Profile of the participating mental health specialists
A total of n = 105 outpatient specialists for psychiatry and psychotherapy (“Facharzt für Psychiatrie und Psychotherapie”), psychiatry and neurology (“Facharzt für Nervenheilkunde”, “Nervenarzt”) and psychosomatic medicine and psychotherapy (“Facharzt für psychosomatische Medizin und Psychotherapie”) took part in the survey. Table 1 shows their specialization.
Table 1
Characteristics of the survey’s participants
Health insurance accreditation | % oft the participants n = 105 |
psychiatry | 70,5% |
psychosomatic medicine | 4,8% |
psychiatry and neurology („Nervenheilkunde“) | 33,3% |
neurology | 29,5% |
psychotherapy | 54,3% |
Type of psychotherapy of participants with health insurance accreditation for psychotherapy | % oft the participants n = 57 |
cognitive behavioral therapy | 43,9% |
brief psychodynamic therapy | 64,9% |
psychoanalysis | 3,5% |
systemic therapy | 5,3% |
other forms of psychotherapy | 5,3% |
Offer of individual and/or group therapy | % oft the participants n = 57 |
individual therapy | 98,2% |
group therapy | 15,8% |
Service utilization
First, we asked if the amount of contacts to patients changed in the three HIPs during the COVID-19 pandemic compared to 2019. 30,5% (n = 32) indicated a relevant decrease of more than 20% in the number of contacts during the first HIP, while 4,8% (n = 5) indicated a relevant increase (> 20%). During the second HIP 8,6% (n = 9) indicated a relevant decrease (> 20%) in the number of contacts, while 17,1% (n = 18) indicated a relevant increase (> 20%). During the third HIP 3,8% (n = 4) indicated a relevant decrease (> 20%) in the number of contacts, while 29,5% (n = 31) indicated a relevant increase (> 20%). See Fig. 1a for the detailed results.
Subsequently, we evaluated possible causes of the decrease of contacts for each HIP separately. Participants that indicated a decrease of contacts in a HIP could select pre-formulated responses or enter additional free text: “Patient demand decreased due to fears of becoming infected with SARS-CoV-2 in practice/therapy”, “Patient demand was reduced due to reduced stress during lockdown”, “The offer was reduced for patients as a protective measure to minimize contacts”, “The offer was reduced for new patients”, “The offer was reduced because staff was absent”. During the first HIP 78,1% (n = 25) attributed the decrease to a reduced demand from patients due to fears of becoming infected with SARS-CoV-2 in practice/therapy and 59,4% (n = 19) to a reduced offer as a protective measure to minimize contacts. See Fig. 1b for the detailed results.
Next, we asked for reasons of increasing number of contacts. Participants that indicated increases in contacts could select again pre-formulated responses or enter additional free text: “Demand increased due to pandemic-related fears and stress”, “Demand increased because of economic concerns and stress”, “Demand increased as a consequence of Lockdown-measures” and “Demand increased due to pandemic-related restrictions on admissions by the local inpatient departments/clinics”. Most frequently selected responses during the third HIP were an increase in demand because of Lockdown measures (93,5%; n = 29), due to pandemic-related fears and stress (90,3%; n = 28) and due to economic concerns and stress (67,7%; n = 21). See Fig. 1c for the detailed results.
From all participants (n = 105), 41,9% (n = 44) reported a change in service utilization amongst certain patient groups (both previously known and previously unknown) during or after the first HIP, 29,5% (n = 31) during or after the second HIP and 36,2% (n = 38) during or after the third HIP. In free text answers, less contacts were mentioned especially for the first and second HIP for patients with addiction disorders, depression and anxiety disorders, previously known patients, those of higher age and those living in retirement homes. More contacts were reported especially for the second and third HIP for patients with depressive and anxiety disorders, previously unknown patients, patients of younger age, certain groups like (especially single) parents (for a detailed analysis see Fehr et al. in preparation), socially isolated persons and those with post-COVID-syndromes.
Problems related to changes in utilization
We additionally asked about perceived difficulties of the patients due to the pandemic-related adjustments in the outpatient and inpatient mental health care system. Overall, 78,1% (n = 82) of the participants reported difficulties. Participants that indicated difficulties in a HIP could select the following pre-formulated responses or enter additional free text: “increased demand from patients”, “increased exacerbations”, “deteriorations and relapses”, “treatment discontinuations and loss of contact” and “increases in suicide attempts and suicides”. Most frequently reported difficulties were an increased demand from patients (1st HIP 32,9%, n = 27; 2nd HIP 42,7%, n = 35; 3rd HIP 50%, n = 41) and increased exacerbations (1st HIP 23,2%, n = 19; 2nd HIP 48,8%, n = 40; 3rd HIP 61%, n = 50). See Fig. 1d for the results. In free text answers the outpatient specialists marked that there were difficulties to transfer patients to inpatient and day-clinic institutions, an increase of the already before existing difficulties to find psychotherapy offerings, closures of psychosocial and self-help offers but as well a deterioration of the doctor-patient relationship due to the hygiene measures (for the detailed free text analysis see Fehr et al. in preparation).
