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Citation information
Suggested citation: Mental Health Commission of Canada. (2021). COVID-19 and people living with
serious mental illness: Policy brief. Ottawa, Canada: Mental Health Commission of Canada.
© 2021 Mental Health Commission of Canada
The views represented herein solely represent the views of the Mental Health Commission of Canada.
ISBN: 978-1-77318-263-6
Legal deposit National Library of Canada
Acknowledgments
The Mental Health Commission of Canada operates primarily on the unceded traditional Territory of the
Anishinabe Algonquin Nation whose presence here reaches back to time immemorial. The Algonquin
people have lived on this land as keepers and defenders of the Ottawa River Watershed and its
tributaries. We are privileged to benefit from their long history of welcoming many Nations to this
beautiful territory. We also recognize the traditional lands across what is known as Canada on which our
staff and stakeholders reside.
Our policy research work uses an intersectional Sex and Gender-Based Plus lens to identify, articulate,
and address health and social inequities through policy action. In this respect, our work is guided by
engagement with diverse lived experiences and other forms of expertise to shape our knowledge
synthesis and policy recommendations. We are committed to continuous learning and welcome
feedback.
The Mental Health Commission of Canada (MHCC) would like to thank the external reviewers and staff
who provided important and valued contributions to this work.
Expert reviewers
• Eugène LeBlanc and members of the MHCC’s Hallway Group and Youth Council
• Dr. Manon Charbonneau and members of the Canadian Psychiatric Association Public Policy
Committee
• Tim Simboli, Executive Director, Canadian Mental Health Association, Ottawa Branch
• Vicky Huehn and Executive Committee members of PSR Canada
MHCC staff
• Katerina Kalenteridis, Analyst, Policy and Research
• Francine Knoops, Manager, Policy and Research
• Dr. Mary Bartram, Director, Policy
Contents
Introduction ...............................................................................................................................1
Purpose ...............................................................................................................................................1
Background .........................................................................................................................................1
Population health............................................................................................................................................ 2
Government responses during COVID-19......................................................................................................... 3
Impact of COVID-19 on mental health and substance use services.................................................................... 3
Risks and vulnerabilities for people living with serious mental illnesses .............................................5
Comorbidities with physical health risk factors................................................................................................. 5
Challenges of symptoms.................................................................................................................................. 5
Social determinants ........................................................................................................................................ 5
Racialization.................................................................................................................................................... 6
Gender ........................................................................................................................................................... 7
Life span dimensions....................................................................................................................................... 7
Family caregiver dimensions............................................................................................................................ 8
Recovery, resilience, and self-determination in the COVID-19 context ...............................................8
Impact on mental health services........................................................................................................9
Inpatient settings .......................................................................................................................................... 10
Community-based services............................................................................................................................ 11
References................................................................................................................................16
Introduction
Purpose
This brief provides an overview of issues faced by people living with serious mental illnesses (and their
circles of care) during COVID-19, along with considerations for policy development as we move into the
post-pandemic period. It builds on the Mental Health Commission of Canada’s (MHCC’s) preliminary
scan on COVID-19 and mental health policy and draws on Canadian and international academic and
policy literature, information gleaned from the media and key stakeholders, and contributions from the
MHCC’s Hallway Group and Youth Council. To amplify the voices of lived experience, some quotes —
both anonymous and attributed — are included throughout the document.
Key messages
1. COVID-19 has had a significant impact on the well-being of people living with serious mental
illnesses. People who were already living with serious mental illnesses prior to the pandemic were
not only at higher risk for contracting COVID-19; social distancing protocols, service disruptions, and
the nature of their illnesses also placed them at higher risk for poor mental health outcomes.
2. Their needs have taken a back seat to other priorities. The clinical and social support needs of
people living with serious mental illnesses were subordinated to broader public health and mental
health priorities during COVID-19.
3. Services for people living with serious mental illnesses were significantly disrupted. Services for
people living with serious mental illnesses were significantly disrupted, and providers were
challenged to meet their needs during the pandemic — especially for community-based services.
4. Peer support has played a critical role. There are some indications that virtual peer support services
may have helped mitigate the impact of isolation and disruption in services, reinforcing the
importance of social connections and strong social support systems in maintaining well-being.
5. Pandemic impacts were compounded by layers of inequity. People living with serious mental
illnesses facing additional layers of inequities due to racialization, socio-economic status, and health
status experienced additional challenges to their well-being during the pandemic.
6. More research that engages lived experience directly is needed. It is still too early to project the
enduring impacts of the disruptions people living with serious mental illnesses faced during the
pandemic. But research that engages lived experience directly should be prioritized to fully
understand the scope of their challenges, address the systemic issues that exacerbated their
experiences, and guide planning for future pandemics.
