Management of Patients With Severe Mental Illness During the Coronavirus Disease 2019 Pandemic

Attention has focused on patients with coronavirus disease 2019 (COVID-19), frontline responders, and attributable deaths, leading to enlarged intensive care unit and ventilator capacities and reduction of elective care. Subsequently, marginalized populations are easily overlooked, such as patients with severe mental illness who are at high risk for medical comorbidities predisposing them to COVID-19 and whose psychiatric condition can worsen owing to COVID-19 infection.

Severe mental disorders, including schizophrenia, bipolar disorder, and major depressive disorder, are chronic conditions that frequently need maintenance treatment to prevent relapse and rehospitalization. However, in the COVID-19 pandemic, many medical procedures have been reduced, leading to the global challenge of balancing provision of medical resources. For example, the serious disruption of normal medical care has reduced functioning of stroke centers across China because of fear of in-hospital cross-infection and lack of experienced stroke care experts.¹

Patients with severe mental illness may be among the most vulnerable populations affected by the COVID-19 pandemic.² Among other factors that disproportionally disadvantage patients with severe mental illness are stigmatization,³ less provision of physical health care, low household income, worse lifestyle factors, residential instability, and small social networks.² Sanctions, such as lockdown, no-contact provision, and quarantine, may further increase stress/mental illness in this population. Most studies on disaster-related quarantine reported negative psychological effects including posttraumatic stress symptoms, confusion, and anger. Stressors included longer quarantine duration, infection fears, frustration, boredom, inadequate supplies, inadequate information, financial loss, and stigma.⁴ Likely, severely mentally ill individuals need extra support during the pandemic; however, the number of inpatient and outpatient contacts of patients with severe mental illness has largely reduced during the COVID-19 outbreak, with expected increases thereafter.

As a result, lack of access to regular psychosocial treatments and subsequently reduced adherence may increase the risk of psychiatric exacerbation, including acute agitation, psychosis, mania, or severe depression. Agitated patients put an additional burden on caregivers, peers, and health care workers, increasing the risk of infection. The following management strategies are suggested to improve care and outcome of patients with severe mental illness during the COVID-19 pandemic.

Structures of the mental health care system should be sustained to yield necessary psychosocial treatments. Patients should actively be informed how to avoid and where/when to get help for COVID-19 infection² and their mental illness.

In the ambulatory setting, physical (not social) distancing and density diffusion measures are needed, including spacing out of schedules and waiting rooms and evening/weekend appointments to accommodate backlog or high-risk/COVID-19–positive patients. Patients who have COVID-19 (and close contacts) must quickly be notified, educated, and isolated/quarantined while considering their mental health needs. Additionally, clinicians should proactively screen for suicidality since fear, social isolation, and economic uncertainty are known risk factors for depression and suicide. When personal contact is restricted, telemedicine should be used as much as possible. In outpatient settings, psychosocial support can be offered via video conferencing. Although telemedicine has demonstrated effectiveness in the context of severe mental illness, patients are reported to be concerned about establishing rapport, privacy, safety, security, and technological limitations.⁵ Further limitations may apply to physicians’ concerns about regulatory, licensure, and educational issues.⁵ Overcoming these barriers may include providing patients with information about the opportunities of telemedicine, expanding mental health policies, integrating of telepsychiatry into treatment workflow and reimbursement, and shifting organizational culture.^2,5

Prevention is best to deal with COVID-19. Staff treating patients with severe mental illness and COVID-19 should be equipped with protective clothing, including masks. To protect other patients and hospital staff from infection, patients should whenever possible be isolated, eg, on a special unit, and advised to wear protective masks.

To maintain continuous outpatient treatment, prescriptions may be converted to mail-order dispensation. Further, long-acting injectable antipsychotics should be considered. A 2020 consensus statement for patients receiving clozapine proposed that the frequency of absolute neutrophil count testing can be reduced from monthly to every 3 months, with clozapine dispensation for up to 90 days in patients receiving continuous clozapine treatment for more than 1 year.⁶ Such relaxed monitoring requirements could also apply to cardiometabolic and lithium level monitoring, especially in patients receiving stable medication and in patients receiving medication-assisted treatments for substance use disorders, such as methadone.

