Impact of the COVID-19 Pandemic on the Management of Inpatients and Outpatients With Schizophrenia
The COVID-19 pandemic has created challenges for the health professionals and programs that provide services to patients with schizophrenia. Continuity of care is critical for these patients to prevent decompensation and its consequences, including emergency department visits and hospital admissions resulting in further strain on the health care system, mental and physical deterioration, and even deaths. In February 2020, a cluster of approximately 50 patients and 30 medical staff were diagnosed with COVID-19 at the Wuhan Mental Health Center. Factors hypothesized to have increased the risk of outbreak on an inpatient psychiatric unit included: crowded wards, lack of isolation of suspected or early cases, and lack of clinical pathways to prevent infectious diseases in mental health settings. A COVID-19 outbreak in a South Korean inpatient psychiatric unit infected 100 of its 102 patients and resulted in 7 deaths, at the time accounting for nearly half the COVID-19-related deaths in the country. Factors identified as having contributed to this outbreak were the lack of ventilation due to windows having been sealed shut to prevent suicides, and restrictions on the use of hand sanitizer due to fears that some patients would drink it. The recommendations of the Wuhan group included: use of a preadmission observation ward; screening of admitted patients; screening of hospital staff; temporary prohibition of in-person visitors, external food, and clothing; and improved skills among psychiatric care providers to identify and treat physical diseases. Similar practices—including isolation of at-risk individuals, infection control training and audits—were successfully implemented on some psychiatric inpatient units during the 2003 SARS outbreak. Additional concerns for psychiatric inpatient units include managing agitation, given the risk of contagion, and managing patients and staff who may have been exposed to COVID-19 in the face of shortages of both personal protective equipment and staff. Strategies implemented at the Centre for Addiction and Mental Health in Toronto, Canada, modeled after a system developed during the 2003 SARS outbreak, involve designating different units to segregate patients with suspected infection, diagnosed infection, or absence of infection, and assignment to every inpatient psychiatrist of backup outpatient psychiatrists prepared to seamlessly assume care in the event that an inpatient psychiatrist becomes unable to work.
The immediate impact of COVID-19 could be even greater in outpatient settings, where the majority of mental health care is delivered. Evidence-based models of care for schizophrenia, including assertive community treatment and intensive case management, emphasize in-person contacts in the community and in patients' homes. While outreach visits increase the risk of transmission to both patients and providers, abrupt changes to how mental health services are delivered could increase the risk of service disengagement, medication nonadherence, and distress, all leading to decompensation and relapse.
Phone and video consultations have been rapidly implemented as an alternative to in-person clinical care during the COVID-19 outbreak.[46,47] However, there is little research examining the suitability of telepsychiatry for schizophrenia compared with other less severe mental disorders (eg, depressive and anxiety disorders) for which it has been typically used to date. A recent randomized-controlled trial of adjunct videoconferencing in patients with severe mental illness compared with usual care found high levels of satisfaction associated with the service, but low use over the 18-month study period. While mobile phone ownership approaches 100% in the general population in North America or Europe, the use of digital technologies is lower in those with psychosis.[50,51] Despite these challenges, outpatient services should strive to reduce in-person contacts when it is safe to do so through the use of telepsychiatry and the provision of longer prescription durations. In addition to digital solutions used to deliver direct patient care, automated text messages and mobile applications can augment care and provide support between appointments. In the midst of the pandemic, providers should be flexible and payers should remunerate care provided over either videoconferencing or phone to ensure access and uptake.
Despite its merits, virtual care cannot completely replace in-person care for schizophrenia. For example, the ability to detain someone involuntarily still requires in person assessment and hearings in many jurisdictions. The COVID-19 pandemic may lead to an increase in the acceptability of telepsychiatry for these quasilegal processes, much as it has facilitated novel funding mechanisms for the expanded delivery of telehealth services. Furthermore, in-person visits are required for the administration of long-acting injectable antipsychotic medications, which are increasingly used in the management of schizophrenia. Given the role of long-acting injectable antipsychotics in reducing hospitalizations compared with oral medications, it is prudent to continue using them, even if these visits may increase the risk of infection for patients and providers. Similarly, clozapine is associated with superior outcomes (and reduced mortality) in treatment-resistant schizophrenia, but it requires regular bloodwork. In response to the COVID-19 pandemic, the US Food and Drug Administration (FDA) has changed some of their regulations for laboratory monitoring requirements on an emergency basis. Thus, during the pandemic, the frequency of blood monitoring required for clozapine maintenance could be reduced. However, the risks and benefits of such a change need to be carefully considered.
Schizophr Bull. 2020;46(4):752-757. © 2020 Oxford University Press