Find out more about specific considerations you need to make when working with more vulnerable patients, such as older people or those who use drugs. If you'd like us to cover a topic that is not listed here, you can submit a question to the College and we'll consider it for inclusion in our guidance.
Older people are at increased risk of severe illness from COVID-19. Our current advice for psychiatrists and staff working in old age mental health services is:
For community services
- Put systems in place to ensure the ability to respond rapidly to appropriate adjustments of care packages.
- Ensure those at home with dementia whose care arrangements may be altered or who have to self-isolate are given understandable information which addresses their concerns and provides comfort. This is likely to take extra time. Consider using simple reminder notes or pictures for those with more severe dementia.
- Be mindful of vulnerable older people who might be put at higher risk due to the social distancing (or reduced visits from hard-pressed social services). Consider what can be done to protect them by encouraging collaboration from local health, social care and third sector agencies.
- Encourage them to seek support from friends and/or family members using regular phone calls and technologies if possible (such as WhatsApp and Skype).
- Encourage them to undertake activities that will enrich them and their environment, such as learning something new. Encourage those with mild dementia to consider self-help activities such as relaxation and exercise.
- Be mindful of older carers who may be particularly negatively impacted by the social isolation and are very likely to need increased support.
For acute hospital services
- Older people with suspected or actual infection and their relatives may find being in an intensive care environment and/or being cared for by staff taking precautionary measures extremely anxiety-provoking or distressing. Consider what can be done to make the environment less threatening and more familiar and reduce the number of investigations, if possible.
- Try to ensure that care staff are aware of non-pharmacological ways to address distressed behaviour.
- Older people will often be at increased risk of delirium. Staff should be encouraged to consider risk reduction strategies early on (nutrition, hydration, constipation and pain etc).
- The College has published a joint report, Coronavirus: managing delirium in confirmed and suspected cases, with the British Geriatric Society and European Delirium Association (available via the link under ‘Our reports and resources’).
- The Faculty of Old Age Psychiatry has developed Delirium management advice for patients with confirmed or suspected COVID-19 in acute trust settings. (pdf)
For inpatient services
- Review your procedures and plans for inpatient units.
- Ensure that oxygen cylinders are available and that the physical knowledge and skills of staff are as updated as possible.
- Check care plans reflect any updated lasting power of attorney documentation and advance directives.
People with dementia
Supporting patients of all ages who are unwell with coronavirus (COVID-19) in mental health, learning disability, autism, dementia and specialist inpatient facilities” (PDF) guidance developed in collaboration with NHS England and Improvement, the Royal College of Nursing’s Mental Health Programme, the Royal College of Psychiatrists and Unite in Health sets out:
- Most people with dementia are over 70, have other long-term conditions and are frail, putting them into the particularly vulnerable group to develop complications if infected with COVID19.
- Clinicians involved in screening and treatment should be aware of the additional anxieties people with dementia may experience on admission. It is advisable to allocate additional time for a holistic assessment. Advance care planning (ACP) can be used to identify the wishes and preferences of people with dementia; see My Future Wishes for further detail. Clinicians should identify if an individual has an ACP or a ‘health and welfare power of attorney’. Further detail on ACP can be found on the NHS England and Improvement website.
- It may also be necessary to complete a swallowing assessment, to identify any potential swallowing difficulties that may put someone with dementia at increased risk of chest infections or dehydration.
- It is important to ensure that all information regarding personal care and support for preventing COVID-19, such as self-isolation and handwashing, are available in accessible formats to ensure that all people with dementia can access it.
- Individuals with dementia are much more prone to develop delirium (a confused state) if they become infected. They may also be less able to report symptoms because of communication difficulties. Clinicians should be alert to the presence of signs as well as symptoms of the virus (eg ‘look beyond words’).
- Where required, conversations about end-of-life care should be tailored to reflect expectations in these two situations and palliative comfort measures offered.
- If a person with dementia and COVID-19 is imminently close to dying and has symptoms such as breathlessness or severe delirium that are difficult to manage, specialist palliative care support and advice should be sought.
- In some cases, people with dementia may have impaired mental capacity. The Mental Capacity Act (2005) provides guidance on assessment of capacity and compliance with legal guidance to act in the individual’s best interests.
