Evidence-Based Reviews

Becoming vaccine ambassadors: A new role for psychiatrists

Current Psychiatry. 2021 August;20(8):10-11,17-21,26-28,38 | doi:10.12788/cp.0155

References

1. Mazereel V, Van Assche K, Detraux J, et al. COVID-19 vaccination for people with severe mental illness: why, what, and how? Lancet Psychiatry. 2021;8(5):444-450.

2. Freudenreich O, Van Alphen MU, Lim C. The ABCs of successful vaccinations: a role for psychiatry. Current Psychiatry. 2021;20(3):48-50.

3. World Health Organization (WHO). Ten threats to global health in 2019. Accessed July 2, 2021. https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019

4. MacDonald NE. Vaccine hesitancy: definition, scope and determinants. Vaccine. 2015;33(34):4161-4164.

5. McClure CC, Cataldi JR, O’Leary ST. Vaccine hesitancy: where we are and where we are going. Clin Ther. 2017;39(8):1550-1562.

6. Betsch C, Korn L, Holtmann C. Don’t try to convert the antivaccinators, instead target the fence-sitters. Proc Natl Acad Sci. 2015;112(49):E6725-E6726.

7. Rahman T, Hartz SM, Xiong W, et al. Extreme overvalued beliefs. J Am Acad Psychiatry Law. 2020;48(3):319-326.

8. Leask J. Target the fence-sitters. Nature. 2011;473(7348):443-445.

9. United States Census Bureau. Household Pulse Survey COVID-19 Vaccination Tracker. Updated June 30, 2021. Accessed July 2, 2021. https://www.census.gov/library/visualizations/interactive/household-pulse-survey-covid-19-vaccination-tracker.html

10. United States Census Bureau. Measuring household experiences during the coronavirus pandemic. Updated May 5, 2021. Accessed July 2, 2021. https://www.census.gov/data/experimental-data-products/household-pulse-survey.html

11. Jefsen OH, Kølbæk P, Gil Y, et al. COVID-19 vaccine willingness among patients with mental illness compared with the general population. Acta Neuropsychiatrica. 2021:1-24. doi:10.1017/neu.2021.15

12. Miles LW, Williams N, Luthy KE, et al. Adult vaccination rates in the mentally ill population: an outpatient improvement project. J Am Psychiatr Nurses Assoc. 2020;26(2):172-180.

13. Lewandowsky S, Ecker UK, Seifert CM, et al. Misinformation and its correction: continued influence and successful debiasing. Psychol Sci Public Interest. 2012;13(3):106-131.

14. Druss BG, Rosenheck RA. Locus of mental health treatment in an integrated service system. Psychiatr Serv. 2000;51(7):890-892.

15. Freudenreich O, Kontos N, Querques J. COVID-19 and patients with serious mental illness. Current Psychiatry. 2020;19(9):24-35.

16. Hamel L, Kirzinger A, Muñana C, et al. KFF COVID-19 vaccine monitor: December 2020. Accessed July 2, 2021. https://www.kff.org/coronavirus-covid-19/report/kff-covid-19-vaccine-monitor-december-2020/

17. Kai J, Crosland A. Perspectives of people with enduring mental ill health from a community-based qualitative study. Br J Gen Pract. 2001;51(470):730-736.

18. Mather G, Baker D, Laugharne R. Patient trust in psychiatrists. Psychosis. 2012;4(2):161-167.

19. Miller WR, Rollnick S. Motivational interviewing: helping people change. Guilford Press; 2012.

20. Reno JE, O’Leary S, Garrett K, et al. Improving provider communication about HPV vaccines for vaccine-hesitant parents through the use of motivational interviewing. J Health Commun. 2018;23(4):313-320.

21. Baddeley M. Behavioural economics: a very short introduction. Volume 505. Oxford University Press; 2017.

22. Nemani K, Li C, Olfson M, et al. Association of psychiatric disorders with mortality among patients with COVID-19. JAMA Psychiatry. 2021;78(4):380-386.

23. De Hert M, Correll CU, Bobes J, et al. Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry. 2011;10(1):52.

24. Lorenz RA, Norris MM, Norton LC, et al. Factors associated with influenza vaccination decisions among patients with mental illness. Int J Psychiatry Med. 2013;46(1):1-13.

25. Bitan DT. Patients with schizophrenia are under‐vaccinated for COVID‐19: a report from Israel. World Psychiatry. 2021;20(2):300.

26. Robotham D, Satkunanathan S, Doughty L, et al. Do we still have a digital divide in mental health? A five-year survey follow-up. J Med Internet Res. 2016;18(11):e309.

27. De Hert M, Cohen D, Bobes J, et al. Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level. World Psychiatry. 2011;10(2):138.

28. Carrà G, Bartoli F, Carretta D, et al. The prevalence of metabolic syndrome in people with severe mental illness: a mediation analysis. Soc Psychiatry Psychiatr Epidemiol. 2014;49(11):1739-1746.

29. Lin MT, Burgess JF, Carey K. The association between serious psychological distress and emergency department utilization among young adults in the USA. Soc Psychiatry Psychiatr Epidemiol. 2012;47(6):939-947.

30. DeCoux M. Acute versus primary care: the health care decision making process for individuals with severe mental illness. Issues Ment Health Nurs. 2005;26(9):935-951.

31. Hoffman L, Wisniewski H, Hays R, et al. Digital opportunities for outcomes in recovery services (DOORS): a pragmatic hands-on group approach toward increasing digital health and smartphone competencies, autonomy, relatedness, and alliance for those with serious mental illness. J Psychiatr Pract. 2020;26(2):80-88.

