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Public health
Original research
Impact of the COVID-19 pandemic on psychotropic prescribing: a systematic review
  1. Swettha Mahesarajah1,
  2. Marie Line El Asmar2,
  3. Ryan Irwin3,
  4. Antonio J Vallejo-Vaz4,
  5. Nikolaos Mastellos2,
  6. Kanika I Dharmayat5
  1. 1School of Public Health, Imperial College London Faculty of Medicine, London, UK
  2. 2Imperial College London, London, UK
  3. 3Institute of Applied Health Research, University of Birmingham, Birmingham, UK
  4. 4Medicine, University of Seville, Sevilla, Spain
  5. 5Imperial Centre for Cardiovascular Disease Prevention (ICCP), Department of Primary Care and Public Health, Imperial College London, London, UK
  1. Correspondence to Dr Nikolaos Mastellos; n.mastellos{at}imperial.ac.uk

Abstract

Objectives The global prevalence of mental health disorders has risen significantly since the beginning of the COVID-19 pandemic. The pandemic has additionally caused disruption to mental health services, leading to a shift from in-person to remote service delivery. Given its long-term impact, it has become critical to evaluate whether changes in health delivery during the pandemic have had an effect on prescribing patterns for commonly prescribed psychotropic drugs. This study aims to assess the impact of the COVID-19 pandemic on changes in psychotropic prescribing patterns in adults, as well as differences in prescribing in different healthcare delivery approaches across various geographical contexts.

Design and eligibility requirements Systematic review of cohort, interrupted time-series and cross-sectional studies examining prescribing trends for at least one commonly prescribed psychotropic drug during and after COVID-19 in accessing care remotely or face to face between 1 January 2020 and 17 June 2022.

Data sources MEDLINE, EMBASE, CINAHL, HMIC and PsycINFO databases were searched in addition to citation chaining of relevant reviews.

Extraction and analysis Study screening, data extraction and quality assessment were completed by two independent reviewers. The PECO strategy was used to devise the systematic review and findings were synthesised narratively.

Results 16 studies were eligible for inclusion. Studies documenting changes in psychotropic prescribing trends provided very conflicting findings. There were no stark differences in prescribing outcomes between different healthcare delivery methods (ie, face-to-face consultations vs remote consultations). A noteworthy finding was that the prescribing rate of benzodiazepines was higher in women than men. No particular trends were observed for the prescription rates of hypnotics, antidepressants or antipsychotics.

Conclusions Findings support mixed trends in the prescription of psychotropic medications in a range of settings, hindering conclusive statements on COVID-19’s impact on prescribing. In areas where remote consultations are in use, more comprehensive research is required to assess the safety of prescribing in these settings to inform public health policy and assess if the observed trends in our systematic review persist over time (given the increased consideration of remote and telehealth care in delivering services), particularly the safe and effective deployment of these services.

  • MENTAL HEALTH
  • COVID-19
  • Telemedicine

Data availability statement

All data relevant to the study are included in the article or uploaded as online supplemental information.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjopen-2023-076791

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    STRENGTHS AND LIMITATIONS OF THIS STUDY

    • This study considered the limitations of previous studies, which included insufficient search results due to the omission of key drug names in the search methodology.

    • This study incorporated full comprehensive pharmacological terms and broad keywords to ensure search results contained studies examining the prescription rates of older psychotropic medications that are still in use, as well as new psychotropic medications that have been newly introduced into care settings.

    • There were no geographical constraints in our search strategy which may have limited the generalisability of the findings to individual geographical regions.

    • This study did not consider children and adolescents.

    Introduction

    Mental health disorders are one of the leading causes of the global disease burden.1 COVID-19 has had deleterious effects on mental health, and precautionary measures have inevitably contributed to an increase in the reported symptoms of emotional disturbance, insomnia, anxiety, depression and post-traumatic stress disorder.2 The emergence of COVID-19 amid an existing global mental health crisis has prompted widespread concerns regarding mental health ramifications, both in terms of immediate psychological effects and long-term social consequences.3 Research has shown that the pandemic has triggered a 25% increase in the prevalence of anxiety and depression disorders worldwide. An additional 53.2 and 76.2 million anxiety and depression diagnoses, respectively, have been made since the beginning of the pandemic,3 with the prevalence of mental health disorders expected to climb during the current postpandemic period.4

