Special Report: Patients With SMI in the Age of COVID-19—What Psychiatrists Need to Know

The world’s response to COVID-19 needs to be understood in the context of patients’ symptoms as the symptoms can significantly alter what has been the general population’s response.

Paranoia. Remote forms of communication can increase patients’ paranoia as they are required to communicate through electronic tools—seeing their psychiatrist on a screen, for example. The fear experienced by staff is felt by patients whose paranoid thinking can be magnified. Staff: “Those in power are misleading us, particularly in light of the rapidly evolving (or perceived flip-flopping) responses and parameters to dealing with the pandemic.” Patients: “You’re pumping the virus through the vents in my room because you want to kill us”; “The staff are all wearing personal protective equipment [PPE] and we patients will die so you can live.”

Delusions. Besides beliefs about an evil government or an evil world, some patients have incorporated COVID-19 into their long-held beliefs such as the illuminati being in control of the world pandemic or the world’s population deserving to be punished. Another example is a patient who believes she is a physician but is giving misinformed medical advice on COVID-19 to other patients on the unit.

Hallucinations. People with SMI may attribute information they receive to their “voices” or hear the viruses making noises. Most important is the need for the psychiatrist to be sensitive to the fact that auditory hallucinations can interfere with one’s ability to communicate by telephone. The patient mixes up all the voices, including the psychiatrist’s. The loss of visual cues may seriously compromise communication between doctor and patient that has previously been effective.

Cognitive deficits. Individuals with cognitive deficits may not understand what this is all about, leading to their inability to appreciate the seriousness of the situation. They may not remember what they’ve been taught about the virus and may require reminders multiple times a day to get them to adopt new habits such as washing their hands more often and practicing social distancing. Individuals with cognitive deficits can be incontinent, leading caretakers to have physical contact with the individual multiple times a day. And patients with cognitive deficits can be agitated, aggressive, and assaultive, again requiring caretakers to have physical contact with the individual multiple times a day. How do staff put someone in a hold or in restraints and maintain social distance? All staff need to be trained how to avoid being spit on by patients during these procedures.

Disorganization. Like those with cognitive deficits, disorganized patients may struggle with following procedures about hand hygiene and social distancing. They may also be confused about their stay in the hospital or why they can’t have visitors. Real-time examples include a patient who assents to extend her stay in the hospital, then follows up with “I prefer to be discharged to go visit my family and check on them with this virus thing.” Another patient said he had COVID-19, but despite having an unrealistic and incoherent story, this triggered a major staff response due to the potential backlash of ignoring such statements in light of the seriousness of the disease.

Anxiety. Patients with previous trauma symptoms or posttraumatic stress disorder (PTSD), especially complex PTSD, can be triggered by COVID-19 fears: “The hospital is no longer a place of safety”; “My therapist can’t even meet with me in person”; “I was told, ‘We don’t have time for your cutting.’ ” Symptoms of COVID-19, especially shortness of breath, may compound anxiety and panic attacks that patients experience. This can lead to difficulties in breathing, confusing two origins for poor oxygenation. Anxiety can lead to ignoring early symptoms of the virus or to confabulating symptoms, with or without secondary gain.

During this pandemic, it is reasonable to expect that new cases of SMI will arise and need to be addressed by the current psychiatric workforce. But there is reason to believe there will be additional cases that mimic or may in fact become SMI.

In 1919, Karl Menninger reported that as a result of the Spanish flu epidemic, infected people he saw at the Boston Psychopathic Hospital had psychotic symptoms that appeared to result from their infection (1). One-third of these patients were diagnosed as having schizophrenia (dementia praecox). Of the 50 of 175 cases that could be traced one to five years later, two-thirds had apparently recovered (2). Contemporary extensions of this work have found that “a recent onset of psychotic symptoms was significantly associated with coronavirus exposure as determined by bivariate analysis of quantitative antibody levels and qualitatively determined seroprevalance” (3). This means that coronavirus exposure may be a comorbid risk factor in individuals diagnosed with SMI (3).

