Organisation and timeline of measures in French psychiatric establishments during the first wave of the COVID-19 epidemic: EvOlu’Psy study

The onset of the pandemic of SARS-CoV2 (Coronavirus-19) and the illness it causes (COVID-19) required rapid organisational changes in the mental health domain [1]. Patients with psychiatric disorders generally present a higher risk of infection and specially to SARS-CoV2 than people without mental disorders and may be at greater risk of developing multiorgan failure and more likely to die in an intensive care unit (ICU) as they suffer from untreated comorbidities (diabetes, obesity, hypertension) [2, 3].

Among outpatients, the lockdown measures (home confinement), the remoteness of daily activities, and the imposition of social distancing have particularly affected those with psychiatric disorders, with an increase in anxiety and depression disorders and high rates of sleep disorders and post-traumatic stress disorders (PTSD) [4]. Moreover, based on an extensive literature review, Chevance et al., demonstrated that early hospital discharges and breaks in in-person psychiatric follow-up were frequent, with consequences including relapse, suicidal behaviour, difficulties in access to care, and social isolation [5].

In inpatient care, compliance with social distancing and other barrier measures have appeared to be challenges in psychiatry departments: patients receiving care in these departments may have cognitive and behavioural vulnerabilities and learning difficulties, all of which can impede the application of these measures [6]. Moreover, although scientific data on the topic are sparse as revealed by Legrand et al., adherence to standard and additional hospital hygiene guidelines in psychiatry departments must be improved, especially in emergency situations [7].

Most mental health-care departments appear to have set up infection control measures [8‐18]. They also organised planning, coordination and measures that enabled them to provide psychiatric care in a restrictive environment. They were able to develop rapid, even innovative, strategies of adaptation. For example, the COVID-19 pandemic has accelerated the development of telepsychiatry and strengthened home care and liaison psychiatry [9, 19, 20].

The collection and evaluation of these organisational measures and strategies during the COVID-19 crisis appear important for understanding the course of the epidemic [21]. This collection needs to take place at local, national, and international levels. Currently, very few studies are available about the organisational response of psychiatric facilities to this pandemic [22‐25].

Our objective was to assess the organisation by psychiatric facilities in France of their response to COVID-19 during the first wave which lasted from 5 March 2020 to 6 June 2020, while considering their timelines and their sector (public/private for-profit, private non-profit).

Of the 331 establishments contacted, 94 (28.4%) agreed to respond to the survey questionnaire, administered by telephone by a trained investigator to guarantee the quality of the data entry; 29 (8.7%) refused to participate, and 208 (62.8%) did not respond at all.

French psychiatric establishments on the whole were able to provide a necessary reorganisation of their management of patients and their families, regardless of facility status. Thus, day hospitalisation, CATTP activities, and psychosocial rehabilitation were reorganised toward either complete closure or maintenance of some activities. These results are consistent with those of a study from Italy, which found that the number of day hospitalisation days diminished by 78%, while those of day hospitalisation for psychosocial rehabilitation dropped by 85% [28]. This reorganisation of psychiatric activities took place very quickly, in many establishments before the French guidelines for psychiatric facilities were published on 23 March 2020. To our knowledge, there are no data in the literature with which we can compare this organisational timeline, but it is important to note that these French governmental guidelines specific for psychiatry appeared rather late — on 23 March although the national lockdown began on 17 March. Nonetheless, a very large majority of psychiatric facilities had made and implemented these measures before the lockdown. Implementation of home care, on the other hand, was very inadequate: only half of the facilities responding to this survey set it up during the first COVID-19 wave. We also note that specific guidelines for the management of patients with psychiatric diseases who were confined at home were published very late, on 2 April [29]. Facilities in the private for-profit sector set up these measures least often. These results are explained by the fact that home care is essentially managed in France by “public service” establishments; this type of care is not part of the culture of private for-profit facilities. On the other hand, these private for-profit facilities set up “listening services” more rapidly, probably to make up for their lesser use of home care.

The other measures considered very inadequate concerned essentially the ethical and legal aspects. Only 58.50% of the facilities reported that they had updated their procedures concerning the patients’ freedom of movement and the dignity of hospitalised people. Nonetheless, the restriction of liberties induced by the measures sometimes necessary to limit disease transmission (respiratory isolation measures) has raised again the fundamental question of the rights of patients in psychiatric hospitals [30]. Some psychiatric hospitals in China systematically isolated all new patients for 14 days before admitting them to specific hospital departments [31]. The COVID-19 crisis appears to have had a disproportionate effect on the loss of civil and political rights of persons with mental and cognitive disorders, which must nonetheless be considered absolute to guarantee respect of the person’s fundamental rights [32]. French public establishments appear to have done a better job of considering the issue of patients’ rights than the private facilities. No comparative data are currently available but this result is probably is explained by the fact that patients admitted without consent can only be admitted to establishments providing public service, which are principally public institutions.

Along the same lines, only 54.9% of the establishments responding to our survey reported that the hearings continued to take place in front of a judge to determine their detention (in-person hearings complying with barrier measures or videoconferences) for patients hospitalised in psychiatry departments without their consent. Although these hearings depend on the court system rather than the psychiatric hospitals, these results highlight once again the very inadequate consideration of these patients’ rights. On 27 March 2020, the controller general of places of deprivation of liberty alerted the ministry of health about several points concerning the rights of psychiatry inpatients and warned especially that most of the judges involved were not traveling to hospital sites and were ruling solely based on their own files [33].

