Reduction in beds

The overarching message from the UK Government at the start of lockdown was to stay home, not only to stay safe, but also to help save the lives of others. The collective fear of the unknown coupled with uncertainties about work stability appeared to cause a rise in community anxiety and depression – according to the headlines.^{Reference Marshall, Bibby and Abbs15} However, the effect on the rate of psychiatric admissions was unclear.

In KMPT, there was a 5.2% reduction in admissions between March and August 2020, compared with 2019. However, this should be taken in the context of available beds. Over the same time period, KMPT saw a 4.13% reduction in beds. Therefore, the decrease in admissions was non-significant. If we were to view a reduction in available beds as an unrelated variable, it is likely that the admissions data in 2019 and 2020 would be similar with regards to gender, diagnosis and route of admission. However, we hypothesise that a change would occur in relation to the legal status of admissions. Formal sectioning of patients would likely remain constant because of its urgency and the fact that it must result in admission. Therefore, a reduction in beds is most likely to result in a reduction in informal admissions, as these patients can be treated more readily in the community. However, the 11.8% increase in sectioning is unlikely to be solely because of a 4.13% reduction in available beds.

In England, March 2020 saw emergency department attendances for acute coronary syndrome drop by 40% compared with March 2019.^{Reference Mafham, Spata, Goldacre, Gair, Curnow and Bray16} There is no public health measure that could explain an improvement in cardiovascular health of this magnitude, in the space of 12 months. Therefore, this drop in attendance is likely to have resulted in an increase in out-of-hospital deaths and long-term complications of myocardial infarction.^{Reference Mafham, Spata, Goldacre, Gair, Curnow and Bray16} Similarly, Scotland saw an average reduction of 40.7% in emergency department attendances^{Reference Mulholland, Wood, Stagg, Fischbacher, Villacampa and Simpson17} in the first few months of the first COVID-19 lockdown. This avoidance of healthcare services was seen across the board. The long-term consequences of this reduction are likely to affect all healthcare specialities. There is widespread concern among healthcare professionals that there are many patients in the community who are still not attending services,^{Reference Owens18} risking significant mortality and even death.^{Reference Owens18}

The decreases seen in physical health conditions appears to be much more pronounced than those seen by KMPT psychiatry. Why would those with severe physical health problems appear to avoid presenting to hospital any more than those with psychiatric health problems? Lockdown may have provoked a spike in psychiatric conditions, counteracting the general reduction in patients seeking help and explaining why admissions did not drop off as sharply as acute coronary syndrome, for example. Conversely, lockdown should not cause a sudden rise in physical health conditions not related to COVID-19, and it is likely that fear of presenting to hospital (and therefore exposing oneself to COVID-19) resulted in a dramatic drop in acute coronary presentations.

Increased rate of formal admissions (sectioning)

There was an increased rate of sectioning across 2020, affecting both female and male patients. The largest percentage increase of 20%. was seen in April. Comparatively, in 2018–2019 there was an estimated 2% increase in sectioning from the previous year.¹⁹

A potential reason for this increase could be linked to the reduction in social and community visits during lockdown. Services in the community needed to be adapted to ensure that social distancing rules were adhered to. Unfortunately, this meant that multiple public and clinical services were closed, including shelters, schools and social services.^{Reference Luming12} Telephone consultations suddenly played an important role in community psychiatry services. Closure of social services may have negatively affected discharge destinations, creating issues with obtaining social housing and locations for follow-up appointments.^{Reference Luming12}

Lack of insight and capacity indicates the need for formal sectioning under the MHA. A reduction in community visits had the potential to delay the assessment of psychiatric patients. A delay in assessment could subsequently delay the treatment of acute deterioration of psychiatric conditions. Delayed illness recognition can result in a missed window of opportunity for informal admission, with the patient being more vulnerable to a deterioration of insight. It could also be hypothesised that telephone consultations may have negatively affected assessments; for example, when reviewing a patient's appearance, personal hygiene (including smell) and home environment, all of which factor into a mental state examination.

To counter this argument, however, is the established used of telephone consultations in Australia.^{Reference Morley, Pirkis, Sanderson, Burgess, Kohn and Naccarella20} Rural Australian communities have relied on telephone consultations for many years,^{Reference Morley, Pirkis, Sanderson, Burgess, Kohn and Naccarella20} facilitating improved rural access to psychiatric healthcare for residents with depression and anxiety.^{Reference Morley, Pirkis, Naccarella, Kohn, Blashki and Burgess21} Therefore, the use of telephone consultations in themselves may not be inferior, but instead the inferiority may stem from the lack of familiarity and efficiency during lockdown.

