Hrev_master [page 16] [Emergency Care Journal 2021; 17:9827] Emergency Care Journal 2021; volume 17:9827 Abstract The aim was to study the number of accesses to the Emergency Room (ER) requiring psychiatric evaluation in the four months fol- lowing the lockdown period for the COVID-19 outbreak (May 4th, 2020-August 31th, 2020). The study is a retrospective longitudinal observational study of the ER admissions of the Hospitals of Cesena and Forlì (Emilia Romagna region) leading to psychiatric assessment. Sociodemographic variables, history for medical comorbidities or psychiatric disorders, reason for ER admission, psychiatric diagnosis at discharge and measures taken by the psy- chiatrist were collected. An increase of 9.4% of psychiatric assess- ments was observed. The difference was more pronounced in the first two months after lockdown, with a 21.7% increase of number of ER accesses, while after two months numbers were the same as those of the year before. Admission with anxiety symptoms and history of psychiatric disorder decreased significantly. Moreover, there is an age trend with an increasing age of admission. Introduction Between March 9th and May 3rd 2020, the Italian Government imposed a national lockdown, restricting the movements of the population except for certified needs such as work and health cir- cumstances, the temporary closure of non-essential services, pro- ductive activities and businesses, in response to the growing pan- demic of COVID-19 in the country. After this phase, the Italian Government decided to ease the lockdown restricting measures, and people who had been at home during the lockdown returned to their workplaces and were also allowed to visit relatives and other loved ones. The WHO declared the novel COVID-19 disease a pandemic, with severe consequences for health and global economic activity and Italy is one of the hardest hit countries.1 A recent systematic review of the literature2 has underlined the negative psychological effects of quarantine, such as the development of Post-Traumatic Stress Disorder (PTSD) symptoms, like confusion and anger. Stressful factors during quarantine were identified, including quar- antine length >10 days, fear to contract the infection, boredom and frustration for not doing daily-life activities, lack of basic elements of food, water, clothes, that could be extended to the following months.2 After lockdown, the financial loss as a result of lockdown cre- ated serious socioeconomic distress and was found to be the main risk factor for symptoms of psychological disorders and both anger and anxiety several months after lockdown.2 Access to the Emergency Room (ER) is considered an index of severe psychiatric distress, since it underlines a compelling request due to patient’s discomfort. Recent reports from Italy, France, Germany, and Portugal, found a decrease of psychiatric ER visits3- 6 during the lockdown. However, data on psychiatric distress after the lockdown are still scarce. Data from the United Kingdom7 show a longer-term urgent or emergency mental health referrals acceleration after an instantaneous drop at the beginning of the lockdown. Correspondence: Massimiliano Beghi, Department of Mental Health, AUSL Romagna, Piazzale Giommi, 47521, Cesena, Italy. Tel.: +390547352702, +390547646294 E-mail: massibeghi@libero.it Key words: Pandemic; follow-up; outbreak; COVID-19; mental health. Acknowledgements: We would like to thank Eleonora Monti for her important contribution in data collection and Dr. Elisa Bianchi for sta- tistical analysis. Contributions: MB: study design, data collection, manuscript prepara- tion; RB: data collection, revision of the literature; LB: data collection, revision of the literature; CC: manuscript preparation; CF: manuscript preparation; RSA: manuscript preparation; GDP: study design. Conflict of interest: The authors declare no conflict of interest. Availability of data and materials: All data generated or analyzed during this study are included in this published article. Ethics approval and consent to participate: The Ethics Committee of Romagna (CEROM) approved this study (Prot. 3069/2021). The study is conformed to the Helsinki Declaration of 1964, as revised in 2013, concerning human and animal rights. Informed consent: According to the ethic committee (CEROM) Written informed consent was not required, since all the data were collected anonymously to allow statistical elaboration and were managed in aggregate form to avoid patients’ identification. Received for publication: 23 April 2021. Revision received: 16 August 2021. Accepted for publication: 16 August 2021. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2021 Licensee PAGEPress, Italy Emergency Care Journal 2021; 17:9827 doi:10.4081/ecj.2021.9827 Effects after the lockdown on emergency room admissions for psychiatric evaluation: An observational study from the province of Forlì-Cesena, Italy Massimiliano Beghi,1 Riccardo Brandolini,2 Laura Biondi,3,4 Claudia Corsini,3 Carlo Fraticelli,5 Rosa Sant’Angelo,1 Giovanni De Paoli1 1Department of Mental Health and Pathological Dependencies, AUSL Romagna, Cesena; 2Department of Mental Health and Pathological Dependencies, AUSL Romagna, Rimini; 3Department of Mental Health and Pathological Dependencies, AUSL Romagna, Ravenna; 4Department of Biomedical and NeuroMotor Sciences, Psychiatry Unit, Alma Mater Studiorum, Bologna; 5Department of Mental Health and Addictions, ASST Lariana, Como, Italy Non -co mmerc ial us e o nly The aim of our study was to compare the number of accesses to the ER requiring psychiatric evaluation in the province of Forlì- Cesena in the region Emilia-Romagna, North-Eastern Italy, in the four months following the “phase one” of the restrictions for the COVID-19 outbreak (from May 4th, 2020 to August 31th, 2020) with those of the same period of the year 2019, and also to inves- tigate the socio-demographic and clinical characteristics of patients admitted. Materials and Methods The study is a retrospective longitudinal observational study of the ER admissions of the Hospitals of Cesena and Forlì leading to psychiatric assessment. The catchment area included 333,112 adult inhabitants, distributed as follows: Cesena, 176,232; Forlì, 156,884. Measures The electronic databases were searched for of following data: sociodemographic variables (age, gender, ethnicity, marital status, housing status), positive history for medical comorbidities or psy- chiatric disorders, reason for ER admission, psychiatric diagnosis at discharge and measures taken by the caring psychiatrist (hospi- talization in psychiatric ward, other). The study was approved by the local ethics committee on March 19th, 2021. A consent form was not required, since all the data were collected anonymously to allow statistical elaboration and were managed in aggregate form to avoid patients’ identifica- tion. Statistical Analysis All relevant variables were included in a general database and analyzed by using the SPSS 16.0 software. Basic descriptive statis- tics were performed, with continuous variables presented as abso- lute Numbers (N), mean, Standard Deviation (SD) and categorical variables as frequencies and percentages. The sample was divided into two groups: variables related to post lockdown period (May 4th, 2020-August 31th, 2020) and vari- ables related to the control period (May 4th, 2020-August 31th, 2019). The association between each variable and the period was test- ed using the chi-square. All variables found to be statistically sig- nificant in univariate analyses and with a missing rate <20% were included in a multivariable binary logistic regression model. Results are reported as Odds Ratios (OR) with 95% confidence intervals (95% CI). The significance level was set at 5%. Results Considering the whole period, an increase of 9.4% of psychi- atric assessments was observed (p=0.16). The difference was thus significant in the first two months after lockdown (p=0.04), with a 21.7% increase of number of ER accesses (Table 1), while after two months numbers were the same as those of the year before. Comparison between post-quarantine period and cor- responding antecedent period Table 1 displays the comparison of variables referring to the two time periods, outlining some statistically significant changes. In the multivariate logistic regression model, only admission with anxiety symptoms (OR:0.53 CI: 0.36-0.80) and history of psychi- atric disorder (OR:0.52 CI:0.32-0.85) decreased significantly. Moreover, there is an age trend with an increasing age of admis- sion and a significant reduction in people aged <30 years (OR: 0.64 CI:0.42-0.98). Discussion In the light of our results there has been a slight increase in number of ER admissions, after the lockdown, compared to those of the previous year, especially in people who had not a positive psychiatric history. Our results, even if lower than expected con- sidering findings of the systematic review2 and than previous data,7 point out the psychological discomfort due to the pandemic, the social restrictions during and following lockdown, and the subse- quent economic burden, especially in males. The discrepancy with the current literature could be explained in part by the decree approved by the Italian Government in support to workers and their families blocked the collective terminations; this could have postponed the consequences of the economic burden of the pan- demic and lowered the psychological discomfort, since the loss