Psychiatric Boarding in Emergency Departments and the COVID-19 First Wave: The New Hampshire Response.

The COVID-19 pandemic forced unprecedented challenges for emergency department operations during the spring of 2020. Before the COVID-19 pandemic, psychiatric boarding in emergency departments required a substantial amount of staffing and administrative resources. This case study describes one state's efforts to rapidly decrease psychiatric boarding by 93% in 2 weeks with a multipronged approach, and simultaneously minimal effects observed on outcome measures of psychiatric hospital readmissions and suicide rates. Lessons learned are discussed regarding workflow adaptations and leadership implications.

Increased anxiety and stress-related visits to the Shanghai psychiatric emergency department during the COVID-19 pandemic in 2020 compared to 2018-2019.

Background: The coronavirus disease 2019 (COVID-19) pandemic has had a significant and far-reaching impact on mental health. The psychiatric emergency department (PED) is pivotal in the management of acute and severe mental illnesses, especially anxiety-and stress-related disorders. Aims: This study aimed to evaluate whether changes in the frequency or patients' demographics of visiting the PED occurred during the COVID-19 pandemic among individuals with anxiety and stress-related disorders. Methods: This cross-sectional study used data on PED visit counts from the largest psychiatric hospital in China between 2018 and 2020 (before and during the COVID-19 pandemic). Data from 2020, representing the COVID-19 pandemic period, were extracted from electronic medical records and compared using descriptive statistics for the same periods in 2018 and 2019. Results: The number of PED visits related to anxiety and stress disorders per year increased from 83 in 2018 to 136 (63.9% increase) in 2019 and 239 (188.0% increase) in 2020. Compared to that in 2018 and 2019, the proportion of PED visits in 2020 among patients with anxiety and stress disorders increased significantly. Patients with anxiety-and stress-related disorders during PED visits in 2020 were younger than those in 2018 and 2019 (three-year groups: F = 9.124, df = 2, p < 0.001). Conclusion: Despite the epidemic-policy barriers against PED visits, PED care seeking has increased, thereby underscoring the need for crisis prevention services for patients with stress and anxiety disorders.

Retrospective and comparative study about the impact of the health crisis on the activity of a pedopsychiatric emergency unit

Objectives: The aim of this retrospective study was to question the psychological consequences of the health crisis in a pediatric population, through an analysis of the variations in the activity data of a pedopsychiatric emergency consultation service. Material(s) and Method(s): The present study is a retrospective and comparative epidemiological study based on an analysis of activity data from a pedopsychiatric emergency consultation at the Lille University Hospital center collected over the period contemporary of the social restriction measures of March 17th, 2020 to May 19th, 2021 as well as those collected after the lifting of these measures from May 19th, 2021 to May 31st, 2022 by comparing them to the activity on this same service over the equivalent periods between January 1st, 2017 and March 17th, 2020. Comparisons centered around the three confinement periods were also carried out. Any patient between 0 and 18 years old taken care of in this emergency consultation was included in this study. Result(s): A significant increase in drug prescriptions and consultations for suicidal ideations was observed during, but also at a distance from social restriction measures. The first confinement was marked by a significant drop in the number of consultations and a significant increase in the drafting of child protection documents. Discussion(s): These results were therefore in favor of an increase in suicidality in the pediatric population during and after the lifting of social restriction measures, as well as an increase in situations relating to child protection during the first confinement. The significant increase in discordant discharge drug prescriptions with the more modest increase in hospitalizations foreshadowed a mismatch between needs and hospitalization capacity. Conclusion(s): An impact of the health crisis could therefore be observed on the activity of a pedopsychiatric emergency consultation during, but also after the lifting of social restriction measures. This raises the importance of not limiting research to periods of confinement, as well as the question of the reversibility of the variations observed for the generation considered. Copyright © 2022 Elsevier Masson SAS

The Evaluation of the Comparision Between pre- and post Pandemic Era Regarding Emergency Psychiatric Consultations

