Covid19: Interim Considerations for State Psychiatric Hospitals 

Updated: May 8, 2020 

Individuals with serious mental illness, particularly those who are older or who have chronic medical 

conditions, can be at higher risk for illness with Covid-19. It is important that mental health facilities be 

prepared for Covid-19 to keep both patients as well as healthcare staff safe, and this may include proactive 

measures to reduce the psychiatric disease burden caused by the COVID-19 pandemic. While SAMHSA 

has preferentially recommended outpatient treatment during the COVID-19 crisis as telehealth 

technology and social distancing can be more effectively implemented, inpatient psychiatric care will 

inevitably be required for a number of patients. Psychiatric care on an inpatient service is typically 

reserved for the most severe conditions, and inpatient care at state psychiatric hospitals is typically 

reserved for the most refractory cases.

State psychiatric hospitals have typically developed Disaster Plans that require the establishment of 

protocols and relationships with other local government and healthcare entities. Each accredited facility 

should have existing infection control plans that are designed to address scenarios such as for MRSA, HIV, 

Hepatitis, and infectious diseases. Plans to manage COVID-19 at the facility should now be in place at all 

of these sites. However, in contrast to general healthcare settings, psychiatric facilities may experience

unique challenges in prevention and infection control.

In addition to consideration of infection control guidelines with the goal of minimizing spread, described 

below, it is also important to be aware of the psychological impact of quarantine and major disruptions 

to everyday life. Healthcare workers already support the mental health of their patients, but they also 

need to attend to their own needs and those of their families. i

 It is important to provide access to 

accurate information sources such as the Centers for Disease Control and Prevention (CDC).ii The 

American Psychiatric Association has resources on the mental health impacts of Covid-19.iii Others also 

have studied and reported on the adverse effects of quarantine on individuals.iv Patients at mental health 

facilities are vulnerable both to the infection itself, but also to worsening anxiety, mood, or psychosis 

during this time. Given the uncertainty and rapid change associated with the virus, anxiety and distress 

should be anticipated.

v

 

In response to the CDC recommendations for all healthcare facilities, SAMHSA offers further 

considerations specific to psychiatric hospitals.

1) Reduce morbidity and mortality:

a. Many patients admitted to state psychiatric facilities have a number of health comorbidities 

that increase their risk of developing severe symptoms from COVID-19 infection. These 

include the very high incidence of tobacco use with resultant COPD and lung disease or 

metabolic syndrome with diabetes, hypertension, and heart disease. In addition to intake 

screening and testing when appropriate, these patients should be informed of their elevated 

risk and frequent follow up COVID-19 screening should be performed. These patients should 

be segregated from new or symptomatic patients due to their higher stratified risk.

b. SAMHSA recommends that when possible all new admissions be segregated until COVID-19 

testing results are available for review. For new and existing patients, all suspected and 
symptomatic cases should be immediately segregated and transferred, if necessary, to 

appropriate healthcare facilities with capabilities of treating more severely ill patients. 

Advanced directives should be updated on all existing patients and should be completed for 

new patients upon admission. Psychiatric hospitals may not have the capacity to respond to 

severe respiratory infections.

c. Symptoms associated with psychotic illness, such as paranoia or anxiety disorders such as 

OCD may worsen during the COVID-19 crisis, and patients with these conditions may require 

additional redirection as they are exposed to more negative news about the pandemic. 

2) Considerations when attempting to minimize disease transmission: 

a. Limit the movement of COVID-19 patients (e.g., have them remain in their room) 

1. Capacity of informed consent may be lacking for those admitted involuntarily. Individuals 

with serious mental illnesses may have varying degrees of capacity to follow appropriate 

infection control procedures, therefore it is important to establish the patient’s capacity 

or lack of capacity when developing the modified COVID-19 treatment plan. Those who 

lack capacity may not fully appreciate the dangers of exposure. The nature of the 

therapeutic milieu may make minimal contact rules more challenging. Patients without 

capacity may require more frequent reorientation to the rules, more activities one on one 

with staff, and an individual room. While restrictions of movement outside of their room 

will be implemented for some patients, the presence of mental illness does not mean an 

individual is incapable of practicing safe hygiene and social distancing practices. Staff 

should make the assessment based on the patient’s capacity and behavior and carefully 

avoid stigmatizing those with mental illness. 

