Holistic care amid the Coronavirus-19 pandemic

Esther YT Yu 余懿德

HK Pract 2022;44:67-68

Into the third year of the Coronavirus-19 (COVID-19) pandemic, the availability of vaccines, rapid antigen testing and oral medications against the SARS-CoV-2 infection have enabled family doctors to take up a pivotal role in the combat against the fifth wave of COVID-19 outbreak in Hong Kong. In addition to staying vigilant to diagnose and treat patients with COVID-19 while protecting other patients and self from the infection through diligent infection control measures at one’s own practices¹ , family doctors relentlessly promoted and provided vaccinations to protect the vulnerable, set up designated clinics and offered outreach services at various community isolation facilities. Meanwhile, as providers of primary, continuous, and holistic care, family doctors must also recognise and manage the “spill-over” impact of the pandemic on the bio-psycho-social well-being of their patients and their family members.

Implementation of strict infection control strategies were linked to social isolation, loneliness and poor mental health.² Coupled with fear of being infected with COVID-19 and contradictory information overload, a local study conducted by Choi et al ³ in May 2020 found that one in four adult residents in Hong Kong reported deterioration of mental health since the pandemic began. Just three months after the pandemic onset, the estimated prevalence of depression and anxiety in Hong Kong have increased by almost two-fold from 10.7% to 19.8%, and four-fold from 4.1% to 14.0%, respectively. When the fifth wave of COVID-19 outbreak swept across Hong Kong and took more than 5000 lives cumulatively⁴ , an acute surge of mental crisis was observed in March 2022: the seven-day average estimate for suicides exceeded an “extremely high” level of 3.54.⁵ Family members who lost their loved ones so tragically during this difficult period, either from the COVID-19 infection or suicide, are at high risk of developing complicated grief.⁶ Yet, these bereaving, depressed or anxious individuals may not be aware of the significance and severity of their condition and often do not seek medical attention.

Moreover, reallocation of resources to enhance emergency care for patients infected with COVID-19 has deflected usual care for non-communicable disease management. In Hong Kong, elective care at both public hospitals and primary care clinics were reduced. Compounded by the diffidence of patients in seeking medical assistance for fear of iatrogenic exposure to COVID-19, patients who suffered from poor control or complications of their non-communicable diseases might endure their symptoms until intolerant. A recent review by Mak et al ⁷ found that the incidence of outof-hospital cardiac arrest increased by up to 5-fold in various countries including the United States, the United Kingdom, Italy and Spain; all with less favourable outcomes upon discharge and almost doubling of pronounced deaths on the scene. Delays in patient presentation were similarly reported in stroke centres across the world. Up to 40% of adults with diabetes mellitus reported their follow-up appointments being postponed or cancelled. Poor glycaemic control and increased body weights were observed among patients with type 2 diabetes mellitus, who experienced greater stress, changes in dietary habits, physical activity levels and self-management practices. Although the actual spillover impact of COVID-19 pandemic on the outcomes of patients with non-communicable diseases in Hong Kong is still being evaluated, similar problems can be anticipated in view of the prolonged disrupted access to health facilities and services.

Family doctors in the community are best positioned to mitigate these adverse spill-over impacts of COVID-19 pandemic through provision of comprehensive and holistic care. Opportunistic screening should be conducted on every patient, especially those at high risk such as the elderly and those with poor social support and/or financial constraint, in order to identify and provide timely care for patients with clinically significant depression, anxiety, or complicated grief. In the case report by Yip and Chung⁸ , the application of interpersonal psychotherapy (IPT) for the management of complicated grief was introduced. IPT is an office-based time-limited therapy to facilitate the griever to mourn for the loss and rebuild social support through improving communication and interpersonal effectiveness. In particular, the authors recommended two IPT techniques – facilitating the expression emotions and building social support - as effective first-line psychological intervention feasible to be used by family doctors in routine primary care setting. On the other hand, when patients with non-communicable diseases present either for regular review of their conditions, other health problems or especially with new onset symptoms, family doctors should thoroughly assess for indicators of poor disease control, complications and/or co-morbidities. Pang illustrated the importance of avoiding premature convergence on a hypothesis and always considering other possible differential diagnoses with a case of sterile pyuria.⁹ Notably, a proportion of patients may be found to have high blood pressure at the clinic because of their underlying psychological distress. To avoid misdiagnosis or overly aggressive treatment, ambulatory blood pressure monitoring should be offered to guide treatment as recommended by Wong et al.¹⁰ By taking care of the bio-psycho-social health of each patient and their family members – with or without COVID-19, family doctors together will contribute to a healthier, happier Hong Kong amid the unprecedented pandemic. 

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