The Challenges of Providing Community Psychiatric Services in the COVID-19 Era: The Probability of Soaring Rehospitalization and Caregivers' Burden of People with Severe Mental Illnesses.

Chronic diseases, in addition to having a significant impact on the life of patients, also have a serious negative effect on the life of their caregivers. This effect in chronic psychiatric disease is more noticeable than physical chronic diseases like diabetes mellitus or hypertension. People with schizophrenia and bipolar mood disorder mostly have limited insight and compliance, which makes both long-term medication and psychoeducation more difficult (1). They also may have some behaviors that cause distress to their family or caregivers. Smoking and alcohol abuse is more prevalent among them (2). In addition, the stigma of having a mental disorder is extremely painful and could isolate these families (3). The combination of these factors puts a lot of burden on the caregivers, as conducted studies showed that 18-47% of caregivers are suffering from depression (4). Previous studies in Iran showed that the rate of depression in psychiatric patients’ caregivers is 30% (5), while the depression rate in the general population is 12.7 % (6). In this context, supporting these vulnerable individuals is necessary for both patients and the community. In recent decades the main focus of mental health policymakers has been to replace community-based services such as outpatient, daycare, home-visit, supported employment with long-term hospitalization as a psychiatric asylum. Community-based services have a remarkable positive impact on mental health in society. A study in Iran reported that the hospitalization rate after providing comprehensive community-based services was reduced by 67% (7). Although new medications can control the acute phase of the disease, they help remarkably with the independent living of people with severe mental illnesses (SMIs) in the communities.

In our country, there are several organizations authorized by the Welfare Organization that provide community-based psychiatric services, daycare, home visiting, psychoeducation, family therapy for patients with SMIs. Providing these services not only helps patients living somehow independently but also reduces the caregivers’ burden (3).

After the COVID-19 pandemic, closure of providing in-person services of these centers in order to reduce the transmission of the disease, telerehabilitation and telepsychiatry were noticed as alternative methods (8, 9). According to the Welfare Organization’s protocol, home-visit and daycare services are provided by telephone call or using available social media such as WhatsApp. Individual or group sessions for clients and group conferences for their caregivers are being held.

However, the new way of providing services faces some serious challenges. First challenge is less accessibility to the internet and smartphones. In 2018, only 66% of people with schizophrenia in the US owned smartphones (10). This rate is probably lower in developing countries. For instance, in a rehabilitation center in Tehran, only 30% of patients have access to the internet and smartphones. In some cases, only one member of the family, for example a sibling, has a smartphone and when he/she is at work, patient access was disrupted. This problem caused some difficulties in communication with the patient, especially for online group meetings. The second problem is being unfamiliar with using technological tools. This issue is seen more in older or illiterate populations (11). The third problem relates to the efficacy of telepsychiatry in comparison to the usual face-to-face services. One of the important aspects of rehabilitation for psychiatric patients is involving them in the community. Although some studies have demonstrated that telepsychiatry has equal results and can be a useful replacement for neurotic psychiatric patients (12), the question is whether or not this method can be used for rehabilitation of chronic psychiatric patients and is it equally effective (13). Most of the caregivers afraid of being infected by COVID-19 do not allow their loved ones with SMI to leave the house as much as they possibly could. Reduction of community-based services during the COVID-19 pandemic may increase the rate of rehospitalization as well as increasing the burden on their caregivers.

Given that tackling the COVID-19 pandemic may continue for several years, some effective solutions are required. Restoring in-person services with a small group of patients with implementation of health protocols and putting them on a priority for vaccination, serious education and close monitoring the clients on how to protect themselves while using public transportation services may be a compensatory solution for the problems. Perhaps the most important issue is vaccination, since, resumption of community-based psychiatric services almost depends on it. Furthermore, mobilizing public and charity resources to obtain smartphone devices for each client could be considered as well. It may be necessary to train not only the client but also the caregivers on how to use the smartphone to communicate in effective ways with the programs.

Conflict of Interests

The authors declare that they have no competing interests.