Provision of Medical-psychological and Psychiatric Care to Patients with Post-covid Syndrome in Telemedicine Conditions

Objective. The need for scientific understanding of the revolutionary changes that have occurred associated with the situation of the COVID-19 pandemic, both in the organization of psychological and psychiatric care, and in the direction of developing effective treatment and prevention measures, determines the relevance of this study, the purpose of which is to study the clinical manifestations of psychopathological symptoms in patients, survivors of the COVID-19 disease, and develop a conceptual model for providing them with medical care in telemedicine. Materials and methods. We studied the psychopathological manifestations of post-covid syndrome in 129 patients who had recovered from COVID-19 and who applied to us for remote medical counseling psychological and psychiatric help for 10 months, from March to December 2020, using clinical psychopathological and psychodiagnostic test research methods. Results and Discussion. The high level of stress, anxiety and depression identified in the studied patients is primarily associated with the negative situation of the pandemic and the COVID-19 disease. A follow-up study proved the effectiveness of a treatment carried out in a telemedicine setting and combining cognitive-behavioral therapy with antidepressants and non-benzodiazepine tranquilizers. In patients who underwent a severe form of COVID-19, in the presence of premorbid chronic bronchopulmonary pathology, in addition to long-lasting psychopathological symptoms, somatic post-covid complications were also observed, and the stressfulness of the situation was perceived at a deeper personal level. For such patients, the course of treatment in telemedicine conditions should be extended and medical and psychological support provided during the entire period of convalescence. on the protocols of cognitive-behavioral therapy for hypochondriacal and generalized anxiety disorder, in combination with antidepressants and tranquilizers of the non-benzodiazepine series, which ensures the stability of the positive results of therapeutic interventions, confirmed by our studies. The conceptual patient-centered model developed by us for the provision of psychological and psychiatric care for post-covid syndrome in telemedicine can be recommended as a universal algorithm for psycho-psychiatric interventions when providing remote assistance to patients with post-covid mental disorders.


Introduction
The COVID-19 pandemic has become a global challenge to humanity, affecting all health parameters -physical, mental, social and spiritual. In addition to the symptoms of the bronchopulmonary system in the form of a severe respiratory syndrome, 1,2 2. Khrystyna S. Zhyvaho -PhD, MD, Assistant Professor of the Psychiatric Department,Bohomolets National Medical University, bul. Shevchenko, 13, Kyiv, Ukraine; k.zhyvago@gmail.com neuropsychological and mental disorders are observed in patients with COVID-19, but they are not well understood. The existence of links between depressive symptoms and viral diseases predicts a significant and persistent negative impact of the previous coronavirus infection on mental health. 3 The need to ensure the safety of doctors and patients in a situation of shortage of medicines and personal protective equipment, 4,5 has led to the predominant provision of psychological and psychiatric assistance remotely, through telemedicine technologies. The need for scientific understanding of the revolutionary changes that have occurred associated with the situation of the COVID-19 pandemic, both in the organization of psychological and psychiatric care, and in the direction of developing effective treatment and prevention measures, determines the relevance of this study.

The aim
The object of our study is the impact of the COVID-19 pandemic on the psychological state and mental health of the population, the subject of the study is the process of providing psycho-psychiatric care to patients with post-covid syndrome in telemedicine conditions. The aim of the study is to study the clinical manifestations of psychopathological symptoms in patients with COVID-19 disease and develop a conceptual model for providing them with medical care in telemedicine.

Research objectives:
 analyze scientific literature data on the impact of COVID-19 on mental health and the possibilities of using telemedicine technologies to provide psychological and psychiatric care to patients;  to identify the main clinical manifestations of post-covid syndrome and evaluate the effectiveness of appropriate treatment measures, with remote management of these patients using telemedicine technologies;  based on the results of the study, develop a conceptual model for the diagnosis and treatment of patients with psycho-psychiatric disorders due to the previous COVID-19 disease in the context of telemedicine.
The hypothesis of the study is the assumption that telemedicine is an effective way to provide remote psychological and psychiatric assistance to patients with mental disorders associated with the previous COVID-19 disease.

