Psychiatric Treatment of a Health Care Worker After Infection With Ebola Virus in Lagos, Nigeria

A young single male health worker was admitted to the isolation ward of the infectious disease hospital in Lagos with Ebola virus disease, which he had contracted in the course of rendering services to the index case in Nigeria. Three weeks after the admission, he appeared confused and was sleeping poorly, talking tangentially, and exhibiting unruly, disruptive behavior toward those caring for him. His behavioral symptoms were worse during relatives’ visits. The clinical management team considered a diagnosis of permanent brain injury secondary to the Ebola virus infection but could not conduct the relevant investigations because of the contagious nature of the illness. The patient was referred to the psychosocial team.

On evaluation, the psychosocial team found the patient to be apprehensive and fearful about the outcome of his illness. He lamented having contracted the virus, despite having taken what he considered adequate precautions while attending to an infected patient. He had feelings of sadness and self-pity, saying that God had forsaken him and at other times saying that God did not exist. He often paced up and down the corridor. His poor sleep seemed to contribute to his daytime anxiety. He was angry with his clinical colleagues, who were now his clinical management team, and his relatives for “ostracizing” him in the isolation ward. He felt very sad about both groups seeing him in “this helpless situation.” He had no past history of mental disorder.

Mental state examination revealed a restless and agitated young man. He described his mood as not happy. His thinking was slowed but goal directed. He worried that some patients admitted after him had already been discharged after achieving remission and believed that his condition was probably not responding to treatment. He had no delusions, obsessions, or hallucinations. He was oriented in time, place, and person, but his attention and concentration were impaired. He could recall only one of five objects in 5 minutes. He lacked insight into his mental problem. Further cognitive and neurological evaluation was not attempted because of the patient’s contagious status. He had been physically stable for several days prior to consultation, although his blood test was still positive for Ebola virus. A diagnosis of adjustment disorder with mixed disturbances of emotion and conduct was made.

The psychosocial team commenced supportive psychotherapy and problem solving therapy. The patient was encouraged to cooperate with the management team and caregivers for the desired therapeutic outcome. Because of his poor sleep and anxiety, we prescribed 25 mg of amitriptyline at night, and increased the dose to 37.5 mg 48 hours later. The primary management team was educated on the nature of his psychological disorder, which could mimic cognitive impairment secondary to Ebola virus disease-induced brain encephalopathy. They were informed that his behavior could be ascribed to the psychological stress of having a life-threatening disorder. The patient’s relatives were also given psychoeducation. Like the patient, they were allowed to express their frustration and were educated on how best to manage their expectations.

Three days after amitriptyline and supportive psychotherapy were started, the management team reported noticeable improvement in the patient’s sleep pattern and a gradual reduction in his disruptive behavior. By the time the patient was discharged, after fulfilling the clinical management team’s discharge criteria, which included a negative blood test for Ebola virus, he was no longer considered disruptive or exhibiting features of confusion. He had nightmares during the first and second weeks after discharge that gradually subsided. Serial scores on the Mini-Mental State Examination (MMSE) were consistently in the normal range (29 to 30). Supportive psychotherapy and counseling continued over the telephone. The patient had 24-hour access to a psychiatrist and a social worker by mobile telephone.

Four weeks after discharge, the patient’s condition remained stable. He was sleeping well, without nightmares. His amitriptyline dose was reduced to 25 mg at night, and further reduced to 12.5 mg 7 weeks after discharge. The patient has since resumed his health care work and reports no clinically significant psychological distress. Nine weeks after discharge, the amitriptyline was discontinued.