Hrev_master Abstract We aimed to compare psychiatric hospital visits during the COVID-19 quarantine period with the same period in 2019, to reveal the predictors of underutilization of mental health services. We then investigated the fluctuation of telemedicine service during the quarantine period. The retrospective study included patients with non-psychotic mental disorders who consecutively visited the Moscow clinic. The number of outpatient visits, inpatient admissions, sociodemographic factors were analyzed. We assessed the sample within two periods - the “quarantine period” (March 30 - June 9, 2020) and “control period” (March 30 - June 9, 2019). Psychiatric visits decreased in older, retired and disabled persons, and increased among the unemployed. In multivariate analysis, the reduction became significant for the number of inpatient admissions. Telemedicine calls gradually increased from the start of the service, but decreased towards the end of the quarantine. In conclusion, referrals to outpatient and inpatient psychiatric services decreased during the quarantine period, with newly established TMS potentially compensating for that decrease. The strongest factor associated with visits during the pandemic is employment status. Introduction The first case of COVID-19 infection in Moscow was confirmed on March 2, 2020. In order to prevent the dramatic spread of the disease, between March 30 and May 13, the Government imposed a regimen of “non-working days” in most Russian regions – resembling lockdowns in other countries. In the Moscow area, the “non-working days” period lasted six weeks (until June 9). During this period, all residents were obliged to have a pass (retrievable online) to go out more than 100 meters from their homes in order to minimize contacts. Similar to what happened almost everywhere in the world, all non-essential shops, theatres, cafes and restaurants, public parks and recreational zones, fitness centres and swimming pools, were temporarily closed. Elementary school students were sent to unscheduled vacations until the fall, and university and high school students were transferred to distance learning. Since June 2020, people were allowed to walk in the parks (3 times a week according to a schedule). A number of studies have reported an increase in anxiety, mood and stress-related disorders and also in suicide attempts across the population during the pandemic period.1–3 Telephone surveys in people with a history of mental disorder have shown an exacerbation of disorders.4 This is consistent with the data on the surge in search Emergency Care Journal 2023; volume 19:10994 [Emergency Care Journal 2023; 19:10994] [page 9] The impact of COVID-19 quarantine on mental health: an observational study from an outpatient service for non-psychotic patients in Russia (Moscow) Mikhail Zinchuk,1 Massimiliano Beghi,2 Giulio Castelpietra,3,4 Silvia Ferrari,5,6 Evgenii Pashnin,1 Alla Guekht1,7 1Moscow Research and Clinical Center for Neuropsychiatry, Moscow, Russian Federation;2Department of Mental and Addictions Health, AUSL Romagna, Cesena, Italy; 3Outpatient and Inpatient Care Service, Central Health Directorate, Region Friuli Venezia Giulia (FVG), Trieste, Italy; 4Clinical Department of Medical and Surgical Sciences, University of Trieste, Trieste, Italy; 5Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Italy; 6Department of Mental Health and Addictions, AUSL IRCCS Reggio Emilia, Reggio Emilia, Italy; 7Department of Neurology, Neurosurgery and Medical Genetics, Pirogov Russian National Research, Medical University, Russian Federation Correspondence: Mikhail Zinchuk, Donskayast., 43, 115419 Moscow, Russian Federation. Tel.: +7.9169367606. E-mail: mzinchuk@mail.ru Key words: lockdown; pandemic; psychiatric; non-psychotic mental disorders; telemedicine. Contributions: MZ, conceptualization, investigation, data curation, resources, visualization, manuscript drafting and reviewing; MB, concep- tualization, investigation, data curation, resources, visualization, manu- script drafting; GC, formal analysis, software, data curation, methodolo- gy; SF, investigation, resources, formal analysis, software, contribution to manuscript drafting; EP, investigation manuscript drafting and reviewing; AG, methodology, project administration, manuscript reviewing. Conflict of interest: the authors declare no conflict of interest. Ethics approval and consent to participate: the Ethics Committee of the Moscow Research and Clinical Centre for Neuropsychiatry approved this study (45). The study is conformed with the Helsinki Declaration of 1964, as revised in 2013, concerning human and animal rights. Informed consent: all patients participating in this study signed a written informed consent form for participating in this study. Patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Funding: this study was performed as part of the Moscow Research and Clinical Center for Neuropsychiatry research program. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Acknowledgements: the authors are grateful to Dr Georgii Kustov and Andrey Razmakhnin for data collection assistance and to Drs. Nadezhda Voinova and Sofia Popova technical assistance in the preparation of the manuscript. Received for publication: 6 November 2022. Accepted for publication: 21 March 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Emergency Care Journal 2023; 19:10994 doi:10.4081/ecj.2023.10994 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. No n- co mm er cia l u se on ly queries for psychological support, and anxiolytic consumption during the pandemic.5 Some factors during the quarantine were identified as the most stressful, such as quarantine duration >10 days, fear of getting the infection, worry, and frustration for not doing daily-life activities.6 However, recent reports examining the impact of the COVID- 19 quarantine found a decrease in psychiatric ER visits,3,7–12 psychiatric ward admissions,2,13,14 and psychiatric outpatient visits.15–17 The greatest decrease in the number of new outpatient visits in 2020 was among the youngest and oldest patients.16 However, data for the Russian population are missing. Moreover, the spread of the pandemic had a strong impact on mental health services’organization.18 In particular, the massive implementation of a telemedicine service (TMS) approach, which was less than two per 1,000 between 2005 and 201719in different psychiatric centres around the world, started with the pandemic onset,20- 23 albeit the prospects of a more active use of TMS in psychiatry had been discussed for a long time before.22,24 The rise of TMS was mainly due to the need of reducing the number of face- to-face contacts in order to prevent the spread of infection. Nonetheless, we found only few studies reporting epidemiologic evidence of the use of TMS in a public mental health context.23–25 Overall, young women aged between 25 and 34 years of age had the highest use of both videoconferencing and telephone.21 The aim of our study was to compare the number of psychiatric patients visited the Moscow Research and Clinical Center for Neuropsychiatry during the quarantine («non-working days») and the same period of the 2019; then to compare the sociodemographic and clinical characteristics of both groups. An additional aim was to study the factors associated with admission to a psychiatric inpatient ward, since hospitalization is a direct consequence of the severity of the patient’s clinical condition, and underutilization in this group is fraught with more severe consequences compared to the entire sample. We also looked at the fluctuation in telemedicine calls (incoming and outgoing) during the quarantine period to assess its potential compensatory role in providing psychiatric healthcare during the lockdown. Materials and Methods Population The study retrospectively included non-psychotic adult patients without drug and alcohol use disorders who were longitudinally admitted to the Moscow Research and Clinical Center for Neuropsychiatry for psychiatric evaluation and treatment. The recruitment center has a catchment area of 12,538,000 inhabitants (86.7% adults). All Moscow residents can request psychiatric assistance at the centre. Most patients arrive on their own; a small proportion of patients were referred by a general practitioner or other physicians. All data were retrieved from the centre’s electronic database, and included: sociodemographic variables (age, gender, occupational status, presence of chronic comorbidities, psychiatric diagnosis at discharge, based on ICD-10 classification); and actions taken by the caring psychiatrist (hospitalization in a psychiatric ward, other). We assessed the occupational status of the participants to further divide them into four groups: currently employed, unemployed, retired and economically inactive. The latter group consisted of those who were neither employed nor actively seeking employment. Patients, already known to have schizophrenia and related disorders, and drug and alcohol and use disorders, were excluded, because they were referred to different services. To mitigate the underutilization of mental health services during the quarantine, a TMS was created at the Research and Clinical Center for Neuropsychiatry in order to provide counseling and active contact with patients who had previously been prescribed a treatment. The TMS started at the beginning of the pandemic and consisted of about 20 doctors - psychiatrists and psychotherapists – and operated as a remote outpatient service with outgoing and incoming calls. It was aimed to help those who were experiencing psychological distress, for a variety of reasons, including theimpact of the