The coronavirus 2019 (COVID-19) pandemic has so far impacted every aspect of the lives of health care professionals, physicians, and nurses, particularly their contact with family, friends, and even patients (1-3). This condition has further transformed some aspects of psychiatrists' professional lives, including psychiatry-related management and training programs (3). Throughout the COVID-19 pandemic, there has been much effort to flatten the curve for this crisis in the consultation-liaison (CL) psychiatry unit in the city of Sari, Mazandaran Province, Iran. In addition to managing patients with COVID-19 who had associated psychiatric problems, addressing other issues, such as physical and mental health in colleagues and nurses (4), and especially trainees, who in the latter case were more necessary than their education, and ultimately ensuring that the whole system continues to operate in the face of emerging constraints and limitations, had increased the responsibility of psychiatrists. In summary, during this period, the training directors of the residency program had been actively involved in regulating the broad workflow of various clinical activities in the COVID-19 patient wards, as well as the CL psychiatry rotating courses and psychosomatic medicine fellowship programs. According to (3), training directors were required to adopt strong leadership styles, take systematic approaches to dealing with problems, update their communications, rapidly change policies, and promote well-being with all available means in such circumstances.
The first confirmed case of COVID-19 was officially declared on February 19, 2020, in Iran (5). Throughout the first peak of this pandemic, which started from March 16, 2020, and lasted to May 19, 2020, there were several limitations regarding personal protective equipment (PPE) for physicians. Therefore, reducing the exposure of physicians, professors, and psychiatry assistants to patients with COVID-19 was at odds with the provision of quality health services. CL psychiatrists working at Imam Khomeini teaching hospital in Sari, who were also in charge of training, as well as psychiatry assistants, had been subjected to face-to-face contacts with COVID-19 patients every day. In the first four weeks, psychiatry interns had thus been trained online due to some concerns about the pandemic, and then, by the end of April, 2022, the CL psychiatry unit had not offered any internship training programs. In view of the hierarchy of needs, the priority of the psychiatric team was to protect these interns against COVID-19 (6, 7).
The first training session in the CL psychiatry unit was scheduled for March 8, 2020, two weeks after the closure of educational affairs due to the COVID-19 outbreak via the Skype platform, by the training director of the course, and was held by the relevant professors. This was a session dedicated to the Journal Club on "Interactions between psychotropic medications and antiviral drugs". At that time, there were no guidelines about the interactions of antiretroviral drugs for the treatment of COVID-19 and psychotropic medications. This session aimed to provide a reliable source of information for the team and even send a message to trainees that education was in progress, although COVID-19 has so far had a significant impact on it. The most important achievement of the first session was to help the whole team gain some control over the situation during that period of uncertainty. For the first five months, the topics of all training sessions were on COVID-19 and psychosomatic issues, as well as the review of some guidelines for PPE, COVID-19 testing, and medical treatments.
It is worth noting that CL psychiatrists had encountered many challenges worldwide so far in the COVID-19 era, due to some complications, side effects, and drug interactions to combat the pandemic, particularly some medications that were less commonly used before, such as chloroquine, hydroxychloroquine, remdesivir, atazanavir, lopinavir, ritonavir, favipiravir, azithromycin, etc. (8).
During the first two months of the COVID-19 outbreak, the major articles were published in China (9, 10). In other countries, such as the United States of America, there were also many changes to training curricula, policies, and guidelines since the pandemic started (11).
During the pandemic, due to the existing needs and crises, training directors and heads of hospitals repeatedly decided to seek medical treatment and health care services by assistants in various fields in the wards for COVID-19 patients in order to work with the residents of internal medicine, emergency, and infectious diseases. Nevertheless, psychiatry residents were only engaged in specific activities related to their own field due to the need for psychiatric interventions for COVID-19 patients and the limited number of assistants in the CL psychiatry units. Evaluation, management, and psychological education of patients were performed face to face during the COVID-19 pandemic and no telepsychiatry was exploited. From the first to the fifth peaks in Sari, the psychosomatic ward was closed and turned into one for COVID-19 outpatients to have remdesivir injections. The main activity of the CL psychiatry unit was providing psychiatric consultation to the patients admitted to general teaching hospitals. In the intervals between the peaks, the CL psychiatry unit, in addition to the above-mentioned activities, provided services to inpatients with psychosomatic disorders, which continues until the time of writing this article.
