COVID-19 in People with Mental Illness: Challenges and Vulnerabilities.

The number of confirmed cases of COVID-19 world-wide has transcended to over 400,000 (World Health Organization, 2020). The numbers appear to be increasing by the day, prompting rapidly changing measures by the governments to contain the spread. World Health Organization (WHO) has recommended increasing level of preparedness, limiting spread by preventing transmission amplification events at an appropriate scale and other hygiene measures.

The global health system is facing a serious challenge with this sudden outbreak, with a foreseeable negative impact on provision of mental health care services. Staff numbers in mental health services may drop due to possible infection in health workers with a need to self-quarantine, that may affect low priority services like routine case manager visits, focus on medication adherence, and routine psychiatrist reviews, amongst others. Relapse in severe mental illness can translate to poor hygiene, inability to practice social distancing or other preventive strategies, absence of timely reporting or seeking medical attention and inability to comply with expected treatment.

Life-style related risk factors like smoking, obesity and inactivity engender medical conditions leading to an increased mortality and morbidity amongst patients with mental disorders. Authors have estimated a 13-30 year shortening in life span of people with severe mental illness (Schneider et al., 2019). Type 2 Diabetes, cardiovascular disease and coronary heart disease amongst others are the most common medical conditions in this population (Łopuszańska et al., 2014). It may be too early to determine the impact of a rapidly spreading infection like COVID-19 in this population but one may conjecture outcomes based on risk factors and known vulnerabilities. A recent retrospective multicenter cohort study by Zhou et al (2020) in Wuhan that included 191 patients affected by COVID-19, found that the odds of death was higher in patients with pre-existing diabetes or coronary heart disease. This emphasizes greater vulnerability for serious complications of COVID-19 in persons with severe mental illnesses and a subsequent health care exigency of pro-active measures by mental health professionals for screening and timely referral of patients that may at times be against their will.

Apart from mentally ill persons in the community, residential settings for persons with mental disability and psychiatric inpatient units may particularly be at risk. A case in point of the complexity of control measures in such settings was the reported outbreak of pandemic virus (H1N1) 2009 in a residence for persons with mental disability in Spain, while the incidence rates in the community had reduced significantly in that flu season. An attack rate of 35.2% was found, with 38 cases detected. Seven of the thirty eight, who had pre-existing risk factors, suffered additional serious complications. The role of vaccination was emphasized by the authors for not only patients but also health workers, whose role in initiation and transmission was identified. (Giménez Duran et al., 2010)

Until such time as a vaccine or cure is available for the viral infection, preventive strategies are of paramount importance. Zhou and colleagues (2020) have found the median duration of viral shedding to vary between 8-37 days in survivors and to continue until death in fatal cases, during which time risk of transmission is very high. Standard recommendations to prevent spread of infection like hand washing, covering mouth and nose while coughing and sneezing, cooking meat and eggs thoroughly and avoiding close contact with anyone showing symptoms of respiratory illness, may be difficult to enforce in persons with mental illness, both chronic patients with deficits and cases of relapse. They may not only be vulnerable to contracting the infection easily but may also play a part in transmission. In addition, self- quarantine measures in this population may pose several challenges. Apart from practical difficulties in implementation, there can be further deterioration in their mental status, including anger and anxiety 4-6 months after release from quarantine (Jeong et al., 2016). Brooks et al. (2020), following a review of evidence have recommended strategies to minimize psychological effects of quarantine by good communication, restricting duration to absolute minimum, providing adequate supplies and practical advice on coping with boredom and stress.

Recently, authors have drawn our attention to the effects of a pandemic of this magnitude, on the mental health of general population (Zandifar and Badrfam, 2020; Banerjee, 2020). Health anxiety, fear of death, fear of losing loved ones, loss of social connectedness, loss of employment and homelessness are some of the social stressors that may even trigger serious mental illnesses like depression or anxiety in previously healthy persons and likewise contribute to added burden in the mentally ill. The role of psychiatrists in diagnosing short-term effects, providing integrated health care and preventing the long-term effects on mental health is distinctive and valuable. Some of the suggested interventions are education and management of common symptoms of stress (sleep hygiene, relaxation and others), promoting precautionary measures, limiting exposure to media-related misinformation, promoting self-efficacy by problem solving (Banerjee, 2020) and advocating against stigmatization and marginalization.

Provision of care with an egalitarian approach in the face of crisis where circumstances are swiftly changing can be arduous. Prioritization and rapid adaptation within mental health services with available resources may be required with increasing demands of mentally ill persons.

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