April 25, 2024

Iscuk

International Student Club UK

Indirect acute effects of the COVID-19 pandemic on physical and mental health in the UK: a population-based study

Summary

Background

There are concerns that the response to the COVID-19 pandemic in the UK might have worsened physical and mental health, and reduced use of health services. However, the scale of the problem is unquantified, impeding development of effective mitigations. We aimed to ascertain what has happened to general practice contacts for acute physical and mental health outcomes during the pandemic.

Methods

Using de-identified electronic health records from the Clinical Research Practice Datalink (CPRD) Aurum (covering 13% of the UK population), between 2017 and 2020, we calculated weekly primary care contacts for selected acute physical and mental health conditions: anxiety, depression, self-harm (fatal and non-fatal), severe mental illness, eating disorder, obsessive-compulsive disorder, acute alcohol-related events, asthma exacerbation, chronic obstructive pulmonary disease exacerbation, acute cardiovascular events (cerebrovascular accident, heart failure, myocardial infarction, transient ischaemic attacks, unstable angina, and venous thromboembolism), and diabetic emergency. Primary care contacts included remote and face-to-face consultations, diagnoses from hospital discharge letters, and secondary care referrals, and conditions were identified through primary care records for diagnoses, symptoms, and prescribing. Our overall study population included individuals aged 11 years or older who had at least 1 year of registration with practices contributing to CPRD Aurum in the specified period, but denominator populations varied depending on the condition being analysed. We used an interrupted time-series analysis to formally quantify changes in conditions after the introduction of population-wide restrictions (defined as March 29, 2020) compared with the period before their introduction (defined as Jan 1, 2017 to March 7, 2020), with data excluded for an adjustment-to-restrictions period (March 8–28).

Findings

The overall population included 9 863 903 individuals on Jan 1, 2017, and increased to 10 226 939 by Jan 1, 2020. Primary care contacts for almost all conditions dropped considerably after the introduction of population-wide restrictions. The largest reductions were observed for contacts for diabetic emergencies (odds ratio 0·35 [95% CI 0·25–0·50]), depression (0·53 [0·52–0·53]), and self-harm (0·56 [0·54–0·58]). In the interrupted time-series analysis, with the exception of acute alcohol-related events (0·98 [0·89–1·10]), there was evidence of a reduction in contacts for all conditions (anxiety 0·67 [0·66–0·67], eating disorders 0·62 [0·59–0·66], obsessive-compulsive disorder [0·69 [0·64–0·74]], self-harm 0·56 [0·54–0·58], severe mental illness 0·80 [0·78–0·83], stroke 0·59 [0·56–0·62], transient ischaemic attack 0·63 [0·58–0·67], heart failure 0·62 [0·60–0·64], myocardial infarction 0·72 [0·68–0·77], unstable angina 0·72 [0·60–0·87], venous thromboembolism 0·94 [0·90–0·99], and asthma exacerbation 0·88 [0·86–0·90]). By July, 2020, except for unstable angina and acute alcohol-related events, contacts for all conditions had not recovered to pre-lockdown levels.

Interpretation

There were substantial reductions in primary care contacts for acute physical and mental conditions following the introduction of restrictions, with limited recovery by July, 2020. Further research is needed to ascertain whether these reductions reflect changes in disease frequency or missed opportunities for care. Maintaining health-care access should be a key priority in future public health planning, including further restrictions. The conditions we studied are sufficiently severe that any unmet need will have substantial ramifications for the people with the conditions as well as health-care provision.

Funding

Wellcome Trust Senior Fellowship, Health Data Research UK.

Results

The overall denominator population included 9 863 903 individuals on Jan 1, 2017, and numbers remained relatively stable throughout the study (table 2). The characteristics of condition-specific study populations are shown in the appendix (pp 4–8).

Table 2General denominator population defined in the first week of each year from 2017 to 2020

Figure 1 shows the percentage of a given study population with primary care contacts for each condition in 2020 and a 3-year historical average for the corresponding week. Across the majority of conditions, we observed rapid and sustained decreases in GP contacts between March and July, 2020, compared with pre-lockdown periods. Despite gradual increases in contacts as a percentage of denominator population following restrictions, levels remained below the 3-year average for all conditions except acute alcohol-related events (which were higher than the historical average in 2020) and unstable angina. During March, 2020, we observed pronounced increases in contacts related to asthma exacerbations. Patterns were broadly consistent when stratified by age (figure 2), sex, region, and ethnicity (appendix pp 9–11).

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Figure 1Proportions of each study population with contacts for each condition in 2017–19 and 2020

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Percentage of eligible population with contacts for each health condition studied in 2020 compared with the historical (2017–19) average for that week. Shaded regions show the difference between the 2020 data and the historical average. Vertical dashed lines indicate the introduction of lockdown restrictions in the UK on March 23, 2020. Tick marks on the x-axis represent the first day of the specified month. COPD=chronic obstructive pulmonary disease.

