Introduction

The first case of SARS-CoV-2 infection was identified in China on November 17, 2019; Europe was the epicenter for a period in February and March 2020; and the WHO declared a pandemic on March 11, 2020 [1]. In the context of work overload, health care professionals are faced with a situation of helping and caring for others while being exposed to the disease themselves [2]. To draw a parallel with SARS-CoV-2, studies of the 2003 SARS outbreak revealed that health care professionals who had friends or relatives infected with SARS were two to three times more likely to experience elevated post-traumatic symptoms than those who had not been directly exposed to the infection themselves. During this period of SARS, health professionals expressed deep concern for their loved ones, colleagues, and themselves in terms of their safety in the health care field. They exhibited signs of anger, anxiety, and stress related to the risk of contamination when providing care and the uncertainty generated by the situation in general [3]. Lasting negative effects were observed several years after SARS, such as alcohol-related symptoms, insomnia, and depressive disorders [3–5].

This unprecedented health crisis has raised questions about the role of psychiatry in assisting the population in dealing with the stress generated by the uncertainty and loss of reference points, in particular during lockdown and post-lockdown periods. Psychiatric-care professionals find themselves in the dual position of having to defend the urgent and essential needs of their patients and also having to prove their resistance and resilience in the social or family ordeal they are experiencing and imposing on their relatives. Nevertheless, psychiatric-care professionals can provide significant contributions in overcoming the pandemic by supporting other medical disciplines and absorbing the psychological impact of the event.

These successive events have had direct and indirect impacts on inpatient and outpatient organizations. In order to deal as effectively as possible with these stress and trauma management challenges, the scientific literature [3–6] recommends a number of interventions, notably:

1. Clarity in the communication of guidelines and precautionary measures;
2. Capacity to dialogue with establishment management in order to obtain its support;
3. Support from supervisors and co-workers;
4. Family support;
5. Capacity to talk to someone about their experiences;
6. Religious beliefs [7].

In order to obtain a real-time overview of the psychiatry and mental-health service status in Europe, Israel, and Turkey at the beginning of March 2020, we set up an ad hoc group of 23 contributors willing to participate in the review by describing the situation in their countries of origin by means of interviews and questionnaire feedback.

The preliminary results of the pre-study carried out from March to May 2020 identified several challenges facing mental health professionals and mental health services during the COVID-19 pandemic. These include [8,9]:

1. Access to psychiatric diagnosis and treatment should be maintained despite increasingly difficult circumstances.
2. Mental health services must be provided to patients who test positive for COVID-19. Various treatment regimens need to be developed for patients with and without respiratory symptoms with clear rules when a psychiatric patient needs to be transferred to respiratory care services. The question must be addressed of how to treat patients who need to remain in psychiatric clinics (isolation required, employee protection, possible need to establish a specific psychiatric service for COVID-19-positive patients).
3. For psychiatric patients treated in respiratory or intensive care units, functioning psychiatric liaison services should be provided and possibly increased; meanwhile, routine services for patients with somatic and psychiatric symptoms should be maintained.
4. It is also important to take measures to protect particularly vulnerable psychiatric patients, such as those treated in geriatric psychiatry departments, because the elderly are much more likely to develop severe symptoms when they are infected with COVID-19. As evidence from China indicates [10], there is a considerable risk that insufficient and inadequate attention will be given to this specific and vulnerable group of patients.
5. Psychiatric and mental health personnel need to be informed and trained in the control of infectious diseases, an area in which they generally have limited expertise. Innovation projects, for example, in the form of mentoring, are necessary and should be modeled in Europe because economic or structural crises affect training content, entry into employment, and qualifications [11].
6. With regard to the risk of infection of psychiatric and mental health professionals, the increased use of electronic tools that enable telepsychiatry has the potential to play a major role. These tools should be introduced in an ethical manner, both for the psychiatric professionals and users as well as for research in this field.
7. Both staff and patients must be frequently informed and reminded of the basic hygiene measures that are essential to reduce the spread of infectious diseases.
8. Psychiatric hospitals also have a duty to provide services to health care professionals involved in the fight against COVID-19 who develop secondary psychiatric symptoms, such as stress-related disorders or signs of anxiety or panic [12].
9. There is a significant risk that the need for psychiatric services will increase considerably at a time when services and their staffs are under intense stress. The current form of the organization of service provision must be restructured to meet the needs of this specific emergency situation, in compliance with ethical and therapeutic frameworks.
10. Psychiatric and mental health professionals need to liaise with decision-makers in order to ensure that the special needs of patients with mental and psychological disorders are taken into account when emergency measures are implemented.
11. In addition to online psychological consultation services, there are indications that digital psychiatry also allows for rigorous online monitoring of psychological health and mental health education [13]. This kind of research is essential in order to learn from the current crisis and for the future by integrating the ethical dimensions and those of the fight against social inequalities in health. For many of these challenges, specific solutions need to be developed at European, national, and regional levels. To address the challenges now and in the future, the solutions must take into account the structure of specific services in each area (e.g., availability or lack of inpatient facilities, role of community psychiatry, etc.).

