key: cord-0905332-elpudid5
authors: Sacco, Dana L.; Probst, Marc A.; Schultebraucks, Katharina; Greene, M. Claire; Chang, Bernard P.
title: Evaluation of emergency department visits for mental health complaints during the COVID‐19 pandemic
date: 2022-04-29
journal: J Am Coll Emerg Physicians Open
DOI: 10.1002/emp2.12728
sha: ee28f44ea0eabd4cf0b01aedc30b92a8bf7801ef
doc_id: 905332
cord_uid: elpudid5

BACKGROUND: The COVID‐19 pandemic has resulted in over 6 million deaths worldwide as of March 2022. Adverse psychological effects on patients and the general public linked to the pandemic have been well documented. METHODS: We conducted a retrospective analysis of adult emergency department (ED) encounters with diagnoses of anxiety, depression, and suicidal ideation using International Classification of Diseases, Tenth Revision (ICD‐10) codes at a tertiary care hospital in New York City from March 15 through July 31, 2020 and compared it with ED encounters during the same time period in the previous 3 years (2017–2019). The relative risk (RR) of these diagnoses was calculated comparing a prepandemic sample to a pandemic sample, accounting for total volume of ED visits. RESULTS: A total of 2816 patient encounters met the inclusion criteria. The study period in 2020 had 31.5% lower overall ED volume seen during the same time period in the previous 3 years (27,874 vs average 40,716 ED encounters). The risk of presenting with anxiety during the study period in 2020 compared to prior 3 years was 1.40 (95% confidence interval [CI] 1.21–1.63), for depression was 1.47 (95% CI 1.28–1.69), and for suicidal ideation was 1.05 (95% CI 0.90–1.23). There was an increase in admissions for depression during the pandemic period (15.2% increase, 95% CI 4.6%–25.7%). CONCLUSION: There was a relative increase in patients presenting to the ED with complaints of anxiety and depression during the height of the COVID‐19 pandemic, while absolute numbers remained stable. Our results highlight the importance of acute care‐based mental health resources and interventions to support patients during this pandemic.

The COVID-19 pandemic has resulted in significant morbidity and mortality, with over 6 million deaths worldwide as of March 2022. 1 Besides the well-documented physical sequelae after COVID-19, 2 adverse effects on the psychological well-being of patients and the general population linked to the pandemic were hypothesized early during the pandemic 3 and have subsequently been studied and confirmed. 4, 5 Multiple survey studies have indicated that many people experienced greater levels of self-reported anxiety and depression during the height of the pandemic, 6-10 likely due to increased social isolation, disruption of daily routines (such as work and exercise), and fear of becoming infected. 11 Two recent studies of adolescents found increased positive screens of depression and suicidal ideation during the pandemic as compared to the same time period in 2019, 12, 13 including a prevalence ratio (PR) for depression that was 24% greater during the pandemic than the same period in 2019 (PR: 1.24, 95% confidence interval

[CI] 1.15-1.34). 13 Overall emergency department (ED) volumes in many countries fell during the pandemic 14, 15 likely related to restrictions in movement and guidelines enforced during the pandemic, as well as patient fear of contracting COVID-19 when seeking in-person ED care. 11 It is less well understood whether these factors had the same effect on patients seeking ED care for acute symptoms of psychological distress, specifically anxiety, depression, and suicidal ideation.

Data on the impact of the COVID-19 pandemic on mental healthrelated ED visits have been mixed, and most studies were conducted in Europe. 14, 15 Few studies have examined the pandemic's impact on ED visits for psychiatric complaints in the United States, 16, 17 and, in particular the New York metropolitan area, one of the areas that experienced sustained and high volumes of COVID-19 cases early in the pandemic. 18

The objective of this study was to measure the volume of patients presenting to the ED with psychiatric conditions, specifically anxiety, depression, and suicidal ideation, during the height of the COVID-19

pandemic in New York City in early 2020 and compare those presentations to the same time period in the 3 prior years (2017, 2018, and 2019).

We performed a retrospective, cohort study of adult patients presenting to the ED (annual prepandemic ED volume of 109,000 patients) York. We also collected information on total volume of patients older than 18 years who presented to the ED to construct the denominator for the analysis.

All patients over 18 years of age presenting to our ED between March 15 and July 31 (2017-2020) and receiving a final ED diagnosis of anxiety, depression, and suicidal ideation as conferred by ED physicians, according to ICD-10 code classification, were included in the study.

The primary outcome was the number of patients being conferred a For individuals presenting to the ED who were diagnosed with these psychiatric conditions, we also obtained from the EHR patient demographic information, including age, sex, spoken language, and insurance status. Means of arrival to ED and patient disposition (hospital admission, ED discharge, or walk out) were also obtained from the EHR for patients receiving one of these psychiatric diagnoses. Patients being admitted for any reason were analyzed broadly as admissions.

