Providing crisis care in a pandemic: a virtual based crisis stabilization unit.

Background: Winnipeg, Canada operates a 16-bed subacute unit, the Crisis Stabilization Unit (CSU), for voluntary patients in crisis not requiring hospital admission. The virtual CSU (vCSU) launched in March 2020 as an adjunct to the in-person CSU during the COVID-19 pandemic, providing the same resources virtually, allowing patients to remain at home. Methods: Program data were collected for vCSU admissions between April 1, 2020 and April 7, 2021 (n = 266) to examine patient characteristics and discharge outcomes. Data were retrieved from the electronic patient record (EPR) for both in-person and vCSU admissions during the same period for comparison (n = 712). vCSU admissions (n = 191) were summarized by patient demographics, clinical factors/outcomes, and compared on the same measures to in-person CSU admissions (n = 521) using binary logistic regression. Results: 30.1% of patients admitted to the vCSU received initial mental health assessment virtually (phone/videoconference), therefore receiving all care at home. Clinical symptoms at assessment included depression/anxiety (39.0%), psychosis/mania (2.7%), suicidal behaviour/self-harm (27.4%), psychosocial event/stressor (19.8%). Average stay was 4.9 days. Compared to the in-person CSU, vCSU referrals were associated with the absence of psychosis [odds ratio (OR).40, 95% confidence interval (CI).18-0.89] and no prior 1-year contact with referral site (OR.43, 95% CI.28-0.64). Those living farther away from the referral site were more likely to receive a vCSU referral. Conclusion: The vCSU model is feasible for a diverse group of patients experiencing mental health crises. Future work is needed to better determine who the model is right for and examine longer term outcomes.

Mental health and addiction health service use by physicians compared to non-physicians before and during the COVID-19 pandemic: A population-based cohort study in Ontario, Canada.

BACKGROUND: The Coronavirus Disease 2019 (COVID-19) pandemic has exacerbated mental health challenges among physicians and non-physicians. However, it is unclear if the worsening mental health among physicians is due to specific occupational stressors, reflective of general societal stressors during the pandemic, or a combination. We evaluated the difference in mental health and addictions health service use between physicians and non-physicians, before and during the COVID-19 pandemic. METHODS AND FINDINGS: We conducted a population-based cohort study in Ontario, Canada between March 11, 2017 and August 11, 2021 using data collected from Ontario's universal health system. Physicians were identified using registrations with the College of Physicians and Surgeons of Ontario between 1990 and 2020. Participants included 41,814 physicians and 12,054,070 non-physicians. We compared the first 18 months of the COVID-19 pandemic (March 11, 2020 to August 11, 2021) to the period before COVID-19 pandemic (March 11, 2017 to February 11, 2020). The primary outcome was mental health and addiction outpatient visits overall and subdivided into virtual versus in-person, psychiatrists versus family medicine and general practice clinicians. We used generalized estimating equations for the analyses. Pre-pandemic, after adjustment for age and sex, physicians had higher rates of psychiatry visits (aIRR 3.91 95% CI 3.55 to 4.30) and lower rates of family medicine visits (aIRR 0.62 95% CI 0.58 to 0.66) compared to non-physicians. During the first 18 months of the COVID-19 pandemic, the rate of outpatient mental health and addiction (MHA) visits increased by 23.2% in physicians (888.4 pre versus 1,094.7 during per 1,000 person-years, aIRR 1.39 95% CI 1.28 to 1.51) and 9.8% in non-physicians (615.5 pre versus 675.9 during per 1,000 person-years, aIRR 1.12 95% CI 1.09 to 1.14). Outpatient MHA and virtual care visits increased more among physicians than non-physicians during the first 18 months of the pandemic. Limitations include residual confounding between physician and non-physicians and challenges differentiating whether observed increases in MHA visits during the pandemic are due to stressors or changes in health care access. CONCLUSIONS: The first 18 months of the COVID-19 pandemic was associated with a larger increase in outpatient MHA visits in physicians than non-physicians. These findings suggest physicians may have had larger negative mental health during COVID-19 than the general population and highlight the need for increased access to mental health services and system level changes to promote physician wellness.

Physician benzodiazepine self-use prior to and during the COVID-19 pandemic in Ontario, Canada: a population-level cohort study.

