Interview with Prof. Arūnas Germanavičius
In Lithuania, as in many countries, mental health system including mental hospitals had to be reorganized to correspond the requirements of the pandemic times. Vilnius Republican Psychiatric hospital, the biggest mental hospital in Lithuania, met the challenges, and now, after some time, it is time to conclude what was done, how it was done, and what are the consequences.
During the covid pandemia what were the initial changes in the hospital and in services? Have you closed or reorganized some of the departments or services?
Republican Vilnius psychiatric hospital (RVPH) is the biggest psychiatric hospital in Vilnius region (Lithuania), serving for the catchment area of approximately 1 mil. inhabitants.
The full capacity is 402 psychiatric beds covering the whole spectrum of age (from child and adolescents department with 12 beds, to gerontopsychiatric service in the department for treatment of Alzheimer disease and somatopsychiatric conditions with 25 beds. However, the real occupation of inpatient beds in 2020-2021 was 270 patients treated each day, with providing psychiatric consultations and admissions 24/7. In 2020 we have treated about 5000 patients.
Since the beginning of COVID-19 pandemics in March 2020, the decision was made to reduce planned hospitalisations, day-care unit, and psychosocial rehabilitation activities temporary. Old age psychiatric department (gerontopsychiatric) patients were gradually discharged for 30 days, and the department was re-organized into the short quarantine department for acutely admitted patients waiting for two PGR tests in-a-row. Also, we have divided acute admissions into two flow lines regarding epidemiological risk. At the admission department triage of nurses was introduced, trying to assess risk (contacts, temperature, signs of infection etc.), and after the triage patients were referred to: 1) patients with small risk for contact with COVID-19 infected persons, and 2) patients with high risk for infection with COVID-19.
In our hospital we have intensive somatic care unit with ventilators, oxygen supply with 6 beds, so we divided it by half, and 3 beds were made available for COVID-19 patients with psychiatric conditions, who require ventilator or intensive oxygen therapy or cardiopulmonary monitoring 24/7.
Also, department for acute psychoses with 14 beds was transformed into COVID-19 department, where oxygen concentrators made available for patients on demand.
Because our hospital is tertiary university level specialized hospital, we receive many patients with treatment-resistant psychiatric disorders, so neurostimulation (ECT, TMS) is provided in accordance with indications and the treatment protocol. During COVID-19 pandemics, we had to interrupt ECT provision for COVID-19 infected psychiatric patients, who have had psychiatric conditions resistant to psychiatric treatment, because of the shortage of anaesthesiologists, and scrutinized this high risk for COVID-19 infection of staff procedure and appropriateness of protective measures. However, since July 2020, we resumed ECT also for COVID-19 infected psychiatric patients, and continuing until now, covering the need for many patients from the whole Lithuania.
Were these changes temporary or they still persist?
Department for gerontopsychiatry is still closed, and instead of it short quarantine department for acutely admitted patients waiting for two PGR tests in-a-row. Because pandemic continues, we keep divided acute admissions into two flow lines with regard to epidemiological risk. However, day-care, psychosocial rehabilitation and planned hospitalisations are provided since January 2021 without interruptions.
What was the reaction of staff to the pandemic work reorganization? Have you lost some staff because of this COVID-19 situation?
Yes, this was the most tragic consequence for the hospital: there were about 30 staff members, belonging to age group 55-65 decided to leave hospital during first 4 months fearing for their own health and safety. Also, we lost some head psychiatrists of departments, because of psychological burden of reorganisation and necessary rotation of medical staff, while some departments were temporary isolated due to internal COVID-19 outbreaks. During two waves of pandemics in 2020, about 15% of all staff members got infected with COVID-19, but fortunately none has died. Later, when vaccines were available, and about 62% of staff got two jabs at the end of January 2021, some staff members decided to leave, because they were against mandatory testing / vaccination.
What was the reaction of the patients? Have you noticed any new tendencies in their behaviour?
We have learned, that during the pandemics many psychiatric patients withdraw and isolate themselves. This led to interruptions in prescription medicine, not receiving consultations timely, even during the relapses. So, many patients were brought to us by emergency first medical help cars in severe deterioration of their mental health, and duration of their hospital treatment became longer.
Also, our psychologists dr. Ieva Vaskelienė and Ieva Salialionė have researched, whether during the pandemic to RVPH admitted patients experience increased suicide crisis rates, and which groups were affected the most. They have found that the number of suicide crisis increases in 30-39 and 80+ groups of men, who were diagnosed with disorders related to substance use (SUD) and organic mental disorders; also in a group of 70-79 years old women. However, there were not significantly increased suicide risk among all hospital patients during the pandemics period, compared with year 2019 before the pandemics. There were 1323 patients surviving suicide crisis assessed with psychosocial assessment form, age from 10 to 91 years (mean 37,61 years; 51,8 % men and 48,2 % women). In the sample of women, suicide crisis was found to be most common among 10–19 years of age, the frequency decreases steadily in the later age; in the sample of men, the frequency of suicide crisis increased from 10 to 19 years of age, reaches a peak in 30-39 years of age, and later it decreases. Suicide crisis are the rarest in 80+ years men. In the sample of women, suicide crisis were most common among patients with a primary diagnosis of schizophrenia spectrum disorder, while in a sample of men – personality disorder, frequently combined with SUD.
Most people complain about the changes because of the pandemia. But maybe there were some useful changes?
In December 2019 I had Professor Wolfgang Gaebel from Germany as the distinguished guest of Lithuanian Psychiatric association also visiting our hospital. Professor Gaebel has asked me, why having such a big hospital infrastructure scattered in the very old buildings (hospital was built in 1903, part of departments is already closed, and premises are conserved as historical heritage) among nice very old park, we don’t have modern communication technologies among the staff and management, just phones (mobile or fixed landlines), without video chats. This was just some weeks before pandemics broke out. And in April 2020 we already installed computer-based communications not only within the hospital, but also with outside healthcare organisations, coordinating admissions and providing consultations for both patients and healthcare workers.
So, distance communication tools and skills have been developed very rapidly in the course of 2020.
Another very positive element is elevated standards of hygiene both by the staff and the patients. Yes, washing hands and sanitizing them with disinfectants, was not the strongest skill of our staff, and especially among our patients. Previously having sneezing nose or coughing while going to work to hospital was absolute normal. Pandemics made us aware about potential viral infections and damaging consequences of spreading it, especially among vulnerable or immunosuppressed populations, as many psychiatric patients are.
As I told before, we have learned, that during the pandemics many psychiatric patients withdraw and isolate themselves. This leads that they will not be vaccinated unless we will provide them vaccine against COVID-19 during the hospital admission. So, during the end of year 2020 and 2021 we have vaccinated about 200 patients, while they were treated due to relapse of mental disorder. This was never happening in Lithuania before, that patients have been vaccinated during their hospital admission. □