Analysis of the demand for care in a psychiatric emergency room and an acute inpatient unit in the context of the COVID-19 pandemic.

Abstract

Introduction: The aim is to analyze the impact of COVID-19 on the demand for emergency care and psychiatric admissions during the first month of the pandemic.

Methods: We conducted a retrospective, observational and cross-sectional study. We reviewed the clinical records of all patients attending the psychiatric emergency room (ER) between March 11th and April 11th, of both 2019 and 2020. Sociodemographic and clinical variables were included in the study. Chi-square test or Fisher's exact test were performed to compare categorical variables, while U Mann-Whitney U test was used for quantitative variables. The level of statistical significance was set at p<0.05. Analysis were conducted using IBM SPSS Statistics.

Results: The was a significant decrease in the number of patients attended in the ER. An average of 5.91 (±2.53) patients were treated per day in 2019 compared to 2.41 (±1.81) in 2020 (p<0.001). There was also a significant decrease in the occupancy rate at the inpatient psychiatric unit, with a 91.84% (±7.72) of beds occupied in 2019 and only 58.85% (±13.81) in 2020 (p<0.001). Regarding the percentage of patients admitted after assessment in the ER, there was a significant increase in 2020 compared to the previous year.

Conclusions: The demand for care in the psychiatric emergency room and the average bed occupancy have decreased during the first month after the declaration of the pandemic. Fear of contagion may act as a modulator of psychiatric demand.

Key words: COVID-19, Mental Health, Psychiatric Care Demand, Emergency Room, Acute Inpatient Unit

Introduction

On December 31st, 2019, the Municipal Health/Sanitary Committee of Wuhan ( Hubei Province, China) reported a clustering of cases of pneumonia of an unknown origin which started with symptoms on December 8th. On January 7th, 2020, the Chinese authorities identified the agent causing the outbreak as a new type of virus from the family Coronaviridae, which has been named as SARS-CoV-2. The disease caused by this new virus has been named, according to international consensus as COVID-19. The Emergency Committee of the International Sanitary Regulation (IHR, 2005) has declared the current outbreak of new corona virus as a Public Health Emergency of International Concern (PHEIC) in its meeting on January 30th, 2020. After that, the WHO recognized it as a global pandemic global, on March 11th, 2020. On March 13th the State of Alarm Statement was announced by the Government of Spain (1). On May 15th, in Spain a total of 230,698 confirmed cases of COVID-19 with PCR have been reported: 27,563 dead and 144.446 solved infections. The Community of Madrid has been the most affected in number of cases (2).

Just like in other countries the Spanish government had to dictate strict policies of social distancing, thus affecting more than 47 million of Spanish inhabitants. Such measures include home lock in, cease of all education activities, and also provisional ease of non-essential professional activities. This has caused an increase on online work, a decrease of leisure activities and closure of public places plus restrictions on free circulation(3). At a sanitary level, it has been necessary to reform and optimize assistance resources. In this sense, hospitals has reorganized their assistance areas and Emergency Rooms in order to execute safety measures and to prioritize assistance to patients with COVID-19. All this has caused the Psychiatric Hospitals, Rehabilitation Departments and outpatients assistance to close, making follow up by phone or online. The number of Psychiatric Hospitalization Units has been reduced more than 50% to be used for assisting patients with COVID-19, while many psychiatric patients have been referred to specialized Hospitals (4).

There is significant evidence in previous studies on the impact in mental health of infectious diseases outbreaks such as SARS, MERS or Ebola; where it has also been necessary to adopt preventive distancing measures(5–7). In a pandemic, fear increases levels of anxiety and stress in healthy people and increases symptoms of people with preexisting psychiatric disorders (8). A series of negative psychological consequences in the long term has been observed, including confusion, fear and rage (9,10). Likewise, psychiatric comorbidities, such as depression, anxiety, panic attacks,  psychomotor excitement, suicidal behavior or psychotic symptoms have been observed (5,6).

According to the WHO psychological impact of COVID-19 to date is a high rate of stress and anxiety (11). In China, after the COVID-19 outbreak, an increase of negative emotions has been found, such as anxiety and depression, higher sensitivity to social risks, an also a decrease of positive emotions and vital satisfaction (12,13). Similar situation is lived in Japan, where cases of social rejection, discrimination and stigmatization have been reported (14).

People with previous psychiatric pathology have been observed to have higher vulnerability (9). In a cross sectional study developed recently in the Chinese region of Chongqing, it was observed that psychiatric patients had, during the peak of the pandemic, higher levels of anxiety, depression, insomnia and irritability, and also symptoms of post-traumatic stress and suicidal ideation compared with healthy controls (15). Likewise, it has been observed that people with a background of suicidal ideation, panic disorder and stress, low self-esteem, are easily susceptible to catastrophic thinking (16).

