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Face mask exemptions, psychiatric patients, and COVID-19

Published online by Cambridge University Press:  07 December 2020

José Luis Ayuso-Mateos
Affiliation:
Department of Psychiatry, Universidad Autónoma de Madrid, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), CIBERSAM, Madrid, Spain
Joan B. Soriano*
Affiliation:
Department of Pneumology, Hospital Universitario de la Princesa, Universidad Autónoma de Madrid, Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
Julio Ancochea
Affiliation:
Department of Pneumology, Hospital Universitario de la Princesa, Universidad Autónoma de Madrid, Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
*
*Joan B. Soriano, E-mail: jbsoriano2@gmail.com

Extract

It has been compulsory to wear face masks in all public spaces, both indoor and outdoor, since May 21, 2020 throughout Spain [1], a measure intended to prevent the spread of coronavirus disease 2019 (COVID-19). However, there are some exceptions to this rule, including “… People for whom the use of a mask is inadvisable for duly justified health reasons, or who, due to their disability or dependency, present behavioural alterations that make its use unviable.

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This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
© The Author(s), 2021. Published by Cambridge University Press on behalf of European Psychiatry Association

It has been compulsory to wear face masks in all public spaces, both indoor and outdoor, since May 21, 2020 throughout Spain [1], a measure intended to prevent the spread of coronavirus disease 2019 (COVID-19). However, there are some exceptions to this rule, including “… People for whom the use of a mask is inadvisable for duly justified health reasons, or who, due to their disability or dependency, present behavioural alterations that make its use unviable.

Such exemptions are not unique to Spain. For example, in England wearing a face covering is mandated since July 2020, but exemptions include “… not being able to put on, wear or remove a face covering because of a physical or mental illness or impairment, or disability” [2].

We believe that the generalized use of this exemption may carry significant risk of COVID-19 for many of the millions of mental patients in Spain, England, or elsewhere worldwide [3]. A recent paper by Wang et al. [Reference Wang, Xu and Volkow4], concludes that patients diagnosed with a mental disorder in the last 12 months have a significantly higher risk of COVID-19 infection than patients without mental disorders, and they also present a worse outcome, as evidenced by higher rates of hospitalization and death.

Although several research groups have already examined the possible future magnifier effects of COVID-19 on mental health, and how to mitigate them [Reference Kuzman, Curkovic and Wasserman5, Reference Sheridan Rains, Johnson, Barnett, Steare, Needle and Carr6], there is still very limited evidence regarding how the use of face masks can affect mental health. A recent study from Poland examined the impact of face mask mandates on psychopathological manifestations, and found lower scores on all of the General Health Questionnaire-28 (GHQ-28) subscales after the implementation of such mandates [Reference Szczesniak, Ciulkowicz, Maciaszek, Misiak, Luc and Wieczorek7]. We agree with these authors’ findings that face masks not only provide protection against COVID-19, but also increase the individuals’ level of perceived self-protection, as well as the level of social solidarity, thereby improving mental wellbeing. A study conducted between March and early April 2020 in healthcare workers across three regions in China found that the strongest significant risk factor for depression was reporting difficulty obtaining face masks [Reference Lam, Arora, Grey, Suen, Huang and Li8].

There are medical and legal criteria to orient the debate on whether medical exemptions for masking are necessary or appropriate [Reference Dorfman and Raz9], and indeed similar exemptions for respiratory patients have been strongly questioned [Reference Soriano, Anzueto, Bosnic Anticevich, Kaplan, Miravitlles and Usmani10, Reference Samannan, Holt, Calderon-Candelario, Mirsaeidi and Campos11]. Somehow, the ongoing uncertainty resembles past exemptions on tobacco restriction is psychiatric venues [Reference Brandt12]. We concur that most/all health systems will need to adapt the delivery of mental health care to the demands of COVID-19 and both its direct and indirect consequences [Reference Fiorillo and Gorwood13].

