key: cord-1038572-71pyk0j2
authors: Mishra, Biswa Ranjan; Biswas, Tathagata; Ranjan, Rajeev
title: A sustainable Mental Health Care Delivery Model for Severe Mental Illness during COVID-19
date: 2021-02-09
journal: Asian J Psychiatr
DOI: 10.1016/j.ajp.2021.102594
sha: 983aea21dc47e6aaf6d97987c214526c92dbfc9e
doc_id: 1038572
cord_uid: 71pyk0j2

nan

The ongoing pandemic greatly compromised the health care delivery to the general population.

Among the most affected are the patients with severe mental illness (SMI), who need constant care due to their impaired insight (Muruganandam et al., 2020) . Their limited understanding of COVID-19 symptoms, negative health behaviours and residential instability further puts them at higher risks of exposure (Muruganandam et al., 2020; Shinn and Viron, 2020) . Moreover, infection in this marginalized population may have a difficult course owing to their higher rates of smoking (Druss, 2020) and greater prevalence of respiratory and medical comorbidities.

Administrative impositions like lockdown, isolation and quarantine have hampered their access to mental health care services and regular supply of medicines resulting in symptom exacerbations, relapses, and suicides posing an additional burden on the caregivers (Kahl and Correll, 2020) .

Telemedicine is an innovative approach at minimizing hospital visits but has limitations regarding building rapport with patients, evaluating new patients and managing emergencies (Kahl and Correll, 2020; Nath et al., 2020) .

Amidst this mayhem, there was a lack of guidelines/directives about meeting the urgent needs of the people with SMI. Thus, psychiatric facilities across the globe relied on innovations and newer plans to mitigate these challenges. A Continuum of Service Delivery Mode (Kopelovich et al., 2020) which involves leveraging every available support (clinical staff, ancillary service, administrative staff) may be difficult to sustain when a major part of the health facility is diverted towards frontline services. Help-lines run by 'peers', people with similar experiences who can help and acknowledge, called 'warm lines' (Kopelovich et al., 2020) may not be feasible for SMI patients due to lack of professional knowledge. A multi-axial design (Kopelovich et al., 2020; Maulik et al., 2020) involving close co-operation between different disciplinaries, modalities and strata of health services may seem ideal but is farfetched in resource-limited regions. In countries like India, the mental health gap is already alarming, and the pandemic needed shifting of a significant portion of the health sector to help the rising COVID-19 cases in the general population.

While the general advisories and strategies in the advent of pandemic (Kahl and Correll, 2020; Maulik et al., 2020) remain same, none provided any structured, time-tested model for the patients of SMI in COVID-19.

Our tertiary health care setting in India approached these challenges through a novel mental health care delivery model while abiding by the regulations imposed due to COVID-19 (Fig-1) .

Our model used Telepsychiatry facility to monitor the SMI patients for adequate compliance and identification of the early signs of relapse. Use of long-acting depot antipsychotics, and drugs with less anticholinergic or sedating side-effects were advocated for extended periods (Druss, 2020) .

The seemingly difficult to manage patients (those needing urgent neuroleptisation, acute in-patient care or psychosomatic treatment, and the SMI patients with symptoms of COVID-19) were advised out-patient visits, while strictly following the COVID-19 appropriate behaviours (Kahl J o u r n a l P r e -p r o o f and Correll, 2020). Furthermore, in the out-patient settings, consultations were provided from an adequate distance across large transparent shields which safeguarded our mental health professionals without jeopardizing the essence of face-to-face communications (Nath et al., 2020) .

Patients who needed in-patient care were first sent for COVID-19 testing, preferably by RTPCR or by Rapid Antigen Test in situations where time delay in clinical decision making was undesirable. Those who tested positive were initially kept at an intermediate arrangement where they were catered by health care professionals (HCPs) and the Psychiatry on-call residents in PPE.

They were kept there until they tested negative on a repeat sample with a primary focus on rapid tranquilization, the commencement of psychiatric medications alongside management of COVID-19, and ensuring a protected environment during the stay. Patients testing negative were admitted in the Psychiatry ward for conventional management and patient care. Electroconvulsive therapy (ECT) was encouraged (in indicated conditions) for faster response and an early discharge with a focus on continued home-based treatment via telepsychiatry.

The model successfully alleviated the health care needs of the SMI patients during the pandemic while minimizing their risk of exposure; and thus, provides a sustainable framework for mental health care delivery during the future waves of COVID-19. The world is still searching for a cure, and vaccines are in early stages of their trials with unclear long-term efficacy; thereby a sustainable health care delivery model like this one is the need of the hour. The robust model is suitable for the most vulnerable population in stressful situations especially in resource-deficient regions. Its step-wise structure may be replicated with needful changes to meet health care needs during other similar emergencies like epidemics, disasters, riots and warfare; where transportation and health care accessibility gets disrupted. 

Addressing the COVID-19 pandemic in populations with serious mental illness

Management of patients with severe mental illness during the coronavirus disease 2019 pandemic

Community mental health care delivery during the COVID-19 pandemic: practical strategies for improving care for people with serious mental illness

Roadmap to strengthen global mental health systems to tackle the impact of the COVID-19 pandemic

COVID-19 and Severe Mental Illness: Impact on patients and its relation with their awareness about COVID-19

Meeting the Unmet Mental Health Needs during COVID-19: Where Does Telemedicine Stands during These Times in India

Perspectives on the COVID-19 pandemic and individuals with serious mental illness