Further resources and advice are available via the Old Age Psychiatry Faculty.
The following information may change in line with national guidance. People who use drugs may be at greater risk from COVID-19 than the general population, for the following reasons:
Thus far, deaths and serious illness from COVID-19 seem concentrated among people who are older and who have underlying health issues, such as diabetes, cancer, and respiratory conditions. It is therefore reasonable to be concerned that compromised lung function or lung disease related to smoking history, such as chronic obstructive pulmonary disease (COPD), could put people at risk for serious complications of COVID-19. People with a history of problematic drug use have a significantly higher prevalence of chronic respiratory disease (asthma and COPD) than the general population.
Other risks for people include decreased access to health care, housing insecurity, and greater likelihood for imprisonment or detention in hospital. Limited access to healthcare places people with addiction at greater risk for many illnesses. If hospitals, clinics and ancillary health systems are pushed to their capacity, people with addiction - who are already stigmatized and underserved by the healthcare system - will experience even greater barriers to treatment for COVID-19.
Homelessness or imprisonment can expose people to environments where they are in close contact with others who might also be at higher risk for infections. Reduced stability due to unmanaged opioid dependence increases these risks.
Other important considerations are:
Drug-related deaths and harm are at their highest on record.
Access to traditionally traded street opioids may be impacted by global restrictions on movement (as has already been seen in the street SCRAs/’Spice’ market) leading to a possible acceleration of the emerging synthetic potent opioids such as fentanyl and related analogues. If supply chains are disrupted, we may see more acute withdrawal from a variety of street drugs.
Services for the most vulnerable members of our community, such as homeless services may become more difficult to access or be completely unavailable. This may lead to an increased and unexpected demand on addiction services. Those with substance use disorders are also more likely to be immunosuppressed.
Therefore, we should consider people who use drugs as having the potential to be considered one of the high-risk groups with respect to COVID-19, and tailor our treatment delivery accordingly.
Our current advice for psychiatrists and staff working in addiction services is:
For individuals on Medication-Assisted Treatment (MAT)
- The clinical priority currently is to safeguard delivery of life-saving clinical treatments such as opioid Medication-Assisted Treatment (MAT) such as methadone and buprenorphine.
- Another priority area is access to harm reduction measures such as needle and syringe supplies for those who inject.
- Under normal circumstances these treatments are delivered in the community, require people to be able to move freely while feeling comfortable making frequent trips out of their home, and depend on other elements such as routine access to community pharmacies and reliable supply of essential medications.
- As the external environment changes, it is likely that the disruption we are already noticing will increase and make it more challenging for individuals on MAT, particularly those on more restrictive MAT regimes, to continue receiving treatment as usual. We know that pharmacies have already started to restrict access for our service users due to reduced capacity and other reasons, even refusing to provide supervised consumption. This will probably become an even greater issue as the situation progresses.
- People on MAT have raised concerns about frequent attendance at pharmacies, in some cases choosing to stop their treatment rather than increase risk of exposure and potentially put themselves or their loved ones at risk.
- At this time, and wherever possible, it would be appropriate to consider relaxing the usual requirement for people to frequently attend community pharmacy, and to consider how treatment can be continued. Engagement with treatment in this population is challenging, so removing barriers to access and making treatment regimes acceptable to people will be a vital consideration.
- It is almost always safer for opioid-dependent people to have MAT available to take-home, than to be off MAT and feel compelled to use street opioids with all the risks that entails. MAT does have the potential to cause harm if not taken as directed, but on balance is far more likely to benefit individuals. It is a lifesaving and harm-reducing intervention that is safer than using street opioids of unknown potency and purity. Safeguarding of children needs to remain a consideration.
Pharmacological considerations for people using drugs
Buprenorphine formulations are partial opioid agonists and have a better safety profile compared to full agonists such as methadone with respect to overdose. They are also less likely to cause harm to opioid-naive people should they be consumed inadvertently. This may be a more suitable option in situations where there are safeguarding concerns or other risks in the patient’s immediate environment.
The choice of MAT depends on individual circumstances, and choice is a key factor in adherence. Wherever possible continue the current MAT drug.
