“They didn’t isolate the patients that had a cough.”
News of psychiatric wards being potential hotbeds for the COVID-19 pandemic is no surprise, thanks to close quarters and patients coming in and out without testing.
Places like Western State Hospital in Lakewood, Washington have had as many as 34 patients test positive for COVID-19 as early as mid-March. In New York, at least 30 deaths tied to the pandemic have been recorded in the state’s system of 23 psychiatric centers.
In many psychiatric hospitals and units across the country, staff and people admitted aren’t even able to get tests.
But there are equally important questions to ask about how psychiatric hospitals are working harder to ensure their patients’ mental well-being during a time period where everyone is more strained than usual.
It’s clear people need help.
Dr. Keita Franklin, former senior executive director of the Office of Mental Health and Suicide Prevention at the VA, and current chief clinical officer at PsychHub, says that the site has seen an increase of over 2,000 percent of new users since the pandemic started.
Most people have found the sites’ resources through Google searches like “resources on COVID-19 and mental health,” proving that people are searching for answers.
With focus on the physical aspects of the pandemic, are people getting the support they need? And what needs to change in psychiatric care during this critical moment where increases in mental health issues are being seen all around?
The ability for psychiatric wards to run “business as usual” depends mostly on location.
In a secure psychiatric unit in North Carolina, where people are mostly admitted involuntarily, many people with paranoia have been admitted recently worried they’re sick or have gotten others sick.
While in some places it’s been hard to help patients concerned about COVID-19, the pandemic has also opened up telemedicine as a more viable and now more accessible practice.
Dr. Scott Zeller, a psychiatrist with 29 years of experience treating patients facing psychiatric emergencies, is currently consulting psychiatric facilities across the country on how to provide the best care for people during this time.
There might be a lot of stigma attached to going to an inpatient facility, but it’s much safer for someone to check themselves into a psychiatric hospital than to try to weather their mental health crises alone, Zeller explains.
“It’s safe for anyone experiencing urgent symptoms, including behavioral health emergencies, to come to the ED or hospital. This is difficult at a time when patients are overwhelmed with conflicting, anxiety-provoking information from news outlets and social media. Critical care cannot wait, and hospitals are prepared to safely treat patients experiencing symptoms requiring acute care or fast evaluation,” he says.
“What our work is showing is that the vast majority of psychiatric emergencies can be resolved in less than 24 hours if you initiate treatment, and even more so if you can get patients out of the scary part of the ER into a place that’s a little more therapeutic,” Zeller adds.
Calming people in a psychiatric ward is tricky, though, says Wesley, a worker from the psych unit in North Carolina who spoke with Healthline.
While nurses and doctors have been doing their best to keep patients safe and to continue to provide them the psychiatric care they need, patients with mental illness can’t always understand an infectious disease like COVID-19.
“Not every patient that we have is necessarily psychotic, sometimes they have a brain injury, or they have inflammation of the brain. But trying to get people to understand what’s needed from them and understand what’s going on and how to keep themselves and others safe is really difficult, and you know we’re not testing,” Wesley says.
Part of the challenge has been learning to keep patients calm when paranoia is rampant in such a new way, and often feels at least partially warranted.
Still, in places like New York where people are scared about physical health risks tied to going to hospitals, many healthcare facilities have begun leveraging alternative approaches like telehealth, which helps patients access care where and when they need it.
In a recent survey from Merritt Hawkins, nearly 50 percent of physicians surveyed were currently using telehealth, up 18 percent from 2018.
With the increased demand for remote healthcare, as well as the recent expansion of telehealth guidelines through Medicare and Medicaid that permit more frontline teams to practice telehealth, more people are gaining access to the healthcare they need.
Dr. Chen, the chief medical officer at Houston Behavioral Healthcare Hospital, an inpatient psychiatric hospital, explains that PPE priority goes to medical hospitals and that it’s been difficult to obtain protective equipment for staff.
While the staff’s temperatures are taken before every shift, and risk factors are looked at before admitting patients to try to determine if they have the virus or not, there’s very little that psychiatric units can do right now with the focus on hospitals’ COVID-19 needs.
Some psychiatric hospitals and units do, however, have separate infectious disease units for patients dealing with mental health concerns as well as physical diseases, and infectious disease nurses to help.
Still, hospitals will have to work to develop COVID-specific isolated units now and in the future.
The problem is, according to Chen, that most freestanding psychiatric hospitals don’t have the resources and aren’t prepared enough to open up a special unit for people with COVID-19 without a shift in priorities and funding.
In New York, at Metropolitan Hospital, they screen for COVID-19 specific symptoms when bringing people into the psychiatric emergency unit, explains Dr. Shailinder Singh, attending in the psychiatric emergency department.
They ask about sick contacts, recent travel, if patients are aware if they’ve had any contact with a COVID-positive person, and then look at things like vital signs to see if patients are running temperatures or if their oxygen saturation is anything below where it should be.
That being said, a lot of patients are asymptomatic, so Singh and his colleagues provide the option for people to take nasal swab tests, which is a rare occurrence according to the psychiatric workers who spoke with Healthline.
Because testing availability in America is still sparse, most psych units and hospitals where people are receiving acute psychiatric care don’t have the ability to test.
In Houston, Chen says that patients are able to keep 6 feet apart and wear masks. In North Carolina, at the hospital where Wesley works, patients have their temperatures taken as frequently as possible.
But in many places, patients who have recently been in psych wards told Healthline the quality of care was subpar and COVID-19 precautions were not taken.
Lindsey Romain, who has bipolar disorder and was hospitalized in June in Austin, Texas, says there were almost zero COVID precautions taken during the week she was there.
