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      Forty Percent Reduction in Referrals to Psychiatric Services during the COVID-19 Pandemic

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          Abstract

          Dear Editor, In a recent issue of Psychotherapy and Psychosomatics, Wright and Caudill [1] advocate for remote delivery of psychiatric treatment during the COVID-19 pandemic. While remote delivery of treatment indeed has an enormous potential in psychiatry − especially in times of crisis [2, 3, 4] − a prerequisite for its use is that individuals with mental illness in need of specialized treatment actually get in contact with the psychiatric services in the first place. Recently, as part of a quality improvement project that aims at optimizing the treatment of mental disorders during the COVID-19 pandemic, we obtained data on all referrals to the psychiatric services of the Central Denmark Region (catchment area of approximately 1.3 million individuals) in the period from week 9–18 in 2019 and 2020, respectively (the Danish Prime Minister announced nationwide lockdown of schools, kindergartens, restaurants, and bars on Wednesday, March 11, 2020 [week 11]). Notably, we found that the number of referrals from week 12–16 in 2020 (n = 1,471) was 40% lower than for the corresponding weeks in 2019 (n = 2,465). For comparison, there were 19% more referrals in weeks 9 and 10 (preceding lockdown) in 2020 (n = 1,224) compared to 2019 (n = 1,032). In weeks 17 and 18 in 2020 (gradual lift of lockdown), the number of referrals (n = 868) was approaching that of the same weeks in 2019 (n = 922). There are essentially two potential explanations for the observed 40% reduction in referrals to the psychiatric services (which was seen across referral diagnoses, age groups, and for both males and females), namely (1) that the level of mental illness in the Danish population has decreased during the COVID-19 pandemic, or (2) that individuals in need of specialized treatment are not referred to the psychiatric services. While the first explanation seems highly unlikely given reports of reduced psychological well-being and increased psychological distress from a number of countries affected by the COVID-19 pandemic (including Denmark) [5, 6, 7, 8, 9], the latter seems highly probable. In Denmark, the primary referrers to specialist psychiatric treatment are the general practitioners. Our findings are consistent with concerns raised by the Danish General Practitioner's Association regarding an alarming reduction (approximately 40%) in the number of consultations during the COVID-19 pandemic (the general practitioners remained open during the entire lockdown period) − a reduction, which is probably driven by fear of contracting the coronavirus and/or by the assumption that general practitioners are too busy handling COVID-19 to attend to other things (which is not the case) [10]. Thus, the most likely explanation for the reduced number of referrals seems to be that those in need of specialized psychiatric treatment have not consulted their general practitioner, who consequently has not been able to refer these patients to the psychiatric services. The consequence of the observed “under-referral” is most likely that the condition of the individuals who were in need of specialized psychiatric treatment during the COVID-19 pandemic, but not referred to the psychiatric services, will have deteriorated and may be more difficult to treat once/if these individuals eventually get referred. This is unfortunate for obvious reasons and suggests that in the case of future pandemics, the authorities should more actively inform citizens of the fact that the health services (including general practitioners and psychiatric services) remain “open for business,” underline the safety measures that are being taken to minimize risks of contamination at the general practitioner clinics and at hospitals, and increase awareness regarding the possibilities for using telemedicine. Disclosure Statement The authors have no conflicts of interest to declare. Funding Sources This project was supported by an unconditional grant from the Novo Nordisk Foundation (Grant No.: NNF20SA0062874). Author Contributions All authors contributed to the design of this project. B.N. extracted and managed the data, which was assessed and interpreted by all authors. The manuscript was drafted by P.K. and S.D.Ø. and revised by B.N. The final version of the manuscript was approved by all authors prior to submission.