of a job is a predictor of social distress. A study carried out in Lombardy during the economic crisis8 found that the subjects who lost their permanent employment were 17% more likely to receive psychotropic drug prescriptions than the controls, but the differ- ence was significant only for males. This discomfort is in line with the current literature9,10 and could be justified by the higher number of admissions for suicide ideation/self-harm/suicide attempt, even if our findings did not attain statistically significance due to the small numbers. This increase was significant only in the first two months after quarantine, while after that period the numbers aligned to those of the previous year. In our opinion, there has been a sort of rebound effect just after the lockdown, when fragmentation symptoms, that found their place in the ‘outside world’ during lockdown, come back in the inside world, resulting in discomfort with a consequent worsening of psychotic and mood symptoms.11 By contrast, there was a significant decrease in people referring to the ER for anxiety symptoms, in line with data during lockdown from the same area3 and with those of previous reports, that reported a gradual decrease in anxiety symptoms.9,10,12-14 These data are in contrast with a sur- vey from a large Italian sample that found a 17.6% of patients experiencing anxiety symptoms and 41.6% (N = 8,619) reporting to feel at least moderately stressed by the situation.15 The fear of COVID-19 contagion could influence people with anxiety symp- toms, since hospitals were by far places at highest risk of contact. They tried to avoid an admission using different strategies as at- need therapies and contacts with the outpatient clinics. The increasing age of people referring to the ER is in line with previous data, but only among younger individuals.7 Our data are not surprising: it is known that the consequences of the pandemic are more severe in people aged 65+ years both in terms of death (about 8/10 deaths) and intensive care admissions.16 The fear for the pandemic could thus induce or worsen a psychi- atric disorder. Moreover, old people have a reduced perception of their life and physical health, and they usually suffer also from co- morbid conditions requiring follow-up visits and on-going assis- tance: the loss of social networks may create a situation in which mental health and psychosocial support needs of many older peo- ple are no longer met. For the millions of older people who live in care facilities, physical distancing measures (that restrict visitors and group activities) persisting after the lockdown, can negatively affect their well-being and, consequently, their mental health. Article [Emergency Care Journal 2021; 17:9827] [page 17] Non -co mmerc ial us e o nly Article [page 18] [Emergency Care Journal 2021; 17:9827] Table 1. General characteristics of the sample during lockdown and, for comparison, during a corresponding period in 2019. Variable post- lockdown 2019 control period Significance (p) N % N % Age range (years) p=0.003 <31 115 23.1 148 32.5 31-45 133 26.7 112 24.6 46-65 152 30.5 136 29.8 >65 98 19.7 60 13.2 Gender p=0.363 Male 262 50.7 226 49.6 Female 237 47.5 230 50.4 Marital status p=0.048 Single 230 52 233 59.6 Married/cohabitant 125 28.3 105 26.9 Divorced 63 14.3 34 8.7 Widowed 24 5.4 19 4.9 Ethnicity p=0.192 Italian 422 84.7 372 81.6 Foreign 76 15.3 84 18.4 Occupation p=0.003 Current worker 125 29.6 113 31.8 Retired 99 23.4 46 13 Socially inactive (student, housewife, disabled) 70 16.5 66 18.6 Unemployed 129 30.5 130 36.6 Housing status p=0.776 Alone 79 17.1 62 14.5 Family of origin 158 34.3 146 34.1 Acquired family 140 30.4 131 30.6 Therapeutic center 66 14.3 65 15.2 Homeless 5 1.1 6 1.4 Other 13 2.8 18 4.2 Comorbidity p=0.033 No 280 64.8 284 71.7 Yes 152 35.2 112 28.3 History of psychiatric disorders p=0.019 No 91 18.2 58 12.7 Yes 408 81.8 398 87.3 In psychiatric care 0=0.350 Current 295 59.1 289 63.3 Past 86 17.2 75 16.4 Never 118 23.6 92 20.2 Reason for ER admission p=0.007 Suicide ideation/self-harm/ suicide attempt 65 13.0 44 9.6 Psychomotor agitation/intoxication/confusion 181 36.3 148 32.5 Psychotic episode 64 12.8 43 9.4 Mood symptoms 79 15.8 77 16.9 Anxiety symptoms 110 22.0 144 31.6 Psychiatric diagnosis p=0.362 Psycho-organic disorder 24 5.3 37 7.4 Psychotic disorder 65 14.3 79 15.9 Mood disorder 84 18.5 110 22.1 Anxiety disorder 38 8.4 38 7.6 Personality disorder 48 10.5 31 6.2 Intellectual disability 18 4 26 5.2 Addiction disorder 31 6.4 37 5.8 Adjustment disorder 51 11.2 51 10.3 Axis I/Axis II diagnosis 14 3.1 13 2.6 Dual diagnosis 82 18 81 16.3 Measure taken by the psychiatrist p=0.030 No measure, drug prescription 112 24.6 125 25.1 Send to the outpatient 212 46.6 203 