Consider providing individuals who already take-home medications with a longer duration of take-home medications. Two weeks supply could be considered and extended depending on external circumstances.
Robustly consider whether people on supervised consumption can move to unsupervised and be provided with take-home supply. In some places supervised consumption may cease to be an option, and its utility should be balanced against the risk of compelling people to make more trips out of the home than they would otherwise wish to do.
Take the opportunity to optimise dose as appropriate.
If only remote assessments are possible, and people are unable to have access to/provide a drug test – consider proceeding with buprenorphine titration based on an adequate assessment. This is unlikely to be possible for methadone but consider on a case by case basis.
Opioid detoxifications and dose reductions should be deferred, with people encouraged to maintain stability during this period of uncertainty. However, if individuals need to detox, then support accordingly.
If people are advised to self-isolate (but not treated in hospital) they could be asked to nominate an individual to collect the prescription on their behalf and could be provided with a longer supply of medication. If they cannot nominate an individual to do this, where possible, a member of staff could collect and deliver the medication.
The above should be supported with a) Provision of Take-home Naloxone b) Safe storage boxes c) Harm reduction advice d) Regular communication with first-line support.
This is in line with the clinical guidance issued by NHS England and NHS Improvement on 8 April. Further College guidance will follow in due course.
The best local solutions should be sought to enable the proper management of non-elective patients with alcohol dependence in need of care. It is acknowledged that societal factors arising from the current circumstances may result in an increased number and frequency of patients presenting in acute alcohol withdrawal. Patients with alcohol dependence are a vulnerable group due to the high prevalence of co-morbid physical and mental health problems.
Categories of people with alcohol dependence to consider
- Emergency department presentations - focus on minimising harm and reducing re-attendance, taking individual risk factors and clinical need into account
- Obligatory admissions and inpatients to acute trusts - patients with complications of alcohol withdrawal and underlying conditions continue to require admission and medical management. Early identification at triage is essential to optimise treatment and expedite discharge
- Obligatory admissions and inpatients to mental health trusts - patients with serious mental disorder and co-morbid alcohol dependence continue to require admission and management. Early identification on admission is essential to ensure appropriate management and expedite discharge.
- Secondary mental health community services - patients with co-morbid alcohol dependence presenting to and managed in community mental health services will require more integrated management to reduce crisis presentations
- Primary and community care - patients presenting to these services or NHS111 should be offered harm minimisation advice and signposted to community addiction services.
Three areas are identified for particular consideration when planning local responses. These are:
- Each acute and mental health trust should designate someone as COVID-19 alcohol lead with appropriate skills from within available workforce. They will be responsible for specialist support to staff in relation to protocols for the safest patient management and pathways to partner agencies.
- Alcohol leads must be competent to offer guidance on current best practice specifically relating to (not limited to) alcohol-dependent patients presenting with: COVID-19 and risks of respiratory depression during medically assisted alcohol withdrawal; complicated severe alcohol withdrawal; and co-morbid opioid use.
Emergency department presentations
- Referral for mental health assessment where appropriate
- Consistent harm minimisation and signposting to available resources if admission not required. Obligatory admissions and inpatients to acute and mental health trusts
- 5% of acute and 25% of mental health inpatient beds are occupied by someone with alcohol dependence. People with alcohol dependence often have multiple co-morbidities that put them at greater risk of severe manifestations of COVID-19 infection
- Alcohol lead to ensure: clear local/regional plans and policies for safe discharge into community; availability of clinical tools for alcohol withdrawal management; safeguarding of children and adults remains essential; integrated management of alcohol dependence, co-morbid conditions and coronavirus by non-specialist teams; and links with community addiction services to provide remote to those discharged if necessary.
Secondary mental health community services
- Co-morbid alcohol dependence is not a barrier to accessing mental health services
- Mental health services should maintain and optimise health of patients with co-morbid alcohol dependence throughout the pandemic
- Mental health staff should familiarise themselves with alcohol harm minimisation advice
- Many contacts can be performed remotely, which can also help to reduce crisis presentations
- Joint working with community addiction services should be established if not already in place
- Senior clinicians should support staff in risk management to prevent unproductive referrals to hospital attendance
- Seven-day services may need to be considered.
