Acute psychiatry is on the NHS frontline, yet it has not always been at the forefront of people’s minds in the fight against the coronavirus.
We admit new patients everyday with psychosis, self-harming behaviours, and suicidal thoughts so severe that they are no longer safe to stay at home. Although their primary problem is a mental health issue, they are as vulnerable to coronavirus as anyone else, and many more so, due to physical co-morbidities. Furthermore, they have limited physical space and are in close proximity to others who may harbour the virus, including staff going between wards and new patients from the community. There is a huge challenge in trying to explain infection control guidance to patients who are acutely unwell, and maintaining a distance of two metres from others can be impossible at times.
Just as in a general hospital, we have seen changes in the pathology coming through the front door. Coronavirus has instilled fear in us all and there are now patients being admitted with neurotic disorders where the main perceived threat to their wellbeing is coronavirus. Patients have become so immobilised with fear that their mind is no longer a safe place and they cannot function at all in their own homes. It is difficult to tell in many cases whether these patients would have become ill regardless, and which have had acute mental deterioration caused by the pandemic itself.
It is known that a person’s psychosis is influenced by their environment and we have seen cases where the content of a patient’s psychosis has come to focus on coronavirus. Paranoia is increased when patients see staff wearing masks and are told of new government guidelines further limiting their freedom. In the past, if a patient suggested that the government was controlling their life or that they feared everything was contaminated, we might have been seen this as pathological, but not now.
The care we can offer has been affected. The physical environment of the mental health ward has had to change. Staff are wearing scrubs, masks, gloves, aprons and visors. Patients are asked to sit apart when they eat. Peer interaction is reduced, while ward rounds and psychological therapies are offered via video link. New admissions are asked to self-isolate until we have a negative swab result. This is the moment at which patients are most unwell. For many, it will be one of the scariest moments in their life, having been admitted against their will under the mental health act and some even brought in by police. They are separated from family and friends and find themselves on a mental health ward, only to be greeted by someone in a visor.
Discharge has also become trickier. As patients improve, they are usually given increasing amounts of escorted and unescorted leave. This is good for them in re-establishing their independence and is a useful way of assessing when they might be ready for discharge. This is no longer permitted. When patients are home, they would usually have follow-up visits. Now we have to balance a lack of community support with the infection risk of the ward.
Staff too have been affected. Some feel that they are not on the “true” frontline, and felt fraudulent during the weekly clap. Others are terrified by the risks posed to them at work, particularly as it took longer for mental health trusts to receive appropriate PPE than many general hospitals. All of us have been on a steep learning curve, especially around infection control. Mental health wards just aren’t set up for handling an infectious outbreak—we don’t have sinks located around the ward, hand gel dispensers or even a bin by the door for PPE. We have been asked to consider administering IV fluids and nebulisers, to keep the pressure off general hospitals. Staff have had crash courses in how to calculate a NEWS score, cannulate a patient and set up an IV infusion. Furthermore, staff shortages and increasing physical health management have meant that we have all been pushed into new leadership roles, often having to decide how to implement new guidance on a daily basis.
One area in which mental health staff have benefited, is in the provision of extra psychotherapeutic support groups via zoom, where staff are able to talk about their experiences and worries. It has helped to create a feeling of camaraderie among trainees and provides a support structure. This could be of huge benefit to medical and surgical trainees, not just during this pandemic, but in their careers going forward. Doctors from all specialties are exposed to suffering and loss on a daily basis. If this pandemic has taught us nothing else, it’s that it’s good to talk.
Elizabeth Charlton, Birmingham and Solihull Mental Health NHS Foundation Trust, UK
Competing interests: none declared