Background
Policy makers have been guided by a “whole of society” public health approach when addressing the
impacts of the COVID-19 pandemic, with early recognition of distinct vulnerabilities in the population.
1,2
This orientation was in evidence when Health Canada asked the MHCC to prioritize vulnerable
populations (including people living with mental health problems and illnesses) for policy research early
in the pandemic.
1
Extensive polling throughout the course of the pandemic, in Canada and internationally, has highlighted
the extent to which COVID-19 has contributed to increased stress among the general population.
3-8
However, less attention has been paid to how people living with pre-existing serious mental illnesses
fared during the pandemic, with studies tending to include a broader range of pre-existing mental health
conditions or else drawing on small samples and key informant reports.
9
In collaboration with Leger and
the Canadian Centre on Substance Use and Addiction (CCSA), the MHCC has undertaken a series of polls
that includes a focus on how people with a prior diagnosis of mental illness and substance use are faring
during the pandemic. To date, moderate and severe anxiety have been among the most reported
symptoms for these respondents.
10
There are many types of mental illnesses, and an estimated one in five people in Canada are living with a
mental illness at any given time. Still, less than five per cent of the population are living with what is
usually thought of as a serious mental illness (based on the nature of the symptoms associated with a
more severe impact on daily living for a longer period of time).
11
The U.S. National Institute on Mental
Health defines serious mental illness “as a mental, behavioral, or emotional disorder resulting in serious
functional impairment, which substantially interferes with or limits one or more major life activities”
(para. 4).
12
These types illnesses include schizophrenia, bipolar disorder, chronic depression, eating
disorders, and post-traumatic stress disorder (PTSD), among others.
13,14
People with serious mental
illnesses can also experience concurrent physical illnesses such as diabetes.
15,16
Concurring substance
use in individuals living with serious mental illness is also common,
17,18
and up to 49 per cent of adults
with serious mental illnesses use non-prescription substances, compared to 16 per cent in the general
population.
19
Population health
The MHCC developed a population health model (Figure 1) to frame policy areas in need of attention in
response to COVID-19. This triangle model conceptualizes how the stress from COVID-19 has created the
potential for pressure increases across different levels of need for mental health and substance use in
the population. In particular, and as expected, increases in demand have been coupled with disruptions
in the supply of services.
For people living with serious mental illnesses, the focus is often on needs related to higher-intensity
services (at the top of the triangle), which include acute and tertiary care as well as ongoing supports for
secondary prevention. However, it is equally important to recognize the deep capacity for resilience,
along with the fact that policies and services to meet people’s needs are also encompassed in the first
and second service tiers. Mental health promotion strategies, social determinants of health, access to
primary care, psychotherapy, peer support, and other services that can be part of individual care plans
in support of the journey of recovery are all important policy and service components for people living
with serious mental illnesses.
2
Figure 1. Population Approach to Addressing Mental Health and Substance Use During a Pandemic
Government responses during COVID-19
Canada’s federal, provincial, and territorial (FPT) governments took steps early on to increase mental
health services and supports, with a focus on the needs of people experiencing increased levels of
distress or living with mild-to-moderate mental health problems. Mental health promotion messages
directed at the general population, such as tips for mental health self-care, encouraging physical
movement such as walking, and staying connected virtually, were integral to public health messages in
most if not all jurisdictions. As part of its Safe Restart Agreement, the federal government provided the
provinces and territories with $500 million to address needs and service gaps for people experiencing
challenges during the pandemic related to mental health, substance use, or homelessness.
20
The federal
Emergency Community Support Fund and Canada Emergency Wage Subsidy also provided relief and
added capacity for community mental health services.
21-23
Further, FPT governments invested quickly in e-mental health initiatives. At the federal level, Health
Canada’s Wellness Together Canada portal provided online mental health supports and access to free
virtual counselling services to anyone living in Canada, with the intention of quickly filling gaps in
access.
24
With programs such as Ontario Structured Psychotherapy and Bridge the gApp in
Newfoundland and Labrador, provinces and territories were able to support shifts to virtual care by
building on work begun over the past few years to improve access to psychotherapies, stepped care
programming, and e-mental health services.
25
Impact of COVID-19 on mental health and substance use services
Out of the spotlight, high intensity services for serious mental illnesses across most developed countries
were required to adapt access so it could meet pandemic infection control protocols. Such adjusments
had the effect of closing most in-person day programs and limiting the capacity of inpatient care.
26
In
Canada, some of these responses required rapid policy making while addressing long-standing systemic
3
problems. One case in point was Nunavut, which quickly pivoted from a reliance on fly-in specialists and
fly-out inpatient treatment to building capacity for assessing and providing inpatient care inside the
territory.
27
Federal funding to shelters, community groups, and community mental health services
provided some assistance with filling gaps at the community level.
