With COVID-19 spreading across the United States, governmental bodies at various levels are taking steps to address the anxiety it has caused. In these circumstances, it’s easy to overlook the impact of COVID-19 on people with serious mental-health issues, such as schizophrenia and bipolar disorder. Without strong and immediate action, the severely mentally ill could exacerbate the spread of COVID-19 and place themselves and others in danger. For starters, here are a number of important steps, most of which could be taken simply by suspending or revising regulations currently in place.
First of all, on the federal level, the government should swiftly suspend Medicaid’s IMD (Institutes for Mental Disease) exclusion and its prison exclusion. Those provisions prevent states from using Medicaid funds to help seriously mentally ill adults who are in psychiatric hospitals and jails, on the grounds that they should be the state’s responsibility. These provisions cause states to empty psychiatric beds and withhold treatment from the incarcerated. This means that the seriously mentally ill who contract coronavirus will be sent to already overcrowded emergency rooms that are ill-equipped to serve them, instead of to specially equipped psychiatric hospitals. The prohibitions on using Medicaid for the incarcerated and hospitalized mentally ill should be waived during the pandemic so that they can be treated appropriately.
Most parents of the seriously mentally ill would love to have their children at home, but when the symptoms of the illness don’t prevent that, financial constraints often do. If a parent provides housing for a mentally ill loved one, he or she gets penalized: The child’s Supplemental Security Income (SSI) disability check is reduced by one-third, making it harder to contribute to the family’s food, clothing, and household expenses. The federal government should abolish this one-third-reduction rule during the pandemic, and preferably permanently, to let parents reduce the demands their children place on already overextended social services. In fact, while our lawmakers are increasing unemployment benefits and making them easier to access, they should also increase the amount of disability payments, because many social services that people with mental illness rely on, such as transportation, have shut down.
People with serious mental illness often need medications to keep them from becoming psychotic and delusional. To ensure that this key connection goes unbroken, the federal government should issue emergency orders requiring all psychiatric prescriptions to be written and filled for 90 days, rather than just 30 days. This may require amending Medicaid, Medicare, or insurance regulations, but it will reduce the need to travel for refills (or even eliminate it, if the patient uses a mail-order pharmacy, which requires a prescription of 90 days). Finally, the federal government should take a close look at the supply chain for psychoactive medications so any potential global-supply-line interruptions can be addressed while there is still time.
The federal government is currently considering giving hotel operators a cash bailout with no strings attached. Instead, the government should rent rooms from hotel chains to house the homeless, many of whom suffer from serious mental illness. This scheme, which is already being tried in California, will help stop homelessness, temper the spread of coronavirus by enabling the homeless to self-isolate, and provide income for hotels. Police and mental-health departments should make sure the hotels are properly patrolled and residents are provided on-site services. Hotels could decline to lease the rooms to the government, but by doing so, they would forfeit their eligibility for bailout funds.
States and localities also need to take action. State Medicaid directors should immediately apply for “1115 waivers,” which would allow the use of Medicaid funds to support state psychiatric hospitals. The federal government should instantly approve the waivers.
States should resist the temptation, which we are already seeing, to divert mental-health resources away from programs for the seriously mentally ill, who may become homeless, arrested, violent, or incarcerated without treatment, to programs that address coronavirus-driven anxiety and sadness among the otherwise healthy public. Anxiety and sadness are quite understandable, of course, but they are normal reactions to a crisis, not mental illnesses. Social networks can often address them by phone. Complaints about anxiety and sadness should be carefully triaged, and only if they are long-lasting and severe should mental-health workers be taken off assignment with the seriously mentally ill to address them.
To counteract the shortage of psychiatrists, and what is likely to be a greater demand for them, states that haven’t given prescribing privileges to psychiatric nurse practitioners and properly trained psychologists should immediately do so. States should also make it easier for pharmacies to make deliveries, perhaps by contracting with Uber, Lyft, or food-delivery services. The federal government has made telemedicine easier to use, and states should make use of that as well. In addition, states should hire and mobilize students from shuttered social-work schools to look in on the seriously ill, reassure them, and connect them to food and services as needed.
Instead of ending visitations by friends and families in jails and psychiatric hospitals, states should arrange safe ways to conduct them, for example by requiring temperature checks and handwashing before visitors enter facilities and setting up visitation tables that maintain social-isolation distances. Officials should also expand e-visitation options, including Skype, Facetime, Facebook, and closed-circuit video. States should also waive all fees and unnecessary limits on phone calls from or to jails, prisons, and psychiatric hospitals so that families can maintain contact in these difficult times.
And all citizens should make it their job to help and stay in touch with the seriously mentally ill, who are more likely than usual to be forgotten in the present crisis. Communities of faith and others can set up phone trees to maintain contact with the housebound mentally ill, help them register themselves for at-home food-pantry services or Meals on Wheels, or give them gift certificates to restaurants where they can get meals to go or have them delivered (while supporting vulnerable local businesses!).
The seriously mentally ill can become infected by viruses just like everyone else, and they may have lost touch with reality or any social network that can help them address the virus, or they may be afraid of doctors. When they tell someone about symptoms, the symptoms are often written off as figments of their imagination. If it’s coronavirus, such write-offs could be dangerous, and could lead to further spreading of the disease. So everyone should pay attention.
If government at all levels and private citizens take these steps immediately, it can help reduce the tragedy for all of us that will inevitably occur if we allow the seriously mentally ill to go untreated.