key: cord-0755142-e9v5pfyk
authors: Capuzzi, Enrico; Di Brita, Carmen; Caldiroli, Alice; Colmegna, Fabrizia; Nava, Roberto; Buoli, Massimiliano; Clerici, Massimo
title: Psychiatric emergency care during Coronavirus 2019 (COVID 19) pandemic lockdown: results from a Department of Mental Health and Addiction of northern Italy
date: 2020-09-18
journal: Psychiatry Res
DOI: 10.1016/j.psychres.2020.113463
sha: 59a9b3d3d680bd014913bd96b9230b1ca89ee5bb
doc_id: 755142
cord_uid: e9v5pfyk

BACKGROUND: The current COVID-19 pandemic and the consequent containment measures are leading to increasing mental health issues both in psychiatric patients and general population. OBJECTIVE: We aimed to compare the number and characteristics of emergency psychiatric consultations during the phase 1 of lockdown with respect to the same period in 2019 in a Department of Mental Health and Addiction (DMHA) located in Lombardy region. METHODS: We conducted a cross-sectional study including subjects consecutively admitted to two psychiatric emergency rooms of DMHA in Monza, Lombardy, Italy. Sociodemographic data, clinical characteristics, referred symptoms, diagnosis and information on patients’ illness course following the emergency consultations were collected. No subjects were excluded for the purposes of the study. RESULTS: Between February 21st and May 3rd 2020, there was a marked reduction in the number of psychiatric emergency consultations, if compared to the same period of 2019. Subjects who were living in psychiatric residential treatment facilities, had cannabis addiction and a diagnosis of OCD were significantly more likely to present to emergency psychiatric consultations during lockdown. CONCLUSIONS: COVID-19 epidemic may have a negative impact on more vulnerable individuals. Strategies to enhance relapse prevention and the use of alternative approaches as e-health technologies should be promoted.

In mid-December the novel coronavirus disease (COVID- 19) was initially detected in Wuhan, China, and then it propagated quickly across the country as well as worldwide (Cucinotta and Vanelli, 2020) . Since the first documented cases on February 21 st 2020, Italy was one of the most affected countries after China. Particularly, the Lombardy region in northern Italy was severely affected by this infection. As a consequence, on March 9 th , the government imposed a national quarantine, restricting the movement of the population except for necessity, work, and health reasons in order to reduce the spread of coronavirus. Subsequently, on May 3 rd , Italian Government ended the so-called "Phase 1" of the lockdown period, gradually resuming economic activities, easing restrictions, and slowly allowing movements inside the Region.

Following the reorganization of the Healthcare system to manage COVID-19 emergency, Regional Health Authorities acknowledged mental health as a priority and authorized the continuation of psychiatry care services for general population (Percudani et al., 2020) . In this framework important changes occurred within the Departments of Mental Health and Addiction (DMHAs). Particularly, some psychiatric wards were structurally modified for the purpose of admitting patients with COVID-19, many physicians and nurses were diverted to other clinical wards, consultations were restricted to the most severe cases, and most day hospital services and day-therapy programs for patients with psychiatric disorders were temporarily closed (Fagiolini et al., 2020) . Nevertheless, patients living in psychiatric residential treatment facilities (PRTFs) had to be confined in these structures with important restrictions on the movement . In addition to these changes affecting public health system and resulting in high stress levels both on general population and people with mental conditions, the fear associated with the coronavirus pandemic and the consequent lockdown had a relevant impact on psychological well-being (Naqvi, 2020) . First of all, quarantine and lockdown were associated with boredom, anger, psychological unrest, uncertainty, frustration, irritability, suicidal ideation and sleep disorders, which are in turn related to poor mental health, including the occurrence of psychiatric disorders as well as the exacerbation of pre-existing conditions (Brooks et al., 2020; Courtet et al., 2020; Kelly, 2020) . Some findings showed that confinement may increase addiction-related habits, including substance use (Rolland et al., 2020) . Secondly, contamination fear may be accompanied by anxious and obsessional symptoms, as well as the recurrence of obsessive compulsive disorder (OCD) symptoms (Fiorillo and Gorwood, 2020; French and Lyne 2020). Finally, some studies cited the economic crisis associated with COVID-19 pandemic as potential factor of vulnerability for psychiatric disorders (Pfefferbaum and North, 2020) . Despite the negative impact of pandemic on mental health, preliminary evidence showed a substantial decrease both of total number of psychiatric emergency consultations and psychiatric admission rates during lockdown Pignon et al., 2020) , if compared to the same period of 2019. More precisely Pignon (2020) reported over 50 per cent of decrease of emergency psychiatry consultations in three psychiatric centers in Paris and its suburbs. The decrease was evident across all psychiatric disorders, although the rate of patients consulting for psychotic disorders was higher in 2020 than in 2019, as was the rate of compulsory hospitalizations. On the other hand the study by and collaborators, carried out in four DMHAs in the Lombardy region, reported a marked reduction in psychiatric admission rates between 2020 and the same period of 2019, except for involuntary admissions.

