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April 3, 2020

Addressing the COVID-19 Pandemic in Populations With Serious Mental Illness

Author Affiliations
  • 1Rollins School of Public Health, Emory University, Atlanta, Georgia
JAMA Psychiatry. Published online April 3, 2020. doi:10.1001/jamapsychiatry.2020.0894

The coronavirus disease 2019 (COVID-19) pandemic will present an unprecedented stressor to patients and health care systems across the globe. Because there is currently no vaccine or treatment for the underlying infection, current health efforts are focused on providing prevention and screening, maintaining continuity of treatment for other chronic conditions, and ensuring access to appropriately intensive services for those with the most severe symptoms.1

Disasters disproportionately affect poor and vulnerable populations, and patients with serious mental illness may be among the hardest hit. High rates of smoking in this population may raise the risk of infection and confer a worse prognosis among those who develop the illness.2 Residential instability and homelessness can raise the risk of infection and make it harder to identify, follow up, and treat those who are infected.3 Individuals with serious mental illnesses who are employed may have challenges taking time off from work and may lack sufficient insurance coverage to cover testing or treatment. Small social networks may limit opportunities to obtain support from friends and family members should individuals with serious mental illness become ill. Taken together, these factors may lead to elevated infection rates and worse prognoses in this population.

What strategies are available to mitigate the outcome of this epidemic among patients with serious mental illness? Federal preparedness policies developed in the wake of complex disasters have increasingly embraced the notion of whole community preparedness, which supports building and supporting structures at multiple levels to prepare and respond, particularly for vulnerable populations.4 Within the public mental health care system, this includes engagement with mental health service users, clinicians, and federal and state policies.

Supporting Patients With Serious Mental Illness

People with serious mental illnesses should be provided with up-to-date, accurate information about strategies for mitigating risk and knowing when to seek medical treatment for COVID-19. Patient-facing materials developed for general populations will need to be tailored to address limited health literacy and challenges in implementing physical distancing recommendations because of poverty and unstable living situations. Messaging will need to provide assurances that those who seek care will not face penalties with regards to cost or immigration status. Patients will need support in maintaining healthy habits, including diet and physical activity, as well as self-management of chronic mental and physical health conditions.

It will also be important to address the psychological and social dimensions of this epidemic for patients. Worry could both exacerbate and be exacerbated by existing anxiety and depressive symptoms. Physical distancing strategies critical for mitigating the spread of disease may also increase the risk of loneliness and isolation in this population. Those who become ill may face dual stigma associated with their infections and their mental health conditions. For any given patient, psychological symptoms will emerge in a unique personal and social context that should be considered in developing a treatment plan.

Empowering Mental Health Clinicians

Mental health clinicians are often the primary point of contact with the broader health care system for their patients with serious mental illnesses, and as such will represent the first responders to the COVID-19 pandemic for many of these individuals. Mental health clinicians need training to recognize the signs and symptoms of this illness and develop knowledge about basic strategies to mitigate the spread of disease for both in their patients and themselves. Clinicians should have discussions with their patients about how best to implement the strategies.

Clinicians will need support in maintaining their own safety and well-being. Where possible, services should be delivered via telehealth rather than in person, and when in-person visits are necessary, in individual rather than group formats. Child and elder care should be made available for mental health clinicians working extra shifts. Support from colleagues will be essential for maintaining physical, mental, and social well-being, particularly if the pandemic is of an extended duration.

Strengthening Mental Health Care Systems

The COVID-19 pandemic is likely to place a major strain on community mental health centers and state psychiatric hospitals. These facilities have limited capacity to screen for or treat medical conditions, and few have existing relationships with local or state public health agencies. It is critical for these organizations to develop continuity-of-operations plans to ensure that they can maintain vital functions in the face of staff illnesses or shortages of psychotropic medications. Clinics will need protocols for identifying and referring patients at risk for infection and self-quarantine strategies for clinicians who develop symptoms of the illness. Adequate environmental protections including well-ventilated spaces, easy access to handwashing, and personal protective equipment should be available. Institutional settings, including state psychiatric hospitals, nursing homes, and long-term care facilities, will be at particularly high risk for outbreaks and need to ensure that they have contingency plans to detect and contain them if they occur.

Expanding Mental Health Policies

The coming weeks will see a wave of new federal legislation and regulations and state policies developed to mitigate the health and economic outcomes of the COVID-19 outbreak.5 These policies will have particular urgency for populations with serious mental illness because of their elevated risks. State mental health authorities will play a critical role in creating and administering policies regarding COVID-19 in their state hospitals and community mental health clinics. The role of social policies, such as the Supplemental Nutrition Assistance Program, housing support, and paid sick leave for hourly employees will be vital for ensuring the health and well-being of this population.

The COVID-19 pandemic will create unprecedented health and social challenges both in the US and internationally. People with serious mental illnesses will be at uniquely high risk during this period, as will be the public mental health care system central to delivering their care. Careful planning and execution at multiple levels will be essential for minimizing the adverse outcomes of this pandemic for this vulnerable population.

