A perfect storm: Patients, psychiatrists and the pandemic

By Prof Judy Laing, Professor of Mental Health Law, Rights and Policy (University of Bristol Law School)

Mental Health Awareness week is an important time to reflect on how the Covid-19 pandemic is generating a global crisis in mental health. Earlier this month, the United Nations published a policy brief warning that:  ‘Although the Covid crisis is, in the first instance, a physical health crisis, is has the seeds of a major mental health crisis as well.

Stringent lockdown measures have increased social isolation, and for many, this is creating huge psychological distress. That is further impacted by the fear of infection, death and losing relatives and close friends to the virus. The state of the economy is creating additional anxiety and stress for those who have lost or are at risk of losing their income and livelihoods. Professor David Gunnell (a colleague at the University of Bristol who researches on suicide and self-harm) has highlighted with others in The Lancet  that the pandemic will ‘leave many people vulnerable to mental health problems and suicidal behaviour, and increased risks of suicide’. Taking action now to prevent the risk of suicide is therefore imperative. And the United Nations policy brief also urges national governments to take positive action to ensure widespread availability of mental health support, as well as building mental health services for the future to promote recovery from the pandemic.

There is no doubt that the pandemic is having a massive impact on the physical and mental health of the world’s population.  In the UK, there is already another deeper crisis emerging within the current mental health system. An anonymous piece written by a psychiatrist was recently published in The Guardian which highlighted the immense challenges faced by those working on the NHS front line in mental health services during the pandemic. The writer describes how the pandemic and resulting lockdown is affecting psychiatric wards. Patient mental health, care and recovery is severely compromised by the current restrictions, and staff morale is low, with high levels of stress and anxiety. There are concerns that the spread of Covid-19 in mental health settings, particularly locked wards, could eventually be as high as the levels in some care homes in England and Wales. The Royal College of Psychiatrists is particularly worried about these increased health risks for patients and staff during the current  pandemic.

For staff, the lack of Personal Protective Equipment (PPE) and testing in mental health settings has significantly increased the risks of infection. A national survey by the Royal College of Psychiatrists at the end of April found that only half of psychiatrists confirmed that they could access Covid tests for themselves and their patients, and only one in four psychiatrists could access appropriate PPE, putting themselves and their patients at significant risk.

Patient health is also severely compromised by the lack of PPE, and the lockdown measures mean that many psychiatric in-patients face increased restrictions on movement, with hospital leave severely curtailed or cancelled. Patients with Covid-19 symptoms could be placed in isolation, which brings with it added mental health risks. It could increase the risk of self-harm for some patients and add to their psychological distress. It also has repercussions for staff. In the words of the anonymous psychiatrist: ‘Lockdown has ended patients’ leave and visits. This affects their stability, and to many feels punitive……As emotions ignite, staff are blamed, putting us at higher risk of assault’.  Staff may be at increased risk of violence as the pandemic leads to  staff shortages on wards, due to self-isolation and illness, and environmental constraints may deepen anxiety for patients. There are significant logistical difficulties to care for and safely manage patients in psychiatric wards and buildings that are not designed for physical distancing.

Whilst NHS guidance reminds mental health care providers and staff to guard against the use of overly restrictive practices during the pandemic, there are undoubtedly difficulties with the daily care and management of individuals in locked wards and specialist psychiatric inpatient facilities, with the added complications that Covid-19 brings for both patients and staff.

The Coronavirus Act 2020 anticipated some potential impacts of the pandemic on mental health settings, in particular the pressure on services and staff. It included provisions to make temporary changes to several provisions of the Mental Health Act 2007, such as reducing the number of doctors needed for compulsory admission to hospital; dispensing with a second medical opinion to approve compulsory treatment; and lengthening compulsory detention periods.  Many of these provisions provide important safeguards in the Mental Health Act for patients who are detained in hospital and subject to compulsory treatment for mental disorder.  Although some of these changes have not been immediately implemented, they may be used if staff shortages worsen.

Evidence suggests that people with mental health and learning disabilities are at increased risk of the virus due to significant comorbidities. And recent data from the Care Quality Commission (CQC), the independent health and social care regulator in England, has highlighted that a growing number of patients detained under the Mental Health Act have died from suspected or confirmed coronavirus. As the CQC has pointed out, these patients are some of the most vulnerable people in society and this is hugely concerning. This increase in the number of deaths of detained patients reported to the CQC raises questions about whether additional action needs to be taken to safeguard detained patients, to ensure safe staffing levels and provide additional guidance and protective equipment for staff.

The Care Quality Commission has reacted by changing its complaints process to prioritise complaints from, or about patients who are detained under the Mental Health Act on in-patient wards.  The regulator had also announced changes to its regulatory approach at the end of April in response to the pandemic, which means focusing inspections on those who are most at risk of human rights violations, and making greater use of other sources to gather data and information. Though it is not clear how these changes impact on the mental health sector, and patients detained under the Mental Health Act in particular.

The CQC is a member of the UK National Preventive Mechanism (NPM). The NPM was established in March 2009 after the UK ratified the United Nations Optional Protocol to the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (OPCAT) in December 2003. It is made up of 21 statutory bodies that independently monitor places of detention. The Chair of the UK NPM, John Wadham has written to the Ministry of Justice to highlight the particular mental and physical health needs of persons who are deprived of their liberty during the pandemic.  In the context of mental health detention, the letter cautions that:

The potential impact of COVID-19 on staffing levels ….. could limit both general support to patients and specialist roles such as psychological input. This could lead to an increase in mental distress of patients and then an increase in the use of restraint, segregation and seclusion which may compromise people’s human rights. Reduced staffing levels could also impact people who are already in segregation/seclusion.’

There are clear risks in times of national emergency for mentally vulnerable detained patients, especially if key statutory safeguards are removed, albeit temporarily. The UK NPM is aware of the challenges and is working with its members to modify and develop approaches to monitoring to ensure they are able to fulfil their statutory duties and protect the rights of those in detention. As the World Health Organisation’s recent guidance on the outbreak of Covid-19 in places of detention states: ‘people in prisons and other places of detention are not only likely to be more vulnerable to infection with COVID-19, they are also especially vulnerable to human rights violations’.

The pandemic is clearly giving rise to significant practical, ethical, legal and human rights challenges in the context of mental health. The rising tide of psychological distress among mental health staff and patients; the shortage of PPE for mental health staff; as well as the increase in reported deaths of detained patients indicates that the storm is already brewing, and reinforces the pressing need for heightened vigilance to safeguard the health, well-being and human rights of mental health patients and front-line staff.

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