From the Editor:
It’s here. Less than a year after COVID-19 arrived in North America, two vaccines have been created, approved, and given (at least to some).
In the coming months, as the supply improves, people – including our patients – will have the opportunity to get a vaccine. But what are the challenges? First, some will hesitate. In a recent essay, Dr. Nadia Alam notes that: “Vaccine hesitancy is a significant issue with only 57.5% of Canadians saying they are very likely to be vaccinated for COVID-19.” And special populations will present further challenges – such as those with major mental illness.
This week, we focus on vaccinations with two papers and an article.
In the first selection, drawing from JAMA Psychiatry, we consider a paper by Dr. Nicola Warren (of the University of Queensland) and her co-authors. They note the challenges of reaching people with serious mental illness – just one in four get a flu vaccine. “It is vital to commence planning and development of appropriate policies to ensure rapid delivery of a COVID-19 vaccine when it becomes available.”
In a New England Journal of Medicine paper, Dr. Joshua A. Barocas (of the Boston University School of Medicine) thinks about the needs of those with substance use disorders. “Officials devising vaccination strategies and allocation plans would be wise to do so from the perspective of the virus, rather than that of stigmatizing personal beliefs.”
How to speak to our patients? In the final selection, we look at a short piece by Dr. Joshua C. Morganstein (of the Uniformed Services University of the Health Sciences). His advice is very practical, and emphasizes that we should tailor our approach not by diagnosis but by patient interest in the vaccination. He also urges us to be careful in our choice of language: “Health care professionals are trained to use complex medical terminology, though more understandable and down-to-earth language often serves to enhance trust and build rapport.”
Selection 1: “Maximizing the Uptake of a COVID-19 Vaccine in People With Severe Mental Illness: A Public Health Priority”
Nicola Warren, Steve Kisely, Dan Siskind
JAMA Psychiatry, 15 December 2020
People with serious mental illness (SMI) are at increased risk of being infected by coronavirus disease 2019 (COVID-19) and have higher subsequent rates of hospitalization, morbidity, and mortality. Factors that contribute to worse outcomes include concomitant medications, poorer premorbid general health, physical comorbidity, reduced access to medical care, and environmental and lifestyle factors such as lower socioeconomic status, overcrowding, smoking, or obesity. In light of these vulnerabilities, it is important that people with SMI are a priority group to receive a vaccination, should one be developed and deemed safe and effective…
So begins a paper by Warren et al.
They note the challenges of this population:
“People with SMI are less likely to receive preventive or guideline-appropriate health care for concerns such as cardiovascular disease and cancer. This reduced access to preventive care is reflected in the low uptake of immunizations recommended for adults among people with SMI. Of these, influenza may serve as a particularly useful model given the recommendation for an annual vaccination. In contrast with other vulnerable groups in the United States, influenza vaccination rates among people with SMI are as low as 25%.”
How to move forward?
Individual-Level Barriers and Solutions
“In people with SMI, a willingness to adopt preventive measures, such as vaccination, is facilitated by their perceived risk to self of a preventable disease, peer support, influence, and belief in the effectiveness of the vaccine. Notably, as reported in a cross-sectional study, education by a health care professional about the role and importance of vaccination increased uptake by 4-fold. Negative beliefs about safety and misconceptions that the vaccine itself can cause the illness may be held by people with SMI.”
They propose: “Mental health professionals are uniquely skilled to deliver this education, being able to adapt for those with communication difficulties and balance factors influencing decision-making. There may be a delicate balance between factors that facilitate immunization, such as perceived fear of infection, and those that reduce uptake, such as concurrent general anxiety.”
System-Level Barriers and Solutions
“Systemic barriers to vaccination include access, acceptability, awareness of services, cost, and other practical considerations. Historical enrollment into influenza vaccination programs was predictive of future vaccination completion, suggesting these existing routines and resources could also be harnessed for a COVID-19 vaccine.”
They suggest: “Running vaccination clinics parallel to mental health services can increase vaccination rates by up to 25%. Transportation to the vaccination clinics, even when colocated with a mental health service, may be a significant barrier, especially for infrequent service users. Therefore, one solution may be to embed vaccination clinics within mental health services, although none have been evaluated to date and to our knowledge.”
A few thoughts:
- This is a good paper.
- The authors make important points about reaching those with serious mental illness.
- The core message: be creative. For months, we have hoped for a vaccine. Two are now approved by Health Canada, with more to come. In some ways, though, our work is only beginning. Just as people with serious mental illness often need care that goes beyond a simple office appointment, some will need extra help and planning for vaccination. The stakes are high: as a recent Lancet Psychiatry paper showed, people with mental disorders are at higher risk of getting COVID and significantly higher risk of getting very ill with it.
The JAMA Psychiatry paper can be found here:
“Business Not as Usual – Covid-19 Vaccination in Persons with Substance Use Disorders”
Joshua A. Barocas
The New England Journal of Medicine, 30 December 2020
Persons with substance use disorders (SUD) in the United States have been disproportionately affected by the Covid-19 pandemic – not only are they, like patients with other chronic diseases such as diabetes, at increased risk for severe disease and death due to Covid, but data show that overdose deaths have increased during the pandemic. Furthermore, there is significant overlap between populations with SUD and those facing housing instability and homelessness, domestic and sexual violence, and incarceration – social conditions that increase Covid risk. To date, only persons who use tobacco, not substances such as opioids, are being prioritized for early vaccination. Given the data, however, I believe it’s imperative not only that persons with SUD – particularly those in living conditions that increase Covid risk – be prioritized to receive the vaccine, but also that rollout plans account for specific barriers to uptake in this population.