32. Rosenberg SD, Goldberg RW, Dixon LB, et al. Assessing the STIRR model of best practices for blood-borne infections of clients with severe mental illness. Psychiatr Serv. 2010;61(9):885-891.

33. Slade EP, Rosenberg S, Dixon LB, et al. Costs of a public health model to increase receipt of hepatitis-related services for persons with mental illness. Psychiatr Serv. 2013;64(2):127-133.

34. Brewer NT, Chapman GB, Rothman AJ, et al. Increasing vaccination: putting psychological science into action. Psychol Sci Public Interest. 2017;18(3):149-207.

35. Nabet B, Gable J, Eder J, et al. PolicyLab evidence to action brief: addressing vaccine hesitancy to protect children & communities against preventable diseases. Children’s Hospital of Philadelphia. Published Spring 2017. Accessed July 2, 2021. https://policylab.chop.edu/sites/default/files/pdf/publications/Addressing_Vaccine_Hesitancy.pdf

36. Opel DJ, Heritage J, Taylor JA, et al. The architecture of provider-parent vaccine discussions at health supervision visits. Pediatrics. 2013;132(6):1037-1046.

37. Betsch C, Böhm R, Korn L, et al. On the benefits of explaining herd immunity in vaccine advocacy. Nat Hum Behav. 2017;1(3):1-6.

38. Shen F, Sheer VC, Li R. Impact of narratives on persuasion in health communication: a meta-analysis. J Advert. 2015;44(2):105-113.

39. Parkerson N, Leader A. Vaccine hesitancy in the era of COVID. Population Health Leadership Series: PopTalk webinars. Paper 26. Published February 10, 2021. https://jdc.jefferson.edu/phlspoptalk/26/

40. Dempsey AF, O’Leary ST. Human papillomavirus vaccination: narrative review of studies on how providers’ vaccine communication affects attitudes and uptake. Acad Pediatr. 2018;18(2):S23-S27.

41. Chou W, Burgdorf C, Gaysynsky A, et al. COVID-19 vaccination communication: applying behavioral and social science to address vaccine hesitancy and foster vaccine confidence. National Institutes of Health. Published 2020. https://obssr.od.nih.gov/sites/obssr/files/inline-files/OBSSR_VaccineWhitePaper_FINAL_508.pdf

42. International Society for Vaccines and the MJH Life Sciences COVID-19 coalition. Building confidence in COVID-19 vaccination: a toolbox of talks from leaders in the field. March 9, 2021. https://globalmeet.webcasts.com/starthere.jsp?ei=1435659&tp_key=59ed660099

43. Centers for Disease Control and Prevention. Frequently asked questions about COVID-19 vaccination. Accessed July 2, 2021. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/faq.html

44. Singh BR, Gandharava S, Gandharva R. Covid-19 vaccines and community immunity. Infectious Diseases Research. 2021;2(1):5.

45. Goldfarb JL, Kreps S, Brownstein JS, et al. Beyond the first dose - Covid-19 vaccine follow-through and continued protective measures. N Engl J Med. 2021;85(2):101-103.

Patients with SMI face additional individual challenges that impede vaccine uptake, such as lack of knowledge and awareness about the virus and vaccinations, general cognitive impairment, low digital literacy skills,³¹ low language literacy and educational attainment, baseline delusions, and negative symptoms such as apathy, avolition, and anhedonia.¹ Thus, even if they overcome the external barriers and obtain vaccine-related information, these patients may experience difficulty in understanding the content and applying this information to their personal circumstances as a result of low health literacy.

How psychiatrists can help

The concept of using mental health care sites and trained clinicians to increase medical disease prevention is not new. The rigorously tested intervention model STIRR (Screen, Test, Immunize, Reduce risk, and Refer) uses co-located nurse practitioners in community mental health centers to provide risk assessment, counseling, and blood testing for hepatitis and HIV, as well as on-site vaccinations for hepatitis to patients dually diagnosed with SMI and substance use disorders.³²Similarly, when a vaccination program was integrated into an outpatient mental health clinic offering various on-site vaccinations, vaccination rates increased by up to 25% over baseline.¹² Such public health approaches of integrating medical care at the site of mental health care, where patients with SMI are most reliably engaged, can be highly cost-effective³³ in terms of reducing disease burden among patients with SMI.

While the psychiatrist may not have the time and resources to directly follow through on all aspects of vaccinations, they can assume leadership and work with the larger team—including therapists and counselors, nurse practitioners, social workers, case managers, care coordinators, or PCPs with whom they regularly collaborate in caring for patients with SMI—to communicate what they have learned about patient hesitancies, share suggestions for future conversations to address these hesitancies, and relay what structural barriers the patient may need assistance to address.

Prioritization of patients with SMI for vaccine eligibility does not directly lead to vaccine uptake. Patients with SMI need extra support from their primary point of health care contact, namely their psychiatrists. Psychiatrists may bring a set of specialized skills uniquely suited to this moment to address vaccine hesitancy and overall lack of vaccine resources and awareness. Freudenreich et al² recently proposed “The ABCs of Successful Vaccinations” framework that psychiatrists can use in their interactions with patients to encourage vaccination by focusing on:

attitudes towards vaccination
barriers to vaccination
completed vaccination series.

Understand attitudes toward vaccination. Decision-making may be an emotional and psychological experience that is informed by thoughts and feelings,³⁴ and psychiatrists are uniquely positioned to tailor messages to individual patients by using motivational interviewing and applying nudging techniques.⁸Given the large role of the pandemic in everyday life, it would be natural to address vaccine-related concerns in the course of routine rapport-building. Table 2^19,34-38 shows example phrases of COVID-19 vaccine messages that are based on communication strategies that have demonstrated success in health behavior domains (including vaccinations).³⁹

Continue to: First, a strong recommendation...