Emergency psychiatry during COVID-19

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The reaction to the COVID-19 pandemic in the comprehensive psychiatric emergency program (CPEP) began insidiously, with an initial sense of unease. Patients are brought into CPEP when they pose a danger to themselves or others. Often they are brought by police, but occasionally they come on their own or with concerned family members. CPEP is a locked unit, separated via locked double doors that require a valid ID badge to pass. It is its own world, walled off from the rest of the hospital, and is a place where overwhelmed patients tell their stories and seek help.

In early March, cases were mounting, but schools remained in session, and the NBA had not canceled games. Some patients began reacting to the underlying current of now omnipresent fear. One manic patient was found in the stockroom of a grocery store, drinking directly from a bottle of wine after trying to purchase every loaf of bread. We found another in the CPEP bathroom, stuffing toilet paper into his baggy scrub pants. A patient leaned against the single Purell dispenser adhered to the wall, and staff found that he was trying to push the handle to dispense the Purell into an empty cup hidden beneath his shirt.

Yet many patients remained unaffected by the impending crisis. One mother brought her child in for school refusal. We spoke through face masks, which were recommended but not yet required. “Do you think your child is afraid of the virus, and that’s why he won’t go to school?” I asked.

She shrugged offhandedly. “No, not at all. We don’t care about that stuff. We’re not really … virus type of people.”

It was mid-March, and neither of us knew that we were all about to become virus types of people.

Schools closed. South by Southwest and the NBA were canceled. The hospital stopped allowing visitation. A chronically psychotic but very stable patient came into CPEP for the first time in his life and said he wanted to overdose.

“Why now?” I asked him.

“Because for the first time, I don’t have anywhere to go, and I don’t know what I’m living for,” he told me. He was accustomed to homelessness, not total isolation.

The next day a man with longstanding schizophrenia, stable for 25 years on a long-acting injectable antipsychotic medication, was brought in by police after being found standing in the middle of the street. He wouldn’t speak to me; he just kept repeating, “They’re watching. They’re listening. They’re waiting.”

He didn’t say who.

The next week took us into the last week of March. Patients began to come in after domestic disputes related to their cleanliness or lack thereof. Unemployed people began to flood the CPEP, brought in after making suicidal statements about the hopelessness of their financial situation. “There’s nothing you can do for me,” one man told me, with his head in his hands. “Whatever you do won’t help me feed my family.”

A woman with cancer was brought in after her oncologist called her to tell her that her chemo would be delayed. She had replied, “OK, I’ll just drop dead right now. No point fighting anymore.”

When she saw me, she said bitterly, “So they don’t mind taking me to the hospital. Just not the part of the hospital I need.”

A grocery store employee who had collapsed at the register told me that she had been called a racial slur after informing a customer that they were out of toilet paper.

The last few days of March led to an influx of chronically ill patients from desperately understaffed group homes. None of these patients understood the sudden change in their strict routines, and the confusion led to violent reactions.

April brought more domestic disputes, more overdose, and more grief, as many began to feel the effects of the virus close to home. There was little to tell these patients as there seemed to be no end in sight. I had no calming words that could alleviate the fears that were alive in all of us.

May has brought new hope. Better weather heralds brighter moods, and social distancing has been effective. We are proud of COVID-19 numbers that, through no small effort, have decreased to pre-surge levels. Patients now look anxiously towards a future they hope will include friendship and joy.

I am hopeful too. I hope that we are vigilant enough to maintain these changes, and if we are, then I hope the worst is behind us. I hope that as a sense of normalcy returns, the close memory of the horror behind follows to temper our expectations. I believe that mental health will be at the forefront of the next stage. To that end, our CPEP is ready as always to weather the storm, whatever it brings.

Ruchi Vikas is a psychiatry resident.

Image credit: Shutterstock.com

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