On the 13th of March, 2020 Ghanaians received news of the first confirmed case of COVID-19. I knew my life was going to change over the next few weeks. There was intense health education locally on the pandemic and measures to curb its spread across the airwaves and social media platforms. On midnight of 22nd March 2020, the borders of Ghana were closed, and individuals who arrived after the restriction were subjected to mandatory quarantine and testing. All health institutions had a mandate to prepare to screen, identify and isolate suspected cases using the national case definition based on symptoms such as fever > 38.⁰C, respiratory symptoms and a travel history, within the last two weeks, from a country that had recorded a positive case of COVID-19. Local responses were to be activated and protocols were put in place for notifying District Health Directorates through the District Disease Control Officer.

This was not my first experience in confronting an infectious disease outbreak. Like many countries in the region, Ghana has a wealth of experience from years of dealing with malaria and other infectious diseases such as cholera, cerebrospinal meningitis and haemorrhagic fevers, some of which have become endemic. As a result, surveillance activities, case detection or identification, isolation and specific management have become routine activities under the public health division of Ghana Health Service. In addition, the nation has the advantage of many health professionals, like myself, who served in Liberia and Sierra Leone during the Ebola Virus outbreak in 2014 and other epidemics. In December 2014, I was one of 42 health workers deployed to Liberia and Sierra Leone to support the host nations in managing the Ebola Virus epidemic. During this period I experienced first-hand the multipronged approach in the management of an epidemic.  Working in the Ebola Treatment Centre and in a county hospital in Liberia, required keeping to the principles of Infection Prevention and Control (IPC) to ensure my safety and that of other members of the team. We have drawn on this expertise in our approach to managing the current pandemic.

Pantang Hospital grounds. Picture & copyright: Pantang Hospital

Pantang Hospital, where I work as a psychiatrist, was established in 1975 and is one of three main psychiatric hospitals in Ghana with a bed capacity of 200. It offers outpatient and in-patient specialist psychiatric and general medical services. Our services include dental, reproductive and child health, diagnostic services including X-ray, ultrasound and electrocardiogram and a well-resourced medical laboratory. Due to the availability of more holistic care including occupational therapy, psychology, and specialized substance misuse rehabilitation, alongside extensive grounds in a semi-urban setting, it is fast becoming the public institution of choice, particularly among residents in its catchment area.

The facility arguably has a unique role in being the most suitable treatment option for individuals who may have COVID infection and are living with a mental disability. As part of our institutional preparedness at the early onset of the pandemic, staff received retraining in IPC at all levels. Four staff from Pantang, comprising two psychiatric nurses, a nurse prescriber and myself, all of us with experience in working in Liberia during the Ebola outbreak, made up the team. This team worked to develop protocols for triaging, consultation, isolation and self-care for staff. A ward was identified and designated as an isolation unit. The management of the hospital also procured additional essential personal protective equipment (PPEs) for use by staff. Some laboratory staff were trained on sample-taking for COVID-19 by the Noguchi Memorial Institute for Medical Research at the University of Ghana, which is home to experts in infectious disease research. By the time Ghana recorded its first confirmed case, the institution was well-advanced in its preparedness.

The team at the isolation ward of Pantang Hospital planning their activities before entering the red zone. Picture & copyright: Dr Leveana Gyimah

On the 23rd of March, 2020, just when I was packing my bag to leave work, I heard a knock on my door. I was asked to see the hospital director for an urgent discussion. As I turned the key to lock my door, I pondered over what the problem could be. As I climbed the stairs, I met my Director in the hallway. The moment I saw his facial expression, I knew it must be very serious. The Director informed me that we had an emergency referral from the national COVID response team. The patient was suspected to have been exposed to the virus on account of his travel history and had a history of previous psychiatric care most likely for a mood disorder. As the clinical care coordinator, I double as the local incident commander for COVID activities. I was mandated to take charge to receive the patient. We immediately triggered our local response team. Everyone got to work. Though this was not what anyone looked forward to, particularly at that time of the day, we had to obey the call to duty and act.

