Patients with Serious Mental Illness in the Era of COVID-19: Addressing Vulnerabilities and Treatment Needs

The tsunami of information about COVID-19 has overwhelmed us all. The advisories and directives, for the most part, have been directed at the population as a whole. People with disabilities have been pushed aside and few are addressing the problems they face in this pandemic.

This article looks at people with serious mental illness (SMI) and examines COVID-19 issues affecting both inpatients and outpatients, looking at symptoms, comorbidities, and medications.

Additionally, the authors examine how COVID-19 affects bias against people with SMI and how some patients show clinical improvement as a result of the pandemic.

The goal is to increase awareness and facilitate the treatment of people with SMI during this pandemic, in every hospital and outpatient setting.

Symptoms

The global response to COVID-19 must be understood in the context of patients’ symptoms, as symptoms can significantly alter the response of the general population.

Paranoia . Remote forms of communication can increase patients’ paranoia as they are required to communicate through electronic tools, for example seeing their psychiatrist on a screen. The fear experienced by staff is felt by patients whose paranoid thinking can be magnified.

Delusions . Some patients have incorporated COVID-19 into their deeply held beliefs, such as that the Illuminati is in control of the global pandemic or that the world’s population deserves to be punished. Another example could be a patient who believes he is a doctor and who gives erroneous medical advice about COVID-19 to other patients on the unit.

Hallucinations . People with EMG may attribute the information they receive to their "voices" or hear the noise of viruses. Most important is the need for the psychiatrist to be sensitive to the fact that auditory hallucinations can interfere with the ability to communicate by telephone. The patient mixes all the voices, including those of the psychiatrist. The loss of visual cues can seriously compromise previously effective doctor-patient communication.

Cognitive deficit . People with cognitive deficits may not understand what this is all about, leading to their inability to understand the seriousness of the situation. They may not remember what they have been taught about the virus and may require reminders several times a day to adopt new habits, such as washing their hands more frequently and practicing social distancing. People with cognitive deficits may be incontinent, leading caregivers to have physical contact with the individual several times a day, which worsens if patients are agitated or aggressive. How do staff stop and restrain someone while maintaining social distancing?

Disorganization . Like those with cognitive deficits, disorganized patients may have difficulty following procedures on hand hygiene and social distancing. They may also be confused about their hospital stay or why they can’t have visitors.

Anxiety . Patients with symptoms of prior trauma or post-traumatic stress disorder (PTSD), especially complex PTSD, may be triggered by fears about COVID-19: “The hospital is no longer a safe place”; "My therapist can’t even meet with me in person." COVID-19 symptoms, especially breathlessness, can aggravate the anxiety and panic attacks patients experience. This can lead to breathing difficulties, confusing two origins for poor oxygenation. Anxiety can lead to ignoring the first symptoms of the virus or conspiring about the symptoms.

EMG incidence

During this pandemic, it is reasonable to expect that new cases of SMI will arise and will need to be addressed by the current psychiatric workforce. But there is reason to believe that there will be additional cases that mimic or may actually become EMG.

In 1919, Karl Menninger reported that, as a result of the Spanish flu epidemic, infected people he saw at the Boston Psychopathic Hospital had psychotic symptoms that appeared to be a result of their infection. One third of these patients were diagnosed with schizophrenia (dementia praecox). Of the cases that could be traced one to five years later, two-thirds had apparently recovered. Exposure to coronavirus could be a comorbid risk factor in people diagnosed with SMI.

What this will mean in the context of COVID-19 remains to be seen. Emergency departments, psychiatric units, and state hospitals may see psychotic presentations in people with COVID-19 who need treatment, recognizing that these symptoms will likely not subside when symptoms of the infection have dissipated. These people will need long-term monitoring of their psychotic symptoms.

It’s no surprise that anxiety is at high levels during the pandemic in the United States. One would expect people to exhibit symptoms of post-traumatic stress. In China, women have experienced higher rates of re-experiencing trauma, negative alterations in cognition or mood, and hyperarousal. Many people will need acute treatment for these symptoms, and some will progress to PTSD and require long-term treatment.

