The issue is old and has been the subject of debate frequently guided by excessive ideological arguments and rarely focused on the needs of the sick person. Today there is still no satisfactory answer. By who, where and how should medical care be provided for people with long-term mental illness?

The pandemic that the world is trying to solve has so far killed some 400,000 people and nearly 7 million have been affected in 213 countries. The clinical picture triggers an acute respiratory syndrome of varying complexity, and although it affects everyone equally, some people are more at risk. People with previous clinical conditions, such as advanced age, suffering from previous medical or psychiatric pathologies and residing in communities or residential institutions, are at higher risk.

If we go back a little in time, we will all remember the lobby to deinstitutionalize mental illness in the 80s and 90s, which had as its central idea the closure of large psychiatric institutions and the assimilation of the person with mental illness into the community. Within this concept, the person with a mental illness should preferably receive primary care so that general doctors treat them for all their health problems.

However, the person with a long-term mental illness cannot be treated for their health problems in the primary care model, which is highly oriented to the treatment of uncomplicated chronic diseases and primary and secondary prevention and has a focused management principle in the results with an evaluation of services which is exclusively quantitative. What has happened over the years is something that many have witnessed and recognized, but it is an issue that still needs to be debated and requires repair.

The reality of the pandemic has only brought to light what we already knew:

• Treating diabetes or hypertension in a person with a mental illness is not the same as treating the same illness in a person without mental illness.
• This reality is especially critical as patients age since cognitive loss occurs with more severity, and autonomy, previously affected, is even more limited. Therefore the patient is not in a position to follow the self-protection guidelines.
• When people with mental illnesses live in residential environments, there is often not enough equipment to treat organic illnesses, and investment in the technical quality of medical care is scarce within the framework of General Medicine.
• When these people live in the community, as a consequence of the history of the disease and their own life, they always present other cardiovascular, cardiorespiratory and endocrine pathologies and, at the same time, they have fewer resources in all areas: family, financial and even community. In other words, they are even more alone!

This questions the existing model for most residential units for people with mental illness, designed following current regulations, with little investment in technical equipment, especially in the area of medicine.

To neglect this is to deny mental illness, its nature and its total harm with its determining factors and its consequences and, above all, to stop putting the person with mental illness at the centre of the decision-making process.

Lourdes Santos, Bachelor of Medicine from the Faculty of Medicine of the University of Porto. Psychiatry specialist. Sisters Hospitallers’  Clinical advisor, Portuguese Province.