Supporting people with severe mental health conditions during the COVID-19 pandemic: considerations for low- and middle-income countries using telehealth case management

The coronavirus disease 2019 (COVID-19) pandemic is a global challenge to humankind. Such disasters might disproportionally affect patients with severe mental health conditions from low- and middle-income countries, who might need modifications to their care.1 Here we present data on the feasibility of implementing intensive telehealth case management to fight the COVID-19 pandemic in a Community Psychosocial Center in Brazil.

Mitigating the risks of human physical contact is a difficult task in mental health community centers because minimizing physical contact implies reducing face-to-face patient interactions, a key component of mental health treatment. Although too many visits might unnecessarily increase the risk of COVID-19 exposure, too few visits might also increase the risk of destabilization, particularly for severe cases, resulting in crowded emergency services. To achieve that optimal balance, we tested the feasibility of implementing a telehealth intensive care management system.

The service currently delivers health services to 154 patients who attend the service on a regular basis, 61% male, with an average age of 38.8 (standard deviation = 13.6). Most patients have used the service for less than a year (66%), 22% between 2-5 years and 12% more than 5-years. The most frequent diagnoses include: psychosis (54%), intellectual disability (20%), bipolar (16%), and other mental health conditions (11%). Before launching the telehealth program, 48% attended the community center daily or at least 3 times a week, while the remaining 52% used the service biweekly/weekly/monthly. A total of 21% used depot formulations.

At the beginning of the telehealth program (March 23rd, 2020), patient care was divided among seven case managers. Phone contact was possible for 61% of patients, with 29% being advised face-to-face through regular service attendance. We were unable to contact around 7% of service users despite significant effort. Currently, all patients are telemonitored weekly or biweekly to investigate signs of psychiatric instability. We are also monitoring respiratory symptoms and fever, reinforcing the importance of hand washing and restricting physical contact.

Case managers classify patients as “stable” or “unstable” based on current changes in behavior. All stable cases are being asked to stay home. Unstable cases are being asked to visit the service for face-to-face consultations in addition to frequent systematic telemonitoring. Patients in the COVID-19 risk group (over 60 and with any chronic condition; 24%) who use depot medications are being visited at home for treatment. Increased food insecurity was detected, and all patients with basic food needs (50%) received donations, which were organized by the service. All group activities have been canceled. All actions and information about dynamic changes in patient status are coordinated with an online spreadsheet (https://figshare.com/s/826f200d872e35ea67f1). This spreadsheet is kept on a local server and information is kept private and secured by password.

Intensive case management via telehealth is a feasible strategy that can be used in mental health community centers in low- and middle-income countries and could mitigate the exacerbated risks of psychiatric instability from stress related to COVID-19 in this vulnerable population.

Disclosure

The authors report no conflicts of interest.