In December 2019, Wuhan, a city in China, reported an outbreak of a novel coronavirus, later named SARS-CoV-2, or COVID-19. Its global spread caused countries to take varying measures to contain the virus, to differing effect.Reference Anderson, Heesterbeek, Klinkenbeek and Hollingsworth1 Equally, health services had to quickly adapt to minimise risk of contamination of staff and patients. Recent guidance provided by the World Health Organization2 highlighted changes that physical healthcare services can implement to maintain service delivery and mobilise the workforce. There is also growing literature emphasising the importance of service changes to support staff well-being during contagions,Reference Kang, Li, Hu, Chen, Yang and Yang3,Reference Son, Lee, Kim, Lee and You4 and the provision of additional mental health services as a response to increased mental health difficulties in the general public.Reference Ahmed, Ahmed, Aibao, Hanbin, Siyu and Ahmad5–Reference Zhai and Du7 However, there is little guidance how mental healthcare services should adapt service provision to better support staff and patients and maintain service delivery despite a number of challenges within these settings, such as the effect of isolation on increasing mental health symptoms,Reference Garety, Kuipers, Fowler, Freeman and Bebbington8,Reference White, Bebbington, Pearson, Johnson and Ellis9 an increase in the number of patients needing to access in-patient settings,Reference Mgutshini10 increased patient vulnerability (particularly when faced with social circumstances such as unemployment,11 which has increased as a result of the COVID-19 pandemic) and poor service provisions owing to reduced funding.12 Additionally, patient lack of capacity could affect patient ability to adhere to new guidelines around contagion containment,Reference Lowry13 such as social distancing. Because of the relative lack of literature on mental health service adaptations during the COVID-19 pandemic, this work was undertaken to systematically review and synthesise literature regarding adaptations to practice in mental health settings during global and localised (non-global)/viral or infectious disease outbreaks. By exploring current and historical recommendations relating to COVID-19 and other airborne, human-to-human contact and blood and body fluid contagions such as Ebola, SARS and HIV outbreaks, which also prove fatal for humans, we aim to provide a guide for good practice and service adaptations across mental health services to minimise risks and better support mental health workers and patients during global and localised contagion.
Method
Systematic review
Search strategy
A review protocol was registered (International Prospective Register of Systematic Reviews registration number: CRD42020186969) before starting data searching and extraction. The review adopted the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.Reference Moher, Liberati, Tetzlaff and Altman14 Searches were undertaken using the Allied and Complementary Medicine database (AMED), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Medline, PsycINFO and Web of Science. Databases were searched from inception to 30 April 2020, using search terms listed in Table 1. Searches were limited to English-language publications (or those translated to English). Additional studies were identified by scanning the references of those included papers.
Search strategy
Eligibility criteria
Inclusion criteria were peer-reviewed articles (qualitative and quantitative studies, literature reviews, briefings, reflective/discussions based on author experience and commentaries/point-of-view based on author expertise), federal government guidelines, official international guidelines and World Health Organization recommendations; reference to mental health services/staff/patients (including out-patient and in-patient services); and reference to any adaptations to practice during any global pandemic, epidemics or localised infections (non-global contagions)/outbreaks related to viruses and infectious diseases.
Exclusion criteria were books/book chapters, conference abstracts and newspaper articles; sole reference to physical health services, mental health in the general population and mental health needs in physical health staff; sole reference to any virus or diseases that do not result in a pandemic, epidemic or localised infection; no mention of adaptations to practice; and description of provision of mental health services for people with infectious diseases (e.g. HIV) rather than service adaptations in response to an outbreak.
Study selection
All studies meeting the eligibility criteria were imported into a referencing software program (Endnote version 9 for Windows) and duplicate references identified and deleted. Initially, the first author independently screened titles and abstracts identified from the systematic search for relevance, using the inclusion criteria set out above. The second author independently screened 50% of the titles and abstracts of the literature. Where both authors agreed on exclusions, titles and abstracts were discarded. Where both authors agreed on inclusion the full-text article was retrieved. Disagreements were resolved through discussion between both authors. Following discussion, both authors agreed either the paper did or did not meet criteria, when uncertainty remained, full texts were retrieved. Moderate levels of agreement were found between the raters (κ = 0.583) at the title and abstract stage. In the second stage, both authors independently assessed 100% of the full texts against the inclusion criteria. Where both authors agreed on exclusion, full texts were discarded and reasons for exclusion noted. Almost perfect agreement were found between the raters (κ = 0.975). Disagreements regarding inclusion were discussed by the first and second author, and where disputes were not resolved, a third reviewer arbitrated.
Assessing rigour and credibility of included studies
To enable the reader to judge rigour, eligible papers were described using the Critical Appraisal Tool to Assess the Quality of Cross-Sectional Studies (AXIS) (Supplementary Table 1).Reference Downes, Brennan, Williams and Dean15 The tool was selected because of the different study designs and methodologies the review incorporated. The authors agreed on definitions of the quality appraisal tool questions (see Supplementary Table 2 available at https://doi.org/10.1192/bjo.2021.20). The first stage involved the first and second author independently assessing the quality of the papers. The second stage involved checking the authors’ level of agreement; the authors had complete agreement.
