H5N1

Research: 1 in 8 adult Canadians experienced depression for first time during pandemic

Via the Helsinki Times: Research: 1 in 8 adult experienced depression for first time during pandemic. Excerpt:

One in eight older persons in Canada, according to recent large-scale research that included more than 20,000, experienced their first episode of depression during the epidemic.  

The statistics were significantly worse for people who had previously struggled with depression. Nearly half (45 per cent) of this population reported having depression by the fall of 2020.  

The analysis of responses from the Canadian Longitudinal Study on Aging, which gathered information from participants for an average of seven years, was published in the International Journal of Environmental Research and Public Health.  

"The high rate of first-onset depression in 2020 highlights the substantial mental health toll that the pandemic caused in a formerly mentally healthy group of older adults." says first author, Andie MacNeil, a recent Master of Social Work graduate from the Factor-Inwentash Faculty of Social Work (FIFSW) and the Institute for Life Course and Aging, University of Toronto.  

Although it is well known that depression among older adults increased during the pandemic, few studies have examined the proportion of people who developed the disorder for the first time or the proportion of people with a history of the condition who had a relapse.  

"The devastation of the pandemic which upended so many aspects of daily life hit those with a history of depression particularly hard," said co-author Sapriya Birk, a researcher formerly based in the Department of Neuroscience, Carleton University, Ottawa who is currently a medical student at McMaster University, Hamilton, Canada, adding, "Health professionals need to be vigilant in screening their patients who had mental health problems at an earlier time in their life."  

The researchers determined that a number of factors, such as low income and savings, loneliness, chronic pain, difficulty accessing healthcare, a history of traumatic childhood experiences, and family conflict, were linked to depression in older adults during the pandemic.

Individual and work factors associated with psychosocial health of registered nurses during the Covid-19 pandemic

Via the Journal of Occupational and Environmental Medicine: Individual and Work Factors Associated with Psychosocial Health of Registered Nurses During the Covid-19 Pandemic. The abstract:

Objective:   

To describe the initial influence of the Covid-19 pandemic on U.S. nurses’ psychosocial health, and to identify factors associated with poor psychosocial health outcomes.  

Methods:   

We conducted a convergent (QUAN+qual) mixed methods study. From June-August 2020, we administered surveys (N=629) and conducted semi-structured interviews (N = 34) among nurses working across healthcare settings in 18 states. We developed separate multivariable logistic regression models for three psychosocial outcomes (anxiety, depressive symptoms, insomnia). We used content analysis to process and analyze qualitative data, and integrated results in the final analysis step.  

Results:   

Nurses reported high rates of depressive symptoms (22%), anxiety (52%), and insomnia (55%). Disturbances to sleep were both a contributing factor to, and an outcome of, poor psychosocial health.  

Conclusions:   

Evidence-based interventions addressing work stress and sleep, and proactive monitoring of nurses’ psychosocial health by employers are urgently needed.

Global prevalence and burden of depressive and anxiety disorders in 204 countries and territories in 2020 due to the COVID-19 pandemic

Via The Lancet: Global prevalence and burden of depressive and anxiety disorders in 204 countries and territories in 2020 due to the COVID-19 pandemic. The summary:

Background  

Before 2020, mental disorders were leading causes of the global health-related burden, with depressive and anxiety disorders being leading contributors to this burden. The emergence of the COVID-19 pandemic has created an environment where many determinants of poor mental health are exacerbated. The need for up-to-date information on the mental health impacts of COVID-19 in a way that informs health system responses is imperative. In this study, we aimed to quantify the impact of the COVID-19 pandemic on the prevalence and burden of major depressive disorder and anxiety disorders globally in 2020.  

Methods  

We conducted a systematic review of data reporting the prevalence of major depressive disorder and anxiety disorders during the COVID-19 pandemic and published between Jan 1, 2020, and Jan 29, 2021. We searched PubMed, Google Scholar, preprint servers, grey literature sources, and consulted experts. Eligible studies reported prevalence of depressive or anxiety disorders that were representative of the general population during the COVID-19 pandemic and had a pre-pandemic baseline. 