Despite the potential impact on mental health both, in general population and also on that with prior psychiatric pathologies, there are almost not objective data about assistance demand in psychiatric emergency rooms or at hospitalization units during the initial phase of the current pandemic or other previous ones.

The main objective of this study is to analyze the initial impact of COVID-19 in assistance demand on psychiatric emergency rooms and on Hospitalization Units (BHU) for adults at a hospital in Madrid (Spain) during the first month after the pandemic was declared by the WHO (March 11th to April 11th). according to observations on assistance demand for emergency rooms of other pathologies different from COVID-19 (17), we think demand of psychiatric assistance will also decrease in this first lock in phase, as a consequence of fear to contagion.

Materials and Methods

Procedure and sample:

This works is a cross sectional retrospective observational study. All those patients with an age equal or older than 18 years who went for psychiatric emergency rooms at the Hospital Universitario Puerta de Hierro de Majadahonda (HUPH) between March 11th and April 11th, 2019 and 2020 respectively, have been included.

Clinical records of all patients who required assistance during the aforementioned period were reviewed. Psychiatric referrals made to hospitalized patients, being analyzed independently have been excluded from the sample.

Data retrieval was carried out by two independent researchers. In case of discrepancies an agreement was made by asking a third researcher.

The study was approved by the Ethics Committee of HUPH.

Measures:

the following socio demographic variables were included in the study: age, sex, and Hospital reference area on mental health. Several clinical variables were chosen, among them: previous follow up on mental health, reason of assistance, main diagnosis, type of consult (voluntary or involuntary) and behavior to be followed.

The total number of emergency rooms in both periods was registered, and also the occupation of the BHU.

Statistical Analysis:

A Descriptive Analysis of the categorical variables by means of absolute/relative frequencies, and numeric variables by means of the median was made (+/- standard deviation). Chi square Tests or Fisher's exact Test were used to contrast the hypothesis of categorical variables and the Mann–Whitney U test for the contrast of quantitative variables. The level of significance statistic was fixed in 0.05. The statistical pack used for management and analysis was the IBM SPSS Statistics.

Results

Figure 1 describes assistance demand at Psychiatric Emergency Room of patients assisted between March 11th and April 11th, per day in 2019 and 2020, respectively. A total of 189 patients went to the Emergency Room in 2019; and 77 patients in 2020.

A significant decrease of the median of patients assisted per day at Emergency Room between both periods was observed, being this of 5.91 (±2,53) in 2019; 2.41 (±1.81) in 2020, with a p<0.001.

Table 1 depicts socio demographic and clinic characteristics of the patients treated at the psychiatric urgency in the described periods. 182 patients out of the 189 who required assistance were treated in 2019, as 7 of them left voluntarily without communicating their decision. In 2020, 76 out of the 77 patients were treated, for the same reason. A significant increase was observed in the percentage of patients treated from other sanitary areas, in 2020 against 2019. On the other hand, an increase of involuntary consultations being this 48.7% in 2020 was observed, with respect to 29.7% in 2019 with a p<0.01.

Figure 2 depicts the reason for consultation of the patients who went to the emergency room during the periods studied. No significant differences were observed between both years.

regarding the proportion of patients´ income requiring assistance at the emergency room, a significant increase in 2020 has been observed, against the previous year (Table 1). Figure 3 depicts the BHU occupation during the same periods. A decrease of the average occupation beds in the BHU was observed, occupying 91.84% (±7,72) of beds in 2019 and 58,85% (±13,81) in 2020 with a p<0,001.

Figure 4 depicts the main diagnosis of patients who were admitted in the BHU in both periods.

Finally, there is an increase of the psychiatry interconsultation at emergency rooms in 2020 compared with 2019. A total of 9 patients in 2019 and 23 patients in 2020 were treated. An increase of 60.87% of the demand was observed.

Discussion

COVID-19 is a new disease; therefore, it is understandable that its outbreak may cause anguish, anxiety and fear in the population (10). Some people say that the wide scope and broadcasting this COVID infection has had may cause mental health crisis, mainly in countries with many cases (18). Among the results, a significant decrease both, in assistance demand at emergency rooms and in the daily occupation rate at the BHU is observed. In 2019 at emergency rooms a total of 182 patients (54. 9% women), were treated in 2020 it was only 76 (61.8% women), a decrease of 58.25% of the demand was observed. From the patients treated at emergency rooms, a significant increase of the involuntary referrals to the hospital for psychiatric evaluation has been observed. The main reason for consultation is still behavior disturbances; however, there is a significant decrease in patients who went to emergency rooms, due to anxious symptomatology (26.5% in 2019 with respect to 16.9% in 2020). Temporary closure of some Psychiatric BHU in Madrid has influenced on the results as there was an increase of the patients treated at emergency rooms, but belonging to other sanitary areas. However, this has not caused an increase in assistance demand. Regarding hospitalization, a decrease was also observed in the daily occupation rate, being this 91.84% (±7.72) in 2019 and 58.85% (±13.81) in 2020. Despite a decrease in absolute numbers of admissions, a significant increase of the proportion of admissions against the total of patients who went to emergency rooms has been observed.