2. Take steps to prevent known or suspected COVID-19 patients from exposing other 

patients. 

a. It is advisable when possible to segregate the areas or individual floors as nonCOVID-19 and COVID-19. This may require further restrictions in movement and 

accommodations should be explored. For instance, the dayroom is often the 

location where patients congregate and receive the therapeutic benefits of the 

milieu. Having an alternate dayroom location, when possible, could help to 

reduce a patient’s anxiety about exposure and maintain continuity. Also, those 

patients with severe anxiety disorder or paranoia may feel some relief in 

segregation as their risk of exposure is reduced. 

b. Identify dedicated staff to care for COVID-19 patients. 

c. Psychosocial group treatment sessions may have to be suspended if these 

sessions cannot be safely modified with fewer individuals reliably practicing social 

distancing or with video technology available. One on one psychosocial 

counseling sessions with social distancing can be considered.

b. Another important consideration is that most psychiatric facilities have restricted access with 

limited visitation. This is stigmatizing in itself as these units are locked for the security of the 

patients and staff. During the COVID-19 crisis, visitation by friends, family, and various 

stakeholders may be curtailed. This necessary step to reduce exposure risk can leave the 

patients feeling more isolated. When visitation is restricted staff of all levels should be aware 

of this and take steps to reach out and check on patients more often. 
c. Often family members and community support are vital components of the patients’ 

recovery. These individuals are heavily involved in the patient’s lives and have traditionally 

participated in family meetings and therapy. When safely implemented, this important part 

of treatment should continue. Continuing these meetings by confirmed appointment in 

designated area, frequently sanitized between visits, can facilitate disposition planning, 

reduce recidivism rates, and improve patient satisfaction. Such dedicated spaces could also 

be used for visitation with a schedule and protocol for safe interaction including social 

distancing and sanitizing after each use. Alternative steps depending on resources could 

include setting up a computer with a webcam and microphone in another area within the 

facility that can be cleaned between uses. This would allow patients and family members to 

communicate visually as well as via audio. 

d. Post visual alerts (signs, posters) at entrances and in strategic places providing instruction on 

hand hygiene, respiratory hygiene, and cough etiquette. For patients with limited capacity 

frequent reorientation to these is required. 

e. Observe newly arriving patients/residents for development of respiratory symptoms in an 

area designated for new patient evaluation. 

f. Confirm or obtain psychiatric advance directives to facilitate medication and treatment 

compliance in the event of change of capacity for informed consent.

3) Protect healthcare personnel

a. Ensure that staff are aware of sick leave policies, and staff should be encouraged to 

stay home if they are not feeling well. 

b. Limit visitors to the facility and perform screening on all who enter the facility.

c. Ensure cleaning and disinfectant supplies are available as well as tissues, waste 

receptacles, and alcohol-based hand sanitizer. 

d. Ensure housekeeping and dietary personnel frequently sanitize and disinfect all areas 

where staff and patients can be found. 

e. Healthcare workers may also develop symptoms of anxiety during this crisis, 

therefore supervisors and managers should perform more frequent meetings and 

checks with frontline staff. Flexibilities when possible should be accommodated. 

Occupational health departments should now be actively engaging staff and 

implementing plans for staff that are experiencing greater stress and anxiety. 

Resources should be made available for staff experiencing increased stress, 

depression, or substance use disorder relapse. 

