Rural psychiatric care in the time of COVID-19

In writing this, I feel a bit strange to contribute my thoughts on a pandemic I’ve had mostly a peripheral experience with dealing first hand. In my brief month on the medicine ward, I did interact with a patient who then was tested positive for SARS-CoV-2 (the official name for COVID-19), and subsequently, I was on a state-mandated quarantine. Asides from that experience, I have not truly seen first-hand the medical complications and the strenuous aspects related to medical care in a pandemic.

However, I deal with the insidious effects of COVID-19 that people are starting to talk more and more about: the mental health burden of a pandemic. As a resident psychiatrist, I spend my days working with patients who are highly vulnerable and experiencing severe mental illness, whether it is suicidal thoughts or new-onset psychosis. We are well equipped to handle these types of cases. However, the virus has caused a new sense of anxiety, panic, and dread amongst the patients. Almost every case that now comes into the unit seems to connect back to the virus, whether it is increased anxiety from social distancing to increased paranoia in psychotic patients.

Our unit alone has seen more cases of decompensated psychosis and mania than normal. Our depression cases are more severe than normal. More and more patients are getting ECT (electroconvulsive therapy) on the unit for severe depression, and in addition, we have fewer psychiatrists in-house. Telehealth has done wonders for continuing our hospital’s outpatient clinics, but there is only so much telehealth can do in an inpatient setting. Triaging patients in the hospital becomes trickier with technology, and often, with severely manic or psychotic patients, it is not an option to use technologic interfaces to help these patients.

Like many states, our laws regarding psychiatric care involve having involuntary facilities and voluntary facilities. Where I train at is a voluntary facility, and therefore, when patients are severely ill, or if they are deemed to be high risk with discharge, they are changed to involuntary and then transferred to a facility with a higher level of care. Since the pandemic, we have had more cases coming into our facility that have required this process.

I work in a rural setting, and as such, resources are scarce for mental health. We have some community mental health sites, and within those sites are care teams designed for long-term patients. We have one homeless shelter. There are a few food shelves in the area, and we have a domestic violence network. However, for a catchment area of nearly 2 million people, this doesn’t always suffice. There are towns more than thirty minutes away, where people often live without indoor plumbing or electricity. There are no grocery stores within 20 miles, and while we are lucky to have a mass transit system in operation for part of the week, it can only service so large of an area.

At baseline, our resources are severely limited. The COVID-19 pandemic has shed light on how fragile this system is because now, it is exceedingly more difficult to connect our patients to resources. Patients that are discharged from our unit face an alarming and new reality in the outside world where there is little human contact and fewer supports. While rural areas are less densely populated, and therefore somewhat protective for viral transmission, mental health severity is rising with the combination of decreased resources, increased isolation, and income loss that I see in our patients daily.

In addition, the very set-up of our inpatient psychiatric unit has also posed several unique challenges. Most psychiatric facilities do not permit intravenous lines, surgical drains, or additional equipment that could be used to hurt oneself with. Our units are designed to be safe: soft doors are placed on private bathrooms, patient rooms have doors without locks, and nurses perform frequent monitoring on patients to assess for safety. But when there is a highly contagious virus, these supports impede infection control if there is a suspected COVID-19 case. Just a few weeks ago, our unit had to test a patient and quarantine them in a unit that has no ability to create a negative-pressure room (a common ability in most hospital rooms to control the direction of air-flow in a room to minimize pathogen spread). Our unit also does not have a well-demarcated area to wear full, infection-protocol personal protective equipment. Thankfully, the patient did not have the virus.

However, it is a grim reality that could easily be a possibility, and has been a reality in other psychiatric hospitals throughout the country. Rolling Stone Magazine published an article talking about the dire effect of COVID-19 upon psychiatric patients, showing how urban psychiatric facilities already have seen rapid COVID-19 transmissions in facilities. Many of these facilities have addressed these outbreaks by trying to re-route these patients to medical facilities and adjusting their regular practices in the psychiatric ward to minimize infection. Even so, psychiatric facilities have even less personal protective equipment than most medical facilities normally, and the risk of infection without PPE is significant. Psychiatric wards often have to restrain patients who are a harm to themselves, and asking psychiatric workers to do this in units without the appropriate equipment is disastrous.

Psychiatric patients, on the whole, have higher comorbidities and increased rates of chronic diseases, such as hypertension, high cholesterol, and diabetes. I worry that COVID-19 will be another barrier for our patients, both to receive medical treatment and to receive psychiatric treatment.

Rural psychiatric hospitals are in many ways some of the most vulnerable places for COVID-19; while not necessarily for the infection itself, rural psychiatric hospitals are struggling to keep up with the demand for mental health services secondary to COVID-19.

Many of my patients have asked me when they think this will all end; I worry that it is going to become our new normal. My hope is that there will be enough supports and resources ready for those who need mental health support through this pandemic.

Thara Nagarajan is a psychiatry resident.

Image credit: Shutterstock.com

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