Telemedicine
Regarding telemedicine use before, during and (planned) after the pandemic out of the n = 99 participants, telephone consultation services were used by 37,1% (n = 37) before the pandemic, 55,6% (n = 55) newly introduced them during the pandemic, 27,3% (n = 27) planned to further use them after the pandemic and 9,1% (n = 9) did not use them at all. Video consultation services were used by 3% (n = 3) before the pandemic, 49,5% (n = 49) newly introduced them during the pandemic, 22,2% (n = 22) planned to use them further after the pandemic and 47,5% (n = 47) did not used them at all. Self-help apps for the patients were used by 5,1% (n = 5) before the pandemic, 14,1% (n = 14) newly introduced them during the pandemic, 12,1% (n = 12) indicated a further planned use after the pandemic and 78,8% (n = 78) did not used them at all. Results on the use and experiences of telemedicine services for specific diagnostic groups (n = 94 participants) are shown in Fig. 2.
Referrals to inpatient institutions
Asked how transferals from the outpatient specialists to mental health inpatient institutions changed during the pandemic, out of the n = 96 participants a reduction in transferals was reported by 61,5% (n = 59) for the first HIP, by 54,2% (n = 52) for the second HIP, and 38,5% (n = 37) for the third HIP. No participants reported increases in transferals for the first HIP, but 2,1% (n = 2) and 8,3% (n = 8) for the second and third HIP.
We additionally asked the participants which indicated a reduction in transferals to hospitals about possible reasons for these changes with pre-formulated responses: 87,1% (n = 54) of the participants (n = 62) reduced offer by the hospitals as a reason for fewer admissions, 67,7% (n = 42) less demand from patients because of fear of getting infected with SARS-CoV-2 in the hospital and 66,1% (n = 41) less demand from patients due to restrictions during inpatient treatment (e.g. because of hygiene measures). 24,2% (n = 15) reported having been reluctant themselves to initiate transferals due to restrictions of inpatient treatment (e.g. due to hygiene measures), 12,9% (n = 8) reported having been reluctant themselves out of concern for patient infections in the hospital, and 9,7% (n = 6) reported less demand due to a lower burden of disease.
Medical attendance in nursing homes and assisted living institutions
Out of the n = 96 participants, 66,7% (n = 64) reported that they provided mental health care for old people`s homes, nursing homes or complementary facilities such as assisted living for people with mental illness. Asked how their provision of mental health care for those institutions had changed during the pandemic, 45,3% (n = 29) reported no change, 50% (n = 32) fewer medical visits and 4,7% (n = 3) more medical visits. When asked why there had been fewer medical visits, the participants could select out of pre-formulated responses. 75% (n = 24) of the participants reported that the facilities did not want visits as a COVID-19 protective measure, 59,4% (n = 19) that they had visited as few facilities as possible as a self-initiated COVID-19 protective measure, and 9,4% (n = 3) each stated less demand from patients due to COVID-19 outbreaks, less demand because patients were in inpatient treatment due to COVID-19 and less demand from patients because they died from COVID-19. 6,3% (n = 2) reported less demand from patients due to fear of SARS-CoV-2 infection and 3,1% (n = 1) less demand due to a decrease in mental illnesses or exacerbations.
Furthermore, we evaluated the need for inpatient admission of inhabitants of nursing homes and assisted living facilities. 20,3% (n = 13) reported a change in the need for inpatient admission for psychiatric patients, 71,9% (n = 46) stated no difference in the need of inpatient admission, and 7,8% (n = 5) did not know if there was a change.
Post-COVID Syndromes
55% (n = 55) of the responding participants (n = 100) affirmed that they had treated patients whose mental illness could be classified as a result of a confirmed SARS-CoV-2-infection (post-COVID syndrome). The most observed psychopathology was fatigue (91%, n = 49), depressed mood (67%, n = 36 and sleep disorders (64%, n = 35), for further results see supplementary Fig. 1. Asked about the treatment of their post-COVID patients, 90,9% (n = 50) stated that they offered supportive conversations, 69,1% (n = 38) used both antidepressants as well as psychotherapeutic interventions, 58,2% (n = 32) reported transferals to rehabilitation treatments, 40% (n = 22) transferals to complementary treatments, 16,4% (n = 9) used sedative medication, and 5,5% (n = 3) high potency neuroleptics. 7,3% (n = 4) reported that they filed out retirement applications for their patients.