The impact of COVID-19 on suicidal ideation and alcohol presentations to emergency departments in a large healthcare system

Non-fatal suicide behaviours across phases in the COVID-19 pandemic: a population-based study in a Catalan cohort

BACKGROUND

The COVID-19 pandemic has been extensively discussed in the context of its effect on mental health. Although global suicide rates have remained stable during the pandemic, the specific effect on non-fatal suicide behaviours during and after the pandemic remains underexplored. This study aims to investigate patterns of non-fatal suicide behaviours before, during, and after the pandemic.

METHODS

In this cohort study, we used data from all hospitals in Catalonia, Spain, collected through the Catalan Suicide Risk Code, which is a specifically designed suicide attempt surveillance protocol, involving a face-to-face, in-depth psychiatric evaluation, after a Catalan resident presents any suicide risk behaviour in any public health-care setting. This evaluation centralises data from suicide registries across the territory. We included non-fatal suicide behaviours, meaning suicidal ideation or attempts that did not result in death, and excluded self-harm behaviours not judged to be linked with suicidal ideation. We considered three periods: the pre-confinement period (Jan 1, 2018, to the enforcement of the lockdown in Spain on March 14, 2020); the confinement period (March 14, 2020, to the end of lockdown on June 21, 2020); and the post-confinement period (June 21, 2020, to Dec 31, 2022). We used Bayesian structural time series models to assess the effect of pandemic phases on non-fatal suicide behaviours, and we ran stratified analyses by sex and age to identify distinct patterns among demographic cohorts.

FINDINGS

We obtained 26 482 records from Jan 1, 2018, to Dec 31, 2022. The mean age was 37·94 years (SD 18·07), and the sample included 17 584 (66·4%) women and 8898 (33·6%) men. Data on ethnicity were not collected. Temporal trends showed a mild increase in non-fatal suicide behaviours from Jan 1, 2018, to March 13, 2020; a reduction during the confinement period; and a subsequent rise after confinement. Bayesian models suggested a significant causal effect of lockdown easing, resulting in a 50·77% increase in non-fatal suicide behaviours (95% credible interval [CrI] 26·62-76·58; p<0·0001). Stratified analyses indicated that the easing of lockdown resulted in a significant increase in non-fatal suicide behaviours among women (25·92%; 6·71-44·72; p=0·011) and among individuals aged 18 years and younger (72·75%; 38·81-108·11; p<0·0001).

INTERPRETATION

This study provides a comprehensive examination of non-fatal suicide behaviours in Catalonia, Spain, emphasising the dynamics of different COVID-19 pandemic phases. The initial reduction during strict lockdown aligns with Joiner's Interpersonal Theory of Suicide, whereas the post-confinement rise reflects complex factors, including social isolation and economic challenges. Sex-specific and age-specific analyses underscore distinct vulnerabilities, emphasising the need for targeted preventive strategies.

FUNDING

Centro de Investigación Biomédica en Red de Salud Mental annual budget of G21, Agència de Gestió d'Ajuts Universitaris i de Recerca of the Generalitat de Catalunya.

TRANSLATIONS

For the Catalan and Spanish translations of the abstract see Supplementary Materials section.

The association between community-level economic deprivation and incidences of emergency department visits on account of attempted suicides in Maryland

Background

Suicide is a major cause of mortality in the United States, accounting for 14.5 deaths per 100,000 population. Many emergency department (ED) visits in the United States are due to attempted suicides. Suicide attempts predict subsequent completed suicides. Socioeconomic factors, such as community-level socioeconomic deprivation, significantly affect many traditional risk factors for attempted suicides and suicides.

Aim

To determine the association between community-level socioeconomic deprivation and ED visits for attempted suicide in Maryland.

Methods

A retrospective analysis of attempted suicides in the Maryland State Emergency Department Database from January 2018 to December 2020. Community-level socioeconomic deprivation was measured using the Distress Community Index (DCI). Multivariate regression analyses were conducted to identify the association between DCI and attempted suicides/self-harm.

Results

There were 3,564,987 ED visits reported in the study period, with DCI data available for 3,236,568 ED visits; 86.8% were younger than 45 years, 64.8% were females, and 54.6% non-Hispanic Whites. Over the study period, the proportion of ED visits due to attempted suicide was 0.3%. In the multivariate logistic regression, compared to prosperous zones, those in comfortable (OR = 0.80, 95% CI: 0.73-0.88, p < 0.01), Mid-Tier (OR = 0.76, 95%CI:0.67-0.86, p < 0.01), At-Risk (OR = 0.77; 95%CI: 0.65-0.92, p < 0.01) and Distressed zones (OR = 0.53; 95% CI:0.42-0.66, p < 0.01) were less likely to visit the ED for attempted suicide.

Conclusion

Prosperous communities had the highest rate of attempted suicides, with the risk of attempted suicide increasing as individuals move from the least prosperous to more prosperous areas.

Anticonvulsant Role of Adenosine is Blunted During Alcohol Withdrawal Syndrome in an Adult Zebrafish Model

Alcohol (ethanol) dependence and related disorders are life-threatening conditions and source of suffering for the user, family members and society. Alcohol withdrawal syndrome (AWS) is a little-known dynamic process associated with a high frequency of relapses. A state of hyperglutamatergic neurotransmission and imbalanced GABAergic function is related to an increased susceptibility to seizures during alcohol withdrawal. Adenosine signaling display an important role in endogenous response to decrease seizure and related damages. Here, an intermittent alcohol exposure regimen (1 h daily of 0.5% ethanol solution) for 16 days or 8 days of the same ethanol exposure regimen followed by 1 or 8 days of ethanol withdrawal was used to assess adenosine signaling in the context of seizure susceptibility using adult zebrafish. In both abstainer groups, a sub-convulsant dose of pentylenetetrazol (2.5 mM) was able to increase the frequency of animals reaching a clonic seizure-like state, while continuous-treated animals had no seizure, as did control animals. The total brain mRNA expression of A1 adenosine receptor was decreased in animals with 1 day of ethanol withdrawal. The agonism of A1 adenosine receptor induced an anticonvulsant effect in animals with 1 day of ethanol withdrawal after the injection of the specific agonist (N6-cyclopentyladenosine, 10 mg.Kg- 1; i.p.). These findings reinforce A1 adenosine receptor as a key target in acute alcohol withdrawal syndrome and zebrafish as an excellent platform to study biological mechanism of AWS.

One year of psychiatric presentations to a hospital emergency department during COVID-19

OBJECTIVES

To examine the impact of the first full year of the COVID-19 pandemic and its associated restrictions on the volume and nature of psychiatric presentations to an emergency department (ED) in a large academic hospital.

METHODS

Anonymised clinical data on psychiatric presentations to the ED were collected for the 52-week period from the start of the COVID-19 pandemic and compared with corresponding 1 year periods in 2019 and 2018.

RESULTS

There was a significant increase in psychiatric presentations overall to the ED during the first year of the COVID-19 pandemic compared to previous years, in contrast to a reduction in total presentations for all other specialties. There was a marked increase in psychiatric presentations of those below 18 years, and in the 30-39 years and 40-49 years age groups, but a decrease in the 18-29 years group. There was a significant increase in anxiety disorder presentations but a decrease in alcohol related presentations. There was no significant change observed in the rates of presentations for self-harm or suicidal ideation.

