key: cord-1052321-77n078pw authors: Pignon, B.; Gourevitch, R.; Tebeka, S.; Dubertret, C.; Cardot, H.; Dauriac-Le Masson, V.; Trebalag, A.-K.; Barruel, D.; Yon, L.; Hemery, F.; Loric, M.; Rabu, C.; Pelissolo, A.; Leboyer, M.; Schurhoff, F.; Pham-Scottez, A. title: Dramatic reduction of psychiatric emergency consultations during lockdown linked to COVID-19 in Paris and suburbs date: 2020-05-22 journal: nan DOI: 10.1101/2020.05.19.20095901 sha: 22be16fc3cf7cc00b055c31ad5fd5f019019be9d doc_id: 1052321 cord_uid: 77n078pw Background The COVID-19 pandemic and associated lockdown may have psychiatric consequences and increase the number of psychiatric emergency consultations. Methods Three psychiatric centers in Paris and its suburbs took part in the study. We compared the number of total psychiatric emergency consultations during the 4 first weeks of the lockdown in France to the corresponding 4 weeks in 2019. We also compared the number of consultations during these 4-week time periods in 2020 and 2019 across different diagnostic categories. Findings In the 4 first weeks of the lockdown in France, 553 emergency psychiatry consultations were carried out, compared to 1224 consultations during the corresponding period of 2019, representing a 54.8 % decrease. This decrease was evident across all psychiatric disorders, including anxiety (number of consultations in 2020 representing 36.1 % of 2019), mood (41.1 %), and psychotic disorders (57.3 %). The number of suicide attempts also decreased (number of suicide attempts in 2020 representing 42.6 % of 2019). In comparison to 2019, the proportion of total consultations for anxiety disorders also decreased (16.6 % vs. 20.8 %), whilst the proportion of total consultations increased for psychotic disorders (31.1 % vs. 24.1 %). Conclusions The total number of psychiatric emergency consultations during lockdown dramatically decreased. The psychological consequences of lockdown may be delayed, indicating that psychiatric services should be prepared for a secondary increase in emergency presentations. On March 17 th , 2020 a national lockdown began in France in response to the COVID-19 pandemic. The virus underpinning the COVID-19 pandemic first appeared in China in November 2019, being declared as pandemic by WHO on March 11 th, 2020 (Zhou et al., 2020 . To date, France and Western Europe, per head population, are the most affected areas (Yuan et al., 2020) . A number of psychiatric consequences arising from the pandemic and lockdown have been proposed (Fagiolini et al., 2020; Fiorillo and Gorwood, 2020; Xiang et al., 2020) . First, loneliness and social isolation caused by social distancing are long-established major risk factors for a number of psychiatric disorders, including anxiety and depression (Beutel et al., 2017; Courtet et al., 2020; Erzen and Çikrikci, 2018; Michalska da Rocha et al., 2018) . Social isolation not only disrupts regular social rhythms, but can aggravate the negative symptoms evident in psychosis, including social withdrawal, apathy, and lack of social interest. The economic impact of the COVID-19 crisis may also increase psychiatric vulnerability (Pfefferbaum and North, 2020; Wickham et al., 2014) . Confinement can also increase family/partner conflicts and violence. Quarantine and lockdown have other psychological consequences, such as boredom, anger, frustration, irritability, and sleep dysregulation, which are all associated with poorer psychiatric outcomes, including first episode emergence of psychiatric disorders as well as the exacerbation of pre-existing psychiatric conditions (Brooks et al., 2020; Rajkumar, 2020; Rolland et al., 2020) . Contamination fear has additional stress associations, especially for health anxiety associated with anxious and obsessional symptoms, as well as some delusional symptoms (Brown et al., 2020; Fiorillo and Gorwood, 2020) . In addition to these stressors, psychiatric services have had to be extensively reorganized in response to the COVID-19 pandemic (Arango, 2020; Corruble, 2020; Fagiolini et al., 2020; Fiorillo and Gorwood, 2020; Freeman, 2020; Xiang et al., 2020) , including in France (Chevance et al., 2020) . A number of organizational changes have had to occur in order to maintain the continuity of public psychiatric care, including restricting consultations to severe cases and re-organization of health care via teleconsultation, as well as early hospital release and restrictions on new hospitalizations. Moreover, several daily care facilities, . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 22, 2020. . including psychiatric day hospital services and day-therapy day programs, have been closed to reduce contacts among patients, and between patients and mental health care professionals. Most private psychiatric consultations have been closed or re-organized via teleconsultation. Consequently, patients may experience difficulties in accessing psychiatric services, or worry about being fined for non-compliance of lockdown rules. Overall, such factors may create a treatment gap and/or lead to break in follow-up and ongoing treatment, thereby increasing emergency consultations (Font et al., 2018; Reger et al., 2020) . This study aimed to compare the number and characteristics of emergency psychiatric consultations during the four first weeks of the lockdown in three psychiatric emergency services from Paris and its suburbs, and to compare them to the same period in 2019. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 22, 2020. . Three psychiatric emergency centers took part in the study: one in Paris, and two in adjacent suburban cities, Colombes (Northwest Paris) and Créteil (Southeast Paris). The Paris center is called CPOA ("Centre Psychiatrique d'Orientation et d'Accueil"). It is located in Sainte-Anne hospital, and is the biggest emergency psychiatric units in Paris and its suburbs. The two suburban emergency centers are part of two University-affiliated hospitals of the Assistance Publique-Hôpitaux de Paris (Louis-Mourier for Colombes, and Henri-Mondor for Créteil). The Colombes center is the only center of the three to admit children. The data of this study was extracted anonymously from hospital registers. We assessed the number of emergency consultations during the 4 first weeks of the French lockdown, viz from Tuesday 17 th March to Monday 13 th April 2020 inclusive, and of the corresponding weeks of 2019, viz from Tuesday 19 th March to Monday 15 th April 2019). Age, gender, and provenance (i.e., the patient's origin, such as patient's home, public roads, etc.) were extracted for all patients visiting the emergency services. Patient's provenance was only available for the Paris and Créteil centers. We also extracted data concerning the presence of a recent (< 1 week) suicide attempt (except for Créteil center, as this data was not available) and psychiatric diagnosis of each patient. Psychiatric diagnoses utilized ICD-10 classification and were pooled as follows: psychotic disorders (F20 to F29), mood disorders (F30 to F39), anxiety and stress-related disorders (F40 to F48), personality disorders (F60 to F69), addictive disorders (F10 to F19) and other. Patients' outcomes following the emergency consultations were also noted, including the rates of hospitalization, and as to whether this was with or without the patient's consent (except for Créteil center, as this data was not available). For the Paris center, consultations were also rated as to whether this was a first psychiatric consultation or not. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 22, 2020. . The study was performed in accordance with the Declaration of Helsinki. The data was extracted anonymously from registers, in accordance with the ethical and security standards of the French National Data Protection Authority. According to the INSERM ethics committee, this study does not need an opinion of a research ethics committee according to the French law. The sociodemographic, clinical, and outcome characteristics were compared using chisquare tests. For each variable, 2019 and 2020 rates of each category were compared. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 22, 2020. . During the four first weeks of the national COVID-19 related lockdown, 553 emergency psychiatric consultations were carried out, representing less than half (45.2 %) of the corresponding weeks in 2019 (1224 consultations). This decrease was evident in each of the three centers, with the number of the consultations in 2020, compared to 2019, representing 38.8 % in Paris, 52.4 % in Créteil, and 63 % in Colombes. Sociodemographic characteristics (i.e., sex-ratio and age-bands proportions) of subjects between the year 2019 and the year 2020 were not significantly different, except for the proportion of 16-25 years-old patients, which was lower in 2020 (21.7 % in 2020 vs. 27.5 % in 2019, p-value = 0.012, see Table 1 for details). Details concerning clinical and outcome characteristics are shown in Table 2 . The rate of hospital admission after emergency consultation was not significantly different between 2019 and 2020. However, in 2020, hospitalization without patients' consent significantly increased (54.2 % in 2020 vs. 43.8 % in 2019, p-value = 0.023). . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 22, 2020 . . https://doi.org/10.1101 Given the multi-faceted stressors associated with lockdown, the above results show a surprising, and dramatic, 54.8 % drop in the number of psychiatric emergency consultations, during the first 4 weeks of the COVID-19 pandemic, compared to the same period in 2019. As indicated by the presented data, this decrease is evident in the 3 emergency departments of Paris and its suburbs, covering both the psychiatric emergency service and general hospital emergency services of these units. Further, this decrease is evident across all psychiatric diagnostic categories, and concerns also suicide attempts. The percentage of anxiety disorders was lower in 2020 than in 2019, whilst the