Adult Mental Health in the COVID-19 Context

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The Adult Mental Health in the COVID-19 Context tool is revised often and new content is added regularly to guarantee that the latest evidence and regulatory recommendations are included. The CEP is committed to ensuring this information is accurate and up to date.

Last reviewed: December 21, 2020

Last reviewed: October 21, 2020

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Now more than ever it is important for your patients to look after their health and receive care from you as their healthcare provider. It’s essential that patients continue to seek out care that they need.

This tool has has been developed to support primary care providers in navigating and providing patient care in a world where COVID-19 is the ‘new normal’, with considerations and recommendations on what’s ‘new’ and what’s ‘changed’ in the delivery of care for adults living with previously diagnosed and/or new mental health conditions. While how care is delivered has changed, efforts should be made to ensure that the quality has not. As always, when treating your patients, continue to use your clinical judgement and follow standards of care, best practices, evidence and guidelines.

Key takeaway

For patients requiring urgent care:

If your patient is experiencing a mental health crisis, they should call 911 or report to their local emergency department. For a list of crisis lines in Ontario, visit eMentalHealth.ca.

Consult COVID-19 and the Mental Health Act (CAMH, 2020) for information on the completion of Form 1s, and guidance on the completion of Form 1, 3, 4, 4A, 49 and capacity assessments via phone or video.

The COVID-19 pandemic may cause or exacerbate mental health conditions. In addition, barriers for patient access to supports and treatments have or may lead to negative health outcomes. Therefore, proactive identification and management of adult patients with or at risk of developing mental health conditions should be followed to ensure continuity of care.

Click on the sections below to get started:

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What’s new, what’s changed

Screening

You can provide screening and assessment for mental health conditions remotely. It is important to leverage existing remote/virtual care resources which can be found in Primary Care Operations in the COVID-19 Context > Delivering patient care remotely section.

The pandemic has led to increased rates of alcohol consumption and drug use. Therefore, it is also important to actively screen for substance misuse (CCSA, 2020).

Putting it into practice

For patients with scheduled appointments (even those that are non-mental health related) consider using it as an opportunity to inquire about the patient’s mental health and how they are coping with the current situation.
When feasible, consider proactively identifying patients who have been diagnosed with a mental health condition and reach out to book a remote/virtual appointment.
Use and leverage validated self-report instruments for screening.^† See a list of validated screening tools for various mental health conditions (eMentalHealth, 2020).
For screening patients with suspected substance use disorders, see the on Alcohol use disorder (AUD) in the COVID-19 Context Tool (AUD) and Opioid use disorder (OUD) in the COVID-19 Context Tool.
Provide patients with coping strategies to maintain wellness. See Coping with stress and anxiety (CAMH, April 6, 2020).

† Source: Expert opinion/consensus. See Acknowledgement and legal for clinical working group and contributors.

Diagnosis

Scenarios to consider for patients with pre-existing mental health conditions^†

Patient in active treatment and in an active phase of symptoms prior the pandemic (March 11, 2020).
Patient was on maintenance treatment, but is now in partial remission.
Patient had been in full remission and stable, and is now undergoing relapse.

Scenarios to consider for new cases^†

Conditions now surfacing because of circumstances involving isolation, stress, and fear, but which were previously mitigated by activities and supports.
Mental health conditions due to the patient’s response to an absence of regular routines, in addition to pandemic-induced stress.

† Source: Expert opinion/consensus. See Acknowledgement and legal for clinical working group and contributors.

Putting it into practice

Diagnoses can be done remotely using validated self-report instruments. For patients undergoing a relapse, determine if presentation is consistent with prior diagnosis and treat accordingly. If the patient is presenting with new and/or different symptoms, conduct a formal assessment using:

Management

Management of adult patients with pre-existing or newly diagnosed mental health conditions during the COVID-19 pandemic consists of a tailored treatment plan for each individual that consists of ensuring patient access to treatment, providing patients with remote/virtual supports and following-up on the effects of the treatment in regular intervals.