We used the assembled data in a meta-regression to estimate change in the prevalence of major depressive disorder and anxiety disorders between pre-pandemic and mid-pandemic (using periods as defined by each study) via COVID-19 impact indicators (human mobility, daily SARS-CoV-2 infection rate, and daily excess mortality rate).  

We then used this model to estimate the change from pre-pandemic prevalence (estimated using Disease Modelling Meta-Regression version 2.1 [known as DisMod-MR 2.1]) by age, sex, and location. We used final prevalence estimates and disability weights to estimate years lived with disability and disability-adjusted life-years (DALYs) for major depressive disorder and anxiety disorders.  

Findings  

We identified 5683 unique data sources, of which 48 met inclusion criteria (46 studies met criteria for major depressive disorder and 27 for anxiety disorders). Two COVID-19 impact indicators, specifically daily SARS-CoV-2 infection rates and reductions in human mobility, were associated with increased prevalence of major depressive disorder (regression coefficient [B] 0·9 [95% uncertainty interval 0·1 to 1·8; p=0·029] for human mobility, 18·1 [7·9 to 28·3; p=0·0005] for daily SARS-CoV-2 infection) and anxiety disorders (0·9 [0·1 to 1·7; p=0·022] and 13·8 [10·7 to 17·0; p<0·0001]. Females were affected more by the pandemic than males (B 0·1 [0·1 to 0·2; p=0·0001] for major depressive disorder, 0·1 [0·1 to 0·2; p=0·0001] for anxiety disorders) and younger age groups were more affected than older age groups (−0·007 [–0·009 to −0·006; p=0·0001] for major depressive disorder, −0·003 [–0·005 to −0·002; p=0·0001] for anxiety disorders). 

We estimated that the locations hit hardest by the pandemic in 2020, as measured with decreased human mobility and daily SARS-CoV-2 infection rate, had the greatest increases in prevalence of major depressive disorder and anxiety disorders. We estimated an additional 53·2 million (44·8 to 62·9) cases of major depressive disorder globally (an increase of 27·6% [25·1 to 30·3]) due to the COVID-19 pandemic, such that the total prevalence was 3152·9 cases (2722·5 to 3654·5) per 100 000 population. We also estimated an additional 76·2 million (64·3 to 90·6) cases of anxiety disorders globally (an increase of 25·6% [23·2 to 28·0]), such that the total prevalence was 4802·4 cases (4108·2 to 5588·6) per 100 000 population. 

Altogether, major depressive disorder caused 49·4 million (33·6 to 68·7) DALYs and anxiety disorders caused 44·5 million (30·2 to 62·5) DALYs globally in 2020. 

Interpretation 

This pandemic has created an increased urgency to strengthen mental health systems in most countries. Mitigation strategies could incorporate ways to promote mental wellbeing and target determinants of poor mental health and interventions to treat those with a mental disorder. Taking no action to address the burden of major depressive disorder and anxiety disorders should not be an option.

Investigating the impact of COVID-19 on newly qualified nurses

Via the City University of London: Investigating the impact of COVID-19 on newly qualified nurses. Excerpt:

Nurses are at the heart of our NHS, but many leave the medical profession soon after qualifying, with 30–60% of nurses leaving their first place of employment within one year. Now, the COVID-19 pandemic has made the transition from student to nurse even more challenging. 

For the last 3 years, researchers at City, University of London School of Health Sciences have studied 190 newly qualified Barts Health NHS nurses. The nurses received regular questionnaire surveys, as well as face-to-face and telephone interviews, designed to measure depression, anxiety, stress, and burnout, along with resilience and work environment. Half of the nurses were given psychological skills training to see if this was an effective intervention. 

Using £29,000 funding from Barts Charity, the researchers are building on previous work which studied the pressures on nurses in their first year of qualifying. In this follow-on study, the research team will look deeper into the effect that COVID-19 has had, and how organisations can better support nurses. 

COVID-19 hit during this initial study and provided researchers with an early insight into how the pandemic added to the pressure on these newly qualified staff. The initial data indicated that the nurses were significantly affected by their experiences and that more than 25% had experienced symptoms related to post-traumatic stress disorder (PTSD). 

