Oliver Freudenreich, MD, FACLP Co-Director, MGH Schizophrenia Clinical and Research Program Associate Professor of Psychiatry Massachusetts General Hospital Harvard Medical School Boston, Massachusetts
Nicholas Kontos, MD, FACLP Director, Fellowship in Consultation-Liaison Psychiatry Assistant Professor of Psychiatry Massachusetts General Hospital Harvard Medical School Boston, Massachusetts
John Querques, MD Vice Chairman for Hospital Services Department of Psychiatry Tufts Medical Center Associate Professor of Psychiatry Tufts University School of Medicine Boston, Massachusetts
Disclosures Dr. Freudenreich has received grant or research support from Alkermes, Avanir, Janssen, and Otsuka, and has served as a consultant to American Psychiatric Association, Alkermes, Janssen, Neurocrine, Novartis, and Roche. Dr. Kontos and Dr. Querques report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
This primer summarizes the clinical management of this easily forgotten group during a pandemic.
“This whole thing is not about heroism. It’s about decency. It may seem a ridiculous idea, but the only way to fight the plague is with decency . ”
– Albert Camus, La Peste (1947)1
Severe acute respiratory syndrome (SARS), H1N1 swine flu, Ebola, Zika, and Middle East respiratory syndrome (MERS): the 21st century has already been witness to several serious infectious outbreaks and pandemics,2 but none has been as deadly and consequential as the current one. The ongoing SARS-coronavirus-2 (SARS-CoV-2) pandemic is shaping not only current psychiatric care but the future of psychiatry. Now that we are beyond the initial stages of the coronavirus disease 2019 (COVID-19) pandemic, when psychiatrists had a crash course in disaster psychiatry, our attention must shift to rebuilding and managing disillusionment and other psychological fallout of the intense early days.3
In this article, we offer guidance to psychiatrists caring for patients with serious mental illness (SMI) during the SARS-CoV-2 pandemic. Patients with SMI are easily forgotten as other issues (eg, preserving ICU capacity) overshadow the already historically neglected needs of this impoverished group.4 From both human and public-health perspectives, this inattention is a mistake. Assuring psychiatric stability is critically important to prevent the spread of COVID-19 in marginalized communities comprised of individuals who are poor, members of racial minorities, and others who already experience health disparities.5 Without controlling transmission in these groups, the pandemic will not be sufficiently contained.
We begin by highlighting general principles of pandemic management because caring for patients with SMI does not occur in a vacuum. Infectious outbreaks require not only helping those who need direct medical care because they are infected, but also managing populations that are at risk of getting infected, including health care and other essential workers.
Principles of pandemic management
Delivery of medical care during a pandemic differs from routine care. An effective disaster response requires collaboration and coordination among public-health, treatment, and emergency systems. Many institutions shift to an incident management system and crisis leadership, with clear lines of authority to coordinate responders and build medical surge capacity. Such a top-down leadership approach must plan and allow for the emergence of other credible leaders and for the restoration of people’s agency.
Unfortunately, adaptive capacity may be limited, especially in the public sector and psychiatric care system, where resources are already poor. Particularly early in a pandemic, services considered non-essential—which includes most psychiatric outpatient care—can become unavailable. A major effort is needed to prevent the psychiatric care system from contracting further, as happened during 9/11.6 Additionally, “essential” cannot be conflated with “emergent,” as can easily occur in extreme circumstances. Early and sustained efforts are required to ensure that patients with SMI who may be teetering on the edge of emergency status do not slip off that edge, especially when the emergency medical system is operating over capacity.
A comprehensive outbreak response must consider that a pandemic is not only a medical crisis but a mental health crisis and a communication emergency.7 Mental health clinicians need to provide accurate information and help patients cope with their fears.
