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

Abstract

On 17 March 2020, a national lockdown began in France in response to the COVID-19 pandemic. Loneliness and social isolation caused by social distancing are long-established major risk factors for a number of psychiatric disorders.1, 2 Quarantine and lockdown have other psychological consequences, such as boredom, irritability, and sleep dysregulation, which are associated with first-episode emergence of psychiatric disorders as well as the exacerbation of pre-existing psychiatric conditions.3, 4 Contamination fear has additional stress associations, for example anxious and obsessional symptoms, or delusional symptoms.5 In addition, psychiatric services have had to be reorganized5, 6 to reduce contact among patients and between patients and professionals; for example, restricting consultations to severe cases; reorganization of health care via teleconsultation; early hospital release and restrictions on new hospitalizations; and closure of daily care facilities. Consequently, patients may have experienced 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 a break in follow-up and ongoing treatment, thereby increasing emergency consultations during lockdown.7 This study aimed to compare the number and characteristics of emergency psychiatric consultations during the first 4 weeks of the lockdown in three psychiatric emergency services from Paris and its suburbs, and to compare them to the same period in 2019. Three psychiatric emergency centers took part in the study: one in Paris, and one each in adjacent suburban cities, Colombes and Créteil. We assessed and compared the number and characteristics of emergency consultations during the first 4 weeks of the French lockdown and of the corresponding weeks of 2019. The data from the three centers were pooled. Concerning the categorical variables, the proportions of each sociodemographic, clinical, and outcome category were compared between 2019 and 2020 using two-tailed χ2-tests, with the null hypothesis of an absence of difference between 2019 and 2020. Additional details concerning the data collection and statistical analyses are available in the supplementary materials (Appendix S1). The study was performed in accordance with the Declaration of Helsinki. The data were extracted anonymously from registers, in accordance with the ethical standards of the French National Data Protection Authority. During the first 4 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. The decrease concerned all psychiatric diagnoses, especially for anxiety disorders (number of consultations in 2020 representing 36.1% of consultations in 2019), mood disorders (41.1%), and psychotic disorders (67.2%). Total suicide attempts also decreased in 2020 to 42.6% of those in 2019. The diagnostic pattern of presentations significantly changed, with the percentage of consultations for psychotic disorders increasing (31.1% in 2020 vs 24.1% in 2019), and the percentage of anxiety and stress-related disorders decreasing (16.6% vs 20.8%). The rate of first-episode psychiatric consultations decreased (13.8% vs 20.1%). Hospitalization without patients' consent increased (54.2% vs 43.8%). More details are available in Table 1. Given the multifaceted stressors associated with lockdown, the above results show a surprising 54.8% drop in the number of psychiatric emergency consultations during the first 4 weeks of the COVID-19 pandemic. This decrease is evident in the three considered emergency departments and across all psychiatric diagnosis categories, and also concerns suicide attempts. This decrease is not specific to psychiatry: a greater than 50% decrease in daily total consultations was reported in the West China Hospital emergency,8 and similarly in England.9 Clearly, a fear of contamination in emergency departments has contributed to this. Moreover, unnecessary hospital emergency department visits may have decreased. In France, and elsewhere, recent decades have seen a significant increase in the number of emergency department consultations.10 This increase is contributed to by multiple complex factors, including a deterioration in accessibility of primary care services, leading to unnecessary visits. The treatment gap in psychiatry, the gap between experiencing a psychiatric disorder and using treatment services for this disorder, has already been described.7 Our results seem in line with this, given the significant increased proportion of consultations for psychotic disorders, and of hospitalizations without consent, coupled with the significant decrease in primary psychiatric consultations. For the most severe psychiatric disorders, emergency consultations are more necessary, and the decrease is less important. The development of telemedicine would also seem to have contributed to our results. The 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. Finally, as some people may find new strengths and coping strategies during disasters, the current results may arise from an elevation in resilience capacity. 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. Clearly, COVID-19 has had an impact on psychiatric service utilization and will continue to do so,6 whilst also having possible implications for the nature of psychiatric service organization. The data are available on request. We want to thank Dr Yohann Dabi for his advice, Dr Andrei Szöke for his reviewing, and Dr George Anderson for his prompt editing work. No funding was secured for this study. The authors have declared that there are no conflicts of interest in relation to the subject of this study. Appendix S1 Supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.