Rachel Cooper, Josh Landry, and Angel Petropanagos summarize ethical issues related to pandemic-related practices and policies that disproportionately impact mental health patients and urge decision makers to include the perspectives of marginalized mental health patients in pandemic planning and policy decisions. 

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There has been little public discussion about the impact of COVID-19 pandemic-related practices and policies on mental health services and patients (clients or service users). A Joint Centre for Bioethics working group of ethicists and stakeholders, which includes individuals with lived experiences of mental health, is exploring how the pandemic magnifies ethical issues for mental health patients. This commentary aims to raise public awareness of these issues and summarizes key challenges identified by stakeholders within the Greater Toronto Area. We hope that these issues and the unique perspectives of mental health patients whose lives are most impacted by practices and policies can inform decisions at local, provincial, and national levels. Although many service providers and organizations are working hard to engage with and serve mental health patients during this pandemic, there are opportunities for system-wide coordination and better awareness of and funding for “localized ingenuities” (creative, grassroots solutions that respond to local needs) to further support mental health patients during this pandemic.

First, when healthcare organizations “ramped down” all non-essential or non-urgent services to preserve and reallocate limited resources in preparation for a surge of COVID-19 cases, access to mental health services decreased. Many community and outpatient services moved to virtual or telecare models to comply with physical distancing and limit the use of personal protective equipment as did some essential rights advice and opportunities to challenge findings of incapacity. However, some patients with pre-existing structural disadvantages including poverty, or the inability to access a private space for confidential conversations, are unable to access care via video or phone. Certain treatments, including those that can be lifesaving such as electroconvulsive therapy, are limited because of resource allocation or risks of spreading COVID-19. Other services, like the provision of treatment or enforcement of Community Treatment Orders, may be delayed which can result in harm for patients whose condition deteriorates. Also, no-visitor policies in hospitals or long-term care can restrict mental health patients’ access to social connections or routines that are fundamental for their treatment or recovery.

Photo Credit: Natasha Spencer.  & totalshape.com. Image Description: An inscription that reads “Mental Health”.

Second, in an effort to reduce the spread of COVID-19, mental health patients, like other patient populations, are enduring restrictions on various rights and freedoms. Most commonly, movement has been restricted through self-isolation or quarantine. This restriction may be experienced more negatively by individuals with histories of severe and persistent mental illness, histories of trauma, or lived experiences of homelessness, racialization, or disabilities. Negative impacts on mental health related to self-isolation or quarantine may also include an exacerbation of challenges to activities of daily living, such as personal hygiene. An additional restriction during this pandemic could result from the potentially inappropriate use of the Mental Health Act to force involuntary admission or treatment related to COVID-19. This use of mental health laws to detain persons in relation to COVID-19 has been observed elsewhere among patients who are not acutely distressed as well as those who are precariously housed, “as a result of non-compliance with confinement measures.” Furthermore, many mental health inpatients have had limited or no access off-unit, to hospital grounds, or into the community, due to COVID-19 restrictions, which can negatively impact recovery.

Third, existing income inequalities, which are linked to a higher prevalence of mental illness, may create additional challenges for certain mental health patient populations during the pandemic. People with lived experience of mental health and addictions are disproportionately impacted by being precariously housed. Public health guidance related to physical distancing, isolation, and other issues challenge the implementation of Community Treatment Orders, and are difficult to monitor or enforce in subpopulations who are without, or have unreliable housing. There are also limitations to implementing infection prevention and control measures for such groups (e.g. requiring access to clean water, soap, masks, ability to physically distance). Patients who live in group homes or shelters are particularly vulnerable during this pandemic and may not be allowed to remain if they aren’t adhering to COVID-19 physical distancing requirements.

The COVID-19 pandemic has magnified ethical issues related to access to services, restrictions to freedoms, and existing social inequities, among other things, for people living with mental illness. Yet, it’s also providing opportunities to reimagine how mental health services might be improved moving forward. Ultimately, the unique needs, priorities, and values of mental health patients should inform practice and policy decisions. Opportunities for engagement and inclusivity mean being attentive to intersectional identities and including people of colour, immigrants, refugees, and people living with other marginalized identities who face a disproportionate impact to their mental health. There are also opportunities for recognition and support of localized ingenuities that are addressing the needs of various marginalized mental health patients. We advocate for the perspectives of mental health patients, especially those who are most marginalized, to inform practice and policy agendas.

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Rachel Cooper is a Research Analyst in Education at the Centre for Addiction and Mental Health (CAMH). @RachBCooper

Josh Landry is an Ethicist at Ontario Shores Centre for Mental Health Sciences, and a CORE Member of the University of Toronto’s Joint Centre for Bioethics.

Angel Petropanagos is an Ethicist at William Osler Health System and a CORE Member of the University of Toronto’s Joint Centre for Bioethics. @APetropanagos

This commentary was developed in collaboration with members of the Joint Centre for Bioethics CORE Mental Health working group.