Data extraction and analysis
Data were extracted using a data extraction tool developed in Microsoft Excel version 16 for Windows by the authors, which required the authors to extract author, year, country, article type, method, sample, results and changes to service. Data were extracted from each paper from the relevant sections of the included papers: recommendations within commentaries and guidelines, plus methods, results and discussion sections. The first author checked 100% of the data extracts extracted by the second author. and the second author checked 54% of the data extracts of the first author. There were no disagreements with the data extracted. Data were analysed using thematic analysis informed by Braun and Clarke,Reference Braun and Clarke16 because of the range of different studies included in the systematic review and a lack of prior theory. First, the first and second author familiarised themselves with the data to systematically assess the findings from each study, understand similarities and difference between papers and highlight important paper characteristics. The data were coded initially by using an inductive, data-driven approach, by the first author. When exploring relationships within and between papers, data saturation was achieved after ten papers. Codes that appeared related were grouped into ‘code families’ by the first author. The first author wrote a codebook including a brief description about each code family. The second author then applied the codebook to the remaining papers. Following completion of initial coding, the codebook was refined through discussion between the first and second author. After the codebook was refined, the first and second author dual-coded each other's coding. There were no conflicts. The first author reviewed code families for similarities and generated themes; themes were then discussed between the first and second author, who collaboratively refined, defined and named the themes.
Results
Overview of studies and quality appraisal
Nineteen papers met inclusion criteria (Fig. 1, Table 2). There were six correspondence/point-of-view papers,Reference Druss21,Reference Kim and Su26,Reference Percudani, Corradin, Moreno, Indelicato and Vita31,Reference Ripp, Peccoralo and Charney33,Reference Zhu, Chen, Ji, Xi, Fang and Li35 five research papers,Reference Amaratunga, O'Sullivan, Phillips, Lemyre, O'Connor and Dow17,Reference Gaspard, Mosnier, Gunther, Lochert, Larocca and Minery23,Reference Liebrenz, Bhugra, Buadze and Schleifer27,Reference Maguire, Reay and Looi29,Reference Musau, Baumann, Kolotylo, O'Shea and Bialachowski30 five reflection papers,Reference Chevance, Gourion, Hoertel, Llorca, Thomas and Bocher18–Reference Cournos, Empfield, Horwath and Schrage20,Reference Duley22,Reference Kamara, Walder, Duncan, Kabbedijk, Hughes and Muana25 two healthcare guidelines24,Reference Starace and Ferrara34 and one government document.32 Five papers were from the USA,Reference Cournos, Empfield, Horwath and Kramer19–Reference Duley22,Reference Ripp, Peccoralo and Charney33 three from Canada,Reference Amaratunga, O'Sullivan, Phillips, Lemyre, O'Connor and Dow17,Reference Musau, Baumann, Kolotylo, O'Shea and Bialachowski30,32 two were global,24,Reference Liebrenz, Bhugra, Buadze and Schleifer27 two from FranceReference Chevance, Gourion, Hoertel, Llorca, Thomas and Bocher18,Reference Gaspard, Mosnier, Gunther, Lochert, Larocca and Minery23 two from Italy,Reference Percudani, Corradin, Moreno, Indelicato and Vita31,Reference Starace and Ferrara34 two from China,Reference Liu, Yang, Zhang, Xiang, Liu and Hu28,Reference Zhu, Chen, Ji, Xi, Fang and Li35 one from Sierra Leone,Reference Kamara, Walder, Duncan, Kabbedijk, Hughes and Muana25 one from TaiwanReference Kim and Su26 and one from Australia.Reference Liu, Yang, Zhang, Xiang, Liu and Hu28 Papers covered a wide range of contagions, including COVID-19,Reference Chevance, Gourion, Hoertel, Llorca, Thomas and Bocher18,Reference Druss21,Reference Kim and Su26–Reference Liu, Yang, Zhang, Xiang, Liu and Hu28,Reference Percudani, Corradin, Moreno, Indelicato and Vita31,Reference Ripp, Peccoralo and Charney33–Reference Zhu, Chen, Ji, Xi, Fang and Li35 HIV,Reference Cournos, Empfield, Horwath and Kramer19,Reference Cournos, Empfield, Horwath and Schrage20 influenza,Reference Duley22,Reference Gaspard, Mosnier, Gunther, Lochert, Larocca and Minery23,Reference Maguire, Reay and Looi29,32 non-specified pandemics,Reference Amaratunga, O'Sullivan, Phillips, Lemyre, O'Connor and Dow17,24 EbolaReference Kamara, Walder, Duncan, Kabbedijk, Hughes and Muana25 and non-specified infectious diseases.Reference Musau, Baumann, Kolotylo, O'Shea and Bialachowski30 Results of the quality appraisal tool are reported in Supplementary Table 1. AXISReference Downes, Brennan, Williams and Dean15 scores show that the included papers were of moderate to good quality. Based on the included studies, the majority were considered appropriate study/report design for the aim (n = 14), and the discussions and conclusions justified by the results (n = 12). However, it is important to highlight that the majority of included papers did not use a specific research design as defined by Babbie,Reference Babbie36 O'Sullivan et alReference O'Sullivan, Rassel and Berner37 or Creswell.Reference Creswell38 No studies were omitted from analysis.Reference Dixon-Woods, Bonas, Booth, Jones, Miller and Sutton39
Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram.