What this will mean in the context of COVID-19 is yet to be seen. Emergency departments (EDs), psychiatric units, and state hospitals might well see psychotic presentations in people with COVID-19 needing treatment, recognizing that these symptoms in all likelihood will not abate when the symptoms of the infection have dissipated. These individuals will need much longer-term follow-up for their psychotic symptoms.

It comes as no surprise that anxiety is at high levels during the pandemic in the United States. One would expect that individuals will present with posttraumatic stress symptoms (PTSS). That is the finding coming from China, where women have experienced higher rates of re-experiencing trauma, negative alterations in cognition or mood, and hyperarousal (4). Many people will need acute treatment for these symptoms, and some will progress to PTSD and require long-term treatment. There is no way to know how many individuals who were coping adequately with PTSS prior to the pandemic will subsequently meet criteria for PTSD.

In health care workers exposed to COVID-19 in China, depression showed a rate of reported symptoms in a sample of 1,257, higher than any symptom other than distress, exceeding anxiety and insomnia (5). As with PTSS, some who develop depressive symptoms will achieve resolution of those symptoms through brief interventions, but others will progress to major depressive disorder and need longer-term treatment.

In addition, beyond fear of, exposure to, or actual infection by coronavirus producing psychiatric symptoms, the act of quarantine and isolation itself induces psychiatric symptoms. Quarantine will not only exacerbate symptoms in those with known SMI, but it also may bring to treatment people with SMI, who were previously undiagnosed and/or untreated due to exacerbation of symptoms.

Inpatient hospitals. Psychiatric hospitals have followed general hospitals in restricting who is going into the building and in setting up screening of those who enter. Psychiatric hospitals have to enact additional restrictions that limit the movement of patients within the building: In hospitals with multiple units, patients are being restricted to their own unit. Off-unit endeavors, such as group activities and meals, have moved onto the unit. Many of these units, especially those in newly constructed facilities, were never designed to have patients stay on them during the day as the model is off-unit programming. Increased restrictions and overcrowding lead to increased behavioral outbursts, leading to more staff involvement (for example, application of restraints), and hence increased staff exposure. Disrupting patterns of patients’ meals increases the risk of choking and medically dangerous confusion of patients’ diets. Poor hygiene in hospitals, where no windows are open and the air recycles through a ventilation system, is a heightened risk for, or is perceived by patients and staff to be a heightened risk for, viral transmission.

Patients in psychiatric hospitals loan, exchange, barter, or steal possessions. These objects have been in the hands and against the faces of patients. Patients often share food despite rules forbidding it.

In states where “patients’ rights” are paramount, sometimes at the risk of violating the general rights and safety of others, delayed response in implementing visitor restrictions and restrictions in incoming mail and food increases the risk of exposure throughout the facility. While perhaps not the highest priority, psychiatric hospitals need to have adequate PPE for their staff since the hospital is at high risk not only to have an infection sweep through it, but also to be a center that seeds a community.

Some states are considering or are implementing the placement of all of its coronavirus-positive patients at their public psychiatric hospitals into one of these hospitals. This is available only in states where there is more than one public psychiatric hospital and where geographic distances do not prohibit such an intervention. The challenges of completely isolating the coronavirus-positive patients and the staff who care for them from the hospital’s other patients and staff are enormous.

With the outpatient community not able to accommodate discharges as it could before, patients’ hospital stays are lengthened. Psychiatrists are making uncharted risk-benefit analyses: Is the patient and others at more or less risk if the patient stays in the hospital or if the patient is discharged with a less-than-optimal discharge plan? For example, should a patient originally planned to be discharged to a residential program be discharged to his parents’ home instead because he would be at much lower risk for infection?