CONCLUSIONS

Psychiatric presentations to the ED have increased during the first year of the COVID-19 pandemic in contrast to a decrease in presentations for other medical specialties, with this increase being driven by out-of-hours presentations. The fourfold increase in presentations of young people below the age of 18 years to the ED with mental health difficulties is an important finding and suggests a disproportionate burden of psychological strain placed on this group during the pandemic.

Substance use and self-harm emergency department presentations during COVID19: evidence from a National Clinical Programme for Self-Harm

INTRODUCTION

Given the evidence that drinking patterns and self-harm hospital presentations have changed during COVID-19, this study aimed to examine any change in self-harm and suicide-related ideation presentations, together with any possible contribution made by alcohol or substance misuse, to Irish Emergency Departments in 2020, compared with 2018 and 2019.

METHODS

A population-based cohort with self-harm and suicide-related ideation presenting to Irish hospitals derived from the National Clinical Programme for Self-Harm was analysed. Descriptive analyses were conducted based on sociodemographic variables and types of presentation for the period January to August 2020 and compared with the same period in 2018 and 2019. Binomial regression analyses were performed to investigate the independent effect of demographic characteristics and pre/during COVID-19 periods on the use of substances as contributory factors in the self-harm and suicide-related ideation presentations.

RESULTS

12,075 presentations due to self-harm and suicide-related ideation were recorded for the periods January-August 2018-2020 across nine emergency departments. The COVID-19 year was significantly associated with substances contributing to self-harm and suicide-related ideation ED presentations (OR = 1.183; 95% CI, 1.075-1.301, p < 0.001). No changes in the demographic characteristics were found for those with self-harm or suicide-related ideation across the years. Suicide-related ideation seemed to be increased after May 2020 compared with previous years. In terms of self-harm episodes with comorbid drug and alcohol overdose and poisoning, these were significantly increased in January-August 2020, compared with previous timepoints (χ2 = 42.424, df = 6, p < 0.001).

CONCLUSION

An increase in suicide-related ideation and substance-related self-harm presentations may indicate longer term effects of the pandemic and its relevant restrictions. Future studies might explore whether those presenting with ideation will develop a risk of suicide in post-pandemic periods.

Mental Health in the Post-Lockdown Scenario: A Scientometric Investigation of the Main Thematic Trends of Research

Since the outbreak of COVID-19, researchers and clinicians have published scientific articles on the SARS-CoV-2 virus and its medical, organizational, financial, and psychological implications. However, many effects have been observed in the post-lockdown scenario. In this study, we adopted a scientometric-bibliometric approach to drawing the state of the art regarding the emotional and psychological effects of the pandemic after the lockdown. In Scopus, we found 791 papers that were subsequently analyzed using CiteSpace. The document co-citation analysis (DCA) computation generated a network of eight major clusters, each representing a central area of investigation. Specifically, one major cluster-cluster no. 1-focuses on the long-term effects of the COVID-19 pandemic and individuals' ability to develop adaptive coping mechanisms and resilience. The results allow us to frame the fields covered by researchers more precisely and the areas that still need more investigation.

Trends and Prevalence of Hospital Admissions Related to Deliberate Self-Poisoning and Used Substances in Romanian Adolescents between 2016 and 2022

Rates of self-poisoning are increasing substantially all around the world, with self-poisoning being the most common form of self-harm leading to hospitalization in children and adolescents. This study aims to investigate the trends in the number of deliberate self-poisoning admissions in Romanian adolescents during the period of 2016-2022, as well as the most frequently used substances and the impact of the COVID-19 pandemic on hospital admissions due to self-poisoning and substance use in relation to these episodes. The sample included 178 patients admitted to the Clinic of Pediatric Psychiatry in Cluj-Napoca from 2016 to 2022 due to an episode of self-poisoning. Data were collected on patients' sociodemographic characteristics, psychosocial characteristics, and medical histories. We report a slight overall increase in the self-poisoning admission rate during the studied period. There was a decrease during the initial period of the pandemic, with significantly increasing rates in the second year of the pandemic. The mean prevalence rate of hospital admissions due to self-poisoning episodes during the study period was 3.14% (95% CI 2.72, 3.63). Adolescent girls were identified as the most vulnerable group, with the female-to-male ratio increasing dramatically. In terms of substance use, benzodiazepines; over-the-counter analgesics, including paracetamol; and antidepressants were the most frequently used substances. We emphasize the importance of careful consideration in prescribing psychotropic drugs, as well as the need for regulation of over-the-counter drug dispensation.

Prevalence of suicidal behavior in a northeastern Mexican border population during the COVID-19 pandemic

Introduction

Before the pandemic, suicide was already considered a global public health problem. The outbreak of COVID-19, a coronavirus-related infectious disease, began to impact people's physical and mental health. The factors that either contribute to or mitigate this risk need to be better understood, and this can only be accomplished through research. Therefore, this study aimed to study the prevalence of suicidal ideation and behavior in Tamaulipas, Mexico, during the COVID-19 pandemic.

Methods

A quantitative, descriptive, and cross-sectional study was conducted. The sample consisted of 659 participants, of whom 194 (29.5%) were men and 465 (70.5%) participants were oldwomen, ranging in age between 16 and 68 years (M = 22.56, SD = 7.26). An adapted version of the Spanish version of the Columbia Suicidal Severity Rating Scale was used to assess the seriousness of suicidal ideation and behavior.

Results

The higher rates of suicidal indicators were suicidal ideation with "wish to dead" (39.9%), while the lower was suicidal ideation with a specific plan (8.2%). A total of 18.2% of participants reported "suicidal attempts before COVID-19," of whom 40% reported "suicidal attempts in the last 3 months." Suicidal behavior rates were lower: 13.7% of participants reported "non-specific preparatory behavior" and 13.3% reported "actual suicide attempts." Women were more likely than men to exhibit almost all indicators of suicidal ideation and behavior (OR = 1.63-2.54; 95% CI = 1.11-2.41, 1.76-3.68), as well as confinement (OR = 2.60; 95% CI = 1.73-3.91). Confinement for more than 40 days (OR = 0.55-0.66; 95% CI = 0.40-0.75, 0.47-0.93) and knowing a person infected with COVID-19 (OR = 1.57-2.01; 95% CI = 1.02-2.42, 1.20-3.34) were associated with a higher risk of exhibiting several suicidal indicators and having previously attempted suicide.

Conclusion

Being a woman, knowing a person infected with COVID-19, and being confined, especially for longer than 40 days, are all risk factors for suicidal ideation. Therefore, intervention programs are needed to reduce the suicide risk prevalence, especially these days because of the influence of the pandemic, and should be primarily focused on those who present the risk factors associated with suicidal behavior identified in this study.

The Impact of the COVID-19 Pandemic on Pediatric Mental Health Emergency

OBJECTIVE

The aim of this study was to compare pre/post-coronavirus disease 2019 pandemic changes in mental health-related visits to the pediatric emergency department.

MATERIALS AND METHODS

We conducted a retrospective analysis of all mental health-related pediatric emergency department visits to a tertiary general hospital between June and September 2019, 2020, and 2021. We described pre/post-coronavirus disease 2019 changes in the use of pediatric emergency departments, such as timing of visits, sex discrepancies, diagnostic distribution, discharge planning, and others.

