Managing the impact of Covid-19 on psychiatric problems in primary care
Specialist registrar in general psychiatry Dr Hannah Fosker outlines how GPs can support patients with mental health problems during the Covid-19 pandemic
Health services are having to change rapidly because of the Covid-19 pandemic and all staff will be concerned about how to support patients who already struggle with their mental health.
Here I will focus on a few key areas where the pandemic may exacerbate mental health problems.
The Royal College of Psychiatry has published advice on these and other topics.1 Further advice might especially be needed when working with children and adolescents or older patients.
Advice and support for referrals
First, it is important to emphasise that although mental health services are undergoing frequent change at this time, they are still there for the patients most in need.
If you need guidance, your local mental health trust or crisis teams should still have points of contact to advise you. Senior clinicians remain on call 24 hours a day, seven days a week and mental health trust pharmacy teams should also be contactable through the trust switchboard.
Check with your local crisis teams for changes in service provision. For example, my mental health trust has moved all urgent triage from A&E to a location on our own site to minimise possible contact and spread of Covid-19.
Because the mental health workforce will have reduced capacity from staff illness, self-isolation and redeployment, services will need to prioritise patients who are most in need. So it’s important that referrals are informative and risk assessments are thorough.
You can still discuss referrals with your local approved mental health professional (AMHP) team, and refer patients at acute high risk for a Mental Health Act assessment.
People experiencing ‘normal’ psychological upset
Anyone, including people without any pre-existing mental illness, may be at increased risk of stress or mental health difficulties at this uncertain time.
Exacerbating factors include: isolation and loneliness; bereavement; income cuts or unemployment; maladaptive coping strategies such as alcohol misuse; poor sleep; a lack of routine; and the relentless stream of Covid-19 news.
A number of websites offer a range of resources for anyone struggling psychologically, whether or not they meet diagnostic criteria for a psychiatric illness, with dedicated articles on mental wellbeing during the pandemic (see patient resources, page 28).
People with worsening anxiety or depression
In people with pre-existing anxiety and depression, it is important to recognise worsening of core and biological symptoms. Changes could include worsening sleep, loss of appetite, loss of enjoyment in activities and an inability to perform simple tasks – even getting out of bed, showering or cooking a meal may become a struggle.
Patients taking SSRIs or similar antidepressants may benefit from an increase in dose, even if temporarily. For individual drugs and dosage instructions consult the BNF as usual, but if a drug is unfamiliar seek further advice from the secondary care psychiatry team or pharmacist.
As always, appropriate use of as-needed medications such as benzodiazepines remains a last resort and an option for the short term only, for situations where you judge that the risks, suffering or functional difficulties require it.
Access to psychological therapies is likely to be reduced and IAPT services are implementing online video calling options for those already undergoing face-to-face therapy.
Signpost patients waiting for psychological treatments to self-help websites and worksheets. The Living Life to the Full website has free resources and the NHS Every Mind Matters website is easily accessible and informative (see patient resources, page 28). Explain to patients that it can be beneficial for them to take the first steps in the therapeutic journey themselves, learning to understand the basic concepts in therapy and developing psychological mindedness so they are able to engage with therapy when the time comes.
Arranging a Mental Health Act assessment during the pandemic
Emergency temporary changes have been made to Mental Health Act legislation to allow ongoing service provision in light of potential staffing difficulties.
Remember these assessments are not only available for patients presenting a physical risk to themselves or others. Patients who lack insight may present a risk to themselves without treatment to prevent further deterioration in their mental health, while a range of social risks can constitute an emergency – from social or financial vulnerability through to driving or behaving in a dangerous way because of diminished capacity.
Discuss your concerns with the mental health professional on duty via the usual social services contact number. They can advise further and arrange section 12-approved doctors, or use of the emergency legislation if section 12-approved doctors are not easily available, and organise a warrant if needed.
