Speed, imagination, technology and flexibility: COVID-19 and mental health in Spain

A small silver lining for Australia as we respond to the COVID-19 pandemic is that we are relatively “late to the party”. We can learn from what has worked, and what has not, in other places.

An ongoing series of Zoom meetings seeks to facilitate this process in the field of mental health via interactive presentations by international experts who are dealing with the challenges of delivering ongoing care, and responding to new need.

Mental health policy expert and researcher Dr Sebastian Rosenberg has been attending these presentations. Below, in the second of an ongoing series of articles, he takes us to Spain, where the COVID-19 outbreak has been characterised by rapid escalation of cases and a sobering mortality rate.

With mental health’s inclusion in a Federal Government funding package to support COVID-19-related needs last week, the message from Spain to act fast and with imagination, use technology and be flexible, is well timed.

Sebastian Rosenberg writes:

Last week at Croakey, I wrote about a recent Zoom meeting, in which two leading mental health experts from the COVID-19-affected Friuli region of Italy shared some of their learnings about providing mental health care during the crisis.

Here I summarise some take-aways from the second of a series of e-presentations about the international impact of COVID-19 on mental health, jointly hosted by The Centre for Mental Health Research (CMHR) at the Australian National University and ConNetica Consulting. 

This week we are in Spain, with a presentation by Professor Jose-Luis Ayuso-Mateos, Director of the Department of Psychiatry at the Hospital Universitario de La Princesa in Madrid.

The meeting included 85 participants from Australia and other countries.

COVID-19 in Spain

Ayuso began by explaining that Spain is typically regarded as having one of the top ten health systems in the world, with its citizens enjoying the longest life expectancy. Spain also has the highest rate of organ transplantation donations in the world.

But this did not stop the country being completely overwhelmed by a situation unimaginable just three weeks ago. Within just days of the first escalation of cases in early March, Spain was affected by COVID-19 at an incredible speed, eliciting major changes in health and mental health.

Spain has around 126,000 cases of COVID-19 (as at 5 April), with one-third of them in Madrid. Around 12,500 deaths have occurred, again with a third in the capital.  As in Australia, the spread of cases is uneven across Spain, with the capital Madrid particularly hard hit.

One remarkable feature of the Spanish experience of COVID-19 has been the high mortality rate, at around 15%, in comparison with Germany at around one percent.

Ayuso suggested this was partly due to the limited testing for the virus, restricted initially to people with significant symptoms on presentation to hospital. Madrid too, like many parts of Italy, has an older demographic.

Impact on the Mental Health Service

One early decision was to close the public mental health hospital services to people with all but the most severe needs. Mental health wards and spaces in public Spanish public hospitals were given over to COVID-19 and other cases. 

As Australia is doing, Spain ‘nationalised’ its private hospitals, creating more capacity. Many of the existing public inpatients were transferred into these private facilities to continue treatment.

As a result, again like Italy, the numbers of existing mental health clients seeking ‘care as usual’ has declined significantly. Jose Luis explained how his Madrid hospital has responded.

Face to face client visits have been limited, again only to those with the most severe needs, or experiencing suicidality. Telehealth has been used for assessments and treatments.  This is a significant change for a service in which only three of the 25-strong psychiatric workforce normally work in the inpatient facility, with the rest working in community centres or day clinics. 

It should be noted that Ayuso’s team continues to operate to a rule whereby a person who has attempted suicide must be seen by a psychiatrist face to face in the community within one week of hospital discharge.

Telehealth services, rarely used before COVID-19, have become critical.  These have been supported by an electronic clinical record and the capacity for electronic prescribing directly to the consumer’s home.

Patients with significant mental health care needs, for example those requiring oral or depot antipsychotic agents or blood monitoring, are still visited by a team of two, one psychiatrist and one nurse.  Staff attend the patients’ houses in full PPE gear for safety reasons. 

Training was required to enable mental health staff to operate in this emergency environment. Among people with COVID-19 there are many mental health clients. Ayuso stated that an important consideration here was to ensure compatibility between patients’ existing mental health drug treatments and any medication used to manage COVID-19.

Ayuso stated that one big factor in his favour was that, as staff were shifted across the health service to help cope with COVID-19, he lost only junior resident staff and was able to keep his core, more senior staff.

Another pre-existing strength of the Spanish system has been the close articulation of hospital and primary care services. One of Ayuso’s community mental health teams is located in a primary care centre. The acute service gets 80 percent of its referrals from this source. 

General practitioners, nurses and community pharmacists operate as part a team and connected to the same e-health record. However, COVID-19 has impacted this, with primary care staff being transferred to work in other parts of the health system. All residents of Madrid are currently being encouraged to take their own temperature daily and call their primary care provider if they are unwell.

It should also be noted that issues concerning the treatment of involuntary patients are handled centrally, not by individual services. This has created some consistency and oversight in deciding treatment options. Daily status reports and information on bed vacancies were also provided centrally (from the Department of Health).

Impact of quarantine

Spain’s strict lockdown means even a walk outside is limited to 600 metres. You can purchase food and tobacco. You cannot exercise outdoors.  

This confinement, which began on 14 March, is difficult for many mental health clients, affecting not only individuals but also the strong peer support networks that had operated. 

While structured community and peer support for mental health has been affected by these isolation rules, there are still social actions to assist the more vulnerable in the community.  

Residents within apartment blocks were cooperating to buy food for the elderly, more contact was being made by phone and so on.

Impact on staff

COVID-19 has impacted the continuity of care normally provided by the mental health service. Ayuso pointed out that 12 percent of all Spanish cases are in health care workers – around 13,000 people. The physical and mental toll on staff has been colossal. 

The mental health team meets twice daily to check in and provide mutual support. Consultant Liaison Psychiatry plays a significant role in providing support not only to clients but also to other staff.

Speed, imagination, technology and flexibility

The key lesson perhaps from this presentation was that an effective response needs the four ingredients listed above. 

The COVID-19 crisis in Spain reached such significant proportions so quickly that the challenges presented were enormous.

Staff are monitoring now the extent to which the changes in service delivery over this period will impact on the ongoing mental health of existing clients.

 Dr Sebastian Rosenberg was a public servant for 16 years, working in health in state and federal governments. He was Deputy CEO of the Mental Health Council of Australia from 2005-2009. He is Head of the Mental Health Policy Unit at the Centre for Mental Health Research ANU and also holds a position as Senior Lecturer at the Brain and Mind Centre at the University of Sydney.

*The virtual meeting described above is one of a series of meetings that The Centre for Mental Health Research at the Australian National University and ConNetica Consulting are jointly hosting with mental health leaders around the world to better understand responses to COVID-19.  A recording of this presentation  and discussion is available here.  Next in this series of international insights will be Professor Helen Killaspy, University College London (UK) on the impact of COVID-19 on mental health services in London.