In healthcare workers exposed to COVID-19 in China, depression showed a higher rate than any symptom other than distress, outperforming anxiety and insomnia. As with post-traumatic stress disorder, some will achieve resolution of these symptoms through brief interventions, but others will progress to major depressive disorder and require longer-term treatment.

Furthermore, beyond the fear of actual coronavirus exposure or infection that produces psychiatric symptoms, quarantine and isolation itself induces psychiatric symptoms . Quarantine will not only exacerbate symptoms in people with known SMI, but may also lead to treatment for people with SMI, who were previously undiagnosed and/or untreated due to symptom exacerbation.

Settings

In addition to the restrictions already in place for all hospitals, psychiatric hospitals have to enact additional restrictions limiting the movement of patients within the building: in multi-unit hospitals, patients are restricted to their own unit. Efforts outside the unit, such as group activities and meals, have been moved into the unit. Many of these units, especially those in newly built facilities, were never designed for patients to stay in them all day.

Increased restrictions and overcrowding lead to increased attacks of aberrant behavior, leading to increased staff involvement and therefore increased staff exposure. Poor hygiene in hospitals, where there are no open windows and air is recycled through a ventilation system, is a risk, or perceived by patients and staff as a high risk of viral transmission.

Patients in psychiatric hospitals lend, trade, or steal possessions. These objects have been in the hands and against the faces of patients. Patients often share food despite rules against it. While perhaps not the highest priority, psychiatric hospitals should have adequate personal protective equipment (PPE) for their workers.

Because the outpatient community cannot accommodate discharges as before, patients’ hospital stays are prolonged. Psychiatrists are doing unexplored risk-benefit analyses: Are the patient and others more or less at risk if the patient remains in the hospital or is discharged with a suboptimal discharge plan?

Community . In some places, such as in the New York City metropolitan area, psychiatrists are switching, in patients who are believed to be able to handle the switch, from long-acting injectables to pills so that they do not need to leave their residence to receive an injection. Once again, we are on a new frontier of risk-benefit analysis. If the result is a substantially greater number of psychotic decompensations, leading to more visits to the emergency department, then a failure has been made. If only a small percentage of those who switched need acute intervention and everyone else has stayed home, then success will be achieved.

Residential settings for people with SMI are making preventive interventions, such as having residents spend very little time in common areas of the home, staggering meals, and avoiding visitors. Residents visiting family must remain with the family until the crisis is over.

Substance abuse is another problem in the community. The rate of sharing needles and cigarettes may increase as supplies become scarcer. People with limited resources or those whose pharmacy has run out of their medications are taking drugs that were never prescribed to them.

People taking opioids and benzodiazepines are at increased risk of respiratory compromise. An increase in patients with severe respiratory depression from opioids will compete for the attention of emergency personnel with patients with severe respiratory distress from COVID-19. More attention to substance abuse is needed right now, not less.

Social isolation .

For many people with mental illness, being alone is a terrible burden, far beyond what others experience.

The costs of their loneliness are similar to those of many older adults. Loneliness precipitates psychiatric symptoms in those without SMI, and also in those with these disorders. The message can be quite confusing for the person with SMI: “For years I was told not to isolate myself and to go out with other people. Now they tell me to stay home and isolate myself. I’m confused."

People living in abusive homes may be in danger, not just because of the coronavirus. They may be isolated with their abusers ; Tempers can flare, and violence can ensue. Their abuser may threaten them with eviction if they show symptoms. Among all the other reasons they have been afraid to seek help, they have a new fear of going out and contracting COVID-19. Will we see more women with signs of severe physical trauma on emergency department stretchers? Will we have a higher rate of murder and suicide?

Medical comorbidities

Physical Health . SMI patients are particularly vulnerable to COVID-19 because they are generally in poorer health than the general population. They typically delay seeking medical care for various reasons and have more medical comorbidities, such as hypertension and diabetes.

In addition to widely recognized risk factors for COVID-19 such as diabetes, COPD, and cardiovascular disease (CVD), the American College of Cardiology also identified obesity and hypertension as risk factors for viral respiratory diseases, including COVID-19. 19. CVD and its risk factors are twice as high in patients with schizophrenia as in the general population.