Literature review
The coronavirus disease COVID-19 directly and indirectly affects all aspects of society on a global scale, including both physical and mental health, [6][7][8][9][10][11] causing stress, causing depression and anxiety. This is objectively confirmed by studies using valid methods, in particular, IES-R and DASS-21, 12,13 which is considered a reliable tool for the diagnosis of depression, anxiety and stress and is used for this purpose in many countries of the world. 14 There is sufficient evidence for the possible existence of a post-COVID syndrome or for the justification to correspondingly designate these possible sequelae with persisting symptoms in this waythere is sufficient evidence for the possible existence of a post-COVID syndrome or for the justification to correspondingly designate these possible sequelae with persisting symptoms in this way. 15 Mental health disorders associated with COVID-19 are prone to young patients of working age, and risk factors are female gender, unemployment, and the presence of concomitant chronic pathology, [16][17][18] however, the psychological stress aspect of the global emergency of the COVID-19 pandemic has long been neglected. 17 Nurses, doctors and other healthcare professionals are at risk, 19 showing symptoms of insomnia, anxiety, depression, somatization and obsessive-compulsive disorder, [19][20][21] while psychological and social support increased their psychological stability. [22][23][24][25] During the pandemic, there was also a decrease in public confidence in healthcare systems. 2 Positive thinking, active coping with stress, and social support were positive predictors of psychological quality of life, well-being, and negative predictors of perceived stress, depression, anxiety and insomnia. 26,27 It has been established that the psychological status of the population during a pandemic is influenced by: young age; female gender (however, in men, mental health also deteriorated, up to the presence of suicidal thoughts, 28 especially in the presence of chronic obstructive bronchopulmonary disease) 29 ; higher self-esteem of the likelihood of infection; anxiety about psychological barriers and mistrust. 30,31 A direct damaging effect of coronavirus on the central nervous system has been found, 18 and an intense stress response associated with an epidemic situation has both short-term and long-term negative consequences for mental health. 19,32 When developing differential diagnostic and therapeutic measures, one should take into account the polymorphism of psychopathological symptoms associated with COVID-19, 33,34 and the mechanisms of neuropsychological deficit. 35 The neuropsychiatric complications of COVID-19 can be short-term and long-term, [35][36][37] require increased attention to this problem and its further study. 38 Psychological prevention of the negative consequences of the COVID-19 pandemic should take into account psychological, social and neurobiological aspects. 6,19,32 Public health faced the task of developing and implementing a public health policy aimed at controlling the situation and stopping the COVID-19 pandemic. 39 The mental health problem associated with the COVID-19 pandemic prioritizes the development of global psychopreventive interventions, 35,40 as well as the need for psychological support and psychological assistance through telemedicine. 20,[41][42][43][44][45] This is especially important due to the fact that fear of infection leads to a decrease in the number of psychiatric care seekers in medical institutions. 46 The COVID-19 pandemic has led to the development of remote mental health care, 20 but it depends on the availability and quality of the Internet and telecommunications. [47][48][49] One of the alternative options for remote psychological and psychiatric assistance is the organization of a psychological support service by telephone. 50 However, video platforms make it possible to assess psychiatric symptoms that cannot be observed over the telephone. 36 The positive assessment by patients with mental disorders with COVID-19 makes it a promising direction. 51 At the same time, it is necessary that the doctor pays attention to ensuring the quality of the therapeutic relationship, and the patient feels safe and comfortable when interacting with the therapist in a virtual environment. 51 The challenge of meeting the health needs of the population has led to the elimination of regulatory barriers that have limited the spread of telemedicine, 52 which has proven to be a reliable and quality method of health care delivery. 53 The COVID-19 pandemic provides an opportunity for wider use of telemedicine, 54,55 overcoming skepticism and confirming its effectiveness in the treatment of mental disorders. 47 The massive cultural changes in the provision of psychotherapy services to patients, due to the COVID-19 pandemic, quickly translated into a virtual format, raises the question of creating protocols aimed at ensuring the ethical provision of services to patients at high risk. 56