While far from extensive, there are some resources available to those working in state hospitals. The Substance Abuse and Mental Health Services Administration (SAMHSA) has a guideline, “Covid-19: Interim Considerations for the State Psychiatric Hospital,” but it is cursory and needs to be quickly updated. A valuable resource from the Centers for Disease Control and Prevention is not directed at state hospitals at all, but rather at correctional facilities: “Interim Guidance on Management of Coronavirus Disease 2019 (COVID-19) in Correctional and Detention Facilities.” We make no statement here that state hospitals are like jails and prisons, but these are the best guidelines available that address how to manage a population locked in a facility in close quarters where all the previous day-to-day rules need to be changed. State hospital leaders can take from these guidelines whatever might work for them.

Community. With agencies providing community services operating on skeleton crews and/or with no face-to-face contact, how do individuals who have been dependent on these services for decades survive? What about patients without phones or who know nothing about their phone other than it is an instrument with which to make calls? One temporary change that should make communications easier among those providing services to people with SMI in residences, supported apartments, or in single dwellings is the relaxation of HIPAA standards for sharing information.

In some locations, such as in the greater New York City area, psychiatrists are switching patients they think can manage the change from long-acting injectables to pills so that they do not need to leave their residence to get a shot. Again, we are on a new frontier of risk-benefit analysis. If the result is a substantially greater number of psychotic decompensations, leading to more ED visits, then we have failed. If only a small percentage of those who switched need acute intervention and all the others have stayed home, then we’ve succeeded. At best we are making an educated guess for each individual.

Residential settings for individuals with SMI are doing preventive interventions, such as having residents spend very little time in common areas of the house, staggering mealtimes, and excluding all visitors. Residents who visit their family must remain with the family until the crisis is over. Some state departments of mental health have set up designated residences where individuals who test positive for the virus but are not in need of hospital care can live.

Shelters need to adjust business as usual: It has long been their practice to put people out during daytime hours; yet, they, too, may be facing problems with overcrowding and the inability to accommodate the same numbers of individuals. Unsheltered homeless people, at least one-third of whom have SMI, represent another problem because they often congregate at night in open-air locations. For example, on Massachusetts Avenue in Boston, homeless people still gather along the street, in close contact with each other and within half a mile (or less) of the Boston Medical Center.

Substance misuse is another problem in the community. The rate of sharing needles and joints may rise as supplies are harder to find. People with limited resources or those turned away because the pharmacy ran out of their medication are taking pills never prescribed for them. Given that care is being channeled to the COVID-19 crisis, to what degree are psychiatrists and others still paying attention to the opioid epidemic and the overdoses that were headlines just weeks ago or to the escalating death rates from benzodiazepines and methamphetamine? And people on opiates and benzodiazepines are at higher risk for respiratory compromise. We hardly need an increase in patients with severe respiratory depression from opiates competing with patients in severe respiratory distress from COVID-19 for the ED staff’s attention. We need greater attention to substance misuse at this time, not less. To this end, the Drug Enforcement Administration (DEA), in its statement “Use of Telemedicine While Providing Medication Assisted Treatment,” exempted DEA-registered practitioners from the in-person medical evaluation requirement as a prerequisite to prescribing or otherwise dispensing controlled substances. Furthermore, the SAMHSA recently announced increasing the first-year 30-patient limit for qualifying practitioners to a hundred if the need arises to meet demand. SAMHSA also released “OTP Guidance for Patients Quarantined at Home With the Coronavirus” and is permitting states to request blanket exceptions for all stable patients in an opioid treatment program (OTP) to receive 28 days of take-home doses and 14 days for patients who are less stable in their OTP.

Social isolation. For many persons with mental illness, being alone is a terrible burden, far beyond that experienced by many others. The costs of their loneliness are similar to those of many elderly Americans. Loneliness precipitates psychiatric symptoms in those without SMI, let alone those with these disorders. And the message can be quite confusing to the person with SMI: A clubhouse member living at home said, “For years they told me not to isolate myself and to be out with other people. Now they’re telling me to stay home and isolate myself. I’m confused.”

People in abusive households can be in danger from sources other than the coronavirus. They can be isolated with their abusers; tempers may flare, and violence could ensue. Their abuser may threaten them with eviction if they show symptoms. Among all the other reasons they have feared seeking help, they have a new fear of going outside and contracting COVID-19. Will we see more women with signs of severe physical trauma being pushed into EDs on stretchers? Will we have an increased rate of murder-suicides?