Introduction: COVID-19 had direct and indirect impacts on both mental health and healthcare systems. Evaluating urgent psychiatric consultations may be useful to determine the effects of COVID-19 pandemic since it reflects the condition of psychiatric patients and healthcare systems Objectives: This study aims to determine the quantitative or qualitative changes in emergency psychiatry consultations after COVID- 19 pandemic. Method(s): The socio-demographic characteristics and clinical features of two hundred thirty three patients were retrospectively collected and analyzed in order to compare the emergency psychiatry consultations before (between the dates 11th of March 2019- 10th of March 2020) and after (between 11th of March 2020-10th of March 2021) the COVID-19 pandemic. Result(s): The ratio of patients consulted to psychiatry to total emergency department increase after pandemic (%0.03 vs %0.07). Among these patients, the diagnosis of 'alcohol and substance use disorder' (%6.1 vs. %15.4) (p=0.03) increased while the diagnoses of 'obsessive compulsive disorder (5.3% vs. 0%)(p=0.01) and bipolar disorder (%21.1 vs. %20.5) (p=0.02) decreased. Hostility among patient during consultation increased (%19.1 vs. %30.8)(p=0.04). Suicidal thoughts decreased (%25.2 vs. %14.5) (p=0.04). Furthermore, voluntary inpatient treatment (%20.9-%34.2) (p =0.02) increased, transfer to another clinic (%25.2 vs. %12) (p=0.01) and outpatient treatment (%46.1 vs. %42.7) (p=0.01) decreased. An increase in oral treatments (%10.4 vs. %26.5) (p=0.02) and decrease in parenteral treatments (%71.3 vs. 54.7) ( p=0.01) were also reported. Conclusion(s): Our findings confirmed that after COVID-19 spread the clinical features diagnosis, and treatment modality have changed among urgent psychiatric consultations.

Use of Acute Mental Health Care in U.S. Children's Hospitals Before and After Statewide COVID-19 School Closure Orders.

Objective: This study aimed to examine changes in child emergency department (ED) discharges and hospitalizations for primary general medical (GM) and primary psychiatric disorders; prevalence of psychiatric disorders among acute care encounters; and change in acute mental health (MH) care encounters by disorder type and, within these categories, by child sociodemographic characteristics before and after statewide COVID-19­related school closure orders. Methods: This retrospective, cross-sectional cohort study used the Pediatric Health Information System database to assess percent changes in ED discharges and hospitalizations (N=2,658,474 total encounters) among children ages 3­17 years in 44 U.S. children's hospitals in 2020 compared with 2019, by using matched data for 36- and 12-calendar-week intervals. Results: Decline in MH ED discharges accounted for about half of the decline in ED discharges and hospitalizations for primary GM disorders (−24.8% vs. −49.1%), and MH hospitalizations declined 3.4 times less (−8.0% vs. −26.8%) in 2020. Suicide attempt or self-injury and depressive disorders accounted for >50% of acute MH care encounters before and after the statewide school closures. The increase in both ED discharges and hospitalizations for suicide attempt or self-injury was 5.1 percentage points (p<0.001). By fall 2020, MH hospitalizations for suicide attempt or self-injury rose by 41.7%, with a 43.8% and 49.2% rise among adolescents and girls, respectively. Conclusions: Suicide or self-injury and depressive disorders drove acute MH care encounters in 44 U.S. children's hospitals after COVID-19­related school closures. Research is needed to identify continuing risk indicators (e.g., sociodemographic characteristics, psychiatric disorder types, and social determinants of health) of acute child MH care.

The impact of COVID-19 on the psychiatric emergency departments of two Italian hospitals in Milan.

During the first wave of the SARS-CoV-2 contagion in Italy, mental health care services continuity has been granted to the general population. Emergent and urgent conditions, however, are managed in collaboration with Emergency Departments (EDs). This collaboration may have suffered from the overload of the EDs due to the high number of SARS-CoV-2 positive patients. In this perspective, we analysed the possible impact of COVID-19 on the EDs accesses of psychiatric patients in two of the main hospitals of Milan, the "Luigi Sacco" Hospital and the "Fatebenefratelli" Hospital, comparing their admissions between the periods of March, April and May 2019 and 2020. We found a significant reduction in the number of evaluated patients in 2020 in both EDs. Emergency Medical Services (EMSs) brought a significant lower number of patients to the ED of Sacco Hospital during 2020, while this number increased for the ED of Fatebenefratelli Hospital, confirming the hypothesis that the overload of the Sacco Hospital ED significantly influenced the possibility to receive a psychiatric evaluation there. Moreover, we found a significant difference between diagnosis at discharge of the different samples.

