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The impact of COVID-19 on suicidal ideation and alcohol presentations to emergency departments in a large healthcare system

  • Courtney M. Smalley
    Correspondence
    Corresponding author at: Emergency Services Institute/E19, Cleveland Clinic Health System, 9500 Euclid Avenue, Cleveland, OH 44195.
    Affiliations
    Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH, United States of America

    Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States of America
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  • Donald A. Malone Jr.
    Affiliations
    Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States of America

    Department of Psychiatry and Psychology, Neurological Institute, Center for Behavioral Health, Cleveland Clinic Health System, Cleveland, OH, United States of America
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  • Stephen W. Meldon
    Affiliations
    Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH, United States of America

    Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States of America
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  • Bradford L. Borden
    Affiliations
    Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH, United States of America

    Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States of America
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  • Erin L. Simon
    Affiliations
    Department of Emergency Medicine, Akron General Medical Center, Akron, OH, United States of America

    Northeast Ohio Medical University (NEOMED), Rootstown, OH, United States of America
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  • McKinsey R. Muir
    Affiliations
    Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH, United States of America
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  • Baruch S. Fertel
    Affiliations
    Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH, United States of America

    Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States of America

    Enterprise Quality and Patient Safety, Cleveland Clinic Health System, Cleveland, OH, United States of America
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      Keywords

      Dear Editor:
      Behavioral health (BH) complaints, including suicidal ideation (SI) and alcohol, are common in US Emergency Departments (EDs), [
      • Drapeau C.W.
      • JL McIntosh
      U.S.A. suicide: 2018 official final data.
      ,
      • Plemmons G.
      • Hall M.
      • Doupnik S.
      • et al.
      Hospitalization for suicide ideation or attempt: 2008-2015.
      ,
      • Ting S.A.
      • Sullivan A.F.
      • Boudreaux E.D.
      • Miller I.
      • Camargo Jr., C.A.
      Trends in US emergency department visits for attempted suicide and self-inflicted injury, 1993-2008.
      ]. The CDC published data in 2018 demonstrating a 25% overall increase in ED visits for SI and/or self-directed violence [
      • Zwald M.L.
      • Holland K.M.
      • Annor F.B.
      • et al.
      Syndromic surveillance of suicidal ideation and self-directed violence — United States, January 2017–December 2018.
      ]. Additionally, the CDC reported that 24.5% of the population > 12 years old engaged in binge alcohol use in 2017 [
      • National Center for Health Statistics
      Health, United States, 2018. Hyattsville, Maryland.
      ]. A public health crisis occurred with the onset of novel coronavirus 2019 (COVID-19). Current “stay at home” orders have reduced human contact through social distancing [
      • Reger M.A.
      • Stanley I.H.
      • Joiner T.E.
      Suicide mortality and coronavirus disease 2019—a perfect storm?.
      ]. The effects on behavioral health visits to EDs as a secondary consequence of these measures has yet to be reported.
      We conducted a retrospective multicenter study in 20 diverse EDs across a large Midwest integrated healthcare system with >750,000 ED visits annually to investigate the effects of current “stay at home” orders on psychiatric visits to our EDs. The study was performed as a quality improvement project. All patient encounters and BH visits during the study period were included. All EDs used the same electronic medical record (EMR) (EPIC Systems, Verona WI) allowing for data acquisition.
      “Stay at home” orders were initiated on March 24th, 2020 due to COVID-19. Data on all BH visits were collected for 1-month (March 25th to April 24, 2020) following “stay at home” orders. Visits were identified if a BH ICD-10 code was used as a primary diagnosis or if behavioral complaints were listed. Secondary analysis examined complaints and ICD-10 codes for suicidal ideation and alcohol. The same parameters were used to collect data for the same time period for 2019 to compare effects of COVID-19 on ED visits. Statistical analysis was conducted using SAS® software (SAS Institute, Inc., Cary, NC).
      During the one-month study period, the hospital system had 31,387 ED encounters with 2477 (7.9% of visits) BH visits, compared to 56,453 visits with 3438 (6.1% of visits) BH visits during the same period in 2019. Overall, between 2019 and 2020, there was 44.4% decrease in overall ED visits and 28.0% decrease in BH visits, (Table 1).
      Table 1Overall ED encounters, behavioral health complaints, suicide, and alcohol chief complaints in the healthcare system.
      CategoryEMS
      EMS: Emergency Medical Service – As a method of ED arrival (municipal or private).
      ED Encounters
      20192020% Change
      OverallEMS10,9587889−28.01%
      Not EMS45,49523,498−48.35%
      Overall Total56,45331,387−44.40%
      Comprehensive BHEMS17811438−19.26%
      Not EMS16571039−37.30%
      Comprehensive BH Total34382477−27.95%
      Suicidal Chief