    The pandemic has also posed an unparalleled challenge to healthcare delivery. The implementation of various mandated public health initiatives necessitated health facilities and institutions to adjust the ways in which their organisations and practises deliver services.5 Consequently, these adjustments substantially hindered individuals’ ability to access primary and mental health services. A survey conducted in May 2020 revealed that 22% of individuals with mental health issues in the UK had their appointments cancelled, and 40% did not have any access to care.6 In addition, following the introduction of remote consultations, approximately two million fewer general practitioner (GP) consultations were made in March 2020 compared with March 2019. The provision of mental health services and psychiatric care has undergone a re-evaluation in response to the crises presented by the global pandemic.5 6 The prevailing approach to outpatient mental healthcare has witnessed a noteworthy shift from traditional face-to-face consultations towards remote modalities, predominantly mediated by telephone or videoconferencing technologies largely due to the pandemic.7

    With previous research highlighting a yearly rise in antidepressant prescriptions that is consistent with seasonality patterns it was anticipated that during the pandemic, increased exposure to variables exacerbating mental health disorders would lead to a rise in the diagnosis of mental health disorders and subsequent prescriptions of psychotropics.8–10 Conversely, access to psychiatric drugs was disrupted due to changes in healthcare delivery, drug shortages or clinician prescribing behaviour.11 12 The impact of the pandemic on prescription patterns, however, remains a contentious subject, with divergent findings. Some studies report an increase in psychotropic prescriptions since the start of the pandemic.13–16 Other studies, however, do not report any changes in psychotropic prescribing patterns in health service delivery or other factors induced by the pandemic.17–21

    To date, there has been a surge in primary research into the impact of the COVID-19 pandemic on prescribing trends for various psychiatric drugs. However, no systematic reviews have been published that consolidate the results of these studies. Given the pandemic’s long-term implications, it is crucial to investigate whether changes in healthcare services have had some impact on prescribing patterns to guide healthcare policy and promote safe prescribing. Thus, this systematic review endeavours to determine whether the COVID-19 pandemic has affected psychotropic medication prescribing patterns and whether these changes coincide with changes in healthcare delivery.

    Methods

    Eligibility criteria

    A research protocol (online supplemental material 1) was prepared in advance to minimise the risk of bias. A systematic review of the existing literature was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.22 Studies were required to compare prescription trends for at least one psychotropic medicine during the COVID-19 pandemic with prescribing patterns prior to the pandemic. In this analysis, we defined ‘before’ the pandemic as any time frame preceding December 2019, ‘during’ as any time frame that was associated with the lockdown measures in the relevant country, and ‘after’ as any time frame that was associated with the lifting of lockdown and restrictions in the relevant countries.23 24 Studies that examined prescribing rates of any medication during the pandemic without identifying the medication under discussion were excluded. To assess the impact of changes in healthcare delivery during the pandemic on psychotropic prescribing patterns, the review included studies comparing remote consultations, or mixed approaches, to face-to-face consultations. Studies that assessed the impact of remote consultations exclusively prior to the COVID-19 pandemic were excluded. Moreover, research that employed an unsuitable study design, did not provide adequate detail on study methodology or non-English language studies were excluded. Further details on the eligibility criteria are provided in online supplemental material 2.

    Search strategy

    This study’s search strategy considered the limitations of previous studies,13–20 which included insufficient search results due to the omission of key drug names in the search methodology. The present study’s search methodology incorporated full comprehensive pharmacological terms in addition to broad keywords such as ‘antipsychotics’, with the aim of maximising the scope and depth of the search results. Key search terms yielded numerous results, the inclusion of common typical antipsychotics, atypical antipsychotics, selective serotonin reuptake inhibitors (SSRIs), tricyclics, serotonin-norepinephrine reuptake inhibitors, antianxiety medications, stimulants and mood stabilisers yielded the maximum quantity of relevant studies. This ensured that the search results displayed studies examining the prescription rates of older psychotropic medications that are still in use, as well as new psychotropic medications that have been newly introduced into care settings.

    Electronic databases MEDLINE, EMBASE, CINAHL, HMIC and PsycINFO were searched; the search period was set from 1 January 2020 to the date of search (17 June 2022) in order to incorporate studies analysing psychotropic prescribing patterns after the first confirmed case of COVID-19. To avoid misclassification issues, the constraints for ‘English only’ and ‘human only’ were not defined at this point and were detected manually. In addition to searching the above databases, citation chaining was also conducted. Preprints via Europe PMC and ongoing studies via the WHO International Clinical Trials Registry Platform were also searched. A full list of the search strategy is available in online supplemental material 3.