4) Preserve healthcare system functioning

a. As staffing shortages may become more common as healthcare workers also become infected 

and are quarantined, it is important that supervisors and managers establish contact with 

outside staffing sources to ensure continuity of care. More flexibility in task assignment may 

be an option, for instance, the ability to “buddy team” with paraprofessional staff if regular 

staff ratios are limited due to staff illness. 

b. As the anxiety and fear from COVID-19 can preclude improvement in the patient’s psychiatric 

condition, providers should instruct staff to engage patients in more one to one activities and 
should be mindful of this consideration when ordering prn medications to keep the patient 

as comfortable as possible. It is important to note that these measures should be 

implemented in conjunction with the utilization of clear clinical indications and, when 

applicable, validated psychiatric screening instruments. For example increased screening for 

worsening symptoms may prompt detection earlier and inform changes to the treatment 

plan. These measures may prevent escalation of symptoms of agitation, psychosis, or loss of 

control and thereby avoid seclusion and restraints. Additionally staff should be mindful that

overcrowding and restrictions can be potential triggers for behavioral instability. These 

seclusion events are stressful for staff and traumatic for both the patients and to those 

patients who observe such incidents. The significant negativity following such events can, in 

some instances, temporarily transform the nature of the psychiatric unit. Therefore, 

identifying and addressing issues prior to the outburst should be the goal.

c. Discharge planning may be more difficult. As many step down residential facilities and 

outpatient facilities are limiting intakes, social workers may find it more difficult to plan 

disposition of patients. This may result in longer lengths of stay. The treatment team as well 

as utilization review staff should adjust with this expectation. Also, questions may arise about 

the risk of the patient’s exposure to those at the receiving facility. Repeat testing for COVID19 should ideally be completed prior to discharge as further reassurance for receiving 

facilities. More resources from varied sources should be mobilized such as family, friends, 

assisted living, county resources, and local charity. 

There are a number of steps that healthcare facilities can take to be prepared should an individual 

become infected with Covid-19.

vi Psychiatric hospitals should follow all infection control guidelines as 

stipulated by the CDC. For general infection control guidelines, see 

https://www.cdc.gov/coronavirus/2019-ncov/infection-control/index.html. vii 

During this rapidly changing situation, mental health providers should refer to the CDC website for the 

most updated information. Individuals with serious mental illness are at particular risk related to cooccurring medical conditions as well as challenges with accessing healthcare. Attention to proper 

prevention and infection control procedures as well as attention to the psychological impacts of the virus 

are important in reducing morbidity and mortality for this vulnerable population. 

i Sustaining the Well-Being of Healthcare Personnel during Coronavirus and other Infectious Disease 

Outbreaks 

https://www.cstsonline.org/assets/media/documents/CSTS_FS_Sustaining_Well_Being_Healthcare_Pe

rsonnel_du ring.pdf.pdf Accessed March 17, 2020 

ii Centers for Disease Control, Coronavirus https://www.cdc.gov/coronavirus/2019-

ncov/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2Findex.html 

Accessed March 17, 2020 

iii Covid-19 Mental Health Impacts Resources for Psychiatrist https://www.psychiatry.org/newsroom/apablogs/apa-blog/2020/03/covid-19-mental-health-impacts-resources-for-psychiatrists 

Accessed March 17, 2020 

iv The Psychological Impact of Quarantine and How to Reduce It: Rapid Review of the Evidence. Lancet

2020; 395: pgs. 912-20. Brooks, Samantha K. and Webster, Rebecca K. and Smith, Louise E. and 

Woodland, Lisa and Wessely, Simon and Greenberg, Neil and Rubin, G. James

 
 v Caring for patient mental well-being during coronavirus 

https://www.cstsonline.org/assets/media/documents/CSTS_FS_Caring_for_Patients_Mental_WellBeing

_during_C oronavirus.pdf.pdf Accessed March 17, 2020 

vi Ibid 

vii Infection control guidelines https://www.cdc.gov/coronavirus/2019-ncov/infectioncontrol/index.html. Accessed March 17, 2020