The objective of this study was to monitor the trend of psychiatric visits and medication prescriptions among people tested for SARS-CoV-2 during the initial phase of coronavirus disease 2019 (COVID-19) pandemic in South Korea.
We conducted a population-based cohort study using data from the National Health Insurance Service (NHIS) linked to the Korea Disease Control and Prevention Agency (KDCA) data. The overall trend of psychiatric visits during COVID-19 for each month was compared to the month prior to COVID-19. The number of psychiatric medication prescription records was monitored from January 2019 to May 2020.
A total of 212,678 individuals were tested for SARS-CoV-2 between January 2020 and May 2020. Among these individuals, 72.1% (n=153,309) did not have pre-existing mental illness, and 27.9% (n=59,369) had pre-existing mental illness. We found that most psychiatric visits were made in March, and patients without pre-existing mental illness significantly increased in psychiatric outpatients during the COVID-19 pandemic (p trend<0.001). In addition, psychiatric medication prescriptions were the most prescribed between March and April 2020.
We identified a rising trend in psychiatric visits and medication prescriptions among people who were tested for SARS-CoV-2 during the initial phase of COVID-19 pandemic in South Korea.
Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), first emerged in December 2019 and rapidly developed into a global pandemic that continues to progress in terms of an increase in the number of confirmed cases and mortality worldwide. Consequently, the World Health Organization (WHO) declared a global pandemic in March 2020 [
To counteract this crisis, the Korean government has set up screening stations in various areas to enhance access to SARS-CoV-2 tests and to identify confirmed cases through quick and extensive tests [
Several factors of COVID-19, such as uncertainty of prognosis, limited professionals and equipment, restrictions on traveling, and conflicting messages from authorities, are worrisome with respect to the mental health of the population [
These findings are in line with those of previous studies [
According to a systematic review regarding mental health and COVID-19 [
Previous studies on mental health problems during COVID-19 have utilized self-administered surveys [
Korea has a national health insurance system that includes 98% of the nation’s population; the patient database is recorded based on ICD-10 codes [
We included 212,678 individuals aged 20 years or older who were tested for SARS-CoV-2 between January 1 and May 31, 2020. SARS-CoV-2 testing was confirmed by laboratory testing with real-time reverse transcription polymerase chain reaction (RT-PCR) assays of nasal and pharyngeal swabs, as recommended by the WHO [
We defined patients with a pre-existing mental illness as those who had a diagnostic code for mental and behavioral disorders (ICD-10 codes: F00–F99, G47) at least once within the 1-year period prior to January 2020.
We classified medication into four main categories: antianxiety, antidepressants, sedative-hypnotics, and antipsychotics. Sedative-hypnotic medications included Z-drugs, benzodiazepines, and other medications prescribed for off-label uses (antidepressants: imipramine, amitriptyline, low-dose formulation mirtazapine, trazodone, and nortriptyline; and low-dose antipsychotics: levomepromazine, chlorpromazine, quetiapine) [
Demographic variables included gender, age (20–29, 30–39, 40–49, 50–59, 60–69, 70–79, ≥80). Region of residence (Seoul, Daegu, Gyeonggi-do, Gyeongsangbuk-do, other), income level (low, medium, high, unknown), and insurance type (self-employed, employee, medical aid).
