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Cited by 129COVID-19 and Mental HealthCOVID-19 and healthcare impactsMental Health Treatment and Access

The early impact of COVID-19 on mental health and community physical health services and their patients' mortality in Cambridgeshire and Peterborough, UK.

Open access
Chen, Shanquan, Jones, Peter B., Underwood, Benjamin R., Moore, Anna, Bullmore, Edward T., Banerjee, Soumya, Osimo, Emanuele F., Deakin, Julia B. +6 more·2020·Journal of Psychiatric Research
DOI 10.1016/j.jpsychires.2020.09.020PMC PMC7508053
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Abstract

Background COVID-19 has affected social interaction and healthcare worldwide.Methods We examined changes in presentations and referrals to the primary provider of mental health and community health services in Cambridgeshire and Peterborough, UK (population ~0·86 million), plus service activity and deaths. We conducted interrupted time series analyses with respect to the time of UK "lockdown", which was shortly before the peak of COVID-19 infections in this area. We examined changes in standardized mortality ratio for those with and without severe mental illness (SMI).Results Referrals and presentations to nearly all mental and physical health services dropped at lockdown, with evidence for changes in both supply (service provision) and demand (help-seeking). This was followed by an increase in demand for some services. This pattern was seen for all major forms of presentation to liaison psychiatry services, except for eating disorders, for which there was no evidence of change. Inpatient numbers fell, but new detentions under the Mental Health Act were unchanged. Many services shifted from face-to-face to remote contacts. Excess mortality was primarily in the over-70s. There was a much greater increase in mortality for patients with SMI, which was not explained by ethnicity.Conclusions COVID-19 has been associated with a system-wide drop in the use of mental health services, with some subsequent return in activity. "Supply" changes may have reduced access to mental health services for some. "Demand" changes may reflect a genuine reduction of need or a lack of help-seeking with pent-up demand. There has been a disproportionate increase in death among those with SMI during the pandemic.

Integrity signals

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Crossref · 10.1016/j.jpsychires.2020.09.020

Cites

24 of 24 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 7 cited sources checked · 0 supported · 0 flagged

  • Findingnone given

    The authors found no prior observational study reporting the pandemic's impact on clinical mental health services.

    “to our knowledge, no previous observational study has reported the impact of the pandemic on clinical mental health services”
    Quote in the paperSubstantial claim
  • Findingown data

    The excess deaths in 2020 among physical health patients with open referrals were predominantly in people over 70.

    “The excess of deaths in 2020 was predominantly in the over-70s (Fig. 5B).”
    Quote in the paperNot a substantial claim
  • Findingown data

    The number of inpatients decreased at lockdown.

    “Inpatient numbers fell”
    Quote in the paperNot a substantial claim
  • Findingown data

    Ethnicity did not account for the larger mortality increase in patients with severe mental illness.

    “which was not explained by ethnicity”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Lifetime coded ICD-10 diagnoses adequately identify severe mental illness despite possible under-coding.
  • Findingown data

    Crisis team referrals did not change for patients with severe mental illness.

    “for example, referrals to crisis teams did not change for those with SMI”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Lifetime coded ICD-10 diagnoses adequately identify severe mental illness despite possible under-coding.
  • May combine two claims. 27
  • The quote only partly states this claim. 1
  • Classified as probably not a substantial claim. 11

  • May combine two claims.

    Findingown data

    Attendance at the minor injury unit that stayed open fell dramatically at lockdown and then rose slightly, despite two other units closing.

    “Attendance at the MIU that remained open dropped dramatically at lockdown and increased slightly thereafter, despite the closure of two other MIUs”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Liaison psychiatry referrals from the emergency department fell substantially and then rose slowly.

    “There was a substantial reduction in LP referrals from the ED followed by a slow increase”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data

    Mortality rose much more for patients with severe mental illness than for those without it.

    “There was a much greater increase in mortality for patients with SMI”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Lifetime coded ICD-10 diagnoses adequately identify severe mental illness despite possible under-coding.

  • May combine two claims.

    Findingreasoning

    COVID-19 was linked to a system-wide decline in mental health service use, followed by some recovery in activity.

    “COVID-19 has been associated with a system-wide drop in the use of mental health services, with some subsequent return in activity.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Both detained and voluntary inpatient numbers fell sharply at lockdown.

