King's College London

Research led by King’s College London has found that the introduction and lifting of COVID-19 ‘lockdown’ policy in Spring 2020 was associated with significant changes in mortality and service delivery across mental healthcare providers.

The study was published in BMJ Open and the researchers believe this is the most extensive multi-site evaluation of mental health providers to date.

People with mental health problems are thought to be particularly vulnerable to the isolating effects of the pandemic, face greater hurdles in accessing healthcare, and are more likely to have risk factors for severe COVID-19 illness (such as heart and lung problems) in addition to already-reduced life expectancy. Experts have warned that the impact of social distancing on at-risk populations poses a significant threat to their mental health. Health services worldwide had to implement radical changes to deal with the disruption of COVID-19, and the longer-term effect on mental healthcare services is unclear.

UK-wide collaboration

While individual sites have previously reported decreases in activity and a rise in mortality following the March 2020 lockdown, this study is the first to look at nationwide changes. Mental healthcare data were compiled from ten sources: eight NHS foundation trusts in England, one NHS trust in Scotland and the data on all health services provided to the population of Wales.

Researchers extracted data including patient deaths from all causes, inpatient admissions and discharges, and contacts with community healthcare teams for January to May 2019 and 2020. The analysis focussed on the changes following the implementing and relaxing of lockdown policies on 23^rd March and May 10^th.

Transition to lockdown in March 2020 was followed by increased daily deaths (from all causes), reduced referrals and reduced inpatient admissions and caseloads compared to the same time the year before, pre-Covid. At the same time, community services saw a rapid shift from face-to-face to non-face-to-face contacts.

Policies on social distancing continued to affect services after the relaxation of lockdown rules on 10^th May 2020. While the lift of lockdown was followed by an increase in inpatient admissions and caseloads compared to the lockdown period, only the number of daily deaths reverted to pre-lockdown levels. Compared to pre-lockdown levels, community mental health services still had reduced face-to-face contacts with patients while the number of remote consultations continued to increase, suggesting that this may be a long-term change.

Implications and consequences

The results of the study show that mental health service delivery underwent sizeable changes following the first national lockdown, with as-yet unevaluated consequences. While some observations are likely to be unsurprising, such as the decline in face-to-face community contacts as a result of social distancing, others may be a cause for concern.

For example, the abrupt decline in inpatient admissions may have been the result of an avoidance of health services because of the perceived risk of infection. Alternatively, it could conceivably be attributed to a reduced demand due to better mental health, perhaps stemming from less exposure to social pressures outside of the home.

No information is available on the causes of death that are behind the increase in daily mortality around lockdown.

Hear from the authors

Joint lead author Robert Stewart, Professor of Psychiatric Epidemiology and Clinical Informatics at Institute of Psychiatry, Psychology & Neuroscience, King’s College London and Clinical and Population Informatics Lead at NIHR Maudsley BRC, said:

“As well as a rise in mortality rates, these findings show the profound changes that occurred in mental healthcare around the first lockdown in March 2020, including the switches in many services from face-to-face to virtual contacts, many of which are likely to be persisting. While some of these service changes may have benefits for some people, we simply don’t know what the consequences will be, so there’s an urgent need for further evaluation.”

Professor Stewart added, “This study is one of the largest collections of routine mental healthcare information to date, showing what can be achieved by multiple services working together. It was not specifically funded and was generously supported by the participating sites and staff who collated the data at short notice and at a very busy time last summer.”

Dr Ioannis Bakolis, joint lead author and Senior Lecturer in Biostatistics and Epidemiology at Institute of Psychiatry, Psychology & Neuroscience, King’s College London, said:

“Our findings presented a highly concerning reduction of 25% of inpatient new admissions and 55% of face-to-face community contacts during the first national lockdown. These substantial changes highlight the challenges in mental health care service provision and access due to the COVID-19 lockdown policies and the urgency to further understand the impact of re-configuration of services to population mental health.”

The paper ‘Changes in daily mental health service use and mortality at the commencement and lifting of COVID-19 ‘lockdown’ policy in ten UK sites: A regression discontinuity in time design’ is published in BMJ Open.

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