Opinion: COVID-19 mental health threats to vulnerable populations

This piece was written collaboratively by the Association of Chairs of Psychiatry of Canada (ACPC). The ACPC is a group of leaders from 17 psychiatry departments from medical schools across Canada, including Dr. Chandlee Dickey, Chair/Chief of the Department of Psychiatry at Schulich Medicine & Dentistry. The group is responsible for the training of psychiatrists, the majority of psychiatric research taking place in Canada, and for supporting clinical service networks across the country.

To-date, COVID-19 pandemic responses have focused on reducing the risk of spread of infection, treating severely ill, and sustaining healthcare system capacity.

While concerns about the general population's mental distress are being addressed through various online support strategies, these initiatives do not address COVID-19-related threats to mental health in people with serious mental illnesses or addictions, vulnerable populations in violent living situations, and frontline healthcare providers.

We call on government, business, and civil leaders to recognize the needs of these populations now and work with leaders in psychiatry and mental health to rapidly develop solutions as failure to act now could seriously undermine Canada’s efforts to control the disease and its negative impacts on post-pandemic recovery.

Comprising three to five per cent of the Canadian population, people with serious mental illnesses are at risk of contracting COVID-19 because their mental illness may compromise their ability to stay safe. Homelessness or group living arrangements further increase risk of infection and spread.

Many have co-existing medical disorders that put them at risk for COVID-19 complications. And people with serious mental illnesses face a unique additional risk factor: psychiatric inpatient hospitalization. Rapid spread of infection on psychiatric units is possible due to communal bathrooms, avoidance of alcohol-based hand sanitizers, and difficulties in separating those who are infected from those who aren’t.

Patients with serious mental issues are therefore potentially at high risk to become infected, transmit the infection to each other and staff, and return to the community as asymptomatic carriers.

People with addiction or substance use problems such as alcohol, drugs, or gambling, face multiple challenges during COVID-19 infection control. Support groups, a key part of recovery, have been shut down or now exist only virtually. Social distancing can lead to unstructured time and the loss of social supports, recreational activities, or jobs --all risk factors for addictions relapse. These problems can also escalate recreational behaviours to problem use. For those who are addicted, the closure of cannabis or alcohol stores can reduce access, leading to withdrawal. Virtual support and care are limited by lack of devices or access to the Internet.

Persons in violent living situations who are exposed to domestic violence, child abuse, or dependent adult abuse, will suffer during this pandemic. For children, living with violence is associated with abnormal brain and stress response system function, adult medical disorders, and mental health disorders across the lifespan. Social isolation increases the chance of victimization. Many programs exist to help families or victims, but operation during social distancing is difficult. Home-bound victims are less likely to be identified by neighbours, teachers, or co-workers, or to be able to escape to safe places. Services interruption for the developmentally or mentally disabled living with caregivers can increase stress, possibly resulting in new abuse. Without attention to this population's needs, many children, youth, and adults may be victimized during COVID-19.

Frontline healthcare providers and first responders provide care in situations of personal danger and may need to make decisions violating their moral beliefs. They are vulnerable to disruption of their own mental health now and in the future. Trauma treatment works best when applied quickly, which may not be possible under our already strained system.

Acting now to address the mental health needs of these groups is critical.
Three over-arching innovations, rapidly developed and implemented, would dramatically affect the outcomes for all.

First, every Canadian should have access to affordable broadband, a device, and virtual mental healthcare, no matter where they live, their socioeconomic status, or the severity of their mental illness. Accomplishing this vision requires pioneering partnerships between business, government, academic centres, and communities, but it can be done.

Second, creative housing solutions must be found now for better infection control in persons with SMI, the homeless, and people with severe addictions. Hotels with ensuite rooms could be a solution.

Third, we need rapid innovation in trauma treatment for COVID-19 experiences. COVID-19 research for diagnostic testing, treatments, and a vaccine is moving at lightning speed and the same is needed for pioneering treatments for the trauma that will remain after the infection is gone.