28,29
However, outside these specific
funding streams, the needs of people living with serious mental illnesses have not received policy
attention.
30
I am super proud of my colleagues across Canada working across various community non-profits who
have been super creative, working long hours ramping up their efforts. I want to make sure that these
efforts made by the non-profit sector are not overlooked or missed because we have been so innovative
and creative in responding to the needs of people living with mental illness in real time. There are some
great success stories, but we need more support from government including continuation of the targeted
wage subsidy.
— MHCC Hallway Group Member
The pandemic has accentuated the extent to which the mental health system is under-resourced and
the gaps that exist in health and social policies to meet mental health needs across the continuum, from
mental health promotion and illness prevention to intensive specialized services.
31
Canadian mental
health advocacy organizations have set out frameworks for tackling these gaps.
32,33
Some efforts were
also undertaken to update guidelines, both in Canada and internationally, to support front-line services
in addressing the impacts of COVID-19 at the clinical level.
34-36
Early in the pandemic, the Canadian
Institutes of Health Research (CIHR) provided rapid knowledge-synthesis grants that yielded a degree of
attention to serious mental illnesses, including a review that explored virtual care issues for people living
with schizophrenia.
37
However, the pressures on the system to meet increasing needs across the
population are likely to continue overshadowing the distinct high-intensity needs of people living with
serious mental illnesses. To date, the Senate hearings on COVID-19 were one of the few policy-making
arenas in which the needs of people living with serious mental illnesses were specifically and publicly
explored.
38-40
‘People living with serious mental illness are an extremely marginalized group whose needs have been
inadequately addressed by the mental health and social services systems for years. There is risk that with
the focus on the negative mental health impacts of COVID-19 on other vulnerable groups and the general
population that the needs of people living with serious mental illness will continue to be neglected. We
must make sure that does not happen.’ (p. 4)
— Centre for Addiction and Mental Health, 2020, Mental Health in Canada: Covid-19 and Beyond
4
Considerations
Risks and vulnerabilities for people living with serious mental illnesses
People living with serious mental illnesses are at increased risk for a range of poorer health, mental
health, and social outcomes that in turn increase their risk of COVID-19 infection. Further, these risks are
compounded by their intersection with other social determinants, including race, ethnicity, gender,
income, age, and family caregiving responsibilities.
Comorbidities with physical health risk factors
The high rates of comorbidity between serious mental illnesses and common physical health conditions,
including cardiovascular disease, diabetes, chronic respiratory disease, and chronic malnutrition, pose
additional risks.
41
Among the more significant risk factors is the comorbidity between serious mental
illness, substance use, and physical health conditions — in part due to lower access and adherence to
medical care, as well the prevalence of risk behaviours such as smoking — which can increase the risk of
disease progression and complications from COVID-19.
42,43
Due to its effects on respiratory and
pulmonary health, COVID-19 can cause especially serious morbidity for people who smoke tobacco or
cannabis and/or are using opioids and methamphetamines.
44
Challenges of symptoms
The context in which symptoms associated with serious mental illnesses occur can alter a person’s
response to COVID-19, and there are distinct concerns related to different types of illness, including
psychosis, eating disorders, prior PTSD, obsessive-compulsive disorder, and severe mood disorders.
Psychiatric experts have pointed out that COVID-19 can be a catalyst for a new onset of psychosis or the
exacerbation of symptoms.
45
A range of symptoms associated with serious mental illnesses could lead to
a lower awareness of risk or a magnification of paranoid and anxious thinking, while certain symptoms
such as disorganization can make it challenging to follow public health directives around social
distancing and mask wearing.
46
For people living with serious mental illness, social distancing can lead to
significant emotional distress that can trigger a relapse of psychotic symptoms as well as eating
disorders and increase the risk of rehospitalization.
47,48
Social determinants
The social determinants of health play an important part in elevating the risk of contracting COVID-19
and/or experiencing poorer outcomes over the medium and long term. If people living with serious
mental illnesses are living independently, they are more likely to be living in poorer or crowded housing
or be part of the significant percentage living in group home or residence settings — both of which
present challenges for infection control. In addition, many do not have access to the internet services,
computers, or cellphones needed to avail themselves of virtual services.
49,50
Mental health experts have increasingly argued that more attention should be paid to the social
underpinnings of mental distress.
51
Strong evidence highlights how higher rates of poverty, limitations in
social supports, and poor physical health among people living with serious mental illnesses place them
at increased risk of developing comorbid illnesses, mortality through suicide, injury through self-harm,
and self-neglect. In addition, while limited U.S. data (and no Canadian data) exists on COVID-19
5
outcomes among people living with serious mental illnesses, we know that social stressors and
conditions can increase the risk of relapse, recurrence, or increased severity of symptoms during the
COVID-19 pandemic.
