COVID-19 testing and patients in mental health facilities
Authors: Nicole M Benson, Dost Öngür, John Hsu
Journal: The Lancet Psychiatry (2020)

People residing in psychiatric treatment facilities are at high risk for coronavirus disease 2019 (COVID-19). Given the absence of a vaccine or treatment, prevention is the primary guard against adverse events, such as acute respiratory distress syndrome and death. However, prevention requires keeping infected and uninfected patients apart as much as possible. Because some patients with COVID-19 can be contagious yet asymptomatic, especially in the initial days after infection, knowing who is infected requires timely diagnostic testing as well as when and how a patient was exposed and when symptoms began. This could be challenging in individuals with psychiatric or substance use disorders as some are unable to recall or are unaware of potential exposures and symptom onset. Even under optimal conditions, current diagnostic tests do not effectively identify infected individuals and, as more people become infected, the number of false negatives increases. Furthermore, new polymerase chain reaction and serological tests arise each week, often with limited performance information, which adds to the confusion about COVID-19 tests.1Congress of the United States House of Representatives Committee on Oversight and Reform Subcommittee StaffPreliminary findings of the subcommittee's coronavirus antibody testing investigation.https://oversight.house.gov/sites/democrats.oversight.house.gov/files/ECP%20Staff%20Report%20on%20Preliminary%20Findings%20of%20the%20Subcommittee's%20Coronavirus%20Antibody%20Testing%20Investigation.pdfDate: 2020Date accessed: April 29, 2020Google Scholar People with psychiatric conditions or substance use disorders, particularly those in residential treatment or inpatient facilities, are at increased risk of exposure to COVID-19, not only because of the difficulty in evaluating their medical symptoms and history, but also because of frequent patient turnover, limited space and staff, and general resource constraints in many facilities. Patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)—the virus responsible for the development of COVID-19—pose a substantial threat of spreading the virus because they come in contact with other susceptible individuals given the close quarters and communal living environments. Furthermore, these patients are at higher risk for complications of COVID-19 because they frequently have underlying medical conditions that worsen their prognosis (eg, cardiac disease, history of smoking). The vulnerability of institutionalised populations has been noted by clinicians and researchers, and we extend this work by drawing attention to this particularly high-risk subgroup and the problems posed by the performance of current diagnostic technology.2Barnett ML Grabowski DC Nursing homes are ground zero for COVID-19 pandemic.https://jamanetwork.com/channels/health-forum/fullarticle/2763666Date: 2020Date accessed: April 8, 2020Google Scholar, 3Gessen M Why psychiatric wards are uniquely vulnerable to the coronavirus.https://www.newyorker.com/news/news-desk/why-psychiatric-wards-are-uniquely-vulnerable-to-the-coronavirusDate: 2020Date accessed: April 22, 2020Google Scholar One solution would be to test all individuals for COVID-19 before entry into treatment facilities. Testing capacity has improved; however, access remains limited and test sensitivity is modest, which results in false negatives.4Marcotte LM Liao JM Incorporating test characteristics into SARS-CoV-2 testing policy—sense and sensitivity.https://jamanetwork.com/channels/health-forum/fullarticle/2764750Date: 2020Date accessed: April 14, 2020Google Scholar, 5Stein R Study raises questions about false negatives from quick COVID-19 test.https://www.npr.org/sections/health-shots/2020/04/21/838794281/study-raises-questions-about-false-negatives-from-quick-covid-19-testDate: 2020Date accessed: April 21, 2020Google Scholar Test performance is further compromised by variations in test quality, sample collection, and duration of symptom onset, increasing the potential for error.6Koerth M There are not enough COVID-19 tests. There are also too many COVID-19 tests.https://fivethirtyeight.com/features/there-are-not-enough-covid-19-tests-there-are-also-too-many-covid-19-tests/Date: 2020Date accessed: April 21, 2020Google Scholar For example, for a patient presenting with disorganised thinking or altered mental status, determining the date of onset of non-specific symptoms such as a cough might be difficult. Thus, the pretest probability of infection with SARS-CoV-2 could be hard to estimate. Fundamentally, when the sensitivity of a test is limited and the disease course for a patient is unknown, the test outcome could be unreliable and infectious patients could be placed erroneously in treatment facilities. Already, there has been evidence of rapid spread of COVID-19 through long-term care facilities and inpatient psychiatry units,7Ramgopal K Coronavirus in a psychiatric hospital: 'it's the worst of all worlds'.https://www.nbcnews.com/health/mental-health/coronavirus-psychiatric-hospital-it-s-worst-all-worlds-n1184266Date: 2020Date accessed: April 18, 2020Google Scholar, 8Yao H Chen JH Xu YF Patients with mental health disorders in the COVID-19 epidemic.Lancet Psychiatry. 2020; 7: e21Summary Full Text Full Text PDF PubMed Scopus (977) Google Scholar with several reporting patient deaths attributed to COVID-19. Non-pharmacological interventions such as physical distancing and frequent handwashing can be difficult to implement in these types of inpatient or residential settings, as some individuals might not be able to adhere to recommendations. Best practice should involve screening all patients for symptoms of COVID-19, particularly before admission, and a protocol should be implemented for management of inpatients who develop symptoms.9Li L Challenges and priorities in responding to COVID-19 in inpatient psychiatry.Psychiatric Serv. 2020; (published online April 23)DOI:10.1176/appi.ps.202000166Crossref Scopus (85) Google Scholar One potential strategy for improving detection could involve testing all patients for COVID-19 at two or more time points before entry to the inpatient unit to mitigate the risk of false negative results for those with uncertain time of disease onset. Another would be to require sample testing from multiple body sites with more than one sample, analogous to blood culture protocols, which could address concerns about sampling technique. Patients infected with SARS-CoV-2 should remain separated from other people until testing indicates they are no longer infectious. As serological tests and additional diagnostic or risk information become available, diagnostic certainty and detection should improve, at which point existing protocols should be adapted. Because of the potential for rapid spread and serious complications, implementation of such preventative efforts must occur immediately. This should be done in combination with the development of a rigorous evidence base monitoring diagnostic testing and disease transmission in this rapidly changing environment by use of creative study designs. In addition to testing patients, prevention should centre around providing safe conditions for patients and staff. The United States Centers for Medicare and Medicaid Services recently released guidelines allowing for patient separation on the basis of COVID-19 status for patients in long-term care facilities.10Center for Clinical Standards and Quality/QualitySafety & Oversight Group2019 novel coronavirus (COVID-19) long-term care facility transfer scenarios.https://www.cms.gov/files/document/qso-20-25-nh.pdfDate: 2020Date accessed: April 27, 2020Google Scholar Analogous considerations for individuals with mental illness in residential or acute care facilities would probably benefit this population. These recommendations are burdensome, but necessary given increasing reports of rapid spread within facilities housing susceptible individuals. The structure of these facilities and patient populations make monitoring illness course and preventing the spread of COVID-19 more difficult, but these risks can be mitigated by employing testing strategies that attempt to lift the shroud of false negative test results. JH and DÖ received support from NIMH P50MH115846. NMB received support from the National Library of Medicine Biomedical Informatics and Data Science Research Training Grant T15 LM007092. JH reports providing consultation services for Community Servings, Delta Health Alliance, Columbia University, University of Southern California, University of California at Irvine, DaVita, Sidley Austin, Cambridge Health Alliance, and American Association for the Advancement of Science. None of the above consultations were related to COVID-19 or prevention with respect to the outbreak. NMB reports receiving travel awards from American College of Psychiatrists, American Academy of Child and Adolescent Psychiatry, and Partners Healthcare.