Psychiatric Emergencies in Los Angeles County During, and After, Initial COVID-19 Societal Restrictions: An Interrupted Time- Series Analysis

ABSTRACT

Background: In the USA, the early stage of COVID-19 led to stateimposed restrictions on population movement, work activity, and social gatherings. Some research finds that emergency department (ED) visits for psychiatric care declined during these restrictions. This work, however, does not control for strong patterning over time in ED visits, does not examine subtypes of ED visits, and does not test whether these visits strongly rose above expected levels after the loosening of societal restrictions. Aims of the study We improve upon the literature and analyze, in the largest hospital in the most populous county in the US (Los Angeles, California), two COVID-19-related aims. First, we control for strong temporal patterning and test whether psychiatric ED visits fall below expected levels during the 1st stage of strong societal restrictions-and if so, which ED subtypes account for this decline. Second, we test whether psychiatric ED visits rebounded to greater than expected levels after the loosening of societal restrictions. Method: We obtained counts of psychiatric ED visits (66,451 total over 156 weeks, Jan 2018 to Dec 2020) from Los Angeles County and USC (LAC+USC) hospital. We applied Box-Jenkins time series methods to identify and remove autocorrelation in psychiatric ED visits before examining their relation with the 1st stage of societal restrictions (i.e., March 13 to May 8, 2020) as well as the subsequent period of relaxed restrictions (i.e., May 8 to Dec 31, 2020). If results rejected the null, we explored which type of visits (i.e., depression, schizophrenia, anxiety, suicidal ideation, alcohol use, substance use) accounted for the changes. Results: Psychiatric ED visits fell by 58.47 per week during the 1st stage of societal restrictions (SD=17.59, p<.005). This coefficient sums to 526 fewer visits over the 9-week period, accounting for a 13% fall in visits. Alcohol use and anxiety disorder accounted for the largest share of the reduction. After the 1st stage of societal restrictions, however, we observe no ''rebound'' above expected values in psychiatric ED visits overall (coef= -6.89, SD=13.86, p=.60) or by diagnostic subtype. Discussion: Initial societal restrictions due to COVID-19 reduced the demand for psychiatric ED care. However, after the relaxing of societal restrictions, psychiatric ED visits did not experience a compensatory rebound. This pattern of results does not support the speculation that foregone ED care during the initial societal restrictions subsequently led to a psychiatric ''pandemic'' of urgent visits. Implications for Health Care Provision and Use The perturbation of ED visits during COVID-19 societal restrictions does not appear to warrant an increase in psychiatric care teams to meet higher ED demand in the long-run. Implications for Health Policies If replicated, results should encourage attempts to shift, to non-urgent settings, a portion of psychiatric visits that present in the ED. Implications for Further Research The effectiveness of alternative treatment modalities during the COVID-19 pandemic (e.g., telemedicine) in lieu of ED care, as well as a more careful understanding of potential resilience during societal disruptions, merits further investigation.