Comparison of Mental Health Visits at a Military Treatment Facility Emergency Department Pre- and Post-COVID-19 Pandemic

ABSTRACT

Introduction

There is a paucity of quantitative research regarding the effect of coronavirus 2019 (COVID-19) on Emergency Department (ED) visits in the United States, and specifically mental health–related ED visits. The small existing body of research describes an overall decline in ED visits worldwide; however, there are anecdotal reports that psychiatric complaints to the ED have increased during the pandemic. The primary objective of this study was to describe the volume of mental health ED visits at a single ED during the COVID-19 pandemic compared to previous years.

Materials and Methods

This was a single-center, retrospective chart review of adult patients evaluated in the ED at an academic military medical facility from March to December of 2017-2020 for mental health. The electronic medical record was queried for mental health International Classification of Diseases, 10th Revision diagnosis codes. Demographic data including age, gender, disposition, diagnosis, and beneficiary status were collected, and Pearson Chi-Square was used to assess for statistical significance between years.

Results

There was a total of 1,486 mental health ED visits from March to December 2020, compared to an average of 1,668 visits from March to December 2017-2019. Statistically significant (P < 0.05) differences, between 2020 and the prior 3 years combined, were identified in the categories of age, disposition, beneficiary status, and diagnosis. In 2020, there was a lower proportion of visits for patients aged ≥60 (1.2%) than in 2017-2019 (2.5%). Active-duty patients comprised a higher proportion of mental health visits in 2020 (82.4%) versus 2017-2019 (77%). Proportionately fewer patients were admitted in 2020 (25.2%) versus 2017-2019 (29.2%). Adjustment disorders made up 19.0% of visits in 2020 versus 23.2% in 2017-2019, and suicidal ideation and intentional self-inflicted injury comprised 43.3% in 2020 compared with 40.4% in 2017-2019.

Conclusion

There was a significant decline in ED visits for patients over the age of 60 but a significant increase in visits for active-duty patients. Fewer patients were admitted compared to previous years. There was a significant increase in patients diagnosed with suicidal ideation and intentional self-inflicted injury in 2020 compared to previous years. Alarmingly, this study shows increased rates of self-harm and suicidal ideation. Further study is needed to determine why these effects were seen and if there is a higher risk for suicide attempt or completion in these populations. These results indicate that military leadership and the military health system is failing to adequately support and protect service members and their families during these uniquely stressful times. High-level attention to this issue by military leadership is required; the readiness and safety of the nation’s fighting force is at stake.

INTRODUCTION

In December 2019, the first case of the novel coronavirus 2019 (COVID-19) was diagnosed. Nations responded by taking unprecedented actions to mitigate the spread. The United States implemented physical distancing, stay-at-home orders, and the shutdown of gyms, restaurants, parks, beaches, and places of worship. This presented numerous psychological stressors including complete disruption in patterns of daily life, loss of freedom of mobility, economic difficulties, and fear of infection. Quarantine measures curtailed common coping mechanisms for stress, anxiety, and depression such as regular exercise, socialization, and community.¹ A review on the psychologic impact of quarantine has shown multiple negative psychological impacts including confusion and anger in addition to stressors of longer quarantine duration such as infection fears, frustration, and boredom.² Studies found increased rates of anxiety and depression associated with the COVID-19 pandemic.^3–5

Early studies sought to determine the impact of COVID-19 on the utilization of emergency department (ED) services. Multiple global studies show decreased overall visits with concomitant decrease in the number of mental health (MH)–related visits compared with pre-pandemic years. This pattern was found in both pediatric and adult literature.^6–10 The United States exhibited similar trends, and early in the pandemic following the US declaration of the COVID-19 pandemic as a national emergency on March 13, 2020, the number of ED visits decreased 42% compared with the same period in 2019.^11,12 Some studies found an overall decrease in the number of ED visits as well as MH-related visits but with an increase in the proportion of MH-related visits^.13,14

Active-duty military members faced unique stressors such as mandatory restriction of movement (ROM), which in certain circumstances meant confinement to a barracks room, and incongruent military and civilian restrictions. While access to health care may affect rates of presentation to civilian EDs, this was expected to be a minimal contributing factor in this population due to universal access to care for military members and their beneficiaries. An improved understanding of the impact of the COVID-19 pandemic on the demand for ED and MH services may advise logistical and resource planning for the military population.