pandemic and the lockdown. Outgoing calls were intended to inquire about health status of: i) those had recently been discharged, and ii) those who had not visited the Center for a long time (missed appointments). Incoming calls were mainly from people complaining about their psychological condition. Thephone number was distributed via the Center’s website and social media. Moreover, all patients who came to the Center or were discharged from the inpatient ward received a flyer with the phone number. Incoming TMS started on April 15, while the outgoing TMS started one week later. The study was approved by the local ethics committee. A consent form was not required since all the data were collected using an anonymous unique code to allow statistical elaboration and were managed in aggregate form to avoid identification. Statistical analysis Data were provided to the researchers in descriptive and inferential statistics and data concerning the patients’ characteristics at visit. The number of visits was entered into a common database and analyzed using SPSS 16.0 software. Descriptive statistics were performed. The sample was divided in two groups: “quarantine period” (March 30 - June 9, 2020) and “control period”, which included the same six weeks of 2019. A Poisson distribution was assumed for the total number of visits/patients and for the TMS (outgoing and incoming calls). The total number of visits/patients was compared between periods using a z-test (normal approximation for the Poisson distribution). All data arepresented as numbers and percentages. The association between each variable and the period was tested using the chi-squared test. All variables found to be statistically significant in univariate analyses and with amissing rate <20% were included in a multivariable binary logistic regression model (MV). Results are reported as odds ratios (OR) with 95% confidence intervals (95% CI). The significance level was set at 5%. Results During the lockdown, a 25.8% reduction of psychiatric assessments (from 6389 to 4741) was observed compared to the same period in 2019 (p<0.001). This reduction was found in all age groups, with a higher significance in the elderly. A decrease of 43.4% and of 82.1% was observed in the 65-80 and in the >80 age groups, respectively. According to the employment status, psychiatric assessments differed significantly, with a greater decrease among retired (-62.8%) and economically inactive (-43.5%) persons, while an increase of 17.2% was observed among unemployed persons (Table 1). In MV, age 65-80 (OR:1.46; 95% CI: 1.23-1.53), retired (OR: 0.38; 95% CI: 0.33-0.44) and economically inactive status (OR: 0.66; 95% CI: 0.57-0.75) remained correlated with decrease of psychiatric assessments while Article [page 10] [Emergency Care Journal 2023; 19:10994] No n- co mm er cia l u se on ly unemployed status (OR: 1.46; 95% CI: 1.23-1.53) remained correlated with an increase. A significant difference was also found between psychiatric diagnoses. In particular, there was a significant decrease in visits for organic psychiatric disorders (-43.5%). In contrast to other diagnostic groups, the absolute numbers of personality disorders remained almost the same as in the previous year. However, this result was lost in the MV analysis. The rates of inpatient admissions during the quarantine period decreased significantly (-67.9%) as well (Table 1). We compared the sociodemographic and clinical characteristics of patients whose first visit resulted in hospitalization. Factors significantly associated with hospitalization after a visit to the Center in 2019 were: an increasing age, the diagnosis of “organic disorder”, an “economically inactive” status and the absence of “unemployed” status (Table 2). The MV confirmed this results: compared to people with anxiety disorders, patients with psychorganic disorder were significantly associated with inpatient admission (OR 1.49; 95% CI: 1.29-1.72); similarly compared to people aged 46-64, age classes 18-30 (OR 0.69; 95% CI: 0.58-0.81) and 31-45 (OR 0.72; 95% CI: 0.62-0.84) were associated to no admission, while age classes 65-80 (OR 1.40; 95% CI: 1.20-1.63) and >80 (OR 1.83; 95% CI: 1.37-2.44) were associated with admission, while the working status lost its significance. In 2020, only the absence of unemployment and male sex were significantly associated with hospitalization (Table 3). The MV confirmed these results: compared to employed patients, unemployed were at lower risk of psychiatric word admission (OR 0.60; CI: 0.50-0.71); similarly, male patients were at lower risk of psychiatric word admission (OR 0.70; CI: 0.60-0.83). A gradual increase with a peak and further stabilization was observed for both incoming and outgoing calls. When comparing each week with the previous one, significant increases were observed in the week from April 