In the study, one nurse noted: “There have been lots of situations with handling dying patients whose families are unable to come and visit and if they are allowed only one is allowed to visit. This has been very distressing.” 

Another said “the stressful experience was looking after patients who were acutely unwell with COVID. I found it stressful because there was little we could do for patients other than give them oxygen, so that added to the feeling of helplessness.” 

The Barts Charity seed funding will allow the project to be developed further, with researchers now looking at the long-lasting effects of COVID-19, the main causes of distress and PTSD symptoms and how they can be mitigated, including the relationship between the nurses’ resilience and PTSD symptoms. The funding follows a £3m grant for staff wellbeing at Barts Health NHS Trust and signals its commitment to supporting NHS staff across East London. 

This follow-on study aims to provide practical recommendations to assist the NHS in better understanding the wellbeing and psychological support needs of early career nurses – not just at Barts Health NHS Trust, but across the country.

COVID-19: A heavy toll on health-care workers

An important comment in The Lancet Respiratory Medicine: COVID-19: a heavy toll on health-care workers. Excerpt:

Health-care workers are known to be at risk for anxiety, depression, burnout, insomnia, moral distress, and post-traumatic stress disorder. Under usual working conditions, severe burnout syndrome affects as many as 33% of critical care nurses and up to 45% of critical care physicians. Extrinsic organisational risk factors—including increased work demands and little control over the work environment—and the trauma of caring for patients who are critically ill have been heightened by the COVID-19 pandemic and represent important exacerbating factors for poor mental health among health-care workers. 

Following the outbreak of severe acute respiratory syndrome in 2003, health-care workers reported chronic stress effects for months to years. Among health-care workers treating patients with COVID-19, a Chinese study reported high rates of depression (50%), anxiety (45%), insomnia (34%), and distress (72%). These findings were supported by a systematic review of 13 studies including more than 33 000 participants. 

Studies from Italy and France reported a high prevalence of depressive symptoms, post-traumatic stress disorder, and burnout; risk factors for adverse psychological outcomes included younger age, female sex, being a nurse, and working directly with patients with COVID-19. The long-term effect on the health of those working in health care remains to be seen. 

The COVID-19 pandemic is a stark reminder of racial and socioeconomic disparities, with disproportionate infection and death rates among migrants, the poor, and racialised groups. COVID-19 has also had a disproportionate effect on women health-care workers. Women comprise 70% of the global health and social care workforce, putting them at risk of infection and the range of physical and mental health problems associated with their role as health professionals and carers in the context of a pandemic. The pandemic exacerbated gender inequities in formal and informal work, and in the distribution of home responsibilities, and increased the risk of unemployment and domestic violence. 

While trying to fulfil their professional responsibilities, women had to meet their families' needs, including childcare, home schooling, care for older people, and home care. Burdened by these obligations, women had reduced academic productivity relative to men, as evidenced by fewer women being part of the cohort producing new knowledge about the pandemic. There was a disconnect between the demands of parenting and the expectations of the scientific community, as shown by ultra-short timelines for COVID-19-related grant proposals, which further deepened the divide between women and men. 

During the pandemic, there have been glimmers of hope and solace. We were buoyed by support from institutional and government leadership, the spirit of teamwork, the celebration of lives saved, and the acknowledgement of our value by the public. Social media was a venue for health-care workers to share their anxiety, insomnia, and fatigue, which reduced the sense of isolation and normalised conversations about mental health. 

To effectively support health-care workers—the greatest assets of our health-care systems—we must understand their challenges and needs. Burnout and other forms of work-related psychological distress are unavoidable occupational health issues. By acknowledging the commonality of psychological distress related to caring for patients with COVID-19, we can destigmatise work-related mental health issues and appropriately attend to the mental health needs of all health-care workers affected by the pandemic. 

Finally, we hope that the COVID-19 pandemic will prompt a redefinition of essential support workers, with recognition of the contribution of all health-care workers and appropriate education, protection, and compensation.