Overview of studies
K10, 10-item Kessler Psychological Distress Scale; MSHS, Mount Sinai Health System.
Synthesis
Four main themes were developed: infection control measures to minimise contagion spread, service delivery, staff well-being and information and communication. Each theme will be discussed as a set of recommendations for mental health services during localised and global contagion outbreaks. A checklist of mental health services changes has been provided (Table 3), with supporting quotes from relevant papers.
Service change checklist
PPE, personal protective equipment; HCW, healthcare worker.
Infection control measures to minimise contagion spread
Procedural and practical solutions were identified within the data that aimed to minimise spread in either community or in-patient mental health settings.
Procedural solutions: all settings
The data described procedural solutions that mental health services could employ to reduce contagion spread. These included monitoring staff and patient symptoms, such as checking patient and staff temperature, testing for contagions, tracking and tracing the contagion, administering vaccinations where possible,Reference Chevance, Gourion, Hoertel, Llorca, Thomas and Bocher18,Reference Cournos, Empfield, Horwath and Kramer19,Reference Gaspard, Mosnier, Gunther, Lochert, Larocca and Minery23,24,Reference Percudani, Corradin, Moreno, Indelicato and Vita31 and staff reporting their contagion status on a daily basis.Reference Chevance, Gourion, Hoertel, Llorca, Thomas and Bocher18
Procedural solutions: out-patient settings
To avoid spread across different settings, the data suggested that services adopt other procedural solutions, including reviewing regulations regarding repeat prescription dates so patients are not required to attend face-to-face medication appointments.Reference Chevance, Gourion, Hoertel, Llorca, Thomas and Bocher18,Reference Zhu, Chen, Ji, Xi, Fang and Li35 Where the contagion involves an airborne virus, services can employ social distancing measures,Reference Kim and Su26,Reference Starace and Ferrara34 alternative means for staff to get to work avoiding public transport,Reference Musau, Baumann, Kolotylo, O'Shea and Bialachowski30 and patient home visits in open-air areas.Reference Starace and Ferrara34
Procedural solutions: in-patient settings
The synthesis found in-patient-specific considerations to minimise infection rates within wards, including reviewing admission criteria policies to reduce the number of patients requiring admission to hospital; reducing admission duration; managing surge capacity;Reference Duley22,Reference Starace and Ferrara34 and for services to explore using other care settings within the same radius of acute hospital settings and community services, to meet patient needs.Reference Cournos, Empfield, Horwath and Kramer19,Reference Duley22 Where admission is still required, mental health in-patient wards should quarantine patients on admission,Reference Amaratunga, O'Sullivan, Phillips, Lemyre, O'Connor and Dow17,Reference Chevance, Gourion, Hoertel, Llorca, Thomas and Bocher18 and conduct physical health checks to establish whether the patient has the contagion.Reference Percudani, Corradin, Moreno, Indelicato and Vita31,Reference Starace and Ferrara34 In-patient wards should endeavour to provide patients with single bedrooms,32,Reference Ripp, Peccoralo and Charney33 and ask them to stay in their rooms where possible.Reference Gaspard, Mosnier, Gunther, Lochert, Larocca and Minery23
Where these options are not feasible, the data suggested that in-patient wards could reduce transmission by stopping leave and visitors,Reference Chevance, Gourion, Hoertel, Llorca, Thomas and Bocher18,Reference Musau, Baumann, Kolotylo, O'Shea and Bialachowski30,Reference Percudani, Corradin, Moreno, Indelicato and Vita31,Reference Starace and Ferrara34 ensuring food and clothing is only provided through approved channels,Reference Chevance, Gourion, Hoertel, Llorca, Thomas and Bocher18,Reference Musau, Baumann, Kolotylo, O'Shea and Bialachowski30 reducing staffing where possibleReference Chevance, Gourion, Hoertel, Llorca, Thomas and Bocher18 and erecting staff dressing areas for staff to change their clothes before entering and leaving the ward.Reference Chevance, Gourion, Hoertel, Llorca, Thomas and Bocher18,Reference Percudani, Corradin, Moreno, Indelicato and Vita31 To control contagions on the ward, services can reconfigure wards to have specific areas for infected patients.Reference Chevance, Gourion, Hoertel, Llorca, Thomas and Bocher18 Similarly, group activities can be stopped or reduced in frequency, to minimise spread on the wards.Reference Starace and Ferrara34 Infected patients could be placed on continuous observations where it is not possible for them to be confined to a particular area. To protect staff from contracting the contagion, in-patient services should suspend multidisciplinary team meetings or conduct meetings via video calls,Reference Starace and Ferrara34 have appointments with patients in outside spaces, and focus on least-restrictive practice with patients by using verbal de-escalation rather than restraint.Reference Cournos, Empfield, Horwath and Kramer19,Reference Cournos, Empfield, Horwath and Schrage20 Where wards use restraint, they should use restraint blankets, retractable needles and increase personal protective equipment (PPE).