“I barely received any sort of care beyond basic needs and medications. I only talked to a therapist one-on-one once, for about 10 minutes, and they really just went over my reason for being there and asked if I was suicidal. I did some group therapy, but it was pretty nonspecific and wasn’t even mandatory,” she says.
One of her main concerns, however, is that there was no discussion whatsoever of COVID-19 or the protests that had just started that week, and how that might have been affecting mental health situations, Romain told Healthline.
“They mostly just medicated us and then left us alone until meal times. It was pretty traumatizing,” she says.
“Also, no one wore masks — in fact, they took the mask I was wearing upon entry and put it into storage until I checked out, apparently because it had strings, which are prohibited in a psych ward,” Romain adds.
“All-in-all, though the rest and time away was helpful for me, I don’t feel like they did anything to prepare me for re-entering the world, especially during COVID. If anything, I felt less concerned about mask wearing and handwashing when I first got home because I didn’t have to think about it at all for a full week,” she said.
Yael, a person with bipolar disorder, C-PTSD, and generalized anxiety disorder, who was admitted to a psych unit in Seattle in April at the height of the pandemic, told Healthline that her stay, which was about 11 days, was difficult — though not just because of COVID concerns.
“Several of the nurses abused their power and yelled at me, further traumatizing me. It also took quite a long time for them to move me to a wheelchair accessible room, and I had to complain to admin to make it happen,” Yael told Healthline.
In terms of COVID precautions, the psych unit she was in closed down visiting and the cafeteria, but had no masks for patients, no cleaning of common areas that everyone touched, and at least 20 patients per unit.
Patients with symptoms were also not tested or isolated.
“If even one patient had COVID, it would have quickly hit the whole hospital. They did temperature checks and screening 5 or 6 times a day, but since they didn’t isolate the patients that had a cough, I don’t know what good it did,” Yael adds.
In New York City — at one point the U.S. epicenter of the pandemic — Singh says that the psychiatric emergency procedures had to shift overnight to more effectively treat patients.
“We’ve definitely seen an uptick in patients who have been presenting with symptoms like depression and anxiety and increased levels of stress,” says Singh.
Because of job losses, physical distancing, and worries about the health of friends and loved ones, patients are feeling more isolated than ever, suffering mental breakdowns from not knowing how to handle the weight of the pandemic.
For many, financial struggles have led to an onslaught of mental health issues that can’t be ignored, and a majority of patients who come to the psychiatric emergency room are facing acute anxiety about their futures.
In order to meet the needs of patients where some hospitals have had to decrease their psychiatric care, hospitals like Metropolitan have worked in order to take on more patients who need help, says Singh.
In Houston, Chen says that most people are scared to go to emergency rooms and healthcare facilities for fear of catching COVID-19.
Because of this fear of going to hospitals, admissions have decreased — which has actually made it possible to give more attention to those in inpatient wards.
There, many patients have been coming in through the emergency rooms after having breakdowns regarding COVID as well.
“From a patient experience, we certainly treat our normal variety of patients with various different illnesses, but mainly there have been so many patients who have come here specifically with complaints that they’re having difficulty adjusting to sort of this new norm,” says Chen.
Vituity, a physician-led and owned organization headed by Zeller, has led the COVID-19 surge planning in hospitals and healthcare facilities across the country, designing and implementing new healthcare solutions like telehealth, and more fully staffing urgent care centers, emergency departments, inpatient units, and intensive care units for behavioral health patients.
In his work, he’s traveled around the country consulting hospitals about building better psychiatric units that are truly rehabilitative, and that don’t make patients wait for care — which is what happens to many who go for emergency services and are treated as bodies and not people.
“Resolving [acute] symptoms in the standard ED can be a complicated task. The ED can be a frightening or agitating environment for patients in a mental health crisis, as they are often restrained to gurneys, or stuck in corners or cubicles guarded by a sitter, amid police and ambulance personnel, flashing lights, loud noises, and hectic activity, and the cries of nearby others in pain,” explains Zeller.
“Paranoid or anxious patients, who might benefit from extra space or the ability to move about, may instead be restricted to a small, confined area. It has long been recognized that the standard ED setting may actually exacerbate the symptoms of a psychiatric crisis,” he says.
But Zeller is working double time to make emPATH units — which are more calming, supportive settings with trained psychiatric personnel — a reality, and would also prioritize patients’ safety needs around COVID-19.
The real defining factors of an emPATH unit (emergency psychiatric assessment, treatment, and healing unit) is that it’s a big open space where patients come in and aren’t put in beds or locked in small rooms.
“It’s a much more relaxed atmosphere and there tends to be a lot less people having difficult times or getting aggressive or getting agitated. The use of treatments such as physical restraints or forcible medications is almost zero,” says Zeller.
As hospitals try to maximize the amount of available space, there’s been even more of a push in the last couple of months to find alternatives to emergency units for psychiatric patients, which are juggling concerns about the amount of beds available and prioritizing staffing needs as well, says Zeller.
“We could actually treat them and as we get better, make differences instead of just boarding them because of an evaluation,” he explains.
“If possible move them to this more therapeutic environment and then you get numbers as high as 75 or 80 percent of patients who won’t end up being hospitalized because they can be stabilized to the point that they can be discharged most typically to home,” he says.
Zeller’s work has largely been about making more options, and more human, empathetic options available to patients, which is exactly how psych units need to transform in this moment.
Experts and patients alike are still hopeful that this outbreak could ignite real change in psychiatric care.
COVID-19 could be an opportunity to destigmatize mental health services and shine a light on where it needs to improve, given that so many people are struggling right now.
“It can be a scary experience, but it can also be like a very hopeful one. And we should talk about that,” Chen tells Healthline. “I encourage people who go to psych wards to talk about their experiences so people know what that care can actually look like.”