Besides, job burnout during COVID-19 was an issue observed in some members of the treatment team once the pandemic peaked, especially throughout the Delta variant surge. In our study, on a total of 7626 medical personnel across Iran, job burnout had been reported in 18.3% of the cases in the first peak of the pandemic (12). A study of the effects of COVID-19 on American psychiatry trainees in 2022 has demonstrated that job burnout was negatively correlated with satisfaction with the training programs (11).
Another challenge we faced during the pandemic was the issue of presenteeism. Although we do not have exact statistics on this issue, sometimes there were cases that were present in the workplace by denying the symptoms of the disease and probably transmitted the disease to others.
The COVID-19 pandemic strongly influenced residency and fellowship training programs, although it was more pronounced in some disciplines (6). In a 2020 online questionnaire-based study of 400 individuals enrolled in residency and fellowship training programs in Saudi Arabia, 84.6% of the 240 respondents reported a decrease in educational activities, and 97% of surgical assistants had done less surgery due to the pandemic (6). A cross-sectional study of 352 psychiatry assistants revealed that most training changes were a reduction in the number of rotations requiring patient care, as well as an increase in contact hours or duties (11). In that study, the most important concerns related to the pandemic were spreading the virus to family and friends, and peer burnout and anxiety (11).
Most psychiatry training programs in the Sari CL psychiatry unit were in the virtual space until October 2021. A great effort was made to maintain the quality of training and ensure proper psychiatric education to trainees. Due to the filtering imposed due to political sanctions on video conferencing platforms, such as Zoom in Iran, which is extensively used in the world, the Skype platform was chosen in this direction. A few months after the onset of the pandemic, the affiliated university made it possible to run and try the Adobe Connect software, but the Skype platform became more widely used due to its ease of use and fewer unexpected problems.
During the pandemic, accompanied by the CL psychiatrists, three psychiatry professors in Sari were at the forefront of dealing with patients with COVID-19 who had psychiatric comorbidities or coexisting disorders in two general teaching psychiatric hospitals. Other psychiatry professors at another teaching hospital, who treated psychiatric patients, separated and quarantined COVID-19 patients from other psychiatric patients and provided training and treatment in these special wards. But at some peaks of the disease, most of the psychiatric patients admitted to that hospital were infected with COVID-19, and those professors were forced to quarantine non-COVID-19 patients in special wards to prevent them from contracting the coronavirus.
It is worth noting that the field of psychiatry received more attention during the Covid-19 pandemic in other countries, such as Spain. According to (8), many psychiatrists in that country returned to medical practices as general practitioners once the COVID-19 pandemic occurred, which led to strengthening primary health care teams. This experience of Spanish psychiatrists has raised the need to pay attention to the teaching of new medical subjects at the beginning of a psychiatric residency for better training of psychiatrists (8). In other words, the pandemic reaffirmed that psychiatry is a medical specialty and that psychiatrists should act as general physicians in times of need, such as earthquakes and major disasters (8). One of the duties of psychiatrists was to continue the psychiatric treatment of patients with a major mental disorder, such as schizophrenia, who had also developed COVID-19, and then were hospitalized (8). The stress related to the somatic symptoms of COVID-19 in many cases had accordingly led to the worsening of psychiatric disorders in these patients.
Although the pandemic caused great damage to society in many areas, scientific exchanges increased dramatically during this period. Increasing social distance and remote working, and reducing travel, provided more opportunities to study scientific texts and articles. During this time, there was an opportunity for open access to the articles of some reputable journals about COVID-19. On the other hand, holding webinars has improved significantly, both quantitatively and qualitatively. Besides, in many scientific centers and universities (including Mazandaran University of Medical Sciences), facilities were provided for studies related to COVID-19 due to the need to have access to new materials. In addition, joint clinical trials were planned in many countries. Accordingly, research projects were further started and implemented by psychiatrists, including the CL psychiatry unit in Sari, with the cooperation of physicians in various fields, including infectious diseases specialists, pulmonology, anesthesiology, epidemiology, clinical psychology, nursing, midwifery, etc. The results were 17 articles written or co-authored by three psychiatrists working in the CL psychiatry unit about COVID-19, as well as other research in progress.
Coronavirus 2019 taught physicians that they must go on with coping as the pandemic continues. Despite the rapid evolutionary changes in response to this pandemic, little attention paid to psychiatrists, training curricula, and trainees around the world. Covid-19 also helped turn crises into opportunities. A tragedy also emerged that required constructive solutions to find a path to life from death. Also, increased effort and responsibility, solidarity, kindness, courage, adaptability, and coping with uncertainty were all reinforced, and much effort was made to emphasize the importance of teamwork to residents from other disciplines with psychiatry.
