From the Editor
In a heavy moment, a colleague of mine observed that spring is finally here, but none of us can enjoy it. This comment is one of many made over these past weeks about our new life. Our businesses are closed; our elderly are hiding; our colleagues are on the front lines and at risk. And, yes, the simple pleasure of enjoying a spring day – the warmth in the air, the song of the birds – has been lost, at least for now.
This week’s Reading has three selections, and each touches on the intersection between the pandemic and mental health care. Our new life means new challenges as we attempt to deliver mental health care services.
In the first selection, we consider a paper on COVID and serious mental illness. In a JAMA Psychiatry paper, Dr. Benjamin G. Druss (of Emory University) writes: “Disasters disproportionately affect poor and vulnerable populations, and patients with serious mental illness may be among the hardest hit.”
What is the role of mental health care during this pandemic? In the second selection, we consider a new Lancet Psychiatry editorial. The editors write: “Although the mental health field’s interest in trauma has greatly expanded in recent decades, our scientific understanding of trauma has lagged far behind, including our understanding of its definition and aetiology, and, importantly, of how to effectively intervene.”
Finally, in the third selection, we look at a letter by Dr. Yuncheng Zhu (of Shanghai Jiao Tong University School of Medicine) and his co-authors. They discuss inpatient care and the risk and prevention of infection. “Panic is inevitable among patients and medical staff and timely mental health care for dealing with the novel coronavirus outbreak is urgently needed.”
Selection 1: “Addressing the COVID-19 Pandemic in Populations With Serious Mental Illness”
Benjamin G. Druss
JAMA Psychiatry, 3 April 2020
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.
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. Residential instability and homelessness can raise the risk of infection and make it harder to identify, follow up, and treat those who are infected. 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.
So begins a paper by Dr. Druss. He considers four tasks:
Supporting Patients With Serious Mental Illness
He advises strong communication with patients about the pandemic. “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.”
As well, “it will also be important to address the psychological and social dimensions of this epidemic for patients.” For example, he writes: “Worry could both exacerbate and be exacerbated by existing anxiety and depressive symptoms.”
Empowering Mental Health Clinicians
He advocates educating mental health clinicians on the pandemic, seeing them as “first line responders.”
The author also notes that clinicians need to be kept well. “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.”
Strengthening Mental Health Care Systems
He notes the importance of preparation and planning. He writes: “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
In response to the pandemic, the author sees “a wave of new federal legislation and regulations and state policies developed to mitigate the health and economic outcomes of the COVID-19 outbreak.” It’s important that these laws and rules remember those with severe mental illness.
He closes with a reminder:
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.
The commentary is well written and makes important points, though the recommendations are kept at a high level, and thus lack detail.
Still, the central message – the vulnerability of our patients – is sound.
Selection 2: “Send in the therapists?”
The Lancet Psychiatry, April 2020
Public health emergencies, such as coronavirus disease 2019 (COVID-19) and the bush fires in Australia, highlight the inequalities in our societies and the failures of our institutions. The poor suffer the brunt of any new pandemic, earthquake, or flood, while elected leaders seem unfazed and continue to call for policies that will likely lead to more long-term vulnerabilities and suffering. But emergencies also have a way of amplifying the dedication of clinicians, scientists, and public health professionals. One of the most remarkable responses to these recent events has been the emphasis that groups and governments have placed on the mental health consequences of these disasters. Examples include the Australian Government putting AU$76 million of funding specifically towards mental health and wellbeing, and the calls by researchers and clinicians in China for better mental health services for those impacted directly and indirectly by COVID-19.
Even a few decades ago, such calls for an increased focus on mental health during a physical health crisis would have been unlikely from clinicians, and these calls being heeded by governments and public health officials would have been even more unlikely. This change in behaviour coincides with, and undoubtedly has been influenced by, the awareness and sensitivity to trauma of the psychiatric field and the general public, a concept in mental health that has extended beyond post-traumatic stress disorder and the soldiers for whom the disorder was originally formulated.
So begins this editorial.
They continue, arguing that “the change in behaviour” is part of an “encouraging trend” and that physical and mental health are increasingly seen as “intertwined.”