Pandemics/epidemics may cause collective fear and impose changes on life style, not only for those directly impacted by the contagion (19). Studies made on previous outbreaks show that there are cognitive and mental health effects in the long term on population (10). Consequently, an increase of the demand of psychiatric assistance could be expected, because of the current situation, which contrasts with the results obtained in this study where a significant decrease of the demand both at emergency rooms and at hospitalization units has been observed. One of the main reasons is related with protection behavior adopted in response to situations impacting on health, as it is isolation (20). Unlike  huge human disasters from the past,  COVID-19 is deemed to provide a  totally new context, as a pandemic of such magnitude and impact had not been experienced in modern times (21). At least one third of the world population has been subject to some social restrictions and the effects of the adopted policies is spread to nearly all areas of the society (22). COVID-19 pandemic is becoming a massive global event, being one of the most important from the Second World War (23). Along history an exaggerated fear has been observed related with the infection compared with other situations, as it has unique characteristics: it spreads quite easily, it is imminent and invisible (24). Fear experience is magnified when collective and individual traditional sociocultural references, as the traditional  approach of control and diseases treatment, collapse or become invalid (25). It has been proved the crucial factor leading to protection motivation is that perceived threat (26) severity. In this sense, fear of contagion would act as a modulator of psychiatric demand, as both, patients and relatives may perceive hospitals as threat spots to catch the virus. Compared with the previous world pandemic, “Spanish Flu”, now the world has changed significantly: world commerce, trips, global movement and the speed information is shared on the internet has increased significantly. As a support to the previous explanation, a recent study has described  use of social media causes a positive impact on people´s motivation to take preventive measures, such as lock in, due to the increasing perception  of threat and infection experience (21).

Some authors speculate there may be a higher risk of recurrence on people who have  a preexisting psychiatric condition, whether because free movement to Primary Care Units is restricted or because of delayed access thereof (27). Although a decrease has been observed on the rate of daily occupation at the BHU, there is an increasing rate of admissions against the total number of consultations at the emergency rooms and an increase in involuntary referral to the hospitals. Therefore, it is inferred that patients who were treated and admitted during 2020 is highly severe compared with the previous year. For instance, regarding total patients treated at the emergency rooms during 2020, 16.9% of them were diagnosed with bipolar disorder, against only 7.4% during the previous year. Likewise, 5 patients who went to the emergency rooms in 2020 with diagnosis of other secondary neurotic disorders caused by stressful and somatoform situations required admission, compared with 2019 with the same diagnosis who were discharged.

There is a possibility of an increase in the suicide rate, as a consequence of corona virus effects on population´s  mental health  (28). Appearance of depressive symptoms, anxiety and post-traumatic stress (28), social isolation,  distancing from beloved people  or caretakers, and  unemployment are all suicide risk factors (29.30). Some suicide cases in a pandemic context due to COVID-19 (31.32) have been published. Despite the foregoing, interestingly enough in the analysis made, decrease of consultations at emergency rooms due to autolytic ideation and absence of a significant increase in autolytic attempts during the first month, after the pandemic was declared (10.1%, in 2019 against 15.6%, in 2020).

To date, this is the first study aimed to analyze assistance demand on adult population during the beginning of COVID-19 pandemic. It is important to highlight that the main limitation is the small size of the sample as we could only evaluate the first month after the pandemic was declared. This has limited statistical significance of results, mainly on prevalence of various mental disorders. On the other hand, it is not possible to analyze negative consequences in the long term and repercussion on psychiatric disorders evolution or worsening of preexisting ones. It is necessary to perform more studies encompassing a longer time for demand analysis during the months after the first month of the pandemic, in order to deepen impact thereof.

Conclusions

Urgency demand of psychiatric patients and average occupation of beds has decreased during the first month, after pandemic outbreak. This matches restructuring and optimization of assistance resources aimed to prioritize assistance for patients with COVID-19.

Fear to contagion may act as a modulator for psychiatric demand. Before an infection threat, patients and relatives may adopt a protective behavior, as isolation.

An increase in percentage of admissions regarding total of patients who go to emergency rooms has been observed. We infer these patients have a more severe diagnosis. Steady fear increases depression, anxiety and stress, therefore if we continue with the study for a longer period of time, we could see this feature reflected in a further analysis.

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