PSYCHIATRY IS AN ESSENTIAL MEDICAL SERVICE DURING THE COVID-19 PANDEMIC

Vol 8 #3

Author

Eva C. Ihle, MDPhD

University of California, San Francisco (UCSF) and Zuckerberg San Francisco General Hospital.

Correspondence:

Eva C. Ihle, MDPhD

UCSF 401 Parnassus Avenue, San Francisco, CA 94143

Email: [email protected]

Acknowledgements:  The author wishes to thank Drs. James Bourgeois and Robert Grant for their thoughtful feedback on this manuscript, as well as the colleagues on the consultation-liaison service who shared some of the experiences described in this manuscript.

“Do you really think so?”

That was the exclamation from the Chief Operating Officer of the community behavioral health clinic where I provide psychiatric consultation during the conversation explaining why the clinic’s board of directors decided to completely shut down the clinic after one of our patients was found to have been exposed to the novel coronavirus.

I found myself in the remarkable position of having to explain why my medical specialty, psychiatry, is essential and why I continued to go into work in person at my other places of work, the large, university-affiliated hospitals and clinics that were still offering direct care to patients.  How could I not?  After all, they were still there–the pediatricians seeing patients in these clinics where I have been embedded and the adult patients on the inpatient consultation-liaison service at the academic medical center where I serve as a faculty attending physician.  I needed to be there, too.

In the early days of the shelter-in-place edict that was established in the San Francisco Bay Area in response to the COVID-19 pandemic, there were countless departmental meetings at my home institution dedicated to communicating the policy changes that affected personnel in psychiatric hospitals and mental health clinics.  Early topics included whether trainees (from medical students to clinical fellows) would be expected to work directly with patients and strategies for telecommuting.  Some of these meetings were held to revise the conclusions of previous meetings, a reflection of how dynamic the response to the pandemic was.

A number of remarkable policy changes occurred, more quickly than they otherwise would have.  And a number of innovative programs were developed to meet the mental health needs of frontline staff: resilience and emotional well-being videos and webinars; self-care apps; family support programs; and direct assessment and treatment for faculty and staff.

What was missing from these efforts was comparable attention to the emotional and functional well-being of individuals with serious mental illness and even moderate psychiatric symptoms.   It seemed as though more data were being collected about the clinicians’ experiences of transitioning their services to telehealth platforms than the patients’ experiences of not being seen in person.  Public Health Department policies stated that psychiatry services were “essential services” and patients, especially those considered to be at high risk of decompensation or self-harm, could still be seen in person.

However, the reality of day-to-day operations suggested otherwise.  After the first two weeks of sheltering-in-place, when patient appointments could no longer just be postponed, mental health clinics got creative about their interpretations of the “essential” nature of their services.

This situation was exacerbated by the internally inconsistent nature of the policies themselves.  While being “essential” meant that services were expected to be operational as usual, individual clinics could decide whether they were, indeed, providing essential services and whether their services could be consolidated with others so that they could close their own doors.  Many clinics and residential programs simply shut down in the effort to transition services into an urgent care model, where patients could be stabilized in the moment but not supported for the long term.

The consequences of these policy changes on the patients’ well-being were profound, and it appeared that the needs of this vulnerable population were being neglected.  Policies asserted that patients older than 60 years old could not be hospitalized on a psychiatric unit, regardless of their negative COVID-19 status.  Electroconvulsive therapy (ECT) treatments were postponed indefinitely or cancelled outright because ECT is erroneously deemed an elective procedure.  (Any psychiatrist who has tried to obtain ECT for their patient knows how un-elective this treatment is.)

Then there is the shelter system, the congregate living situation that was allowed to persist rather than transferring occupants to the multitudes of empty hotel rooms in the area–until one shelter had the majority of its occupants and staff test positive for the coronavirus.  When the shelters were finally shut down and patients who were usually referred to these community resources were instead being allowed to transition to hotel rooms, social workers were asked to screen potential hotel room occupant for any symptoms of anxiety or depression; these symptoms prevented patients from accessing these newly opened living quarters.

The consequences of such discrimination were obvious very quickly.  The destabilization caused by lost programming spaces meant that patients had to fend for themselves.  They did not fare so well.  For children and youth with developmental disabilities, delivering behavioral treatment over video was not effective enough to compensate for the loss of the structure provided by the schools and after-care programs that had to close; many of these patients suffered with worsening agitation and aggression toward themselves and their caregivers. There were days during my shifts on the adult C/L service when psychiatric patients made up roughly half of the patients in our hospital’s emergency room (ER), presenting with  syndromes of emotional decompensation, such as suicidal ideation, substance-induced psychosis, and mania.  Some of those adult patients appeared to be among the increasing number of individuals who were wandering the streets and setting up tents on the sidewalks near the hospitals.  Unfortunately, some patients were simply “lost to follow-up” after leaving the ER.

And sometimes, in an ironic juxtapose of “parallel process,” we psychiatrists were ourselves overlooked. Early in the pandemic, when ER personnel were first starting to use personal protective equipment (PPE), my psychiatry C/L colleagues and I arrived to the ER to evaluate a patient and found that PPE had not been allocated for consultant use.  Similarly, we would not necessarily be informed if the patient we were being asked to evaluate was considered by the rest of the staff to be a COVID PUI (“person under investigation”) so we would not know what type of PPE to use during the evaluation.  Additionally, there was the suggestion by administrative leadership that all “behavioral health clinicians” can do their work from home—except that non-medical behavioral health clinicians do not do physical exams nor monitor for changes vital signs that come with worsening agitation or response to indicated medications like psychiatrists do.

We recognize that sheltering in place is stressful.  This stress is beyond that experienced as a result of the losses that also occur—the loss of income, the loss of educational progress, the loss of loved ones to the disease.  This trauma cuts across all segments of society.  While we have responded to the potential surge in the incidence of COVID-19 cases and we have been “flattening the curve” of coronavirus infections, we need to anticipate the next surge of victims, those that suffer from the emotional sequelae of the pandemic. There are projections being made about the mental health needs of the COVID-19 survivors¹, not only those who overcame the illness, but also those who lived through our society’s response to the pandemic.  I can already attest to that need.  I can also attest to the needs that have always existed for psychiatric patients and that have only gotten worse.  Now, more than ever, psychiatry is an essential medical service.

References

1. Dean W. Suicides of two health care workers hint at the Covid-19 mental health crisis to come. STAT. April 30, 2020. https://www.statnews.com.   Accessed May 1, 2020.