METHODS

The primary objective of this study was to describe the volume and characteristics of MH ED visits at a military ED during the COVID-19 pandemic compared to previous years. This study was conducted at Navy Medicine Readiness and Training Command San Diego (NMRTC SD), a tertiary care military academic medical facility in San Diego, California. The study was approved as exempt human subjects’ research by the NMRTC Institutional Review Board.

This was a single-center, retrospective chart review of adult patients with MH diagnoses upon discharge or admission from the ED. Data from March to December 2017-2019 was compared with those from March to December 2020. Three years of admission data prior to the start of the COVID-19 pandemic were chosen to control for fluctuations in visit numbers that could occur in any one year. The electronic medical record (EMR) in place at the time limited data acquisition prior to 2017. Data could not be collected past December of 2020 because of changes to the EMR at the hospital. In March 2020, California issued the first “stay-at-home” order, heralding the most stringent restrictions during the pandemic. In June 2020, Southern California military commands placed additional restrictions upon service members beyond the state-wide orders already in place. March through December was selected to examine the time period when restrictions placed on service members were most significant.

MH diagnoses in the ED were queried from the EMR (Essentris) by the International Classification of Diseases (ICD)-10 code. Diagnosis codes included adjustment disorders, anxiety disorders, schizophrenia and other psychotic disorders, suicide and intentional self-inflicted injury, and mood disorders. The unit of analysis was patient visit, meaning repeat patients were not excluded. Data including age, gender, MH diagnosis, disposition, and beneficiary status were collected for each visit. Pearson chi-square analyses were performed to assess differences in variables of interest before and during the COVID-19 pandemic. Statistical significance was assessed at P < 0.05. All analyses were performed in SPSS Statistics for Windows, version 23 (IBM Corp., Amonk, NY, USA).

RESULTS

From March to December 2017, there was a total of 1,592 MH ED visits. Over the same time period in 2018, there was a total of 1,643, and in 2019, there was a total of 1,769 visits. From 2017 to 2019, this yields an average of 1,668 MH ED visits. Comparatively, there was a total of 1,486 MH ED visits from March to December 2020. Between 2020 and the prior 3 years, statistically significant (P < 0.05) differences were identified in the categories of age, beneficiary status, and diagnoses. In 2020, a lower proportion of MH visits was for patients aged ≥60 (1.2%) than in 2017-2019 (2.5%). Active-duty patients comprised a higher proportion of MH visits in 2020 (82.4%) versus 2017-2019 (77%). Proportionately fewer patients were admitted (as opposed to discharged) in 2020 (25.2%) versus 2017-2019 (29.2%). Adjustment disorders made up 19.0% of MH visits in 2020 versus 23.2% in 2017-2019, and suicidal ideation and intentional self-inflicted injury comprised 43.3% in 2020 compared with 40.4% in 2017-2019 (see Table I).

DISCUSSION

The overall number of MH ED visits from March to December 2020 declined compared to previous years. This corroborates previous literature also showing a downtrend in ED visits during the 2020 pandemic year. There were 182 less MH-related ED visits in 2020 compared to the average of March-December 2017-2019. Older patients, greater than age 60, were specifically less likely to seek emergency care for MH-related complaints. Their proportion of MH ED visits declined to 1.2% in 2020 from 2.5% average in previous years. In the early period of the pandemic, elderly patients were felt to be at increased risk for severe COVID-19 and were strongly advised to stay at home. This recommendation could have contributed to a hesitancy to present to the ED for other complaints, such as MH emergencies.