In our knowledge, no Italian studies were performed to explore the characteristics of emergency psychiatric consultations during the weeks of lockdown and comparing them to the same period in 2019. Thus, we aimed to assess sociodemographic and clinical characteristics of patients receiving psychiatric consultations during the whole lockdown in two psychiatric emergency services of DMHA of ASST Monza (Lombardy region) and to compare them to the same period in 2019. We hope that findings of the present study might contribute to focus on the subjects who were deeply affected by COVID-19 pandemic in order to offer targeted assistance.

This study was drawn up following the Strengthening the Reporting of Observational studies in Epidemiology 

We conducted a cross-sectional study including subjects consecutively admitted to two psychiatric emergency rooms of DMHA of Monza, one in Monza and the other in Desio. Monza and Desio University hospitals cover the health demands of almost 850.000 inhabitants, offer psychiatric emergency care 24 hours a day and provide treatment for a range of psychiatric conditions. We compared consultation rates between the first confirmed case of COVID-19 in Italy and the end of "Phase 1" of the lockdown period. Therefore, the period includes from Friday 22 nd February to Sunday 5 th May 2019 (period A) and from Friday 21 st February to Sunday 3 rd May 2020 (period B). No subjects were excluded from the study.

The data of the present study were extracted anonymously from hospital registers. For subjects with multiple admissions the most recent clinical data were used. Information included sociodemographic data, housing status (home or PRTF), current use of outpatient mental health services, ongoing psychopharmacological treatments, co-occurring alcohol and substance use disorders. Data on both alcohol and substance use disorders were obtained using ICD-10 codes along with urine drug toxicology where available. We also extracted data concerning the presence of multiple consultations during the period A and period B. For each patient, referred psychiatric symptoms as well as clinical information on ICD-10 mental disorders were retrieved. Finally, type of management after the emergency consultation was also taken into account: admission at inpatient clinic, compulsory hospitalization, hospital discharge with follow-up in outpatient clinics, only acute medication, prescription of a new pharmacotherapy to be taken at home.

Descriptive analyses of included variables was performed for period A and period B: mean and standard deviation (SD) for quantitative variables, and frequency and percentage for qualitative ones. Then, we carried out univariate analysis in order to detect statistically significant differences in these two periods. The normal distribution of quantitative variables was verified by using Shapiro-Wilk's test. According to this assumption, Student's t test was used (adopting the Welch's variables were analysed via the chi-square or Fisher's Exact tests. Finally, all variables from the univariate analysis with p < 0.05, together with age and gender, were entered as independent variables into a logistic regression model with period B as dependent variable. Adjusted odds ratios (aOR) together with their 95% confidence intervals (CI) were reported.

Analysis were conducted using Stata Version 13.1 SE.

During the lockdown, 225 emergency psychiatric consultations were carried out, representing just over half (58%) of the corresponding period in 2019 (388 emergency room accesses) ( Table 1) .

No statistical differences were observed between the two periods with regard to sociodemographic variables. However, the number of consultations of subjects from PRTFs as well as of subjects with cannabis misuse was statistically higher in 2020 than in 2019. No differences of rate of multiple consultations were observed between two periods. As regards as referred symptoms, mood disturbances were less reported during the lockdown than in the previous year, differently from self-harm or suicide attempts. With regard to the diagnosis of discharge from emergency room, depressive and adjustment disorders were less identified in 2020 than in 2019, differently from OCD that was more diagnosed during the lockdown than in previous year. The rate of hospitalizations after emergency consultation was higher during the lockdown than in the previous year.

The multivariate logistic regression (Table 2) , controlled for age and gender, showed that living in PRTFs (aOR=1.78, p=0.031), cannabis addiction (aOR=1.76, p=0.028) and diagnosis of OCD (aOR=10.94, p=0.003) were all statistically significant predictors of emergency psychiatric consultation during the quarantine. 