Physical health. Patients with SMI are particularly vulnerable to COVID-19 due to generally being in worse physical health than the general population. They typically delay seeking medical care for various reasons and have more medical comorbidities such as hypertension and diabetes (6). In addition to the widely recognized risk factors for COVID-19—diabetes, chronic obstructive pulmonary disease (COPD), and cardiovascular disease (CVD)—the American College of Cardiology also identified obesity and hypertension as risk factors for viral respiratory illnesses, including COVID-19 (7). CVD and its risk factors—psychotic illness being an independent risk factor for CVD (8)—are twice as high in patients with schizophrenia than in the general population (9). Likewise, obesity is twice as prevalent (10) and diabetes is at least three times as prevalent (11) in people with SMI compared with the nonpsychiatric population in all age groups.

Additionally, while the rate of smoking in the general population is about 18%, 53% of people with SMI smoke (12), and the rate of COPD is consequently similarly elevated at 22.6% compared with 5% in the general population (13). The medical needs and comorbidities of people with SMI cannot go untreated; otherwise, they will be yet another subpopulation streaming into EDs.

Antipsychotics. With heart disease and diabetes being major risk factors for severe COVID-19 infection, patients on antipsychotics ought to be considered high risk—a cumulative effect from having an SMI. Long known for their propensity to contribute to obesity, diabetes, and metabolic syndrome (14), antipsychotics also increase risk for hypertension, thrombo-embolic events, QTc prolongations, and change in endothelial function (15).

Additionally, antipsychotics have been linked to respiratory dysfunction and failure (particularly in patients with COPD) likely by causing improper respiratory muscle activity (16) or central respiratory depression (17). First- and second-generation antipsychotics are equal culprits in causing pneumonia, affecting not only elderly individuals, but young patients as well. Smokers, those with chronic respiratory disease, dysphagia, or cerebrovascular disease are particularly at risk. Treatment with multiple antipsychotics further increases the risk for pneumonia. How will those patients fair if they were infected with COVID-19?

Anxiolytics. Even before the COVID-19 pandemic, an increase in the prescription of benzodiazepines by primary care physicians was noted (18). With the rise in anxiety symptoms and diagnosable cases of anxiety disorders such as generalized anxiety disorder and PTSD, an increase in the prescription of anxiolytics followed. Knowing that benzodiazepines contribute to poor respiratory functioning (19), our patients are less able to fight a COVID-19 illness if infected. Alternatively, those unable to fill their long-term prescriptions on time at their pharmacy might either turn to illegitimate ways to obtain them or run the risk of abrupt withdrawal and experiencing seizures.

Side effects. Beyond the physiologic vulnerability to COVID-19 incurred by psychotropics, people with SMI are subject to other side effects that increase their risk of contracting and spreading the virus: sedation and drowsiness may lead patients to put their head on a table and fall asleep, creating face-to-surface contact in common areas. Involuntary movements cause more face touching and contact with others. Drooling from sedation or clozapine-induced sialorrhea (20) can quickly spread the virus over a wide area.

Medication interactions. Experimental drugs are currently used for COVID-19 treatment. Some have unknown side effects, while others can have serious interactions with psychiatric medications and other medications. For example, ritonavir is contraindicated with disulfiram (oral version has 42% alcohol) and decreases metabolism of midazolam and triazolam. Its level is decreased by CYP3A4 inducers such as carbamazepine, and it directly inhibits 3A4 and 2D6 through which several psychotropics are metabolized. The more famous combo hitting the headlines about COVID-19 treatment is made of two QTc prolonging medications: hydroxychloroquine and azithromycin, further increasing the burden on the heart of those on psychotropic medications.

We can anticipate an increased shunning of many people with SMI due to their looking like someone more likely to be infected and their appearance in general. It comes as no surprise that people quickly move away from someone who does not keep usual social distance from them even when there is no pandemic. Most problematic is perceiving people as unable to maintain social distance and handwashing practices just because they have a serious mental illness when, in fact, they are quite capable of doing so. Hospital staff, employers, and family members can be particularly susceptible to this.

