The challenge of mental health during Covid-19 outbreak: experience from metropolitan area of Milan.

After the outbreak of the novel coronavirus, recently named Sars-CoV-2, in Wuhan, China, Europe rapidly became the new epicenter for the virus spread. North of Italy, especially Lombardy, was the first European region where autochthonous cases were discovered, accounting for more than one-third of cases in Italy, with tremendous consequences on the common habits and lifestyle of the Italian population. In the absence of vaccines or specific therapeutics, the Government imposed national measures to reduce social interaction and ultimately limit the viral spread, including isolation, quarantine, and community containment [1]. The need to deal with a growing number of patients affected by severe respiratory symptoms, together with tight travel limitations, posed a great challenge to providing appropriate assistance to patients affected by other conditions, particularly mental disorders.

The effects of Covid-19 in the management of psychiatric conditions could be observed at different levels, both direct and indirect. In few weeks, the whole mental health system was severely remodeled and downsized [2]. With outpatient and day-care services limited to urgent visits that could not be deferred, most of the subjects with chronic disorders suddenly lost direct contact with their psychiatrist and related mental health-care professionals, causing profound limitations in daily routine, interpersonal contacts, and global functioning, possibly leading to distress and symptoms exacerbation. Experiences from previous epidemics and pandemics showed how social isolation itself could lead to anger, loneliness, and boredom, and might have a detrimental effect on mental health, including acute stress disorder, mood and anxiety disorders, psychotic symptoms, and even suicidality [3], both in psychiatric patients and previously healthy subjects. Acutely ill psychiatric patients represent a further challenge to face, especially when in need of hospitalization. Disorganized behaviors, cognitive symptoms, and difficulties or complete lack of physical distancing due to crowded institutions increase the risk of viral transmission, also considering that the occurrence of psychopharmacological drug-related side effects may predispose to more severe Covid-19 manifestations [4].

As previously experienced in China [4], we had to adapt rapidly to these upcoming issues to preserve the general health of those patients referring to our psychiatric outpatient and inpatient services at San Raffaele Turro Hospital mood disorder Unit. Our services are integrated within the Milan metropolitan area, the one with the highest number of cases in Italy at the time of writing. We adopted multiple strategies, including telemedicine, restrictions to hospital access, basic preventive measures, and physical/laboratory monitoring of patients.

With the recent development of multiple tools in the field of telecommunication, telemedicine has already proved to be an effective strategy in the doctor-patient relationship, particularly in psychiatry [5]. The great majority of outpatients was promptly advised to remain home, unless in need of an urgent consultation. Our hospital provided a practical virtual platform to perform specialist assessments, with a generally positive response and thousands of patients who signed up in less than a month. We ensured that all the patients who had a scheduled appointment during the lockdown period were contacted by phone or other telematics platforms. The assessments were based on the evaluation of both mental health conditions and the impact of Covid-19 on everyday life. We used a structured interview, containing items that referred to understanding the lockdown measures, exacerbation of mood, anxiety and sleep symptoms, and economical repercussions of the emergency. We interviewed 179 subjects in 2 months, 97.8% of which expressed satisfaction with the service offered.

In case of hospitalization, we remodeled the clinical routine and organization for inpatients to limit the spread of the virus within a high-risk environment, with the aim of zero infections among patients and health-care workers. Before the admission, every patient underwent a nasopharyngeal swab and a strict contact tracing, in cooperation with the Infectious Diseases staff; those who tested negative for Sars-CoV-2 were admitted under a 3-day isolation regime. During the hospitalization, basic preventive measures were implemented, including frequent hand washing, physical distancing, and use of facemasks, with continuous training operated by the staff. Neither group activities nor visits from relatives were allowed, with the use of common rooms/spaces restricted to adequate distancing. Temperature, vitals, and respiratory symptoms were assessed daily on 39 consecutively admitted patients, which detected only 2 suspected cases. Those were quickly isolated and transferred to the Infectious Diseases ward; none of them were confirmed as Covid-19.

In line with general recommendations [6] and other reports from Lombardy [7, 8], we succeeded in consistently containing the viral transmission among our psychiatric population. Our experience appears crucial in determining measures that proved effective in the viral containment and allowed adequate care in a vulnerable population.