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

doi:10.1136/bmjopen-2021-049721

. 2021 May 26;11(5):e049721.

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

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.

PMID: 34039579
PMCID: PMC8159668
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

Ioannis Bakolis et al. BMJ Open. 2021.

. 2021 May 26;11(5):e049721.

doi: 10.1136/bmjopen-2021-049721.

Authors

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.

PMID: 34039579
PMCID: PMC8159668
DOI: 10.1136/bmjopen-2021-049721

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.

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Conflict of interest statement

Competing interests: RC consults for Campden Instruments Ltd. and receives royalties from Cambridge University Press, Cambridge Enterprise and Routledge. DB reports royalties from Wiley publishers. AC reports research funding from Angelini Pharma and personal fees from INCiPiT, CARIPLO Foundation and Angelini Pharma. AM reports research funding from The Sackler Trust and personal fees from Janssen and Illumina. PP reports research funding from Novo Nordisk and royalties from John Wiley & Sons. SR reports education support from Janssen, Otsuka and Lundbeck. RS reports research support from Janssen, GSK and Takeda and royalties from Oxford University Press.

Figures

**Figure 1**
Forest plots of changes in daily deaths by site associated with lockdown and lift-of-lockdown announcements, with pooled meta-analysis estimates. Incidence rate ratios (IRRs) and 95% CIs, percentage heterogeneity (I²) and p values from χ² tests of heterogeneity are displayed. (A) Initiation of lockdown announcement versus before lockdown. (B) Lift of lockdown announcement. (C) Lift of lockdown versus pre lockdown.

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References

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[1] Kontis V, Bennett JE, Rashid T, et al. . Magnitude, demographics and dynamics of the effect of the first wave of the COVID-19 pandemic on all-cause mortality in 21 industrialized countries. Nat Med 2020;26:1919–28. 10.1038/s41591-020-1112-0 - DOI - PMC - PubMed

[2] Kontis V, Bennett JE, Rashid T, et al. . Magnitude, demographics and dynamics of the effect of the first wave of the COVID-19 pandemic on all-cause mortality in 21 industrialized countries. Nat Med 2020;26:1919–28. 10.1038/s41591-020-1112-0 - DOI - PMC - PubMed

[3] Chang C-K, Hayes RD, Perera G, et al. . Life expectancy at birth for people with serious mental illness and other major disorders from a secondary mental health care case register in London. PLoS One 2011;6:e19590. 10.1371/journal.pone.0019590 - DOI - PMC - PubMed

[4] Chang C-K, Hayes RD, Perera G, et al. . Life expectancy at birth for people with serious mental illness and other major disorders from a secondary mental health care case register in London. PLoS One 2011;6:e19590. 10.1371/journal.pone.0019590 - DOI - PMC - PubMed

[5] Woodhead C, Ashworth M, Broadbent M, et al. . Cardiovascular disease treatment among patients with severe mental illness: a data linkage study between primary and secondary care. Br J Gen Pract 2016;66:e374–81. 10.3399/bjgp16X685189 - DOI - PMC - PubMed

[6] Woodhead C, Ashworth M, Broadbent M, et al. . Cardiovascular disease treatment among patients with severe mental illness: a data linkage study between primary and secondary care. Br J Gen Pract 2016;66:e374–81. 10.3399/bjgp16X685189 - DOI - PMC - PubMed

[7] Woodhead C, Cunningham R, Ashworth M, et al. . Cervical and breast cancer screening uptake among women with serious mental illness: a data linkage study. BMC Cancer 2016;16:819. 10.1186/s12885-016-2842-8 - DOI - PMC - PubMed

[8] Woodhead C, Cunningham R, Ashworth M, et al. . Cervical and breast cancer screening uptake among women with serious mental illness: a data linkage study. BMC Cancer 2016;16:819. 10.1186/s12885-016-2842-8 - DOI - PMC - PubMed

[9] WHO . The impact of COVID-19 on mental, neurological and substance use services: results of a rapid assessment. World Health organization, 2020. Available: https://www.who.int/publications/i/item/978924012455

[10] WHO . The impact of COVID-19 on mental, neurological and substance use services: results of a rapid assessment. World Health organization, 2020. Available: https://www.who.int/publications/i/item/978924012455

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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

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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

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