Staff in psychiatric hospitals are having to make some of the most difficult clinical and ethical decisions they have faced in their careers, writes Aileen O’Brien
Before covid-19 the phrase “parity of esteem” was ubiquitous. Policy makers and politicians emphasised the importance of high quality mental healthcare, insisting that it was viewed as being on an equal footing with physical health. Most mental health professionals viewed this with some cynicism, especially those working at the sharper end of mental healthcare in inpatient secure settings.
Is it reasonable to expect parity when it comes to covid-19? Arguably, it would not be reasonable in an unprecedented public health crisis to expect the same initial focus on, for example, the provision of personal protective equipment (PPE) and testing, as that directed towards the acute emergency services and intensive care. However, when the pandemic initially hit us, mental health inpatient units struggled with the lack of central guidance on managing patients who’d been diagnosed with or were suspected of having covid-19, especially those working in secure settings.
Patients with serious mental disorders are at high risk of physical health problems. While they are acutely unwell, these patients may not have the capacity to understand the need to self-isolate, may be unable or unwilling to agree to covid testing, and if agitated will be unlikely to be able to practise social distancing. An already vulnerable group, they are struggling with bans on visitors and with the prospect of being cared for by staff wearing PPE.
Mental health trusts have suddenly had to address the new challenges that have surfaced with managing a highly infectious disease in an inpatient setting. We’ve been struggling with protocols and the availability of testing for inpatients, managing the direct contacts of patients with suspected or confirmed covid-19, and (like other healthcare settings) with sourcing appropriate PPE and working out a dress code for staff. Recent guidance on PPE in inpatient settings was welcome, but different trusts have interpreted these differently, leading to confusion. The Royal College of Psychiatrists has helpfully issued guidelines for inpatient and high secure settings, but much of it relies on generic guidelines that were initially designed for physical acute services. In mental health services, it feels like we are playing catch up.
Mental health practitioners have a duty to care for patients in the least restrictive manner possible, and there are clear statutory frameworks and codes of practice in order to ensure this is the case. The pandemic has seen proposed emergency changes to the Mental Health Act 1983 (England and Wales) that are not yet in place but if enforced they would lead to significant changes in detention practices. The number of doctors required to recommend detention would be reduced, for example, and the duration of some holding powers would be extended. For instance Section 5(2), which allows a doctor to detain a patient in hospital, could increase from 72 to 120 hours.
Much that was face to face is now remote, including tribunals. There is intense debate about the apparent lack of appropriate legal frameworks for the situation we’re now in, and the challenges of practically managing inpatients who are refusing or unable to understand the need to isolate if confirmed or suspected of having covid-19. In the case of a voluntary or informal patient, can the Mental Health Act be used? The Mental Capacity Act is not appropriate as it applies to decisions in the best interests of the patient, not for the protection of others. The Coronavirus Act 2020 gives public health officers the power to impose isolation on someone suspected of being infected, but this seems unlikely to extend to inpatient units.
The physical environment and staffing constraints of inpatient settings mean that the isolation of individuals or cohorting of groups of patients is practically challenging, even if it is judged to be proportionate. Guidelines about these issues are awaited and are needed urgently, especially now we are being asked to swab and isolate all new admissions to inpatient settings.
On an individual patient basis, we are faced with novel questions around diagnosing suspected covid-19 in our patients, the threshold for transferring them to medical wards, and the management of comorbid acute disturbance—for example, should we use antipsychotic or anxiolytic medication in the case of suspected covid-19 when there is a risk of respiratory depression. The National Association of Psychiatric Intensive Care and Low Secure Units (NAPICU) has swiftly produced provisional guidelines for staff. The hope is that this guidance can be an iterative process, with feedback from wards, and that this can help staff in making some of the most difficult clinical and ethical decisions they have faced in their careers.
If parity of esteem is ever going to be meaningful, and not just a soundbite relating to the more media friendly “good to talk” message, the challenges of safely and securely managing covid-19 in the most seriously unwell patients with mental disorder need to be given a higher priority. Individual trusts should not be expected to produce local policies based on guidelines seemingly written with a different patient group in mind, and when the legal, ethical, and even scientific principles behind them are ambiguous and open to interpretation.
Aileen O’Brien is a honorary psychiatric intensive care unit consultant at South West London and St George’s Mental Health NHS Trust. She is also dean for students and a reader in psychiatry and education at St George’s University of London. Twitter @aileen191
Competing interests: I am the director of educational programmes for NAPICU (non-financial).