Mental health services in Italy during the COVID-19 outbreak

As of March 24, 2020, 63 927 confirmed cases and 6077 deaths due to coronavirus disease 2019 (COVID-19) make Italy one of the most severely affected countries of what has been defined a global pandemic by WHO.¹ In Lombardy, the epicentre of the outbreak in Italy, large metropolitan hospitals in cities like Milan and Bergamo are struggling to contain an exponential growth of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) case presentations requiring hospitalisation.

Italian mental health services are grounded on a community-based model of care, which is organised according to districts serving a defined geographical area.² Multidisciplinary teams of psychiatrists, psychologists, nurses, social workers, occupational therapists, rehabilitation counsellors, and auxiliary staff are distributed across inpatient and outpatient services. These services are coordinated by the department of mental health, which provides a full range of psychiatric care, from acute emergency treatment to long-term rehabilitation.

Within the ASST Santi Paolo e Carlo department of mental health, our unit serves a population of approximately 350 000 citizens in south Milan. Two inpatient units with a maximum capacity of 29 beds are used for voluntary and compulsory admissions with an estimated length of stay of 12·9 days.³ These two locked psychiatric wards are in the context of a large university hospital, which includes 18–20 wards of medical and surgical specialties. Over the past 3 weeks, most wards have been converted to COVID-19 intensive and subintensive care units with a joint effort of pneumologists, infectious disease specialists, internists, anaesthesiologists, and a growing number of other specialists.

On March 8, 2020, the regional authority for welfare ordered a block on all but urgent outpatient services (eg, chemotherapy, radiotherapy, or dialysis), and to maintain full functionality of mental health and substance misuse services. This choice has several implications for mental health workers. First of all, inpatient and outpatient mental health services are recognised by authorities as fundamental services to the community during a global pandemic. Second, given the delay of shared guidelines, individual departments have been challenged to develop an emergency plan within hours.

In this context, we developed the following recommendations, agreed by the hospital management. First, we recommend closure of second-level and third-level outpatient units (eg, perinatal depression, eating disorders, psychiatry for older people, adult neuropsychiatry, adult autism); for these patients, staff have been doing phone calls and video conference-based visits only for emergencies or specific patient requests. Second, general psychiatry outpatient services should be restricted to urgent visits and patients who require daily administration of medicines or long-acting injectables; on a case-by-case individual revision, physicians are required to re-assess the need for patients to access the service daily and medication assignment on a biweekly or weekly basis is strongly encouraged; visits are limited to those identified as urgent by the patient or physician and frequent, brief telephone updates are encouraged. Third, mental health-care staff (including social workers, rehabilitation technicians, and nurses) are encouraged to actively revise patient charts to identify those with severe mental disorders who are considered to be at increased risk for severe outcomes of COVID-19 (including those with comorbid hypertension, diabetes, chronic obstructive pulmonary disease, and coronary heart disease).⁴ These patients should be called via telephone to verify full understanding of the government lockdown procedures and instructed on basic hygiene norms. For those who live with older parents, a clear revision of requirements should be proposed at a time of welfare service restrictions and decreased availability of basic needs such as food. Fourth, patients should be advised to only access the emergency room of the hospital after having discussed alternative possibilities with staff from the outpatient service to follow the lockdown procedure and limit chances of infection.

Within the wards, we make the following seven recommendations: (1) restrict the number of co-working mental health-care staff to preserve material and human resources if needed during the course of the epidemic in other medical wards; (2) provide continuous training of hospitalised patients who have acute symptoms on hygiene norms and social distancing in particular (such patients might have generally disorganised behaviour and frequent repetition of norms should be considered to minimise the risk of infection); (3) be continuously and actively vigilant for suspected COVID-19 symptoms to minimise the risk of outbreak within the ward; (4) continuously revise the mechanism of patient discharge to minimise the risk of contact with newly admitted patients, for all those who can be safely readmitted home; (5) suspend all group activities, including the use of common dining rooms, which should be restricted to those patients who require direct observation during meals (if unavoidable, the minimal recommended distances of 1–2 m should be preserved between patients); (6) develop and review isolation procedures within the ward, based on local architectural and functional conditions, in the likelihood of asymptomatic or paucisymptomatic patients who are positive for SARS-CoV-2 with acute severe mental health conditions that cannot be treated outside the psychiatric ward; and (7) on the basis of local availability, online videoconferencing should be implemented for all staff meeting activities (this should also be considered for patient visits and communication with relatives, whose access to the ward should be greatly restricted.

Finally, psychiatric emergency room activity should be carefully integrated in the revised activity of the hospital. Although the risk of contact with individuals with COVID-19 might increase slightly in this setting as the number of cases who access the emergency room surges, it seems safer to screen for COVID-19 symptoms adequately in the context of the general emergency room before access to the psychiatric ward.

In conclusion, several rapid modifications must be implemented in the context of a department of mental health during a pandemic to protect patients with severe mental disorders and staff. Optimisation of shared procedures is mandatory to also limit the potential lack of adherence of some patients with national lockdown indications. The feasibility and effectiveness of online mental health services has been suggested by colleagues who faced the COVID-19 outbreak in China.⁵ We fully agree that this approach could eventually improve the overall quality of emergency interventions and perhaps increase safety of health-care workers, given the risk of shortages of personal protective equipment.