Forty Percent Reduction in Referrals to Psychiatric Services during the COVID-19 Pandemic
Authors: Pernille Kølbæk, Bettina Nørremark, Søren Dinesen Østergaard
Journal: Psychotherapy and Psychosomatics (2020)

Dear Editor,In a recent issue of Psychotherapy and Psychosomatics, Wright and Caudill [1] advocate for remote delivery of psychiatric treatment during the COVID-19 pandemic. While remote delivery of treatment indeed has an enormous potential in psychiatry – especially in times of crisis [2-4] – a prerequisite for its use is that individuals with mental illness in need of specialized treatment actually get in contact with the psychiatric services in the first place. Recently, as part of a quality improvement project that aims at optimizing the treatment of mental disorders during the COVID-19 pandemic, we obtained data on all referrals to the psychiatric services of the Central Denmark Region (catchment area of approximately 1.3 million individuals) in the period from week 9–18 in 2019 and 2020, respectively (the Danish Prime Minister announced nationwide lockdown of schools, kindergartens, restaurants, and bars on Wednesday, March 11, 2020 [week 11]). Notably, we found that the number of referrals from week 12–16 in 2020 (n = 1,471) was 40% lower than for the corresponding weeks in 2019 (n = 2,465). For comparison, there were 19% more referrals in weeks 9 and 10 (preceding lockdown) in 2020 (n = 1,224) compared to 2019 (n = 1,032). In weeks 17 and 18 in 2020 (gradual lift of lockdown), the number of referrals (n = 868) was approaching that of the same weeks in 2019 (n = 922).There are essentially two potential explanations for the observed 40% reduction in referrals to the psychiatric services (which was seen across referral diagnoses, age groups, and for both males and females), namely (1) that the level of mental illness in the Danish population has decreased during the COVID-19 pandemic, or (2) that individuals in need of specialized treatment are not referred to the psychiatric services. While the first explanation seems highly unlikely given reports of reduced psychological well-being and increased psychological distress from a number of countries affected by the COVID-19 pandemic (including Denmark) [5-9], the latter seems highly probable.In Denmark, the primary referrers to specialist psychiatric treatment are the general practitioners. Our findings are consistent with concerns raised by the Danish General Practitioner's Association regarding an alarming reduction (approximately 40%) in the number of consultations during the COVID-19 pandemic (the general practitioners remained open during the entire lockdown period) – a reduction, which is probably driven by fear of contracting the coronavirus and/or by the assumption that general practitioners are too busy handling COVID-19 to attend to other things (which is not the case) [10]. Thus, the most likely explanation for the reduced number of referrals seems to be that those in need of specialized psychiatric treatment have not consulted their general practitioner, who consequently has not been able to refer these patients to the psychiatric services.The consequence of the observed "under-referral" is most likely that the condition of the individuals who were in need of specialized psychiatric treatment during the COVID-19 pandemic, but not referred to the psychiatric services, will have deteriorated and may be more difficult to treat once/if these individuals eventually get referred. This is unfortunate for obvious reasons and suggests that in the case of future pandemics, the authorities should more actively inform citizens of the fact that the health services (including general practitioners and psychiatric services) remain "open for business," underline the safety measures that are being taken to minimize risks of contamination at the general practitioner clinics and at hospitals, and increase awareness regarding the possibilities for using telemedicine.The authors have no conflicts of interest to declare.This project was supported by an unconditional grant from the Novo Nordisk Foundation (Grant No.: NNF20SA0062874).All authors contributed to the design of this project. B.N. extracted and managed the data, which was assessed and interpreted by all authors. The manuscript was drafted by P.K. and S.D.Ø. and revised by B.N. The final version of the manuscript was approved by all authors prior to submission.