Still, “we should remind ourselves of a few difficult facts.” They list three:
- “Although the mental health field’s interest in trauma has greatly expanded in recent decades, our scientific understanding of trauma has lagged far behind, including our understanding of its definition and aetiology, and, importantly, of how to effectively intervene.”
- “High-quality evidence of the effectiveness of acute psychological interventions for disaster-related trauma is scarce.”
- “Even more concerning is the fact that the potential risks and adverse reactions in response to therapy in the immediate aftermath of a disaster are not well studied.”
The editors suggest that we “take a more complex view of trauma that incorporates pre-existing and comorbid mental health problems.” They suggest: “the epidemiological evidence we do have about disaster-related trauma suggests that most people are highly resilient, with longer lasting negative outcomes in individuals as a result of trauma reflecting existing mental health problems and socioeconomic status.”
Health-care providers and governments need to remember that psychiatry’s history is littered with good intentions that turned out poorly in practice, and interventions that seemed intuitively correct but did not work, or even exacerbated conditions, on contact with reality. The concept of trauma also needs to be removed from its silo and integrated with the complexities of other mental health disorders and persistent social factors such as poverty.
This is a well-written editorial.
It’s also surprisingly hard-hitting. They argue that communities most susceptible to the effects of a disaster are the least likely to have access to mental health care. And it’s not just about access. “How effective will a single session of therapy be when delivered by an outsider?”
The comments are thoughtful. It’s remarkable how much focus mental health has received in recent days. The contrast to the media treatment of SARS is striking. Yet good intentions aren’t enough, and helping affected communities heal will require more than good will.
Selection 3: “The Risk and Prevention of Novel Coronavirus Pneumonia Infections Among Inpatients in Psychiatric Hospitals”
Yuncheng Zhu, Liangliang Chen, Haifeng Ji, Maomao Xi, Yiru Fang, and Yi Li
Neuroscience Bulletin, March 2020
Since the middle of December 2019, human-to-human transmission of novel coronavirus pneumonia (NCP, also called COVID-19) has occurred among close contacts. After the outbreak on January 21, 2020, it was swiftly included among the Class B infectious diseases stipulated in the Law of the People’s Republic of China on the Prevention and Control of Infectious Diseases, and measures for prevention and control of Class A infectious diseases were adopted. At 21:27 on February 12, 2020, the China News Network updated information to include epidemic data from the National Health Commission and official channels in Hong Kong, Macao, and Taiwan regions: the highest death rate was in Wuhan City. Overload of inpatients at hospitals may play a negative role in the overall therapeutic effect and contribute to the death rate.
So opens a letter to the editor by Dr. Zhu and his co-authors.
They note the deep problems of inpatient care during the early days of the pandemic, with both patients and staff becoming ill. They note various factors that increase the risk of outbreak. We focus on a few:
- “The wards are often closed and crowded.”
- “It is difficult for psychiatric patients to accept and cooperate with self-isolation measures…”
- “Medical staff in the psychiatric specialty lack knowledge in coping with infectious diseases.”
The article discusses some structural problems: densely staffed wards, limited space, poor ventilation. The article then goes on to make several suggestions:
- “Fourteen days under observation in hospital is the key to reducing hospital infection;”
- “A pre-admission observation ward needs to be arranged immediately;”
- “Temporarily prohibit on-site visits, and replace them with video chat. In principle, only food and clothing from government-approved institutions are acceptable;”
- “More psychological services should be provided by community workers and family doctors to help the hospital to communicate about the restriction of visitors, so as to obtain consent on the necessity of these temporary arrangements…”
The letter is both invaluable and dated.
Invaluable. It provides a window into the crisis response in inpatient mental health care in China. The authors offer reasonable suggestions.
Dated. Much has changed since February. For example, the concept of segregating out patients before they land on inpatient units is solid advice, but possibly not as relevant now that rapid testing becomes more and more common.
Still, the central point remains: at a time of pandemic, the physical well-being of our mental health patients is more important than ever. And the third selection ties back well to the first selection: those most at risk during these times of crisis are those with severe persistent mental illness.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.