A health care worker speaks to a test patient at a COVID-19 assessment centre in Ottawa. An issue for those trying to contain the outbreak is that some of those with mental illness may not be able to understand the necessity for physical distancing. (The Canadian Press)
This column is an opinion by Dr. Andrew L. Smith, a psychiatrist at The Ottawa Hospital, and Dr. Neil de Laplante, a final-year psychiatry resident at the University of Ottawa. For more information about CBC’s Opinion section, please see the FAQ.
As COVID-19 moves rapidly through our communities, we all see the incredible strain it has put on our health-care system and economy, but we are just beginning to appreciate its impact on mental health.
While necessary and important, the public health measures currently mandated by the government may lead many of us to feelings of isolation and powerlessness, both of which are known to be associated with depression, anxiety, and even suicide. The emotional effects of the COVID-19 pandemic on our society could be catastrophic for a mental health system which is already chronically under-resourced, and it is the vulnerable who will suffer most if the system does not hold.
All Canadians will face hardship over the coming months. Disrupted routines, inaccessible family support, and financial upheaval are real and important challenges which are not to be minimized. But the nearly insurmountable obstacles faced by those with severe and persistent mental illnesses during COVID-19 have been met with a deafening silence.
The day-to-day invisibility of the homeless, poorly housed, and institutionalized is such that their story simply does not have the appeal of a collapsing economy or a large government relief package. As is far too often the case for the voiceless members of society, their story has not begun to be told until it is likely already too late.
At the best of times relegated to the margins of society, individuals with severe and persistent mental illnesses like schizophrenia, bipolar disorder, or treatment-resistant depression often live precarious lives in places like jails and homeless shelters, where physical distancing is impractical and previous outbreaks have spread rapidly through entire facilities. Indeed, many of the most unwell individuals, especially those with schizophrenia, may not be able to understand the necessity for physical distancing even if they are fortunate enough to live in a setting where it would be possible to do so.
While COVID-19 mortality rates are highest in the elderly, the research is equally clear that having poor health before contracting the novel coronavirus increases the risk of death at any age: the sicker you are to begin with, the more likely you are to die from COVID-19.
Those Canadians with chronic mental illnesses have much higher rates of smoking and lung disease (up to 90 per cent in schizophrenia), more chronic medical conditions, and less consistent access to medical care than the general population.
The overall reduction in life expectancy for those with severe mental illness is estimated to be 10 to 20 years.
On March 28, Montreal declared a state of emergency due to fears of a COVID-19 outbreak among the homeless population, prompting efforts to properly house individuals who may be affected. The unfortunate reality is that these efforts may very well be too late, and many of these vulnerable people could die as a result.
A health care worker hands a hot drink to a man at a homeless outdoor day centre in Montreal on March 29. (Graham Hughes/The Canadian Press)
During a pandemic, how we care for our most vulnerable affects all Canadians. If we do not contain outbreaks in places like shelters and jails, providing the people housed there with the care that they need, the volume of cases from these locations alone could be enough to swamp the health care system, leading to higher overall mortality rates for anyone requiring hospital admission.
In Ottawa, there were approximately 1,550 people in jails or homeless shelters at the start of the pandemic. If there is an outbreak of COVID-19 in this group and we assume hospitalization rates consistent with those seen internationally, then 20 per cent of these people could require in-patient care. We fear our local hospitals could not accommodate this surge of more than 300 patients, and the reality in cities and communities across this country is the same.
As with any medical treatment, there are side effects associated with aggressive physical distancing measures, and some Canadians who are otherwise well may require hospital-based mental health care during this incredibly difficult time. Unfortunately, the in-patient psychiatry wards across the country are far from immune to the risks of an outbreak.
With this knowledge, hospitals have acted quickly to approve changes to psychiatric wards, but with looming shortages in essential protective equipment affecting all areas of the health-care system and the pressing need for these limited resources in areas where COVID-19 patients are receiving life-saving treatment, an outbreak in a psychiatric unit could be catastrophic.
The best available data in this pandemic so far has indicated that COVID-19 infection rates on a psychiatric ward in South Korea were above 90 per cent.
It should not take a pandemic for us to see that the conditions in homeless shelters, jails, and other group-living environments are unsafe for people with chronic mental illnesses and pose a risk to public health.
The recent opening of a COVID-19 treatment and isolation centre for the homeless in downtown Ottawa is a step in the right direction, and similar efforts across the country are also to be commended, but the long-term solution to these issues is not merely a matter of containing the disease.
COVID-19 visitation bans for people in institutions put many at risk in other ways
The unsung heroes in local and national community organizations are not miracle workers, and can hardly be blamed for the results of chronic under-funding. It takes leaders in government with moral fortitude and strength of character to make the necessary, but likely unpopular, decisions that are needed during unprecedented challenges.
History will be kind to leaders who govern with kindness. Now more than ever we must provide adequate and sustainable housing for our most vulnerable citizens.
Every crisis presents us with opportunities to do things differently, to demonstrate our resiliency, and to fully inhabit the best versions of ourselves. Those of us fortunate enough to have food and shelter now have a unique opportunity for personal growth and learning if we choose to see it that way. As a society, we have an opportunity during this escalating crisis to treat our vulnerable people with dignity, and to attend to their needs when it is most necessary.
We must not turn a blind eye to their suffering. The stakes, for all of us, are far too high.