to patients in different wards of the hospital, providing these counseling services in wards for patients with COVID-19 (including ICU for patients with COVID-19) were added to the work programs of this unit. These consultations include a range of psychiatric and psychosomatic consultations.
These consultations for patients with COVID-19 are related to anxiety problems, sleep disorders, adjustment disorders and suicidal ideation on the one hand and issues such as delirium, confusion and agitation on the other hand along with counseling related to non-compliance with medical instructions and dissatisfaction with medical and surgical procedures. In this situation, psychopharmacological medication or, in many cases, brief bed side psychotherapy is performed. Teaching simple behavioral techniques for stress management with psychological support, which in some cases was accompanied by psychoeducation of patients’ families, especially with regard to the appropriate results in some previous studies (7), is one of the goals of this short-term psychotherapy. These interventions are mainly performed by senior residents of psychiatry, psychosomatic fellowships and under the supervision of faculty members of the psychosomatic department. It is emphasized that daily psychiatric visits should be performed carefully when necessary. In order to minimize the exposure for staff, it is possible to follow up cases, according to the evaluation of the service provider team and patient readiness, so that part of the follow-up visits can be held online.
On average, there are about 15-20 psychosomatic consultations a day, about half of which are for patients with COVID-19. Follow-up visits are also performed with about 20 daily visits. After discharge, most patients are referred to the hospital’s psychosomatic clinic for outpatient follow-up. If necessary, a group will be referred to the psychosomatic ward after discharge from the relevant ward or through an outpatient clinic.
On the other hand, one of the problems that has emerged since the recent pandemic is psychiatric issues related to health care providers. Due to the new conditions and the prolongation of the current situation, we are witnessing the development and exacerbation of psychiatric disorders such as anxiety, depression, post-traumatic stress symptoms and sleep problems, in a significant number of them (8). In this regard, in this hospital center, services are provided in psychosomatic outpatient clinics. However, in this regard, health care providers seem to have limitations and obstacles. Concerns about stigma and fear of losing job security on the one hand and deny the matter and the use of maladaptive coping mechanisms in this area are raised (9).
Regarding the psychiatric needs assessment of employees related to the COVID-19 Pandemic, quantitative and qualitative studies have been conducted by members of the psychosomatic unit with the participation of faculty members, along with some psychosomatic fellowships and some interested psychiatric residents, under the management of the Psychosomatic Research Center. (Results are in the publishing stage). Following this local needs assessment, cases have been followed up and psychiatric care programs have been designed.
As mentioned, other services in the psychosomatic department, in relation to non-COVID-19 patients, have been going through their normal course during the recent pandemic period. Some of these consultations are related to the selection and prioritization of those who need to receive organ transplant services and psychiatric evaluation and follow-up of cases, before and after transplantation, based on the usefulness of such interventions (10) and based on requests from psychiatric services. Other counseling includes dose adjustment for in-hospital opioid use and a wide range of in-hospital psychosomatic counseling services.
The credibility and value of psychosomatic services in times of multifaceted crisis that affect various aspects of biopsychosocial model around the world seems to be significant (11). The extent of the current pandemic and its negative consequences, in various respects, emphasize the need to pay attention to comprehensive approaches to dealing with medical disorders. In this regard, it seems that providing services in the field of psychosomatic disorders has become an important part of providing essential services in this field.
In the current pandemic situation, due to the high incidence and daily mortality of COVID-19 in Iran, Imam Khomeini Hospital in Tehran is operating with such functions in the field of psychosomatic care of patients during the peak of the pandemic, as the largest and most important service center in this field in Iran. Having software facilities and providing financial resources and capable personnel to provide these services and expand psychosomatic care services to other hospitals, especially in the field of patients with COVID-19 and their families, to improve prognosis and better control of related medical disease can be a source of beneficial effects. The implementation of such a policy by health policy makers can be appropriate to achieve more effective results in the field of psychosomatic medicine.

Financial disclosure
None.
Acknowledgements
We sincerely thank all the staff of Imam Khomeini Hospital who provide psychosomatic services to the needy patients, especially in these difficult recent pandemic conditions.

Conflict of Interest
None.