B. spoke to me by Zoom from the car parked outside their house—we couldn’t talk when B. was at work, or inside the house, where B.’s children were playing. B. has also used the car to Zoom with colleagues about trying to devise safety protocols for their workplace, because those, too, are conversations B. can’t have at work. B. is the medical director of an inpatient psychiatric unit in a small hospital within a large for-profit network. The hospital’s administration, B. told me, was not permitting doctors to wear their own N95 masks or other protective equipment, even though the hospital had little equipment to issue. Nor were doctors able to test or isolate patients with suspected cases of COVID-19. Psychiatrists, B. told me, were still being required to appear for in-person consultations, when remote communication would have been possible and safer. There was no way and no real effort to enforce physical distancing, B. told me. Patients could be isolated only once they were symptomatic and had tested positive, but patients with whom they had been in contact continued to intermingle on the ward.
I heard similar accounts from several other physicians working in inpatient psychiatric wards in for-profit, nonprofit, and state hospitals, across multiple states. All of these doctors, who spoke on condition of anonymity, told me variations on the same story: how a lack of testing, P.P.E., and seclusion protocols were making a difficult task—maintaining the safety of a highly vulnerable population and their care workers during a pandemic—virtually impossible. All of them told me about conflicts with hospital administrators. All of them were battling the cruel logic of business models and insurance payments.
The challenges faced by psychiatric-ward physicians across the country are legible in what few casualty statistics we have. At Western State Hospital in Washington, for example, at least twenty-seven workers and six patients have tested positive for COVID-19, with one death—but these numbers tell us little, since, according to reports, only two patients at the facility were tested during the first two weeks of April. The New York Post wrote that, as of the second week of April, New Jersey’s four psychiatric hospitals had two hundred and forty cases of the coronavirus and five fatalities. Four of the deaths were at a single hospital, Greystone Park Psychiatric Hospital in Morris County, where thirty-three patients—about one in ten people being treated there—and forty-four employees tested positive. Among New York’s twenty-four state mental hospitals, five have patients with COVID-19 in every unit.
The coronavirus, and the public-health measures undertaken to slow its spread, is uniquely hostile to psychiatric care. An ordinary hospital unit is a lonely place: patients are generally in bed, in their rooms, physically distant from one another. By contrast, the prevention of solitude is built into the architecture of psych units, and enshrined in the laws and regulations that govern them. Psychiatric units are often designed to facilitate communication and group activities; now, however, they seem as if they were designed to spread the virus. Unlike in other hospital units, patients do not spend their days in their rooms: they are expected to attend therapy, play games, watch television, go outside, and take their meals together with other patients.
C., the medical director of a state psychiatric hospital, said that his facility has revised patients’ schedules to insure that no more than ten people are in a day room or dining hall at one time. Between meals, therapy, and supervised group activities, patients have four hours when no activities are planned, and this is when hospital staff try to persuade them to stay in their nearly empty rooms, for reasons that are difficult for some patients to process. The rooms have no televisions or telephones; personal devices such as cell phones, tablets, and computers are not allowed because of, among other things, the concern that patients would harm themselves or take pictures or videos, thereby violating privacy regulations. Most facilities have MP3 players, but usually not enough for every patient. New York State is currently trying to arrange a bulk purchase of tablets with disabled cameras for mental-health patients, but the cost is likely to prove prohibitive.
Doctors cannot actually require patients to stay in their rooms. The law in most states allows confining patients to a room only when they pose an immediate danger to themselves or others, and only for a short time. Seclusion itself requires frequent reassessments, each accompanied by copious paperwork, and most units have only one or two seclusion rooms, which are often needed for actual psychiatric emergencies, rather than social distancing. “You can’t use seclusion to isolate someone because of COVID-19,” G., a physician who works for a state regulatory agency, told me. After all, G. argued, in the world outside a psychiatric unit, people are not forcibly locked up to enforce social distancing, so the same rules should apply on the ward. If dysregulation is getting in the way of being able to persuade the patient to observe social distancing, then it’s the doctor’s job to find the right medication until he can have a successful conversation. What about patients whose mental impairment is permanent—such as dementia, which often afflicts people o