52-56
Reviewers emphasized the impact of social determinants on people living with serious mental illnesses
during COVID-19, which was exacerbated by the pre-pandemic lack of social housing and the insufficient
implementation of Housing First approaches. Such approaches, recommended in the At Home/Chez Soi
study, highlight the importance of appropriate supports as a key determinant of an individual’s success
in retaining housing.
57,58
FPT governments and non-governmental organizations have taken measures to address COVID-19
income support and safe housing needs for individuals experiencing homelessness or housing precarity,
food insecurity, and income precariousness, which are all risk factors disproportionately experienced by
people living with serious mental illnesses.
59
At the start of the pandemic, many provinces offered
homeless people and people living in shelters emergency temporary housing in empty hotels and
apartment buildings; for example, in April 2020, Toronto’s city council approved $47.5 million in
spending to develop 250 units of modular housing by the fall of 2020.
60,61
However, COVID-19 has placed
even more strain on the social housing system and shelters, and the emergency municipal, provincial,
and federal response has not met the needs of people experiencing precarious housing and
homelessness. Further, persistent homelessness can raise the risk of infection and make it harder to
identify, follow up, and treat people who are infected.
62-64
As soon as COVID-19 began and places started shutting down, people who are already marginalized are
falling through the cracks and continue to do so compared to the general population. In Moncton, we
have seen a rise in homelessness and there is a greater need for community supports.
— Eugène LeBlanc, MHCC Hallway Group
Racialization
People living with serious mental illnesses from racialized communities, who experience layered forms
of stigma, discrimination, and racism, also face increased risks from the impacts of COVID-19. Yet this
situation has just recently become part of the national conversation, and it continues to go
unrecognized by many governments and organizations in Canada, in part because of the lack of race-
based data collection, which is only now beginning to change.
65,66
As an MHCC report on the 2016
census highlights, racialized groups experience high levels of discrimination that can have an impact on
mental health and well-being.
67
The map used by Toronto Public Health to track the COVID-19 infection
rate (by neighbourhood) in the Greater Toronto Area, underlines the extent of such disparities and areas
where racialized individuals live in cramped quarters, lack programs and services, are dependent on
public transit, and have higher rates of infection.
68
There is also growing evidence that the use of
involuntary detainment and restraint is higher for racialized populations with serious mental illnesses
who come into contact with the law.
69,70,71
During COVID-19, racialized communities and individuals
continue to face varying forms of discrimination, prejudice, stigma, and hate crimes, which are linked to
increased stress and other negative impacts on mental health.
72-77
6
I am also concerned about the populations most vulnerable to COVID-19 as I have been seeing the
pandemic lead to increased racism and I am concerned about the impact that that has on mental health
and access to mental health services and care that people receive.
— MHCC Hallway Group Member
Gender
Mothers and pregnant women have experienced a greater impact from COVID 19 on their mental health
compared with men in their peer group.
78,79
An increased risk of gender-based domestic violence has
also been associated with public health restrictions during the COVID-19 pandemic.
80,81
Earlier studies
have indicated that women with schizophrenia experience additional risks of sexual exploitation,
domestic abuse, and random violence.
82,83
Life span dimensions
The pandemic has had distinct impacts on children and youth as well as on older adults living with
serious mental illnesses.
*,84,85
In general, children and youth have had the critical anchor of a sense of normalcy and routine stripped
away, while having their socializing opportunities limited and access to school and specialized programs
interrupted.
86
A 2020 report from the MHCC and Headstrong, called Lockdown Life: Mental Health
Impacts of COVID-19 on Youth in Canada, found that young people (especially marginalized youth) are
particularly vulnerable to the breakdowns the pandemic has caused across Canada. In an Ontario survey
by the Centre for Addiction and Mental Health (CAMH), 50 per cent of youth who had previously sought
help for mental health concerns reported disruptions in their access to care since the pandemic began.
87
Among children with pre-existing mental health conditions, researchers at Sick Kids Hospital in Toronto
found that children and youth experienced relatively similar overall mental health impacts no matter
what their clinical history said.
88
However, those with autism spectrum disorder (ASD) reported the
greatest deterioration in depression, irritability, attention span, and hyperactivity. Among the
intersecting factors believed to be behind this deterioration were closures of school-based services,
challenges with online learning, reduced care services, and disruptions to daily routines. The study also
found that, for some children with certain pre-existing conditions, the stay-at-home directives may have
provided relief from sources of stress and improved symptoms of anxiety or irritability. By contrast,
children with diagnoses such as ASD or attention deficit hyperactivity disorder experienced a negative
impact due to the loss of structure, consistency, and familiar social interactions.