Materials and methods
We studied the psychopathological manifestations of post-covid syndrome in 129 patients who had recovered from COVID-19 and who applied to us for remote medical consultative psychological and psychiatric help for 10 months, from March to December 2020. All patients were with higher education, their gender and age characteristics are presented in Table 1. We used the following methods to study patients in telemedicine conditions: anamnestic method (retrospective assessment of premorbid mental status); clinical and psychopathological method; method of pathopsychological diagnostics. The following psychodiagnostic test methods were used: "10 words" and "counting according to Bleicher"the study of memory, volitional efforts, exercise and fatigue of patients; 57 DASS-21 (Depression, Anxiety and Stress Scale -21 points), 56 is a valid method used to measure the emotional states of depression, anxiety and stress; Spielberger-Khanin scale of reactive and personal anxiety; 58 The WAM questionnaire, 58 which allows you to quickly assess the patient's well-being, activity and mood in the dynamics of the therapeutic process.
The psychodiagnostic study was carried out three times: at the initial visit of the patient for psychological and psychiatric help in telemedicine, at the end of the main course of treatment (one month after the initial visit), and in the follow-up 3-6 months after the end of treatment.
Methods for the treatment of identified anxietydepressive and other emotional disorders of varying severity were carried out online in accordance with the cognitive-behavioral therapy protocol for generalized anxiety disorder and hypochondriacal disorder, using antidepressants and tranquilizers of the non-benzodiazepine series.

Research design
The research design assumed the sequential implementation of the following stages: Stage 1problem statement, formulation of research goals and objectives; Stage 2 -an analytical review of scientific literature sources on the problem of mental health disorders associated with COVID-19, and the provision of psychological and psychiatric care to patients in a telemedicine setting; Stage 3 -selection of valid research methods and formation of a relevant sample; Stage 4 -conducting a study, statistical processing of the results using the online calculator medstatistic.ru, 59 and their analysis; Stage 5 -based on the results obtained, the creation of a conceptual model for the provision of psychological and psychiatric care to patients with post-covid syndrome in telemedicine conditions; Stage 6 -formulation of conclusions and practical recommendations.

Limitations of the study
The limitations of the study were associated with a relatively small sample of patients, since we conducted studies only of those patients who independently turned to us for psychological and psychiatric help in a telemedicine setting. It is planned to continue research to identify possible subclinical cases of post-covid syndrome.

