It is known that epidemics almost never affect populations equally and these inequalities can drive the spread of infections. In addition to older adults and residents of long-term care facilities, there are other unrecognized but critically vulnerable groups that require immediate attention in the evolving COVID-19 pandemic. This includes populations with severe and persistent mental illness (SPMI) who require uninterrupted access to mental health services for comprehensive treatment with the goal of averting admission. This is a critical goal given the increased susceptibility of patients with SPMI to infections, including the risk of nosocomially acquired COVID-19. Because of the current potential for exponential growth in the population incidence and prevalence of COVID-19, there are concerns that health-care systems will become saturated with critically ill patients such that hospital care may need to be rationed amongst those with seemingly less critical illness whose care may be deemed as ‘non-essential.’ This may have significant impact on patients who present to hospital with other severe conditions, including SPMI. Psychiatric care is not ‘non-essential’ during pandemic events like COVID-19; now more than ever, timely psychiatric care is both essential and indispensable. It is imperative to design and implement clinically relevant and patient-safety-driven risk-stratification algorithms to guide decisionmaking for appropriate access to hospital-based psychiatric care. Psychiatric care for patients with mental illness could pragmatically be stratified from ‘essential’ to ‘least essential.’ The ‘essential’ category would capture those with an increased risk of symptom progression and adverse outcomes and/or functional impairment if care is delayed indefinitely, while ‘least-essential’ reflects that access to care is not medically necessary and could safely be modified or postponed for some time. A clear breakdown of COVID-19 cases by at-risk groups would allow for health care to be matched to those in greatest need. Developing policy based on the evolving epidemiology of COVID-19 would be instrumental in guiding the planning and prioritization of health-care resources so that the most vulnerable groups are well served. This remains a crucial need in psychiatry where the most severely ill experience such an incomparable burden of illness. Finally, the effect of the COVID-19 pandemic on essential clinical research will also need to be considered as the crisis profoundly changes patients and treatment systems. Emerging new infectious diseases, such as COVID-19, can exert a significant psychological impact on the psychiatric community with SPMI, which requires flexible and appropriate interventions. It is an area that urgently needs more research. Three elements are required in future research on the psychological impact of such unprecedented biological events on patients with pre-existing SPMI. First, a systemic perspective is warranted. Just as it is important to evaluate the psychosocial impact of emerging infectious diseases on the general population, it is equally important to examine the psychological effects on the oft overlooked, but disproportionately at-risk, population with SPMI. Second, prospective research is essential as the psychological sequelae may persist or evolve over time in unforeseen but injurious ways in such at-risk groups. Longitudinal studies can assess the role of health determinants further with a view towards identifying protective factors and adaptive coping strategies for subsequent application in cases requiring additional intensive interventions. Third, the outcomes of psychosocial interventions in SPMI during pandemic crises should be evaluated. Identifying beneficial therapeutic strategies during pandemic events may facilitate the implementation of more strategic mental health responses for patients with SPMI in order to balance their disproportionate risk while also attempting to prevent the exacerbation of preexisting socioeconomic disparity.

中文翻译：

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隐藏在显而易见的地方：解决 COVID ‐19 大流行期间高危精神病人群的独特需求

众所周知，流行病几乎从来不会平等地影响人口，而这些不平等会推动感染的传播。除了老年人和长期护理机构的居民之外，还有其他未被认识但极其脆弱的群体需要在不断演变的 COVID-19 大流行中立即得到关注。这包括患有严重和持续性精神疾病 (SPMI) 的人群，他们需要不间断地获得精神卫生服务以进行综合治疗，以避免入院。鉴于 SPMI 患者对感染的易感性增加，包括院内感染 COVID-19 的风险，这是一个关键目标。由于当前 COVID-19 的人口发病率和流行率呈指数增长的潜力，有人担心，医疗保健系统将充斥着危重病人，因此可能需要在那些看似病情较轻、但可能被视为“非必要”的患者中分配医院护理。这可能对因其他严重疾病（包括 SPMI）入院的患者产生重大影响。在 COVID-19 等大流行事件期间，精神科护理并非“非必要”；现在，及时的精神病护理比以往任何时候都更加重要和不可或缺。必须设计和实施临床相关和患者安全驱动的风险分层算法，以指导决策以适当获得基于医院的精神科护理。精神疾病患者的精神科护理可以从“基本”到“最不重要”进行分层。' '基本'类别将涵盖如果无限期延迟护理，症状进展和不良后果和/或功能障碍的风险会增加的人，而'最不重要'则反映获得护理在医学上不是必要的，可以安全地修改或推迟一段时间。按高危人群对 COVID-19 病例进行明确细分将使医疗保健与最需要的人相匹配。根据不断发展的 COVID-19 流行病学制定政策将有助于指导卫生保健资源的规划和优先排序，以便为最弱势群体提供良好的服务。这仍然是精神病学的一个关键需求，其中最严重的病人会经历这种无与伦比的疾病负担。最后，随着危机深刻地改变了患者和治疗系统，还需要考虑 COVID-19 大流行对基本临床研究的影响。新出现的新传染病，例如 COVID-19，会对患有 SPMI 的精神病社区产生重大的心理影响，这需要灵活和适当的干预措施。这是一个迫切需要更多研究的领域。在未来关于这种前所未有的生物事件对预先存在的 SPMI 患者的心理影响的研究中需要三个要素。首先，系统性的观点是必要的。正如评估新发传染病对一般人群的社会心理影响很重要一样，检查对经常被忽视但风险极大的 SPMI 人群的心理影响也同样重要。其次，前瞻性研究是必不可少的，因为心理后遗症可能会随着时间的推移以不可预见但有害的方式在这些高危人群中持续存在或演变。纵向研究可以进一步评估健康决定因素的作用，以确定保护因素和适应性应对策略，以便在需要额外强化干预的情况下进行后续应用。第三，应对大流行危机期间 SPMI 的社会心理干预结果进行评估。在大流行事件期间确定有益的治疗策略可能有助于对 SPMI 患者实施更具战略性的心理健康反应，以平衡他们不成比例的风险，同时也试图防止先前存在的社会经济差距的加剧。前瞻性研究是必不可少的，因为心理后遗症可能会随着时间的推移以不可预见但有害的方式在这些高危人群中持续存在或演变。纵向研究可以进一步评估健康决定因素的作用，以确定保护因素和适应性应对策略，以便在需要额外强化干预的情况下进行后续应用。第三，应对大流行危机期间 SPMI 的社会心理干预结果进行评估。在大流行事件期间确定有益的治疗策略可能有助于对 SPMI 患者实施更具战略性的心理健康反应，以平衡他们不成比例的风险，同时也试图防止先前存在的社会经济差距的加剧。前瞻性研究是必不可少的，因为心理后遗症可能会随着时间的推移以不可预见但有害的方式在这些高危人群中持续存在或演变。纵向研究可以进一步评估健康决定因素的作用，以确定保护因素和适应性应对策略，以便在需要额外强化干预的情况下进行后续应用。第三，应对大流行危机期间 SPMI 的社会心理干预结果进行评估。在大流行事件期间确定有益的治疗策略可能有助于对 SPMI 患者实施更具战略性的心理健康反应，以平衡他们不成比例的风险，同时也试图防止先前存在的社会经济差距的加剧。