Furthermore, while the smoking rate in the general population is approximately 18%, 53% of people with SMI smoke and consequently the COPD rate similarly rises to 22.6% compared to 5% in the general population. The medical needs and comorbidities of people with SMI cannot go untreated; otherwise, they will be another subpopulation referred to the emergency department.

Medicines

Antipsychotics . Since heart disease and diabetes are the main risk factors for severe COVID-19 infection, patients on antipsychotics should be considered high risk. Known for their propensity to contribute to obesity, diabetes, and metabolic syndrome, antipsychotics also increase the risk of hypertension, thromboembolic events, QTc prolongations, and changes in endothelial function.

Additionally, antipsychotics have been linked to respiratory dysfunction and failure (particularly in patients with COPD) probably causing inadequate respiratory muscle activity or central respiratory depression. First and second generation antipsychotics are equally guilty of causing pneumonia and affect not only older people, but also young patients. Smokers, those with chronic respiratory disease, dysphagia or cerebrovascular disease are particularly at risk. Treatment with multiple antipsychotics further increases the risk of pneumonia.

Anxiolytics . Even before the COVID-19 pandemic, an increase in benzodiazepine prescribing by primary care physicians was observed. Knowing that benzodiazepines contribute to poor respiratory function, these patients are less able to fight off a disease like COVID-19 if they are infected. Additionally, those who cannot obtain their prescriptions on time may resort to illegitimate ways to obtain them or risk abrupt withdrawal and experience seizures.

Side effects . Beyond the physiological vulnerability to COVID-19 incurred by psychotropics, people with SMI are subject to other side effects that increase their risk of contracting and spreading the virus: sedation and drowsiness can lead patients to head on a table and fall asleep, creating face-surface contact in common areas. Drooling from sedation or clozapine-induced sialorrhea can rapidly spread the virus over a wide area.

Drug interactions .

Experimental medications are currently used for treatment with COVID-19, which may have serious interactions with psychiatric medications and other medications.

For example, ritonavir is contraindicated with disulfiram (the oral version is 42% alcohol) and decreases the metabolism of midazolam and triazolam. Its level is reduced by CYP3A4 inducers such as carbamazepine, and it directly inhibits 3A4 and 2D6 through which several psychotropics are metabolized.

The most famous combo making headlines for COVID-19 treatment is composed of two QTc-prolonging medications : hydroxychloroquine and azithromycin, further increasing the burden on the heart of those taking psychotropic medications.

Prejudice (stigma)

We can anticipate increased rejection of many people with serious mental illnesses because they are seen as more likely to be infected and because of their appearance in general. It’s no surprise that people are quick to distance themselves from someone who doesn’t maintain the usual social distance from them, even when there isn’t a pandemic.

Rationing of healthcare resources is already under discussion. Because people with schizophrenia have a shorter life expectancy than the general population, will they be the last to receive treatment if the criteria for prioritizing treatment "maximize the number of patients who survive treatment with a shorter life expectancy?" reasonable"? Guidelines have been released saying states, hospitals and doctors cannot put people with disabilities at the back of the line for care, but will everyone adhere to that directive?

Benefits

Amid all these concerns during the COVID-19 pandemic, some psychiatric patients’ symptoms and functioning have actually improved when interventions are deliberately framed by the psychiatrist. Some examples are mentioned below.

Paranoia . A never-married 50-year-old man who is disabled has, for two decades, gone to supermarkets during off-peak hours to avoid as many people as possible. He goes down the halls when they are empty of people. He keeps his distance from store staff in the checkout line. Avoid other shoppers when entering or leaving the store. Now his behavior is normalized, and no one thinks twice about doing it.

Negative symptoms of schizophrenia . A 62-year-old man who lives alone is a member of a very large family, none of whom had moved far from where he grew up. The family gets together almost every week for a holiday or family event, and everyone has to come. The patient, aware that he does not have the ability to engage in social conversation, hates these meetings. He describes them as "torture." He has never been more comfortable in his life since there are no family gatherings, and no one knows when there will be another.

OCD . A 60-year-old woman who became disabled from her teaching job due to OCD symptoms has spent the last decade avoiding touching anything she shouldn’t touch, washing her hands incessantly, and wearing some clothes only outside and other clothes only inside. . When she was in public, people became impatient with her. Now, many people are imitating her usual movements and habits.