Results
Patients who recovered from COVID-19 independently sought psychological and psychiatric help in connection with complaints of memory, sleep and appetite disorders, decreased mood and ability to work, loss of prospects and interest in life, anxiety and fear of death, hypochondriacal disorders and worries about loved ones people, as well as obsessivecompulsive symptoms, which was confirmed by clinical and psychopathological research. The acute period of COVID-19 in the studied patients was expressed to varying degrees, and the severity of the condition was determined not so much by gender and age as by the presence of premorbid chronic bronchopulmonary and immunodeficiency pathology, which was observed in 5 (3.9%) patients. These patients had the most serious illness, were treated intensively with the use of mechanical ventilation, and during the period of convalescence they had various somatic complications. The rest of the patients were treated at home, and if 82 people (63.6%) had a high temperature, from 38 ° to 41 ° C, which lasted 3-7 days, then in 39 patients (30.3%) it did not exceed 37.5 ° C, and in 3 (2.3%) patients, COVID-19 disease was almost asymptomatic, in the form of mild weakness, headache and minor symptoms of SARS, and was accidentally detected by laboratory tests. In addition, no loss of smell was observed in about a third of the patients studied. It should also be pointed out that as a result of a retrospective study of the patients' premorbid state, none of them had any clinically significant mental health problems or personality and behavioral disorders prior to COVID-19, that is, they were previously practically healthy and have never sought help from psychiatrists or medical psychologists before. When examining memory, 98 (76.0%) patients showed impairment of memorization. For complete or almost complete reproduction of 10 words, 56 (43.4%) patients took from 9 to 16 readings, for the rest of the subjects the number of readings did not have a significant effect on the volume of memorized material, and they could not reproduce more than half of the words read. In addition, the patients experienced difficulty in reproducing the words they read one hour after the presentation of the test  Table 2.
None of the patients who applied to us had a normal level of stress, anxiety and depression according to the DASS-21 scales, and only 1 person had an insignificant level of depression, and 1 studied -a slight level of anxiety. Indicators of stress correlated with indicators of anxiety and depression, which indicates the presence of a direct strong connection between the indicators of these scales. We did not find statistically significant differences in the level of anxiety, depression and stress between men and women.
In the next Table 3 presents the results of studies of patients who have had COVID-19, according to the Spielberger-Khanin method. Despite the fact that there is a direct correlation between personal and situational anxiety, the level of indicators of situational anxiety is statistically significantly higher than personal. The results of this test suggest that the high levels of stress, anxiety and depression identified in the studied patients are primarily associated with the negative situation of the pandemic and the COVID-19 disease. Indeed, this is confirmed by the presence of a direct, close, strong correlation between the high situational anxiety of the studied patients, revealed by the Spielberger-Khanin method and a high level on the depression scale (correlation coefficient ρ = 0.813), anxiety scale (correlation coefficient ρ = 0.820) and the scale stress (correlation coefficient ρ = 0.739) of the DASS-21 method.
The subjective state of patients in dynamics was assessed using the WAM method (Well-being, Activity, Mood). The results of the primary research using this technique are presented in Table 4. In patients who had recovered from COVID-19, a decrease was found on all three scales of the WAM technique. They showed low indicators of both wellbeing and activity and mood, which also positively correlated with the results of previous tests. The decrease in activity and mood was expressed to a greater extent than the state of health, which indicated the presence of both anxiety-depressive and hypochondriacal symptoms, which were also detected during clinical and psychopathological research.
After the treatment of psychopathological symptoms, carried out in accordance with the protocols of cognitive-behavioral therapy for hypochondriacal and generalized anxiety disorders, in combination with drug therapy with antidepressants and nonbenzodiazepine tranquilizers, a reduction in psychopathological symptoms was observed, which was objectively confirmed by the results of a second study. The dynamics of stress, anxiety and depression indicators according to the DASS-21 method is graphically presented in Figure 1. As can be concluded from this diagram, in the course of treatment it was possible to achieve the normalization of indicators on the scale of depression in the studied patients.
In patients who underwent a severe form of COVID-19 and suffered from concomitant premorbid chronic bronchopulmonary pathology, in addition to long-term psychopathological symptoms, somatic post-covid complications such as myocarditis, renal dysfunction, etc. were also observed.
The following Figure 2 shows the dynamics of the DASS-21 test indicators on the alarm scale.
The follow-up study showed a tendency of normalization of indicators on the DASS-21 anxiety scale in all patients. Manifestations of moderate anxiety in the follow-up period in 31 patients is associated, in our opinion, with the ongoing stressful situation of the pandemic and premorbid personality traits of the patients, which led to a prolonged negative experience. In Figure 3 shows the dynamics of indicators on the DASS-21 stress scale at the beginning and at the end of treatment and after the follow-up period (3-6 months). In a number of patients, normalization on the stress scale was much slower than on the other two scales of the DASS-21 method. We can assume that for patients with a severe form of COVID-19 and emerging from the acute period of the disease with the presence of complications from the cardiovascular, excretory and other body systems in combination with psychopathological symptoms, the stressfulness of the situation was perceived at a deeper personal level. For such patients, the course of treatment should be extended and medical and psychological support provided during the entire period of convalescence. The next graph (Figure 4) presents the dynamics of the indicators of the WAM technique in the course of treatment and in the follow-up. Despite the fact that communication with patients took place in the context of telemedicine, the psychotherapeutic assistance provided to them using the methods of cognitive-behavioral therapy was quite effective and made it possible to ensure a positive dynamics of indicators on all three scales. In our opinion, psychological support played a leading role in this, which is especially important for overcoming the feeling of loneliness while limiting social contacts due to quarantine measures.
The effectiveness of therapeutic intervention based on the protocols of cognitive-behavioral therapy for hypochondriacal and generalized anxiety disorder, in combination with antidepressants and nonbenzodiazepine tranquilizers, is confirmed by the results of our study, including follow-up, which is especially important for the treatment of mental disorders in patients with COVID-19 disease. According to our observations, chronic premorbid diseases of the bronchopulmonary and immune systems act as predictors of both long-lasting psychopathological symptoms and the occurrence of post-covid somatic complications.
Having analyzed and summarized the obtained research results in comparison with scientific literature data, 20,32,[41][42][43][44][45] we have developed a conceptual model for the provision of psychological and psychiatric care to patients with postcoid syndrome in telemedicine, shown in Figure 6.
This model consists of four semantic blocks: psychodiagnostic, psychotherapeutic, psychopharmacotherapeutic and psychoprophylactic. All blocks of this model are interconnected, and their sequence is determined by the clinical picture of post-covid syndrome and the characteristics of its course in a particular patient. At the same time, the psychodiagnostic unit involves monitoring the patient's condition using not only the clinical and psychopathological method, but also pathopsychological diagnostics, in dynamics, at all stages of the provision of medical and preventive care. The block of psychoprophylaxis implies all its levels, including the stages of medical-psychological and medical-social rehabilitation. This model is patient-centered and is built taking into account the requirements of bioethics and the moral responsibility of the doctor.

