But perhaps the most urgent aspect of this crisis is the one receiving comparatively little attention: the increased strain on systems of care for those with severe mental illnesses such as schizophrenia and bipolar disorder. The frightening reality is that these systems have long been broken and are likely to become even more dysfunctional as the nation grapples with COVID-19.
The Treatment Advocacy Center is dedicated to eliminating barriers to the timely and effective treatment of severe mental illness. We are concerned that while there is a growing understanding that the COVID-19 crisis dramatically impacts the mental health needs of Americans, Congress has yet to prioritize the outsized impact that COVID-19 is having on those with severe mental illness and their families.
For the 8.3 million Americans living with severe mental illness, the care system entered a state of crisis long before the novel coronavirus crossed our borders. On any given day in the United States, about half of these individuals are not receiving treatment, leaving them without support to manage disordered thinking, disconnection from reality, and/or extreme episodes of heightened mania or depression.
So long as these individuals remain untreated and unmonitored, they are ill-equipped to comply with public health directives -- heightening their risk of contracting and spreading the coronavirus. Our failure to serve this vulnerable population presents a significant complicating factor for effective pandemic response.
The recommendations below highlight opportunities for the federal government to improve access to treatment for those with the most severe mental illnesses.
- Provide states with emergency funding that specifically prioritizes the needs of individuals with severe mental illness.
- Ensure any new systems prioritize the care of the most vulnerable populations, including those with severe mental illness.
Remove financial barriers to inpatient care
Due to the widespread closures of state psychiatric hospitals over the past half-century, the United States has far fewer psychiatric beds per capita than most industrialized countries. With many of the remaining psychiatric inpatient hospital beds now being surrendered to accommodate COVID-19 patients, there is an ever-more urgent need for policies to ensure the availability of inpatient psychiatric beds. We are especially concerned that current federal funding restrictions will prevent coverage of inpatient psychiatric care for individuals enrolled in Medicaid and Medicare, further reducing treatment options.
Without access to inpatient care, people in psychiatric crisis will deteriorate further. This will strain safety-net service systems, such as emergency departments, which are already overburdened due to COVID-19.
We are already hearing anecdotes of individuals with mental illness being arrested due to symptomatic behaviors that violate COVID-19 restrictions. The federal government must take steps to ensure that state and local governments are not forced to rely on jails as last-resort facilities for those with severe mental illness.
In addition, efforts to mitigate the spread of the virus in inpatient facilities through social distancing, such as the cancellation of group activities, will impede treatment gains for patients and may lead to longer lengths of stay. Financial barriers to inpatient psychiatric treatment should not be allowed to interfere with decisions on when it is safe and appropriate to discharge a patient to the community.
It is also likely that the most vulnerable of our constituents will experience exacerbations of symptoms of severe mental illness due to a reduction in the availability of outpatient services. This may create a surge in demand for inpatient psychiatric care in the coming weeks and months.
Recommendations:
- End the Institutions for Mental Disease (IMD) exclusion, which prevents Medicaid reimbursement for psychiatric care in inpatient and residential facilities with more than 16 beds.
- Eliminate the 190-day lifetime limit for care in psychiatric facilities for Medicare beneficiarie.
Recognize the unique challenges of people living with severe mental illness
For some individuals with severe mental illness, The COVID-19 pandemic may exacerbate symptoms such as paranoia or persecutory delusions about government control. The symptoms of severe mental illness may also impact some individuals’ ability to act appropriately in the current climate – for example, auditory hallucinations that lead some to avoid communicating by telephone, or disorganized thoughts that prevent some from following public directives on personal hygiene or social distancing.
Individuals with severe mental illness may also lack insight into their illness and thus fail to recognize their own need for treatment, either for their mental illness or for COVID-19 infection. This lack of insight brings added complications for treatment access and adherence during the pandemic.
Recommendations:
- Ensure outreach and education on COVID-19 policies and procedures to limit the spread of the virus among people with severe mental illness. Outreach workers should be trained on how to assist people with severe mental illness who may be symptomatic.
- Develop local protocols for outreach workers to handle a person in psychiatric crisis who may have COVID-19.
- Provide guidance on interpreting state civil commitment laws to recognize the risk of contracting or spreading the coronavirus as a form of “danger to self or others” and a broader interpretation of “gravely disabled” that considers COVID-19.
Protect the community safety net
The workers who comprise the “community safety net” -- including social service providers, group home staff, food bank staff, and the community mental health provider workforce -- make it possible for people with severe mental illness to live in the community. This is even more true during the COVID-19 pandemic.
Community safety-net providers are essential for any relocations of individuals with severe mental illness, such as releases from incarceration or the moving of homeless individuals into hotels or other housing options. Many of these organizations are already stretched thin and may not be able to survive the economic fallout of the current pandemic, especially as populations in need surge and treatment protocols shift.
