Community Mental Health – Before & After COVID-19

Dialogues in Psychiatry

Dr Roberto Galea discusses a local study investigating the impact COVID-19 had on community psychiatry.

While society is attempting to return to its previous conventional customs, we cannot but notice that despite our efforts, remnants of behavioural and psychological changes brought about by COVID-19 persist. COVID-19 required several containment measures which disrupted our daily activities and interactions with an attendant impact on mental health, as well as health services. The first wave of the pandemic hit Malta between 6 March and 24 April 2020 while public health measures were first announced on 12 March 2020. During the first wave, psychiatry outpatient clinics at Mater Dei Hospital were suspended with telepsychiatry taking over followed by significant restructuring of community mental healthcare services. A recent local study investigated the effect COVID-19 had on first contact community psychiatry referrals to a local Mental Health Clinic (MHC) before and after the onset of COVID-19 looking into; referrals, case presentation, demographics, as well as the respective adequacy of the service response.

Participants were identified through the MHC register from 11 March 2019 to 31 December 2020. Data was cross referenced with electronic medical records, while the imposition of public health measures on 12 March 2020 was used to separate the before and after the onset of COVID-19. A total of 236 new cases were identified (92 before & 144 after COVID-19).

The proportion of new case referrals for men aged 60-80 and women aged 60–70 years old have increased, reflecting health-related anxieties, the associated isolation of older persons due to both COVID-19 and public health restrictions together with the increased vulnerability and fragility of this population. However, the proportion of working age adults remained stable. This may be due to a lag and would thus benefit from further research.

Throughout the study most clients attending this MHC were Maltese nationals. Individuals from central and Eastern Europe significantly decreased following the onset of the pandemic, while the number of British citizens remained unchanged. Such numbers were in keeping with the authors’ expectations. Tendentially, central and Eastern Europeans are younger/middle aged workers who would return home if their job security were threatened while UK citizens tend to be longer-term residents.

Following the onset of COVID-19 there was a shift in the presenting complaints received. The commonest, anxiety dropped from 38% to 32% while depression increased from 33% to 40% – becoming the predominant presentation. Similar variations were also noted in psychosis (2 to 4%) and alcohol misuse which also dropped by half.

The study differentiated between three phases – before the onset of the pandemic, during the first wave and six months after. The closure of the Psychiatric Outpatients Department at Mater Dei Hospital meant that clients had to be redistributed to community mental health clinics. While this shift achieved better social distancing, limited potential COVID-19 transmission, and allowed service provision in the clients’ communities (bringing services into close-knit communities); the increased psychological impact COVID-19 had on our communities resulted in increased appointment rates, which put further strains on community mental health services, requiring service to adapt to these new requirements.

Service alteration secondary to disruptions due to pandemic-mandated isolation measures were significant confounding factors in the waiting time for appointments and thus this study. These changes resulted in a collective rise of a fivefold increase in demand in MHC services. To meet these challenges, clinic frequency was increased and staff re-deployed, increasing the monthly capacity of new case appointment reviews from 7 to 20 cases. A threefold increase in new case appointments has increased the burden of the clinic that was met through a fivefold increase in clinic frequency. Waiting time has decreased from a mean of 21.6 weeks before the onset of COVID-19 to 7.4 weeks. Constituting a 66% drop in waiting time despite a threefold increase in workload.

In conclusion, the COVID-19 pandemic resulted in significant challenging changes and difficulties for the community, health-service provision, and the staff who without faltering endured through such times. However, through major restructuring these challenges were tackled with psychiatric services being de-centralised into community MHCs and increased clinic frequency, successfully meeting a three-fold increase in new case appointments while decreasing the waiting time between referral and review by two thirds. This study investigated the associated impact early stages of the COVID-19 pandemic had on our community, further research investigating this pandemic had throughout its course is warranted.