Changes in daily mental health service use and mortality at the commencement and lifting of COVID-19 'lockdown' policy in 10 UK sites: a regression discontinuity in time design

Ioannis Bakolis; Robert Stewart; David Baldwin; Jane Beenstock; Paul Bibby; Matthew Broadbent; Rudolf Cardinal; Shanquan Chen; Karthik Chinnasamy; Andrea Cipriani; Simon Douglas; Philip Horner; Caroline A Jackson; Ann John; Dan W Joyce; Sze Chim Lee; Jonathan Lewis; Andrew McIntosh; Neil Nixon; David Osborn; Peter Phiri; Shanaya Rathod; Tanya Smith; Rachel Sokal; Rob Waller; Sabine Landau

doi:10.1136/bmjopen-2021-049721

Changes in daily mental health service use and mortality at the commencement and lifting of COVID-19 'lockdown' policy in 10 UK sites: a regression discontinuity in time design

BMJ Open. 2021 May 26;11(5):e049721. doi: 10.1136/bmjopen-2021-049721.

Authors

Ioannis Bakolis^#¹, Robert Stewart^#^{2

3}, David Baldwin^{4

5}, Jane Beenstock⁶, Paul Bibby⁶, Matthew Broadbent⁷, Rudolf Cardinal^{8

9}, Shanquan Chen⁸, Karthik Chinnasamy¹⁰, Andrea Cipriani^{11

12}, Simon Douglas¹³, Philip Horner⁶, Caroline A Jackson¹⁴, Ann John¹⁵, Dan W Joyce¹⁶, Sze Chim Lee¹⁵, Jonathan Lewis¹⁷, Andrew McIntosh¹⁸, Neil Nixon^{19

20}, David Osborn²¹, Peter Phiri⁴, Shanaya Rathod⁴, Tanya Smith¹², Rachel Sokal²⁰, Rob Waller²², Sabine Landau¹

Affiliations

¹ Department of Biostatistics and Health Informatics, King's College London Institute of Psychiatry, Psychology and Neuroscience, London, UK.
² South London and Maudsley NHS Foundation Trust, London, UK r.stewart@iop.kcl.ac.uk.
³ Department of Psychological Medicine, King's College London Institute of Psychiatry, Psychology and Neuroscience, London, UK.
⁴ Southern Health NHS Foundation Trust, Southampton, UK.
⁵ Faculty of Medicine, University of Southampton, Southampton, UK.
⁶ Lancashire and South Cumbria NHS Foundation Trust, Preston, UK.
⁷ South London and Maudsley NHS Foundation Trust, London, UK.
⁸ Department of Psychiatry, School of Clinical Medicine, University of Cambridge, Cambridge, Cambridgeshire, UK.
⁹ Liaison Psychiatry Service, Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK.
¹⁰ Camden and Islington NHS Foundation Trust, London, UK.
¹¹ Department of Psychiatry, University of Oxford Medical Sciences Division, Oxford, Oxfordshire, UK.
¹² Oxford Health NHS Foundation Trust, Oxford, Oxfordshire, UK.
¹³ Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK.
¹⁴ Usher Institute of Population Health Sciences & Informatics, University of Edinburgh Division of Medical and Radiological Sciences, Edinburgh, UK.
¹⁵ Population Data Science, Swansea University Medical School, Swansea, UK.
¹⁶ Department of Psychiatry, University of Oxford, Oxford, UK.
¹⁷ Cambridgeshire and Peterborough NHS Foundation Trust, Fulbourn, Cambridgeshire, UK.
¹⁸ Division of Psychiatry, University of Edinburgh Division of Medical and Radiological Sciences, Edinburgh, UK.
¹⁹ Division of Psychiatry and Applied Psychology, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK.
²⁰ Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK.
²¹ Division of Psychiatry, University College London Faculty of Medical Sciences, London, UK.
²² Lothian Primary Care NHS Trust, Edinburgh, UK.

^# Contributed equally.

Abstract

Objectives: To investigate changes in daily mental health (MH) service use and mortality in response to the introduction and the lifting of the COVID-19 'lockdown' policy in Spring 2020.

Design: A regression discontinuity in time (RDiT) analysis of daily service-level activity.

Setting and participants: Mental healthcare data were extracted from 10 UK providers.

Outcome measures: Daily (weekly for one site) deaths from all causes, referrals and discharges, inpatient care (admissions, discharges, caseloads) and community services (face-to-face (f2f)/non-f2f contacts, caseloads): Adult, older adult and child/adolescent mental health; early intervention in psychosis; home treatment teams and liaison/Accident and Emergency (A&E). Data were extracted from 1 Jan 2019 to 31 May 2020 for all sites, supplemented to 31 July 2020 for four sites. Changes around the commencement and lifting of COVID-19 'lockdown' policy (23 March and 10 May, respectively) were estimated using a RDiT design with a difference-in-difference approach generating incidence rate ratios (IRRs), meta-analysed across sites.

Results: Pooled estimates for the lockdown transition showed increased daily deaths (IRR 2.31, 95% CI 1.86 to 2.87), reduced referrals (IRR 0.62, 95% CI 0.55 to 0.70) and reduced inpatient admissions (IRR 0.75, 95% CI 0.67 to 0.83) and caseloads (IRR 0.85, 95% CI 0.79 to 0.91) compared with the pre lockdown period. All community services saw shifts from f2f to non-f2f contacts, but varied in caseload changes. Lift of lockdown was associated with reduced deaths (IRR 0.42, 95% CI 0.27 to 0.66), increased referrals (IRR 1.36, 95% CI 1.15 to 1.60) and increased inpatient admissions (IRR 1.21, 95% CI 1.04 to 1.42) and caseloads (IRR 1.06, 95% CI 1.00 to 1.12) compared with the lockdown period. Site-wide activity, inpatient care and community services did not return to pre lockdown levels after lift of lockdown, while number of deaths did. Between-site heterogeneity most often indicated variation in size rather than direction of effect.

Conclusions: MH service delivery underwent sizeable changes during the first national lockdown, with as-yet unknown and unevaluated consequences.

Keywords: COVID-19; adult psychiatry; mental health; old age psychiatry; organisation of health services.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Adolescent
Aged
COVID-19*
Child
Communicable Disease Control
Humans
Mental Health Services*
Policy
SARS-CoV-2
United Kingdom / epidemiology

Abstract

Publication types

MeSH terms

Grants and funding