For our part, we strongly call on clinicians to be extremely cautious in facilitating any face mask exemption certificates to their patients, given the very limited available evidence on face masks and COVID-19 impacting mental health, and the complete absence of evidence that the potential unpleasantness of wearing a face mask and any associated anxiety might destabilize psychiatric patients. On the contrary, the emphasis should be on trying to educate everyone—regardless of their mental health status—about how to reduce exposure to COVID-19. As to that minority of cases in which, after a personalized assessment of the individual and contextual circumstances, clinicians consider that there are factors which make the use of a mask unviable, other measures such as other protective equipment, limiting external contacts or exposures, and else, should be recommended to minimize exposure to COVID-19.

Acknowledgments

JB Soriano is Senior Consultant at the COVID-19 Clinical Management Team, WHO Health Emergency Programme, World Health Organization HQ, Geneva, Switzerland.

Conflict of Interest

The authors declare no conflict of interest.

References

Estado de alarma. Medidas urgentes [State of Emergency: Urgent measures]. Boletín Oficial del Estado: 20 May 2020, no. 142, https://www.boe.es/boe/dias/2020/05/20/pdfs/BOE-A-2020-5142.pdf [accessed 22 October 2020].Google Scholar
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Wang, Q, Xu, R, Volkow, ND. Increased risk of COVID-19 infection and mortality in people with mental disorders: analysis from electronic health records in the United States. World Psychiatry. 2020. Online ahead of print. doi:10.1002/wps.20806.CrossRefGoogle ScholarPubMed
Kuzman, MR, Curkovic, M, Wasserman, D. Principles of mental health care during the COVID-19 pandemic. Eur Psychiatry. 2020;63(1):e45. doi: 10.1192/j.eurpsy.2020.54.CrossRefGoogle ScholarPubMed
Sheridan Rains, L, Johnson, S, Barnett, P, Steare, T, Needle, JJ, Carr, S, et al. COVID-19 Mental Health Policy Research Unit Group. Early impacts of the COVID-19 pandemic on mental health care and on people with mental health conditions: framework synthesis of international experiences and responses. Soc Psychiatry Psychiatr Epidemiol. 2020;17:112. doi: 10.1007/s00127-020-01924-7.Google Scholar
Szczesniak, D, Ciulkowicz, M, Maciaszek, J, Misiak, B, Luc, D, Wieczorek, T, et al. Psychopathological responses and face mask restrictions during the COVID-19 outbreak: results from a nationwide survey. Brain Behav Immun. 2020;87:161162. doi: 10.1016/j.bbi.2020.05.027.CrossRefGoogle ScholarPubMed
Lam, SC, Arora, T, Grey, I, Suen, LKP, Huang, EY, Li, D, et al. Perceived risk and protection from infection and depressive symptoms among healthcare workers in mainland China and Hong Kong during COVID-19. Front Psychiatry. 2020;11:686. doi: 10.3389/fpsyt.2020.00686.CrossRefGoogle ScholarPubMed
Dorfman, D, Raz, M. Mask exemptions during the COVID-19 pandemic—a new frontier for clinicians. JAMA Health Forum, https://jamanetwork.com/channels/health-forum/fullarticle/2768376 [accessed 17 September 2020].Google Scholar
Soriano, JB, Anzueto, A, Bosnic Anticevich, S, Kaplan, A, Miravitlles, M, Usmani, O, et al. Face masks, respiratory patients and COVID-19. Eur Respir J. 2020:2003325. doi:10.1183/13993003.03325-2020.CrossRefGoogle ScholarPubMed
Samannan, R, Holt, G, Calderon-Candelario, R, Mirsaeidi, M, Campos, M. Effect of face masks on gas exchange in healthy persons and patients with COPD. Ann Am Thorac Soc. 2020. doi:10.1513/AnnalsATS.202007-812RL. Online ahead of print.CrossRefGoogle ScholarPubMed
Brandt, AM. The cigarette century: the rise, fall, and deadly persistence of the product that defined America. Cambridge, MA: Basic Books; 2009.Google Scholar
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