Rationing of health care resources is already under discussion (21). Because individuals with schizophrenia have a shorter lifespan than that of the general population, will they be the last to receive treatment if the criteria for prioritizing treatment “maximizes the number of patients that survive treatment with a reasonable life expectancy” (21)? The Office of Civil Rights of the Department of Health and Human Services has released guidelines saying that states, hospitals, and physicians cannot put people with disabilities at the back of the line for care. But will everyone adhere to that directive?

Amid all these concerns during the COVID-19 pandemic, the symptoms and functioning of some psychiatric patients have actually improved when interventions are knowingly framed by their psychiatrist.

Suicidality. A 23-year-old tall, thin woman who has always felt very much alone in the world has been in the hospital since adolescence. She is afraid she’ll die in some cataclysmic event. To avoid that, she states she will commit suicide if discharged; once alone on pass she had made a very serious suicide attempt. Her psychiatrist pointed out to her that now the whole world feels just like she does, and she is not alone. She has never functioned better than she has since she understood this.

Delusions. A septuagenarian Korean War veteran, with decades of delusions about federal government deceit and his suffering as a result of its lies, was informed that now a good percentage of the U.S. population also thinks the federal government is lying to them. He was asked if he could put aside his own grievance and take up the national grievance. With all his experience in writing thousands of documents about government deception, would he agree to be a consultant to the national effort? He did agree. He writes less. The national problem is addressed with meetings with his psychiatrist. He’s engaged at a time when there’s not much to do on the inpatient unit.

Paranoia. A 50-year-old never-married man on disability has, for two decades, gone to supermarkets at off hours to avoid as many people as possible. He goes down aisles when they are empty of people. He keeps his distance from store personnel in the checkout line. He avoids other shoppers as they enter or leave the store. Now his behavior is normalized, and no one thinks twice about his behavior.

Negative symptoms of schizophrenia. A 62-year-old man who lives alone is a member of a very large Italian family, none of whom had ever moved far from their birthplace. The family gets together almost every week for a holiday or family event, and everyone has to come. Our patient, aware he has no ability to engage in social conversation, hates these gatherings. He describes them as “torture.” He has never been more at ease in his life since there are no family get-togethers, and no one knows when there will be another one.

OCD. A 60-year-old woman who became disabled from her teaching job due to OCD symptoms has spent the last decade avoiding touching anything she didn’t absolutely have to touch, washing her hands incessantly, and wearing some clothing only outside and other clothing only inside. She had garnered the pity of friends and relatives (which she hated). When she was out in public, people would get impatient with her or stare at her as she hesitated before going through doors or picking up items while figuring out how to minimize her exposure. Now, no one pays her any mind at all. Some people are actually mimicking her well-practiced moves.

Mental health support. As indicated by an APA poll released in March, anxiety about COVID-19 runs high among Americans, as does the sense that coronavirus is having a serious impact on their lives. Health care workers are proving to be especially vulnerable to showing elevated psychiatric symptoms. But while some services have become less available, others have been newly developed: The Texas Health and Human Services created a free, statewide, 24/7 mental health hotline to support Texans struggling with mental health repercussions of the COVID-19 pandemic. Will states that have not done so follow suit? Will individuals who were previously reluctant to seek psychiatric help find this pandemic a good reason to do so?

In this article, we have attempted to provide an overview of what is happening to people with SMI in this pandemic to better equip us all to more effectively deliver care and treatment to this vulnerable population. Like so many others in health care, we now find ourselves in rough waters with one broken oar in a craft that requires two paddles. In this health care crisis, psychiatry, like every other medical discipline, finds itself venturing forth in practice patterns with which we have no experience. We might do well to heed the words of Mahatma Gandhi: “You may never know what results come of your actions, but if you do nothing, there will be no results.” ■

1. Menninger K. Psychosis Associated With Influenza. General Data: Statistical Analysis. JAMA. 1919;72(4):235-241.

2. Menninger K. Influenza and Schizophrenia: An Analysis of Post-influenza “Dementia Praecox,” as of 1918, and Five Years Later Further studies of the Psychiatric Aspects of Influenza. 1926. Am J Psychiatry. 1994;151(6 Suppl):182-187.

