Care for Schizophrenia, Bipolar Disorder Plunged During Pandemic

The COVID-19 pandemic brought big care disruptions for those suffering from severe mental illness, a study suggested.

In a population-based study of Medicare beneficiaries with schizophrenia or bipolar I disorder, rates of mental healthcare took a steep nosedive during the first month of the pandemic, reported Alisa B. Busch, MD, MS, of McLean Hospital in Belmont, Massachusetts, and colleagues in JAMA Network Open.

The fraction of patients receiving care during that month dropped compared with the care they received in 2019 for the following:

• Outpatient visits (telemedicine or in-person): 20.3% relative decrease
• Emergency department visits: 27.7% relative decrease
• Hospital admissions: 27.9% relative decrease
• Prescription fills for antipsychotic or mood stabilizer medications: 20.3% relative decrease

Certain patient groups were also slightly but statistically significantly less likely to utilize care during the pandemic: patients with disability (OR 0.95, 95% CI 0.93-0.96), Black patients (OR 0.97 vs white, 95% CI 0.95-0.99), and patients with dual Medicaid eligibility (OR 0.96, 95% CI 0.95-0.98). While relatively small differences, Busch’s group pointed out that they are still “concerning because they represent incremental worsening of sizable preexisting disparities.”

Things did start to improve as the pandemic progressed. However, rates of mental care utilization during the first 9 months of the pandemic (through September 2020) never seemed to return to pre-pandemic levels. By weeks 36 to 39 of the calendar year (early to mid-September), mental healthcare utilization for these patients with schizophrenia or bipolar I rebounded a bit but still remained lower than 2019 levels:

• Outpatient visits (telemedicine or in-person): 2.5% relative decrease
• Emergency department visits: 14.1% relative decrease
• Prescription fills for antipsychotic or mood stabilizer medications: 3.4% relative decrease

Not surprisingly, most of this rebound was brought on by an uptick in telemedicine, which accounted for 56.7% (1,556,403 of 2,743,553) of outpatient visits for which a mental health or substance use disorder diagnosis was the primary or secondary reason for the visit.

“Telemedicine visits were the majority of outpatient visits for patients with severe mental illness, particularly in the initial weeks of the pandemic, and were much higher than what has been observed in the Medicare population as a whole,” Busch’s group wrote.

Although the severe mental health group saw an initial 20.3% relative drop off in outpatient visits at the start of the pandemic, this was nowhere near the roughly 50% decrease in office-based services for the general Medicare population during that time.

“While the disruptions in outpatient care we observed in this population are quite concerning, without telemedicine, the disruptions would likely have been much larger,” the authors wrote.

But regarding access to telemedicine, Busch’s group pointed out that while most patients have access to smartphones, this particular patient population struggling with severe mental illness also faces higher rates of homelessness, housing instability, as well as isolation from support networks that could help troubleshoot such technology. Additionally, they also may deal with more debilitating mental health and cognitive symptoms that could impair their access to consistently connect with a healthcare professional via a telemedicine visit.

“The digital divide may more significantly affect populations with long-standing challenges accessing care, including Black and low-income populations,” they explained.

Drawing on claims from all Medicare beneficiaries ages 18 years and older between January 2018 and September 2020, Busch’s group looked at patterns of care for patients with schizophrenia or related disorders if they had at least one schizophrenia or related disorder hospitalization identified with an ICD-10 code or at least two outpatient visits on different service dates where the primary or secondary diagnosis on the claim was for schizophrenia or related disorders. Similar criteria were used for patients with bipolar I disorder.

The 2019 cohort included 686,214 individuals, while the pandemic cohort included 723,045 individuals.

Emergency department visits were defined as visits with a primary diagnosis of a mental health or substance use disorder or self-injury in any diagnosis field that did not result in a hospitalization, whereas mental health hospitalizations were those with the primary admission reason of a mental health or substance use disorder or with self-injury in the primary or secondary diagnosis field. Prescription fills included oral first- and second-generation antipsychotics, lithium, or anticonvulsants FDA-approved or guideline-recommended for the treatment of bipolar disorder (including valproic acid, carbamazepine, or lamotrigine [Lamictal]).

One limitation of the study was a possible underreporting of telemedicine visits, particularly those that were conducted via audio only during a time when healthcare professionals may not have been billing for them with proper codes.