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| PERSPECTIVE/VIEWPOINT - COUNTRY/REGIONAL |
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| Year : 2020 | Volume
: 2
| Issue : 2 | Page : 106-108 |
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Mental Health and Healthcare in Canada during the COVID-19 Epidemic: A Social Perspective
K Sonu Gaind
Governing Council and Department of Psychiatry, University of Toronto, Ontario; Board, Canadian Association of Social Psychiatry/Association Canadienne de Psychiatrie Sociale, Montreal, Quebec; Mental Health and Addictions Program, Humber River Hospital, Toronto, Ontario, Canada; Board, World Psychiatric Association, Geneva, Switzerland
| Date of Submission | 21-May-2020 |
| Date of Decision | 29-May-2020 |
| Date of Acceptance | 07-Jun-2020 |
| Date of Web Publication | 14-Aug-2020 |
Correspondence Address:
Dr. K Sonu Gaind
Mental Health and Addictions Program, Humber River Hospital, 1235 Wilson Avenue, Toronto
 Source of Support: None, Conflict of Interest: None  | 5 |
DOI: 10.4103/WSP.WSP_45_20
The impacts of COVID-19, both through its direct infectious sequelae, and through massive changes to our societal and health system functioning, are being felt differentially by different populations. In many ways, the disproportionate negative impacts are highlighting preexisting fault lines in our social fabric. Lessons learned during this epidemic can hopefully help guide long-term improvements to models of health-care delivery, and also draw attention to needed social changes for addressing vulnerable marginalized populations and inequities, and improving social resilience.
Keywords: Access, COVID-19, discrimination, health systems, healthcare, inequities, vulnerable populations
How to cite this article:
Gaind K S. Mental Health and Healthcare in Canada during the COVID-19 Epidemic: A Social Perspective. World Soc Psychiatry 2020;2:106-8 |
| Introduction | |  |
As the world and our day-to-day routines changed rapidly in the early months of 2020 to adjust to the expanding COVID-19 pandemic, the health-care system in Canada and elsewhere underwent an unprecedented and almost unrecognizable transformation. Almost exactly 17 years earlier, Canada, and specifically Toronto, was the North American epicenter of the SARS outbreak which tested our health-care system at the time. Already in less than 2 short months, the impact of the current COVID-19 outbreak on our health-care system, society and economy far exceeds the impact of SARS, and we do not yet know how long some of our current system changes and restrictions, either in whole or in part, will need to remain in place.
Difficult as the changes we face are for all of us, the toll on some of us will be even more dear. Emerging data show that certain populations are more vulnerable to the negative impacts associated with COVID-19. Unfortunately, those who already faced inequities from health disparities and barriers to care before are hit even harder by COVID-19, suffering greater morbidity and mortality. This puts already marginalized groups, whether related to ethnicity or socioeconomic disadvantage, at greater risk. Moreover, this risk extends beyond just the negative health impacts if infected with coronavirus.
Consider the consequences of social distancing and isolation. At best of times, self-imposed isolation within the same four walls for stretches of time can lead to “cabin fever.” However, those with adequate space and ability to socially isolate at home, in a family or group with nurturing relationships, will naturally have more resilience than some of our patients who are forced to crowd together in smaller spaces with the very people who may be a significant source of their interpersonal distress. Likewise, the economic pressure pushing an unemployed hourly wage earner to take on available roles such as food delivery, with consequent risk of exposure to coronavirus, is very different than the situation faced by a salaried worker who is able to work from home and maintain income. Such situations speak to the higher risk both of physical harm due to lack of adequate social distancing and increased risk of contagion, and psychological harm due to prolonged exposure to stressful situations that some populations are facing.
COVID-19 itself is impacting different populations differentially as well. It has been known since early on that the illness is more severe, with higher risk of fatality, for the elderly. Beyond that, in addition to being at higher risk of harm if infected, elderly in long-term care have also been seen to have been at higher risk of being infected. While by the end of April, the rate of new cases in Canada had significantly reduced, from doubling every 3 days in late March to doubling every 16 days by the end of April, two different curves were seen, one for the general population and a steeper one for those in long-term care homes.[1] By that point, long-term care and seniors' homes were associated with 79% of all deaths in the country. Similarly it was being reported that in the United States, African Americans were accounting for a disproportionate number of both coronavirus diagnoses and deaths in that country.[2]
The changes to how we are delivering health care also have different consequences for different populations. Early in the outbreak all health-care systems in Canada significantly reduced, if not eliminated, most in-person outpatient services. This included elective surgeries, regular doctor visits, and mental health care. Fortunately, every province quickly introduced frameworks to expand the options available to deliver virtual health care, including by phone or by video. Since the time of SARS in 2003, virtual care medical platforms have matured significantly, as have standards of care and regulatory policies governing virtual health care. Given the infrequency of needing to directly physically examine some patients for ongoing care, mental health care is often particularly amenable to virtual care. However, while the mental health-care system itself is better able to implement virtual care, marginalized patient populations are not as well suited to engage in this shift, and are more likely to lack the fundamental technology, internet access, or even stable housing/contact coordinates required to engage in virtual care. So, while virtual care may expand access to care for some, others will not be able to benefit from it.
