The challenges of keeping psychiatric patients safe in rehabilitation centers during coronavirus outbreak

As the number of patients infected with the 2019 coronavirus disease (COVID-19) increases, the number of deaths has also been increasing. As of 2 June 2020, World Health Organization (WHO) estimated that a total of 6,194,533 cases had tested positive for COVID-19 globally, which 376,320 deaths had recorded, equivalent to a case-fatality rate of 6.07% (World Health Organization, 2020). In addition to physical disorders, coronavirus infection has also affected global mental health and caused psychological problems in all members of society around the world such as moderate-to-severe stress, anxiety, and depression (Torales et al., 2020). Current research findings show that the widespread outbreak of COVID-19 infection has produced significant psychological distress and symptoms of mental illness such as fear of death, anxiety, and depression in the healthcare providers and general public (Rajkumar, 2020). Along with the general public, current evidence shows that patients with psychiatric problems are at a higher risk of severe disease following infection with COVID-19 (Yao et al., 2020). In addition, as a more vulnerable member of the community, it seems that patients with mental illness, in particular, who are kept in the mental health rehabilitation centers (MHRCs) are highly susceptible to panic attacks due to the outbreak of COVID-19 infection (Rajkumar, 2020; Yao et al., 2020). Accordingly, there are several challenges to safely manage patients with psychiatric disorders in MHRCs during the COVID-19 outbreak.

The virus is very contagious via human-to-human transmission and most of the MHRCs are crowded by a spectrum of patients with mental illnesses. Therefore, practically, it is not possible to completely create social distancing measures in these centers or the patients refuse to fully cooperate with social distancing.

Studies have demonstrated that patients with psychological disorders have a weak and dysregulated immune system and immunological abnormalities such as altered cytokine profile. In this regard, solid evidence confirmed the relationship between COVID-19 infection and cytokine storm syndrome which is characterized by a fatal hypercytokinaemia with multiorgan failure (Mehta et al., 2020). In addition, most of the antipsychotic and antidepressant therapies possess immunomodulating effects such as weakening of natural killer cell and changes in lymphocyte proliferation (Gibney and Drexhage, 2013). These factors could significantly predispose mentally ill patients to get infected with COVID-19 and therefore, have raised concerns among the center's officials.

Lack of facilities to isolate patients suspected of having COVID-19 infection is another major problem. On the other hand, hospitalizing mentally ill patients in general hospitals has several challenges. For example, most of the general hospitals refuse to admit these patients because they do not have the facilities to care for them. In most parts of the world, the provision of optimum physical health care for mentally ill persons remains a challenge (Collins et al., 2012). Isolating such patients in a crowded environment with a lack of facilities is a major concern.

As most of the psychological disorders frequently coexist with Anorexia Nervosa, many patients with mental disorders suffer from nutritional problems such as poor nutrition or malnutrition (Mattar et al., 2011). Undoubtedly, immunodeficiency is a hallmark of malnutrition and infectious mortality is elevated in malnutrition (Bourke et al., 2016). How to manage the nutritional status of these patients to strengthen the immune system is a complex issue.

Lack of health awareness, poor personal hygiene, and help-seeking behavior are other challenging issues for the safe management of patients with chronic mental illness (Hsu et al., 2017). Practicing basic hygiene measures such as hand washing is a key component to prevent COVID-9 infection. However, most of the patients with moderate to severe mental disorders in MHRCs are generally unconcerned with personal hygiene and are more likely to have poor obedience to follow health instructions and recommendations.

Due to COVID-19 Outbreak, the nationwide lockdown is enforced in most offices, organizations, universities, and so on. However, there is impossible to reduce daily commutes to and from MHRCs due to the in- or out-patients visits. One of the main reasons is that many of the patients with moderate to severe mental illness in MHRCs have one or more medical comorbidities such as metabolic diseases, cardiovascular diseases, or respiratory tract diseases (M et al., 2011). These patients frequently need to be visited by healthcare practitioners, which can increase the risk of involving with coronavirus and subsequently spread it to others.

One of the other challenging issues which could amplify the panic attacks in patients in MHRCs is minute-by-minute updates on COVID-19 spreading and lethality, either by health authorities or social networks. A large number of these patients are heavy social media users (as a hoppy) and follow various news related to coronavirus from different unreliable media, and thus, can somewhat exaggerate the risks of COVID-19 and spread fear and anxiety in the centers among other people. Practically, it is difficult to control and monitor the behavior of these people.

The abovementioned items were a small part of the challenges to keep and manage psychiatric patients safely in MHRCs during coronavirus outbreak. In addressing these challenges, healthcare policymakers are necessary to distribute resources to community-based MHRCs. Despite all resources employed to counteract the spreading of the coronavirus in the general public, additional strategies are needed to help MHRCs to face their challenges. In addition, healthcare researchers, in particular psychologists, psychiatric nurses, and community nurses are invited to design research-based intervention to handle these challenges.

As a summary, the main challenges of keeping psychiatric patients safe in rehabilitation centers during coronavirus outbreak are as follows: social distancing measures are not completely applicable; a weak and dysregulated immune system significantly predispose mentally ill patients to get infected with COVID-19; facilities to isolate infected patients from other are lack; general hospitals usually refuse to admit psychological patients with COVID-19 infection; the provision of physical health care for mentally ill persons in general hospital is suboptimal; psychological disorders frequently coexist with chronic disease, which increase the vulnerability of these patients to COVID-19 infection; lack of health awareness and poor personal hygiene of psychological patients could increase the outbreak of COVID-19; and last but not least, regular updates on COVID-19 spreading and lethality significantly increase the panic attacks in these patients. Resolving these challenges requires a multifaceted cooperation between healthcare systems and health policy makers.

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Declaration of competing interest

None declared.