ACEP COVID-19 Field Guide

Authors: Michael Ferebee, MD; and Aisha T. Terry, MD, MPH, FACEP

A significant number of Americans have a mental illness diagnosis. Approximately 47 million adults have mental illness, with the majority of those being women and the largest burden being young adults. Of these diagnoses, 40% received services in 2017. In addition, 11 million adults in the US have a mental illness that functionally limits them from successfully completing day-to-day tasks.¹ Given such vulnerabilities, this patient population can be expected to be adversely affected by the current SARS-CoV-2 pandemic.¹ This will inevitably have consequences for emergency medicine, so advanced preparation is vital.

For those with mental illness, keen attention must be paid to their support structures, access to medications, and potential mental health deterioration. In terms of support, those who previously attended in-person and group therapy sessions for addiction, depression, and other mental health disorders will have to work with providers to find alternative delivery of those sessions, perhaps via telepsych services.² Changing the therapy routine of these patients could pose a problem, given that stability and consistency are often key tenets of successful mental health management. Timely access to medications during the COVID-19 pandemic is also imperative, as reduced access could lead to poor compliance to treatment and worsening mental health status.³ Utilization of the emergency department would likely be affected by inadequate medication access for the mentally ill, as these patients may subsequently be at increased risk of homelessness, incarceration, hospitalization, and needing emergency care.⁴

There is a high likelihood that emergency department care will be particularly impacted by patients with mental illness. Patients who acutely experience a mental health crisis are sometimes incapable of functioning with optimal awareness and behavioral control. Their ability to protect themselves from contracting and spreading infection may be limited, potentially posing an increased risk to themselves and others while in the emergency department and during admission to an inpatient psychiatric ward. Thus, appropriate medical clearance of psychiatric emergency department patients, including COVID-19 screening and testing, as warranted, must be pursued to avoid an inpatient infectious disease outbreak. Risk versus benefit of admission should be carefully considered, and coordinated care for this patient population is particularly important during the COVID-19 pandemic. 

Being on the front lines of this pandemic, staff in the emergency department should be able to direct the psychiatric patient population to the appropriate mental health resources. Many organizations have compiled mental health resources that can be accessed freely by anyone. For example, the National Institute of Mental Health has published instructions for accessing federal, state, university-associated, and other resources for these patients.⁵ Participating in organizing good follow-up for patients seen in the emergency department improves adherence to follow-up plans.⁶ This tenet should be applied to patients with psychiatric illnesses during this time. Having a working knowledge of how to direct patients for follow-up, and at best organizing appointments by discharge, will be beneficial for these patients. 

It is important to realize the prevalence of patients with psychiatric illnesses.¹ Missed diagnoses can carry significant morbidity or mortality, and this is not the time to focus practice on one disease entity. Some data have even shown that there has been decreased reporting of psychiatric symptoms in the emergency department and outpatient settings.⁷ Emergency department physicians must understand that patients with psychiatric diagnoses are being affected by forced self-quarantine, difficulties in obtaining medicines, the inability to access group or individual therapies, the breaking of routines, decreased availability of caretakers, and fear of contracting new illnesses. All of these stressors must be acknowledged by those on the front lines. With awareness, emergency physicians can help patients access appropriate resources while in the emergency department and also help outpatient, inpatient, and triage providers better serve psychiatric patients.

References

1. Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2017 National Survey on Drug Use and Health (HHS Publication No. SMA 18-5068, NSDUH Series H-53). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration; 2018.
2. Living with mental illness during COVID-19 outbreak–preparing for your wellness. Mental Health America website.
3. Soumerai SB, Zhang F, Ross-Degnan D, et al. Use of atypical antipsychotic drugs for schizophrenia in Maine Medicaid following a policy change. Health Aff (Millwood). 2008;27(3):w185-w195. doi:10.1377/hlthaff.27.3.w185
4. West JC. Psychopharmacologic treatment access and continuity: findings from ten states. American Psychiatric Association.
5. Help for mental illnesses. National Institute of Mental Health website.
6. Atzema CL, Maclagan LC. The transition of care between emergency department and primary care: a scoping study. Acad Emerg Med. 2017;24(2):201-215. doi:10.1111/acem.13125
7. Castro VM, Perlis RH. Impact of COVID-19 on psychiatric assessment in emergency and outpatient settings measured using electronic health records [preprint from medRxiv and bioRxiv]. medRxiv website. Posted 2020 Apr 1.