22 to April 28 (p<0.001) and then in the two weeks from May 13 to May 26 (p<0.05) for incoming calls (Table 3, Figure 1). Outgoing calls increased significantly (p<0.001) in the three weeks from April 15 to May 12 (Table 4, Figure 1). Article Table 1. Characteristics of patients who visited the Centre during the lockdown and control periods. Variable Control period (March 29th - June 9th 2019) Lockdown period (March 29th - June 9tth 2020) p N % N % Age range (years) p<0.001 18-30 975 15.3 783 16.5 31-45 1426 22.3 1221 25.8 46-64 2306 36.1 1833 38.7 65-80 1430 22.4 810 17.1 >80 252 3.9 94 2.0 Gender p=0.851 Male 1511 23.7 1114 23.5 Female 4878 76.3 3627 76.5 Occupation p<0.001 Currently employed 1661 26.0 1368 28.9 Economically inactive 1564 24.4 884 18.6 Retired 1525 23.9 568 12.0 Unemployed 1639 25.7 1921 40.5 Psychiatric diagnosis p<0.001 Psycho-organic disorder 2435 38.1 1375 29.0 Mood disorder 940 14.7 816 17.2 Anxiety disorder 2823 44.2 2377 50.1 Personality disorder 160 2.5 158 3.3 Eating disorder 30 0.5 15 0.3 Inpatient admission p<0.001 No 3469 54.3 3804 80.2 Yes 2920 45.7 937 19.8 Total 6389 4741 [Emergency Care Journal 2023; 19:10994] [page 11] Figure 1. Number of incoming and outgoing Telehealth service calls during the lockdown period. No n- co mm er cia l u se on ly Article Table 2. Variables associated with an admission to the psychiatric ward in control period. Variable Non-admitted Admitted p N % N % Age range (years) p<0.001 18-30 624 18.0 351 12.0 31-45 885 25.5 541 18.5 46-64 1251 36.1 1055 36.1 65-80 623 18.0 807 27.6 >80 86 2.5 166 5.7 Gender p=0.813 Male 816 23.5 695 23.8 Female 2653 76.5 2225 76.2 Occupation p<0.000 Currently employed 934 26.9 727 24.9 Economically inactive 742 21.4 822 28.2 Retired 811 23.4 714 24.5 Unemployed 982 28.3 657 22.5 Psychiatric diagnosis p<0.000 Psycho-organic disorder 1080 31.1 1355 46.4 Mood disorder 556 16.0 384 13.2 Anxiety disorder 1705 49.2 1118 38.3 Personality disorder 110 3.2 50 1.7 Eating disorder 17 0.5 13 0.4 Table 3. Variables associated with an admission to the psychiatric ward in lockdown period. Variable Non-admitted Admitted p N % N % Age range (years) p<0.447 18-30 627 16.5 156 16.6 31-45 997 26.2 224 23.9 46-64 1449 38.1 384 41.0 65-80 653 17.2 157 16.8 >80 78 2.1 16 1.7 Gender p=0.000 Male 846 22.2 268 28.6 Female 2958 78.8 669 71.4 Occupation p=0.000 Currently employed 1060 27.9 308 32.9 Economically inactive 667 17.5 217 23.2 Retired 438 11.5 130 12.0 Psychiatric diagnosis p<0.058 Psycho-organic disorder 1071 28.2 304 32.4 Mood disorder 672 17.7 144 15.4 Anxiety disorder 1920 50.5 457 48.8 Personality disorder 127 3.3 31 3.3 Eating disorder 14 0.4 1 0.1 Table 4. Outgoing calls: all periods vs previous period. Previous period N° of calls Referringperiod N° of calls Variation % p 22/04-28/04 43 29/04-05/05 193 +348 0.0000 29/04-05/05 193 06/05-12/05 313 +62 0.0000 06/05-12/05 313 13/05-19/05 354 +13 0.1124 13/05-19/05 354 20/05-26/05 305 -14 0.0563 20/05-26/05 305 27/05-02/06 300 -2 0.8389 27/05-02/06 300 03/06-09/06 265 -12 0.1409 [page 12] [Emergency Care Journal 2023; 19:10994] No n- co mm er cia l u se on ly Discussion The aim of the present study was to measure changes in the number of patients visited the Moscow Research and Clinical Center for Neuropsychiatry during the COVID-19 quarantine, and their characteristics. In line with other studies3,7-19, we found a significant reduction in the number of psychiatric evaluations. This may be explained by the established restrictions, as in the definition of the lockdown regime, and by the fear of being infected; although seeking medical help was not restricted. According to the literature, the maximum reduction in the psychiatric help utilization was observed in the group of patients with non-psychotic mental disorders, while this seldom applied to acute psychotic disorders.7,8,26,27 This is also confirmed by the stable number of involuntary admissions to psychiatric wards during the pandemic.8,11 Since the clinical target of the Research and Clinical Center for Neuropsychiatry in Moscow is non-psychotic mental disorders, this may explain the significantreduction in the frequency of admissions to the inpatient department compared to other centres. More generally, the fear of infection itself could be another reason for the decrease in admissions and visits, since hospitals were by far the places at highest risk of contact. This could also justify the greater decrease in visits observed among the elderly, who were clearly identified as the most vulnerable group in terms of the health challenges posed by Sars-Cov-2 infection, and who were consequently targeted by strong educational campaigns.7,8 Another possible reason for the decrease in visits could be an increased tolerance to the psychiatric symptoms during the pandemic, both among inpatients and family members.8 