The baseline characteristics of the entire individuals included in this study were demonstrated as percentages for categorical variables. A chi-square test for categorical variables was used to compare the differences between the groups with and without pre-existing mental illness, and also the differences between the negative and positive results of SARS-CoV-2 test. The overall trend of psychiatric visits during COVID-19 for each month was compared to the same month prior to COVID-19 (e.g., the trend of May 2020 was compared with the trend of May 2019) [
A total of 212,678 individuals were tested for SARS-CoV-2 between January 2020 and May 2020. Among these individuals, 72.1% (n=153,309) did not have pre-existing mental illness, and 27.9% (n=59,369) had pre-existing mental illness. The total number of women was 112,640 (53%). Among patients without pre-existing mental illness, the age group of 20–29 years showed the highest proportion (22.8%), and among patients with pre-existing mental illness, those aged 80 years or older showed the highest proportion (23.5%). In total, 25% of those who were tested for SARS-CoV-2 had a psychiatric visit record between January and May 2020. Among those without pre-existing mental illness, 14,864 (9.7%) and 39,026 (65.7%) patients with pre-existing mental illness had a psychiatric visit (
Of the total 212,678 patients who were tested for the SARS-CoV-2, 7,713 (3.6%) tested positive. The highest proportion of SARS-CoV-2 positive patients was in Daegu region (65.3%). The proportion of people who had pre-existing mental illnesses was slightly higher in people who tested negative compared to those who tested positive (28.1% vs. 22.7%) (
The number of outpatient visits without pre-existing mental illnesses increased significantly by April and slightly decreased in May, and the number of inpatient visits increased more than five times in April compared to January 2020 (p trend<0.001) (
Furthermore, we identified trends in psychiatric medication prescriptions from January 2019 to May 2020. During the COVID-19 pandemic, prescriptions for antipsychotic, sedative-hypnosis and antianxiety medications were the highest in March 2020, which shows an increased rate of prescription of 61.0%, 43.4% and 38.9%, respectively, compared to the same months of the previous year. Antidepressant medication prescription rate was highest in April, which is a 21.3% increase from the same month of the previous year (
We analyzed the monthly trend of psychiatric visits along with psychiatric medication prescriptions before and during the initial phase of COVID-19 pandemic in Korea among people tested for SARS-CoV-2. In particular, we showed psychiatric visits separately for patients with and without pre-existing mental illness, and for those who tested negative and positive for SARS-CoV-2 test.
We found that most psychiatric visits were made in March, when COVID-19 was declared a pandemic by the WHO. In addition, since the first case of COVID-19 in Korea on January 20, 2020, the number of confirmed COVID-19 cases has exponentially increased due to the massive infection of a religious group called Shincheonji and the outbreak of COVID-19 patients in a psychiatric hospital (i.e., Cheongdo Daenam Hospital) [
Several recent studies on mental health during the COVID-19 pandemic have shown similar results. In one study [
We further analyzed the psychiatric visit trends based on the mental illness status before the COVID-19 pandemic. According to our results, the psychiatric outpatient visits of patients without pre-existing mental illness significantly increased during the COVID-19 pandemic. The rate of mental health service utilization in Korea tends to be lower than that in other countries [
Our study focused on patients who were tested for SARS-CoV-2. During the COVID-19 pandemic, the general population has suffered from a loss of daily life and reduced access to favored physical activities [
Regarding the mental health of those with pre-existing mental illnesses, most studies reported that patients with pre-existing mental illness experienced more psychological symptoms and worsened mental health during COVID-19 [
We found that among those who were tested for SARS-CoV-2, the number of psychiatric inpatients noticeably increased in April 2020 during the initial phase of COVID-19 pandemic. Moreover, among these individuals, the number of outpatient visits peaked in March, while inpatient visits peaked in April. This shows that the spread of the virus may increase the risk of recurrence due to enhanced social distancing and the lack of adequate medical services due to the closure of some medical centers. A study from Japan showed that the length of hospitalization for mental health care increased during COVID-19 [
According to our results, the number of inpatient visits has increased significantly compared to the same month of the previous year. Among the “negative for SARS-CoV-2” group, the number of inpatient visits increased until April and decreased in May. Whereas, in the case of the “positive for SARS-CoV-2” group, the number of inpatient visits continued to increase until May. This means that more psychiatric care was needed for the COVID-19 positive patients. Previous studies have shown that infections are associated with a higher risk of mood disorders [
Finally, we analyzed the number of psychiatric medication prescriptions from January 2019 to May 2020. Our results indicate that all psychiatric medication prescriptions were peaked between March and April 2020. Sedative-hypnotic prescriptions, in particular, were prescribed most frequently in March. These patterns tended to be similar to those of psychiatric outpatient visits. It is notable that among the “positive for SARS-CoV-2” group, the number of psychiatric medication prescriptions continued to increase until May. These patterns tended to be similar to those of psychiatric inpatient visits among the COVID-19 positive patients. A study in the United States showed that the number of prescriptions for antidepressants, antianxiety, and anti-insomnia increased by 21% during the COVID-19 pandemic between February and March 2020 [
Our results indicate an increased need for psychiatric medication during the first COVID-19 outbreak in Korea, especially in COVID-19 positive patients. Many factors may have led to an increase in psychiatric prescriptions, most of which may be due to the increase and deterioration of mental health problems (e.g., anxiety, depression, stress, sleep disorder, etc.) during the COVID-19 pandemic [
Despite the meaningful findings, this study has some limitations. First, since this study was conducted on all people who tested for SARS-CoV-2 for a certain period of time, the results are representative of Korean people who tested for COVID-19, but cannot be generalized to the general population. Second, the data included individuals who tested for SARS-CoV-2 from January 2020 to May 2020. The results are related only to the early phases of the pandemic. Therefore, it is necessary to replicate these findings in later periods through additional data. Third, in the case of medications, though other studies [
In conclusion, we identified that the number of psychiatric visits increased during the initial phase of COVID-19 pandemic. This pattern was particularly noticeable in patients who did not have pre-existing mental illness before the COVID-19 pandemic, which means that mental problems were newly developed during the COVID-19 outbreak. For patients with pre-existing mental illness, especially those who tested positive for SARS-CoV-2, the decrease in outpatient visits, worsening symptoms, and a subsequent increase in hospitalization seem to be noteworthy problems. In addition, we identified that the prescriptions of psychiatric medications were higher as compared to COVID-19 among those who were tested for SARS-CoV-2. However, our study was only able to confirm the trends in psychiatric visits and medication prescription patterns during the first wave of the COVID-19 pandemic, and further research is needed to evaluate how these results change. With the prolonged COVID-19 pandemic, mental problems are expected to worsen or increase in the future. Therefore, government efforts are needed to reduce the mental health issues prevalent in our society and maintain mental health service use among patients with pre-existing severe mental illness during the COVID-19 pandemic.