Practical solutions: all settings
Practical considerations found within the data included regular handwashing for staff, patients and visitors; access to hand-cleaning products;Reference Druss21,32,Reference Starace and Ferrara34 and use of PPE for both staff and patients.Reference Amaratunga, O'Sullivan, Phillips, Lemyre, O'Connor and Dow17,Reference Druss21,Reference Liebrenz, Bhugra, Buadze and Schleifer27,Reference Musau, Baumann, Kolotylo, O'Shea and Bialachowski30,Reference Percudani, Corradin, Moreno, Indelicato and Vita31,Reference Ripp, Peccoralo and Charney33 Services referenced staff PPE as essential to protect staff from contracting and spreading the contagion.
Practical solutions: in-patient settings
The literature highlighted where PPE were limited, mental health in-patient wards can implement a policy to use PPE for patients on a needs basis. Priorities included patients who had symptoms,Reference Starace and Ferrara34 were at high risk of severe symptoms because of underlying health conditions,Reference Gaspard, Mosnier, Gunther, Lochert, Larocca and Minery23 lacked capacityReference Cournos, Empfield, Horwath and Kramer19 to adhere to alternative measures to minimise spread or were unable to isolate in bedrooms.Reference Musau, Baumann, Kolotylo, O'Shea and Bialachowski30 Measures to improve cleaning practices during contagions should be used, such as ensuring the ward is decluttered, improving ventilation, assigning patients their own equipment, using more vigorous cleaning controls for equipment and bedding, using disposable crockery and adopting stricter waste management measures.Reference Chevance, Gourion, Hoertel, Llorca, Thomas and Bocher18,Reference Druss21,32,Reference Starace and Ferrara34
Service delivery
Within the service delivery considerations highlighted in the literature, there are three subthemes: service delivery changes requiring service planning both during outbreaks and for future provision; operational planning requiring services to be adaptable and flexible, responding to ever-changing circumstances and service and patient needs; and maintaining continuity of care.
Service changes
The data suggested that out-patient services adopt telephone triaging to assess patient need.Reference Duley22,Reference Liebrenz, Bhugra, Buadze and Schleifer27,Reference Percudani, Corradin, Moreno, Indelicato and Vita31 Therefore, services can prioritise patient care and collaborate with patients regarding the suitability of continuing with prescheduled appointments face to face or remotely. Additionally, clinicians can assess risk and explore whether more frequent contact is required. Following triage, low-risk patients can continue to access care through telephone or video call consultations with clinicians, whereas high-risk patients can continue to receive home visits.Reference Starace and Ferrara34 Other remote service options include telephone hotlines for suicide prevention,Reference Chevance, Gourion, Hoertel, Llorca, Thomas and Bocher18 developing reactive software that runs algorithms to predict patients at risk of self-harmReference Liu, Yang, Zhang, Xiang, Liu and Hu28 and adopting targeted crisis interventions.Reference Starace and Ferrara34 Other mental health out-patient service changes include prioritising preventative measures to reduce patient need during contagion outbreaks.Reference Chevance, Gourion, Hoertel, Llorca, Thomas and Bocher18,Reference Cournos, Empfield, Horwath and Kramer19,Reference Gaspard, Mosnier, Gunther, Lochert, Larocca and Minery23,Reference Kim and Su26,Reference Musau, Baumann, Kolotylo, O'Shea and Bialachowski30,Reference Starace and Ferrara34 For example, services can provide patients with coping strategiesReference Starace and Ferrara34 and psychological therapy to support patient well-being.Reference Kamara, Walder, Duncan, Kabbedijk, Hughes and Muana25,Reference Liu, Yang, Zhang, Xiang, Liu and Hu28 Recommendations included providing free telephone counselling,Reference Kim and Su26,Reference Liu, Yang, Zhang, Xiang, Liu and Hu28,Reference Ripp, Peccoralo and Charney33 continuing therapy or counselling services remotely, increasing access to one-to-one therapy, providing therapy by community and family doctors,Reference Zhu, Chen, Ji, Xi, Fang and Li35 and creating targeted crisis interventions.Reference Kim and Su26 However, these recommendations are dependent on all parties having sufficient information technology software and hardware.
