key: cord-1028960-abib2mvw
authors: Mutlu, Emre; Anıl Yağcıoğlu, A. Elif
title: Relapse in patients with serious mental disorders during the COVID-19 outbreak: a retrospective chart review from a community mental health center
date: 2020-10-26
journal: Eur Arch Psychiatry Clin Neurosci
DOI: 10.1007/s00406-020-01203-1
sha: 9f44bf481e0357e06d1a3a2d4d72f02c8b5412ce
doc_id: 1028960
cord_uid: abib2mvw

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Once reopened, telepsychiatry monitoring at CMHC was initiated once/twice a week or biweekly according to the patient's clinical status. From a number of total 188 patients, 155 could be contacted. The medical charts of these 155 patients (schizophrenia/schizoaffective disorder n = 131 [84%], bipolar disorder n = 24 [16%]) were investigated retrospectively. The demographic, clinical characteristics and medication adherence of the patients were recorded. Relapse criteria were defined as: (1) psychiatric hospitalization, (2) admission to emergency department (ER) for psychiatric reasons, (3) discontinuing antipsychotics (defined as not using oral formulations for a week or delaying the next LAI injection for two weeks), (4) new onset of suicidal thoughts or suicide attempt, and (5) non-suicidal self-harm or violent behavior.

The mean age of the sample was 46.6 ± 12.5, with a mean duration of education 9 ± 3.6 years. Most of the patients were male (68%), single/separated (59%), unemployed (56%) and living with their families (90%). The mean duration of illness was 20 ± 10.6, and follow-up duration at the CMHC was 2.9 ± 1.5 years. The median number of previous hospitalization was 2 (min-max: 0-10, IQR:2), and the median duration after the last hospitalization was 6 years (min-max: 0-30, IQR: 4).

The relapse rate of the patients in the first trimester of COVID-19 outbreak was 11% (bipolar disorder n = 2, schizophrenia n = 15). Most of the patients who experienced relapse reported discontinuation of antipsychotics (59%). In addition, 2 patients were hospitalized, 4 were admitted to the ER, 2 had new onset of suicidal thoughts/suicide attempt, and 3 showed self-harm or violent behavior.

The relapse and the non-relapse groups were similar regarding age, gender, duration of education, employment and marital status, diagnosis, duration of illness and followup and the number of previous hospitalizations (p > 0.05). The relapse group had been hospitalized more recently compared to the non-relapse group (Median (IQR): 3 (4) vs 6 (4) years, respectively, Mann-Whitney U = 320.500, p = 0.001).

Most patients in the relapse group were using LAIs (82% see Table 1 ). Twelve patients reported a wish to discontinue their medications, and 9 of these were receiving LAIs. Among the 8 patients who actually discontinued their LAIs, 5 did so in the first month of the outbreak. Medication details of the patients are presented in Table 1 . The number of patients who wished to discontinue their medications was significantly higher in the relapse group (71% vs 5%, respectively, χ 2 (1, 155) = 64.701, p < 0.001). One patient older than 65 years of age could not receive an LAI because of the outbreak restrictions.

In the non-relapse group (n = 138), 19 patients (13.7%) experienced one or more difficulties to continue their medications (n: 6 wishing to discontinue medication, n:3 delay of LAI injection < 2 weeks, n:10 difficulty in procuring medications).

The relapse rate of the sample in 2019 was 6.5% (bipolar disorder n = 1, schizophrenia or schizoaffective disorder n = 9), and did not differ from the first trimester of COVID-19 (McNemar test p = 0.167). The odds ratio for the association between LAI and relapse was 1.07 in 2019. The odds ratio increased to 3.69 in 2020. But the Mantel-Haenszel analysis showed that the change of the odds ratio was not statistically significant (Breslow-Day χ 2 = 1.739, df = 1, p = 0.188).

Although most of the patients in the relapse group were using LAIs (Table 1) , they tended to discontinue their medications. Non-adherence to LAIs may be an unexpected problem which can be faced during an outbreak. With some evidence indicating that LAIs are more effective in patients under the age of 40 [8] , it could also be argued that this sample was too old to benefit from the advantages of using LAIs.

Our data did not support the superiority of LAIs over oral antipsychotics for relapse prevention in patients from a CMHC in the first trimester of the outbreak. Loss of contact between the CMHC team and patients may have facilitated the onset of relapse as the majority of the patients discontinued LAIs in the first month of the outbreak, in which our CMHC had been closed. Taking into account that the CMHC team was able to follow and support 19 patients who experienced some form of difficulty in continuing medications in the non-relapse group, it is plausible to state that carrying on community-based mental health care services during COVID-19 outbreak is essential. Our data also suggest that the patients who are more recently hospitalized may be more vulnerable for relapse.

Finally, telepsychiatry appears to be an efficient patient management tool, and the described CMHC experience gives further support to the need of adopting digital health 

The challenge of mental health during COVID-19 outbreak: experience from metropolitan area of Milan

Patients with mental health disorders in the COVID-19 epidemic

The Association Between Medication Adherence and Disease Stability in Patients with Severe Mental Disorders and Area Variation: Community-Based Prospective Study in Southwest China

Risperidone nonadherence and return of positive symptoms in the early course of schizophrenia

Hidden in plain sight: Addressing the unique needs of high risk psychiatric populations during COVID-19 pandemic

Impact of COVID-19 pandemic on pre-existing mental health problems

Arango C (2020) How mental health care should change as a consequence of the COVID-19 pandemic

Long-acting injectable antipsychotics: shall the last be first?

Acknowledgements To Ankara Etimesgut CMHC team, for their