Response to: What’s the psychiatrist’s role in the COVID-19 outbreak?

To the Editor

Singh (2020) highlighted the important role of psychiatrists in supporting individuals susceptible to mental illness during the COVID-19 pandemic. We report trends in public service response to the first lockdown in Melbourne, Australia, to further inform the role of psychiatrists during COVID-19.

A retrospective audit was conducted on all emergency contacts to the Mental Health Services (EMH) at St. Vincent’s Hospital over a 6-month period straddling the first city-wide COVID-19 lockdown. Reasons for contact were summarised for presentations 3 months prior (B-CV) and 3 months post (P-CV) COVID-19 lockdown (23 March 2020) in Melbourne, Australia.

We found no evidence of an overall change in contact frequency to EMH in the 3 months after COVID-19 lockdown (N = 1085 B-CV vs N = 989 P-CV). There was a striking increase in the proportion of people making contact because of anxiety (9.2% B-CV vs 14.4% P-CV, p < 0.001). While individuals with anxiety disorders are more likely to self-isolate, they also report higher rates of COVID-related distress than those with no history of mental illness (Asmundson et al., 2020). Interestingly, there was a decrease in depression (6.1% B-CV vs 3.6% P-CV, p = 0.011), psychosis (10% B-CV vs 8.1% P-CV, p = 0.034) and borderline personality disorder (BPD)-related (8.1% B-CV vs 5.1% P-CV, p = 0.006) contacts to EMH services post COVID-19 lockdown. Continued observation is important to see if these changes are reflected in our catchment area as time goes on, particularly in the context of repeated lockdowns, and without a definite availability of a vaccine. The reduction in presentations of patients with primary concerns of psychosis points to a potential problem associated with underservicing. In particular, people with schizophrenia are more likely to present with relapses due to compromise in follow-up in the community, reduced availability of regular medications and medication compliance issues (Chatterjee et al., 2020). Increased reliance on telehealth may be a particular barrier for people with severe mental illness, which needs to be taken into account by psychiatrists. The demonstrated reduction in BPD presentations may be due to people with BPD being less inclined to present to EMH due to fear of contracting COVID-19 or concerns that emergency departments would struggle for resources. This is of concern, as it is likely this population are experiencing distress and carry a high risk of suicide and self-harm without access to effective emergency services.

Overall, our results suggest that certain vulnerable individuals, notably those with psychosis and BPD, are slipping through the cracks in terms of accessing care. It will be important for psychiatrists to monitor how further lockdowns impact on mental health presentations, so that appropriate interventions can be put in place.