At the end of April, a state of emergency remained in place in most provinces in Canada. In our hospital, a large academic affiliated community hospital in Toronto with a catchment of nearly a million people and well over 50,000 annual outpatient visits, the vast majority of outpatient mental health services are currently only being provided virtually, through video or telephone visits. Given provincial directives, unless a patient is in an emergent situation, essentially requiring an emergency visit, they will not be seen in person. While the rapid shift to virtual care has been impressive, this does leave certain populations without access to needed care, including as above those who lack access to necessary technology, and also others for whom virtual care is not feasible (e.g., having hearing or visual deficits, or behavioral issues, limiting use of virtual technologies). Unfortunately, this means some already vulnerable populations face barriers to access to care, and are forced to either present to the emergency room after destabilizing, or to go for prolonged periods without access to care.
Delving further into the impact of system changes on patients needing mental health care, some services that cannot be provided virtually have been severely limited, including electroconvulsive therapy (ECT) that can help treat our most severely ill patients. Some regions had to suspend ECT entirely, while others faced dramatic reductions of number of patients able to be provided ECT, forcing difficult clinical and ethical decisions regarding which patients from amongst many in need would be able to undergo a course of ECT. In the Greater Toronto Area, with a population of over 6 million people, child-adolescent mental health inpatient beds in many facilities were re-purposed for COVID-19, leading to a 50% reduction of child-adolescent beds across the city. This naturally impacts not just the children needing mental health admission, but also their family systems, and adds pressure to the remaining hospitals such as Humber River where child-adolescent beds remained open.
While the focus during an outbreak is often on the numbers of new cases and deaths caused by infection, the true toll of the outbreak extends far beyond that. Both the outbreak, and resulting system changes, have the potential to impact different cultural and socioeconomic groups in different ways. In many ways, the disproportionate negative impacts these groups face during the outbreak reveal preexisting weaknesses and fault lines in our social fabric. However, there are also lessons to learn that show strengths that we can build on.
The pandemic has led to increased coordination of services across sites and regions. For example, the Toronto Region COVID-19 Inpatient Psychiatry Working Group has developed guidelines for local pandemic planning for psychiatric bed management across sites, including mechanisms for patient transfer and repatriation in accordance with different clinical circumstances.[3] Multiple other regional stakeholder tables have been meeting regularly to assess needs and attempt to coordinate services, and hopefully future system planning beyond COVID-19 will remain more coordinated to help overcome traditional silos of care.
The rapid shift to virtual care, while prompted by the need for social distancing and isolation, has also pushed adoption of care delivery models that can increase access to care even beyond this COVID-19 outbreak. It would be important for health systems not to simply remove the ability to deliver virtual care in appropriate situations once the current epidemic passes, but rather to continue building on these models to improve resilience and flexibility of care delivery.
And finally, the current crisis reveals particular populations to be at higher risk both from COVID-19 and related system changes. The disproportionate toll that both the direct and indirect impacts of COVID-19 are taking on marginalized populations shows us that, while coronavirus may not discriminate between rich and poor, black, brown, or white, it reveals where we do. Hopefully through this crisis, attention drawn to some of the long unaddressed inequities that persist for these groups spurs positive action not just in the health-care system, but also for broader social policy change.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Walsh M, Semeniuk I. Long-Term Care Connected to 79 Per Cent of COVID-19 Deaths in Canada. Globe Mail; 2020.  |
| 2. | Barrón-López L. A New Study Shows Just how Badly Black Americans have been hit by Covid-19. Politico; 2020. |
| 3. | TR COVID-19 Inpatient Psychiatric Working Group. Recommendations for Toronto Region Inpatient Psychiatric Units Coordinated Planning for COVID-19 Related System Needs. Toronto: Ontario Health; 2020. |
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