For in-patient services, which have stopped visitations, wards can instead hold patient–family video conferences, provide regular telephone updates to families and provide patients with telephones to contact family and friends.Reference Chevance, Gourion, Hoertel, Llorca, Thomas and Bocher18,Reference Percudani, Corradin, Moreno, Indelicato and Vita31 Services could ensure patient discharges include consideration of the physical and psychological impact of a contagion, including follow-up calls by ward staff as part of a suicide prevention plan, and to ensure that rapid in-patient to out-patient care transfers are in place.Reference Chevance, Gourion, Hoertel, Llorca, Thomas and Bocher18,Reference Cournos, Empfield, Horwath and Kramer19,Reference Zhu, Chen, Ji, Xi, Fang and Li35 In addition to maintaining usual well-being patient standards, including dignity for vulnerable patients, avoiding discrimination and meeting basic physical needs,24,Reference Kamara, Walder, Duncan, Kabbedijk, Hughes and Muana25 the literature identified proactive measures services could adopt to support patient well-being. These measures include the provision of self-care guidance; psychoeducation tools for maintaining well-being during confinement;Reference Chevance, Gourion, Hoertel, Llorca, Thomas and Bocher18,Reference Duley22,Reference Kamara, Walder, Duncan, Kabbedijk, Hughes and Muana25,Reference Ripp, Peccoralo and Charney33 and monitoring patient well-being and symptoms through regular follow-up telephone calls,Reference Starace and Ferrara34 exploring patient long-term needs and conducting risk assessments at discharge to consider the effects of home circumstances and to prevent addiction risks.Reference Chevance, Gourion, Hoertel, Llorca, Thomas and Bocher18
Operational planning
The data suggested that mental health services should be proactive and have infection resources in place, in addition to reactive planning in relation to factors such as reduced staff resource. In anticipation of contagions, mental health services should stockpile PPE, medical equipment and medication, including antibiotics.Reference Amaratunga, O'Sullivan, Phillips, Lemyre, O'Connor and Dow17,Reference Duley22 Services should have emergency action plans, with details about alternative sites for surge capacity.Reference Duley22,24 Additionally, service change plans that are in their infancy should be brought forward, if beneficial for overcoming service demands during contagion.Reference Kamara, Walder, Duncan, Kabbedijk, Hughes and Muana25 In readiness for staff shortages as a result of a contagion, services should mobilise a human resources management team to oversee staff resourcing;Reference Amaratunga, O'Sullivan, Phillips, Lemyre, O'Connor and Dow17,32 this would enable quick contact with staff at short notice. Services should identify high-risk areas with gaps in service owing to high staffing shortages, and redeploy staff to services with increased need.Reference Duley22,24 If there are insufficient staff to fill gaps, services can recruit and train licensed volunteers; utilise non-healthcare worker support and family care; redeploy students, newly qualified staff and retired staff; and establish a primary response corps involving immunised survivors in the case of a second wave of contagions.Reference Duley22,24,Reference Kamara, Walder, Duncan, Kabbedijk, Hughes and Muana25,32,Reference Ripp, Peccoralo and Charney33
Continuity of care
The literature stipulated that services should endeavour to provide consistent mental healthcare. Where services are not already meeting basic patient needs before outbreaks, services should continue to deliver basic care as a priority, rather than focusing on service changes during contagion outbreaks.Reference Kamara, Walder, Duncan, Kabbedijk, Hughes and Muana25 The literature identified several ways to achieve continuity by maintaining face-to-face appointments with patients where possible; maintaining scheduled appointments related to critical situations, pharmacology and legal obligations; maintaining delivery of psychological therapy sessions; and ensuring acute care services are available.Reference Chevance, Gourion, Hoertel, Llorca, Thomas and Bocher18,Reference Kim and Su26,Reference Percudani, Corradin, Moreno, Indelicato and Vita31,Reference Starace and Ferrara34,Reference Zhu, Chen, Ji, Xi, Fang and Li35 The literature suggested ensuring continuity of care through liaison with agencies (e.g. social care services) could help to prevent patient relapse.Reference Cournos, Empfield, Horwath and Kramer19,Reference Duley22 Similarly, the literature identified the importance of integrated care to maintain patient well-being, and suggested ways to ensure integration between mental and physical health services, including establishing a specific ward for ‘infected’ patients so as to meet their physical and psychological needs, providing psychological support during contagion testing and carrying out physical and mental health well-being assessments.Reference Chevance, Gourion, Hoertel, Llorca, Thomas and Bocher18,Reference Cournos, Empfield, Horwath and Kramer19,Reference Druss21,24,Reference Liebrenz, Bhugra, Buadze and Schleifer27,Reference Starace and Ferrara34,Reference Zhu, Chen, Ji, Xi, Fang and Li35 When care plans involve multi-agency resources, it is important for services work in partnership and establish the responsible party.24,Reference Kamara, Walder, Duncan, Kabbedijk, Hughes and Muana25 Additionally, training staff in anticipation of contagions should be provided, including how to implement infection control measures such as use of PPE.Reference Amaratunga, O'Sullivan, Phillips, Lemyre, O'Connor and Dow17,Reference Chevance, Gourion, Hoertel, Llorca, Thomas and Bocher18 Training should also include monitoring symptoms, and diagnosis and management of the contagion;Reference Chevance, Gourion, Hoertel, Llorca, Thomas and Bocher18,Reference Druss21,Reference Duley22 psychological ‘first aid’ for patients;Reference Kamara, Walder, Duncan, Kabbedijk, Hughes and Muana25 restraint and aggression management;Reference Cournos, Empfield, Horwath and Kramer19,24 and how newly mobilised workforces can maintain self-care.24 The literature suggested that training should be delivered by external parties to improve staff adherence.Reference Cournos, Empfield, Horwath and Kramer19 Finally, to maintain high service delivery standards, strong leadership is important during contagion outbreaks. Strong leadership skills included visibility of leaders within services, agreement with other managers regarding the level of patient support provision, ability to form partnerships across services and with other providers and providing ongoing supervision to all staff.Reference Amaratunga, O'Sullivan, Phillips, Lemyre, O'Connor and Dow17,Reference Kamara, Walder, Duncan, Kabbedijk, Hughes and Muana25 The literature also referenced the need for managers to have access to senior support for ethical decision-making.Reference Chevance, Gourion, Hoertel, Llorca, Thomas and Bocher18