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          The depressive state of Denmark during the COVID-19 pandemic

          Introduction The ongoing COVID-19 pandemic (World Health Organization (WHO), 2020) is likely to have negative health consequences beyond those caused by the virus per se. As outlined in the recent paper by Druss (2020), a medical field likely to experience significant consequences of the pandemic and its accompanying societal changes is that of psychiatry. Indeed, there are studies suggesting that there may be a general worsening of mental health in the populations affected by the pandemic. In a recent survey from China, 54% of the respondents rated the COVID-19 outbreak to have a moderate or severe negative psychological impact (Wang et al., 2020). A similar tendency was seen in a survey conducted in the USA by the American Psychiatric Association (2020). However – in both cases – there were no prior survey data targeting the same population available to allow for a benchmark comparison. Therefore, the aim of the present study was to measure the level of psychological well-being in Denmark during the COVID-19 pandemic and to compare it to prior Danish data obtained with the same measure. Methods We commissioned the survey agency ‘Epinion’ to conduct an online survey [the COVID-19 Consequences Denmark Panel Survey 2020 (CCDPS 2020)], which included the five-item WHO-5 well-being scale (Topp et al., 2015) – a widely used and psychometrically valid measure of psychological well-being experienced over the past 2 weeks. The WHO-5 score ranges from 0 (minimum well-being) to 100 (maximum well-being). The survey also contained six questions regarding the experienced level of anxiety/depression over the past 2 weeks reported on a scale from 0 (not present) to 10 (present to an extreme degree). The survey was fielded from March 31 to April 6, 2020 and was completed by 2458 respondents. After weighting (applied in all analyses), the sample is representative of the population on key demographic and political variables (gender, age, education, region and party choice in the last election). We compared two properties of the WHO-5 well-being scale from the CCDPS 2020 with those from a previous survey, namely the Danish Mental Health and Well-Being Survey 2016 (DMHWBS 2016 – see the Supplementary Material for a description) (Nielsen et al., 2017), the WHO-5 mean score (two-sample t-test, one-sided p-value) and the proportion of individuals who had WHO-5 scores <50, for whom assessment for depression is recommended when the WHO-5 is used as a screening tool by general practitioners (two-sample test of proportions, one-sided p-value) (Topp et al., 2015). Finally, the relationship between the reported symptom levels of anxiety/depression and the WHO-5 scores from the CCDPS 2020 was characterised by Spearman’s correlation coefficients. Based on the known gender differences in the prevalence of anxiety/depression, we also conducted analyses stratified by gender. Results The mean age of respondents in the CCDPS 2020 was 49.1 years and 51% were females. The mean WHO-5 score was 62.0 for the total sample, 64.5 for males and 59.7 for females. The corresponding mean scores from the DMHWBS 2016 were significantly higher (64.3, p < 0.001; 65.8, p = 0.035; and 63.0, p < 0.001, respectively). Fig. 1 shows the distribution of WHO-5 scores by gender for the two surveys. The proportion of respondents from the CCDPS 2020 with WHO-5 scores <50 was significantly higher than for the DMHWBS 2016 survey for the total sample (25.4% vs. 22.5%, p < 0.001) and for females (28.8% vs. 24.6%, p = 0.005), but not for males (21.8% vs. 20.0%, p = 0.110). We found quite strong negative correlations between the reported levels of depression/anxiety and the WHO-5 scores (Table 1). Fig. 1. Histogram showing the distribution of WHO-5 scores stratified by gender. (A) The COVID-19 Consequences Denmark Panel Survey 2020 (n = 2458). (B) The Danish Mental Health and Well-Being Survey 2016 (n = 3501). Table 1. Spearman correlation coefficients for the association between six self-reported symptoms of anxiety and depression (past 2 weeks) and the WHO-5 scores in the COVID-19 Consequences Denmark Panel Survey 2020 Overall Females Males Worry −0.366 −0.385 −0.317 Nervousness −0.525 −0.552 −0.472 Anxiety −0.461 −0.464 −0.429 Depressed mood −0.652 −0.657 −0.628 Hopelessness −0.565 −0.575 −0.529 Guilt −0.319 −0.314 −0.312 Discussion While we cannot rule out alternative explanations, the results of this study suggest that the psychological well-being of the general Danish population is affected negatively by the COVID-19 pandemic – and more so for females than for males. This resonates well with results from surveys conducted in other countries(American Psychiatric Association, 2020; Wang et al., 2020; ) and will likely translate into increased demands for psychiatric treatment in the wake and aftermath of the pandemic.
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            Remote Treatment Delivery in Response to the COVID-19 Pandemic

