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.
Materials and explanations must be adapted for patient understanding.
Patients with disorganization or cognitive disturbances may have difficulties cooperating or problem-solving. Patients with negative symptoms may be inappropriately unconcerned and also inaccurately report symptoms that suggest COVID-19. Acute psychosis or mania can prevent patients from complying with public-health efforts. Some measures may be difficult to implement if the means are simply not there (eg, physical distancing in a crowded apartment). Previously open settings (eg, group homes) have had to develop new mechanisms under the primacy of infection control. Inpatient units—traditionally places where community, shared healing, and group therapy are prized—have had to decrease maximum occupancy, limit the number of patients attending groups, and discourage or outrightly prohibit social interaction (eg, dining together).
Relapse prevention.Patients who take maintenance medications need to be supported. A manic or psychotic relapse during a pandemic puts patients at risk of acquiring and spreading COVID-19. “Treatment as prevention” is a slogan from human immunodeficiency virus (HIV) care that captures the importance of antiretroviral treatment to prevent medical complications from HIV, and also to reduce infecting other people. By analogy, psychiatric treatment for patients with SMI can prevent psychiatric instability and thereby control viral transmission. Avoiding sending psychiatric patients to a potentially stressed acute-care system is important.
Psychosocial support.Clinics need to ensure that patients continue to engage in care beyond medication-taking to proactively prevent psychiatric exacerbations. Healthful, resilience-building behaviors should be encouraged while monitoring and counseling against maladaptive ones (eg, increased substance use). Supporting patients emotionally and helping them solve problems are critical, particularly for those who are subjected to quarantine or isolation. Obviously, in these latter situations, outreach will be necessary and may require creative delivery systems and dedicated clinicians for patients who lack access to the technology necessary for virtual visits. Havens and Ghaemi21 have suggested that a good therapeutic alliance can be viewed as a mood stabilizer. Helping patients grieve losses (loved ones, jobs, sense of safety) may be an important part of support.
Even before COVID-19, loneliness was a major factor for patients with schizophrenia.22 A psychiatric clinic is one aspect of a person with SMI’s social network; during the initial phase of the pandemic, many clinics and treatment programs closed. Patients for whom clinics structure and anchor their activities are at high risk of disconnecting from treatment, staying at home, and becoming lonely.
