key: cord-0753457-2oa3zmg3
authors: Seiler, Natalie; Ng, Matthew; Dawud, Midya; Das, Subhash; Ooi, Shu-Haur; Waterdrinker, Astrid
title: Demographic and clinical factors associated with psychiatric inpatient admissions during the COVID-19 pandemic
date: 2022-04-03
journal: Australas Psychiatry
DOI: 10.1177/10398562211052903
sha: 99188b135cdf7bdaadcc99a53e803ca0562d1542
doc_id: 753457
cord_uid: 2oa3zmg3

OBJECTIVE: The COVID-19 pandemic may cause a major mental health impact. We aimed to identify demographic or clinical factors associated with psychiatric admissions where COVID-19 was attributed to contribute to mental state, compared to admissions which did not. METHODS: A retrospective cohort study was undertaken of inpatients admitted to Northern Psychiatric Unit 1, Northern Hospital in Melbourne, Victoria, Australia during 27/02/2020 to 08/07/2020. Data were extracted for participants who identified COVID-19 as a stressor compared to participants who did not. Fisher’s exact test and Mann-Whitley rank sum test were used. RESULTS: Thirty six of 242 inpatients reported the COVID-19 pandemic contributed to mental ill health and subsequent admission. Reasons given included social isolation, generalized distress about the pandemic, barriers to support services, disruption to daily routine, impact on employment, media coverage, re-traumatization, cancelled ECT sessions, loss of loved ones, and increased drug use during the lockdown. Chronic medical conditions or psychiatric multimorbidity were positively associated and smoking status was negatively associated with reporting the COVID-19 pandemic as a contributor to mental ill health. CONCLUSION: Screening and identifying vulnerable populations during and after the global disaster is vital for timely and appropriate interventions to reduce the impact of the pandemic worldwide.

D espite higher rates of mental illness than the general population, 1 people with an intellectual disability (ID) experience multiple barriers to accessing appropriately equipped mental health services. 2 Generic mental health services are often illprepared for the complex presentations and multiple comorbidities frequently associated with ID, and lack knowledge of how to make necessary adaptations to practice. 3 Recent recommendations have called for the implementation of specialist ID mental health (IDMH) services to support mainstream services. [4] [5] [6] However, there is a lack of evidence regarding the optimal design of mental health services to meet the needs of people with ID. 7 To address this, our team undertook a scoping study of the need for an adult tertiary IDMH service in New South Wales (NSW). We have previously described findings from a survey of family members and support persons of people with ID. 8 Here we report on another phase of the scoping study, which utilised an online Delphi consultation with IDMH experts to identify and reach consensus on the priorities and resource requirements of a statewide tertiary IDMH service.

IDMH experts were identified through the research team's clinical networks, peak bodies in ID health and advocacy, and the snowballing technique. Eligible participants were required to be currently practising in Expert consensus on the operation of an adult tertiary intellectual disability mental health service in New South Wales, Australia Psychiatric Unit 1 of Northern Hospital in Melbourne, Victoria, Australia. Admissions between 27/02/2020 (the date the COVID-19 pandemic was declared by the Australian Prime Minister 5 ) to 08/07/2020 (the date before Melbourne was placed into a second lockdown 6 ) were included. Inclusion criteria included explicit documentation that reported patient/collateral history which clearly identified COVID-19 as a stressor which had precipitated or contributed to poor mental state, with subsequent inpatient admission. Exclusion criteria included documentation of COVID-19 that did not directly identify COVID-19 as a stressor, such as incorporation of COVID-19 into delusions/hallucinations.

A trained clinician reviewed registration forms, admission note, and discharge summary for each file to assess whether COVID-19 was attributed to mental state as per documentation. Demographic and clinical data were extracted and recorded for participants who identified COVID-19 as a stressor compared to participants who did not.

Demographic data included age, sex, Aboriginal or Torres Strait Islander status, country of birth, English speaking status, relationship status, living circumstances, education and employment, and presence of dependents. Clinical data included primary diagnosis on discharge, medical comorbidity, psychiatric multimorbidity, trauma history, substance use, family or patient history of mental illness, self-harm or self-harm ideation, and suicidal ideation or recent suicide attempt.

Fisher's exact test and Mann-Whitley rank sum test were used to identify demographic or clinical factors associated with inpatient admissions where COVID-19 was identified as a contributor to mental state as per documentation. Significance level was set at p < 0.05. Minitab 17 was used for statistical analysis. 7

The study was approved by Northern Health (ALR 104.2020) and Melbourne Health (QA2020203).

Two hundred and forty-three adult psychiatric inpatients were admitted to Northern Psychiatric Unit 1, Northern Hospital between 27/02/20 to 08/07/20. Of these, one duplicate file was excluded. Thirty-six patients had documentation indicating COVID-19 or COVID-19 restrictions contributed to mental ill health and subsequent psychiatric admission. The average age was 38.1 years, and most were female (n = 138, 57.0%), born in Australia (n = 179, 74.0%), neither Aboriginal nor Torres Strait Islander (n = 225, 93.0%), and spoke English (n = 236, 97.5%) ( Table 1) . Most were single (n = 179, 74.0%), unemployed (n = 200, 82.6%), had not completed secondary education (n = 88, 36.4%) and lived with others (n = 169, 69.8%) without dependents (n = 180, 74.4%) ( Table 1) .