RCPsych, RCN, NHS England and Unite’s Mental Health Nurses Association have worked to develop these guidelines which set out the key issues that ID staff teams should be conscious of at this time.
It provides advice on a range of areas that will be relevant to colleagues working in ID services and which they may find useful to share in clinical teams. A more detailed version of this guidance with references to other useful material will be available via our faculty page.
Guidance from NHS England on Managing capacity and demand within inpatient and community mental health, learning disabilities and autism services for all ages is available on the NHS England website (see pages 12-16).
Infection with Covid-19
People with intellectual disabilities are at greater risk of infection because of the higher prevalence of comorbid health problems and personal habits. It is important that families, carers and staff are aware of the risks to the person and reduce them as much as possible.
- Follow local and national guidance on reducing the risk of infection
- Follow national guidance on assessment and diagnosis,and management of suspected and confirmed cases.
- Encourage carers and family members to engage in regular hand washing
- Encourage families and carers to teach and support people with ID to wash their hands regularly
- Engage in social distancing while supporting the person
- Engage in telephone contact and use technology to maintain contact with people
- Have easy read information for people on preventing spread of infection, on self-isolation.
The practice of reducing social contact will have a direct effect on the delivery of clinical care by psychiatrists where clinical reviews often require the psychiatrist and patient to meet in person. To implement social distancing effectively, we need to consider what contacts are necessary to the tasks and to achieve specific clinical outcomes.
- Consider developing a register of people most at risk of COVID-19 infection and serious health complications as a result or consider creating a register of people at risk of placement breakdown.
- Follow Personal Protective Equipment (PPE) guidance for mental health staff.
- Use telephone contact and video conferencing technology with families, carers patients, and colleagues where possible.
- Be familiar with advice on using video conferencing safely and share in accessible formats with families and carers as far as possible.
- Use technology to review written records and prescription sheets.
- Reduce face-to-face contact with patients and carers.
- Maintain social distancing when meeting with patients, families, and carers.
- Co-operate with MDT colleagues on clinical and mental state reviews to reduce duplication of work and limit in-person contact .
- Reduce the number of professionals attending multi-disciplinary meetings by using other ways of sharing information, such as written feedback or teleconferencing.
- Support other carers/professionals who have direct contact to deliver the support skilling them up to do so where required and appropriate.
- Maintain good liaison with Social Care Services to support vulnerable people.
- Develop Covid-19 risk assessment as part of clinical care plans.
People with ID in in-patient care services are among the most vulnerable due to their intellectual disability. They are likely to have severe symptoms when infected with Covid-19. Controlling infection in congregated settings can be a challenge to staff..
Services will have to support patients and staff who develop the infection in order to reduce the risk of spread.
- Adhere national policies on managing cases of Covid-19 in in-patient services and develop and follow local policies
- Local areas should have dynamic support processes and ‘at risk of admission’ registers that help to identify those children, young people and adults with specific support needs.
- Local areas should review their processes and ensure they include everyone with intellectual disability autism or both.
- Local areas should identify children, young people and adults with ID who may be placed outside their local area in a residential special school or college, social care children placement or adult placement.
- Consider carefully if admission to an ATU is needed and the impact of admissions on services.
- Psychiatrists should support safe nursing environments when staffing is under strain.
- Support clinical staff in gaining relevant skills in managing people with infection.
- Maintain regular communication with ward managers and senior team members.
- Explore the use of technology when convening clinical meetings.
- Explore using telephone and video conferencing between patients and carers.
- Reduce the number of contacts at meetings and visits to wards.
- Be alert to a rise in the number of episodes of restraint and seclusion. Teams should continue to support safe care environments whilst services are under strain, including a minimum use of restraint and seclusion.
- Engage in active discharge planning to manage capacity in services.
Forensic Intellectual Disability Services
Covid-19 poses additional pressures to services for offenders with ID in supporting them in in-patient settings. The risk of infection is likely to be higher in congregated settings.
- Encourage use of technology to limit face to face contact, for example video-conferencing, to maintain family contact. Where such communication possibilities do not exist, units must prioritise setting up facilities for such communication as soon as basic safety precautions have been implemented.