Staff well-being
The review highlighted the importance of considering practical and psychological well-being of staff, and ways to maintain well-being through increased support and resources.Reference Amaratunga, O'Sullivan, Phillips, Lemyre, O'Connor and Dow17,Reference Chevance, Gourion, Hoertel, Llorca, Thomas and Bocher18,Reference Druss21,24,Reference Kamara, Walder, Duncan, Kabbedijk, Hughes and Muana25,Reference Liebrenz, Bhugra, Buadze and Schleifer27,Reference Percudani, Corradin, Moreno, Indelicato and Vita31,Reference Ripp, Peccoralo and Charney33,Reference Zhu, Chen, Ji, Xi, Fang and Li35
Psychological support
Psychological support included providing staff with information on maintaining well-being;24,Reference Ripp, Peccoralo and Charney33 monitoring staff burnout;Reference Amaratunga, O'Sullivan, Phillips, Lemyre, O'Connor and Dow17 offering psychological therapy or counselling sessions either online or via the telephone, including staff-specific crisis lines;Reference Amaratunga, O'Sullivan, Phillips, Lemyre, O'Connor and Dow17,Reference Chevance, Gourion, Hoertel, Llorca, Thomas and Bocher18,24,Reference Kamara, Walder, Duncan, Kabbedijk, Hughes and Muana25,Reference Liebrenz, Bhugra, Buadze and Schleifer27,32,Reference Ripp, Peccoralo and Charney33 peer support through hotlines and monthly supervision,Reference Druss21,Reference Kamara, Walder, Duncan, Kabbedijk, Hughes and Muana25 and supervision of newly mobilised workforces.24
Practical support
Practical support included recognition of staff commitment,Reference Amaratunga, O'Sullivan, Phillips, Lemyre, O'Connor and Dow17 compensation through financial support and incentives,Reference Amaratunga, O'Sullivan, Phillips, Lemyre, O'Connor and Dow17 guaranteed job protection where staff are redeployed,32 providing in-patient staff with food for infection control,32 allowing staff time to rest,32 free parking and bike rental to reduce reliance on public transport,Reference Ripp, Peccoralo and Charney33 child/dependent care for staff who would be unable to work otherwise,Reference Druss21,Reference Duley22 and accommodation if staff need to isolate away from those they live with.Reference Druss21
Information and communication
Data suggested that mental health organisations need to ensure they provide clear and honest information and communication to staff, patients and family members, relating to service changes in response to outbreaks, including a rationale for changes,Reference Amaratunga, O'Sullivan, Phillips, Lemyre, O'Connor and Dow17,Reference Duley22,Reference Liebrenz, Bhugra, Buadze and Schleifer27,Reference Musau, Baumann, Kolotylo, O'Shea and Bialachowski30 signposting to other services where appropriate, and practical measures in place to minimise contagion spread.Reference Druss21–Reference Gaspard, Mosnier, Gunther, Lochert, Larocca and Minery23,Reference Liebrenz, Bhugra, Buadze and Schleifer27 Mental health services should also review their communication plans in light of localised and global contagion outbreaks to ensure communication with staff, patients and families/carers is honest and open, and minimalize sensationalism and stigma relating to infected individuals.Reference Amaratunga, O'Sullivan, Phillips, Lemyre, O'Connor and Dow17,Reference Maguire, Reay and Looi29,32 Similarly, patient information should be provided through multiple sources and by a range of parties, ensuring it is accessibly written and presented for maximum effect.Reference Amaratunga, O'Sullivan, Phillips, Lemyre, O'Connor and Dow17,Reference Druss21,Reference Ripp, Peccoralo and Charney33 For staff, information can be delivered through staff meetings, weekly bulleted emails and on whiteboards in staff areas.Reference Musau, Baumann, Kolotylo, O'Shea and Bialachowski30,Reference Ripp, Peccoralo and Charney33 Patients and staff should both have access to visible, accessible signs regarding new procedures.Reference Musau, Baumann, Kolotylo, O'Shea and Bialachowski30 In in-patient settings where visitations have stopped, families should be provided with information about alternative ways to contact their loved ones, and be kept informed of patient well-being.Reference Chevance, Gourion, Hoertel, Llorca, Thomas and Bocher18,Reference Musau, Baumann, Kolotylo, O'Shea and Bialachowski30,32,Reference Zhu, Chen, Ji, Xi, Fang and Li35 Finally, the literature suggested that mental health services should provide patients, family members and staff with information to provide knowledge about the contagion itself and ways to minimise contagion spread, including vaccination administration (where applicable), hand hygiene, PPE and social distancing.Reference Duley22,Reference Gaspard, Mosnier, Gunther, Lochert, Larocca and Minery23,Reference Liebrenz, Bhugra, Buadze and Schleifer27,Reference Musau, Baumann, Kolotylo, O'Shea and Bialachowski30,Reference Zhu, Chen, Ji, Xi, Fang and Li35
Discussion
Since the COVID-19 outbreak, mental health services have relied on using infection control measures and service adaptations that have been primarily directed at physical healthcare settings.40 Given the number of challenges mental health settings face as a result of increased patient vulnerability11 and poor service provisions attributable to reduced funding,12 this review explored how mental health services should adapt practice and procedures during the COVID-19 pandemic, and in anticipation of future contagion outbreaks. The data suggested that a number of adaptations relating to infection control measures, service delivery, staff well-being and information, communication and training.
