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Psychiatric emergency department volume during Covid-19 pandemic

      To the Editors:
      One commonly reported phenomenon in the first months of the Covid-19 era in the United States has been the reduction in emergency department (ED) visits and hospitalizations of patients with heart attacks, strokes and other acute, non-Covid illnesses [
      • Krumholz H.M.
      Where have all the heart attacks gone?.
      ]. Less is known about whether and how the number of patients presenting to EDs for psychiatric problems has changed.
      Prior to the pandemic, there were reasons to believe that psychiatric ED visits might increase. Many people could experience distress such as anxiety, sadness, grief and anger during this uncertain time [
      • Pfefferbaum B.
      • North C.S.
      Mental health and the Covid-19 pandemic.
      ]. Because of physical distancing measures, normal sources of support might be less directly accessible. People with pre-existing mental illness may be particularly vulnerable to such change. Alterations to outpatient practices may mean that prior mental health treatment could be disrupted. Access to social services such as shelters or soup kitchens might decrease.
      Connecticut reported its first case of Covid-19 on March 8, 2020. Several local school districts shuttered the following week, and the governor issued an order for the suspension of non-essential business and for residents to stay at home effective March 23. As of the end of April, 27,700 cases and 2257 Covid-associated deaths had been reported in the state [

      State of Connecticut. Covid-19 Update April 30, 2020. https://portal.ct.gov/-/media/Coronavirus/CTDPHCOVID19summary4302020.pdf. Accessed May 17, 2020.

      ].
      Yale-New Haven Hospital (YNHH) is a 1541-bed tertiary care medical center with three local EDs (two in downtown New Haven and one in a nearby suburb), the sixth largest hospital by bed capacity in the country. The psychiatric emergency service (PES) is staffed 24 h per day and treats patients 16 years and older. Each year, the ED has about 200,000 patient visits per year including roughly 9000 PES visits.
      At YNHH, PES and overall ED volumes for January, February and early March 2020 were similar to prior years (see Table 1). However, starting in the last two weeks of March through the first week in May, PES volume declined about 26%, from an average of 24.2 patients per day to 18 patients per day (see Fig. 1). For the month of April (the first full month of the local outbreak), PES volume was only about 70% of prior years' average. Overall ED monthly volume was 58% of prior years' average. Roughly the same percentage of psychiatric patients was admitted as in prior years (32% vs. 30.6%); overall ED admission rate was higher than in prior years (35% vs 27%).
      Table 1Monthly (and average daily) emergency department patient volume.
      JanuaryFebruaryMarchApril
      201820192020201820192020201820192020201820192020
      Psychiatry ED patients771 (24.8)768

      (24.7)
      821

      (26.5)
      713

      (25.5)
      679

      (24.2)
      715

      (24.7)
      761

      (24.5)
      745

      (24.0)
      696

      (22.5)
      833

      (27.8)
      751

      (25.0)
      557

      (18.6)
      % Hospitalized29.330.131.327.530.030.626.430.632.130.031.232.3
      Overall ED patients15,795

      (509.5)
      15,231

      (491.3)
      15,814

      (510.1)
      16,312

      (582.6)
      15,609

      (557.5)
      16,356

      (564.0)
      16,841

      (543.3)
      17,289

      (557.7)
      13,383

      (441.4)
      14,868

      (495.6)
      14,775

      (492.5)
      8620

      (287.3)
      % Hospitalized27.427.026.623.623.123.823.823.524.927.426.635.1
      Psych % of total ED4.885.045.194.374.354.374.524.425.25.605.086.46
      Fig. 1
      Fig. 1Average daily ED volume by week, Feb 17–May 9, 2020.
      The reasons for the decline in psychiatric ED visits are likely multiple. Patients may have feared contracting the novel coronavirus if they came to the ED [

      American College of Emergency Physicians. Public poll: emergency care concerns amidst Covid-19. https://www.emergencyphysicians.org/article/covid19/public-poll-emergency-care-concerns-amidst-covid-19. Accessed May 17, 2020.

      ]. Some may have wrongly believed that the hospital was only treating Covid-19 or that their problem was not severe enough to warrant emergent treatment. While there may have been more psychic distress in the population overall (reports have suggested increased call volume to helplines [

      Noguchi Y. Flood of calls and texts to crisis hotlines reflects Americans' rising anxiety. NPR. May 4, 2020. https://www.npr.org/sections/health-shots/2020/05/04/847841791/flood-of-calls-and-texts-to-crisis-hotlines-reflects-americans-rising-anxiety. Accessed May 17, 2020.

      ], e.g.), ED psychiatry visits may be a poor proxy for overall mental well-being of a community. The rapid establishment of robust outpatient services via telepsychiatry may have preserved or even expanded access to treatment for many patients. Increased attention to other social services including housing and food security may have at least temporarily addressed the immediate needs of many vulnerable individuals in the community.
      PES volume decreased less than overall ED volume, suggesting that patients may be less willing or able to defer their need for acute psychiatric care as opposed to other acute medical care. Psychiatric patients may be less able than other patients to identify or utilize alternatives to the ED. Some patients do not make the decision to come to the ED themselves, being brought by family, friends or the police. Whether some of the relatively preserved volume is due to patients' experiencing pandemic-related distress is not known.
      The fact that ED patients overall were admitted at a higher rate suggests they were, on average, sicker than usual, perhaps because of delayed help-seeking. That the rate of hospitalization of psychiatric patients was just slightly higher than prior years may indicate that the overall acuity in PES was similar to previous years.
      To our knowledge, this letter is one of the first formal descriptions of psychiatric ED volume during the unprecedented Covid-19 public health crisis in the US. The data presented is from one large academic medical center in a heavily impacted state, so the findings may not be generalizable to other settings. The overall volume data lack granularity and raises additional questions about the drivers of the decreased ED volume that was observed.
      Further study will elucidate how the ED psychiatry patient population during Covid-19 compared with prior periods in terms of various demographic factors (e.g. age, gender, race, housing status) and diagnostic categories. Such analysis should increase understanding of the decisions of people to seek (or not seek) emergency psychiatric care during a pandemic and help explain the substantial decrease in ED psychiatric volume.

      Disclosures and acknowledgments

      The authors have nothing to disclose.

      Previous presentation

      No prior presentation of this data.

      References

        • Krumholz H.M.
        Where have all the heart attacks gone?.
        The New York Times: April. 2020; 6
        • Pfefferbaum B.
        • North C.S.
        Mental health and the Covid-19 pandemic.
        N Engl J Med. 2020; https://doi.org/10.1056/NEJMp2008017
      1. State of Connecticut. Covid-19 Update April 30, 2020. https://portal.ct.gov/-/media/Coronavirus/CTDPHCOVID19summary4302020.pdf. Accessed May 17, 2020.

      2. American College of Emergency Physicians. Public poll: emergency care concerns amidst Covid-19. https://www.emergencyphysicians.org/article/covid19/public-poll-emergency-care-concerns-amidst-covid-19. Accessed May 17, 2020.

      3. Noguchi Y. Flood of calls and texts to crisis hotlines reflects Americans' rising anxiety. NPR. May 4, 2020. https://www.npr.org/sections/health-shots/2020/05/04/847841791/flood-of-calls-and-texts-to-crisis-hotlines-reflects-americans-rising-anxiety. Accessed May 17, 2020.