      Complaints and Orders
      EMS567245−56.79%
      Not EMS577206−64.30%
      Suicidal Total1144451−60.58%
      Alcohol Chief

      Complaints and Dx
      EMS599512−14.52%
      Not EMS372317−14.78%
      Alcohol Total971829−14.62%
      Study Time Period: 3/25–4/24.
      a EMS: Emergency Medical Service – As a method of ED arrival (municipal or private).
      When comparing 2019 to 2020, SI encounters decreased by 60.6%. As a percentage of all ED encounters, SI encounters decreased from 2.03% to 1.44% from 2019 to 2020, (Table 2).
      Table 2Suicidal ideation and alcohol encounters as a percentage of total ED encounters and as a percentage of behavioral health ED encounters.
      CategoryEMS
      EMS: Emergency Medical Service – As a method of ED arrival (municipal or private).
      ED Encounters
      20192020
      Behavioral health encounters:

      percentage of overall ED encounters
      Comprehensive BHEMS16.25%18.23%
      Not EMS3.64%4.42%
      Comprehensive BH Total6.09%7.89%
      Suicidal Chief

      Complaints and Orders
      EMS5.17%3.11%
      Not EMS1.27%0.88%
      Suicidal Total2.03%1.44%
      Alcohol Chief

      Complaints and Dx
      EMS5.47%6.49%
      Not EMS0.82%1.35%
      Alcohol Total1.72%2.64%
      Suicidal and alcohol encounters:

      percentage of comprehensive behavioral health ED encounters
      Suicidal Chief

      Complaints and Orders
      EMS31.84%17.04%
      Not EMS34.82%19.83%
      Suicidal Total33.28%18.21%
      Alcohol Chief

      Complaints and Dx
      EMS33.63%35.61%
      Not EMS22.45%30.51%
      Alcohol Total28.24%33.47%
      Study Time Period: 3/25–4/24.
      a EMS: Emergency Medical Service – As a method of ED arrival (municipal or private).
      SI encounters fell from 33.28% in 2019 to 18.21% in 2020 (p < .001) when examining percentage of overall BH encounters within the system. The total number of alcohol related complaints decreased during the time period but overall increased from 28.2% to 33.5% as a percentage of total BH ED visits, (Table 2).
      Our study demonstrates the impact of “stay at home” orders for COVID-19 on BH patients that present to EDs. Our data found that SI complaints fell significantly during the “stay at home” orders when compared to the previous year. It is unclear whether these patients were simply not seeking mental health care, using alternative methods of obtaining mental health care through tele-visits, or whether social distancing had some effect on stressors that may decrease suicidal thoughts. We were unable to ascertain the suicide rate of the population during the study period. It will be important to correlate the decline in ED visits with the actual suicide rate once it becomes available. This could inform future interventions during times of crisis. Additionally, our study found that the percentage of alcohol presentations increased. Psychological stressors of social distancing may also have significant effects on alcohol abuse.
      Further studies are needed to examine factors that may have led to decreased SI and increased alcohol complaints in EDs and whether this short-term phenomenon will be sustained or lead to an uptick in the aftermath. Strategies are needed to proactively manage risk in vulnerable populations and assure adequate access.

      Grants/financial support

      No outside funding provided support for this project.

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