3. Severance E, Dickerson F, Viscidi R, et al. Coronavirus Immunoreactivity in Individuals With a Recent Onset of Psychotic Symptoms. Schizophr Bull. 2011; 37:101-107.

4. Liu N, Zhang F, Wei C, et al. Prevalence and Predictors of PTSS During COVID-19 Outbreak in China Hardest-hit Areas: Gender Differences Matter. Psychiatry Res. March 16, 2020. [Epub ahead of print]

5. Lai J, Ma S, Wang Y, et al. Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Netw Open. 2020;3(3):e203976.

6. Spivak S, Cullen BA, Eaton W, et al. Delays in Seeking General Medical Services and Measurable Abnormalities Among Individuals With Serious Mental Illness. Psychiatr Serv. 2018; 69(4):479-482.

7. Beck D. Coronavirus Disease 2019 (COVID-19) Provides Potent Reminder of the Risk of Infectious Agents. Cardiology Magazine. March 6, 2020.

8. Ösby U, Westman J, Hallgren J, et al. Mortality Trends in Cardiovascular Causes in Schizophrenia, Bipolar and Unipolar Mood Disorder in Sweden 1987–2010. Eur J Pub Health. 2016; 26(5):867-871.

9. Whicher C, Price H, Holt R. Mechanisms in Endocrinology: Antipsychotic Medication and Type 2 Diabetes and Impaired Glucose regulation. Eur J of Endocrinol. 2018; 178(6):R245-R258.

10. Dickerson F, Brown C, Kreyenbuhl J, et al. Obesity Among Individuals With Serious Mental Illness. Acta Psychiatr Scand. 2006;113(4):306-313.

11. Réthelyi J, Sawalhe AD. Comorbidity of Metabolic Syndrome, Diabetes and Schizophrenia: Theoretical and Practical Considerations. Orv Hetil. 2011;152(13):505-511.

12. Aschbrenner K, Bobak C, Schneider E, et al. Egocentric Social Networks and Smoking Among Adults With Serious Mental Illness. Transl Behav Med. 2018;8(4): 531-539.

13. Himelhoch S, Lehman A, Kreyenbuhl J, et. al. Prevalence of Chronic Obstructive Pulmonary Disease Among Those With Serious Mental Illness. Am J Psychiatry. 2004;161(12):2317-2319.

14. Gury C. Schizophrenia, Diabetes Mellitus and Antipsychotics. Encephale. 2004;30(4):382-391.

15. Kahl K, Westhoff-Bleck M, Krüger T. Effects of Psychopharmacological Treatment With Antipsychotic Drugs on the Vascular System. Vascul Pharmacol. 2018;100:20-25.

16. Yagmur F, Ulusoy H, Buyukoglan H, et al. Acute Respiratory Distress Due to Antipsychotic Drugs. Pharmacopsychiatry. 2010; 43(3):118-119.

17. Soriano F, Vianna E dos S, Velasco I. Neuroleptic-induced Acute Respiratory Distress Syndrome. Sao Paulo Med J. 2003;121(3):121-124.

18. Agarwal S, Landon B. Patterns in Outpatient Benzodiazepine Prescribing in the United States. JAMA Netw Open. 2019; 2(1):e187399.

19. Vozoris N. Do Benzodiazepines Contribute to Respiratory Problems? Expert Rev Respir Med. 2014;8(6):661-663.

20. Praharaj SK, Arora M, Gandotra, S. Clozapine-induced Sialorrhea: Pathophysiology and Management Strategies. Psychopharmacology. 2006;185(3):265-273.

21. Emanuel E, Persad G, Upshur R, et al. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. N Engl J Med. March 23, 2020. [Epub ahead of print]