In Vietnam, aggressive social distancing, imposed for COVID-19, acted as a ‘catalyst’ to transform healthcare service delivery.^{Reference Tran, Hoang and Vo22} Fears of unreliability and limited infrastructure^{Reference Tran, Hoang and Vo22} were overshadowed by the immediate demand for a service that was COVID-19-friendly. The shift, born in a time of desperation, could be the motivation needed to accelerated telemedicine-based practice, promoting a more efficient healthcare system.^{Reference Tran, Hoang and Vo22} With the risk of future lockdowns, telephone services should improve with increased use and funding.

Increase in psychoactive substance admissions for male patients

In the UK, substance misuse is more common for male patients than female patients.^{Reference Buccelli, Della Casa, Paternoster, Niola and Pieri23} Stress, particularly in the form of loss, isolation and poor support systems, is a known risk factor for the development of addiction and increased vulnerability to addiction relapse.^{Reference Sinha24} It has also been found that those trying to recover from substance misuse benefit from social support^{Reference Volkow25} – something that could not be provided to the same extent during lockdown.

This reliance or coping mechanism during times of stress should result in an increase in percentage of male admissions for mental and behavioural disorders secondary to substance misuse. However, our findings were not clinically significant. Regardless, it is important that addiction care is reinforced during lockdown.^{Reference Ornell, Moura, Scherer, Pechansky, Kessler and von Diemen26} The goal is to ensure social support is provided in-line with social distancing as support of this nature has a proven benefit.^{Reference Volkow25}

Spike in schizophrenia admissions in both male and female patients

Social interaction is a known benefit in the recovery from schizophrenia,^{Reference Neelam, Duddu, Anyim, Neelam and Lewis27} and is a treatment option that would inevitably be affected by lockdown regulations. As well as limited in-person social interaction, the pandemic restrictions may affect daily routine and group activities, which in turn creates time for vulnerable patients to ruminate on negative cognitions, which has the potential to manifest as paranoid thoughts.^{Reference Neelam, Duddu, Anyim, Neelam and Lewis27}

A meta-analysis looking at individuals with pre-existing mental illness during historical pandemics found not only an increase in psychiatric symptoms, but also a reduction in the utilisation of psychiatric services during the pandemics.^{Reference Neelam, Duddu, Anyim, Neelam and Lewis27} The 1918 influenza pandemic had a non-significant increase in compulsory psychiatric admissions.^{Reference Neelam, Duddu, Anyim, Neelam and Lewis27} The spread of the virus, and the extent and duration of the lockdown, makes the COVID-19 pandemic different from previous pandemics.^{Reference Neelam, Duddu, Anyim, Neelam and Lewis27}

Extreme uncertainty surrounding the virus has been predicted to exacerbate anxiety, sleep disorders, depression and psychotic symptoms.^{Reference Shanbour, Khalid and Fana28} There is the potential for blurring of lines between conspiracy theories and paranoid delusions. Conspiracy theories are often shared by others, and in the context of an unprecedented global pandemic, there is a risk of delusion-like beliefs.^{Reference Shanbour, Khalid and Fana28} Self-quarantine measures can even lead to a preoccupation with the virus. These are all thoughts and beliefs that, before 2020, would have been more aligned with psychotic delusions. However, for psychotic symptoms to result in a psychiatric admission, paranoid delusions need to be personal, idiosyncratic and implausible.^{Reference Shanbour, Khalid and Fana28} ‘Common’ COVID-19 conspiracies alone do not warrant a schizophrenic diagnosis.

Instead, the spike in admissions could be driven by the circumstances created by lockdown; for example, loneliness is a direct threat to psychological health,^{Reference Shanbour, Khalid and Fana28} and fear of contracting the virus from others may also intensify pre-existing paranoid tendencies and exacerbate suspicion toward others.^{Reference Kozloff, Mulsant, Stergiopoulos and Voineskos29} Lockdown may support the persecutory representation of others, that is pre-existing in those with known diagnoses of schizophrenia.^{Reference Kozloff, Mulsant, Stergiopoulos and Voineskos29}

Decrease in anxiety-related admission for male patients

Across the population, fear and anxiety can proliferate during a pandemic.^{Reference Freckelton Qc30} This anxiety, along with hospitals being a source of virus contraction, would inevitably create a widespread avoidance of healthcare services. Fear and avoidance are not just limited to psychiatric services.^{Reference Mafham, Spata, Goldacre, Gair, Curnow and Bray16} Looking at our data, a decrease in anxiety-related admissions for men could reflect this fear of the virus and not wanting to burden services.^{Reference Mulholland, Wood, Stagg, Fischbacher, Villacampa and Simpson17}

There may be an alternative viewpoint. Initially it was believed that more people would suffer from anxiety, relating to the fear of losing their jobs and suffering financial struggles. However, there may have been a release of stress and pressure in other aspects. It could be argued that aspects such as commuting were improved by lockdown. The UK Government furlough scheme ensured that the majority of wages were paid, and evictions were stalled. This could be argued as a potential decrease in work-related stress.