Conclusion
Based on the results we obtained, the main psychopathological and pathopsychological phenomena of specific asthenic post-covid syndrome were identified, which can be presented in the form A repeated study of memory and attention showed that cognitive impairments in patients with post-covid syndrome are reduced more slowly than anxietydepressive symptoms, which can be associated with both a long-term asthenic state and the direct neurotoxic effect of the virus. This aspect must be taken into account in the development of treatment and rehabilitation tactics for managing such patients.

Discussion
The results of our study confirm the scientific literature data on the damaging effects of COVID-19 on the central nervous system. 19,32 The COVID-19 disease is characterized by psychopathological symptoms in the form of manifestations of anxietydepressive syndrome of varying severity, [19][20][21] cognitive dysfunction, 19,33,34 and other phenomena that persist for a long time after the end of the acute period of the disease, 36

Disorders of memory and attention
Stress, panic attacks, hypochondriacal syndrome, anxiety-depressive syndrome, PTSD Asthenic postcovid syndrome of two blocks: cognitive impairment (impairment of memory and attention) and emotional disorders (anxiety-depressive syndrome, stress and panic reactions, hypochondriacal symptoms posttraumatic stress disorder). To objectify the clinical and psychopathological manifestations of post-covid syndrome in telemedicine, when observation of the patient is difficult, we recommend using a battery of valid psychodiagnostic tests, consisting of the following methods: "10 words" and "Bleicher count" -for the diagnosis of cognitive impairments; DASS-21 -for measuring the level of anxiety, depression and stress; Spielberger-Khanin, which allows differentiating personal and situational anxiety; WAM (Well-being, Activity, Mood) -for a quick assessment of the effectiveness of medical psychological and psychiatric care in dynamics. According to our observations, chronic premorbid diseases of the bronchopulmonary and immune systems are predictors of both long-lasting psychopathological symptoms and the occurrence of post-covid somatic complications. The treatment tactics of patients with post-covid mental health disorders should be based on the protocols of cognitive-behavioral therapy for hypochondriacal and generalized anxiety disorder, in combination with antidepressants and tranquilizers of the non-benzodiazepine series. A persistent reduction in anxiety-depressive symptoms, combined with an improvement in patients' well-being, an increase in their activity and mood, indicates the high therapeutic effectiveness of such a therapeutic intervention. Follow-up studies confirm the achievement of a long-term positive result in the treatment of mental disorders in post-covid syndrome, which is evidence of the success of the use of telemedicine for the provision of psychological and psychiatric care to patients with the consequences of COVID-19 disease.
The conceptual patient-centered model developed by us for the provision of psycho-psychiatric care to patients with post-covid syndrome in telemedicine is built taking into account the principles of bioethics and the moral responsibility of a doctor, consists of four semantic blocks: psychodiagnostic, psychotherapeutic, psychopharmacotherapeutic and psychoprophylactic, and can be recommended as a universal algorithm for psychologica; and psychiatric interventions in the provision of remote assistance to patients with post-covid mental disorders.

Funding
This article was carried out within the framework of the research work of the Department of Medical Psychology, PJSC "PHEI "Interregional Academy of Personnel Management" and the Department of Psychiatry of Bogomolets National Medical University, Kyiv, Ukraine.

Conflict of interests
Authors declare that they have no conflict of interests.

Data availability
Data will be available on request.

Ethical clearance
Ethical issues were ensured by the anonymity of the