The impact of COVID-19 pandemic on people with severe mental illness.

PURPOSE: The purpose of this review was to address the impact of the COVID-19 pandemic on people with severe mental illness.
CONCLUSION: Given the psychosocial effects of the COVID-19 pandemic process and the vulnerability of individuals with mental illness, it is clear that some preventive measures will increase the well-being of these individuals and reduce relapses. Careful planning and execution of preventive measures to be taken at the individual, institutional, and social level are essential to minimize the negative consequences of this pandemic for this vulnerable population. PRACTICE IMPLICATIONS: The results of this first review on the topic provide preliminary support for effectively address the needs and healthcare necessities of individuals with serious mental illness by raising awareness among healthcare workers during the COVID-19 pandemic.

INTRODUCTION

Coronavirus disease (COVID‐19) emerged in Wuhan, China and spread worldwide, and there are more than 4.5 million confirmed cases in the world. Along with the increasing number of cases of COVID‐19, the outbreak is tried to control with the taking action by governments. The global health system faces a serious problem as a result of rapid epidemic, which has predictable negative effects on the providing of mental health services. The COVID‐19 pandemic, lead to anxiety and fear cause of the uncertain process and treatment of the disease. Posttraumatic stress disorder, depression, panic attack, and behavioral disorders occur in humans with the effect of COVID‐19 and social isolation. According to factor such as staying away from family, loneliness, misinformation on social media, stigmatization, the healthy people also affect significantly in a negative way. , , ,

Although the emotional wellbeing of the elderly who have been discriminated, healthcare workers who work intensively and infected patients have been mentioned during the COVID‐19 epidemic around the world, it has been less emphasized that the difficulties experienced by individuals with mental disorders. Ignoring the effect of the outbreak on people with mental illness will not only inhibit the measures taken to prevent further spread of COVID‐19, but also increase existing health inequalities.

Outbreaks do not affect the whole population equally in countries. Some vulnerable groups may be more indefensible to infection as well as more negatively from the virus and the process. Understanding the effect on individuals with mental health illness of the outbreak, it is necessary and important to protect these individuals who are a vulnerable group and provide the health services they need.

COVID‐19 AND PEOPLE WITH SEVERE MENTAL ILLNESS

On the world 792 million people suffering from mental health disorders and they struggles with negligence and stigmatization. Individuals with serious mental disorders are inevitably affected by the outbreak of COVID‐19. For example, the beginning of February 2020, about 40 inpatients diagnosed by COVID‐19 in Wuhan Mental Health Center and on February 18, 2020, totally 323 patients with mental health disorders were infected by COVID‐19. The sudden increase of the cases has raised concerns about the role of mental disorders in the transmission of coronavirus infection.

The nature of psychiatric illness and infectious disease

The individual with severe mental illness are more sensitive against infection for various reasons such as decreasing cognitive ability and awareness of self‐care, using medication continuously and limited conditions in psychiatry clinics. One of the risk factors for the transmission of infection in psychotic patients is the lack of insight of the patient. This can lead to an increase the risk of infection, including pneumonia, in individuals with mental health illness. It is known that infections transmitted from person to person through droplet or close contact spread more easily, especially in limited areas. Inpatients, such as closed or chronic psychiatric clinics, may have a higher risk of cluster contamination, particularly in closed clinics. The importance of preventive measures is strongly emphasized, especially in viral droplet infections. The psychiatry clinics are not designed according to the isolation standards for respiratory diseases like other clinics, and the equipment also may be inadequate in this regard. Besides psychiatry patients are more resistant to the isolation process. Therefore, sometimes it is harder to cooperate with patients. Patients with no insight are not aware of the changes in their environment and they can't protect their self from the external environment.

The difficulties of management of preventive strategies for people with severe mental illness

The preventive strategies are very important until a vaccine or treatment is found for viral infections. The standard recommendations, like washing hand with soap and water, covering the mouth and nose while sneezing or coughing, cooking to food well‐done, avoiding close contact with anyone who has symptoms with respiratory diseases, prevent the spread of infections can be difficult to individuals who has chronic disease as well as mental health disorders. Individuals with serious mental disorders may not only be vulnerable to easy transmission of infection, but can also play a role in the transmission and self‐quarantine prevention in this population can pose several that population. In addition to the practical difficulties in practice, even 4–6 months after the quarantine, there may be further deterioration in mental state, including anger and anxiety. , ,

The effect of psychosocial problems caused by COVID‐19 among people with severe mental illness

COVID‐19 outbreak also causes the fear and anxiety. Prevention measures such as isolation and quarantine can lead to fear, anxiety, and uncertainty for patients, causing to increase the diseases related with stress and at the same time it can cause exacerbation of pre‐existing mental disorders. , Individuals with mental health disorders are more affected by the emotional reactions due to COVID‐19 outbreaks and it can lead to relapse and worsening their conditions. Individuals with mental disorders are more vulnerable to stress when compared with the general population. Relapse in serious mental disorders can cause poor hygiene, not being able to implement social distance or other preventive strategies, not reporting in a timely manner or getting medical help, and nonadherence expected treatment.