RESULTS

Compared with the corresponding months before the pandemic (n = 187), mental health-related pediatric emergency department visits decreased by 20.8% in June-September 2020 (n = 148) and increased by 12.2% in 2021 (n = 210). The distributions of age, sex, timing of visits, reasons for presentations, hospitalization, and outpatient clinic appointment rates were not statistically significant between the years. Self-harm in females and aggression/violence in males were the most common reasons for presentation to pediatric emergency departments in each year. In the post-pandemic period, ambulance use and patients referred by other hospitals for psychiatric consultation increased, while the completion time of consultations decreased (P < .05). The frequency of attention-deficit hyperactivity disorder and depression decreased, but obsessive-compulsive disorder and anxiety disorders were more common in the post-pandemic period than in the corresponding months before the pandemic (P < .05).

CONCLUSION

Our results suggest that the coronavirus disease 2019 pandemic resulted in a significant change in mental health-related visits to the pediatric emergency department. Those in the groups with reduced visits may be at risk for delayed access to treatment for their mental and behavioral difficulties.

The profile, clinical characteristics, and outcomes of alcohol- and non-alcohol-related patient presentations to Queensland emergency departments: a multi-site observational study

Objective The harmful use of alcohol is a global issue. This study aimed to describe and compare the profiles, emergency department (ED) clinical characteristics, and outcomes of alcohol-related ED presentations (ARPs) and non-alcohol-related ED presentations (NARPs). Methods A multi-site observational study of all presentations to four EDs between 4 April 2016 and 31 August 2017, was conducted. Routinely collected ED clinical, administrative and costings data were used. Classification of ARPs were prospectively recorded by clinicians. Analysis was performed at the presentation, rather than person level. Univariate tests were undertaken to compare demographics, ED clinical characteristics and outcomes between ARPs and NARPs. Results A total of 418 051 ED presentations occurred within the 17-month study period; 5% (n  = 19 875) were ARPs. Presentations made by people classified as ARPs were younger, more likely to be male, present on weekends or at night, and arrive by ambulance or police compared to NARPs. Compared with NARPs, ARPs had a longer median ED length of stay of over 20 min (95% CI 18-22, median 196 min vs 177 min, P  < 0.001), a 5.5% (95% CI 4.9-5.3) lower admission rate (36% vs 42%, P  < 0.001), and a AUD69 (95% CI 64-75) more expensive ED episode-of-care (AUD689 vs AUD622, P  < 0.001). Conclusion Clinically meaningful differences were noted between alcohol-related and non-alcohol-related ED presentations. The higher cost of care for ARPs likely reflects their longer time in the ED. The healthcare and economic implications of incidents of alcohol-related harm extend beyond the ED, with ARPs having higher rates of ambulance and police use than NARPs.

Comparison of Mental Health Visits at a Military Treatment Facility Emergency Department Pre- and Post-COVID-19 Pandemic

INTRODUCTION

There is a paucity of quantitative research regarding the effect of coronavirus 2019 (COVID-19) on Emergency Department (ED) visits in the United States, and specifically mental health-related ED visits. The small existing body of research describes an overall decline in ED visits worldwide; however, there are anecdotal reports that psychiatric complaints to the ED have increased during the pandemic. The primary objective of this study was to describe the volume of mental health ED visits at a single ED during the COVID-19 pandemic compared to previous years.

MATERIALS AND METHODS

This was a single-center, retrospective chart review of adult patients evaluated in the ED at an academic military medical facility from March to December of 2017-2020 for mental health. The electronic medical record was queried for mental health International Classification of Diseases, 10th Revision diagnosis codes. Demographic data including age, gender, disposition, diagnosis, and beneficiary status were collected, and Pearson Chi-Square was used to assess for statistical significance between years.

RESULTS

There was a total of 1,486 mental health ED visits from March to December 2020, compared to an average of 1,668 visits from March to December 2017-2019. Statistically significant (P < 0.05) differences, between 2020 and the prior 3 years combined, were identified in the categories of age, disposition, beneficiary status, and diagnosis. In 2020, there was a lower proportion of visits for patients aged ≥60 (1.2%) than in 2017-2019 (2.5%). Active-duty patients comprised a higher proportion of mental health visits in 2020 (82.4%) versus 2017-2019 (77%). Proportionately fewer patients were admitted in 2020 (25.2%) versus 2017-2019 (29.2%). Adjustment disorders made up 19.0% of visits in 2020 versus 23.2% in 2017-2019, and suicidal ideation and intentional self-inflicted injury comprised 43.3% in 2020 compared with 40.4% in 2017-2019.

CONCLUSION

There was a significant decline in ED visits for patients over the age of 60 but a significant increase in visits for active-duty patients. Fewer patients were admitted compared to previous years. There was a significant increase in patients diagnosed with suicidal ideation and intentional self-inflicted injury in 2020 compared to previous years. Alarmingly, this study shows increased rates of self-harm and suicidal ideation. Further study is needed to determine why these effects were seen and if there is a higher risk for suicide attempt or completion in these populations. These results indicate that military leadership and the military health system is failing to adequately support and protect service members and their families during these uniquely stressful times. High-level attention to this issue by military leadership is required; the readiness and safety of the nation's fighting force is at stake.

Pandemics and Suicide Risk: Lessons From COVID and Its Predecessors

ABSTRACT

In its mortality and global reach, COVID-19 is among the worst pandemics to hit the globe since the 1918 influenza. During a pandemic, it is not uncommon for deaths from suicide to be downplayed as communities respond to the immediate mortality of the disease. In this analysis, we review pandemic history to uncover its impact on suicide rates, a frequent proxy for community mental health, and whether public health responses were effective. We incorporate lessons from more than 100 years of epidemics to assess whether the current public health response can benefit from the lessons of history.

Suicidality in psychiatric emergency department situations during the first and the second wave of COVID-19 pandemic

Psychiatric patients are prone to mental health deterioration during the Covid-19 pandemic. Little is known about suicidality in psychiatric patients during the Covid-19 pandemic. This study is a retrospective chart review of psychiatric emergency department (pED) presentations with present or absent suicidality (5634 pED attendances, 4110 patients) in an academic pED in Berlin, Germany. Poisson regression analysis was performed on the effect of Covid-19 period on suicidality (suicidal ideation (SI), suicide plans (SP) or suicide attempt (SA)) during the first (3/2/2020-5/24/2020 "first-wave") and second (9/15/2020-3/1/2021 "second-wave") wave of the Covid-19 pandemic compared to the same periods one year earlier. During the first-wave the number of pED visits per person with SI, SP and SA was higher compared to one year earlier (SI RR = 1.614; p = 0.016; SP RR = 2.900; p = 0.004; SA RR = 9.862; p = 0.003). SI and SP were predicted by interaction between substance use disorder (SUD) and second-wave (SI RR = 1.305, p = 0.043; SP RR = 1.645, p = 0.018), SA was predicted by interaction between borderline personality disorder (BPD) and second-wave (RR = 7.128; p = 0.012). Suicidality increased during the first-wave of Covid-19 pandemic in our sample. In the second-wave this was found in patients with SUD and BPD. These patients may be at particular risk of suicidality during the Covid-19 pandemic.

Toxicology presentations to a tertiary unit in New South Wales during the COVID-19 pandemic first wave: A retrospective comparison study

OBJECTIVE

To compare presentation numbers, class of exposure, poison severity score (PSS) and drugs ingested by patients in a tertiary toxicology service during the first wave of the COVID-19 pandemic to the corresponding time periods in 2018 and 2019.