40.7 Psychiatric ward admission 95 20.9 142 28.5 Other measure (e.g. other ward admission) 36 7.9 29 5.8 ER: Emergency Room. Non -co mmerc ial us e o nly Lastly, older people have always suffered from the lack of structur- al training and work policies, the precariousness or the protections necessary for carrying out the same. The data on employment, in fact, emphasize how accesses of people socially/working inactive, are high in both periods, defining the work as a determinant of health. Limitations Our study has several limitations. First, the retrospective design could have led to biases in the collection of some variables. Second, we focused on psychiatric visits: in some cases, the same patient may have more than one admission and this could lead to an overestimation of some demographic variables. Third, due to the fact that ER database does not provide diagnoses following international classifications, such as ICD, we used descriptive psy- chiatric diagnoses formulated by the clinician, following clinical evaluation and using natural language. Finally, the study was per- formed in a local setting and, hence, generalizability of our find- ings may be limited. Conclusions There has been a mild increase in number of ER admissions, after the lockdown, compared to those of the previous year, espe- cially in people who had not a positive psychiatric history. Further studies in larger populations are needed to confirm data from our sample. Moreover, studies carried when collective terminations will be unblocked could give us the real economic burden of the pandemic and the psychiatric consequences. References 1. Nurchis MC, Pascucci D, Sapienza M, et al. Impact of the Burden of COVID-19 in Italy: Results of Disability-Adjusted Life Years (DALYs) and Productivity Loss. Int J Environ Res Public Health 2020;17:4233. 2. Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet 2020;395:912-20. 3. Beghi M, Brandolini R, Casolaro I, et al. Effects of lockdown on emergency room admissions for psychiatric evaluation: an observational study from the AUSL Romagna, Italy. Int J Psychiatry Clin Pract 2020;21:1-5. 4. Pignon B, Gourevitch R, Tebeka S, et al. Dramatic reduction of psychiatric emergency consultations during lockdown linked to COVID-19 in Paris and suburbs. Psychiatry Clin Neurosci 2020;74:557-9. 5. Hoyer C, Ebert A, Szabo K, et al. Decreased utilization of mental health emergency service during the COVID-19 pande- mic. Eur Arch Psychiatry Clin Neurosci 2021;271:377-9. 6. Gonçalves-Pinho M, Mota P, Ribeiro J, et al. The impact of COVID-19 pandemic on psychiatric emergency department visits - A descriptive study. Psychiatr Q 2020;25:1–11. 7. Chen S, She R, Qin P, et al. The medium-term impact of COVID-19 lockdown on referrals to secondary care mental health services: A controlled interrupted time series study. Front Psychiatry 2020;11:585915. 8. Cornaggia CM, Beghi M, Mezzanzanica M, et al. Psychotropic drug consumption and employment status in time of economic crisis (2007-2011). Psychiatr Q 2017;88:371-84. 9. O’Connor RC, Wetherall K, Cleare S, et al. Mental health and well-being during the COVID-19 pandemic: longitudinal ana- lyses of adults in the UK COVID-19 Mental Health & Wellbeing study. Br J Psychiarty 2020;1-8. 10. Killgore WDS, Cloonan SA, Taylor EC, et al. Trends in suici- dal ideation over the first three months of COVID-19 lock- downs. Psychiatry Res 2020;293:113390. 11. Gabbard GO. Psychodynamic psychiatry in clinical practice, 3rd edition. Washington DC: American Psychiatry Press, 2000. 12. Fancourt D, Steptoe A, Bu F. Trajectories of anxiety and depressive symptoms during enforced isolation due to COVID-19 in England: a longitudinal observational study. Lancet Psychiatry 2020;8:141-9. 13. Gijzen M, Shields-Zeeman L, Kleinjan M, et al. The bitterswe- et effects of COVID-19 on mental health: Results of an online survey among a sample of the dutch population five weeks after relaxation of lockdown restrictions. Int J Environ Res Public Health 2020;17:9073. 14. González-Sanguino C, Ausín B, Castellanos MA, et al. Mental health consequences of the Covid-19 outbreak in Spain. A lon- gitudinal study of the alarm situation and return to the new nor- mality. Prog Neuropsychopharmacol Biol Psychiatry 2020;107:110219. 15. Fiorillo A, Sampogna G, Giallonardo V, et al. Effects of the lockdown on the mental health of the general population during the COVID-19 pandemic in Italy: Results from the COMET collaborative network. Eur Psychiatry 2020;63:e87. 16. Ritchie H, Mathieu E, Rodés-Guirao L, et al. Coronavirus Pandemic (COVID-19). Our World in Data; 2020. Available from: https://ourworldindata.org/coronavirus Article [Emergency Care Journal 2021; 17:9827] [page 19] Non -co mmerc ial us e o nly