89
Within the older adult population, despite histories of a shorter life expectancy, one segment has been
living with serious and complex mental illnesses for many years. While the distinct needs of older adults
living with serious mental illnesses are rarely explored, the pandemic has impacted their lives on several
layers, including disruptions in access to services for maintaining their well-being and reductions in their
quality of life from imposed isolation.
90
One expert reviewer shared a personal observation that, in
various settings, elderly clients living with serious mental illness were particularly affected by the
*
The MHCC has separate briefs underway for each population group that explore these issues more fully.
7
restrictions imposed on visits by close family members and friends, with some making a request for
medical assistance in dying.
91
There is increasing evidence that isolation measures compounded the pandemic’s impact for people
living with dementia and mental illness in long-term care (LTC) settings.
92,93
A meta-analysis of 74 studies
on LTC populations concluded that certain serious mental illnesses are more widespread in LTC settings
than in the community. The most prevalent among LTC residents was dementia (median prevalence: 58
per cent) and major depression (median prevalence: 10 per cent), yet the median prevalence of
depressive symptoms was 29 per cent.
94
In Ontario, 40 per cent of older adults in nursing homes need
psychiatric services, but less than five per cent receive the care they need.
95
Further, emerging
anecdotal evidence indicates an increase in the use of anti-psychotics and restraints in LTC settings.
96
Family caregiver dimensions
The increased load carried by family caregivers of people living with serious mental illnesses, due to
service disruptions and isolation measures, has been difficult and overwhelming for some. Concerns
have been raised by some experts regarding a substantial decline in families’ capacity to address these
needs because of public health restrictions and the deterioration of caregivers’ own physical and mental
health.
97
A 2020 study found caregiver burden to be especially high in some circumstances, a situation it
associated with “poor social support, high negative expressed emotions, [and] domestic violence” by an
intimate partner toward their family member. It also found that “financial strain, social isolation, low
emotional support, negative social interactions, and psychological distress” increased caregiver burden
(p. 4).
98
In addition, while social distancing measures required family peer support services to pivot to
virtual modalities, no studies have yet been found on the outcomes or challenges of this experience.
Recovery, resilience, and self-determination in the COVID-19 context
The importance of focusing on the strengths and resiliency of individuals and communities rather than
on weaknesses and vulnerabilities is a critical aspect of the recovery-oriented approach in mental
health. This approach integrates the principles of hope, person-centred care, human rights, and social
connectedness within recovery-oriented programs and services for people living with serious mental
illnesses. Implementing this approach necessarily means paying attention to the factors that maintain
99,100
An well-being and build resilience, which in turn require that systemic inequities are addressed.
early commentary in Nature highlighted this point by noting that, while it was encouraging to see strong
attention to mental health as part of the COVID 19 response, it was disappointing that the focus was on
only half the equation: it was ignoring how mental ill-health increases a person’s exposure to economic
shocks and the need to attend to the social needs of those with pre-existing mental-health conditions
who are most at risk of “social drift.”
*,101
Just as recovery does not necessarily mean cure, resilience does not equate with any ideal level of
mental health; rather, it is constantly developed by engaging in life’s challenges and opportunities,
including the challenges associated with serious mental illnesses. There are multiple pathways to
*
The social drift hypothesis proposes that people living with mental illness “drift”; in other words, they have downward
social mobility into lower income and/or socio-economic status during the course of their lives due to a number of
factors that could include stigma, increased health expenditures, or reduced earning potential.
8
resilience, but they are all built on the need for social support and sufficient resources, which serve as
the underpinnings for dealing with challenges, including a pandemic.
102
As part of fulfilling fundamental social needs (a home, a job, a friend), recovery-oriented principles
reinforce the importance of paying attention to opportunities for social connectedness. Early concerns
were raised within the mental health sector that social distancing requirements would lead to poor
psychiatric outcomes during the pandemic for people living with serious mental illnesses. These
concerns included increased social isolation and loneliness, which are already common experiences for
these individuals
103
and are associated with a lower quality of life, depression, paranoid thinking, and
suicide ideation.
104
Social isolation and loneliness can also lead to significant emotional distress and
recurrences of psychotic symptoms, resulting in increased risk of rehospitalization in this population.
105
Access to peer support is considered an especially important facilitating contributor to supporting well-
being for people living with serious mental illnesses.
106
Reports through the MHCC’s Hallway Group
provide some evidence that maintaining peer support services virtually can help to mitigate the impact
of isolation for some people living with serious and chronic mental illnesses, a portion of whom were
able to tap into federal funding for community groups and wage subsidies to refocus their work in a
virtual context.
107
Peer support groups, community mental health programs, and psychiatric services
may all consider playing a role in undertaking more robust research to better understand the experience
of social isolation during the pandemic among people living with serious mental illnesses.