    “Both detained and voluntary inpatient numbers dropped sharply at lockdown”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    All liaison psychiatry presentation types fell at lockdown and then rose toward normal levels, except psychosis or mood elevation, which showed a small sustained reduction, and eating disorders, which showed no significant change.

    “All types of presentation dropped at lockdown and then increased towards normal levels, except presentation with psychosis/mood elevation (small sustained reduction) or eating disorders (no significant change)”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Face-to-face contacts fell across age groups, while non-face-to-face contacts increased.

    “Face-to-face contacts fell across age groups, with an increase in non-face-to-face contacts”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Patients with and without severe mental illness showed the same patterns, except that admission rates did not fall significantly for those with severe mental illness.

    “The same patterns were seen for patients with and without SMI, except that the admission rate did not drop significantly for those with SMI”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Lifetime coded ICD-10 diagnoses adequately identify severe mental illness despite possible under-coding.

  • May combine two claims.

    Findingown data

    Triage assessments by the NHS 111 mental health crisis service showed a small immediate drop at lockdown and no significant change afterward.

    “a small immediate drop in triage assessments by that service (p < 0·05) with no significant change thereafter”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    For liaison psychiatry, every major presentation type fell at lockdown and later rose toward normal levels, except eating disorders, which showed no evidence of change.

    “This pattern was seen for all major forms of presentation to liaison psychiatry services, except for eating disorders, for which there was no evidence of change.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingreasoning

    Liaison psychiatry referrals from wards fell sharply and then gradually returned to normal.

    “LP referrals from wards dropped sharply then gradually increased back to normal”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    These changes were large and sustained.

    “These changes were substantial and sustained.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    No increase was observed in mental health presentations with affective disorders, other stress-exacerbated disorders, or referrals for delirium associated with severe COVID-19.

    “None of these effects were observed.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    No evidence indicated that suppressing demand in some services caused redistribution to any other service, and demand for mental health emergency services did not increase, even for services allowing self-referral and remote consultation.

    “There was no evidence that suppression of demand in some services led to “redistribution” to any other service, with no increase in demand for MH emergency services (111, crisis teams, ED), even for services permitting self-referral and remote consultation (111).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Presentations to the open minor injury unit fell abruptly and dramatically, even though two other minor injury units in the area had closed.

    “The reduction in presentations to the open MIU was abrupt and dramatic, and occurred despite the closure of two others in the area.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    During the early pandemic, both demand and supply fell for mental health and community physical health services covering about 0.86 million people.

    “We show a reduction in demand as well as supply during the early phase of the pandemic for MH and community PH services covering a population of ~0·86 million.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Cambridgeshire and Peterborough had a population of about 0.86 million.

    “which has a population of ~0·86 million (Office for National Statistics, 2020a)”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Office for National Statistics, 2020a

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    Service reorganization may have contributed to the referral drop.

    “Service reorganization may therefore have contributed.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    The final seven days of SystmOne death data and the final fourteen days of RiO death data were removed to account for delays in death reporting.

    “We truncated the last 7 days of SystmOne death data, to allow for delays in death reporting to the NHS Spine (lag estimated), and 14 days of RiO death data, to allow for additional delays in Spine-to-RiO updates.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    The final seven days of RiO contact data were removed to account for delays in recording appointment outcomes.

    “We truncated the last 7 days of RiO contact data, to allow for delays in recording appointment outcomes (lag estimated).”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    Black, Asian, and minority ethnic groups face disproportionate risk compared with White ethnic groups for COVID-19 infection, hospital admission, critical care admission, and death.

    “Since Black, Asian, and minority ethnic (BAME) groups are at disproportionate hazard compared to White ethnic groups of contracting COVID-19, hospital admission, critical care admission, and death from COVID-19 (UK Government Office for Science, 2020)”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites UK Government Office for Science, 2020

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationown data

    The high pre-pandemic proportion of detained inpatients suggested greater acuity.

    “suggesting higher acuity”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    The lockdown-period drop was accompanied by signs of change in both service provision and help-seeking.

    “with evidence for changes in both supply (service provision) and demand (help-seeking)”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    The study obtained data from four clinical record systems that covered all CPFT clinical record systems plus one system for CPFT services delivered in another trust.