Infection control
Our review found out-patient and in-patient mental health settings should use infection control measures during contagion outbreaks, including staff and patient symptom monitoring and strict handwashing hygiene, both of which are in line with Royal College of Nursing41 guidance.
Where infections are highly contagious due to ease of spread via respiratory droplets, such as COVID-19,42 the data suggested that services should conduct staff meetings and patient appointments via video calls and that any face-to-face appointments could be carried out in open-air areas such as patient gardens. Using video calls to carry out appointments with patients could prove effective given that, in the UK, nine out of ten people have access to the internet at home.43 However, services need to consider the patient group when implementing delivery of online appointments, given that research has found that some patients, in particular those who are elderly, can struggle to use the hardware and software required to have an online appointment.Reference Berry, Raphael, Winter, Adams, Dykes and Hartley44 Additionally, there is disparity in access to technology across mental health clinical services;Reference Raphael, Winter, Adams and Berry45 for example, variation in the UK National Health Service Trusts between using paper versus electronic patient records.Reference Warren, Clarke, Arora and Darzi46
The review also suggested that services should use social distancing measures to reduce contagion spread. However, there are challenges to social distancing in in-patient settings and office spaces.Reference Raphael, Winter, Adams and Berry45,Reference Rodger47 To overcome this, the data recommended that in-patient wards consider reducing the number of admissions to increase the ability to follow social distancing measures; however, recent consultation work has found that the number of reduced admission are often short-lived.Reference Raphael, Winter, Adams and Berry45 The data suggested that staff and patients could use PPE where social distancing is not possible. However, this provides new challenges, particularly in acute mental health settings, as patients can lack capacity to comply with measures to minimise spread, as found by a previous literature review exploring issues of non-adherence in those with mental health difficulties.Reference Lowry13 Additionally, a literature view by Edwards et al, exploring emotion recognition in individuals with schizophrenia, found that individuals diagnosed with schizophrenia find it particularly difficult to engage in meaningful communication when they are unable to view facial expressions, because of prior impaired facial affect recognition.Reference Edwards, Jackson and Pattison48
Our data suggested that other infection control measures in-patient wards may consider, including stopping leave, visits and group activities. However, recent consultation work conducted in the UK found that these measures may have a detrimental effect on patient well-being.Reference Raphael, Winter, Adams and Berry45 It is also noteworthy that previous literature has demonstrated the therapeutic benefits of leave,Reference Dickens and Barlow49 meaningful activitiesReference Janner50 and social support networks on recovery,Reference Breier and Strauss51,Reference Onken, Craig, Ridgway, Ralph and Cook52 and therefore caution should be taken where these are stopped.
If patients or staff on in-patient wards contract a viral contagion, the data suggested improving ward ventilation, which is in line with prior international guidelines recommending that natural ventilation for infection control measures in healthcare settings are most effective.53
Service changes
Our review highlights a number of service changes that out-patient mental health services may consider adopting during a contagion outbreak. Patient triage and psychological therapy via telephone and video calls were recommended, in addition to provision of psychoeducation to prevent increase in patient need; a previous review of psychological therapies found that this can reduce patient relapse when provided to patients with serious mental health difficultiesReference Stafford and Colom54 and their family members.Reference McFarlane, Dixon, Lukens and Lucksted55 The data also recommended that mental health services should use digital technology, which is in line with recent literature suggesting that healthcare providers should move toward adopting virtual mental health services to meet demand.Reference Cotton56
In-patient service changes suggested by our review also included supporting patient contact with family members through video calls in replace of visits, and providing family members with regular telephone updates regarding their loved one's well-being. Previous studies have highlighted the benefits of involving families in in-patient care, such as reduced length of admission and relapse prevention,Reference Pharoah, Mari, Rathbone and Wong57,Reference Pilling, Bebbington, Kuipers, Garety, Geddes and Orbach58 which highlights the importance of maintaining patient contact with families through technology.