    Data extraction, quality assessment and synthesis

    EndNote is a commonly utilised software for managing duplicates of extracted articles. Covidence is a new online platform that streamlines the review process of comparing included and excluded articles conducted by two independent reviewers. Search results were exported to EndNote whereby duplicates were identified and removed. Studies were then screened using Covidence by two reviewers independently (SM and MLEA). In instances where discrepancies arose between the reviewers, a consensus was reached within the review group. Relevant studies were then subjected to full-text screening after the initial assessment of their title and abstract. Following the initial title and abstract screening, relevant studies were selected for full-text review.

    A standardised data extraction form was used to collect: bibliographic information, study design, study location, sample size, indication of psychotropic medication use, reported changes in prescribing, indication of confounder control, primary outcomes and consultation type. Following the form’s pilot, two reviewers (KID and SM) independently extracted data. The 95% CIs for continuous data were reported together with the appropriate p values, SD and SE, where possible. To mitigate confirmation bias, in cases where studies’ methodology or results had missing data, the corresponding author of the respective studies was contacted.

    The quality of the included studies was assessed using the Quality Assessment Tool for Observational Cohort and Cross-Sectional studies by the National Heart, Lung and Blood Institute.25 Two reviewers (SM and MLEA) carried out the quality assessment independently. The quality assessments were compared and reviewed and any disagreements were resolved through collective discussion. Studies were assessed for study design, drug categories (hypnotics, benzodiazepines, antidepressants and antipsychotics) and the form of healthcare consultation evaluated in the study. Based on a critical analysis of these factors individually, each study was assigned a score out of 14. The final study quality report was divided into three categories. Studies receiving Y (yes) of 60% or more were given a quality rating of ‘good,’ those receiving Y (yes) response of 40% or more were given a rating of ‘fair,’ and studies receiving Y (yes) response of less than 40% were given a quality rating of ‘poor’.

    In light of the significant heterogeneity among the studies and data available, it was deemed inappropriate to pool and combine the results for a meta-analysis. Therefore, a narrative approach was used to synthesise the findings of the review.

    Patient and public involvement

    Patients and/or public were not involved in this research.

    Results

    Search results

    The search resulted in the identification of 644 studies in total. Following the removal of duplicates and thorough evaluation of the titles and abstracts, 83 studies were found to be eligible for full-text screening. A total of 16 studies met the review criteria and were included. The full PRISMA flow chart can be seen in figure 1.

    Figure 1
    Figure 1

    PRISMA flow chart detailing the studies that were identified using the search strategy, the number of publications that were evaluated for eligibility, the studies that were included or omitted and the justifications for each. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

    Study characteristics

    Seven studies analysed the prescribing trends of psychotropics in Europe,15 19 26–30 eight studies assessed trends in North America13 17 18 31–35 and one examined changes in psychotropic prescribing in Australia.36 All studies assessed prescribing trends during the pandemic and changes in prescribing patterns using data from previous years for comparison. All studies were observational, including four cross-sectional,15 17 29 30 six interrupted time-series19 27 31 33–35 and six cohort studies.13 18 26 28 30 32 All studies collected data from health administrative databases to examine trends in psychotropic prescribing patterns before, during and after the pandemic. Results were expressed as changes in the percentage or slope/degree of psychotropic prescriptions. Tables 1 and 2 in the main text and in online supplemental table 1 present the characteristics and outcomes of all included studies.

    View this table:
    Table 1

    Characteristics of studies

    View this table:
    Table 2

    Prescribing trends in remote, face-to-face and mixed approach settings

    Quality assessment

    All studies clearly stated their objectives, data collection sources and outcome measures while some studies produced more specific outcome measures based on the type of psychotropic rather than a broad estimate of psychotropic prescription trends. Eight studies met all but two of the criteria, indicating good methodological quality and low bias susceptibility. Four studies failed to address up to six of the exploratory questions, resulting in medium methodological quality. Finally, four studies were deemed to have inadequate methodological quality since they failed to comply with more than six of the specified exploratory questions. The majority of studies demonstrated that confounding variables were not appropriately adjusted for. These variables include but are not limited to, a history of prior mental health issues and the severity and duration and severity of such pre-existing disorders. The quality assessment is presented in online supplemental material 4.