    “We obtained data from four clinical records systems (RiO, SystmOne, PCMIS, and Epic; see Supplementary Methods), representing all clinical records systems for CPFT plus one for services provided by CPFT within another Trust (Epic).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    Changes in help-seeking may indicate either a real decrease in need or unmet need with later pent-up demand.

    ““Demand” changes may reflect a genuine reduction of need or a lack of help-seeking with pent-up demand.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    The associations observed via interrupted time series analysis do not prove causation.

    “they do not prove causation.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    The sustained reduction in admissions, at least for patients without severe mental illness, suggests a changed threshold for admission, probably including voluntary admission.

    “The sustained reduction in admissions, at least for those without SMI, suggests also a changed threshold for admission—though not for detention and by inference probably therefore for voluntary admission.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    Referral changes in some services could reflect shifts in demand, supply, or both, while activity in other services was more clearly driven by patient help-seeking.

    “Changes in referrals to some services may have reflected changes to “demand” or “supply” or both, though activity in other services was more clearly led by patient help-seeking (demand).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Because new Mental Health Act detentions did not change, Responsible Clinicians probably saw a higher risk of admission from COVID-19 transmission, which shifted the risk/benefit balance toward earlier discharge near the end of a detained admission.

    “Given the lack of change in new MHA detentions, we suggest that Responsible Clinicians perceived an increase in the risk of being admitted (relating to COVID-19 transmission) that shifted the risk/benefit balance, near the end of a detained admission, towards earlier discharge.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductnone given

    National reporting provided mortality data for all mental health patients, but only for physical health patients with open CPFT referrals; these data may be incomplete if reporting delays exceeded seven days.

    “Mortality data was available via national reporting mechanisms for all MH patients, but only for PH patients with open referrals to CPFT, and mortality data may be incomplete if delays in national reporting exceeded 7 days.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Interrupted time series analysis is a recommended method for assessing changes in routine data tied to a clearly defined event.

    “a recommended approach for evaluating changes in routine data associated with a well-defined event (Bernal et al., 2017)”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Bernal et al., 2017

      Not checked in the free run.

  • May combine two claims.

    Study design and conductreasoning

    The data give a fairly comprehensive picture of NHS mental health services in one area, so decreases were less likely to be offset by help-seeking through another NHS service.

    “These data represent a relatively comprehensive view of NHS-provided MH services in one geographical area (because CPFT provides psychological therapy and all secondary MH care to the entire population of C&P), making it less likely that decreases were compensated for by help-seeking via another NHS service.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: CPFT provides psychological therapy and all secondary mental health care to the entire population of Cambridgeshire and Peterborough.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    A reduction in help-seeking for injuries cannot be excluded as an explanation for the reduction in minor injury unit presentations.

    “Whilst a reduction in help-seeking cannot be excluded (injuries still occurring but people not seeking medical attention or presenting to an ED instead)”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Rising activity in several services points to unmet patient need and a temporary suppression of help-seeking.

    “this suggests that there is patient need but that help-seeking has been transiently suppressed.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    The biphasic mortality pattern in patients without recorded severe mental illness points to a temporal shift, with some patients dying earlier in 2020 than they otherwise would have.

    “suggests a degree of temporal shift in mortality, i.e. that some patients died earlier within 2020 than they would otherwise have done.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductreasoning

    Physical health service data are less complete, but still allow some comparison of health-seeking and mortality between the two domains.

    “The data are less comprehensive for PH services, but sufficient to allow some comparison of health-seeking and mortality in the two domains.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Wars that unite a population against a common enemy and thereby raise social cohesion are associated with lower suicide rates.

    “In contrast, suicide rates fall during wars that increase social cohesion by uniting a population against a common foe (Pridmore et al., 2018).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Pridmore et al., 2018

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    For some services there were unmeasured alternatives, such as mental health support from charities or support for children from the Local Authority.

    “For some services there were “unmeasured” alternatives (e.g. MH support from charities; support for children from the Local Authority).”
    Quote in the paperNot a substantial claim
38 of 38

  • The paper relies on this without support.

    CPFT is the sole provider of all secondary care mental health services to Cambridgeshire and Peterborough.

    “CPFT) provides community PH services, psychological therapy services, and all secondary care MH services (including some embedded within primary care) to C&P”

  • The paper relies on this without support.

    Lifetime coded ICD-10 diagnoses adequately identify severe mental illness despite possible under-coding.

    “Any under-coding of diagnosis was unmeasured.”

