ABSTRACT
Background: The Covid-19 pandemic has had a significant impact on population mental health and the demand for mental health services while also disrupting and halting some critical mental health services. Mental health providers have been under pressure to respond to the pandemic in a variety of ways. Many have seen sharp changes in activity levels, for example, at the outset, there was a rush to clear hospital beds and rapidly discharge patients. Wards were reconfigured to accommodate patients with Covid which reduced capacity. Many services saw reductions in inpatient admissions. But patterns changed over time with bed occupancy levels apparently returning back to pre-pandemic levels and urgent referrals going up. The complex interplay of factors may have affected providers differently during the different pandemic waves. Mental health providers have called for greater understanding of capacity requirements, to facilitate service recovery and navigate future phases of the pandemic. There is therefore a pressing need for a robust examination of the impact of the pandemic on the delivery of mental health services. Aims of the Study: We examine (i) whether during Covid-19, relative to pre-Covid, there were changes in activity levels for mental health providers in England in terms of numbers of inpatient admissions, length of stay, bed days and discharges, (ii)) whether changes in levels differed with respect to certain groups e.g. mental health diagnosis, ethnicity, or socio-economic status, and (iii) whether mental health patients discharged from mental health providers at the start of the pandemic, present in other parts of the healthcare system e.g. outpatient services. Methods: We conducted an interrupted time-series analysis (where March 2020 was the point of interruption) on monthly (and daily) mental health activity data from a sample of mental health providers for the period 1 January 2015 to 31 August 2021. We used monthly release data from the Hospital Episodes Statistics (HES) Admitted Patient Care data in England. We examined changes in activity for admissions, bed days and discharges for all mental health providers, and changes in length of stay at provider/month level, using a rich set of explanatory variables. We stratified analyses by mental health condition (using ICD-10 diagnostic codes), deprivation quintile and ethnicity. We examined measures of excess admissions and their duration to quantify how many patients were not treated as a result of the pandemic. Finally, we undertook a descriptive analysis of the discharge destinations (e.g. usual place of residence, transfer elsewhere) of mental health patients immediately prior to and during the pandemic and tracked whether they reappear in other parts of the healthcare system such as outpatients. Results: Preliminary results show a sharp and significant reduction in certain activity levels e.g. around 117 fewer admissions per month. Discussion and Limitations: We are only able to include data from a subset of mental health providers that submit data to HES. Implications for Health Care Provision and Use: Mental health providers need to be able to respond swiftly to the sharp changes in demand for different services. Implications for Health Policies: Our analysis can help policymakers and services with future pandemic preparedness. Implications for Further Research: Future research should examine the response of mental health providers with other types of activity such as community care.
ABSTRACT
AIMS: To describe the neuropathological findings in two cases of fatal Coronavirus Disease 2019 (COVID-19) with neurological decline. METHODS: Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection was confirmed in both patients by reverse transcription polymerase chain reaction (RT-PCR) from nasopharyngeal swabs antemortem. Coronial autopsies were performed on both patients and histological sampling of the brain was undertaken with a variety of histochemical and immunohistochemical stains. RNAscope® in situ hybridization (ISH) using the V-nCoV2019-S probe and RT-PCR SARS-CoV-2 ribonucleic acid (RNA) was performed in paraffin-embedded brain tissue sampled from areas of pathology. RESULTS: Case 1 demonstrated severe multifocal cortical infarction with extensive perivascular calcification and numerous megakaryocytes, consistent with a severe multi-territorial cerebral vascular injury. There was associated cerebral thrombotic microangiopathy. Case 2 demonstrated a brainstem encephalitis centred on the dorsal medulla and a subacute regional infarct involving the cerebellar cortex. In both cases, ISH and RT-PCR for SARS-CoV-2 RNA were negative in tissue sampled from the area of pathology. CONCLUSIONS: Our case series adds calcifying cerebral cortical infarction with associated megakaryocytes and brainstem encephalitis to the spectrum of neuropathological findings that may contribute to the neurological decompensation seen in some COVID-19 patients. Viral RNA was not detected in post-mortem brain tissue, suggesting that these pathologies may not be a direct consequence of viral neuroinvasion and may represent para-infectious phenomena, relating to the systemic hyperinflammatory and hypercoagulable syndromes that both patients suffered.