Decreasing Psychiatric Emergency Visits, but Stable Addiction Emergency Visits, During COVID-19-A Time Series Analysis 10 Months Into the Pandemic.

Background: The COVID-19 pandemic has been suspected to increase mental health problems, but also to possibly lead to a decreased treatment seeking, for example due to fear of attending hospital. Early findings demonstrate decreased treatment seeking for mental health, which may differ across diagnostic groups. This study aimed to examine treatment uptake at a general psychiatry emergency unit and at an addiction psychiatry emergency unit in Malmö, Sweden, separately. In addition, the study aimed to investigate treatment uptake for different diagnostic groups-during and prior to the COVID-19 pandemic. Methods: Monthly data for number of unique patients and number of contacts were extracted for the three-year period of January 2018 through December 2020. Data from each facility were analyzed separately for women, men and patients with psychotic, affective, anxiety and substance use-related disorders. Interrupted time series were used to demonstrate possible effects of COVID-19. Results: COVID-19 was associated with a marked decrease in treatment contacts, both for women and men, in the general psychiatry emergency unit-driven by a significant decrease in anxiety-related disorders (p < 0.001) and affective disorders (p < 0.01)-but not in psychotic or substance use disorders (SUDs). Also, in the addiction psychiatry emergency unit, no significant impact of COVID-19 was seen. Conclusions: COVID-19 may decrease treatment uptake for acute affective and anxiety-related disorders. Given the hypothesized increase in the population regarding these conditions, societal efforts are needed to facilitate adequate treatment for these patients during the COVID-19 pandemic. Society should also remain vigilant with respect to SUDs during the pandemic.

The Impact of the COVID-19 Pandemic on Psychiatric Emergency Service Volume and Hospital Admissions.

BACKGROUND: During the COVID-19 pandemic, there have been an increasing number of emergency department visits for behavioral health reasons, even as overall emergency department volumes have decreased. The impact of the pandemic and related public health interventions on specialized psychiatric emergency services has not been described. These services provide high-intensity care for severely ill patients who are likely to be homeless and underserved. OBJECTIVE: We describe the change in total volume and psychiatric hospitalization rates among three psychiatric emergency services across the United States. METHODS: Changes in volumes and hospitalization were assessed for statistical significance using a seasonal autoregressive integrated moving average with exogenous factors model from January 2018 to December 2020. RESULTS: The pandemic's impact on volumes and hospitalization varied by site. In Denver (CO), there was a statistically significant 9% decrease in overall volumes, although an 18% increase in hospitalizations was not significant. In New York City (NY), there was a significant 7% decrease in volumes as well as a significant 6% decrease in hospitalizations. In Portland (OR), volumes decreased by 4% and hospitalizations increased by 6% although differences did not reach statistical significance. CONCLUSIONS: There has been a decrease in volume at these services after the pandemic, but there are substantial variations in the magnitude of change and demand for hospitalization by region. These findings suggest a need to understand where patients in crisis are seeking care and how systems of care must adapt to changing utilization in the pandemic era.

A "Mental Health PPE" model of proactive mental health support for frontline health care workers during the COVID-19 pandemic.

We summarize in this article the development, roll out, and preliminary outcomes of a large-scale proactive mental health support model for frontline healthcare workers during the early stages of the COVID-19 pandemic, specifically during New York City's initial case surge in March through June of 2020. This paper summarizes the program design and output for two types of dedicated teams of behavioral health clinicians: 1) Mental Health Liaisons, who provided preventative support to COVID-19 hospital units and Emergency Departments, and 2) Mental Health Crisis Response Teams, who staffed 24/7 crisis response lines to support and mitigate staff crises as needed. In addition to the specifics of this model, we discuss the strategies, rewards, and difficulties of rapidly staging and evaluating such a model in the context of an ongoing disaster situation. We also offer recommendations for how this multi-dimensional model may be replicated in other settings.

American Association for Emergency Psychiatry Recommendations to Address Psychiatric Staff Shortages in Emergency Settings.