The datasets generated or analyzed during the current study are available in the National Health Insurance Service (NHIS) repository,
Subin Park, a contributing editor of the
Conceptualization: Subin Park. Data curation: Minkyung Jo. Formal analysis: Min Geu Lee. Investigation: Jungeun Kim, Soo Jung Rim. Methodology: Jungeun Kim. Project administration: Subin Park. Supervision: Subin Park, Minkyung Jo. Visualization: Jungeun Kim. Writing—original draft: Jungeun Kim, Soo Jung Rim, Subin Park. Writing—review & editing: Jungeun Kim, Soo Jung Rim, Subin Park.
This study was supported by an Intramural Research Grant (No. R2019- 06) from the National Center for Mental Health, Ministry of Health & Welfare, Korea.
Number of SARS-CoV-2 tests per month and cumulative tests performed from January 2020 to May 2020. SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.
Number of psychiatric outpatient and inpatient visits per month from January 2019 to May 2020 among people tested for SARS-CoV-2. SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.
Number of outpatient and inpatient visits, based on the presence of pre-existing mental illness according to SARS-CoV-2 test result. A: Patients who tested for the SARS-CoV-2 test. B: Negative patients who tested for the SARS-CoV-2 test. C: Positive patients who tested for the SARS-CoV-2 test. SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.
Number of prescribed medications per month from January 2019 to May 2020 according to SARS-CoV-2 test result. A: Patients who tested for the SARS-CoV-2 test. B: Negative patients who tested for the SARS-CoV-2 test. C: Positive patients who tested for the SARS-CoV-2 test. SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.
Baseline characteristics of individuals tested for SARS-CoV-2
Variables | Total (N=212,678) | Without pre-existing mental illness (N=153,309) | With pre-existing mental illness (N=59,369) | p-value | |
---|---|---|---|---|---|
Gender | <0.001 | ||||
Male | 100,038 (47.0) | 74,193 (48.4) | 25,845 (43.5) | ||
Female | 112,640 (53.0) | 79,116 (51.6) | 33,524 (56.5) | ||
Age group | <0.001 | ||||
20–29 | 39,563 (18.6) | 34,960 (22.8) | 4,603 (7.8) | ||
30–39 | 38,809 (18.2) | 33,394 (21.8) | 5,415 (9.1) | ||
40–49 | 32,397 (15.2) | 26,509 (17.3) | 5,888 (9.9) | ||
50–59 | 30,660 (14.4) | 22,664 (14.8) | 7,996 (13.5) | ||
60–69 | 27,098 (12.7) | 17,244 (11.2) | 9,854 (16.6) | ||
70–79 | 22,704 (10.7) | 11,024 (7.2) | 11,680 (19.7) | ||
80+ | 21,447 (10.1) | 7,514 (4.9) | 13,933 (23.5) | ||
Region of residence | <0.001 | ||||
Seoul | 46,419 (21.8) | 33,904 (22.1) | 12,515 (21.1) | ||
Daegu | 25,787 (12.1) | 19,002 (12.4) | 6,785 (11.4) | ||
Gyeonggi-do | 51,314 (24.1) | 38,122 (24.9) | 13,192 (22.2) | ||
Gyeongsangbuk-do | 13,276 (6.2) | 8,750 (5.7) | 4,526 (7.6) | ||