Finally, the decrease in the availability of street drugs during the lockdown period could account for the reduction in psychiatric visits, especially in the younger group.28,29 Interestingly, the unemployed persons were the only group to show an increased rate of visits compared to the control period. On the one hand, this finding is in the line with multiple reports from different countries of increased level of unemployment during the pandemic. On the other hand, those who were seeking for job before the lockdown faced even more struggle becoming employed due to overall reduction in vacancies. The economic burden during the lockdown could have had a greater impact on this group, leading to or exacerbating mood and anxiety symptoms. A large study conducted in northern Italy during the economic crisis3032 found that the subjects who lost their permanent jobs were 17% more likely to receive one or more psychotropic drug prescriptions than the controls. This is also supported by the results of pre-pandemic studies, which showed that revealed a lower risk of psychiatric hospitalization among the employed14. During self-isolation, most specialists continued to work remotely, which allowed them to maintain income levels close to pre-pandemic levels. The lower use of mental health services by retirees and the economically inactive reflects a small change in their economic status during the quarantine period. The greatest decrease in visits was observed among persons with organic non-psychotic disorders. This diagnostic category is intertwined with the age variable, because of its predominance in the older age group. In contrast, the number of visits for personality disorders remained stable in 2019 and 2020, in line with previous research.31 Our data support the hypothesis that individuals with personality disorders may be less adherent to the prescribed sanitation measures32. In this regard, patients with personality disorders may require additional special interventions, which should be considered when developing vaccination programs. The decrease in visits to the Center may have led to a reduction in psychiatric hospital admissions, as has been found in other countries.33 Nonetheless, the creation and the rapid development of TMS may also have played a role in the decrease in visits, or at least compensated this decrease – especially at the beginning of the lockdown period, when the number of TMS increased steadily (Figure 1 and Table 4). For example, an Australian study found a reduction of more than 50% in face-to-face visit to a mental care setting following the widespread implementation of a telepsychiatry service.20 In general, the use of TMS for mental health care has proven to be an effective resource-saving strategy, and its use in routine practice after the end of the pandemic has been claimed.2 In addition, the experience of rapidly deploying a TMS to overcome the shortage of face-to-face visits can hopefully be used to develop an algorithm for responding to subsequent epidemics. Also, given that people with mental disorders may be among the priority vaccination groups in some countries, active contact with the use of TMS opens additional opportunities for implementing this program in this population.34 Considering that during quarantine periods some patients groups are more prone to postpone their visits, TMS services could specifically targetthose patients to fully compensate for the decrease in mental health provision. Limitations Our study has both strengths and limitations. This is the first study from the Russian Federation on mental health utilization during the quarantine period. The first limitation is the retrospective design, which may have led to biases in the collection of some variables (data on some variables, such as organic comorbidity, are missing). Second, we lack a follow-up period to evaluate the extent to which visitrates may have varied, considering the rapid sequences of a government’s rules and also the economic burden resulting from the persistence of the pandemic. Third, the sample is based on non- psychotic disorders, and is not representative of the entire psychiatric population. Forth, it would be interesting to study the correlation between the fluctuation of incoming and outgoing calls with clinical characteristics of the patients, but we do not have information about the demographic and clinical variables for patients who called or were called. Finally, the study was performed in a limited area; hence, the generalizability of our findings toother countries, and in Russia as well, may be limited. Conclusions During the period of self-isolation associated with the COVID-19 pandemic in Moscow, there was a significant decrease in the number of people referred for inpatient psychiatric care in all age groups. 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