Our data, collected in a DMHA of Lombardy region, provide clear evidence of a decrease in the number of psychiatric emergency consultations during the lockdown period due the COVID-19 pandemic, compared to the same period of 2019. This finding is consistent with what was recently reported in another paper (Pignon et al., 2020) , albeit other studies found that this decrease may not be merely specific of psychiatry (Thornton,2020) . In addition, three findings regarding patients' clinical features should be highlighted. First of all, we observed that subjects living in PRTFs were more likely to seek emergency psychiatric care than individuals staying at home. As a consequence of COVID-19 pandemic, residential facilities faced unique challenges in controlling the spread of COVID-19. Patients with serious mental disorders, who were used to spending some hour a day outside of PRTFs, were forced to strict confinement (de Caution is required in interpreting our findings and some important methodological limitations should be acknowledged.

First of all, as this study was a cross-sectional one, we cannot evaluate the changes over the time as regards the severity of symptoms. Furthermore, the analyzed data include the early phase of pandemic and it is likely that some findings may reflect short-term worsening related to COVID-19 outbreak. Second, our study could be affected by information bias. The diagnosis of the different mental disorders was made by a team of different psychiatrists with a possible interviewer bias. Nevertheless, important information concerning age at illness onset, illness duration, time on treatment, frequency of substance abuse, severity of mental disorder, type of obsessions and comorbid psychiatric disorders are lacking. Third, our study was conducted in a single DMHA, which limits the generalization of our results to other institutions or other Italian regions. Particularly, the district of Monza and Desio within Lombardy region were one of the most heavily affected areas by the epidemic in Europe. Finally, the sample size of the present study may limit the generalizability of our results.

In sum, despite some limitations, the current study shows that the numbers of patients seeking emergency psychiatric consultations decreased during the lockdown. However, individuals affected by OCD and resident in PRTFs were more likely to present to psychiatric emergency services during the phase 1 of COVID-19 lockdown, if compared with the same period of 2019. Thus, COVID-19 epidemic may have represented an important stressful live event, leading to poor mental health in some vulnerable subjects. Moreover, according to our findings, we cannot completely exclude that the most distressed patients may have taken refuge in addictive substances as cannabis, which is readily available to 

COVID-19 Pandemic and Mental Health: Prevalence and Correlates of New-Onset Obsessive-Compulsive Symptoms in a Canadian Province (Preprint)

The psychological impact of quarantine and how to reduce it: rapid review of the evidence

Psychiatric hospitalization rates in Italy before and during COVID-19: did they change? An analysis of register data

Keep Socially (but Not Physically) Connected and Carry on: Preventing Suicide in the Age of COVID-19

WHO Declares COVID-19 a Pandemic

Mental Health in the Coronavirus Disease 2019 Emergency-The Italian Response

Duration of untreated illness as a predictor of treatment response and remission in obsessive-compulsive disorder. The world journal of biological psychiatry : the official journal of the World Federation of Societies of Biological Psychiatry

COVID-19 Diary From a Psychiatry Department in Italy

Early intervention for obsessive compulsive disorder: An expert consensus statement

The consequences of the COVID-19 pandemic on mental health and implications for clinical practice. European psychiatry : the journal of the Association of European Psychiatrists

Acute exacerbation of OCD symptoms precipitated by media reports of COVID-19

Mental health problems and social media exposure during COVID-19 outbreak

Academic emergency medicine : official journal of the Society for Academic Emergency Medicine

The Endocannabinoid System: A New Treatment Target for Obsessive Compulsive Disorder? Cannabis and Cannabinoid Research (Vo.4, Issue2

Coronavirus disease: challenges for psychiatry. The British journal of psychiatry : the journal of mental science

Obsessivecompulsive disorder and its related disorders: a reappraisal of obsessive-compulsive spectrum concepts

Mental health in the aftermath of COVID-19: A new normal

Preparing for an influenza pandemic: mental health considerations

Mental Health and the Covid-19 Pandemic. The New England journal of medicine

Dramatic reduction of psychiatric emergency consultations during lockdown linked to COVID-19 in Paris and suburbs

The impact of the COVID-19 pandemic on patients with OCD: Effects of contamination symptoms and remission state before the quarantine in a preliminary naturalistic study

Global changes and factors of increase in caloric food, screen and substance use during the early COVID-19 containment phase in France: a general population online survey

The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication

Symptoms of obsessive-compulsive disorder predict cannabis misuse

Psychological symptoms of ordinary Chinese citizens based on SCL-90 during the level I emergency response to COVID-19

Covid-19: A&E visits in England fall by 25% in week after lockdown

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies