Increased use of EDs for mental health during COVID underscored systemic gaps in care: study

People with mental health conditions may have a more difficult time adapting to public health emergencies, as evidenced by the COVID-19 pandemic, and that may indicate that they have a more limited safety net overall, a new study suggests.

The cross-sectional study by researchers with the University of California looked at data from the Department of Health and Human Services that tracked emergency department visits in 10 regions during 11-week increments from January 1, 2019 to December 31, 2021.

The regions studied were Boston, New York, Philadelphia, Atlanta, Chicago, Dallas, Kansas City, Denver, San Francisco and Seattle. In the 10 regions, statistically significant changes were seen in non-mental health and mental health-related ED visits, with the mean total number of ED visits decreasing by 45,117 visits per region in the weeks after the pandemic struck compared to the same weeks in 2019.

The number of mental health ED visits decreased 23% in weeks 12 to 23 of 2020 and hadn’t returned to pre-pandemic levels as of December 2021. Because total ED visits for all causes decreased greatly in those weeks the proportion of mental health-related ED visits rose from 8% in 2019 to 9% in 2020 but then decreased again to 7% in 2021.

Corresponding author Renee Y. Hsia, M.D., told Fierce Healthcare in an email that the fact that non-mental health ED visits decreased more than mental health ED visits indicates that the “demand for mental health emergencies was less elastic than other ED visits, meaning that there is a critical need for mental health services that needs to be addressed. Our findings show that the pandemic unmasked this underlying need for mental healthcare since these mental health emergencies did not have alternative sources of care.”

U of California
Renee Hsia, M.D. (University of California)

Researchers found that after COVID-19 was declared a global pandemic in March 2020, total ED and mental health-related ED visits dropped drastically compared to the same timeframe in 2019—by 39% during weeks 12 to 23 in 2020.

“One of the first things we were surprised from this study, even as authors and practitioners in the field, is that mental health visits constituted 8% of all ED visits,” said Hsia, a professor at the University of California, who also works as an attending physician at San Francisco General Hospital and Trauma Center.

The fact that eight out of 100 ED visits is mental health-related is significant because EDs take care of “all comers, meaning that we take care of patients from car crashes, trauma, falls, as well as patients with shortness of breath such as asthma and pneumonia, to patients with chest pain such as heart attacks and aortic ruptures, to abdominal pain such as infections and surgical emergencies,” said Hsia.

The study found that the mean number of weekly ED visits was 135,260 in 2019 and decreased to 115,277 in 2020 once the global pandemic was declared. The number of total ED visits in 2021 started lower than in 2020 and 2019 but eventually returned to 2019 levels during weeks 24 to 35, a mean of 128,022 visits per week, according to the study.

Hsia said that “we hope that our findings allow the public and policymakers and all stakeholders to recognize the importance and the magnitude of providing adequate mental healthcare services in the community so that people in crisis are not driven to the ED as their only source of care.”

She said that EDs are often the first and last resort of care, and EDs swamped with patients could possibly detract from the quality of that care.

“Documenting the extent of the need is the first step in identifying solutions for how we can better provide care for those in need, with mental health and non-mental health emergencies,” said Hsia.