METHODS

A retrospective cohort observational study of patients admitted or consulted to the Western Sydney Toxicology Service (WSTS) from ED during February to May in 2018-2020. Patient age, sex, triage category, time and date of arrival, mode of arrival, type of poisoning, discharge location, length of stay and PSS were collected from WSTS database and electronic medical records. The total number of ED presentations, hospital admissions and toxicology admissions were gathered from hospital-based data services.

RESULTS

There was an overall increase in toxicology presentations in February to May 2020 (n = 441) compared to 2019 (n = 333) and 2018 (n = 255). The daily rate of presentations increased in March to May 2020 with an overall rate ratio of 1.42, 95% confidence interval 1.23-1.63, P < 0.001. There was an increase in presentations across all drug types. From March to April 2020, there was significantly higher number of daily presentations for recreational drugs use compared to 2018.

CONCLUSION

There was a relative increase in toxicology presentations during the COVID-19 pandemic compared to an overall decrease in presentations to ED. Recreational drug use increased significantly during the pandemic compared to 2018.

Indirect COVID-19 health effects and potential mitigating interventions: Cost-effectiveness framework

Background

The COVID-19 pandemic led to important indirect health and social harms in addition to deaths and morbidity due to SARS-CoV-2 infection. These indirect impacts, such as increased depression and substance abuse, can have persistent effects over the life course. Estimated health and cost outcomes of such conditions and mitigation strategies may guide public health responses.

Methods

We developed a cost-effectiveness framework to evaluate societal costs and quality-adjusted life years (QALYs) lost due to six health-related indirect effects of COVID-19 in California. Short- and long-term outcomes were evaluated for the adult population. We identified one evidence-based mitigation strategy for each condition and estimated QALYs gained, intervention costs, and savings from averted health-related harms. Model data were derived from literature review, public data, and expert opinion.

Results

Pandemic-associated increases in prevalence across these six conditions were estimated to lead to over 192,000 QALYs lost and to approach $7 billion in societal costs per million population over the life course of adults. The greatest costs and QALYs lost per million adults were due to adult depression. All mitigation strategies assessed saved both QALYs and costs, with five strategies achieving savings within one year. The greatest net savings over 10 years would be achieved by addressing depression ($242 million) and excessive alcohol use ($107 million).

Discussion

The COVID-19 pandemic is leading to significant human suffering and societal costs due to its indirect effects. Policymakers have an opportunity to reduce societal costs and health harms by implementing mitigation strategies.

Suicide Presentations to an Emergency Department Pre and During the COVID Lockdown, March-May 2020, in Spain

The impact of the COVID-19 pandemic and lockdown may affect suicide risk and behavior. We compared suicide-related presentations during the national quarantine with pre-COVID data. This observational incidence study compared all suicide-related presentations at the University Hospital Reina Sofia emergency department (ED) in Cordoba, Spain, for the lockdown period from 15 March to 15 May 2020, with the same period in 2019. Descriptive and inferential analyses of case characteristics between 2019 and 2020 periods were conducted, and a multivariable logistic regression model developed. Results: Despite a decrease in overall ED cases during the lockdown, the number of suicide-related presentations stayed the same and represented a significantly larger proportion of cases in comparison to the pre-COVID period (0.42 vs. 0.87%, in 2019 and 2020, respectively; p < .001). The number presenting alone more than doubled during the COVID lockdown, increasing to 42.9% compared with 19.4% in 2019 (p = .002). An increase in presentations with a family history of suicide was also found. Conclusions: Suicide cases represented an increased proportion of ED cases during the lockdown. Presenting to ED alone, having a family history of suicide, habitual drug consumption, and hospital admission to ICU differentiated cases between pre and during COVID periods. These findings should be considered in light of the second wave and further implementation of lockdown measures.

Racial and demographic disparities in emergency department utilization for mental health concerns before and during the COVID-19 pandemic

This study investigated whether emergency department (ED) visits for mental health concerns increased during the COVID-19 pandemic, taking a health disparities lens. ED encounters from the only academic medical center in Mississippi were extracted from March-December 2019 and 2020, totaling 2,842 pediatric (ages 4-17) and 17,887 adult (ages 18-89) patients. Visits were coded based on primary ED diagnosis. For adults, there were fewer depression/anxiety ED visits during the pandemic, not moderated by any demographic factor, but no differences for serious mental illness or alcohol/substance use. For youth, there were significantly fewer ED visits for behavior problems during the pandemic among children in the lower socioeconomic status (SES) category; there were no differences for depression/anxiety. Regardless of year, adults in the lower SES category were more likely to visit the ED for mental health, Black adults were less likely to visit the ED for depression/anxiety or alcohol/substance use, and Black children were less likely to visit the ED for behavioral concerns. Results suggest that access to outpatient and telehealth services remains critical for mental health care during the pandemic and underline the importance of race- and SES-related factors in use of the ED for mental health concerns beyond the pandemic.

A Case of Phenibut Directed Detoxification Leading to Toxicity During the COVID-19 Pandemic

BACKGROUND

Phenibut is a non-Food and Drug Administration-approved gamma-aminobutyric acid analog marketed in the United States as an anxiolytic, cognitive enhancer, and alcohol withdrawal treatment through online supplement vendors. In this case report, we describe a woman's self-directed detoxification with phenibut used to manage withdrawal symptoms from fentanyl and benzodiazepines in March 2020 during the height of the COVID-19 pandemic.

CASE

A 38-year-old woman with severe opioid, benzodiazepine, gabapentin, stimulant use disorders developed altered mental status after oral phenibut ingestion intended to help self-manage opioid and benzodiazepine withdrawal. She chose self-directed detoxification as she feared COVID-19 exposure in detoxification facilities. Her altered mental status drove her to jump out a third-story window causing multiple spinal fractures. After a long hospitalization, she self-directed her discharge home due to concerns about COVID-19. Her premature discharge disrupted opioid and benzodiazepine use disorder treatment plans.

CONCLUSION

This case highlights the risks of phenibut use for selfdirected detoxification. With COVID-19 related changes in the drug supply, people may be more likely to use online pharmaceuticals, therefore, substance use assessments should inquire about the online acquisition of new psychoactive drugs. Public health messaging regarding the risks of infectious disease transmission in addiction care settings is needed to guide addiction treatment choices among people who use substances.

Changes in alcohol-related hospital visits during COVID-19 in New York City

BACKGROUND AND AIMS

Increased alcohol consumption has been proposed as a potential consequence of the coronavirus disease 2019 (COVID-19) pandemic. There has been little scrutiny of alcohol use behaviors resulting in hospital visits, which is essential to guide pandemic public policy. We aimed to determine whether COVID-19 peak restrictions were associated with increased hospital visits for alcohol use or withdrawal. Secondary objectives were to describe differences based on age, sex and race, and to examine alcohol-related complication incidence.

DESIGN

Multi-center, retrospective, pre-post study.

SETTING

New York City health system with five participating hospitals.

PARTICIPANTS

Adult emergency department encounters for alcohol use, alcoholic gastritis or pancreatitis or hepatitis, alcohol withdrawal syndrome, withdrawal seizure or delirium tremens.

MEASUREMENTS

Age, sex, race, site and encounter diagnosis. Encounters were compared between 2019 and 2020 for 1 March to 31 May.