In this context, our priority now is to complete our preliminary work to better understand the psychological and societal impacts of the COVID-19 health crisis on psychiatry professionals (PP), their professional positions, and their work organizations so as to provide the keys to understanding and the means to respond to crisis and post-crisis situations effectively and operationally in the future, based on the experience and the adjustment of an ethical professional position.

Our project, Psychiatry Professionals and COVID-19 in Europe: Psychological Impact Management and Crisis and Post-Crisis Organization (Psy-GIPOC), aims to provide:

1. an overview of the impact of the COVID-19 pandemic on the field of mental health professionals in 24 countries;
2. a model of recommendations for good practice and proposals for methods and digital tools to improve the well-being at work of mental health professionals and the quality of services offered during crisis and post-crisis periods;
3. an in-depth ethics review of the assessment of the use of numerical tools for psychiatry professionals and patient support, including teleconsulting.

Study design and methods

Third step: International online survey

This survey will be conducted online among 2,000 professionals in 23 countries (Belgium, Spain, Finland, France, Germany, Greece, Iceland, Ireland, Israel, Italy, Luxembourg, Malta, Netherlands, Poland, Portugal, Czech Republic, Romania, Russia, Sweden, Switzerland, Turkey, Ukraine, United Kingdom). The results of this quantitative study will be amplified with the 30 semi-structured individual interviews and 20 focus groups. The flow chart of the study is shown in Fig 1.

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Fig 1. Flow chart of Psy-GIPOC study.

https://doi.org/10.1371/journal.pone.0261818.g001

Methods

Selection criteria for the questionnaires among countries

A roster of 2,000 health professionals in psychiatry (HPP), matched according to age, gender, experience, and geographic location, will be compiled using snowball sampling from the networks of ad hoc professionals and researchers mobilized in March 2020 [11]. Thus, 23 experts will provide a database of HPP to whom to send the questionnaire or will relay the questionnaire directly to the professionals, according to the target number of respondents per country, i.e., a total of approximately 2,200 professionals.

After discussion with the scientific committee, we decided that the number of professionals participating in the study would be based on the population threshold of the involved countries with an overestimation of 10% after considering the number of psychiatric hospital beds per country [15], the number of psychiatrists per 100,000 inhabitants [16], and the heterogeneity of this data (Table 1).

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Table 1. Selection criteria for the questionnaires among countries.

https://doi.org/10.1371/journal.pone.0261818.t001

Ethical considerations and dissemination

This research received ethical approval from the ethics committee of the University Hospital of Tours on February 4, 2021, and is registered under number 2020 006.

The project outcomes will be disseminated through selected peer-reviewed journals, conference presentations, workshops, and webinars.

Discussion-conclusion

All recent work on major epidemics links the concepts of territory, epidemiology, and the health care system. There is a geography of virus development. These concepts show the links among the progression of the virus, the organization of care, and the state of the health care system. They show the territorial disparities and health factors that contribute to inequalities in access to health care systems and the vulnerability of fragile populations. This situation has destroyed the relationship of trust in hospitals and clinics: it is estimated that 50% of deaths are not due, for example, to Ebola but to other non-treated diseases [13,17].

The quality of psychiatric services during the COVID-19 pandemic varies from country to country, and public health policies and professional contexts differ. This research will shed light on this geopolitical dimension of COVID-19. The project will provide an intelligent international cross-look that will allow the exchange of innovative practices in a very operational way.

This study will contribute to the co-construction of an international organization and monitoring system that takes into account psychiatric health professionals as major resources to fight against COVID-19 and future pandemics [18]. In a context where the effects of such health crises have a direct impact on the development of the needs for psychiatric services during the crises and several years afterward [19], it is critical to develop research work that sheds light on these two interrelated dimensions.

The objective is to map out a high-quality level of existing structures and the availability of emergency structures with human resources in good physical and mental health. The aim is to draw lessons in order to develop efficient processes for preparing for and anticipating crises by reducing psychosocial risks as much as possible. This project also aims to design tools for remote medicine and to develop the use of digital tools for monitoring and supporting professionals. The aim of these digital tools will be to prevent psychological suffering and its consequences [20,21] while accompanying identifying signs of ill-being. The goal is to help professionals build the conditions for satisfactory operational work during crises and post-crisis situations, using adapted organizational methods. Our ongoing research should support professionals in the search for existing concrete solutions to cope with emergency work situations while maintaining an optimal quality of life.

Supporting information

Acknowledgments

The authors are grateful to the National Research Agency (Agence National de la Recherche) and the Region Centre-Val de Loire. The authors would like to especially thank the psychiatric health professionals for their contributions.