- Manage contact with external professionals and solicitors by telephone or emails .
- Obtain Covid-19 status of service/prison from where the person is being admitted.
- Consider risk rating the Covid-19 status (for example using RAG rating) of the in-patient service, so that persons coming into the service are aware of the risk status.
- Consider increasing activities in hospital to replace discontinued activities.
- Adhere to local policies on escorted and unescorted leave from wards.
Mental health legislation
The Government has introduced emergency legislation to support the implementation of the Mental Health Act in England and Wales that will apply in Scotland and Northern Ireland through amendments to their relevant legislative frameworks. NB these changes are not yet in force. These pages will be updated as soon as changes are made.
NHS England/Improvement have published Legal guidance for mental health, learning disability and autism, and specialised commissioning services supporting people of all ages during the coronavirus pandemic
- Be familiar with the temporary changes to the MHA in your jurisdiction.
- Where possible, apply current good practice for new assessments and reviews and renewals of current detentions.
- Document alternative processes in practice when assessing a person under the MHA.
- Make patients aware of changes in Mental Health Review Tribunals and Hospital Manager’s review hearings.
We know that people with ID use psychotropic medication and the STOMP/STAMP initiatives seek to rationalise the use of medication. It is important that we adhere to these principles wherever practicable.
- Review and support non-pharmacological interventions as part of the person’s Positive Behaviour Support plan. Some primary preventative strategies may not be able to be supported due to staffing constraints and infection risks e.g. community outings, activities, shopping, visiting families, social groups, leisure, recreational, occupational, educational activities etc. This may mean that secondary and tertiary strategies will need to be used more.
- Support families and carers to maintain their current drug regimens.
- Liaise with family doctors and pharmacists to avoid disruption to medication supply.
- Use technology to monitor MARS sheets.
- Avoid overuse of medication where possible.
- Apply best interests framework where practicable.
- Consider how to safely administer depot injections and the frequency of dosing.
Further information on COVID-19 and psychotropic medication.
Community support services
Residential and Supported Living environments are likely to be under pressure on account of staff shortages due to illness or the need to self-isolate. Staffing levels will be stressed with the potential for whole group placements to break down at short notice.
- Maintain contact with families and carers by telephone.
- Support to community support staff by telephone or video calls to discuss clinical work and review patients.
- Use secure electronic communication for contact with GPs.
- Work with the clinical MDT to support paid and family carers.
- Liaise with Commissioners of services on people who are risk of placement breakdown and engage local mental health servicex to support community placements and avoid admission where possible.
Children and young people with ID are especially vulnerable to the impact of infection and
to changes in their care. Disruption to the routines of children and young people with intellectual disability and/or autism spectrum disorder can lead to significant increases in distressed behaviours.
- Consider creating a register of children and families most at risk.
- Maintain regular telephone contact with families.
- Be familiar with the schools that are operating.
- Support children and young people with information on Covid-19.
- Be aware of children who are returning to the parental home from residential schools.
- Make use of easy-read resources to help children and young people with adjusting to current changes in their environments.
Care (Education) and Treatment Reviews (C(E)TR) and safeguarding
The Care and Treatment Reviews framework operates in England to assist services in supporting people who are at risk of hospital admission and to review admissions that have taken place. NHS England expects CTRs to continue, advising services to consider creative ways to conduct the reviews.
- Engage with commissioners and care staff on implementing Care and Treatment Reviews .
- Commissioners should make use of technology to enable virtual C(E)TRs to take place with the input of usual participants, and to involve families, carers and patients in the process.
- COVID-19 guidance may mean that the way C(E)TRs are undertaken needs to be adapted but all local areas must continue to ensure that a process remains that fulfils this role. It is essential that a process remains for clear review and scrutiny before inpatient admission.
- As part of the C(E)TR , assess the person’s risk of infection from Covid-19 and support to protect them.
- The six to eight week commissioner oversight visits may need to be halted to prevent spread of COVID-19 but assurance to commissioners that people are safe remains the same.