Finally, our awaited patient arrived in a private vehicle accompanied by his wife and a team of nurses. We went through all the necessary protocols for admission. The patient, a man in his late 20s, was living in Europe where he had his first episode of mental illness a little over a decade ago. He was reported to have been well over the past ten years. On arrival, the patient was heavily sedated. His wife reported that over the last three months, he had become irritable and was talking a lot. She thought that the relapse in her husband’s mental state might have been due to the stress of the restrictions and changes in lifestyle that were instituted in their country of residence when COVID-19 infections escalated. For example, she said he had become frustrated when he went to the grocery store and was unable to get adequate supplies for the family. During their journey to Ghana to spend time with extended family members, he ignored some of the precautionary measures such as wearing his face mask. On arrival at the quarantine centre, he was observed to be disinhibited, touching people inappropriately, violating social distancing rules and becoming aggressive. He was sedated to enable him to be transferred to Pantang. The patient was reassessed the following day and treatment initiated. Samples were taken for COVID-19 and sent to the Noguchi Memorial Institute for Medical Research.  From previous experience, the result was expected in 4-6 hours. In this instance, it took more than 24 hours! Apparently, the testing agency was overwhelmed as the number of cases requiring testing had begun to rise. Though understandable, the extended waiting period was stressful for the staff, the patient and his family. The fear of the unknown was palpable. Drawing on my experiences during the Ebola outbreak in Liberia, I encouraged my team to stay focused. Finally, the moment came when we received confirmation of the patient’s positive status. Although we had hoped the results were otherwise, we had to confront the reality. We followed the chain of command and arranged onward transfer to a designated COVID_19 Treatment Centre outside the hospital.

Having to manage a patient with COVID-19 and comorbid mental illness has its challenges. Persons with lived experience of mental illness may be at a higher risk of contracting and transmitting the virus. As in this case, when a patient is confused or disinhibited, maintaining social distance or ensuring they wear a facemask can be difficult. It is also important to support the individual and family emotionally because they may be anxious or afraid due to the illness and the possibility of getting infected. Education and reassurance is important to keep them at ease and promote their mental well-being. For a highly contagious condition, it can be a daunting task to ensure the safety of patients, the family and staff. This calls for extra precautions in ensuring a safe distance, wearing appropriate PPE and keeping them intact, particularly should a patient become aggressive while giving care. Patients need prompt intervention and support to ensure they can recover within the shortest possible time. It brings to the fore the importance of proper coordination of the clinical team. Care goes beyond the individual and includes family who may also need emotional support especially at this time of crisis. In essence, this is truly like the Three Musketeers’ ‘all for one and one for all’ for it is only when we work as one that we can succeed.

In addition, the COVID-19 pandemic has the potential to increase the burden of mental illness such as anxiety and depression among the populace. Fear of oneself or loved ones contracting the illness, movement restrictions such as lockdown and quarantine, not being able to attend day-to-day social engagements, to name but a few, may be overbearing. This may trigger symptoms for those without pre-existing mental illness and for those who already are living with a mental illness this may lead to a relapse or an exacerbation of their condition. For first responders and frontline healthcare workers, the stress of work, the fear of being infected and loss of work colleagues or loved ones may have a psychological toll. For families who lose loved ones to COVID-19, they may not have the opportunity to hold memorials and funerals for the deceased, an important aspect of Ghanaian culture. Families may have difficulty attaining closure or coming to terms with their loss. In these times, closure of places of worship also makes access to support difficult.

Mental health is a unique field, which though relevant in every medical specialty, is often neglected. It is however imperative to encompass mental health as vital to holistic management of the pandemic. This is not only important for those directly affected by the virus but the entire population, bearing in mind the specific needs of individuals to avoid long-term complications.

The views and opinions in this article are entirely my own.

Dr Leveana Gyimah
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Dr Leveana Gyimah, Psychiatrist at Pantang Hospital and a senior resident with the Faculty of Psychiatry at the Ghana College of Physicians and Surgeons. She is also the clinical coordinator and incident commander for the COVID-19 response team for Pantang Hospital. In 2014, she served as a medical volunteer in Liberia during the Ebola Virus Epidemic in West Africa through the West African Health Organization.