The quality of the measures taken for hospital hygiene and epidemic control in the French psychiatric establishments during the first COVID-19 wave seems more mixed. Numerous actions in this domain appear to be inadequate or very inadequate. Thus we note that only 68.1% of the facilities had appointed an expert to be responsible for infection vigilance before the health crisis. Nonetheless, health monitoring in France, which includes infection vigilance, was instituted by Law n°98–535 dated 1 July 1998 to reinforce health surveillance and the safety of products intended for human use [34]. Infection vigilance is thus the set of specific measures of surveillance, prevention, and control of infections associated with care. It includes, in particular, the facility’s measures to combat health care-associated infections and its reporting of specific infections to the health authorities. The comprehensive and coordinated management of risks of health care-associated infections is also set forth in the law known as the Hospital, Patient, Health, and Territories Act, dated 21 July 2009, which specifies that these vigilance systems intended to ensure health security are among the responsibilities of each institution’s medical committee [35]. Moreover, even though 95.7% of the facilities reported seeking advice from their EOH during the first wave of the health crisis, only 64.4% had done so before the activation of the emergency “plan blanc”. Each French health care facility is nonetheless required to have an EOH, a hygiene operational team. The team is composed of experts in the management of the risk of infection of patients, professionals, and all persons who visit the facility. Among its missions, the EOH must initiate and coordinate the a priori management of infectious risks and is especially responsible for elaborating, disseminating, and setting up protocols in collaboration with clinical departments for the prevention of infections that may be associated with health care [36].

The first recommendation for hospital hygiene related to COVID-19 in France were published by the SFHH on 20 January 2020 and by the HCSP on 27 February [37, 38]. It thus seems surprising that the EOHs were not sought out for advice in this health crisis before 6 March. Similarly, although all establishments reported that they had set up specific infection control procedures for the admission of patients with COVID-19, more than half of them (59.3%) reported these were set up after 14 March, that is, more than 15 days after the HCSP recommendations on this topic were published. The procedures set up for the management of the bodies of deceased patients with COVID-19 were also late since 93.2% of the facilities who set them up did so after 6 March, and 31.5% after 23 March. Private non-profit facilities set up these procedures most often, perhaps because they also reported admitting more patients with COVID-19.

The results concerning personal protective equipment were judged very inadequate for surgical masks, smocks, and FFP2 masks, and inadequate for the other personal protective equipment. The shortage of personal protective equipment and especially masks was not unique to French psychiatric facilities. It affected all types of facilities and specialties, not only nationwide but around the world, starting at the onset of the first wave in China [39]. Although the implementation of systematic screening for signs of COVID-19 by the psychiatric facilities was very satisfactory, that of systematic screening of individuals with risk factors for severe COVID-19 was not; it was indeed very inadequate, taking place in barely half of the responding facilities (52.1%). This result reinforces the need to improve somatic management of patients with severe chronic psychiatric disorders, as underlined in the clinical practice guidelines in psychiatry issued in June 2015 and approved by the French national authority for health [40]. Finally, surprisingly, more than half of French psychiatric establishments set up routine testing for COVID-19 by nasopharyngeal samples tested by RT-PCR for the virus genome at admission, although no recommendation for this measure had been made for psychiatric facilities. The implementation of this type of measure appears to be associated with the strong desire of these establishments to control the virus and especially to protect their staff. That is, although they did not set up adequate measures to screen for patients at risk, the follow-up of the risk of infection among staff members was very satisfactory (87.4%) as was staff training in additional COVID-19 control precautions (84%). On the other hand, the implementation of an educational programme for patients about barrier measures was very inadequate — only 48.9%.

It thus appears necessary to promote hospital hygiene in psychiatry. To our knowledge, the literature about infection control measures in psychiatry is extremely sparse. A study conducted in 2019 about the practice of intramuscular injections in psychiatry departments suggests that standard hospital hygiene precautions require improvement in these departments, especially in emergency conditions [7]. Other studies on this subject are nonetheless necessary to confirm these results.

In terms of crisis management, in general, it should be noted that none of the different types of establishments collaborated very much during this epidemic wave. Only public institutions reported participating in clinical research on COVID-19, and the inclusion of the occupational physician in the crisis management group was very inadequate, although least poor in the public hospitals. To our knowledge, there are currently no data available in the literature about these organisational points and measures in psychiatric facilities during the first Covid-19 wave. We note that the facilities responding to our survey reported very inadequate availability of thermometers (available in only 57.4%), although these are essential in this epidemic situation.

The principal strength of our study is that it is the first to assess the organisation and measures taken in response to COVID-19 by French psychiatric facilities and their timeline in relation to the date that the principal national recommendations were issued and by the type of establishment. Our study sample is representative of psychiatric inpatient facilities in France. We sought to include 80 facilities and were able to include 94. Moreover, our results are exhaustive, with few missing data in the responses. Finally, it should be noted that a very high percentages of the survey respondents belonged to the establishment’s crisis management group; the information collected thus appears reliable. The limitations of our study are that the data collection is based on a telephone interview three to four months after the implementation of these measures. This survey is based on an internal audit without external evidence, such as documents and protocols. Nonetheless, we note that the respondents knew the questions in advance to enable them to collect the information to provide during the telephone interview.

In conclusion, french psychiatric establishments on the whole were able to provide a necessary reorganisation of their management of patients and their families, regardless of facility status. Moreover, these facilities appear to have set up their responses quite rapidly, often earlier than the national recommendations on this topic. Patients’ rights nonetheless seem to have not received the attention they merited during the early pandemic period, and special and urgent attention to monitoring this aspect is essential to ensure that the individual liberties of psychiatric inpatients are respected in the future. Moreover, somatic management of patients with mental illness must absolutely be improved, as must the screening for risk factors for severe COVID-19, which are frequent in these patients.

Finally, the measures implemented for hospital hygiene for infection control in psychiatry during this first epidemic wave appeared inadequate, even very inadequate, or implemented too late. The promotion of hospital hygiene is essential.