- It may be difficulty to continue the Learning Disability Mortality Review (LeDeR) reviews at this time Local areas should consider how they communicate any pause in their LeDeR reviews with family members to reflect that this is due to unprecedented challenge in the system.
- For further information on specific guidance for community and inpatient C(E)TRs and safeguarding see pages 12-15 of NHS England guidance.
Mental health support
The impact of the pandemic on the mental health of people with ID and their families and carers is uncertain at present. Restriction in activities and the concerns of carers could impact upon the mental health of people leading to evidence of mental disorders and changes in behaviour.
- Offer direct support to patients and focused support to families and carers that will support the patient.
- Make use of all professional contacts as an opportunity to ensure patients, families and carers have accurate information on the risks of Covid-19 and how to minimise them.
- Enlist support from colleagues in the multi-disciplinary to work directly with patients and their carers.
- Work with MDT to develop innovative health and wellbeing resources for use at home by people with ID and by their families and carers.
Access to critical care for patients with ID
Where admission to a general hospital or critical care is required, support may be required for that person and their family to understand and manage the process.
NHS England and NHS Improvement have written to trust chief executives to confirm the amendment to NICE guidelines on critical care in adults, which now state that the Clinical Frailty Scale should not be used for people with ID or autism.
- All patients should have a health action plan and hospital passport with details of underlying health issues that increase vulnerability to COVID-19 complications.
- Clinical staff in ID services to support the person and their carers during a hospital admission.
- Clinical staff to collaborate with Liaison ID nursing colleagues in acute hospitals.
- Advocate on behalf of people with ID for equal access to health interventions.
Working in the current environment with so many uncertainties and as a clinician with contact with families and patients at risk, can cause great pressure on your well-being.
- Maintain contact with colleagues especially where in-person contact is restricted.
- Be alert to the signs of stress in colleagues.
- Offer to assist colleagues when they are under pressure.
- Follow government guidelines on social-isolation.
Guidance for healthcare professionals on managing coronavirus (COVID-19) infection in pregnancy has been published by the Royal College of Obstetricians and Gynaecologists, Royal College of Midwives and Royal College of Paediatrics and Child Health, with input from the Royal College of Anaesthetists, Public Health England and Health Protection Scotland. This covers up-to-date advice on how coronavirus affects pregnant women and their unborn babies, managing labour and birth in women with suspected or confirmed coronavirus, as well as information on neonatal care and infant feeding.
Effect on maternal mental health
The following guidance has been developed by the Royal College of Psychiatrists, Royal College of Obstetricians and Gynaecologists and NHS England and Improvement.
This pandemic will inevitably result in an increased amount of anxiety in the general population, and this is likely to be even more so for pregnant women as it represents an additional period of uncertainty. Specifically these anxieties are likely to revolve around COVID-19 itself, the impact of social isolation resulting in reduced support from wider family and friends, the potential of reduced household finances, major changes in ante-natal and other NHS care with appointments being changed from face to face to telephone contact. The change in appointment style will also make assessment for women experiencing domestic violence, women with safeguarding concerns and women who are misusing substances more difficult.
A general increase in anxiety is to be expected in the current situation. Often simply acknowledging these difficulties can help to contain some of these anxieties. This can be facilitated by maintaining access to midwifery services, accessing sources of self-help for anxiety and stress and when necessary self-referral to local IAPT (Improving Access to Psychological Therapies) Services in England or equivalents in other nations.
Episodes of mental illness during pregnancy are common and effect up to 1 in 5 pregnant women. Mental illness covers a full range of symptoms from mild anxiety and depression to severe mood disorders and psychosis. Episodes of illness are more likely to be precipitated by periods of social stress. Social isolation and the current national situation is clearly stressful and is likely to result in an increased rate of episodes of mental illness.
It is important to be aware of this and for women to utilise strategies which have been useful previously. Some of these strategies may not currently be available due to social isolation – such as maintaining a daily routine, meeting up with friends, attending antenatal groups etc. Consideration needs to be given for how these strategies can be adapted to make them available in some way – this will often be aided by the use of technology to contact friends and family, and attend virtual groups. See advice from PHE. Usual services still exist, albeit in a different form. It is important to continue to inform midwifery services of any concerns so that advice and additional support can be offered. Specialised perinatal mental health services are still running – they can offer additional assessment, advice and support.
