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Castro VM, Perlis RH. Electronic Health Record Documentation of Psychiatric Assessments in Massachusetts Emergency Department and Outpatient Settings During the Coronavirus Disease 2019 (COVID-19) Pandemic. JAMA Netw Open. 2020;3(6):e2011346. doi:10.1001/jamanetworkopen.2020.11346
The emergence of the worldwide coronavirus disease 2019 (COVID-19) pandemic has been associated with increased burden of psychiatric symptoms among health care workers and the general public,1,2 which may increase the risk of longer-term sequelae.3,4 At the same time, the need for quarantine and the strain on clinical resources may reduce the ability of health systems to respond to such symptoms. To quantify shifts in psychiatric evaluation associated with COVID-19, we used electronic health records from 2 large academic medical centers and 3 affiliated community hospitals in Massachusetts to investigate the documentation of psychiatric symptoms in narrative clinical notes as COVID-19 activity increased in eastern Massachusetts.
This cohort study included all individuals seen in outpatient or emergency department visits between January 2 and March 25, 2020. Sociodemographic data, including age, sex, race, and ethnicity, were drawn from the Partners Research Patient Data Registry5 along with narrative clinical notes. Presence of depression, anxiety, suicide, psychosis, and violence was determined by identifying terms drawn from an expert-curated list associated with National Institute of Mental Health Research Domain Criteria.6 These terms included depressed, depressive, dysphoric, dysthymic, sad, and tearful for depression; anxiety, anxious, fearful, frighten, hypervigilant, nervous, panic, phobia, phobic, scared, stress, tense, and worried for anxiety; suicide, suicidal, and suicidality for suicide; psychotic, psychosis, hallucination, delusion, paranoid, paranoia, hallucinate, hallucinated, and delusional for psychosis; and violence and violent for violence.
Presence of a coronavirus test was determined from the enterprise laboratory feed. The Partners HealthCare human research committee approved the study protocol. Given that no participant contact was required in this study based on secondary use of data arising from routine clinical care, the committee waived the requirement for informed consent as detailed by 45 CFR 46.116. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
Primary analysis quantified the volume of documentation by individual symptoms for each week in the study period. Logistic regression was used to examine the association between the presence of COVID-19 testing and psychiatric symptoms, adjusted for age, sex, and race/ethnicity, using R version 3.6.0 (R Project for Statistical Computing). Notes were treated as clustered within individuals and limited to those occurring at or before time of testing. No significance testing was performed.
A total of 205 957 emergency department and 2 483 159 outpatient notes were analyzed (Table), representing 60 428 patients (32 550 [53.9%] women; mean [SD] age, 44.3 [24.5] years) and 541 307 patients (324 823 [60.0%] women; mean [SD] age, 50.9 [21.7] years), respectively. The Figure illustrates the frequency of COVID-19 testing by week (Figure, A) and the frequency of mentions of psychiatric terms in notes by week (Figure, B and C). The initial 2 decrements correspond to 4-day weeks because of holidays. In January and February, with holidays excluded, there were a mean (SD) of 1446 (79) and 49 312 (4841) notes with mentions of depression from emergency department and outpatient visits, respectively, per week. These decreased to 886 (ie, by 44%) and to 9315 (ie, by 81%), respectively, in the week spanning March 19 to March 25. Similar patterns were observed for other symptoms.
In the emergency department setting, the odds of COVID-19 testing, adjusted for age, sex, race/ethnicity, and hospital type, were increased by nearly 50% in visits during which violence was referenced (odds ratio, 1.49; 95% CI, 1.25-1.76). In the outpatient setting, notes with the presence of psychiatric terms were associated with a reduction in the likelihood of COVID-19 testing for an individual patient, with adjusted odds ratios of 0.80 (95% CI, 0.77-0.82) for anxiety, 0.64 (95% CI, 0.61-0.67) for depression, 0.63 (95% CI, 0.56-0.71) for psychosis, 0.73 (95% CI, 0.66-0.81) for suicide, and 0.40 (95% CI, 0.37-0.43) for violence.
In this cohort study, we detected a marked reduction in notes documenting psychiatric symptoms, inclusive of telemedicine, paralleling the emergence of COVID-19 diagnoses in the Boston area. During this period, outpatient visits were cancelled, individuals likely became more reluctant to come to the emergency department, and clinicians seeking to reduce exposure may have conducted more focused interviews. In emergency department evaluations, most symptoms were not associated with COVID-19 testing, but reference to violence was associated with a greater likelihood of testing, perhaps reflecting a shift in clinical presentations. Limitations of these results include the reliance on simple string matching and the inability to determine generalizability from these 5 hospitals to other regions.
Nonetheless, our results indicate an acute reduction in the assessment and documentation of psychiatric symptoms. In light of survey data,2 we might expect to see an increase rather than a decrease in psychiatric presentations in Boston-area hospitals. Efforts to provide more accessible psychiatric care during the acute phase of the COVID-19 pandemic may become particularly important; symptoms are likely to be increasing while access is decreasing. Strategies such as telemedicine are urgently needed to ensure that another consequence of the pandemic is not neglect of psychiatric illness.
Accepted for Publication: May 10, 2020.
Published: June 8, 2020. doi:10.1001/jamanetworkopen.2020.11346
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Castro VM et al. JAMA Network Open.
Corresponding Author: Roy H. Perlis, MD, MSc, Center for Quantitative Health, Division of Clinical Research, Massachusetts General Hospital, 185 Cambridge St, 6th Floor, Boston, MA 02114 (email@example.com).
Author Contributions: Dr Perlis had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Both authors.
Acquisition, analysis, or interpretation of data: Both authors.
Drafting of the manuscript: Both authors.
Critical revision of the manuscript for important intellectual content: Both authors.
Statistical analysis: Both authors.
Administrative, technical, or material support: Castro.
Conflict of Interest Disclosures: Dr Perlis reported receiving personal fees from Psy Therapeutics, Outermost Therapeutics, Genomind, RID Ventures, Burrage Capital, Takeda, and JAMA Network Open outside the submitted work. No other disclosures were reported.
Disclaimer: Dr Perlis is an associate editor of JAMA Network Open, but he was not involved in any of the decisions regarding review of the manuscript or its acceptance.
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