FINDINGS

There were 2790 alcohol-related visits during the 2019 study period and 1793 in 2020, with a decrease in total hospital visits. Of 4583 alcohol-related visits, median age was 47 years, with 22.3% females. In 2020 there was an increase in percentage of visits for alcohol withdrawal [adjusted odds ratio (aOR) = 1.34, 95% confidence interval (CI) = 1.07-1.67] and withdrawal with complications (aOR = 1.40, 95% CI = 1.14-1.72), and a decline in percentage of hospital visits for alcohol use (aOR = 0.70, 95% CI = 0.59-0.85) and use with complications (aOR = 0.71, 95% CI = 0.58-0.88). It is unknown whether use visit changes mirror declines in other chief complaints. The age groups 18-29 and 60-69 years were associated with increased visits for use and decreased visits for withdrawal, as were non-white race groups. Sex was not associated with alcohol-related visit changes despite male predominance.

CONCLUSIONS

In New York City during the initial COVID-19 peak (1 March to 31 May 2020), hospital visits for alcohol withdrawal increased while those for alcohol use decreased.

Suicide, self-harm and suicidal ideation during COVID-19: A systematic review

We aimed to do a systematic review and meta-analysis of studies describing suicidal ideation, suicide attempts and suicide and associated risk factors during COVID-19 pandemic. We searched following electronic databases using relevant search terms: Medline, Embase, PsycInfo and CINAHL and systematically reviewed the evidence following PRISMA guidelines. The meta-analysis of prevalence of suicidal ideation was done using random effect model. The search returned 972 records, we examined 106 in full text and included 38 studies describing 120,076 participants. Nineteen studies described suicide or attempted self-harm, mostly in case reports. Out of 19 studies describing suicidal ideations, 12 provided appropriate data for meta-analysis. The pooled prevalence of suicidal ideation in these studies was 12.1% (CI 9.3-15.2). Main risk factors for suicidal ideations were: low social support, high physical and mental exhaustion and poorer self-reported physical health in frontline medical workers, sleep disturbances, quarantine and exhaustion, loneliness, and mental health difficulties. We provide first meta-analytic estimate of suicidal ideation based on large sample from different countries and populations. The rate of suicidal ideations during COVID pandemic is higher than that reported in studies on general population prior to pandemic and may result in higher suicide rates in future.

The impact of the COVID-19 pandemic on alcohol-related emergency department visits in the Netherlands: The ALCOVID study

INTRODUCTION

The ongoing COVID-19 pandemic has a profound impact on society and healthcare utilisation. Some studies found that alcohol consumption increased. While declines in non-COVID emergency department (ED) visits have been observed worldwide, little is known about the impact of the COVID-19 pandemic on the number of alcohol-related ED visits. We aimed to examine the changes in alcohol-related ED utilisation during the first year of the pandemic in the Netherlands. We assessed whether lockdowns, closure of the catering industry and alcohol bans were associated with changes in ED utilisation for alcohol-related emergencies.

METHODS

We performed a retrospective analysis of alcohol-related ED visits in a Dutch trauma level 2 centre, comparing the pandemic year 2020 and using the year 2019 as a reference. Alcohol-related ED visits were categorised as alcohol intoxication, alcohol-related trauma or a combination of both.

RESULTS

There was an absolute decline of 23.3% in alcohol-related ED visits during 2020 compared to 2019. The decline was most distinct during the second lockdown period (-60%, P ≤ 0.001), which included an alcohol ban. No significant differences were found in the type of alcohol-related ED visits. The proportion of alcohol-related ED visits remained similar (2.2% vs. 2%).

DISCUSSION AND CONCLUSIONS

Despite reports of higher alcohol consumption, we observed a reduction of alcohol-related ED visits during the COVID-19 pandemic. The decline was most distinct during the second lockdown period, which included an alcohol ban. Further prospective studies are warranted to examine this possible association.

Prevention of alcohol withdrawal seizure recurrence and treatment of other alcohol withdrawal symptoms in the emergency department: a rapid review

Background

Patients who experience harms from alcohol and other substance use often seek care in the emergency department (ED). ED visits related to alcohol withdrawal have increased across the world during the COVID-19 pandemic. ED clinicians are responsible for risk-stratifying patients under time and resource constraints and must reliably identify those who are safe for outpatient management versus those who require more intensive levels of care. Published guidelines for alcohol withdrawal are largely limited to the primary care and outpatient settings, and do not provide specific guidance for ED use. The purpose of this review was to synthesize published evidence on the treatment of alcohol withdrawal syndrome in the ED.

Methods

We conducted a rapid review by searching MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (1980 to 2020). We searched for grey literature on Google and hand-searched the conference abstracts of relevant addiction medicine and emergency medicine professional associations (2015 to 2020). We included interventional and observational studies that reported outcomes of clinical interventions aimed at treating alcohol withdrawal syndrome in adults in the ED.

Results

We identified 13 studies that met inclusion criteria for our review (7 randomized controlled trials and 6 observational studies). Most studies were at high/serious risk of bias. We divided studies based on intervention and summarized evidence narratively. Benzodiazepines decrease alcohol withdrawal seizure recurrence and treat other alcohol withdrawal symptoms, but no clear evidence supports the use of one benzodiazepine over another. It is unclear if symptom-triggered benzodiazepine protocols are effective for use in the ED. More evidence is needed to determine if phenobarbital, with or without benzodiazepines, can be used safely and effectively to treat alcohol withdrawal in the ED. Phenytoin does not have evidence of effectiveness at preventing withdrawal seizures in the ED.

Conclusions

Few studies have evaluated the safety and efficacy of pharmacotherapies for alcohol withdrawal specifically in the ED setting. Benzodiazepines are the most evidence-based treatment for alcohol withdrawal in the ED. Pharmacotherapies that have demonstrated benefit for treatment of alcohol withdrawal in other inpatient and outpatient settings should be evaluated in the ED setting before routine use.

Effects of the 2020 health crisis on acute alcohol intoxication: A nationwide retrospective observational study

BACKGROUND

Recent data suggest that the COVID-19 pandemic and associated restrictions may have influenced alcohol use and promoted addictive behavior. We aimed to investigate the impact of the pandemic on acute alcohol intoxication (AAI) in France.

METHODS

We identified all hospital stays related to alcohol abuse in 2018-2020. Differences in number of hospitalizations between 2019 and 2020 were tested using Poisson regressions. Differences between observed and expected deliveries of drugs used in alcohol dependence in 2020 were also studied.

RESULTS

There was a decrease in the number of hospitalizations for AAI between 2019 and 2020 (-9677[-11·4%],RR:0·89[0·88-0·89]). This decrease was observed among men and women of all age groups, except women ≥ 85 years. We observed an increase in in-hospital mortality during 2020 and more hospitalizations for AAI with certain medical complications, especially during the first 2020 lockdown. There was a drop in observed deliveries of drugs used in alcohol dependence during the first 2020 lockdown.

CONCLUSIONS

The decrease in the number of hospitalizations for AAI in 2020 could be explained by several factors: fewer available hospital beds due to COVID-19, individuals with AAI delaying or avoiding medical care due to COVID-19 fears, and decreases driven by younger age groups returning to live with parents and socializing less. While alcohol consumption patterns have changed with the implementation of social distancing measures and lockdowns, the increase in mortality and the share of hospitalizations with complications suggest that these measures had an impact on event severity in a context of strained access to healthcare.

