Oliver Freudenreich, MD, FACLP Co-Director, MGH Schizophrenia Clinical and Research Program Associate Professor of Psychiatry Massachusetts General Hospital Harvard Medical School Boston, Massachusetts
Nicholas Kontos, MD, FACLP Director, Fellowship in Consultation-Liaison Psychiatry Assistant Professor of Psychiatry Massachusetts General Hospital Harvard Medical School Boston, Massachusetts
John Querques, MD Vice Chairman for Hospital Services Department of Psychiatry Tufts Medical Center Associate Professor of Psychiatry Tufts University School of Medicine Boston, Massachusetts
Disclosures Dr. Freudenreich has received grant or research support from Alkermes, Avanir, Janssen, and Otsuka, and has served as a consultant to American Psychiatric Association, Alkermes, Janssen, Neurocrine, Novartis, and Roche. Dr. Kontos and Dr. Querques report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
Workforce protection.Compared to other disasters, infectious outbreaks disproportionally affect the medical community, and care delivery is at stake. While psychological and psychiatric needs may increase during a pandemic, services often contract, day programs and clinics close, teams are reduced to skeleton crews, and only emergency psychiatric care is available. Workforce protection is critical to avoid illness or simple absenteeism due to mistrust of protective measures.
Only a well-briefed, well-led, well-supported, and adequately resourced workforce is going to be effective in managing this public-health emergency. Burnout and moral injury are feared long-term consequences for health care workers that need to be proactively addressed.14 As opposed to other forms of disasters, managing your own fears about safety is important. Clinicians and their patients sit in the proverbial same boat.
Ethics.The anticipated need to ration life-saving care (eg, ventilators) has been at the forefront of ethical concerns.15 In psychiatry, the question of involuntary public-health interventions for uncooperative psychiatric patients sits uncomfortably between public-health ethics and human rights, and is an opportunity for collaboration with public-health and infectious-disease colleagues.
Redeployed clinicians and those working under substandard conditions may be concerned about civil liability due to a modified standard of care during a crisis. Some clinicians may ask if their duty to care must override their natural instinct to protect themselves. There is a lot of room for resentment in these circumstances. Redeployed or otherwise “conscripted” clinicians may resent administrators, especially those administering from the safety of their homes. Those “left behind” to work in potentially precarious circumstances may resent their absent colleagues. Moreover, these front-line clinicians may have been forced to make ethical decisions for which they were not prepared.16 Maintaining morale is far from trivial, not just during the pandemic, but afterward, when (and if) the entire workforce is reunited. All parties need to be mindful of how their actions and decisions impact and are perceived by others, both in the hospital and at home.
Managing patients with SMI during COVID-19
Patients with SMI are potentially hard hit by COVID-19 due to a “tragic” epidemiologic triad of agent-host-environment: SARS-CoV-2 is a highly infectious agent affecting patients with SMI who are vulnerable hosts in permissive environments (Figure).
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