From the Editor
What’s the latest in the literature on COVID and mental health? This week, we focus again on the pandemic with three selections.
In the first, we consider a paper on mental health services at a Chinese hospital during the pandemic. In this American Journal of Psychiatry study, Dr. Junying Zhou (of Sichuan University) and co-authors report on a survey of existing and new outpatients, finding major problems with access. Among the findings: one in five found that their mental health had deteriorated due to a lack of access to care. The authors advocate further study to “ameliorate the negative impact of viral outbreaks in the general public, especially among those vulnerable patients with mental problems.”
Will COVID change health care once the virus has burned out? In the second selection, we consider a new EBMH editorial by Dr. Katharine Smith (of Oxford University) and her co-authors. They write: “In order to reappraise effectively our new ways of working, both in the immediate management of issues during the pandemic and also during the longer-term aftermath, we need fast-track implementation of evidence-based medicine techniques in mental health to supply the best evidence to clinicians on specific questions in real time.”
Finally, in the third selection, we look at an essay from The New Yorker. Reporter Masha Gessen argues that psychiatric wards are particularly vulnerable during the pandemic. Gessen speaks to several doctors who offer a similar if haunting story: “how a lack of testing, P.P.E., and seclusion protocols were making a difficult task – maintaining the safety of a highly vulnerable population and their care workers during a pandemic – virtually impossible.”
Selection 1: “Mental Health Reponse to COVID-19 Outbreak in China”
Junying Zhou, Liu Liu, Pei Xue, and Xiaorong Yang
The American Journal of Psychiatry, 14 April 2020 Online First
The 2019 coronavirus disease (COVID-19) transmission has now widely and rapidly spread around the world. On Mar 11, 2020, WHO announced that COVID-19 is a pandemic. The rapid transmission and potential mortality risk of the COVID-19 infection might increase the risk of mental health problems among healthy individuals in the public and worsen preexisting psychiatric problems in the COVID-19 outbreak being conducted in different vulnerable populations which feelings and psychological distress, including panic, worries and depression could be triggered by the fear of possible infection, being quarantined at hospitals and home, social isolation, and even the shortage of protective gears.
So begins a paper by Zhou et al.
Here’s what they did:
- Participants were surveyed through WeChat, a popular Chinese social media program; they were outpatients seeking care in the departments of Psychiatry, Neurology, or Sleep Medicine in West China Hospital in Chengdu, China.
- The survey considered patients experiencing anxiety (defined as a Generalized Anxiety Disorder-7 score of 5 or more), depression (Patient Health Questionnaire-9 score of 9 or more), or insomnia (a Insomnia Severity Index score of 8 or more).
- The survey ran from February 25 to March 9.
Here’s what they found:
- 589 new patients did the survey; 1,476 patients with existing psychiatric diagnoses also completed it.
- 5% of the respondents experienced anxiety, 26.2% had insomnia, but fewer than 17% scored high on the depression scale.
- Among existing patients, 22.2% could not get their routine care, including those with depression, bipolar, and psychosis. 9% of the patients reported a deterioration of their mental health condition related to the pandemic. (!)
- 1% of the patients had to self-reduce the dosage and 17.2% stopped taking their medications because of problems related to filling their prescriptions.
- Among new patients, 24.5% could not get “timely diagnosis and treatment” at the hospital.
This paper is short and focused – and concerning.
The authors provide several explanations for the difficulties with access to care. They note: “the transport restriction, isolation at home, and fear of cross-infection in hospital have inevitably become the major concerns and barriers to treatment for these patients during the outbreak.”
This hospital did provide outpatient services through telehealth, with over a hundred physicians involved across different specialties, and focused on prescription renewals and new consultations. Yet only 7.4% of mental health patients participated. (!)
The paper is clever, but has clear limitations. Start here: it relies on survey results. And we can wonder how generalizable the conclusions are, given that the data is drawn from one hospital (albeit a major health centre). But the paper raises important questions about access in a time of crisis. Why was it so challenging for patients to receive care? Why was telepsychiatry such a dud?
Selection 2: “Covid-19 and mental health: a transformational opportunity to apply an evidence-based approach to clinical practice and research”
Katharine Smith, Edoardo Ostinelli, and Andrea Cipriani
EBMH, May 2020
Covid-19 was first recognised in December 2019 and is now posing critical challenges for public health, clinical research and medical care worldwide.The covid-19 outbreak has rapidly evolved into a fast-moving global pandemic, with world updates produced on a daily basis. For busy clinicians, this presents a problem of information overload: while there is a sea of information, finding easily accessible, reliable and up-to-date answers to immediate clinical questions can be difficult and time-consuming. The data available are a broad sweep of official guidance from different organisations (including specialty-based, country-based and worldwide), original research papers, personal/professional experiences and commentaries.
Mental health patients are particularly vulnerable in the context of covid-19, both directly because of their mental health difficulties, but also because of some of the long-term effects of psychotropic medication (such as metabolic syndrome with long-term antipsychotics), comorbid physical health problems and the effects of smoking. These factors together mean they are more vulnerable both to covid-19 itself and its complications, as well as to the adverse psychological effects of measures such as self-isolation and disruption to their normal healthcare and lifestyle.
So begins an editorial by Smith et al.
The authors highlight a recent effort to pull together evidence-based information.
They note a document focused on clozapine and inpatient issues: https://oxfordhealthbrc.nihr.ac.uk/our-work/oxppl/covid-19-and-mental-health-guidance/. They also note ongoing work in the area.