Putting it into practice

Managing pre-existing mental health conditions

Let patients know they can refill their prescriptions online and use pharmacy delivery or curbside pickup to minimize contact. For a list of local pharmacies to arrange delivery or pick-up, see Local services > Pharmacies.
Inform patients of the various remote/virtual resources that they can access for mental health. See Resources below.
Increase monitoring of these patients by repeating assessment scales (e.g. PHQ-9, GAD-7) at regular intervals.
For local community services and resources that you can connect your patients to, see the CEP’s Local Services Resource for:

Managing new cases of mental health conditions

Frequency of monitoring should be determined and/or adjusted when clinical decisions are being made or at scheduled follow-up appointments (e.g. if starting medication or when doses are being adjusted).
With respect to initiating treatment that may require regular blood work, such as lithium and valproic acid (CANMAT, 2020), take into consideration the patient’s ability to attend laboratory appointments during the pandemic.
For local community services and resources that you can connect your patients to, see the CEP’s Local Services Resource for:

Resources

For patients

Cognitive behavioural therapy (CBT) (free unless otherwise specified)

BounceBack Ontario (CMHA Ontario, 2020) (phone and online).
AbilitiCBT (Morneau Shepell, 2020) (online).
BEACON [costs may be associated] (MindBeacon Group, 2020) (online).

Counselling and peer support (free)

ConnexOntario, 1-866-531-2600
Wellness Together Canada (Health Canada, 2020).
Big White Wall (Centre for Social Innovation, 2020).

Mindfulness

Maintaining wellness

For providers

Screening tools

Screening Tools (eMentalHealth, 2020).

Management tools

Resource hubs

These supporting materials and resources are hosted by external organizations. The accuracy and accessibility of their links are not guaranteed. CEP will make every effort to keep these links up to date.

Acknowledgement and legal

The COVID-19 Resource Centre was developed by the Centre for Effective Practice (CEP) in collaboration with the Department of Family Medicine at McMaster University, the Ontario College of Family Physicians and the Nurse Practitioners’ Association of Ontario using a rapidly modified version of the CEP’s integrated knowledge translation approach. They are some of several clinical resources developed as part of the Knowledge Translation in Primary Care Initiative. Funded by the Ministry of Health and Long-Term Care, this initiative supports primary care providers with the development of a series of clinical tools and health information resources. Learn more about the Knowledge Translation in Primary Care Initiative.

Clinical Working Group

A clinical working group was established and provides significant input and oversight into the development of this resource. Members include:

• Claudia Mariano, MSc, NP-PHC
• Darren Larsen, MD, CCFP, MPLc
• Derelie Mangin, MBChB (Otago), DPH (Otago), FRNZCGP (NZ)
• Dominik Nowak, MD MHSc, CCFP, CH
• Jennifer P. Young, MD, FCFP-EM
• Lee Donohue MD, CCFP, MHSc, MPLc
• Mira Backo-Shannon, MD, BSc, MHSc
• Paul Preston, MD, CCFP, CCPE, CHE
• Rob Annis, MD, CCFP
• Soreya Dhanji, MD, CCFP

In addition to our clinical working group the CEP also obtained feedback from others, including:

• Arun Radhakrishnan, MSC, MD, CM, CCFP
• Central Region Primary Care Leadership
• David Daien, MD, CCFP
• David Makary, MD, CCFP
• David Price, BSC, MD, CCFP, FCFP
• Jose Silveira, BSC, MD, FRCPC, DIP, ABAM
• Michael Chang MD, FRCP(C)
• Payal Agarwal, MD, CCFP
• Robert Sauls MD, CCFP(PC), FCFP
• Tara Walton, MPH

Lastly, for certain sections, the CEP also obtained feedback from others, specifically:

Readiness assessment for delivering in-person care
Operational requirements for in-person care
COVID-19 Provincial Primary Care Advisory Table
• David Price (Chair), MD
• Andrea Sereda, MD
• Annelind Wakegijig, MD
• Beth Sweeney
• Cathy Faulds, MD
• David Daien, MD
• David Kaplan, MD
• Kamila Premji, MD
• Kelly Van Camp
• Kim McIntosh, MD
• Michael Green, MD
• Rebecca Carson
• Sarah Newbery, MD
• Thuy-Nga (Tia) Pham, MD
System stakeholders
• Registered Nurses Association of Ontario
• Association of Family Health Teams of Ontario

Thank you to everyone who supported the development of this resource.

The Adult Mental Health in the COVID-19 Context resource is a product of the Centre for Effective Practice. Permission to use, copy, and distribute this material for all non-commercial and research purposes is granted, provided the above disclaimer, this paragraph and the following paragraphs, and appropriate citations appear in all copies, modifications, and distributions. Use of the Adult Mental Health in the COVID-19 Context resource for commercial purposes or any modifications of the Tool are subject to charge and use must be negotiated with the Centre for Effective Practice (Email: info@cep.health).

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