To develop effective strategies, health professionals must first contend with this population’s mistrust of us. Addiction remains a disease for which people are routinely denied appropriate care on the basis of providers’ beliefs. The medical profession has often fueled the fire of stigma, driving people away and cementing distrust.
He forwards a few ideas.
Trust-building campaigns and dissemination of accurate information are paramount.
“Health professionals should be accessible to the community to answer questions and improve relations, which can be done, for example, by holding listening sessions at local shelters, SUD treatment or detox centers, or syringe services programs to hear about the fears and needs of the population. Trusted people such as peer navigators, recovery coaches, and harm-reduction service providers could be asked to serve as vaccine ambassadors.”
Vaccination programs should go where people are and investments should be made in removing structural barriers.
“Health departments should plan for vaccine administration at sites such as methadone clinics, syringe services programs, and Alcoholics Anonymous and Narcotics Anonymous meetings. Administration of other vaccines at syringe programs has been highly successful, and providing vaccination at places where trusting relationships exist and where people regularly obtain care will make it easier for people to receive both doses of vaccine.”
Vaccines will probably need to be administered by trusted professionals.
“Those who already serve people with SUD – such as outreach workers and peer navigators – should be classified as essential workers and be prioritized for the vaccine.”
A few thoughts:
- This is a good paper.
- As with the Warren et al. paper, there are good points made here.
- The paper mentions mistrust of authority and government advice. Let’s consider the perspective of our patients with substance problems: for too long, they have been belittled for their disorders and stigmatized – by society and, yes, by government officials. The vaccine rollout will need to be more than just focused on the logistics of reaching people, but also about persuading them by building trust.
The full NEJM paper can be found here:
Selection 3: “Vaccination Conversations: Influencing Critical Health Behaviors in COVID-19”
Joshua C. Morganstein
Psychiatric News, 23 December 2020
Bringing an end to the COVID-19 pandemic requires development of an effective vaccine that is deployed and administered to a sizable portion of our population. For that to happen, citizens must be willing to accept a vaccine. Unfortunately, the willingness of our society to receive a COVID-19 vaccine has generally declined, despite reassurances about safety and efficacy by public health experts as well as national leaders.
So begins a short article by Dr. Morganstein.
He notes the key role of mental health clinicians:
“Behavioral health professionals provide essential support to these efforts by ensuring that the unique needs of people with mental illness are considered in vaccine implementation planning. Though behavioral health professionals may not be directly involved in vaccine delivery, they can play a critical role in public mental health by educating other health care personnel and community leaders about the importance of effective communication in shaping perceptions of risk and subsequent behaviors, such as the willingness to receive COVID-19 vaccination.”
How to speak to our patients? He sees three different tasks for three different groups:
- Preparation. “Patients who are ready for a vaccine should be encouraged for their positive health behavior choices, have any questions answered, and given information about when and where to get a vaccination.”
- Contemplation. “Individuals who express hesitancy may transition to being ‘ready’ following effective motivational interviewing, where the health care professional explores the patient’s concerns and discusses potential benefits and drawbacks of each course of action. This mutually respectful exchange builds trust and enhances therapeutic rapport, a positive predictor of behavior changes in patients. More than one conversation may be necessary…”
- Pre-contemplation. “Those who express refusal should have their perspective respected. Health care professionals can respectfully inform the patient that they recommend the vaccine and offer to speak further if the patient would like to talk later. Efforts to change the behavior of those who are pre-contemplation are rarely successful. Paradoxically, they may have the unintended consequence of furthering mistrust.”
And he urges caution with our words:
“Communication with individual patients should similarly be tailored to increase patient understanding and receptivity. For instance, the use of medical jargon is increasingly associated with confusion, mistrust, and lack of behavior change. Health care professionals are trained to use complex medical terminology, though more understandable and down-to-earth language often serves to enhance trust and build rapport.”
A few thoughts:
- This is a good and important article.
- His advice isn’t earth-shattering, but it is thoughtful.
- We need to be careful about our words. Clinicians tend to use complicated terms. With so much misinformation on social media, we need to speak clearly and understandably.
- Are there resources we can suggest for patients – or even co-workers who are hesitating on the vaccine?
Here are two excellent videos that I’ve been sharing with patients and staff:
Dr. Jeff Powis of Michael Garron Hospital answers five questions about the COVID-19 vaccine (run time: 10 min). Here’s the link: https://www.youtube.com/watch?v=5SOt1pmCBNk&list=UUoQrq91UYI-Usu_ecwNST6g
The Yale School of Medicine’s “Understanding COVID-19: How Vaccines Work” (run time: 4 min). Here’s the link: https://www.youtube.com/watch?v=oNfkE0lKOtM
- To return to the article of Dr. Nadia Alam, a family physician and a past president of the Ontario Medical Association, there is significant vaccine hesitation, even among health care providers. She suggests that government and health care providers avoid a one-size-fits all approach, and consider tailored efforts for different ethnic and religious groups. Her full essay can be found here: https://healthydebate.ca/opinions/tailored-messaging-vaccine-hesitancy
The Psychiatric News article can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.