Remember capacity in an at-risk patient does not preclude use of the Mental Health Act. Detaining somebody against their will is a last resort, and the least restrictive option should always be taken. However, the legislation can be used if a patient with capacity is unable to make a sustained commitment to necessary inpatient care.
Patients with serious mental illness
The risk of relapse among patients receiving treatment for serious psychotic disorders is increased in the pandemic situation. They may be destabilised by a range of factors, including changes in social contacts and routines and unusual constraints on simple tasks such as food shopping. Anxieties about leaving the house or attending healthcare settings may also lead to disruptions in prescriptions.
Loneliness is likely to make psychosis more frightening, which may be further exacerbated if families can no longer offer close support during an episode.
It is vital to maintain the supply of antipsychotic medication. Issuing prescriptions electronically to pharmacies can reduce the need for visits and contacts. My local trust has also arranged for prescriptions to be posted.
If a patient who is due for a depot medication injection has symptoms of Covid-19 or has household contacts with symptoms, contact their secondary care team or the mental health trust pharmacist. It may be possible to extend the window between doses or consider alternative strategies.
Any planned reductions in antipsychotic medication for stable patients may be postponed, in case of destabilisation. For patients with capacity who understand the risks, agree a plan. The secondary care team should take the lead on this, or offer advice.
Usual metabolic monitoring in patients taking antipsychotic medication may not be possible, because of reduced routine services. Patients with a history of cardiovascular disease or other cardiometabolic risk factors should be prioritised, as well as those on higher doses or dual antipsychotic treatment. Check with your local CMHT if you have concerns about patients for whom monitoring cannot be delayed.
For further details, the NHS Specialist Pharmacy Service and Royal College of Psychiatrists have produced Covid-19 advice pages covering the essentials of antipsychotic medication administration.2,3
Patients prescribed clozapine must continue to undergo FBC tests as usual to monitor for neutropenia and agranulocytosis. Monitoring is usually overseen by secondary care services, but GPs must be mindful of these potential adverse drug reactions, which may present as fever and sore throat.
Also bear in mind the increased risk of lithium toxicity in patients who become dehydrated secondary to a febrile illness. Discuss any suspicion of lithium toxicity such as coarse tremor or other neurological signs urgently with the local psychiatric team. Withhold doses and arrange blood monitoring as soon as possible. The NHS Specialist Pharmacy Service and the College of Mental Health Pharmacy have produced summaries outlining lithium and clozapine toxicity and monitoring specifically.4-6
People with substance misuse disorders
Malnourishment and physical health comorbidities related to substance misuse, such as chronic respiratory disease, may make patients vulnerable to Covid-19. This group is also likely to be disproportionately affected by reductions in homeless support services.
Patients with alcohol dependence may be at increased risk of withdrawal syndrome because of loss of income or inconsistent access to alcohol. Signpost patients to local community addiction services and offer harm minimisation advice.
For individuals using illicit substances, disruptions to supply lines may lead to unexpected changes in substances supplied by dealers. Being alone while using substances also increases the risk of overdose. You may notice increased prescription drug seeking in place of illicit drug use; such requests should be considered by a clinician who is familiar with the patient.
This is a highly specialised area of psychiatry usually overseen by its own department. Seek advice from your local community addiction service. Local psychiatry services can signpost you to these or you can search for local services through organisations like FRANK.7
Prescriptions for these patients may be issued daily under supervision and local policies can vary. The Pharmaceutical Services Negotiating Committee has issued advice on community pharmacy provision for people receiving treatment for substance misuse during Covid-19, and the Royal College of Psychiatry has guidance including links to NHS England resources with safeguarding advice.8,9
Patients with eating disorders
Anorexia nervosa in particular may increase vulnerability to serious or atypical effects of Covid-19 infection, due to malnourishment and its secondary physical health effects. Also, stress and lack of control at this time may affect patients’ mental health and ability to manage their condition.
Patients with severe anorexia require frequent monitoring of physiological parameters, including bloods, ECGs and weight. Services for this will vary during the pandemic and may require support from primary care.
Reduction in specialist support will affect patients’ families as well, particularly if the threshold for admission is raised to prioritise those requiring medical stabilisation. Ask advice from your local eating disorders specialist services. Again, the Royal College of Psychiatry has produced Covid-19 guidance on eating disorders.10
People with obsessive compulsive disorder
Patients with obsessive compulsive disorder (OCD) who obsess about contamination may find it difficult to distinguish sensible behaviours from those rooted pathologically in a need to safety net against unhelpful thoughts.
Support them to differentiate between the two and set themselves boundaries, while still ‘being kind to themselves’ when their behaviour may deviate towards pathological. Be mindful that the pandemic may present a huge challenge even to those on the way to recovery.
Encourage patients to question why they feel the need to perform an action. For example, feeling the need to wash hands for 20 seconds after touching surfaces is understandable. But using the pandemic to rationalise a compulsion to wash hands, say, five times, or for prolonged periods, is unhelpful.
The reduced ability to remain distracted and engaged in psychological therapies may exacerbate other forms of OCD and will require compassion from both healthcare professionals and the patients themselves. It is reasonable to offer pharmacological treatment, even for mild functional impairment, if psychological therapy is reduced. First-line use of an SSRI can be initiated as usual in primary care. Refer to NICE guidelines.11 For patients there are OCD charities.
Self-help mental health websites
Anxiety and depression
The suicidal patient
The pandemic situation may heighten the risk of suicide – loss of jobs, routines and social contacts can exacerbate feelings of hopelessness, and a fear of contact with healthcare professionals may reduce help-seeking.
Managing patients who are suicidal may be additionally challenging. The unpredictability of suicide and reliance on self-report are compounded by a lack of collateral information and access to family support. And the patient might not wish to engage with services or attend A&E.
Consider patients’ reasoning for not wanting to attend A&E – many people will be fearful after seeing images of clinicians in protective equipment. Offer reassurance that, for example, the crisis team can often offer support using online technology. Video consultations may be preferable to telephone here, to enable the clinician to pick up visual clues such as loss of eye contact, blunted emotional reactivity or evident poor hygiene.
As always, perform a thorough risk assessment considering the patient’s personal history of attempted suicide and whether they have developed a specific plan or performed any final acts. Other risk factors include male sex, elderly age, loneliness, family suicide, trauma, alcohol or drug dependence and mental illness. Comorbid chronic illnesses as well as socio-economic and unemployment risks may be exacerbated by the pandemic.
Signposting to telephone helplines such as Samaritans, PAPYRUS or any local crisis lines provides a useful safety net, even where a patient has already had input from secondary care psychiatric services.
Speak to care teams involved with the patient, such as their CPN or other members of the CMHT, to gain advice from those who know them well. Although face-to-face contacts are much reduced, there are policies for follow up to be escalated if necessary.
It may be appropriate to use the Mental Health Act.
Dr Hannah Fosker is a specialist registrar in general psychiatry at Leicestershire Partnership NHS Trust
3. NHS Specialist Pharmacy Service. Summary of COVID-19 medicines guidance: Mental health and illness. 7 April 2020; updated 27 April 2020.
4. NHS Specialist Pharmacy Service. Clozapine drug monitoring in primary care during Covid-19 for stable patients
5. College of Mental Health Pharmacy and the Royal Pharmaceutical Society. Monitoring and Supply of Clozapine during the Covid-19 Pandemic
6. NHS Specialist Pharmacy Service. Lithium drug monitoring during COVID-19 for stable adult patients. 7 April 2020.
8. Pharmaceutical Negotiating Services Committee. Shared-Care service provision for people being treated for substance use during the COVID19 pandemic. 25 March 2020.
9. Royal College of Psychiatry. COVID-19: Working with vulnerable patients
10. Royal College of Psychiatry. COVID-19: Eating disorders services