Another key principle of recovery-oriented mental health practice is self-determination and rights,
which may come under threat as health systems prioritize infection control. While Britain moved to
loosen criteria and protections for involuntary treatment and confinement in its mental health acts
during the pandemic,
108
no such policies have been uncovered in Canada. Nevertheless, the extent to
which infection control measures have led to an increase in the use of seclusion and restraint in
inpatient settings in the Canadian context (i.e., that mirror the anecdotal reports of increased use of
antipsychotics in LTC settings) is still unclear.
109
However, PSR Canada reviewers observed pullbacks of
recovery-oriented services with especially concerning impacts on in-hospital units. Members reported
that people in the units lost their rights to go on walks even if public health guidelines were followed:
“Years of advancement towards the rights of people with mental illness and substance use seemed to be
eliminated in some settings due to the pandemic.”
110
This is also an area warranting further research.
Impact on mental health services
COVID-19 has accentuated the extent to which mental health has been poorly resourced in Canada and
across the world.
111
According to a United Nations report, internationally, the vast majority of mental
health needs went unaddressed during the first wave of the pandemic.
112
In Canada, an MHCC-CCSA-
Leger poll found that, as of December 2020, access to services had not kept up with need: only 22 per
cent of respondents with mental health symptoms reported accessing treatment services since the
pandemic began.
113
Regarding people living with serious mental illnesses, the UN found that many
countries’ mental health policies did not sufficiently address their needs in community, outpatient, or
inpatient settings — nor did most COVID-19 risk management and lockdown measures align with human
rights conventions.
114
Additional studies are needed to better understand how much the Wellness
Together Canada and provincial and territorial government virtual services, special provisions for high-
9
intensity services, and mental health promotion efforts mitigated service disruptions and social isolation
measures during the pandemic.
Inpatient settings
Several reports in 2020 indicated that inpatient settings and psychiatric units within mental health
centres and hospitals around the world were unprepared for the sudden onset of the COVID-19
pandemic and did not have the proper policies, guidelines, and resources to respond.
115-121
Other
reporting has found instances of wards and programs having to close in the wake of COVID-19, sending
people living with serious mental illnesses to settings with limited support.
122-124
Further, staff at those
inpatient settings had to advocate both on behalf of people living with serious mental illnesses and to
get support from governments and other organizations.
125
Inpatient settings that stayed open restricted
visits and quickly redeployed staff. But these actions led to difficulties in maintaining essential
treatments — such as medications, electroconvulsive therapy, cognitive behavioural therapy — and in
addressing the needs of people living with serious mental illnesses who had contracted COVID-19.
126,127
While a systematic analysis was not undertaken, a quick scan identified services that were publicly
sharing updated status reports related to the outbreaks they experienced and the measures they were
taking.
128
Yet other reports indicated that peer support services in some institutions were deployed to
mitigate the impact of COVID-19, and that others had opened alternative clinical services.
129-132
There are various documented reports of COVID-19 affecting patients and staff at mental health centres
in countries around the world, including China, South Korea, Italy, and others.
133-137
In Canada, the most
publicized case was at the Douglas Mental Health University Institute in Montreal, which experienced an
outbreak of COVID-19 in its mood disorders clinic arising from the transfer of LTC residents to the
institute.
138
In the aftermath, people living with serious mental illnesses were refused admittance and
discharge while hospital staff were lacking resources and strong guidelines to address the outbreak in
this setting.
139
Inpatient settings are at increased risk of COVID-19 outbreaks because
• they are not set up for aggressive infection control
• staff and patients don’t typically wear protective gear
• wards are crowded
• people living with serious mental illnesses are ambulatory, interactive, and may find it hard to
follow some social distancing protocols.
140-142
The public health response to the pandemic has also limited the programs inpatient settings are able to
offer (such as recreational activities and visitation), which has also led to delays in admissions and
transitions back to the community.
143
While it is still unclear how the implementation of pandemic
protocol plans for psychiatric inpatient settings have unfolded, there are likely differences across
settings; for instance, in hospital psychiatric ward versus a psychiatric centre or a child mental health
centre. In general such unique challenges make it more difficult to quickly put measures in place to
address the COVID-19 pandemic and maintain safety, continuity of care, and a recovery-based
approach.
10
As an occupational therapist, I am familiar with how COVID has impacted in-patient settings and so
there are a lot more barriers to resources. One example is the limits on use of communal areas like
cafeterias, rec and fitness. It has forced people to be more creative to meet restrictions but still offer
services/social support face-to-face. It has been difficult to be in inpatient settings, specifically around
not having visitors. . . . Also, in hospital settings there is the barrier of not being able to do transitional
meetings with folks who are about to integrate back into the community. In the past we were able to
provide transitional programs such as providing opportunities to be in the community, connecting with
folks prior to discharge that could have implications for long-term recovery.