New ways of working: COVID-19 as a catalyst for change in acute mental health services

Background

A need arose to divert patients with psychiatric complaints from the emergency department to alternative settings for psychiatric consultations to reduce footfall during COVID-19. We assessed the effectiveness of alternative referral pathway in reducing COVID-19 infection in our service and its effect on service quality: response time and number of patients leaving before the review. We evaluated the satisfaction of patients, general practitioners (GPs) and mental health service staff with the pathway.

Methods

All patients referred to the mental health service over a 2-month period following the introduction of the pathway were included. Findings were compared against the cohort referred for emergency assessment during the same period in 2019. Feedback surveys were distributed to patients, staff and GPs. χ2 and independent sample t-test were used to compare the variables.

Results

Over 2 months, 255 patients received an emergency assessment via the pathway, representing a 22.3% decrease in the volume of presentations from the same period in 2019. There were no COVID-19 cases among our patients or staff on the roster for assessing patients. In comparison to 2019, response times were improved (p<0.001), and the numbers of patients who left the hospital before the review were reduced by 3.2% during the study period (p<0.001). Patients and GPs were highly satisfied with the referral pathway and believed that the pathway should be retained post-COVID-19. Mental health service staff were divided in their opinions about its sustainability.

Conclusion

The pathway was successful in reducing the spread of infection, improving response times and reducing the numbers of patients who left without an assessment. Given the improved outcomes and acceptability, this is a preferable pathway for emergency referrals into the future.

Opioid overdose crises during the COVID-19 pandemic: implication of health disparities

Background

Recent data suggest a disproportionate impact of opioid overdoses on Black Americans. The study aims to describe emergency department (ED) visits at a Southern, urban ED pertaining to opioid overdose and associated health disparities.

Methods

Patients presenting to the ED at the University of Alabama at Birmingham Hospital with opioid overdoses from January 1 to October 31, 2019, and from January 1 to October 31, 2020, were identified from electronic medical records.

Results

The total number of opioid overdose visits increased 9.7% (556 to 611) between January and October 2020 compared with 2019. Among patients who presented with opioid overdose, the mean ages were 50.3 years and 48.3 years, in 2019 and 2020, respectively. In both 2019 and 2020, more Blacks than whites were treated for opioid overdose in the ED (284 vs. 258 in 2019, and 306 vs. 271 in 2020) although 28 patients did not record their race in 2020. Consistently, more overdose deaths were observed in Blacks than in whites in 2020. More individuals seeking opioid overdose treatment were single in both years.

Conclusions

The study reported a greater number of visits for opioid overdoses from January to October of 2020 in an ED of a southeastern region, as well as higher overdose deaths in Blacks. Our findings highlight the importance of substance use treatment, harm reduction, and overdose prevention efforts that should be immediately present to reduce opioid overdose, especially for vulnerable populations in the South, i.e., Black community, and individuals experiencing singlehood.

How prescribing available pharmacotherapies for alcohol use disorder can impact the healthcare system: A retrospective quality improvement study

Alcohol use disorder is a multifactorial undertreated chronic disorder influenced by genetic, psychological, and environmental factors. Numerous pharmacotherapies are available and effective but are underutilized in healthcare. The purpose of this retrospective quality improvement study is to determine the impact of education sessions on the availability and efficacy of medications (focusing on Naltrexone) to treat alcohol use disorder in the healthcare system. Control charts were implemented to monitor the system change in two comparable urban areas. Dispensing rates increased at three points after a series of presentations. The first increase from baseline was 2.47 times, the second 3.7, and the third 4.81. Coinciding with these, weekly visits to the emergency department also decreased by 35% and stabilized at a 15% reduction. It was also observed that alcohol use disorder hospital admission rates decreased by 21%, but bounced back once the education sessions ended. Combined with counselling, pharmacotherapies can be effective in combating alcohol use disorder, while potentially reducing demands on the healthcare system.

Emergency department presentations in the Southern District of New Zealand during the 2020 COVID-19 pandemic lockdown

OBJECTIVE

To assess changes in presentations to EDs during the COVID-19 pandemic lockdown in the Southern Region of New Zealand.

METHODS

We conducted a retrospective audit of patients attending EDs in the Southern District Health Board (SDHB), from 1 March to 13 May 2020. We made comparisons with attendances during the same period in 2019. The 2020 study period included 'pre-lockdown' (1 March-25 March), 'level 4 (strict) lockdown' (26 March-27 April) and 'level 3 (eased) lockdown' (28 April-13 May).

RESULTS

Patient volumes reduced in all SDHB EDs during levels 4 and 3, mostly representing a loss of low acuity patients (Australasian Triage Scale 3, 4 and 5), although high-acuity presentations also declined. Average patient age increased by 5 years; however, the proportions of sexes and ethnicities did not change. Presentations of cerebrovascular accidents and appendicitis did not change significantly. Trauma, mental health, acute coronary syndrome and infectious respiratory presentations decreased significantly during level 4, and infectious respiratory presentations decreased further in level 3.

CONCLUSIONS

Within the SDHB, patient volumes reduced during levels 4 and 3 of our lockdown, with reduced low-acuity presentations. High-acuity patient numbers also declined. Trauma, mental health, alcohol-related, infectious respiratory and acute coronary syndrome presentations declined while cerebrovascular accident and appendicitis numbers showed little to no change.

Suicide prevention during COVID-19: identification of groups with reduced presentations to emergency departments

OBJECTIVE

Reductions in suicidal and self-harm presentations to emergency departments (EDs) since COVID-19 indicate changes in help-seeking behaviours, but it is unknown if hospital avoidance equally affects all population groups.

METHOD

Socio-demographic and clinical information relating to suicidal and self-harm presentations to EDs in Queensland, Australia, were compared for the period before (March-August 2019) and since the COVID-19 outbreak (March-August 2020).

RESULTS

Since COVID, Indigenous Australians and persons with less severe suicidal and self-harm presentations had significantly reduced presentations, while persons younger than 18 years had more presentations. Less suicidal presentations resulted in an admission to inpatient care.

CONCLUSIONS

Patterns of reduced attendance to ED in some groups suggest the need for innovative and community-based models of care to help prevent suicides during the pandemic.

Impact of the COVID-19 pandemic on suicide and self-harm among patients presenting to the emergency department of a teaching hospital in Nepal

The COVID-19 pandemic is a global challenge that is not just limited to the physical consequences but also a significant degree of a mental health crisis. Self-harm and suicide are its extreme effects. We aim to explore the impact of this pandemic on suicide and self-harm in our Emergency Department. A cross-sectional study was conducted including all fatal and nonfatal self-harm patients presenting to the emergency department during the lockdown period (March 24-June 23, 2020; Period1), matching periods in the previous year (March 24-June 23,2019; Period 2) and 3 months period prior (December 24 2019-March 23, 2020; Period 3) were included through the electronic medical record system. The prevalence and the clinical profile were compared between these three periods. A total of 125 (periods 1 = 55, 2 = 38, and 3 = 32) suicide and self-harm cases were analyzed. Suicide and self-harm had increased by 44% and 71.9% during the lockdown in comparison to periods 2 and 3. Organophosphate poisoning was the most common mode. Females were predominant in all three periods with a mean age of 32 (95%CI: 29.3–34.7). There was a significant delay in arrival of the patients in period 1 (p = 0.045) with increased hospital admission (p = 0.003) and in-hospital mortality (18.2% vs 2.6% and 3.1%) (p<0.001). Our study showed an increase in suicide and self-harm cases in the emergency department during the initial phase of the COVID-19 pandemic which may reflect the increased mental health crisis in the community in low resource settings like Nepal. This study highlights the importance of priming all mental health care stakeholders to initiate mental health screening and intervention for the vulnerable population during this period of crisis.