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Figure 2Percentage of each denominator population with general practitioner contacts for the study conditions throughout 2020, by age group

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Coloured lines represent weekly percentages of the eligible population with primary care contacts for the condition of interest in 2020; eligible populations differed by condition (table 1). Boxplots represent the historical average (median and IQR) percentage of the study population with general practitioner contacts for the condition of interest. Vertical dashed lines indicate the introduction of lockdown restrictions in the UK on March 23, 2020. Tick marks on the x-axis represent the first day of the specified month. Note that cell counts with fewer than five contacts in 1 week in 2020 have been suppressed. COPD=chronic obstructive pulmonary disease.
There was evidence that contacts for all studied conditions, except acute alcohol-related events, were lower after restrictions were announced compared with pre-restriction levels (figure 3A). The largest relative reductions in contact behaviour following restriction introduction were observed for diabetic emergencies (OR 0·35 [95% CI 0·25–0·50]), depression (0·53 [0·52–0·53]), and self-harm (0·56 [0·54–0·58]). With the exception of acute alcohol-related events (0·98 [0·89–1·10]), there was evidence of a reduction in contact behaviour for all conditions studied: anxiety 0·67 (0·66–0·67), eating disorders 0·62 (0·59–0·66), obsessive-compulsive disorder (0·69 [0·64–0·74]), self-harm 0·56 (0·54–0·58), severe mental illness 0·80 (0·78–0·83), stroke 0·59 (0·56–0·62), transient ischaemic attack 0·63 (0·58–0·67), heart failure 0·62 (0·60–0·64), myocardial infarction 0·72 (0·68–0·77), unstable angina 0·72 (0·60–0·87), venous thromboembolism 0·94 (0·90–0·99), and asthma exacerbation 0·88 (0·86–0·90; figure 3B; appendix p 17).

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Figure 3Interrupted time-series analysis of changes in general practitioner contacts before and after the introduction of UK-wide restrictions

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(A) Lines indicate the observed percentage of the denominator population with primary care contacts for each health condition in 2020. Shaded regions indicate the predicted percentage of contacts from the full interrupted time-series model (including data from 2017 onwards). Vertical lines show the adjustment-to-restrictions period from which data were excluded from the analysis (March 8–28, 2020). Tick marks on the x-axis represent the first day of the specified month. (B) 95% CIs of ORs for the estimated relative reduction in contacts as a percentage of the denominator population for each health condition immediately after the adjustment-to-restrictions period (March 29, 2020) compared with the pre-lockdown period (values closer to 0 represent a greater reduction in the estimated percentage of people with general practitioner contacts). (C) 95% CIs of ORs for the estimated effect of time (in weekly increments) since the introduction of restrictions (March 29, 2020)on contacts as a percentage of the denominator population for each condition (values >1 indicate an increasing percentage of population with contacts over time). Results for 2020 only are shown here (see appendix p 24 for full model fit to data from 2017, and appendix pp 17–18 for full relative reduction and recovery ORs and 95% CIs). COPD=chronic obstructive pulmonary disease. OR=odds ratio.
From March 29, 2020, we saw evidence of increasing contacts for most conditions over time. Acute alcohol-related events and unstable angina contacts appeared to recover faster (3–5% increase in odds of contact per week; figure 3C; appendix p 18) than, for example, mental health contacts, for which odds of contact increased by 1–2% per week despite a 20–47% drop following restrictions (figure 3B; appendix p 17). Sensitivity analyses using varying exclusion periods between pre-lockdown and with-restrictions periods provided broadly consistent results over a range of scenarios (appendix pp 17–25).
Table 3 shows the potential impact of reduced contacts on relevant populations. For some rare conditions, such as unstable angina and acute alcohol-related events, the absolute change in contacts was relatively small; however, other more common conditions had a larger absolute change in contacts. For example, compared with expected numbers of COPD exacerbation contacts per million people with COPD, we estimated that there were cumulatively 43 900 fewer contacts between March 29 and July 4; there were 3640 fewer contacts from April 26 to June 2 and 3230 fewer from June 28 to July 4, indicating a slow return to pre-lockdown contact levels but not complete recovery. Cumulatively between March 29 and July 4, we also estimated 14 100 fewer asthma exacerbation contacts for every million people with asthma, 12 800 fewer depression contacts per million people in the denominator population, and 6600 fewer anxiety contacts per million people in the denominator population.

Table 3Estimated reduction in number of primary care contacts

Data represent the estimated number of primary care contacts for acute physical and mental health conditions in a hypothetical non-COVID-19 year compared with the number of contacts estimated from our model for 2020 for two week-long periods: April 26–May 2 and June 28–July 4. Estimates of the number of contacts are in a hypothetical population of 1 million people, but the reference populations are condition specific (table 1). COPD=chronic obstructive pulmonary disease.

Discussion

Primary care contacts for key physical and mental health conditions dropped considerably after the introduction of population-wide restriction measures in March, 2020. By July, 2020, with the exception of unstable angina and acute alcohol-related contacts, primary care contacts for all conditions studied remained below pre-lockdown levels. We estimated that by July, 2020, per million people in the general population, there were very small (<10) drops in the cumulative number of contacts for myocardial infarction, unstable angina, and venous thromboembolism. However, we estimated large drops for anxiety, depression, and COPD contacts.

Our study is the first to explore the effect of lockdown measures on primary care contacts for specific acute physical and mental health conditions across the UK. A study of 47 primary care practices in Salford, a largely deprived urban area in northwest England that was badly affected by the pandemic, suggested that primary care consultations across four broad categories (common mental health problems, cardiovascular and cerebrovascular disease, type 2 diabetes, and cancer) had reduced by up to 50% by the end of May, 2020.

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  • Williams R
  • Jenkins DA
  • Ashcroft DM
  • et al.
Diagnosis of physical and mental health conditions in primary care during the COVID-19 pandemic: a retrospective cohort study.