Maternal mental illnesses remain one of the leading causes of maternal death. There are key red flags identified from the MBRRACE reports which still need to be acted upon promptly:
- Recent significant changes in mental state or emergence of new symptoms
- New thoughts or acts of violent self-harm
- New and persistent expressions of incompetency as a mother or estrangement from the infant
- Referral with mental health concerns on more than one occasion should prompt clinical review, irrespective of usual access thresholds or practice.
These red flag symptoms require immediate referral to specialised perinatal mental health services.
Triage processes should be established to ensure that women with mental health concerns can be appropriately assessed, allowing for review of the relationship between the mother and child using verbal and non verbal information, including face-to-face if necessary, and access specialist perinatal mental health services in the context of changes to the normal processes of care due to COVID-19. Perinatal mental health services are essential and face to face contact will be necessary in some circumstances.
In addition we know that Postpartum Psychosis is directly associated with a diagnosis of bipolar affective disorder or women who have had previous episodes of postpartum psychosis. It is important that this group of women continue to be identified so that robust plans can be put in place for labour and the immediate postpartum period. This is equally true for women who have previous diagnoses of psychotic illness, severe early postnatal depressive disorder or severe enduring mental illness.
Mother and Baby Units are psychiatric inpatient units which allow for joint admission of both mother and baby should admission to a psychiatric hospital be necessary for the mother. They accept women for admission in the later stages of pregnancy or with their baby up to 12 months of age.
Pregnancy has been identified as a risk factor requiring isolation in the community for 12 weeks. This will continue on the MBU, with pregnant women socially isolated on the unit during this time. This will be supported by the obstetric and midwifery services.
All women on the MBU will be helped to develop a COVID-19 management plan, outlining what they would like to happen should they develop symptoms of COVID-19 in respect to their baby. To make this plan they need to have access to the latest advice from RCOG.
Partners/co-parents/significant others should be involved in this plan. The important role of the co-parent will be respected and contact should be facilitated within service protocols and making full use of technology.
Services will continue to maintain links with Social Services, Health Visiting and community services as needed.
Antenatal Mental Health Liaison clinics continue to be an important route for women with mental illness to access joint care between maternity and mental health services. This is now being delivered via virtual clinics in the main. Whilst these clinics offer a valuable service to many women, it is imperative that they continue to identify those women who are most at risk of maternal death or high morbidity in the postpartum period. Specifically comprehensive management plans need to be developed for those women at risk of having Postpartum Psychosis and also for those women with a high degree of complexity. All women with a history of severe mental illness need to be identified so that additional support can be offered during the pregnancy and in the high risk postpartum period.
To supplement this, our current advice to services is:
For perinatal mental health services
- There needs to be careful consideration of how pregnant women are assessed in community perinatal mental health teams following guidelines for community services. These services should continue to operate given perinatal morbidity.
- A careful risk assessment should be undertaken on a case to case basis before planning a psychiatric assessment of a patient on a maternity ward prior to discharge, and only if women show symptoms of acute deterioration in mental state, or if there are significant safeguarding concerns that warrant a pre-discharge meeting requested by social care.
- Women who are well and on a stable treatment plan should be discharged as soon as fit to leave hospital with their baby and be reviewed by their allocated perinatal care coordinator the following working day via phone or by virtual review preferably.
- Perinatal services will continue to work closely with families to ensure that partners and families are aware of the importance of early detection and seeking advice.
- Women who are under community perinatal services and who need a psychiatric review post-delivery should be seen as quickly as possible on the postnatal ward.
For mother and baby units (MBUs)
- Psychiatric illnesses remain amongst the leading causes of maternal deaths. It is important that women continue to have access to inpatient mother and baby units. The benefits of joint admission with mother and baby, for physically well mothers, outweigh the risks. This can be reviewed on a case by case basis should the mother become physically unwell. The needs of co-parents need to be considered and this will be reflected in essential visiting.
- Therefore, MBUs need to continue admitting mothers with babies with usual protocols for admission applying.
- Pregnant women have received the advice to increase social isolation and so those admitted to the MBU should also follow this advice. This needs to be considered at the time of admission.