— MHCC Hallway Group Member
In response to these COVID-19 public health measures, researchers have pointed out the risk of
increased seclusion and involuntary detention rates in inpatient settings.
144,145
In addition, mental health
review tribunals became less accessible, which put people living with serious mental illnesses at
increased risk of being deprived their human rights.
146
With a lack of access to usual support services in
inpatient settings, inappropriate hospitalizations, delayed discharge, and seclusion “clearly falls into the
category of risk management, rather than treatment” (p. 10).
147
Yet such “risk management” violates
the human rights of people living with serious mental illnesses. Not only can it make them unable to
advocate for themselves, it can worsen health and mental health outcomes.
148
At the June 3, 2020, meeting of the Senate Standing Committee on Social Affairs, Science and
Technology, Dr. Georgina Zahirney, president of the Canadian Psychiatric Association (CPA), highlighted
the issues exacerbated by the long-standing lack of appropriately resourced acute inpatient mental
health care beds:
Outside of Quebec and Nunavut, there are 7,242 designated mental health beds, yet the estimated daily mental
health occupancy is over 8,300 in that jurisdiction alone. Extended stays for people who no longer require the
intensity of inpatient care but who cannot be safely discharged back to their housing situation also further impedes
access to acute hospital resources.
149
(p. 8)
Among CPA’s recommendations were better resourcing of intensive mental health services as well as
stronger and more unified guidelines and policies for inpatient settings across Canada.
Community-based services
COMMUNITY MENTAL HEALTH SECTOR
While most mental health care in Canada is delivered in the community, this already under-resourced
sector faced significant challenges in adapting to specific COVID-19 public health restrictions.
150
As one
reviewer said, while acute care services were largely maintained during the pandemic, “it was really the
cut-off from community services that support and help maintain recovery and well-being that [was] the
most devastating for people living with serious mental illnesses.”
151
The continuum of community
mental health care is wide-ranging and includes programs offered by the Canadian Mental Health
Association (CMHA), a growing network of integrated youth hubs, hospital outpatient services (e.g.,
assertive community treatment and housing support), and extensive specialized mental health services
across the lifespan and for population needs.
11
The sector is made up of many small agencies, whose reliance on grants and community funding was
severely hampered during the pandemic. As CMHA has pointed out, they expect that the federal funds
needed to enable community groups to transition to online services would not be sufficient.
152
While
certain federal measures, such as community grants and the wage subsidy program (combined with
resources added by provinces), appear to have helped bridge some of the gaps, no comprehensive
analysis of the sector’s overall ability to meet care needs has yet been undertaken.
Social distancing measures also placed numerous challenges on maintaining access to community health
services for people living with serious mental illnesses, including day programs, peer support,
counselling on housing and income support issues, simply because some services became more difficult
to access due to public health measures and the challenges in maintaining adequate social
distancing.
153,154
CMHA has pointed out that
Many mental health and addictions sector organizations have had to limit or suspend in-person programs and
services at a time when requests for support are increasing. Consequently, many people with mental health
problems and mental illnesses have lost access to the supports and programs, and the routines and connections
that support their well-being and recovery.
155
(p. 3)
These additional challenges impacted the ability of community mental health services to meet the
mental health needs of the public, and particularly the needs of people experiencing serious mental
health problems or illness.
International poll data from April and May 2020 suggests that people living with serious mental illnesses
experienced challenges in accessing a psychiatrist and/or a prescriber as well as prescription medication
during the early stages of the COVID-19 pandemic.
156,157
Further, for a complex array of reasons, certain
population groups including racialized individuals and people with low incomes used fewer second tier
services such as psychologists, and people living with serious mental health problems were often
overlooked for distinct needs for first and second tier community based and health promotion
158
programs.
I have a friend who lives with severe bipolar disorder, who relies on liquid medication for management. A
week or so ago he dropped a prescription as he was coming out of the pharmacy, so it was not usable.
So, he went back to get it refilled but apparently the particular medication he is on is in such shortage
due to COVID that he had to wait almost 4 weeks to get it refilled. He went from being medicated to
completely stopping medications for a month and that is having huge effects on his personal life, job and
professional life, as well in terms of his ability to function.
— MHCC Youth Council Member
In some ways [COVID-19] has increased accessibility to services but conversely there are lots of people
who don’t benefit from virtual services.
— MHCC Youth Council Member
12
VIRTUAL CARE
Since the onset of the COVID-19 pandemic there has been a tremendous shift to virtual service delivery.
While this has spawned important and likely long lasting innovations for the second tier of care,
telemedicine or online approaches may not meet the needs of people living with serious mental
illnesses who may not be able to access these resources, struggle with computer literacy, or may have
needs that go beyond virtual sessions.