  • The paper relies on this without support.

    CPFT provides psychological therapy and all secondary mental health care to the entire population of Cambridgeshire and Peterborough.

    “because CPFT provides psychological therapy and all secondary MH care to the entire population of C&P”

  • The paper relies on this without support.

    For some services, activity is driven by patient self-presentation rather than service supply.

    “For some services, though, activity is driven by patient self-presentation (e.g. 111 crisis calls, attendance at EDs/MIUs) yet activity dropped nonetheless.”
4 of 4

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Eight studies reported a decrease in self-harm/suicide attempts during the first months of the COVID-19 pandemic.

    “Eight studies reported a decrease in self-harm/suicide attempts during the first months of the COVID-19 pandemic ( Capuzzi et al., 2020; Chen et al., 2020; Goncalves-Pinho et al., 2021; Hewson et al., 2020; McIntyre et al., 2020; Pignon et al., 2020; Rajput et al., 2020; Walker et al., 2020).”

    From The impact of the COVID-19 pandemic on self-harm and suicidal behaviour: update of living systematic review (2021) · cites this paper as Chen et al., 2020

  • Studies focusing on suicidal thoughts showed either a reduction or no change in presentations to health/mental health services or self-reported suicidal thoughts, with the majority making comparisons to the same time in 2019.

    “The studies showed either a reduction ( Chen et al., 2020; Hernandez-Calle et al., 2020; Smalley et al., 2021) or no change ( Sade et al., 2020; Titov et al., 2020) in presentations to health/mental health services or self-reported suicidal thoughts, with the majority making comparisons to the same time in 2019.”

    From The impact of the COVID-19 pandemic on self-harm and suicidal behaviour: update of living systematic review (2021) · cites this paper as Chen et al., 2020

  • The new situation with imposed social and physical restrictions may have introduced additional barriers to accessing informal and formal help-seeking for mental health problems in youths, similarly to adults.

    “Furthermore, this new situation with the imposed social and physical restrictions may have also introduced additional barriers to accessing informal and formal help-seeking for mental health problems in youths, similarly to adults [53,54].”

    From Exploring the Impact of COVID-19 on Mental Health Outcomes in Children and Adolescents: A Systematic Review (2020) · cites this paper as [53]

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Authors
Chen, S., Jones, P. B., Underwood, B. R., Moore, A., Bullmore, E. T., Banerjee, S., Osimo, E. F., Deakin, J. B., Hatfield, C. F., Thompson, F. J., Artingstall, J. D., Slann, M. P., Lewis, J. R., & Cardinal, R. N.
Affiliations
  • University of Cambridge (GB)
  • Fulbourn Hospital (GB)
Corresponding author
Cardinal, Rudolf N.
ORCID
Venue
Journal of Psychiatric Research
Publisher
Elsevier BV
Published
2020-12
Volume
131
Pages
244-254
ISSN
0022-3956 (ISSN-L)
DOI
10.1016/j.jpsychires.2020.09.020
PMC
PMC7508053
OpenAlex
W3087124467
Cited by
127
References
27
Citations by year
2026: 3 · 2025: 8 · 2024: 13 · 2023: 26 · 2022: 27 · 2021: 45 · 2020: 5
FWCI
10.31
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of Psychiatric Research (publishedVersion)
  • SSRN Electronic Journal (acceptedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • Apollo (University of Cambridge) (submittedVersion, cc-by-nc-nd)
  • Apollo
Funders
  • National Institute for Health Research
  • Medical Research Council
Topics
  • Social Sciences › Psychology › Clinical Psychology › COVID-19 and Mental Health
  • Health Sciences › Medicine › Oncology › COVID-19 and healthcare impacts
  • Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
Keywords
COVID-19 pandemic, mental health services, standardized mortality ratio, severe mental illness, help-seeking, service supply and demand, lockdown, psychosomatic medicine, eating disorders, Mental Health Act detention, remote care, excess mortality, older adults
MeSH terms
COVID-19, Adolescent, Adult, Aged, Aged, 80 and over, Mental Disorders, Community Health Services, Community Mental Health Services, Female, United Kingdom, Health Services Accessibility, Humans, Male, Middle Aged, Mortality, Patient Acceptance of Health Care, Pneumonia, Viral, Referral and Consultation, Infection Control, Coronavirus Infections, Young Adult, Pandemics

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