The physical health conditions and infectious disease among people with severe mental illness

Life‐related risk factors such as obesity, physical inactivity and smoking have caused cause medical conditions that result in increased mortality and morbidity in people with mental disorders. It is estimated that there is a 13–30‐year shortening in the average life expectancy of individuals with severe mental disorders. Cardiovascular disease, coronary heart disease and type 2 diabetes are the most common medical conditions in this population. , High smoking rate among these individuals may increase the infection risk and is an indicator of poor prognosis among those who develop the disease. It has also known that housing problems and homelessness could increase the risk of infection and make the diagnosis, follow‐up and treatment difficult in infected people. , ,

At the same time, these individuals have lacked health insurance that coverage to diagnostic test or treatment due to problems such as unemployment. Small social networks have limited opportunities to get support from friends and family members if they get sick in these individuals with serious mental illness. Within this scope, these factors have led to higher rates of infection and poor prognosis in this population.

The effect of COVID‐19 on adherence to treatment among people with severe mental illness

It also known that the risk of infection among people with serious mental illness have increased because of going to the outpatient visit for follow‐ups and prescriptions. As a result of the traffic restrictions and social isolation preventions applied due to the Covid‐19 Pandemic, patients receiving outpatient treatment due to serious mental illness have difficulty maintaining their treatment. Therefore, precautions taken due to the outbreak can cause relapses and behaviors such as hyperactivity, agitation, self‐harm, and others. Therefore, these preventive measures which also increase the risk of suicide and negative emotions can lead to a decrease in the well‐being of individuals with serious mental illness. As a result, these individuals may experience feelings such as loneliness, denial, anxiety, depression, insomnia, and hopelessness that may decrease the compliance to treatment. Social stress factors that can trigger serious mental disorders such as depression or anxiety in previously healthy people, such as health anxiety, fear of death, loss of loved ones, loss of social connectedness, loss of employment and homelessness can cause more serious problems in individuals with serious mental illness.

IMPLICATIONS FOR NURSING PRACTICE

Given the psychosocial effects of the COVID‐19 Pandemic process and the vulnerability of individuals with mental illness, it is clear that some preventive measures will increase the well‐being of these individuals and reduce relapses. Careful planning and execution of preventive measures to be taken at the individual, institutional and social level is essential to minimize the negative consequences of this pandemic for this vulnerable population.

Taking infection measures in psychiatric wards, timely treatment and care of psychiatric patients infected with COVID‐19, home treatment of individuals with serious mental illness, and case management have been identified as preventive measures that can be taken at the country level by the expert consensus in China. , Similarly, it has been suggested that psychiatric hospitals reduce their outpatient treatment, tighten admission criteria, and shorten the length of hospital stay. To minimize the risk of potential hospital infections, it is recommended to establish isolation wards and forbidden visits for newly accepted psychiatric patients. Psychiatric clinics will need protocols to identify patients at risk of infection, and quarantine strategies for healthcare professionals who develop COVID‐19 disease symptoms. Adequate environmental protection should be provided, including well‐ventilated areas, easy access to hand washing, and personal protective equipment. It is estimated that the COVID‐19 outbreak will create a great burden on community mental health centers and psychiatric hospitals. It is crucial that these organizations develop continuity plans to ensure that healthcare professionals continue their functions in the face of conditions such as illness or lack of psychotropic medications due to increased workload and COVID‐19 infection.

At the individual level, individuals with severe mental illness and their families should be provided with current and adequate information about strategies to reduce risk and know when to get medical treatment for COVID‐19.

Prevention strategies as like social isolation developed for the general population can be difficult to apply due to conditions such as limited health literacy in these individuals. It is important that to organize these measures to address the challenges mentioned. It will also be important to address the psychological and social dimensions of the COVID‐19 outbreak for psychiatric patients. Social support systems should be activated, because social isolation strategies that are critical to reduce the spread of the disease can also increase the risk of isolation and loneliness in this population. Some of the proposed interventions include managing common stress symptoms (sleep hygiene, relaxation etc.), promoting prevention strategies related to infection, limiting exposure to misinformation through the media, promoting problem‐solving and self‐efficacy. Mental health professionals are the primary point of contact for these individuals with the health system, and therefore it is important to inform mental health professionals about the treatment and basic strategies associated with the COVID‐19 pandemic. Mental health professionals are the primary point of contact for these individuals with the health system, and therefore it is important to inform mental health professionals about the treatment and basic strategies associated with the COVID‐19 pandemic. At the same time, mental health professionals should make decisions with their patients about what strategies to apply for treatment and care. Whenever possible, the delivery of care services, not face‐to‐face, through telemedicine, and individual visits whenever required can also be effective in preventing the epidemic and meeting the needs of patients.

People with serious mental illness are more vulnerable to infectious diseases due to predisposing risk factors. The management of infectious diseases among people with severe mental illness can be more difficult due to the lack of insight, the presence of a comorbid disease, and difficulty in managing applications related to infection management. Mental health professionals have a key role for these individuals' vulnerability to infection. Individuals with serious mental illness are also adversely affected by the Covid19 epidemic, affected the whole world. In these individuals, the best achieving management of the outbreak has been performed by following the rules on infection measures and by adopting a risk minimizing approach when necessary. Relaps symptoms, such as self‐harm or treatment adherence which may develop due to outpatient treatment during the outbreak, should also be considered. Individual‐centered care included the need for flexibility and taken a holistic approach at the center of contemporary mental health practice should be provided to these patients.

CONFLICT OF INTERESTS

The authors declare that there are no conflict of interests.

AUTHOR CONTRIBUTIONS

All authors listed meet the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors, and all authors have contributed and are in agreement with the manuscript. Ozge Sukut and Cemile Hürrem Ayhan Balik designed the study. Cemile Hürrem Ayhan Balik drafted the manuscript and Ozge Sukut revised the manuscript critically for important intellectual content.