The editorial emphasizes, though, the path forward:
The covid-19 pandemic and the challenges it presents are unprecedented within most of our lifetimes. The effects of the pandemic, the associated restrictions in social, occupational and healthcare contact are likely to be long-lasting and wide-ranging. Many ways of living and working will not be the same again. So, this moment represents a step change in many areas of our lives, but, as well as loss of freedoms, this also offers the opportunity for positive change.
They see mental health care as being particularly effected.
For mental healthcare, both service delivery and clinical research, many of these changes will be transformational. Systems of healthcare frequently get ‘stuck’ in ways of operating. The restrictions associated with covid-19 have forced both clinicians and patients to reappraise care and to focus on what is absolutely essential and evidence-based. New ways of contacting and assessing patients using telemedicine have been rapidly adopted. Healthcare systems, such as the National Health Service, have implemented Information Technology systems to support home working and telephone consultations at a rate which would have seemed impossible in normal circumstances. The current situation has given organisations the urgency to implement these quickly and the impetus to patients to try them positively and proactively. Advantages such as efficiency, rapid access to subspecialty expertise and ease of treating patients in their own homes can be used positively well after the pandemic has gone. This change also applies to clinical research where we have an opportunity to think creatively and flexibly about the most efficient and appropriate ways of working, embracing technology to use for example e-consent and videoconferencing more widely.
The paper’s authors include Oxford Professor Andrea Cipriani, and his influence is felt in the call for action on evidence-based change.
With our focus on the pandemic, it’s difficult to look past this present storm to better days ahead (to borrow a phrase). Will our interest in telemedicine fade? Or will e-care become part of our way of delivering health services? And what about those who are less fortunate and may lack smart phones and other computer equipment?
Selection 3: “Why Psychiatric Wards Are Uniquely Vulnerable to the Coronavirus”
The New Yorker, 21 April 2020
B. spoke to me by Zoom from the car parked outside their house – we couldn’t talk when B. was at work, or inside the house, where B.’s children were playing. B. has also used the car to Zoom with colleagues about trying to devise safety protocols for their workplace, because those, too, are conversations B. can’t have at work. B. is the medical director of an inpatient psychiatric unit in a small hospital within a large for-profit network. The hospital’s administration, B. told me, was not permitting doctors to wear their own N95 masks or other protective equipment, even though the hospital had little equipment to issue. Nor were doctors able to test or isolate patients with suspected cases of covid-19. Psychiatrists, B. told me, were still being required to appear for in-person consultations, when remote communication would have been possible and safer. There was no way and no real effort to enforce physical distancing, B. told me. Patients could be isolated only once they were symptomatic and had tested positive, but patients with whom they had been in contact continued to intermingle on the ward.
I heard similar accounts from several other physicians working in inpatient psychiatric wards in for-profit, nonprofit, and state hospitals, across multiple states. All of these doctors, who spoke on condition of anonymity, told me variations on the same story: how a lack of testing, P.P.E., and seclusion protocols were making a difficult task – maintaining the safety of a highly vulnerable population and their care workers during a pandemic – virtually impossible. All of them told me about conflicts with hospital administrators. All of them were battling the cruel logic of business models and insurance payments.
So begins an article by Gessen. This essay is highly readable, and doesn’t require much of a summary here.
Gessen notes how problematic COVID has been for U.S. psychiatric hospitals:
- “At Western State Hospital in Washington, for example, at least twenty-seven workers and six patients have tested positive for covid-19, with one death…”
- “New Jersey’s four psychiatric hospitals had two hundred and forty cases of the coronavirus and five fatalities. Four of the deaths were at a single hospital, Greystone Park Psychiatric Hospital in Morris County, where thirty-three patients – about one in ten people being treated there – and forty-four employees tested positive.”
- “Among New York’s twenty-four state mental hospitals, five have patients with covid-19 in every unit.”
Gessen notes the unique challenges faced by psychiatric wards:
An ordinary hospital unit is a lonely place: patients are generally in bed, in their rooms, physically distant from one another. By contrast, the prevention of solitude is built into the architecture of psych units, and enshrined in the laws and regulations that govern them. Psychiatric units are often designed to facilitate communication and group activities; now, however, they seem as if they were designed to spread the virus. Unlike in other hospital units, patients do not spend their days in their rooms: they are expected to attend therapy, play games, watch television, go outside, and take their meals together with other patients…
Between meals, therapy, and supervised group activities, patients have four hours when no activities are planned, and this is when hospital staff try to persuade them to stay in their nearly empty rooms, for reasons that are difficult for some patients to process. The rooms have no televisions or telephones; personal devices such as cell phones, tablets, and computers are not allowed because of, among other things, the concern that patients would harm themselves or take pictures or videos, thereby violating privacy regulations. Most facilities have MP3 players, but usually not enough for every patient.
The article details further problems, particularly for patients in New York State. As an example, she describes the lack of COVID testing; at one hospital, when such testing is ordered, it’s done at a general hospital (requiring a transfer for the simple test, potentially exposing multiple staff and paramedics). And, of course, there are problems with access to the proper equipment. Gessen interviews doctors who would like to wear proper PPE, but can’t get access – and, in some cases, have been prevented from wearing their own.
The essay ponders whether part of the issue is our historical neglect of mental health problems. Complicating a complicated situation: she notes the business model of American hospitals, and how it undermines basic innovations.
This essay is well written, and raises good questions. Regular readers of this series will note that a past selection had considered a description of the problems of viral containment on an inpatient unit in Wuhan. Whether the ward is in Wuhan or Westchester County, New York, the problems are obvious: some people with severe mental illness are unlikely to maintain social distancing and most psychiatric units are claustrophobic.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.