The most common primary diagnosis was schizophrenia (n = 68, 28%) ( Table 2 ) and the most commonly used drug was tobacco (n = 85, 35.1%) ( Table 1) . Most participants had a psychiatric history (n = 220, 90.9%) and psychiatric multimorbidity (n = 124, 51.2%) while 29.3% (n = 71) had a known family history of mental illness, 39.3% (n = 95) had medical comorbidity and 27.7% (n = 67) had a documented trauma history (Table 1) . Suicidal ideation (n = 102, 42.1%), suicide attempt (n = 36, 14.9%), self-harm ideation (n = 51, 21.1%) and self-harm (n = 23, 9.5%) were present immediately before or during the admission in this population (Table 1) .

Having a comorbid medical condition/s (p = 0.003, OR = 3.293) or more than one mental disorder (p = 0.029, OR=1.602) were associated with reporting the COVID-19 pandemic as a contributor to mental state and subsequently psychiatric admission (Table 1) . Tobacco smoking was also significantly associated with mental state (p = 0.015, OR = 0.321) however other drug use was not ( Table 1 ). The majority of factors were not significantly associated with the COVID-19 pandemic being a contributor to mental ill health (Table 1) .

The most common reasons reported for the COVID-19 pandemic contributing to mental ill health were social isolation, primarily through loss of physical contact with family and friends, and generalized distress due to the impact and implications of the COVID-19 pandemic and restrictions ( Table 3 ). The latter included guilt about insufficiently adhering to restrictions, fear of catching or dying from COVID-19, and severe COVID-19 preoccupation resulting in anxiety. Barriers to support services included outreach visit cancellations, lack of face-to-face contact with mental health services, delays in moving to supported accommodation, and difficulty obtaining appointments for medication prescriptions. Disruption to routine and daily activities included anxiety around routine change and being unable to remain preoccupied, engage in fulfilling activities, or use previous coping strategies.

Participants also reported depressive symptoms from losing employment due to the COVID-19 crisis, resulting in 

In this cohort of 242 psychiatric inpatients, 36 participants reported the COVID-19 pandemic had contributed to their mental state and admission. Reasons given were consistent with previous speculation that social distancing and isolation during the pandemic may particularly affect people who experience mental health issues. 4, 8 The results also reflect previous findings that natural disasters may affect mental health through disrupted routine, increased media consumption, generalized distress and uncertainty about the disaster itself, 2 and reduced social interactions. 3 Furthermore, loss of routine, employment or schooling can lead to a wider loss of sense of purpose.

Having a comorbid medical condition or psychiatric multimorbidity were associated with reporting COVID-19 as contributing to mental ill health and psychiatric admission. Previous research has reported chronic medical conditions are associated with post-disaster mental illness 9 and medical multimorbidity during the COVID-19 pandemic was associated with isolation. 10 In this study, the negative correlation between smoking status and attributing COVID-19 as a stressor was difficult to interpret due to disproportionate sample representation between groups. Other studies have found that experiencing traumatic events during natural disasters has been linked to increased tobacco use. 11, 12 The association between having multiple psychiatric conditions and reporting COVID-19 as a stressor on mental health is an important finding. To the best of our knowledge, previous research has only focused on the association between increased physical multimorbidity and natural disaster. 13 This finding may add to current knowledge regarding vulnerability among people with severe mental illness in natural disasters 4 or suggest that psychiatric multimorbidity can occur in pandemic conditions.

Strengths of this study include analysis of multiple factors implicated in disaster medicine literature. Limitations include reliance on documentation integrity and lack of longitudinal assessment due to the retrospective cross-sectional study design. Our small sample size may have also impacted effect size and findings. However, this is the largest cohort of this type and the data have yielded valuable insights into an area of critical need.

Psychoeducation, coping strategies, peer support, and potentially psychotherapy or pharmacotherapy may be beneficial for at-risk populations and the general community during the COVID-19 pandemic. 2 Telehealth and clear communication from mental health services are key to meet the rising mental health challenge among people with severe mental illness or psychiatric multimorbidity. 2 Social media and technology may bridge social distancing, and clear information dissemination led by the government, healthcare professionals, and media are needed. Implementing routine and structure during restrictions may also be useful.

Screening and identifying populations at risk of mental health issues in response to the pandemic is vital. This may include screening for mental ill health when patients present for care of chronic medical conditions, such as through general practice, and screening for co-morbid psychiatric conditions among mental health presentations. This would support timely and appropriate interventions, which are essential for reducing the impact of COVID-19 and other natural disasters on mental health in the future. 

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None.

The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.

The authors received no financial support for the research, authorship, and/or publication of this article.

Natalie Seiler https://orcid.org/0000-0002-5728-1523