Other | 75,882 (35.7) | 53,531 (34.9) | 22,351 (37.6) | ||
Income level | <0.001 | ||||
Low | 55,455 (26.1) | 35,621 (23.2) | 19,834 (33.4) | ||
Medium | 62,938 (29.6) | 48,751 (31.8) | 14,187 (23.9) | ||
High | 90,717 (42.7) | 66,223 (43.2) | 24,494 (41.3) | ||
Unknown | 3,568 (1.7) | 2,714 (1.8) | 854 (1.4) | ||
Insurance type | <0.001 | ||||
Self-employed | 48,602 (22.9) | 32,759 (21.4) | 15,843 (26.7) | ||
Employee | 152,225 (71.6) | 116,243 (75.8) | 35,982 (60.6) | ||
Medical aid | 11,851 (5.6) | 4,307 (2.8) | 7,544 (12.7) | ||
Test results of SARS-CoV-2 | <0.001 | ||||
Positive | 7,713 (3.6) | 5,962 (3.9) | 1,751 (2.9) | ||
Negative | 204,965 (96.4) | 147,347 (96.1) | 57,618 (97.1) | ||
Psychiatric visit |
<0.001 | ||||
Yes | 53,890 (25.3) | 14,864 (9.7) | 39,026 (65.7) | ||
No | 158,788 (74.7) | 138,445 (90.3) | 20,343 (34.3) |
psychiatric visit: the number of psychiatric visit (inpatient, outpatient) between January and May 2020. SARS-CoV-2, severe acute respiratory syndrome coronavirus 2
Baseline characteristics of individuals according to SARS-CoV-2 test result
Variables | Total (N=212,678) | Negative (N=204,965) | Positive (N=7,713) | p-value | |
---|---|---|---|---|---|
Gender | <0.001 | ||||
Male | 100,038 (47.0) | 96,990 (47.3) | 3,048 (39.5) | ||
Female | 112,640 (53.0) | 107,975 (52.7) | 4,665 (60.5) | ||
Age group | <0.001 | ||||
20–29 | 39,563 (18.6) | 37,506 (18.3) | 2,057 (26.7) | ||
30–39 | 38,809 (18.2) | 37,977 (18.5) | 832 (10.8) | ||
40–49 | 32,397 (15.2) | 31,361 (15.3) | 1,036 (13.4) | ||
50–59 | 30,660 (14.4) | 29,093 (14.2) | 1,567 (20.3) | ||
60–69 | 27,098 (12.7) | 25,899 (12.6) | 1,199 (15.5) | ||
70–79 | 22,704 (10.7) | 22,087 (10.8) | 617 (8.0) | ||
80+ | 21,447 (10.1) | 21,042 (10.3) | 405 (5.3) | ||
Region of residence | <0.001 | ||||
Seoul | 46,419 (21.8) | 45,909 (22.4) | 510 (6.6) | ||
Daegu | 25,787 (12.1) | 20,751 (10.1) | 5,036 (65.3) | ||
Gyeonggi-do | 51,314 (24.1) | 50,883 (24.8) | 431 (5.6) | ||
Gyeongsangbuk-do | 13,276 (6.2) | 12,343 (6.0) | 933 (12.1) | ||
Other | 75,882 (35.7) | 75,079 (36.6) | 803 (10.4) | ||
Income level | <0.001 | ||||
Low | 55,455 (26.1) | 52,692 (25.7) | 2,763 (35.8) | ||
Medium | 62,938 (29.6) | 60,877 (29.7) | 2,061 (26.7) | ||
High | 90,717 (42.7) | 87,945 (42.9) | 2,772 (35.9) | ||
Unknown | 3,568 (1.7) | 3,451 (1.7) | 117 (1.5) | ||
Insurance type | <0.001 | ||||
Self-employed | 48,602 (22.9) | 46,554 (22.7) | 2,048 (26.6) | ||
Employee | 152,225 (71.6) | 147,210 (71.8) | 5,015 (65.0) | ||
Medical aid | 11,851 (5.6) | 11,201 (5.5) | 650 (8.4) | ||
Pre-existing mental illness | <0.001 | ||||
Yes | 59,369 (27.9) | 57,618 (28.1) | 1,751 (22.7) | ||
No | 153,309 (72.1) | 147,347 (71.9) | 5,904 (77.3) |
SARS-CoV-2, severe acute respiratory syndrome coronavirus 2