Patterns and correlates of mental healthcare utilization during the COVID-19 pandemic among individuals with pre-existing mental disorder

Abstract

How did mental healthcare utilization change during the COVID-19 pandemic period among individuals with pre-existing mental disorder? Understanding utilization patterns of these at-risk individuals and identifying those most likely to exhibit increased utilization could improve patient stratification and efficient delivery of mental health services. This study leveraged large-scale electronic health record (EHR) data to describe mental healthcare utilization patterns among individuals with pre-existing mental disorder before and during the COVID-19 pandemic and identify correlates of high mental healthcare utilization. Using EHR data from a large healthcare system in Massachusetts, we identified three "pre-existing mental disorder" groups (PMD) based on having a documented mental disorder diagnosis within the 6 months prior to the March 2020 lockdown, related to: (1) stress-related disorders (e.g., depression, anxiety) (N = 115,849), (2) serious mental illness (e.g., schizophrenia, bipolar disorders) (N = 11,530), or (3) compulsive behavior disorders (e.g., eating disorder, OCD) (N = 5,893). We also identified a "historical comparison" group (HC) for each PMD (N = 113,604, 11,758, and 5,387, respectively) from the previous year (2019). We assessed the monthly number of mental healthcare visits from March 13 to December 31 for PMDs in 2020 and HCs in 2019. Phenome-wide association analyses (PheWAS) were used to identify clinical correlates of high mental healthcare utilization. We found the overall number of mental healthcare visits per patient during the pandemic period in 2020 was 10-12% higher than in 2019. The majority of increased visits was driven by a subset of high mental healthcare utilizers (top decile). PheWAS results indicated that correlates of high utilization (prior mental disorders, chronic pain, insomnia, viral hepatitis C, etc.) were largely similar before and during the pandemic, though several conditions (e.g., back pain) were associated with high utilization only during the pandemic. Limitations included that we were not able to examine other risk factors previously shown to influence mental health during the pandemic (e.g., social support, discrimination) due to lack of social determinants of health information in EHR data. Mental healthcare utilization among patients with pre-existing mental disorder increased overall during the pandemic, likely due to expanded access to telemedicine. Given that clinical correlates of high mental healthcare utilization in a major hospital system were largely similar before and during the COVID-19 pandemic, resource stratification based on known risk factor profiles may aid hospitals in responding to heightened mental healthcare needs during a pandemic.

Fig 1. Patient selection process for pre-existing mental disorder group (PMD) and historical comparison group (HC).

Fig 2. Mean daily number of mental healthcare visits by month among PMDs (red) and HCs (blue).

We report mean daily number of mental health visits for each month to account for the variation in duration of months and because our data reporting starts from March 13^th.

Fig 3

(Top) proportion of total mental healthcare visits by each mental healthcare visits percentile in PMDs (red) and HCs (blue). (Bottom) Ratio of the proportion of mental healthcare visits accounted for by each percentile in PMDs to that of the HCs. The top plots represent the distributions of percentages of mental healthcare visits accounted for by each mental healthcare visits percentile of PMDs (red) and HCs (blue). The bottom plots illustrate the percentage of total mental healthcare visits represented by PMDs divided by that of the HCs for each percentile. The dashed red vertical lines indicate the percentiles in which the percentage of total mental healthcare visits represented by PMDs exceed that of HCs.

Fig 4. PheWAS comparison plot between stress-related disorders group (PMD) in 2020 and its HC in 2019.

The x-axis represents the aOR between each phenotype and high mental healthcare utilization (top decile of utilizer) for the stress-related disorders group (red) and their historical comparison group (HC; blue). The y-axis shows the phenotypes categorized by disease type. The dashed vertical line marks aOR = 1. The red background shows phenotypes that were associated with high mental healthcare utilization only among the stress-related disorders group, and the blue background shows phenotypes that were associated with high mental healthcare utilization only among the HC.