key: cord-0791939-hr26ur77
authors: Grover, Sandeep; Dua, Devakshi; Sahoo, Swapnajeet; Chakrabarti, Subho
title: Profile of patients availing psychiatry emergency services pre and post lockdown at a tertiary care center of North India
date: 2020-10-16
journal: Asian J Psychiatr
DOI: 10.1016/j.ajp.2020.102448
sha: 9eae2817a0fb69231799ae37c80994eeddaa21b9
doc_id: 791939
cord_uid: hr26ur77

nan

was shrinkage of almost all kind of services, except for Telepsychiatry services, which saw expansion during this period (Grover et al, 2002a ; Grover et al., 2020b) .

Lockdown and the ongoing pandemic also have led to an increase in the prevalence of psychological morbidity (Grover et al., 2020d) . Additionally, there are multiple reports of people indulging in self-harming behavior, either due to fear of COVID-19 , substance withdrawal (Rani et al., 2020) , or worsening of primary psychiatric disorder or emergence of new psychiatric ailments (Grover et al., 2020d; Muruganandam et al., 2020) . Attending to patients with COVID-19 has also increased the prevalence of psychological morbidity among health care workers, either due to fear of contracting the infection, fear of carrying the infection to home (Gupta et al., 2020; Sahoo et al., 2020a) , and the use of personal protective equipment (Spoorthy et al., 2020; Dua et al.,n.d.) .

In terms of health care services available to the people requiring the immediate attention of clinicians, besides Telepsychiatry services (Bojdani et al., 2020; Grover et al., 2020a) , patients had no other alternative other than coming to the emergency services was available.

Accordingly, there is a need to understand the impact of the pandemic on the utilization of emergency services, which has not been studied. Thus, this study aimed to assess the profile of patients attending the Psychiatry Emergency Services at a tertiary care center after the imposition of lockdown and compare the same with the profile of the patients attending the emergency services during the pre-lockdown period.

This study was conducted at the Emergency Services Department of the Postgraduate Institute of Medical Education and Research, Chandigarh, which is a tertiary care hospital in North India. The Psychiatry Emergency Services caters to patients attending medical, surgical, trauma, as well as paediatric services. Before the COVID-19 pandemic, patients referred from the out-patient services for urgent care, other hospitals, as well as those coming by self-referrals were seen in the Emergency Services. During the lockdown period, after the onset of the COVID-19 pandemic, mostly only those patients requiring emergency care, referred from other hospitals, or those who attended on their own were attended.

The patients coming to various emergency set-ups of the hospital are initially evaluated by the primary team (i.e., internal medicine, general surgery, orthopaedics, or pediatrics), who based on their evaluation seek psychiatric opinion. The patients referred to the psychiatry emergency team are initially evaluated by a trainee doctor under the supervision of a senior resident and consultants. The patients are managed by the Psychiatry Emergency Services independently or jointly with the medical/surgical teams till they are stabilized, transferred to J o u r n a l P r e -p r o o f the wards, or discharged. After initial medical stabilization, a treatment plan is formulated which may constitute investigations and treatment in the emergency services, consultations with various specialties, transfer of the patient to a medical (including psychiatry) or surgical ward, and discharge and follow-up plan. All psychiatric diagnoses are made per the International Classification of Diseases-10 (ICD-10)("WHO | International Classification of Diseases (ICD)," 1992) criteria.

Besides documenting the details of the psychiatric issues in the parent team file, the Psychiatry Emergency team maintains records of all the patients, from the time of admission to discharge which includes the sociodemographic profile, clinical details, diagnosis, and management done.

For the purpose of this study, the records of all patients attending the Psychiatry Emergency Services from 1 st January 2020 to 25 th July 2020 were retrieved. Comparisons were made between the patient profile before the imposition of the nationwide lockdown i.e. from 1 st January 2020 to 23 rd March 2020 (83 days) and after the imposition of the lockdown i.e. from 24 th March 2020 to 25 th July 2020 (123 days). A longer duration was considered in the postlockdown period to have an equal sample size in both the groups.

During the study period, a total of 587 patients attended the Psychiatry Emergency Services.

In the pre-lockdown period, a total of 291 patients were assessed, while 296 patients were assessed in the post-lockdown period. The average number of patients seen per day was 3.5 before the lockdown, which fell to 2.4 per day after the imposition of the lockdown. The mean age was significantly lower for the patients evaluated in the post-lockdown period (t=2.93; p=0.003**) and there was a reduction in the proportion of elderly patients availing the emergency services, however, it was not statistically significant. Compared to the patients attending the emergency services, during the pre-lockdown period, those attending the service during the post-lockdown period had a significantly higher mean number of years of education (t=-2.54;p=0.01*) (Table 1) . Nearly 15% of the patients in both the time frames had more than one psychiatric diagnosis.

