Emergency psychiatric service seeker referral pattern variations over the course of a pandemic

The coronavirus pandemic has led to significant changes in demand for emergency psychiatric services [[1], [2], [3], [4]]. In January 2020, the first case was detected in Singapore [5,6]. The government's initial strategies focused on tracking affected individuals and selectively executing quarantine orders to reduce transmission. However, as the number of untraceable cases grew, and as the knowledge about virology accrued, Singapore underwent a universal quarantine, locally known as the “circuit breaker” between April 7th and June 1st [7]. Only essential services remained operational, in the community and in healthcare institutions [8] while other services were transitioned to virtual platforms like teleconferencing [9]. Following this period, community transmission declined and services were allowed to resume restricted operations. New cases were mostly detected in repatriated individuals, and in foreign-worker dormitory residents, the population most affected by the pandemic [7]. While active cases continue to decline, some groups are now emerging as requiring psychiatric intervention, possibly due to the stressors of the pandemic. Below we present the way referrals to emergency psychiatric services in Singapore changed over the course of the pandemic.

Operational data traced service use variables, notably number of presentations and referral sources. These are common easily accessible operational metrics that might herald changes in service demand as a result of the easing of quarantine measures. The operational data spanned February 10th 2020 to September 20th 2020 (222 days) and included 11,689 individual visits to emergency services (a mean 52.6 SD11.5 cases per day). We used interrupted time series analyses (ITSA) techniques to split our timeline at the quarantine start and end dates.

Fig. 1 somewhere here.

Fig. 1.

Total number of cases over the pre and post quarantine periods. Quarantine stretched from April 7th to June 1st.

The timeline (Fig. 1) clearly demonstrates a significant decrease in attendance over the quarantine period. Table 1 of the e-supplement presents the ITSA outputs for the various categories of referral.

Our results demonstrate that the demand for emergency psychiatric services changes, yet ultimately returns to pre-quarantine levels. During the pre-quarantine period, Singapore imposed selective quarantine. Considering this measured approach to infection control, we have no reason to suspect changes in external referral patters over this period. However, our hospital did prepare for the quarantine by boosting its capacity to treat medical conditions internally. This reduced the need to refer inpatients elsewhere. This explains the significant but minor decline in the weeks preceding the April 7th quarantine (e-supplement). Uniformed agencies referred significantly fewer cases over the pre-quarantine period as well. We expected a drop across all referral sources as a result of the quarantine. However, we only saw significant drops in the uniformed service seekers. Notably, walk-ins and referrals from hospitals and community service providers (GP and polyclinics/surgeries) did not change. When quarantine was lifted, we expected a significant rise in referrals across all sectors. However, the most significant contributor to the post-quarantine increase in cases appears to be referrals from general hospitals. While we do not at the moment have diagnostic data to determine how the cases changed in terms of psychiatric needs, the sources of the cases are themselves very informative.

The increase in cases referred from other hospitals might indicate a strategic shift: they appear to send a greater proportion of their psychiatric cases to specialist services. However, we do not have the data to determine if this increase is due to an operational shift, or an increase in symptom intensity. The absence of a change in suspected suicide cases might suggest that the impact of the quarantine did not manifest in increased suicide or self-harm activities.

Our psychiatric emergency services saw an estimated 56 cases per day prior to the quarantine measures introduced on April 7th. These measures led to a significant decline in services seekers, dropping to an estimated 48 cases per day. The number of service seekers significantly increased to 55 cases per day following the easing of quarantine measures. Other locations have reported significant decreases in psychiatric emergency department attendance: in Northern Portugal attendance was approximately 36 cases per day in 2019, but fell to 17 as a result of the pandemic [3], in Cambridge, UK, cases per day fell from 342 to 242 [2], and in Yale-New-Haven, US, cases fell from 24 to 18 cases per day [4]. ED attendances in general across England have also fallen [10]. However, these early reports do not indicate how demand may rebound when quarantine measures are eased.

In conclusion, as the communities served by emergency psychiatric services move through phases of immuration over the course of the pandemic, service providers must be prepared for changes in demand. Further research into individual presentations is warranted to determine how the composition of our categories changed: Clinical impression suggests that interventions implemented to serve people over the course of quarantine targeted the typical pre-quarantine service seekers. Service seekers that emerged after the easing of quarantine measures probably have different needs related to socioeconomic-stressors.

Funding

This research required no funding.

Declaration of Competing Interest

Authors declare no financial or professional conflict of interest.

This research required no funding.

Appendix A. Supplementary data

Supplementary material

Data availability

The authors do not have permission to share data.