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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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Bakolis, Ioannis 
Baldwin, David 
Beenstock, Jane 
Bibby, Paul 


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.



Mental health, 1506, 2474, 1712, COVID-19, mental health, organisation of health services, adult psychiatry, old age psychiatry

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BMJ Open

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BMJ Publishing Group
National Institute for Health Research (Cambridge Biomedical Research Centre, Maudsley Biomedical Research Centre, Mental Health TRC, North Thames ARC, Oxford Cognitive Health Clinical Research Facility, Oxford Health Biomedical Research Centre, Oxford and Thames Valley ARC, RP-2017-08-ST2-006, Senior Investigator Award to R Stewart, South London ARC, UCLH Biomedical Research Centre)
Health and Care Research Wales (National Centre for Mental Health)
Medical Research Council (Edinburgh Mental Health Data Pathfinder Award, KCL Mental Health Data Pathfinder Award, MC_PC_17213, Swansea Mental Health Data Pathfinder Award, Swansea University HDRUK)