OBJECTIVE: The psychological sequelae of the COVID-19 crisis will increase demands for psychiatric care in already strained emergency and mental health systems. To address the shortage of psychiatrists (and nurse practitioners and physician assistants) in emergency settings (ESs), the American Association for Emergency Psychiatry (AAEP) has established recommendations for utilizing nonprescribing mental health professionals in the evaluation and management of psychiatric patients in these contexts. METHODS: Faced with limited research on the roles and competencies of nonprescribing psychiatric emergency clinicians (PECs), a multidisciplinary committee of members of AAEP was tasked with developing recommendations for use of PECs. RESULTS: The committee developed eight recommendations regarding the role of PECs in evaluation and management of patients who present to ESs with behavioral emergencies. PECs should have the following competencies: conducting independent psychiatric and substance abuse evaluations; managing behavioral emergencies; aiding in the recognition of confounding medical illnesses, intoxication and withdrawal states, and adverse drug reactions; developing appropriate treatment plans; recognizing when consultation from a psychiatrist or emergency physician is indicated; possessing self-awareness and recognizing clinician-patient dynamics; understanding medicolegal issues, such as involuntary holds and decision-making capacity; and collaborating with clinical teams in ESs. PECs are not meant to replace psychiatrists but to extend the psychiatrist's reach. Use of PECs has already been implemented in some areas of the country. CONCLUSIONS: On the basis of the AAEP recommendations, ESs can address staffing shortages while ensuring safe management of patients with behavioral emergencies. With appropriate orientation and training, the PEC can serve effectively and competently in an ES.

Changing trends in psychiatric emergency service admissions during the COVID-19 outbreak: Report from a worldwide epicentre.

BACKGROUND: During the COVID-19 pandemic, a structural reorganization was imposed on public health systems. Psychiatry services were also affected with the imposed reduction of non-urgent consultations. We aim to explore the effect of these changes on a Psychiatry Emergency Service during COVID-19 lockdown in Spain. METHODS: A retrospective analysis was performed on all patients admitted to our Psychiatric Emergency Service 90 days before and after March 14th, 2020, the first day of lockdown in Spain. Extracted data were compared between the two periods. Poisson regression analysis was performed to analyze changes in admission rates. RESULTS: 1,958 psychiatric emergency admissions were analyzed. Although the number of admissions decreased by 37.9%, we observed a significant increase in the percentage of acute psychiatric hospitalization during the lockdown. Anxiety spectrum disorders accumulated the greatest significant decrease in admission rates during the lockdown. On the other hand, a significant increase in admissions rates was found in patients with dementia, autism spectrum disorders, and substance use disorders during the lockdown. LIMITATIONS: This study was conducted in a single psychiatric emergency service, preventing a generalization of our results. The comparison time period might have biased our results due to the influence of external factors. CONCLUSION: Mental health consequences of COVID-19 are becoming apparent. A reduction of admission rates for anxiety disorders might be related telepsychiatry implementation during the lockdown. Other conditions particularly vulnerable to the routine changes and lack of social support have suffered the most, and efforts should be placed to treat these situations.

Coronavirus disease: challenges for psychiatry.

Coronavirus disease (COVID-19) presents two urgent health problems: the illness caused by the virus itself and the anxiety, panic and psychological problems associated with the pandemic. Both problems present substantial challenges for our patients, their families, our multidisciplinary teams and our psychiatrist colleagues. We need good psychiatry, now more than ever.

COVID-19 disease emergency operational instructions for Mental Health Departments issued by the Italian Society of Epidemiological Psychiatry.

During the current COVID-19 disease emergency, it is not only an ethical imperative but also a public health responsibility to keep the network of community psychiatry services operational, particularly for the most vulnerable subjects (those with mental illness, disability, and chronic conditions). At the same time, it is necessary to reduce the spread of the COVID-19 disease within the outpatient and inpatient services affiliated with Mental Health Departments. These instructions, first published online on 16 March 2020 in their original Italian version, provide a detailed description of actions, proposed by the Italian Society of Epidemiological Psychiatry, addressed to Italian Mental Health Departments during the current COVID-19 pandemic. The overall goal of the operational instructions is to guarantee, during the current health emergency, the provision of the best health care possible, taking into account both public health necessities and the safety of procedures. These instructions could represent a useful resource to mental health providers, and stakeholders to face the current pandemic for which most of Mental Health Departments worldwide are not prepared to. These instructions could provide guidance and offer practical tools which can enable professionals and decision makers to foresee challenges, like those already experienced in Italy, which in part can be avoided or minimised if timely planned. These strategies can be shared and adopted, with the appropriate adjustments, by Mental Health Departments in other countries.