             Jesse H. Wright (corresponding) ,  Robert Caudill (2020)
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              The psychological distress and coping styles in the early stages of the 2019 coronavirus disease (COVID-19) epidemic in the general mainland Chinese population: A web-based survey

              As the epidemic outbreak of 2019 coronavirus disease (COVID-19), general population may experience psychological distress. Evidence has suggested that negative coping styles may be related to subsequent mental illness. Therefore, we investigate the general population’s psychological distress and coping styles in the early stages of the COVID-19 outbreak. A cross-sectional battery of surveys was conducted from February 1–4, 2020. The Kessler 6 psychological distress scale, the simplified coping style questionnaire and a general information questionnaire were administered on-line to a convenience sample of 1599 in China. A multiple linear regression analysis was performed to identify the influence factors of psychological distress. General population’s psychological distress were significant differences based on age, marriage, epidemic contact characteristics, concern with media reports, and perceived impacts of the epidemic outbreak (all p <0.001) except gender (p = 0.316). The population with younger age (F = 102.04), unmarried (t = 15.28), with history of visiting Wuhan in the past month (t = -40.86), with history of epidemics occurring in the community (t = -10.25), more concern with media reports (F = 21.84), perceived more impacts of the epidemic outbreak (changes over living situations, F = 331.71; emotional control, F = 1863.07; epidemic-related dreams, F = 1642.78) and negative coping style (t = 37.41) had higher level of psychological distress. Multivariate analysis found that marriage, epidemic contact characteristics, perceived impacts of the epidemic and coping style were the influence factors of psychological distress (all p <0.001). Epidemic of COVID-19 caused high level of psychological distress. The general mainland Chinese population with unmarried, history of visiting Wuhan in the past month, perceived more impacts of the epidemic and negative coping style had higher level of psychological distress in the early stages of COVID-19 epidemic. Psychological interventions should be implemented early, especially for those general population with such characteristics.
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                Author and article information

                Journal
                Psychother Psychosom
                Psychother Psychosom
                PPS
                Psychotherapy and Psychosomatics
                S. Karger AG (Allschwilerstrasse 10, P.O. Box · Postfach · Case postale, CH–4009, Basel, Switzerland · Schweiz · Suisse, Phone: +41 61 306 11 11, Fax: +41 61 306 12 34, karger@karger.com )
                0033-3190
                1423-0348
                26 June 2020
                : 1-2
                Affiliations
                aPsychosis Research Unit, Aarhus University Hospital − Psychiatry, Aarhus, Denmark
                bDepartment of Clinical Medicine, Aarhus University, Aarhus, Denmark
                cDepartment of Affective Disorders, Aarhus University Hospital − Psychiatry, Aarhus, Denmark
                Author notes
                *Søren Dinesen Østergaard, Department of Affective Disorders, Aarhus University Hospital − Psychiatry, Palle Juul-Jensens Boulevard 175, DK–8200 Aarhus N (Denmark), soeoes@ 123456rm.dk
                Article
                pps-0001
                10.1159/000509575
                7360509
                32594089
                Copyright © 2020 by S. Karger AG, Basel

                This article is made available via the PMC Open Access Subset for unrestricted re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the COVID-19 pandemic or until permissions are revoked in writing. Upon expiration of these permissions, PMC is granted a perpetual license to make this article available via PMC and Europe PMC, consistent with existing copyright protections.

                Page count
                References: 10, Pages: 2
                Categories
                Letter to the Editor

                Clinical Psychology & Psychiatry

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