In the early days of the pandemic, colleagues noted a major reduction in the number of individuals arriving in emergency departments. What were initially anecdotal observations from people who work in these parts of the hospital was soon validated by a study from the Centers for Disease Control and Prevention, which reported a precipitous drop in emergency room visits during the first weeks of the pandemic. The most pronounced decline was during the 4 weeks from March 29 to April 25, 2020, when emergency room visits across the United States plummeted by 42% compared to the same 4-week period the previous year.¹

This finding did not just apply to people who suffered minor injuries or traumas. In the 10 weeks after March 13, 2020, when COVID-19 was declared a national emergency, emergency departments saw declines in the number of patients presenting with myocardial infarction, stroke, and hyperglycemic crisis of 23%, 20%, and 10%, respectively, when compared to the 10 weeks prior to the declaration.ⁱ Meanwhile, surgeries, routine screenings, and clinical trials for new therapies were cancelled and oncologists tried to revise chemotherapy protocols to reduce the frequency of visits and the level of immunosuppression for those receiving treatment.²

While these numbers have since rebounded and are close to their prepandemic levels as of the middle of 2021,³ the trajectory for psychiatric emergencies is slightly different. While there were fewer psychiatric patients arriving in the hospital in the weeks following the declaration of the national emergency,⁴ numbers have since risen back to prepandemic levels though the types of emergencies have changed. Data from December 2020 through January 2021 show that emergencies due to feeding and eating disorders have been and remain relatively low, while more adults and children are seeking emergency care pertaining for behavioral or mental health concerns related to socioeconomic or psychosocial issues.⁵ What remains a question is if these are symptoms associated with COVID-19 or long COVID. Secondly, did these symptoms arise due to pandemic-related stressors or did they occur independently of COVID-19?

As noted throughout several chapters thus far, even those who have not been infected with SARS-CoV-2 have suffered psychological strain due to a multitude of factors and may have developed worsening symptoms or new-onset psychiatric disorders. This is confounded by the fact that anxiety and depression are common symptoms associated with COVID-19; moreover, many of those who were hospitalized with COVID-19 have been diagnosed with posttraumatic stress disorder, and many long haulers have reported psychiatric symptoms that extend beyond anxiety and depression and include difficulty concentrating, malaise, sleep problems, and adjustment disorders.⁶ It should come as no surprise, therefore, that a growing number of patients seeking emergency care report behavioral or mental health concerns related to socioeconomic or psychosocial issues but a full understanding of common etiologies remains unknown.

The pandemic has altered the way that many of us live our daily lives and will likely continue to have an impact on social behaviors going forward. For outpatient psychiatric patients, these issues have been compounded by unique challenges that can make maintaining treatment regimens especially difficult. Nonadherence is common in patients with mental illnesses, particularly in schizophrenia where partial or total nonadherence may reach 75%,⁷ and the dissolution of support networks during the pandemic adversely impacted this figure though data has not revealed to what extent. Long-acting injections may have attenuated these effects but, again, no studies have been released on the subject as of this time.

These were not the only hardships that patients with SPMI (schizophrenia and related disorders, bipolar disorder, and severe depression) experienced.⁸ A systematic review and meta-analysis published in July 2021 that involved 16 observational studies from seven countries found patients with mental health disorders were at risk for higher COVID-19− related mortality and that individuals with schizophrenia and/or bipolar disorder were at an even higher risk of mortality.⁹ There are multiple factors contributing to this association, as individuals with SPMIs oftentimes suffer from poor self-care, comorbid SUDs, poor overall health, and the kinds of chronic inflammatory conditions that make one more vulnerable to severe COVID-19, while also being more likely to experience homelessness or reside in shared housing facilities.¹⁰ Preliminary reports suggest that infection was extremely common in these shelters and that individuals who experienced homelessness during the pandemic were at a far higher risk of dying of COVID-19.¹¹ An analysis published in June 2020 by Coalition for the Homeless, an advocacy group based in New York City, reported that the COVID-19 mortality rate for sheltered homeless New Yorkers was 61% higher than the overall New York City rate.¹² Individuals with SPMIs are also overrepresented in prison populations, where an estimated 14.5% of men and 31.0% of women are believed to have at least one SPMI, and those in prison were estimated to have been infected with the coronavirus
at almost four times the rate of those in the United States overall (9% vs 34%).^{13, 14}

Compliance with preventative measures and public health directives may be more difficult for individuals with SPMIs due to impaired decision-making abilities, which may be compounded by comorbid SUDs. Prophylactic regimens (frequent hand washing, confinement, social distancing, wearing a mask, etc) may also be difficult to follow as patients with these disorders often suffer from delusions, hallucinations, poor insight, and paranoid thinking, which can make public health directives sound sinister or even part of larger plot to harm them. Given the rise of misinformation and conspiracies about both the virus in general and the vaccine in particular, efforts to convince patients about the benefits of vaccination may prove especially difficult.