'Diseases of despair' skyrocket in America

Via HealthDay.com: 'Diseases of Despair' Skyrocket in America. Excerpt:

TUESDAY, Nov. 10, 2020 (HealthDay News) -- Even before the coronavirus pandemic began, Americans were already suffering: A new study reports that alcohol and drug misuse were up dramatically, and suicidal thoughts and behaviors were up 170% between 2009 and 2018. 

Researchers call these conditions "diseases of despair."  

"The origin of these conditions isn't strictly medical. Rather, they seem to follow conditions of despair in people's lives and communities," explained study author Emily Brignone. She's a senior research scientist with Highmark Health in Pittsburgh, Penn. 

Economic decline, stagnant wages, fewer community ties and unemployment are some of the factors she said can be linked to diseases of despair.  

"Over the past 10 years, diagnoses related to drug and alcohol misuse and suicidal thoughts and behaviors have increased across the board for men and women in all age groups," Brignone noted. 

The information in this study was collected long before COVID-19 began spreading across the United States. But Brignone said the pandemic may worsen conditions related to diseases of despair, like unemployment, social isolation, barriers to health care and uncertainty.  

"There is some evidence of COVID-19-related changes in diseases of despair, including increases in opioid overdoses and high numbers of people reporting suicidal thoughts. However, we won't know the full extent of the impact of COVID-19 on diseases and deaths of despair for many years to come," Brignone said.  

The new study included 12 million Americans insured by Highmark, a large U.S.-based health insurance company. The people covered by the company are concentrated in Pennsylvania, West Virginia and Delaware. These are states that have been disproportionately affected by deaths of despair, according to the researchers. 

Almost one in 20 people in the study were diagnosed with a disease of despair during the study period. 

The biggest increases were seen in suicidal thoughts and behaviors, particularly in young people. Suicidal thinking and behaviors rose by 287% between 2009 and 2018 in people under 18 years of age. For those between 18 and 34, the rate increased by 210%. For all other age groups, there was a rise of at least 70% in suicidal thoughts and behaviors, the findings showed.  

"We don't fully understand why this is happening. Some researchers have pointed to changing social structures and the rise of smartphones and social media. There are also questions about the role of bullying and less sleep. But it is a complex issue without easy answers," Brignone said.  

Alcohol problems increased in all age groups, except for those under 18. The biggest jump (59%) in alcohol misuse was seen in people between the ages of 55 and 74.  

Brignone said a number of things might trigger greater alcohol misuse later in life, including increases in health conditions, pain, mental health concerns, and increased disconnection from family, friends and neighbors. She also noted that alcoholism and the other diseases of despair often occur together.  

Older Americans (aged 55 to 74) also had the largest increase in substance misuse, with an increase of 172% during the study. The overall prevalence of substance-related diagnosis increased by 94%. 

Men had nearly 50% higher odds of being diagnosed with a disease of despair than women were, the researchers reported.

Bidirectional associations between COVID-19 and psychiatric disorder: Retrospective cohort studies of 62,354 COVID-19 cases in the USA

Via The Lancet Psychiatry, still more bad news about this wretched virus: Bidirectional associations between COVID-19 and psychiatric disorder: retrospective cohort studies of 62 354 COVID-19 cases in the USA.

Background 

Adverse mental health consequences of COVID-19, including anxiety and depression, have been widely predicted but not yet accurately measured. There are a range of physical health risk factors for COVID-19, but it is not known if there are also psychiatric risk factors. In this electronic health record network cohort study using data from 69 million individuals, 62 354 of whom had a diagnosis of COVID-19, we assessed whether a diagnosis of COVID-19 (compared with other health events) was associated with increased rates of subsequent psychiatric diagnoses, and whether patients with a history of psychiatric illness are at a higher risk of being diagnosed with COVID-19. 