Operational planning
A number of considerations relating to operational planning were suggested by the review. Given the infection control measures required to minimise contagion spread, the data suggested that services should be prepared by stockpiling PPE and medical equipment. In addition, services should have surge capacity plans, including identifying suitable services to signpost patients to, and ensuring sufficient staffing numbers by redeploying staff to high-need areas and utilising voluntary, retired and other healthcare professionals. Other literature that aimed to assess healthcare preparedness for emergencies has previously identified gaps in in emergency planning within hospital settings relating to stockpiling sufficient equipment and surge capacity plans.Reference Braum, Wineman, Finn, Barbera, Schmaltz and Loeb59
Continuity of care
The data found continuity of care was important to prevent patient relapse by maintaining services where possible, and providing integrated mental and physical healthcare. Prior guidance by the World Health Organization demonstrates that integrating care helps services address treatment gaps in a cost-effective manner.60 However, prior literature states that if services adopt an integrated approach, they have to provide staff with additional training regarding how to use infection control measuresReference Raphael, Winter, Adams and Berry45 and how to support patient physical and mental health.Reference Kathol, Butler, McAlpine and Kane61
Staff well-being
The review stressed the importance of supporting staff during the contagion outbreaks through recognition schemes and supporting child/dependent care for staff who would be unable to work otherwise. Psychological support included providing staff with information on maintaining well-being and offering online or telephone psychological therapy or counselling sessions. Previous literature has highlighted the responsibility of healthcare managers in creating and maintaining staff health through the development of policy initiatives,Reference Whitehead62 and the importance of staff well-being to ensure the delivery of high-quality care.Reference Kelly, Fenwick, Brekke and Novaco63
Information and communication
Finally, in support of prior literature that sets out recommendations for providing patients with healthcare information, our review stressed the importance of providing staff and patients with clear and honest informationReference Tang and Newcomb64 through a range of media about service changes, the contagion and infection control measures.
Strengths and limitations
We found consistency between our review findings and findings from previous literature.Reference Raphael, Winter, Adams and Berry45 Despite this, it is important to consider the rigour and credibility of the data on the findings. Although the data included moderate to good levels of reporting, we note that where literature included both mental and physical health settings, it was hard to differentiate between the two within the results and discussion; therefore, the findings may not fully consider challenges that are specific to mental health service delivery.Reference Muijen65 Additionally, the review included a number of different types of data, the majority of which did not use a research design as defined by Babbie,Reference Babbie36 O'Sullivan et alReference O'Sullivan, Rassel and Berner37 or Creswell.Reference Creswell38 It is therefore important to note that despite the frequencies of themes that occurred within the included papers, only three papersReference Gaspard, Mosnier, Gunther, Lochert, Larocca and Minery23,Reference Maguire, Reay and Looi29,Reference Musau, Baumann, Kolotylo, O'Shea and Bialachowski30 conducted research using participant data via known valid and reliable outcome measures. We are therefore unable to comment on whether use of these recommendations result in improved outcomes for staff and patients in mental healthcare settings. To mitigate these limitations, future systematic reviews may be necessary once research has been conducted assessing the effects of changes to service delivery during the COVID-19 pandemic.
Implications
It was evident from our work that although there has been research exploring changes to practices in physical health settings, mental healthcare setting were less considered. This is likely because there is not parity of esteem between mental and physical healthcare despite rhetoric that there should be; in comparison to physical health, mental healthcare is underresourced, undervalued and stigmatised.12 Lack of guidance for changes to mental health settings during contagion outbreaks can affect staff and patient physical well-being through lack of infection control measures, and lack of consideration toward the effects on staff and patient mental well-being. Therefore, this literature review began to address this gap, to provide guidance regarding how out-patient and in-patient mental health services can adapt their practices in response to contagion outbreaks.
The literature review findings can therefore be used to inform mental health services regarding ways to mitigate risk of COVID-19 spread within the services, and how best to support mental health staff during the pandemic. However, the findings from this review not only relate to COVID-19, but also can form the basis for changes to practices for other contagions, whether they are local, epidemic or pandemic outbreaks. Additionally, the findings provide recommendations about service adaptions during an outbreak, and inform future emergency planning within mental health services. These recommendations could aid service preparedness for future outbreaks. Finally, given the specific challenges that mental health in-patient wards face,Reference Raphael, Winter, Adams and Berry45 the findings of the review can help services understand ways to overcome these challenges within the in-patient setting.
In conclusion, we provide findings from the first systematic review of service adaptations in mental health settings during the global COVID-19 pandemic and other more localised contagions. Mental health services need to consider infection control measures and implement service changes to support continuity of care and patient well-being. Mental health services also need to consider the effects of COVID-19 or other localised contagion outbreaks on their staff, and support staff well-being. Throughout contagion outbreaks, mental health services need to ensure that they are communicating important information with their staff and patients regarding service delivery, contagion symptoms, government guidelines and well-being, in an honest and accessible manner.
Supplementary material
Supplementary material is available online at https://doi.org/10.1192/bjo.2021.20.
Data availability
Data availability is not applicable to this article as no new data were created or analysed in this study.
Author contributions
J.R., R.W. and K.B. designed the study and wrote the protocol. J.R. and R.W. conducted the literature searches and assessed for eligibility. J.R. and R.W. extracted data from the literature and K.B. addressed any disputes. J.R. and R.W. analysed the quality of the literature. J.R. conducted the qualitative analysis. R.W. and K.B. assisted with the analysis. J.R. wrote the first draft of the manuscript and all authors contributed to and have approved the final manuscript.
Funding
This project is funded by the Centre for New Treatments and Understanding in Mental Health (CeNTrUM), which is part of the Division of Psychology and Mental Health, School of Health Sciences, at the University of Manchester, UK. The views expressed are those of the authors and not necessarily those of CeNTrUM or the University of Manchester.
Declaration of interest
None.
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