Did COVID-19 early lockdown actually lead to a higher rate of relapses in psychiatric patients?

Abstract

On February 21st 2020, the first case of COVID-19 pneumonia was diagnosed in Codogno Hospital, Italy. On March 11th the Italian government has taken strong national measures to avoid further spreading of the COVID-19 infection by closing schools, stopping industrial production and retail distribution and prohibiting all gathering activities by forcing people to stay in their homes. In order to continue to deliver care to patients with serious mental illness and to fit the ministerial provisions intended to mitigate the epidemic outcome, we reorganized our mental health services and clinical practice. All the staff was trained to constantly monitor the sudden onset of fever or acute respiratory symptoms between patients and health workers; an isolation room was kept for suspicious inpatients cases and the liaison-psychiatric services were available to meet the needs of the intensive care units. All the scheduled routine outpatient visits were switched to telephonic sessions with a similar duration of a face-to-face consultation, and in-person visits were warranted only for urgent situations or upon patients’ specific request after careful symptoms triage. Depression, anxiety and sleep disturbance symptoms were shown to be the most common and wide psychological conditions in the general population during the infectious outbreak (Qui et al., 2020; Wang et al., 2020; Wang et al., 2020; Xiao et al., 2020). Similarly, a worsening of psychiatric symptoms due to the COVID-19 outbreak was also expected in patients, with a greater risk of symptoms worsening or disease relapses triggered by the ongoing situation (Yao et al., 2020). To date, the observational data about the mental health burden of the COVID-19 outbreak on mentally ill people is limited to a survey proposed to 76 psychiatric Chinese patients to evaluate the intensity variation of a range of psychiatric symptoms. The authors observed a negative psychological impact on psychiatric patients during the COVID-19 epidemic (Hao et al., 2020). Unlike the expected, during an entire month of lockdown, we observed fewer requests for consultations, besides the difficulty of psychiatric territorial services and social services in delivering care. In April 2020, despite the possibility of telephone sessions, psychiatric consultations in our outpatient facilities dropped compared to April 2019 (494 vs. 884); similarly, hospitalizations in our acute psychiatric ward decreased (39 vs 47) as well as psychiatric consultations in the emergency department (67 vs 88). These data made us reflect on the impact of early lockdown on mentally ill patients as they did not seem to worsen or have a higher relapse rate than usual. Some variables might be responsible for these observations: the fear of contagion may have made patients more reluctant to go to the hospital, reducing the requests for urgent consultations for milder symptoms; healthcare professionals instead, may have found it difficult to discharge patients to other rehabilitation facilities or community structures thus slowing the normal turnover of patients. However, the ratio between psychiatric consultations in the emergency room and consequent hospitalizations remained constant (April 2020: 67/39, ratio: 1.71 vs. April 2019: 88/52, ratio: 1.69), showing unchanged rates of urgent clinical situations requiring hospitalization. A possible explanation is that many psychiatric patients might have experienced isolation, reduction of social interaction and home working better than general populations, benefitting from a reduction in demand for everyday duties. This could have led for example to a decrease of feelings of guilt and inadequacy in patients suffering from depressive disorders. Furthermore, the ban on social interactions and occasions has reduced both situations that cause anxiety for patients affected by panic, social anxiety and obsessive-compulsive disorders and precipitating events for patients with personality disorders and/or substance abuse, impulse-control diseases and bipolar disorders. However, it has to be considered that we have assumed the patients’ flows to the hospital as an index of disease relapses. In some cases, this may not be equivalent since other variables could have influenced their referral to the hospital. Moreover, it should be emphasized that our analysis is based on the observation of the events of a single month of lockdown: the effects on patients' mental health of the continuous restrictions, the burden of the uncertain future and the financial implications could take months to fully manifest. Therefore, we aim to continue to closely follow up mentally ill patients, to promote telematic initiatives to provide at-home assistance and to implement the strategies available to help psychiatric patients and the general population to cope with the consequences of the COVID outbreak. Authors’ contributions Giuseppe Maina, Gianluca Rosso and Elena Teobaldi collected and analyzed data and managed literature search. Gianluca Rosso wrote the draft. All authors contributed to and have approved the final manuscript. Declaration of Competing Interest The authors declare that they have no competing interests.