OBJECTIVES: The aim of this study was to investigate physician benzodiazepine (BZD) self-use pre-COVID-19 pandemic and to examine changes in BZD self-use during the first year of the pandemic. DESIGN: Population-based retrospective cohort study using linked routinely collected administrative health data comparing the first year of the pandemic to the period before the pandemic. SETTING: Province of Ontario, Canada between March 2016 and March 2021. PARTICIPANTS: INTERVENTION: Onset of the COVID-19 pandemic in March 2020. OUTCOMES MEASURES: The primary outcome measure was the receipt of one or more prescriptions for BZD, which was captured via the Narcotics Monitoring System. RESULTS: In a cohort of 30 798 physicians (mean age 42, 47.8% women), we found that during the year before the pandemic, 4.4% of physicians had 1 or more BZD prescriptions. Older physicians (6.8% aged 50+ years), female physicians (5.1%) and physicians with a prior mental health (MH) diagnosis (12.4%) were more likely than younger (3.7% aged <50 years), male physicians (3.8%) and physicians without a prior MH diagnosis (2.9%) to have received 1 or more BZD prescriptions. The first year of the COVID-19 pandemic was associated with a 10.5% decrease (adjusted OR (aOR) 0.85, 95% CI: 0.80 to 0.91) in the number of physicians with 1 or more BZD prescriptions compared with the year before the pandemic. Female physicians were less likely to reduce BZD self-use (aORfemale=0.90, 95% CI: 0.83 to 0.98) compared with male physicians (aORmale=0.79, 95% CI: 0.72 to 0.87, pinteraction=0.046 during the pandemic. Physicians presenting with an incident MH visit had higher odds of filling a BZD prescription during COVID-19 compared with the prior year. CONCLUSIONS: Physicians' BZD prescriptions decreased during the first year of the COVID-19 pandemic in Ontario, Canada. These findings suggest that previously reported increases in mental distress and MH visits among physicians during the pandemic did not lead to greater self-use of BZDs.

Virtual Acute Psychiatric Ward: Evaluation of Outcomes and Cost Savings.

OBJECTIVE: The COVID-19 pandemic motivated rapid expansion of virtual care. In Winnipeg, Canada, the authors launched a virtual psychiatric acute care ward (vWARD) to divert patients from hospitalization through daily remote treatment by a psychiatry team using telephone or videoconferencing. This study examined vWARD patient characteristics, predictors of transfer to a hospital, use of acute care postdischarge, and costs of the vWARD compared with in-person hospitalization. METHODS: Data for all vWARD admissions from March 23, 2020, to April 30, 2021, were retrieved from program documents and electronic records. Emergency department visits and hospitalizations in the 6 months before admission and the 30 days after discharge were documented. Logistic regression identified factors associated with transfer to a hospital. Thirty-day acute care use after discharge was modeled with Kaplan-Meier curves. A break-even cost analysis was generated with data for usual hospital-based care. RESULTS: The 132 vWARD admissions represented a diverse demographic and clinical population. Overall, 57% involved suicidal behavior, and 29% involved psychosis or mania. Seventeen admissions (13%) were transferred to a hospital. Only presence of psychosis or mania significantly predicted transfer (OR=34.2, 95% CI=3.3-354.6). Eight individuals were hospitalized in the 30 days postdischarge (cumulative survival=0.93). vWARD costs were lower than usual care across several scenarios. CONCLUSIONS: A virtual ward is a feasible, effective, and potentially cost-saving intervention to manage acute psychiatric crises in the community and avoid hospitalization. It has benefits for both the health system and the individual who prefers to receive care at home.

Early Learning From a Low-Resource COVID-Response Virtual Mental Health Crisis Ward: Mixed Methods Study.

BACKGROUND: The COVID-19 pandemic was accompanied by the accelerated uptake of virtual care, leading to a proliferation of virtual ward models as alternatives to facility-based care. Early in the pandemic, our program implemented a virtual mental health crisis ward (vWard) to provide options for individuals requiring intense psychiatric and/or crisis support but who preferred to remain in the community and were deemed safe to do so. OBJECTIVE: The aim of this study was to identify early learnings from the vWard, which was implemented rapidly in a resource-constrained environment, to inform the future state should it be sustained beyond the pandemic. METHODS: Mixed methods of data collection were used to evaluate provider perspectives on the vWard, develop archetypes for individuals who are a good fit for the vWard model, and create a driver diagram. Data sources included an anonymous survey of clinical and managerial staff involved in the vWard, a service planning workshop, and program discharge forms for all individuals admitted between March 2020 and April 2021. Survey responses were coded for themes under categories of "benefits" and "challenges." Discharge forms where the team indicated that the vWard was a good fit for an individual were examined for characteristics common to these admissions. These findings were reviewed in the service planning workshop and refined with input from the participants into patient archetypes. A driver diagram was created for the future state. RESULTS: Survey respondents (N=60) represented diverse roles in crisis services and the vWard team. Ten providers took part in the service planning workshop. A total of 467 discharge forms were reviewed. The vWard was felt to be a model that worked by 39 survey respondents, one respondent felt it did not work, and the remaining participants had no response. Several benefits for the individual and the system were identified alongside challenges, including certain processes and materials related to the nature of rapid implementation during the pandemic, and others due to lack of fit for certain individuals. The model was felt to be a good fit for 67.5% of admissions. Four patient archetypes representing a good fit with the model were developed. The driver diagram connected the program aim with primary drivers of (1) reduce barriers to care; (2) improve outcomes; and (3) provide collaborative, patient- and family-centered care to secondary drivers and interventions that leveraged virtual technology among other crisis care interventions. CONCLUSIONS: Despite some challenges, the vWard demonstrated high levels of provider acceptance and a range of mechanisms by which the model works for a variety of patient archetypes. These early learnings provide a foundation for growth, sustainability, and spread of this model going forward beyond the pandemic.