159
Experts stress that for people living with serious mental illness,
face-to-face appointments with a mental health service provider are essential to make ongoing
160,161
assessments, to receive services and treatments as well as to monitor overall well-being.
Continuing face-to-face appointments throughout the COVID-19 pandemic is essential and psychologist
and psychiatrists will need the proper resources and supports to be able to maintain continuity of care
for people living with serious mental illnesses.
It (isolation) is the worst for a person’s mental health. The telephone does not replace eye to eye contact.
I can’t see the end of the tunnel. I miss my peer support groups. I would like to know why this has
happened to us.
— Nadia, Our Voice/Notre Voix, September/Septembre 2020
English translation of French Original
PEER SUPPORT SERVICES AND ENGAGING LIVED EXPERIENCE
As noted earlier, peer support programs offer important sources of support for people living with
serious mental illnesses. They also make up an increasingly important component of the community
mental health sector. Social distancing and barriers in accessing these services exacerbated isolation and
loneliness for people living with serious mental illness.
162
In MHCC’s consultations with people with lived
experience, 29% of participants described barriers to creating communities of care as a high concern,
while 43% noted that the shift to virtual services, although beneficial, also accentuated the digital divide
and left some people behind.
163
[There has been] uneven access to capacity building for people to build their own communities of care
and advocacy…And with an ongoing pandemic, these barriers are amplified.
— Eugène LeBlanc, MHCC Hallway Group
Beyond peer support services and advocacy, our consultations and research found no evidence of the
extent to which the perspectives of people with lived experience were considered, consulted, or directly
engaged in the changes institutional and community mental health services had to make to respond to
COVID-19 protocols. Yet there were calls early on by advocates to engage lived experience in research
on the impact of COVID-19 on people living with mental illnesses, service delivery and planning
responses.
164
A reviewer pointed out that overlooking the opportunities to engage people living with
serious mental illnesses can also be attributed to the lack sufficient attention and implementation of
person-centered mental health care approaches.
165
13
COVID-19 has put into place more stumbling blocks for how people can access help, and thus the call on
how the mental health system can transform itself and still maintain relevant should be at the forefront
of this agenda. I think that the call for a new kind of street-level mental health workforce is at hand,
otherwise many people will fall on the wayside. For some, help by means of social distancing is not a
form of contact that can sustain one’s mental health.
— Eugène Leblanc, MHCC Hallway Group
FRONT-LINE MENTAL HEALTH SERVICE PROVIDERS
Front-line mental health care professionals (FMHPs) are the core of high-intensity services which are
often emotionally charged and highly stressful environments.
166,167
The onset of the COVID-19 pandemic
has increased the amount of stress placed on FMHPs in relation to the increase in the use of virtual
technology and impacts on capacity, as was expressed by 43% of participants with lived experience in
consultations.
168.169
Stress, burnout, and compassion fatigue can often impact the mental health services
that patients receive and their level of satisfaction, leading to somewhat of a cyclical pattern.
170,171
A
CIHR-funded study of the mental health workforce is currently underway in a collaboration between the
MHCC and the University of Ottawa, that may indirectly provide some additional insights about the
impact on services through the lens of individual providers as well as on their own mental health.
Priority Recommendations for Further Policy
Development
1. Work with researchers and funders to evaluate the impact of COVID-19 formally and systematically
on people living with serious mental illnesses, starting with the development of a shared policy
research agenda, identifying partners, and collaborations.
2. Fund and support peer support groups to collect, publish and disseminate stories of lived experience
during the pandemic.
3. Coordinate across peer support groups, community mental health programs, and psychiatric services
to undertake robust research to better understand the shared experience of social isolation among
people living with serious mental illnesses during the pandemic.
4. Develop, strengthen, and integrate pan-Canadian guidelines for upholding and integrating a
strengths-based, people-centered recovery-oriented practice to reduce the impact of future
pandemics on people living with serious mental illness. These guidelines need to address policies and
practices in institutions, regional/provincial mental health systems, and public health authorities.
5. Meaningfully involve people with lived experience of serious mental illnesses in post-pandemic
mental health system and services planning and policy development. As well as in developing mental
health promotion strategies at the community, provincial, and national levels.
6. Fund and support a separate initiative that focuses on addressing virtual care gaps and issues for
people who need high intensity specialized services.
14
7. Assess from both a health equity and sex and gender-based analysis the intersecting social
determinants of health faced by people living with serious mental illnesses across various policy with
the goal of reducing inequities experienced during the pandemic, including housing, anti-racism, and
income and food security policies.
8. Support and strengthen communication efforts to profile the impact of lack of resources devoted to
mental health, the importance of mental health parity, and to share lessons learned during the
pandemic.
15
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