However, encounters where patients were admitted were reviewed to determine whether the reason for admission was psychiatric or strictly medical. This information is presented in the Results section. Of note, our medical center does not have an observation unit. Race and ethnicity were not included owing to limitations in availability from administrative data.

Data were divided into 2 samples: (1) "pandemic" sample, comprising were compared over the 4 years. The "prepandemic and pandemic samples were compared according to several demographic and clinical variables, including age, sex, language preference, arrival means, insurance status", and disposition from the ED. For each diagnosis, we calculated the differences in percent of demographic and clinical variables (and associated 95% CIs) between the prepandemic and pandemic samples. We used the Bonferroni correction to adjust the critical value for multiple comparisons (18 tests; ie, 6 tests × 3 diagnoses) and used the formula for calculating the 95% CI of a difference in proportions, or difference in means, as appropriate. We calculated the RR and 95% CI comparing the risk of receiving a final ED diagnosis for anxiety, depression, or suicidal ideation during the pandemic relative to the prepandemic period. Analyses were performed using SAS Studio (Version 3.8, Cary, NC). The protocol underwent expedited reviewed and was approved by our local institutional review board. All identifying patient information has been removed.

All patients who presented to the ED during the study period (March 15-July 31) of the years 2017-2020 were eligible for participation in the study if they were assigned an ED diagnosis of interest upon discharge. We observed a decline in the volume of total ED visits between Unknown 0 (0) 6 (1) 1 (0.2 to 1.8)

Data are reported as frequencies (number) and column percentages (%) to unless otherwise stated. Percent differences for the pandemic and prepandemic samples have been calculated with 95% confidence intervals (CIs).

These psychiatric diagnoses were conferred in an acute care setting by and ED diagnoses, which may be affected by unmeasured confounding variables.

Our study found that although overall ED volume fell Data are reported as frequencies (number) and column percentages (%), and differences in percentages with corresponding 95% confidence intervals (CIs), which have been adjusted for multiple comparisons using the Bonferroni correction (18 tests). *Statistically significant differences. Data are reported as frequencies (number) and relative risk (RR), unless otherwise stated. Abbreviations: CI, confidence interval; ICD-10, International Classification of Diseases, Tenth Revision.

diagnosis of these complaints as compared with earlier years that was statistically significant (Table 3 ). Figure 1 shows a graphical depiction of the week-to-week volume of each psychiatric diagnosis as a function of total ED volume and reveals a trend of mostly diverging lines for anxiety and depression. There is more week-to-week variation in the pandemic era because of natural fluctuations in patients presenting to the ED, whereas the prepandemic era takes 3 years into account, which minimizes the week-to-week variation. Our findings suggest that even during the local peak of the pandemic, patients with mental health complaints continued to present in similar absolute volume and greater overall rate compared to prepandemic numbers. These findings are similar to survey research noting the prevalence of anxiety and depression in the general public 5 as well as recent work finding a relative increase in ED visits for psychiatric complaints increasing in 2020 compared to a similar time period in 2019. 16 The reasons why absolute numbers of patients presenting with anxiety and depression, though not suicidal ideation, held relatively constant during the pandemic as compared with prior years may be mul- It could also be valuable to review individual patient records to determine whether these were new psychiatric diagnoses versus exacerbations of known mental health conditions, as well as the extent to which patients reported their symptoms were a result of effects of the pandemic. Additionally, if future studies find that overall depression during the acute phase of a pandemic is more severe (as evidenced by higher rates of admission), interventions could be targeted to those at highest risk, and close follow-up prioritized for patients with depression to help prevent the need for admission.

In summary, although overall ED volume decreased dramatically during the height of the pandemic in New York City, the RR of ED diagnosis of anxiety and depression during the pandemic was approximately 40% higher than prepandemic levels for the same time period, though absolute numbers did not appreciably change. This finding supports hypotheses and survey-based data showing that people were suffering from higher levels of anxiety and depression during the COVID-19 pandemic. We also believe that these findings could be due to increased levels of stress in the population in general. The increased rate of admission for patients with depression in the pandemic era may relate to an increase in severity in symptoms and argues for a greater focus in resources for patients with these behavioral health complaints.

The implication of our results is that mental health resources should be seen as essential, and when population-based risk is high, such as during a pandemic, the health care system should attempt to proactively respond to these increased needs.

This work was supported by a grant from the National Foundation of Emergency Medicine (NFEM-CU20-1987). Dr. Probst is supported by an R01 grant from the National Heart, Lung, and Blood Institute (NHLBI; R01HL149680). Dr. Chang is supported by R01 grants from NHLBI (R01HL146911 and R01HL141811). Dr. Schultebraucks is supported by an R01 grant from the NHLBI (R01HL156134).

None to declare.

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