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Article Information

Corresponding Author: Benjamin G. Druss, MD, MPH, Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA 30322 (bdruss@emory.edu).

Published Online: April 3, 2020. doi:10.1001/jamapsychiatry.2020.0894

Conflict of Interest Disclosures: None reported.

References
1.
Adalja  AA, Toner  E, Inglesby  TV.  Priorities for the US health community responding to COVID-19.   JAMA. Published online March 3, 2020. doi:10.1001/jama.2020.3413 PubMedGoogle Scholar
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Lewis  T. Smoking or vaping may increase the risk of a severe coronavirus infection. Sci Am. Published 2020. Accessed March 26, 2020. https://www.scientificamerican.com/article/smoking-or-vaping-may-increase-the-risk-of-a-severe-coronavirus-infection1/
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Tsai  J, Wilson  M.  COVID-19: a potential public health problem for homeless populations.   Lancet Public Health. 2020;S2468-2667(20)30053-0. doi:10.1016/S2468-2667(20)30053-0 PubMedGoogle Scholar
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Brown  JT. Presidential policy directive 8 and the national preparedness system: background and issues for Congress. 2011. Accessed March 26, 2020. https://fas.org/sgp/crs/homesec/R42073.pdf
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Forman  H, Fowler  E, Ranney  M,  et al.  Health care priorities for a COVID-19 stimulus bill: recommendations to the administration, Congress, and other federal, state and local leaders from public health, medical, policy and legal experts.   Health Aff (Millwood). 2020.Google Scholar
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    1 Comment for this article
    EXPAND ALL
    COVID-19: PPE for the mind
    joseph barker, MRCP | University of Leicester
    D. Koeckerling1, D. Pan2, J. Barker3*.

    Dear Editor,

    In his article, BG Druss outlines the unprecedented challenges psychiatric services and patients with pre-existing mental health conditions will face during the COVID-19 pandemic.[1] As the pandemic is approaching its first peak in the United Kingdom (UK), we would like to make further comment to highlight the inevitable psychological fallout from the healthcare workforce, and more specifically the need for governments to account for this in workforce planning.

    Recent reports outline the impact of COVID-19 on the mental health of frontline healthcare workers in China, describing up
    to 50% of individuals experiencing symptoms of depression, 45% suffering anxiety and 34% insomnia.[2] Similarly, data from the 2003 SARS-CoV-1 outbreak record up to 35% of frontline healthcare workers developed high degrees of psychological distress consistent with post-traumatic stress disorder.[3]

    In the UK, workforce planning has primarily focused on resource provision for acute and intensive care services to the detriment of “non-essential services”. The UK government has ring fenced mental health services from redeployment, though the reality is junior staff are being redeployed at the time of writing. 4 It remains unclear whether resources are being allocated to account for the mental health needs of the frontline workforce in particular.

    This is an essential consideration as the psychological consequences of the pandemic will only serve to diminish the healthcare workforce at a time when it is already stretched beyond its limits. If skilled psychiatric staff are not positioned to catch them when they fall, there will be no one left to return for a predicted second pandemic peak.[5]

    Psychiatric services require protection from redeployment and strategic strengthening of resources at their disposal to support both patients and front line healthcare workers during this pandemic. Their expertise and leadership will be invaluable when the psychological consequences of COVID-19 inevitably start to surface. As such, we advocate for their role in delineating the framework and infrastructure to screen and treat the mental health needs of frontline health workers – who need protection, not only from the virus itself, but from its psychological repercussions.

    Authors: (DK) MBBS, Med. Sci. Division, University of Oxford; (DP) MRCP, Department of Respiratory Medicine; (JB)* MRCP, Department of Cardiovascular Sciences , University of Leicester, UK.

    References
    1. Druss BG. Addressing the COVID-19 Pandemic in Populations With Serious Mental Illness. JAMA Psychiatry. April 2020. doi:10.1001/jamapsychiatry.2020.0894
    2. Lai J, Ma S, Wang Y, et al. Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA network open. 2020;3(3):e203976. doi:10.1001/jamanetworkopen.2020.3976
    3. Maunder R. The experience of the 2003 SARS outbreak as a traumatic stress among frontline healthcare workers in Toronto: Lessons learned. Philosophical Transactions of the Royal Society B: Biological Sciences. 2004;359(1447):1117-1125. doi:10.1098/rstb.2004.1483
    4. NHS England. Redeploying Your Secondary Care Medical Workforce Safely.; 2020. https://www.hee.nhs.uk/coronavirus-. Accessed April 2, 2020.
    5. Prem K, Liu Y, Russell TW, et al. The effect of control strategies to reduce social mixing on outcomes of the COVID-19 epidemic in Wuhan, China: a modelling study. The Lancet Public Health. 2020;0(0). doi:10.1016/S2468-2667(20)30073-6
    CONFLICT OF INTEREST: None Reported
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