Suicide, self-harm and thoughts of suicide or self-harm in infectious disease epidemics: a systematic review and meta-analysis

AIMS

Suicide accounts for 2.2% of all years of life lost worldwide. We aimed to establish whether infectious epidemics are associated with any changes in the incidence of suicide or the period prevalence of self-harm, or thoughts of suicide or self-harm, with a secondary objective of establishing the frequency of these outcomes.

METHODS

In this systematic review and meta-analysis, MEDLINE, Embase, PsycINFO and AMED were searched from inception to 9 September 2020. Studies of infectious epidemics reporting outcomes of (a) death by suicide, (b) self-harm or (c) thoughts of suicide or self-harm were identified. A random-effects model meta-analysis for the period prevalence of thoughts of suicide or self-harm was conducted.

RESULTS

In total, 1354 studies were screened with 57 meeting eligibility criteria, of which 7 described death by suicide, 9 by self-harm, and 45 thoughts of suicide or self-harm. The observation period ranged from 1910 to 2020 and included epidemics of Spanish Flu, severe acute respiratory syndrome, human monkeypox, Ebola virus disease and coronavirus disease 2019 (COVID-19). Regarding death by suicide, data with a clear longitudinal comparison group were available for only two epidemics: SARS in Hong Kong, finding an increase in suicides among the elderly, and COVID-19 in Japan, finding no change in suicides among children and adolescents. In terms of self-harm, five studies examined emergency department attendances in epidemic and non-epidemic periods, of which four found no difference and one showed a reduction during the epidemic. In studies of thoughts of suicide or self-harm, one large survey showed a substantial increase in period prevalence compared to non-epidemic periods, but smaller studies showed no difference. As a secondary objective, a meta-analysis of thoughts of suicide and self-harm found that the pooled prevalence was 8.0% overall (95% confidence interval (CI) 5.2-12.0%; 14 820 of 99 238 cases in 24 studies) over a time period of between seven days and six months. The quality assessment found 42 studies were of high quality, nine of moderate quality and six of high quality.

CONCLUSIONS

There is little robust evidence on the association of infectious epidemics with suicide, self-harm and thoughts of suicide or self-harm. There was an increase in suicides among the elderly in Hong Kong during SARS and no change in suicides among young people in Japan during COVID-19, but it is unclear how far these findings may be generalised. The development of up-to-date self-harm and suicide statistics to monitor the effect of the current pandemic is an urgent priority.

Self-harm during the early period of the COVID-19 pandemic in England: Comparative trend analysis of hospital presentations

BACKGROUND

The COVID-19 pandemic and public health measures necessary to address it may have major effects on mental health, including on self-harm. We have used well-established monitoring systems in two hospitals in England to investigate trends in self-harm presentations to hospitals during the early period of the pandemic.

METHOD

Data collected in Oxford and Derby on patients aged 18 years and over who received a psychosocial assessment after presenting to the emergency departments following self-harm were used to compare trends during the three-month period following lockdown in the UK (23^rd March 2020) to the period preceding lockdown and the equivalent period in 2019.

RESULTS

During the 12 weeks following introduction of lockdown restrictions there was a large reduction in the number of self-harm presentations to hospitals by individuals aged 18 years and over compared to the pre-lockdown weeks in 2020 (mean weekly reduction of 13.5 (95% CI 5.6 - 21.4) and the equivalent period in 2019 (mean weekly reduction of 18.0 (95% CI 13.9 - 22.1). The reduction was greater in females than males, occurred in all age groups, with a larger reduction in presentations following self-poisoning than self-injury.

CONCLUSIONS

A substantial decline in hospital presentations for self-harm occurred during the three months following the introduction of lockdown restrictions. Reasons could include a reduction in self-harm at the community level and individuals avoiding presenting to hospital following self-harm. Longer-term monitoring of self-harm behaviour during the pandemic is essential, together with efforts to encourage help-seeking and the modification of care provision.

Trends in suicide rates during the COVID-19 pandemic restrictions in a major German city

AIMS

It remains unclear whether the coronavirus disease 2019 (COVID-19) pandemic is having an impact on suicide rates (SR). Economic insecurity and mental disorders are risk factors for suicide, which may increase during the pandemic.

METHODS

Data on suicide events in a major city in Germany, and the corresponding life years (LY) were provided by the local authorities. For the year 2020, periods without restrictions on freedom of movement and social contact were compared with periods of moderate and severe COVID-19 restrictions. To avoid distortions due to seasonal fluctuations and linear time trends, suicide risk during the COVID-19 pandemic was compared with data from 2010 to 2019 using an interrupted time series analysis.

RESULTS

A total of 643 suicides were registered and 6 032 690 LY were spent between 2010 and 2020. Of these, 53 suicides and 450 429 LY accounted for the year 2020.In 2020, SR (suicides per 100 000 LY) were lower in periods with severe COVID-19 restrictions (SR = 7.2, χ2 = 4.033, p = 0.045) compared with periods without restrictions (SR = 16.8). A comparison with previous years showed that this difference was caused by unusually high SR before the imposition of restrictions, while SR during the pandemic were within the trend corridor of previous years (expected suicides = 32.3, observed suicides = 35; IRR = 1.084, p = 0.682).

CONCLUSIONS

SR during COVID-19 pandemic are in line with the trend in previous years. Careful monitoring of SR in the further course of the COVID-19 crisis is urgently needed. The findings have regional reference and should not be over-generalised.

Beam Me Out: Review of Emergency Department Telepsychiatry and Lessons Learned During COVID-19

PURPOSE OF REVIEW

The aim of this review is to critically evaluate recent literature on the use of telepsychiatry in emergency departments (EDTP) and synthesize the evidence on telepsychiatry during public health emergencies. We also report on experiences and success stories from a state-wide EDTP program in South Carolina during the COVID-19 pandemic.

RECENT FINDINGS

We identified 12 peer-reviewed articles published between January 2019 and February 2021 that evaluated EDTP interventions and their impact on patient outcomes. The recent evidence on EDTP shows a significant association between EDTP implementation or use and decreased patients' wait time in emergency department (ED), shorter length of stay in certain settings, reduced ED revisit rates, improved ED patient disposition (e.g., more discharge to home, less observational stays, and decreased inpatient admissions), and reduced follow-up encounters involving self-harm diagnosis. The EDTP virtual delivery model can help healthcare systems reduce burden of public health emergencies on providers, staff, and patients alike. While a disruption of magnitude seen by COVID-19 may be infrequent, strategies used during the pandemic may be implemented to enhance care in rural settings, and/or enhance preparedness of communities and healthcare systems during more commonly occurring natural disasters.