Vietnam found that during the first couple of months of a nationwide lockdown, rates of depression, anxiety and stress were lower, with higher level of stress only being a secondary consequence of coming into contact with patients with suspected COVID-19.^{Reference Le, Lai and Sun31} The plan by the Vietnamese Government to keep infections low, with an early and intense lockdown, appeared to also be beneficial for the mental health of the general population.

A decrease in personality-related admissions

Within the spectrum of personality disorders, we can expect individuals to react differently to the pressure of lockdown. For example, patients with borderline or histrionic personality disorders have a strong need for emotional and physical proximity with others.^{Reference Preti, Di Pierro, Fanti, Madeddu and Calati32} Therefore, we would expect lockdown to trigger suffering secondary to abandonment, rejection sensitivity and paranoid preoccupations.^{Reference Preti, Di Pierro, Fanti, Madeddu and Calati32} It may also intensify interpersonal conflicts, with a misinterpretation of distance as disinterest.^{Reference Preti, Di Pierro, Fanti, Madeddu and Calati32} Following this, it would be expected that those with pre-existing borderline/histrionic personality disorders would present more frequently to psychiatric services during lockdown. However, data for March to May suggest that admissions were lower.

In comparison, narcissistic and antisocial personality disorders may struggle with lockdown in other ways, by potentially lacking motivation to follow new guidelines, and being at risk of grandiose self-view with a sense of exemption.^{Reference Preti, Di Pierro, Fanti, Madeddu and Calati32} With a disregard for the rules, this subgroup of patients could be at higher risk of exposing themselves and subsequently contracting COVID-19.

Cluster C personality traits, on the other hand, are individuals who have anxious feelings. Potentially fearing contagion during a pandemic, we would expect these patients to have a higher adherence to lockdown regulations, to avoid exposure to the virus.^{Reference Preti, Di Pierro, Fanti, Madeddu and Calati32} This may provide some support for our initial admissions data at the start of the pandemic.

Reduction in admissions via the crisis team

Across the board, admissions via the crisis team accounted for the largest proportion of admissions for men and women in 2019 and 2020. An admission via the crisis team is deemed an emergency admission. However, between March and August 2020, the admissions were reduced consistently compared with the corresponding months in 2019. There could be multiple reasons for this.

A reduction in face-to-face reviews in the community could have resulted in more patients presenting to hospital emergency departments. This would still result in an emergency admission, but by ‘other’ means.

Another difference to crisis team admissions was the change to the consent form for informal admissions. During lockdown, the KMPT consent form for informal admissions was updated to include an agreement by patients to stay in their room until their COVID-19 swab results were negative. In a drive to ensure COVID-19 infections were controlled in in-patient psychiatric hospitals, patients were tested on admission. If negative, they were able to use the communal spaces with the other patients. Unfortunately, at the start of lockdown, this result of a COVID-19 swab could take up to 72 h. This addition to the consent form may have influenced a patient's decision on whether to consent to an informal admission, instead maybe favouring the option to continue with community treatment in their own homes.

Conversely, the findings could be confounded by the introduction of the new admissions pathway by KMPT in early 2020. This pathway allows patients to be admitted from emergency departments without involving the crisis team, and so 2020 would inevitably have a reduction in crisis team–related admissions compared with 2019, despite the pandemic. To understand the effect of this new pathway, we would have to review the proportion of admissions in 2021, to see if this reduction is sustained.

In conclusion, with the percentage of male and female admissions being static, our initial hypothesis of lockdown having a more detrimental effect on men has been disproved. However, admissions data has allowed us to look deeper into different aspects of our psychiatric service, with the hope that services can become more robust to unprecedented events.

Unfortunately, because diagnosis was confirmed on discharge, we were only able to compare the first 3 months of lockdown. To presume that the same trends would continue through lockdown is unfounded. Following on from this data-set, we would be interested to see how the latter months of COVID-19 restrictions and subsequent lockdowns affect the psychiatric admissions. With time and easing of restrictions, there is a hope that patients will no longer fear interacting with health services. This could cause a surge in contact. However, this would be welcomed as patients would receive the care they need.

KMPT only covers the county of Kent. COVID-19 cases throughout the country have differed in rates. It will be interesting to see if areas with higher cases and deaths from COVID-19 have seen differing trends in their psychiatric admissions.

The end to the COVID-19 pandemic is still hard to predict. Even more difficult is the long-term prediction of its sequelae. Looking to the future, it is essential that psychiatric services remain open and are adaptable, and that patients have access to care, even during the most difficult of circumstances.