Duties toward Patients with Psychiatric Illness.

Patients with psychiatric illness feel the brunt of the intersection of many of our society's and our health care system's disparities, and the vulnerability of this population during the Covid-19 pandemic cannot be overstated. Patients with psychiatric illness often suffer from the stigma of mental illness and receive poor medical care. Many patients with severe and persistent mental illness face additional barriers, including poverty, marginal housing, and food insecurity. Patients who require psychiatric hospitalization now face the risk of transmission of Covid-19 due to the inherent difficulties of social distancing within a psychiatric hospital. Patients whose freedom and self-determination have been temporarily overruled as they receive involuntary psychiatric treatment deserve a setting that maintains their health and safety. While tele-mental health has been rapidly expanded to provide new ways to access psychiatric treatment, some patients may have limitations in technological literacy or access to devices. The social isolation, economic fallout, and potential traumatization related to the current pandemic will disproportionately affect this vulnerable population, and society's duties to them must be considered.

Brief reflections on lessons and questions posed by Covid‐19 for health, medicine, and bioethics

The Covid‐19 pandemic is exacerbating long‐standing problems within society and health care in the United States. One among them is the protection and treatment of vulnerable psychiatric populations. Psychiatric patients have significantly increased risks of suicide, sudden cardiac death, all‐cause mortality, and being victims of violence. Those with psychiatric illness receive poor medical care, and a diagnosis of schizophrenia reduces life expectancy by approximately fifteen years. Additional stigma, lack of reimbursement parity for psychiatric conditions, and a shortage of mental health workers further contribute to their vulnerability.

Patients with severe and persistent mental illness are often less able to advocate for themselves as a function of their symptomatology. Disorganized speech, inappropriate affect, ambivalence about treatment, and difficulty trusting providers may lead to poor communication and misunderstandings. Comorbid substance use may further complicate their conditions and care. Neurocognitive impairments and negative symptoms such as lack of motivation, poor judgment, and impaired executive function may limit their ability to navigate a complex health care system. Many patients with severe and persistent mental illness face additional barriers, including poverty, marginal housing, and food insecurity, and the many challenges that come with any of these factors.

The U.S. health care system is attempting to improve health care access during the pandemic, and its primary strategy has been a rapid expansion of telehealth. The therapeutic potential for telehealth services for mental health care may create new outpatient treatment options for some populations. Tele‐mental health care offers both monitoring and delivery of intensive treatment outside of the hospital and is easily scalable. However, the efficacy has yet to be demonstrated, and it may not reach the most vulnerable populations due to lack of Internet access and technological literacy. Further, disorganization, paranoia, and other symptoms related to underlying illness may become barriers to the use of tele‐mental health services when these resources are most critical.

Patients who require psychiatric hospitalization face further challenges. Due to widespread shortages of psychiatric beds, patients may be kept temporarily in the emergency department, an alternative that has been demonstrated to be unsafe, inappropriate, and ineffective. Anecdotal accounts suggest that this phenomenon has worsened during the pandemic and that the excess time that a patient spends in the emergency department now represents an additional risk of infection with Covid‐19. There are accounts of emergency departments considering discharging suicidal patients because physicians feel that this condition is less concerning than the acute respiratory syndrome caused by Covid‐19. Almost fifty thousand lives are lost every year to suicide. The economic depression and social isolation that have befallen the country in the wake of Covid‐19 are expected to increase this already sobering suicide rate.

The medical community has an especially strong duty to protect patients receiving involuntary psychiatric treatment, patients whose freedom and self‐determination have been temporarily overruled. A patient who is detained for involuntary psychiatric treatment retains certain rights, and involuntary psychiatric treatment should be efficient, effective, safe, and respectful. Once a patient has arrived at a psychiatric hospital, there is a duty to protect them from risk of infection with Covid‐19. Nursing homes, prisons, and homeless shelters are receiving widespread attention for extraordinarily high rates of Covid‐19 transmission and mortality, but outbreaks are occurring within psychiatric hospitals as well. It should go without saying that hospitals should take every precaution to protect patients from infection. Contracting Covid‐19 during an involuntary psychiatric hospitalization could reinforce patients’ paranoia and distrust of the health care system, creating yet another future barrier to adequate medical and psychiatric treatment. It may be appropriate to shift the thresholds between managing psychiatrically decompensated patients in the community, recommending voluntary psychiatric hospitalization, and mandating involuntary psychiatric hospitalization. Safety risk assessments with respect to a patient's psychiatric health should be balanced against the risk of contagion incurred by confinement in a group setting.

Many patients with psychiatric illness experience hardships of our society's and health care system's disparities, and the vulnerability of these patients cannot be overstated. The medical community has an additional duty to provide safe and effective care for patients once we have infringed upon their freedom under the premise of maintaining their safety.

While severe and persistent mental illness presents unique risks, many other psychiatric conditions may be exacerbated by the pandemic. Patients with a history of interpersonal trauma who are living in an unstable family environment are at elevated risk of interpersonal violence, and indeed there has been a surge in domestic violence during the pandemic, with reported increases of up to 700 percent. Patients with obsessive compulsive disorder can become preoccupied with fears of contagion and cleansing rituals. Patients with anxiety and depression are likely to experience a worsening of their symptoms, while health care workers and others on the front line will likely be at increased risk for burnout, moral injury, complex grief, and post‐traumatic stress disorder. And everyone faces increased risks of financial stressors, substance use, social isolation, interpersonal trauma, limitations around common coping skills like exercise, or barriers to social support like twelve‐step programs and religious communities.

The ripples of the current pandemic and the abrupt changes required for social distancing will be far reaching. The rapid expansion and innovation in tele‐mental health services may improve psychiatric access for certain patients, including patients with transportation barriers or those living in rural areas, while marginalizing others even further, given unequal access to technology and technology literacy. Disparities in the social determinants of health have been widely discussed in the media and may prompt renewed efforts to address injustices tightly linked with mental health outcomes. Transmission of infection within psychiatric hospitals has forced recognition of the risks associated with psychiatric hospitalization and stimulated conversation about a patient's right to safety. The light shed on underfunding and gaps within the mental health system will hopefully gain the attention of legislators, the public, and the health care system. Access must be improved by increasing the availability of inpatient psychiatric hospitalization, facilitating efficient transitions in care, offering innovations like virtual partial hospitalization and home hospitalization programs, and finding solutions to reach those with limited technology.

Some portion of the population will likely suffer long‐term traumatic sequalae from the pandemic, and many people may require psychiatric treatment. The duty to provide psychiatric care will, no doubt, be tested by the aftermath of this public health emergency. Though the financial costs to improving the mental health infrastructure may seem substantial, the current circumstances remind us that mental well‐being is integral to the economic and social prosperity of a nation's citizens, families, businesses, and institutions.