Methods 

We used the TriNetX Analytics Network, a global federated network that captures anonymised data from electronic health records in 54 health-care organisations in the USA, totalling 69·8 million patients. TriNetX included 62 354 patients diagnosed with COVID-19 between Jan 20, and Aug 1, 2020. We created cohorts of patients who had been diagnosed with COVID-19 or a range of other health events. We used propensity score matching to control for confounding by risk factors for COVID-19 and for severity of illness. We measured the incidence of and hazard ratios (HRs) for psychiatric disorders, dementia, and insomnia, during the first 14 to 90 days after a diagnosis of COVID-19. 

Findings 

In patients with no previous psychiatric history, a diagnosis of COVID-19 was associated with increased incidence of a first psychiatric diagnosis in the following 14 to 90 days compared with six other health events (HR 2·1, 95% CI 1·8–2·5 vs influenza; 1·7, 1·5–1·9 vs other respiratory tract infections; 1·6, 1·4–1·9 vs skin infection; 1·6, 1·3–1·9 vs cholelithiasis; 2·2, 1·9–2·6 vs urolithiasis, and 2·1, 1·9–2·5 vs fracture of a large bone; all p<0·0001). The HR was greatest for anxiety disorders, insomnia, and dementia. We observed similar findings, although with smaller HRs, when relapses and new diagnoses were measured. 

The incidence of any psychiatric diagnosis in the 14 to 90 days after COVID-19 diagnosis was 18·1% (95% CI 17·6–18·6), including 5·8% (5·2–6·4) that were a first diagnosis. The incidence of a first diagnosis of dementia in the 14 to 90 days after COVID-19 diagnosis was 1·6% (95% CI 1·2–2·1) in people older than 65 years. A psychiatric diagnosis in the previous year was associated with a higher incidence of COVID-19 diagnosis (relative risk 1·65, 95% CI 1·59–1·71; p<0·0001). This risk was independent of known physical health risk factors for COVID-19, but we cannot exclude possible residual confounding by socioeconomic factors. 

Interpretation 

Survivors of COVID-19 appear to be at increased risk of psychiatric sequelae, and a psychiatric diagnosis might be an independent risk factor for COVID-19. Although preliminary, our findings have implications for clinical services, and prospective cohort studies are warranted.

See also this Reuters report on the study.

Prevalence of depression symptoms in US adults before and during the COVID-19 pandemic

Via JAMA Network: Prevalence of Depression Symptoms in US Adults Before and During the COVID-19 Pandemic. The key points and abstract:

Key Points

Question  What is the burden of depression symptoms among US adults during the coronavirus disease 2019 (COVID-19) pandemic compared with before COVID-19, and what are the risk factors associated with depression symptoms?  

Findings  In this survey study that included 1441 respondents from during the COVID-19 pandemic and 5065 respondents from before the pandemic, depression symptom prevalence was more than 3-fold higher during the COVID-19 pandemic than before. Lower income, having less than $5000 in savings, and having exposure to more stressors were associated with greater risk of depression symptoms during COVID-19.  

Meaning  These findings suggest that there is a high burden of depression symptoms in the US associated with the COVID-19 pandemic and that this burden falls disproportionately on individuals who are already at increased risk.  

Abstract 

Importance  The coronavirus disease 2019 (COVID-19) pandemic and the policies to contain it have been a near ubiquitous exposure in the US with unknown effects on depression symptoms. 

Objective  To estimate the prevalence of and risk factors associated with depression symptoms among US adults during vs before the COVID-19 pandemic. 

Design, Setting, and Participants  This nationally representative survey study used 2 population-based surveys of US adults aged 18 or older. During COVID-19, estimates were derived from the COVID-19 and Life Stressors Impact on Mental Health and Well-being study, conducted from March 31, 2020, to April 13, 2020. Before COVID-19 estimates were derived from the National Health and Nutrition Examination Survey, conducted from 2017 to 2018. Data were analyzed from April 15 to 20, 2020. 

Exposures  The COVID-19 pandemic and outcomes associated with the measures to mitigate it.  

Main Outcomes and Measures  Depression symptoms, defined using the Patient Health Questionnaire-9 cutoff of 10 or higher. Categories of depression symptoms were defined as none (score, 0-4), mild (score, 5-9), moderate (score, 10-14), moderately severe (score, 15-19), and severe (score, ≥20). 