percentage of patients consulting for psychotic disorders was higher in 2020 than in 2019, as was the rate of hospitalization without consent. Data from other countries indicates that this decrease is not specific to psychiatry. In the West China Hospital emergency department, a greater than 50 % decrease in daily total consultations was reported, coupled to an elevation in consultations for fever and/or COVID-19 symptoms (Cao et al., 2020) . A similar phenomenon has been observed in England, where lockdown led to a 25 % in general emergency consultations during the week (Thornton, 2020). Clearly, a fear of contamination in emergency departments has contributed to this. A huge rise in psychiatric emergency consultations may be expected after lockdown, and perhaps in the later phases of lockdown. Moreover, the number of consultations, which are not strictly medical emergencies, may also have decreased. In France, as in many other countries, recent decades have seen a significant increase in the number of emergency department consultations (Derlet and Richards, 2000; Hoot and Aronsky, 2008) . This increase is contributed to by multiple complex factors, including a deterioration in accessibility of primary care services, leading to unnecessary hospital emergency departments visits (Cunningham et al., 1995) . The treatment gap in psychiatry, the gap between experiencing a psychiatric disorder and using treatment services for this disorder, has been extensively described in France and elsewhere (Font et al., 2018; Kohn et al., 2004) . The results in the current study seem in line with this, given the significant increase of the proportion of consultations for psychotic disorders and of hospitalizations without consent, coupled to the significant decrease in primary psychiatric consultations in the largest center of our study (Paris). For the most severe psychiatric disorders, the emergency consultations are more necessary, and the number of consultations is less attenuated. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 22, 2020. . The development of telemedicine would also seem to have contributed to our results. Psychiatric services have been quickly mobilized to provide telemedicine consultations, which seems well accepted by patients and mental health care professionals, with the present results possibly indicative of the greater utilization of telemedicine consultations during the COVID-19 pandemic (Kavoor et al., 2020) . For depression or anxiety disorders, telemedicine consultations could even have more efficacy than traditional consultations (Ekeland et al., 2010; Fortney et al., 2013) . This viability and feasibility of telemedicine consultations are likely to emerge subsequent to the COVID-19 triggered lockdown, possibly indicating a role for their sustained implementation. This is a change that may emerge from the COVID-19 pandemic and it will be interesting to determine its impact on factors such as the rates of patients lost to follow-up. As some people may find new strengths and coping strategies during disasters (Pfefferbaum and North, 2020) , the current results may arise from an elevation in resilience capacity. This was observed in New York following the September 11 th terrorist attack, where the expected surge in psychiatric presentations, including post-traumatic stress symptoms and/or disorders, did not emerge (Bonanno et al., 2006) . Such psychological resilience is described as having both individual and collective aspects (Williams and Drury, 2009). Overall, despite the expectation of lockdown-induced stress increasing relapse risk across psychiatric conditions, the numbers of patients seeking emergency psychiatric consultations have decreased during lockdown. This is important to document, as will be the amount of consultation in the post-pandemic period. The reasons underpinning this dramatic reduction, such as telemedicine efficiency and case-management strategies, may be incorporated to improve quality and organization of health care provision. However, the psychological consequences of lockdown may occur later, where a secondary increase of emergency psychiatric presentations may occur. Clearly, COVID-19 has had an impact on psychiatric service utilization and will continue to do so (Chevance et al., 2020) , whilst also having possible implications for the nature of psychiatric service organization. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 22, 2020. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 22, 2020. . Wickham S, Taylor P, Shevlin M, et al. (2014) . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 22, 2020. . is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 22, 2020. . is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 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We want to thank Dr. Yohan Dabi for his advice, and Dr. George Anderson for his prompt editing work. The authors have declared that there are no conflicts of interest in relation to the subject of this study.