Fewer patients received inpatient MH care in 2020 compared to the average of previous years, declining from 29.2% to 25.2% of visits ending in inpatient admission. Decrease in inpatient psychiatric bed availability was seen during the pandemic, related to staffing shortages and requirement for physical distancing on inpatient wards. This could have contributed to more stringent criteria for inpatient psychiatric admission, hesitancy to pursue admission, or increased frequency of disposition of MH patients directly from the ED. Additionally, the overall decline of MH visits to the ED could inform the downtrend in MH-related admissions.

In contrast to the overall decline in visits, active-duty patients sought ED MH care in greater proportions in 2020 compared to prior years, increasing the percentage of visits from 77% in 2017-2019 to 82.4% in 2020. Active-duty patients were uniquely affected during the COVID-19 pandemic. They were subject to mandatory ROM involving prolonged isolation in hotel rooms or barracks. Highly restrictive orders were placed by military commands, limiting recreation and leisure activity above and beyond local government restrictions, in addition to the ongoing stressors of deployment, separation from loved ones, and high operational tempo. Together, these burdens fell uniquely on active-duty service members and could have contributed to increased need for emergency MH care.

Alarmingly, there was an increase in visits due to suicidal ideation and intentional self-inflicted injuries, from 40.4% of visits to 43.3% compared to prior years. This suggests that not only is the military patient population suffering from higher frequency of MH-related distress during the pandemic year but that this may be leading to higher rates of suicidal ideation and self-harm. This results in emotional damage for patients and their family members and threatens the operational readiness of the fighting force. It is imperative for command leaders to consider the potential downstream psychiatric effects when implementing highly restrictive COVID-19 protocols. If such protocols are the mission required, military medicine must be prepared to provide comprehensive and readily available MH support resources and emergency care to the fighting force and their families.

This study is limited by its retrospective design and collection of data from a single military ED. There are several notable differences in emergency care in the military health system that limit generalizability to the civilian community. Emergency care in the military health system is available at no cost to patients, while cost represents a significant roadblock to accessing emergency care in civilian settings. Additionally, active-duty patients requiring inpatient psychiatric care are typically admitted at the military facility; however, dependents must be disengaged to civilian care facilities. This could potentially affect the decision for family members to seek care at our military facility versus seeking care directly from a civilian center. Finally, EMR in place at the time of data collection allowed the option of manually entering a diagnosis or selecting a diagnosis from a drop-down menu of ICD codes. The records in which a diagnosis was manually entered are not able to be queried from the EMR and could not be included in this study. Consequently, this study is likely underestimating the true volume of MH visits.

CONCLUSIONS

There was a significant decline in ED visits for patients over the age of 60 but a significant increase in visits for active-duty patients. Fewer patients were admitted compared to previous years. There was a significant increase in patients diagnosed with suicidal ideation and intentional self-inflicted injury in 2020 compared to previous years.

The COVID-19 pandemic and associated restrictions have negatively affected MH worldwide. Active-duty military patients were uniquely impacted by stringent restrictions put in place by regional government and military commands in addition to existing stressors of high operational tempo and separation from loved ones. Alarmingly, this study shows increased rates of MH ED visits from active-duty service members and increased rates of self-harm and suicidal ideation. This suggests that the current state of psychological health in the military community is poor and warrants immediate attention and intervention. Further study is needed to determine if there is a higher risk for suicide attempt or completion. These results indicate that military leadership and the military health system is failing to adequately support and protect service members and their families during these uniquely stressful times. Military leaders must weigh the decision to implement restrictions cautiously as negative MH effects are likely to be seen. EDs and health-care staff should expect increased utilization of emergency MH care. Attention to this issue by military leadership is required now, before another large-scale health event, to inform medical best practices and to identify necessary areas of improvement. Medical commands should assess the system of psychiatric care, identify points of failure, and advocate aggressively for change. This may require high-level attention to allocation of funding, design of military emergency room layouts to accommodate MH patients, evaluation of emergency care staffing models, and other changes to the current system of military medical care operations to optimize emergency MH care. The readiness and safety of the nation’s fighting force is at stake.

FUNDING

None declared.

CONFLICT OF INTEREST STATEMENT

None declared.

REFERENCES

Author notes