Impact of Pandemics/Epidemics on Emergency Department Utilization for Mental Health and Substance Use: A Rapid Review

Background: A prolonged COVID-19 pandemic has the potential to trigger a global mental health crisis increasing demand for mental health emergency services. We undertook a rapid review of the impact of pandemics and epidemics on emergency department utilization for mental health (MH) and substance use (SU). Objective: To rapidly synthesize available data on emergency department utilization for psychiatric concerns during COVID-19. Methods: An information specialist searched Medline, Embase, Psycinfo, CINAHL, and Scopus on June 16, 2020 and updated the search on July 24, 2020. Our search identified 803 abstracts, 7 of which were included in the review. Six articles reported on the COVID-19 pandemic and one on the SARS epidemic. Results: All studies reported a decrease in overall and MH related ED utilization during the early pandemic/epidemic. Two studies found an increase in SU related visits during the same period. No data were available for mid and late stage pandemics and the definitions for MH and SU related visits were inconsistent across studies. Conclusions: Our results suggest that COVID-19 has resulted in an initial decrease in ED visits for MH and an increase in visits for SU. Given the relative paucity of data on the subject and inconsistent analytic methods used in existing studies, there is an urgent need for investigation of pandemic-related changes in ED case-mix to inform system-level change as the pandemic continues.

Alcohol Use and COVID-19: Can we Predict the Impact of the Pandemic on Alcohol Use Based on the Previous Crises in the 21st Century? A Brief Review

The enormous health and economic challenges precipitated by the 2019 coronavirus disease (COVID-19) pandemic are comparable or even greater than those associated with previous historical world crises. Alcohol use, especially drinking to cope with stress, is a concern, as an increase in its sales has been reported in some countries during the quarantine. This study aims to provide a better understanding of what to expect in terms of alcohol consumption, risk factors for excessive use, and its potential consequences during this pandemic based on previous experiences. We investigated how traumatic events related to alcohol consumption. Studies on mass traumatic events (i.e., terrorism as 9/11), epidemic outbreaks (i.e., severe acute respiratory syndrome [SARS] in 2003), economic crises (such as 2008's Great Recession), and COVID-19 were selected. The main keywords used to select the studies were alcohol use, drinking patterns, alcohol use disorders, and alcohol-related consequences. Previous studies reported increases in alcohol use associated with those events mediated, at least partially, by anxiety and depressive symptoms, and posttraumatic stress disorder (PTSD). Being male, young, and single also seems to be associated with a higher vulnerability to develop risky drinking behavior after those tragic events. The discussion of previous risk and protective factors can contribute to elaborate more specific public health policies to mitigate the impact of the current pandemic on people's mental health, especially alcohol-related problems.

Alcohol Consumption during the COVID-19 Pandemic: A Cross-Sectional Survey of US Adults

Emerging but limited evidence suggests that alcohol consumption has increased during the COVID-19 pandemic. This study assessed: (1) whether drinking behaviors changed during the pandemic; and, (2) how those changes were impacted by COVID-19-related stress. We conducted a cross-sectional online survey with a convenience sample of U.S. adults over 21 years in May 2020. We conducted adjusted linear regressions to assess COVID-19 stress and alcohol consumption, adjusting for gender, race, ethnicity, age, and household income. A total of 832 responded: 84% female, 85% White, and 72% ages 26-49. Participants reported consuming 26.8 alcohol drinks on 12.2 of the past 30 days. One-third of participants (34.1%) reported binge drinking and 7.0% reported extreme binge drinking. Participants who experienced COVID-19-related stress (versus not) reported consuming more drinks (β = 4.7; CI (0.2, 9.1); p = 0.040) and a greater number of days drinking (β = 2.4; CI (0.6, 4.1); p = 0.007). Additionally, 60% reported increased drinking but 13% reported decreased drinking, compared to pre-COVID-19. Reasons for increased drinking included increased stress (45.7%), increased alcohol availability (34.4%), and boredom (30.1%). Participants who reported being stressed by the pandemic consumed more drinks over a greater number of days, which raises concerns from both an individual and public health perspective.

The impact of the COVID-19 pandemic on self-harm and suicidal behaviour: a living systematic review

Background: The COVID-19 pandemic has caused morbidity and mortality, as well as, widespread disruption to people's lives and livelihoods around the world. Given the health and economic threats posed by the pandemic to the global community, there are concerns that rates of suicide and suicidal behaviour may rise during and in its aftermath. Our living systematic review (LSR) focuses on suicide prevention in relation to COVID-19, with this iteration synthesising relevant evidence up to June 7 th 2020. Method:  Automated daily searches feed into a web-based database with screening and data extraction functionalities. Eligibility criteria include incidence/prevalence of suicidal behaviour, exposure-outcome relationships and effects of interventions in relation to the COVID-19 pandemic. Outcomes of interest are suicide, self-harm or attempted suicide and suicidal thoughts. No restrictions are placed on language or study type, except for single-person case reports. Results: Searches identified 2070 articles, 29 (28 studies) met our inclusion criteria, of which 14 articles were research letters or pre-prints awaiting peer review. All articles reported observational data: 12 cross-sectional; eight case series; five modelling; and three service utilisation studies. No studies reported on changes in rates of suicidal behaviour. Case series were largely drawn from news reporting in low/middle income countries and factors associated with suicide included fear of infection, social isolation and economic concerns.   Conclusions:  A marked improvement in the quality of design, methods, and reporting in future studies is needed. There is thus far no clear evidence of an increase in suicide, self-harm, suicidal behaviour, or suicidal thoughts associated with the pandemic. However, suicide data are challenging to collect in real time and economic effects are evolving. Our LSR will provide a regular synthesis of the most up-to-date research evidence to guide public health and clinical policy to mitigate the impact of COVID-19 on suicide. PROSPERO registration: CRD42020183326 01/05/2020.

The impact of the COVID-19 pandemic on self-harm and suicidal behaviour: update of living systematic review

Background: The COVID-19 pandemic has caused considerable morbidity, mortality and disruption to people's lives around the world. There are concerns that rates of suicide and suicidal behaviour may rise during and in its aftermath. Our living systematic review synthesises findings from emerging literature on incidence and prevalence of suicidal behaviour as well as suicide prevention efforts in relation to COVID-19, with this iteration synthesising relevant evidence up to 19 th October 2020. Method:  Automated daily searches feed into a web-based database with screening and data extraction functionalities. Eligibility criteria include incidence/prevalence of suicidal behaviour, exposure-outcome relationships and effects of interventions in relation to the COVID-19 pandemic. Outcomes of interest are suicide, self-harm or attempted suicide and suicidal thoughts. No restrictions are placed on language or study type, except for single-person case reports. We exclude one-off cross-sectional studies without either pre-pandemic measures or comparisons of COVID-19 positive vs. unaffected individuals. Results: Searches identified 6,226 articles. Seventy-eight articles met our inclusion criteria. We identified a further 64 relevant cross-sectional studies that did not meet our revised inclusion criteria. Thirty-four articles were not peer-reviewed (e.g. research letters, pre-prints). All articles were based on observational studies. There was no consistent evidence of a rise in suicide but many studies noted adverse economic effects were evolving. There was evidence of a rise in community distress, fall in hospital presentation for suicidal behaviour and early evidence of an increased frequency of suicidal thoughts in those who had become infected with COVID-19. Conclusions:  Research evidence of the impact of COVID-19 on suicidal behaviour is accumulating rapidly. This living review provides a regular synthesis of the most up-to-date research evidence to guide public health and clinical policy to mitigate the impact of COVID-19 on suicide risk as the longer term impacts of the pandemic on suicide risk are researched.