If urgent medication owing to agitation is required, rapid tranquillization should be the treatment goal.⁷ Parenteral antipsychotics and benzodiazepines are frequently recommended for rapid tranquillization.⁷

However, respiratory and cardiovascular safety require consideration when treating COVID-19–positive psychiatric patients who are at risk of cardiovascular complications, pneumonia, and need for assisted ventilation. Therefore, inhaled drugs, such as inhalable loxepine, are not recommended because these drugs can worsen respiratory function. All benzodiazepines may induce respiratory depression, which is more likely with parenteral dosing.⁷ The same is true for oral and short-acting intramuscular olanzapine, low-potency first-generation antipsychotics, such as chlorpromazine, and sedating antihistamines,⁸ which is why benzodiazepines and low-potency antipsychotics should be avoided and are contraindicated in cases with more severe respiratory dysfunction.

Thus, preferred short-acting injectable medications may be aripiprazole or haloperidol (with or without preventive anticholinergic); preferred oral agents may be risperidone or paliperidone (lower first pass hepatic metabolization) or haloperidol (with or without anticholinergic). When benzodiazepines are considered, shorter half-life agents (eg, etizolam, oxazepam, or lorazepam) are preferred. Further, extrapyramidal symptoms should be avoided/treated owing to the risk of swallowing difficulties that can increase pneumonia risk.

Pharmacokinetic and pharmacodynamic drug-drug interactions between psychiatric and somatic medications used to treat COVID-19 require attention, such as the potential need to temporarily lower medication doses during severe medical illness. Current protocols to treat COVID-19 and its complications include antiviral, antimalarial, and antibiotic drugs,⁹ some of which can induce QTc prolongation that may add to the increased QTc prolongation risk of some psychopharmacological drugs, including amisulpride, clozapine, sertindole, and ziprasidone.

Further, delirium can result from drug-drug interactions and/or severe COVID-19 infection. Treatment recommendations comprise antipsychotics with low/no anticholinergic activity and restrictive use of benzodiazepines dependent on the underlying reason for the delirium.¹⁰

Many institutions and health care systems reduced routine medical procedures and ordered nonessential staff to work from home in response to the COVID-19 pandemic. The resultant disbalance of routine medical treatment likely disadvantages already marginalized patients, such as those with severe mental illness, for whom continuous inpatient and outpatient care is essential to maintain treatment success and reduce the risk of emergencies. A feared second, mental health pandemic must be avoided.

For outpatients not accessing in-person care, telemedicine/video conferencing is recommended, with medication dispensation via mail-order pharmacies. Monitoring intervals for clozapine, lithium, and routine cardiovascular parameters should be extended in stable patients.

For acutely agitated patients with COVID-19, rapid tranquillization is an adequate treatment principle, reducing the risks of transmitting/acquiring the infection and potential harm to self/others. Psychopharmacologic treatment should consider cardiovascular and respiratory adverse effects of commonly used drugs and possible drug-drug interactions. Inhalable antipsychotics, oral and short-acting injectable olanzapine, and ziprasidone as well as low potency first-generation antipsychotics, sedating antihistamines, and benzodiazepines should be avoided. The use of benzodiazepines should be restricted/strictly monitored. If possible, mentally ill patients with COVID-19 should be isolated and staff adequately protected.

Corresponding Author: Kai G. Kahl, MD, Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str 1, 30625 Hannover, Germany (kahl.kai@mh-hannover.de).

Published Online: June 24, 2020. doi:10.1001/jamapsychiatry.2020.1701

Conflict of Interest Disclosures: Dr Kahl has been a consultant and/or advisor to or has received honoraria from Eli Lilly, Janssen/J&J, Lundbeck, Neuraxpharm, Otsuka, Pfizer, Servier, Schwabe, Takeda and Trommsdorff/Ferrer. He has provided expert testimony for Neuraxpharm, Servier, and Takeda. Dr Correll has been a consultant and/or advisor to or has received honoraria from Acadia, Alkermes, Allergan, Angelini, Axsome, Gedeon Richter, Gerson Lehrman Group, IntraCellular Therapies, Janssen/J&J, LB Pharma, Lundbeck, MedAvante-ProPhase, Medscape, Neurocrine, Noven, Otsuka, Pfizer, Recordati, Rovi, Sumitomo Dainippon, Sunovion, Supernus, Takeda, and Teva. He has provided expert testimony for Janssen and Otsuka. He served on a Data Safety Monitoring Board for Lundbeck, Rovi, Supernus, and Teva. He received grant support from the Berlin Institute of Health, Janssen, the National Institute of Mental Health, Patient-Centered Outcomes Research Institute, Takeda, and the Thrasher Foundation. He received royalties from UpToDate and is also a stock option holder of LB Pharma.