Analysis of the uptake and associated factors for virtual crisis care during the pandemic at a 24-h mental health crisis centre in Manitoba, Canada.

BACKGROUND: The coronavirus pandemic necessitated the rapid transition to virtual care. At a 24-h walk-in mental health Crisis Response Centre (CRC) in Winnipeg, Canada we adapted crisis mental health assessments to be offered virtually while the crisis centre also remained open to in person visits. Little is known about the sustainability of virtual visits in the presence of comparable in person care, and which visits are more likely to be done virtually, particularly in the crisis setting. METHODS: An analysis of visits to the CRC from the first local lockdown on March 19, 2020 through the third local wave with heightened public health restrictions in June 2021. Analysis of Variance was used to compare the proportion of visits occurring virtually (telephone or videoconference) during the first wave of heightened public health restrictions (lockdown 1) and subsequent lockdowns as well as the in-between periods. A binary logistic regression examined visit, sociodemographic and clinical factors associated with receipt of a virtual visit compared to an in person visit over the first year of the pandemic. RESULTS: Out of 5,357 visits, 993 (18.5%) occurred virtually. There was a significant difference in proportion of virtual visits across the pandemic time periods (F(4, 62) = 8.56, p < .001). The proportion of visits occurring virtually was highest during lockdown 1 (mean 32.6% by week), with no differences between the other time periods. Receipt of a virtual visit was significantly associated with daytime weekday visits, age, non-male gender, living further away from the CRC, no prior year contact with the CRC, and visits that did not feature suicidal behaviour, substance use, psychosis or cognitive impairment. CONCLUSIONS: A large proportion of virtual care occurring at the outset of the pandemic reflects public anxiety and care avoidance paired with health system rapid transformation. The use of virtual visits reduced over subsequent pandemic periods but was sustained at a meaningful level. Specific visit, sociodemographic and clinical characteristics are more likely to be present in visits occurring virtually compared to those in person. These results can help to inform the future planning and delivery of virtual crisis care.

Videoconferencing at home for psychotherapy in the postpartum period: Identifying drivers of successful engagement and important therapeutic conditions for meaningful use

Purpose Virtual care has almost become the norm since COVID-19 mandated social distancing. Prior, the use of personal videoconferencing was being explored as an appealing option to overcome barriers to care, but little was studied about how we should do it and for whom. This study aimed to answer these questions for women receiving psychotherapy in the postpartum period when there are significant barriers to attending office-based care. Methods Twelve postpartum women who had the option to attend their psychotherapy sessions for the treatment of mood and/or anxiety symptoms via videoconferencing over a 3-month time period were interviewed about their experience. The three therapists providing care were also interviewed early in adoption of the virtual treatment and at the end of the study. Thematic analysis was conducted to identify themes for the initial and ongoing engagement with videoconferencing, which were triangulated with therapist input. Findings Major themes which emerged related to (a) initial willingness to engage with videoconferencing, (b) technological compatibility, and (c) a good patient fit, with positive and negative influencers for each. Therapeutic considerations were identified, including (a) an initial in-person meeting when possible, (b) matching the therapy format to the clinical situation, (c) attention to the home environment, and (d) a clear therapy frame. Conclusions Therapists should consider that videoconferencing might not be appropriate for every patient;but in the right context and with appropriate therapeutic considerations, offering this treatment format may actually facilitate an individual's recovery. These findings can help to inform the future delivery of videoconferencing psychotherapy. (PsycInfo Database Record (c) 2020 APA, all rights reserved)

Innovation Through Virtualization: Crisis Mental Health Care during Covid-19

The covid-19 pandemic created major challenges for mental health crisis care. Our crisis centre in Winnipeg, Manitoba rapidly virtualized the full spectrum of services offered with remarkable uptake, resulting in avoided hospitalizations and reduced transmission risk for covid-19. We must determine how to best adopt these approaches into post-pandemic crisis care.Alternate abstract:La pandémie de Covid-19 a engendré des défis majeurs quant à la prestation des soins en santé mentale en période de crise. Notre centre de crise de Winnipeg, au Manitoba, a rapidement virtualisé la gamme complète des services offerts, et ce, avec succès, permettant ainsi d'éviter des hospitalisations et de diminuer les risques de transmission de la Covid-19. Il s'agit maintenant de convenir de la meilleure façon de mettre en pratique de telles approches dans l'offre de soins de crise postpandémie.