Recommendations:
- Financially strengthen the community safety net to ensure stability during and after the COVID-19 pandemic. Provide specific funding to support community safety net organizations, group homes and other vital mental health support organizations.
- Supply personal protective equipment to the social service and mental health workforce to allow them to perform their duties safely.
- Provide guidance on information sharing to those providing services to people with severe mental illness in community residences.
Safeguard patients in inpatient facilities
Families of those in group treatment settings are fearful for their loved ones’ safety and well-being. Psychiatric treatment facilities are at increased risk for a COVID-19 outbreak due to their group-quarter/institutional environments. In-person visits to loved ones are no longer allowed and team meetings with patients’ clinicians and family are limited due to staffing issues. Cell phones are often not allowed in psychiatric units due to privacy concerns.
Psychiatric care facilities are also not equipped or staffed to screen or treat medical conditions, let alone provide any intensive care services that may be required if a patient were to contract the novel coronavirus. Due to the security needs of individuals placed in these facilities and the potential for an outbreak, policies should be immediately developed to ensure care for any individual who manifests COVID-19 symptoms while in a psychiatric facility that is not equipped to diagnose, treat or contain such illness.
Recommendations:
- Ensure adequate communication between hospital administrators and patients’ families on the steps being taken to safeguard patients.
- Develop contingency plans to detect and contain a COVID-19 outbreak in any psychiatric institutional setting such as a state hospital, nursing home or long-term care facility, while ensuring that vital services provided in such settings are maintained.
- Establish protocols for qualified clinicians to treat mild cases of COVID-19 on premises and refer and transfer severe cases requiring more intensive medical services to area hospitals.
- Ensure that an adequate portion of federal relief funds are allocated specifically to serve individuals with severe mental illness in institutional settings.
Ensure medication access
For the majority of people with severe mental illness, psychiatric medication is an essential component of their treatment regimen. We strongly support general efforts to extend prescriptions and provide reimbursement for increased quantities of medications.
However, we are concerned that such efforts may not go far enough for vulnerable individuals who require assistance with medication administration. This includes those whose recovery is dependent on long-acting injectable (LAI) antipsychotics, who often require assistance or transport to a provider who administers the injection. These services have been greatly impacted by the COVID-19 pandemic.
Recommendations:
- Provide reimbursement for nurses’ travel time to directly administer LAIs to people with severe mental illness in or near their own homes.
- Strengthen federal guidance on LAI administration during the COVID-19 pandemic, following the American Psychiatric Association’s recommendations.
Prioritize alternatives to incarceration of people with severe mental illness
Mentally ill individuals facing criminal charges who are found unable to understand the charges against them must be remanded for competency restoration. But with state hospital beds in short supply, these individuals often spend weeks or months in jail waiting for a bed to open. In many instances, the charges are ultimately dismissed because competency cannot restored within statutory time limits.
The federal government should strongly support efforts to expand community-based competency restoration, by providing funding to ensure successful transitions. Releasing individuals from jail into the community without resources or services greatly increases the likelihood of recidivism, homelessness and psychiatric crisis, adding further strain to systems already overtaxed.
Recommendations:
- Encourage jurisdictions to consider allowing individuals charged with non-violent misdemeanors to undergo competency restoration in the community;
- Coordinate with communities to develop protocols for dismissal of charges, with “warm handoffs” to the community mental health system, for non-violent offenders who are unlikely to be restored to competency within statutory time limits. (If the safety of the individual and/or community are of concern, this should include initiation of civil-court-ordered “assisted outpatient treatment.”)
- Provide federal resources to assist jurisdictions in following the Council for State Governments’ recommendations on reentry.
Prioritize data collection as part of COVID-19 response
People with severe mental illness are among the most vulnerable members of our society. Their greater likelihood of being homeless or incarcerated, having a co-occurring substance use disorder, or suffering from other serious health issues puts them at an increased risk of contracting COVID-19 and suffering from severe symptoms or even death.
As efforts are made to address the needs of this population, states and the federal government should prioritize data collection to ensure that such efforts are having their intended impacts. This should include specific emphasis on collecting and monitoring infection and morbidity rates among the severely mentally ill, given that this population places unique pressures on safety net systems and emergency departments.
Recommendations:
- Ensure data is collected on COVID-19 infection and morbidity rates among those with severe mental illness.
- Prioritize data collection that helps in assessing the efficacy of the temporary increases in funding to programs serving individuals with severe mental illness.
- Monitor and prioritize data-informed responses to the needs of the severely mentally ill, with an explicit recognition of the outsized impact this population’s care may have on public systems.