Compared to the pre-lockdown period, a significantly higher proportion of patients attending the emergency services after the imposition of lockdown was suffering from an Axis I diagnosis ( 2 =6.71; p=0.01*). In the post lockdown period as compared to earlier, a lower proportion had a diagnosis of F0 category ( 2 =19.14; p<0.001***), a higher proportion had a diagnosis belonging to the F2 category ( 2 =4.85; p=0.02*). A higher proportion of patients were diagnosed to be suffering from Mania with psychotic symptoms ( 2 =4.50;p=0.03*). No significant difference was found for other diagnostic categories (Table 2) .

Amongst patients diagnosed to be suffering from the F0 category of ICD-10, compared to the pre-lockdown period, during the lockdown period there was a significant decline in the proportion of patients diagnosed with delirium, acute stress reaction, number of patients presenting with self-harm by ingestion of poison ( Table 2 ).

The majority of the patients received pharmacotherapy as a part of their treatment along with investigations and referrals to other specialties. Psychotherapeutic intervention was done in more than 40% of the patients during both the time frames. In the post-lockdown period, a significantly lower proportion of patients underwent investigations and referrals as compared to the pre-lockdown period ( 2 =3.91;p=0.04*) J o u r n a l P r e -p r o o f The sum of the percentage exceeds one hundred as more than on intervention may have been done in the same patient J o u r n a l P r e -p r o o f

The closure of regular outpatient services due to COVID-19 pandemic has left the patients in a situation, where they have nowhere to go. However, patients experiencing new-onset severe symptoms, experiencing a relapse, or experiencing suicidal behavior, have no other place to go, other than consulting the emergency services.

Compared to the pre-lockdown period, a significantly higher proportion of female patients attended the emergency services during the lockdown period. This may be a reflection of a higher level of stress for females during the lockdown period. There are many reports of domestic violence, an increase in the interpersonal issues between the couples, and increased workload on the women during the lockdown period (Vora et al., 2020) . These all could have led to a more negative impact on women and resultantly seeking psychiatric help more often.

In terms of age, there was a reduction in the proportion of elderly seeking psychiatric help, during the lockdown period, when compared to the lockdown period. This is understandable in the background of the fact that elderly people, especially those with multiple physical comorbidities are more vulnerable to COVID-19 infection and mortality (Leung, 2020) . This could have led to them not availing the emergency psychiatry services.

When the number of patients attending the emergency services per day was evaluated, there was a significant reduction in the number of patients seen per day, which is understandable, considering the travel restrictions. In the present study, during the pre-lockdown period, delirium was the most common psychiatric diagnosis and was the major driver of the F0 diagnostic category of ICD-10. Previous studies from our center also suggest that delirium is the most common psychiatric diagnosis, seen in patients evaluated in emergency setting (Grover et al., 2015) . However, when the diagnostic profile of patients attending the emergency services during the lockdown period was evaluated, it was seen that there was a significant reduction in the proportion of the patients diagnosed with delirium and a F0 diagnosis. This significant reduction, possibly reflects, reduction in the number of patients with severe physical illnesses, attending the outpatient services, as delirium is usually seen in the background of a physical decompensation. This can also be attributed to a possible reduction in referrals from other specialties, as well as overall reduced attendance of patients in the emergency room.

Further, the present study suggests that there was an increase in the proportion of patients with a diagnosis of schizophrenia, availing the emergency services, during the lockdown period. This finding suggests that, in the absence of routine regular services, possibly many patients with schizophrenia experienced a relapse of symptoms and presented to the J o u r n a l P r e -p r o o f emergency services. There could be many reasons for relapse, such as difficulty in procuring/purchasing the medication, an increase in the level of stress, and an adverse household environment. Studies done during the lockdown period have provided evidence for all these (Grover et al., 2020c; Muruganandam et al., 2020) . These findings suggest that people with various mental illnesses are in need of health care services and there is a need to strengthen the emergency services to cater to people with severe mental disorders.

The prevalence of self-harm in both the study periods was similar and comparable to the previous studies. However, the method used showed a change in distribution. Although the use of poison was the most common method, the proportion in the post-lockdown period was lower. A possible reason for this could be lack of access to the same as a result of the restriction of movement and decreased availability at the local shop due to the lockdown.

There was an increase in the absolute number of patients presenting with hanging during the lockdown period, however, when compared to the pre-lockdown period, this was not statistically significant. This finding is supported by many reports suggesting an increase in the number of violent suicidal attempts and completed suicides during the lockdown period (Dsouza et al., 2020) .

The present study has certain limitations, which include the recording of only a few variables for analysis. Second, we did not evaluate the exact reason for seeking psychiatric help, as understanding this could be more useful in organizing the services and fulfilling the need of the patients attending the emergency psychiatry services.

To conclude, the present study suggests that compared to the pre-lockdown period, during the lockdown period there was a significant reduction in the number of patients seeking emergency psychiatry services. The present study also suggests that the major contributor to this reduction was a lower number of patients with delirium. Additionally, the present study suggests that there was an increase in the number of patients diagnosed with schizophrenia, presenting to the emergency. These findings have certain implications for the organization of services in the emergency set-up.

The authors declare that they have no conflict of interest.

Financial disclosure : We have no financial disclosure to make .

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