Results  A total of 1470 participants completed the COVID-19 and Life Stressors Impact on Mental Health and Well-being survey (completion rate, 64.3%), and after removing those with missing data, the final during–COVID-19 sample included 1441 participants (619 participants [43.0%] aged 18-39 years; 723 [50.2%] men; 933 [64.7%] non-Hispanic White). The pre–COVID-19 sample included 5065 participants (1704 participants [37.8%] aged 18-39 years; 2588 [51.4%] women; 1790 [62.9%] non-Hispanic White). 

Depression symptom prevalence was higher in every category during COVID-19 compared with before (mild: 24.6% [95% CI, 21.8%-27.7%] vs 16.2% [95% CI, 15.1%-17.4%]; moderate: 14.8% [95% CI, 12.6%-17.4%] vs 5.7% [95% CI, 4.8%-6.9%]; moderately severe: 7.9% [95% CI, 6.3%-9.8%] vs 2.1% [95% CI, 1.6%-2.8%]; severe: 5.1% [95% CI, 3.8%-6.9%] vs 0.7% [95% CI, 0.5%-0.9%]). 

Higher risk of depression symptoms during COVID-19 was associated with having lower income (odds ratio, 2.37 [95% CI, 1.26-4.43]), having less than $5000 in savings (odds ratio, 1.52 [95% CI, 1.02-2.26]), and exposure to more stressors (odds ratio, 3.05 [95% CI, 1.95-4.77]). 

Conclusions and Relevance  These findings suggest that prevalence of depression symptoms in the US was more than 3-fold higher during COVID-19 compared with before the COVID-19 pandemic. 

Individuals with lower social resources, lower economic resources, and greater exposure to stressors (eg, job loss) reported a greater burden of depression symptoms. Post–COVID-19 plans should account for the probable increase in mental illness to come, particularly among at-risk populations.

'Sheer fear': Mental health impacts of Covid-19 come to fore

Via The Guardian: 'Sheer fear': mental health impacts of Covid-19 come to fore. Excerpt:

Two months after falling ill with Covid-19, Julie had her first hallucination. “It started slowly. I was struggling to track the plot of a TV show, then I couldn’t read the words on my phone screen,” she said. 

Things deteriorated, with an overwhelming sense of her mind and body being consumed. “I know it sounds crazy, and I don’t know how to properly articulate it, but in the moment it really felt like something was taking over my brain and my body. 

“I was so convinced that was happening that I made my sister promise to remember a code word so she’d know if I was still in my body.”  

Amid these delusions, Julie, 36, from Minnesota, was eventually taken to hospital by her family. “My mom told the ER doctor that I was recovering from Covid and that they were concerned this was a strange side-effect. He agreed it was possible, but didn’t seem to have any treatment to suggest.” 

Julie is not alone. As the long and lingering effects of Covid on physical health are emerging, so too are its impacts on mental health.  

NHS England has announced that more staff are being trained to treat people with post-traumatic stress disorder (PTSD) in preparation for a potential increase in demand for mental health services as a result of the coronavirus crisis.  

Almost 3,000 trainees are expected to start courses in psychological therapies and former staff are being asked to consider returning to frontline roles in preparation for growing numbers of people suffering from anxiety, depression and related conditions. 

NHS England said it hoped to boost the number of advanced clinical practitioners, psychiatrists and mental health nurses over the next few months.  

Research from Italy found that more than half of those admitted to hospital with Covid-19 had a psychiatric disorder a month later, with 28% showing signs of post-traumatic stress disorder (PTSD), 31% depression and 42% anxiety. Insomnia and obsessive-compulsive symptoms were also common. 

A study by researchers at University College London (UCL) also flagged psychiatric and neurological problems following Covid infections. The husband of one woman discharged from hospital found her behaving oddly, taking her coat on and off repeatedly and saying she saw lions and monkeys in the house.  

It is not only those ill enough to be admitted to hospital who are affected, as members of a Covid-19 group on the social media platform Slack, who include Julie, attest. 

Before Covid struck, Dawn, 48, also a member of the Slack group, was an organ transplant coordinator in Philadelphia. Now she is unemployed, and on a recent visit to friends took half an hour to feel comfortable getting out of the car.  

After Dawn was diagnosed with Covid, her anxieties about the disease grew. She experienced chest pains and panic attacks. “I would walk around the house [at night] and make sure everyone was breathing,” she said. In June, as her younger daughter became increasingly concerned and physical causes were ruled out, Dawn sought mental health services. 

She has since been diagnosed with PTSD, generalised anxiety disorder and major depression, and is undergoing an intensive outpatient therapy programme. “I am two months into my therapy and … still having quite a difficult time getting out of my house,” she said.

Mental health services in Italy during the COVID-19 outbreak

Via The Lancet Psychiatry: Mental health services in Italy during the COVID-19 outbreak. Excerpt:

As of March 24, 2020, 63 927 confirmed cases and 6077 deaths due to coronavirus disease 2019 (COVID-19) make Italy one of the most severely affected countries of what has been defined a global pandemic by WHO. In Lombardy, the epicentre of the outbreak in Italy, large metropolitan hospitals in cities like Milan and Bergamo are struggling to contain an exponential growth of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) case presentations requiring hospitalisation. 

Italian mental health services are grounded on a community-based model of care, which is organised according to districts serving a defined geographical area. Multidisciplinary teams of psychiatrists, psychologists, nurses, social workers, occupational therapists, rehabilitation counsellors, and auxiliary staff are distributed across inpatient and outpatient services. These services are coordinated by the department of mental health, which provides a full range of psychiatric care, from acute emergency treatment to long-term rehabilitation.  

Within the ASST Santi Paolo e Carlo department of mental health, our unit serves a population of approximately 350 000 citizens in south Milan. Two inpatient units with a maximum capacity of 29 beds are used for voluntary and compulsory admissions with an estimated length of stay of 12·9 days. These two locked psychiatric wards are in the context of a large university hospital, which includes 18–20 wards of medical and surgical specialties. Over the past 3 weeks, most wards have been converted to COVID-19 intensive and subintensive care units with a joint effort of pneumologists, infectious disease specialists, internists, anaesthesiologists, and a growing number of other specialists. 

On March 8, 2020, the regional authority for welfare ordered a block on all but urgent outpatient services (eg, chemotherapy, radiotherapy, or dialysis), and to maintain full functionality of mental health and substance misuse services. This choice has several implications for mental health workers. First of all, inpatient and outpatient mental health services are recognised by authorities as fundamental services to the community during a global pandemic. Second, given the delay of shared guidelines, individual departments have been challenged to develop an emergency plan within hours. 

In this context, we developed the following recommendations, agreed by the hospital management. 

First, we recommend closure of second-level and third-level outpatient units (eg, perinatal depression, eating disorders, psychiatry for older people, adult neuropsychiatry, adult autism); for these patients, staff have been doing phone calls and video conference-based visits only for emergencies or specific patient requests. 

Second, general psychiatry outpatient services should be restricted to urgent visits and patients who require daily administration of medicines or long-acting injectables; on a case-by-case individual revision, physicians are required to re-assess the need for patients to access the service daily and medication assignment on a biweekly or weekly basis is strongly encouraged; visits are limited to those identified as urgent by the patient or physician and frequent, brief telephone updates are encouraged. 

Third, mental health-care staff (including social workers, rehabilitation technicians, and nurses) are encouraged to actively revise patient charts to identify those with severe mental disorders who are considered to be at increased risk for severe outcomes of COVID-19 (including those with comorbid hypertension, diabetes, chronic obstructive pulmonary disease, and coronary heart disease). These patients should be called via telephone to verify full understanding of the government lockdown procedures and instructed on basic hygiene norms. For those who live with older parents, a clear revision of requirements should be proposed at a time of welfare service restrictions and decreased availability of basic needs such as food. 

Fourth, patients should be advised to only access the emergency room of the hospital after having discussed alternative possibilities with staff from the outpatient service to follow the lockdown procedure and limit chances of infection.