- All professional contacts and meetings should be encouraged to happen virtually with exception of Mental Health Act assessments in line with guidance and the coronavirus bill.
- Visitors to MBUs should be limited to partners, fathers or significant carers, with enquiry about possible symptoms and possible contact with those who may have COVID-19. Those who should be self-isolating will not be permitted onto the unit.
- Discharge from MBUs must be planned safely, as it is less likely women will receive face to face home visits during this time of crisis.
If the mother has suspected coronavirus:
- She should be isolated in the MBU isolation area as arranged by local MBU infection control procedures.
- A decision can be made about whether mother and baby remain on the unit based on the mother's wishes and case by case review.
- Guidelines for contact with baby and breast feeding are as per latest RCOG guidelines.
For women and children experiencing domestic abuse
- For women with domestic violence issues, please see the guidance published by Women’s Aid.
Support services for women affected by:
Action on Postpartum Psychosis (APP) will continue their national peer support services throughout the outbreak. The APP forum is available for people affected by PP to talk to other women and partners.
They offer one to one peer support for anyone in the UK, where people are paired with an APP coordinator with lived experience, or a volunteer peer supporter. They offer one to one peer support via email, private messaging on the forum, or via video call. Their regional postpartum psychosis cafe groups will also continue via video call. People personally affected by PP (woman, partner, family members) who would like to access this support should email firstname.lastname@example.org.
Maternal OCD provides guidance and resources for coping with COVID-19 for people with perinatal OCD
Beat Eating Disorders provides resources for people with eating disorders during the COVID-19 pandemic.
Depression and other perinatal mental illnesses
The PANDAS Foundation provides support and advice for any parent and their networks who need support with perinatal mental illness.
Anxiety UK offers support, advice and information on a range of anxiety, stress and anxiety-based depression condition via email, text and live chat services.
Guidance for families
Guidance has been published by Public Health England (PHE) for parents and carers on looking after the mental health and wellbeing of children or young people during the coronavirus (COVID-19) outbreak.
Guidance for parents and carers on supporting children and young people’s mental health and wellbeing during the coronavirus (COVID-19) outbreak.
The advice is to help adults with caring responsibilities look after the mental health and wellbeing of children or young people, including those with additional needs and disabilities, during the coronavirus (COVID-19) outbreak.
The Royal College of Paediatrics and Child Health (RCPCH) has released guidance for Children and Families on COVID-19.
It contains some links on helping children cope with stress or who are worried about coronavirus and highlights tthat if your child has a medical condition it is important that they continue to access treatment and attend medical appointments as recommended by their hospital, GP or healthcare professionals.
- PHE Guidance on shielding and protecting people defined on medical grounds as extremely vulnerable from COVID-19 sets out that the following people should be deemed "extremely vulnerable" and sets out how they should be treated:
- Solid organ transplant recipients
people with cancer who are undergoing active chemotherapy
- People with specific cancers:
- people with lung cancer who are undergoing radical radiotherapy
- people with cancers of the blood or bone marrow such as leukaemia, lymphoma or myeloma who are at any stage of treatment
- people having immunotherapy or other continuing antibody treatments for cancer
- people having other targeted cancer treatments which can affect the immune system, such as protein kinase inhibitors or PARP inhibitors
- people who have had bone marrow or stem cell transplants in the last 6 months, or who are still taking immunosuppression drugs
- People with severe respiratory conditions including all cystic fibrosis, severe asthma and severe COPD.
- People with rare diseases and inborn errors of metabolism that significantly increase the risk of infections (such as SCID, homozygous sickle cell).
- People on immunosuppression therapies sufficient to significantly increase risk of infection.
- Women who are pregnant with significant heart disease, congenital or acquired.
- Solid organ transplant recipients
Clinicians should be aware that the government has revised its guidance to confirm that someone with a specific health condition that requires them to leave the home to maintain their health can do so, even if this means travelling beyond their usual area.
It specifically uses the example of individuals with learning disabilities or autism that require specific exercise in an open space two or three times a day, ideally in line with a care plan agreed with a medical professional. Providing a printed care plan to patients and carers would be advised.