    Changes in hypnotic prescribing rates

    Studies undertaken in the USA indicated declines in hypnotic prescribing,13 17 however, Wolfshlag et al study in Sweden reported an increase in hypnotic prescriptions during and after the COVID-19 pandemic. Their findings reveal an increase in monthly hypnotic prescriptions even after the peak of the pandemic in March 2020 with an increase in prescribing trend (β=+3589±2351, p=0.137).19 In contrast, Hirschtritt et al revealed that prescriptions for hypnotics declined by 3.5% (p<0.001) in patients enrolled in the Kaiser Permanente Northern California integrated healthcare system between 3 December 2019 and 3 March 2020. When prior-year trends were taken into consideration, younger (18–45 years) and middle-aged individuals (46–64 years) had stable hypnotic fills, whereas elderly adults (above 65 years) showed a notable decrease (−3.5%, (p<0.001)) in hypnotic fills.17 Milani et al reported minor changes in monthly prescribing trends. In males and females, hypnotic prescriptions decreased by 0.003% and 0.005%, respectively.13 Similarly, this study found no statistically significant differences in hypnotic prescription rates in younger (18–49 years) and middle-aged adults (50–64 years), but unlike Hirschtritt et al’s, those over the age of 65 years did not show any statistical changes in prescribing patterns after the pandemic’s onset. In contrast to the previous study, which was limited to Northern California, Milani et al sample provides for a more geographically diversified population, covering all 50 states.13 17

    Changes in benzodiazepine prescribing rates

    Some studies revealed increasing rates of benzodiazepine prescribing in Italy and the USA.26 32 Balestrieri et al reported an increase of 7.7% (p<0.001)) in benzodiazepine prescribing in face-to-face settings after the lockdown. This study reported a 37.5% drop in mental health consultations during the lockdown period and a decrease of 17.9% following lockdown.26 Likewise, de Dios et al reported that in the US sample, there was a 2% (p<0.001) rise in benzodiazepines in both remote and face-to-face settings when comparing the January to March 2019 period to the same time frame in 2020.32 However, four American studies found a decline in the dispensing/prescribing of this medicine.13 17 33 34 According to Downs et al, there was a considerable decrease in benzodiazepine prescriptions following implementation of an executive order restricting non-essential or elective procedures (β=−1982, 95% CI −3712.43 to –252.14). A study examining a study population in Northern California found similar results; prescription fills for benzodiazepines declined by 3.6% (p<0.001) between December 2019 and March 2020. Unlike hypnotic prescription patterns, which indicated that different age groups experienced varied trends, this study found that all adult age groups experienced relatively similar drops in benzodiazepine fills.17 In contrast, a study in Sweden similarly reported an increase in benzodiazepine prescriptions in the Scania (region in Sweden) population; prescriptions for this drug had already been declining in recent years.19 Ferro Uriguen et al also noted a substantial drop in benzodiazepine prescriptions and dispensing in Spain during the pandemic period, though the actual observed decrease in benzodiazepine prescriptions was far less than predicted.29

    Changes in antipsychotic prescribing rates

    The majority of studies, including those conducted in Australia, Canada, the USA, Romania, the UK and Spain, observed a decline in antipsychotic prescribing during the pandemic. When compared with other psychotropic prescribing patterns, antipsychotic prescribing, along with antidepressant prescribing, saw the greatest reduction across various countries. Miron et al assessed changes in yearly prescribing rates and reported the greatest reduction in antipsychotic prescriptions; a 48.3% decrease in second-generation antipsychotic long-acting injectable antipsychotics (LAIs) prescriptions were reported following the announcement and the associated restrictions of the pandemic,28 though the statistical significance of these findings is unclear. The outcomes of the study in Romania revealed that risperidone LAI was the only drug that reported an increase in its prescription trend, although statistically insignificant.28 Increases were reported in the prescription trend of antipsychotics in a single study in the UK; a 9.3% and 1.3%15 increase in the prescription rate of the drug was recorded among individuals with no intellectual disability in London and Cornwall, respectively.15 Prescription rates among people with autism increased by 5.7% in London, conversely, a 0.2% decrease was observed in those with autism in Cornwall.15 This distinction, however, was not constant among those with attention-deficit hyperactivity disorder (ADHD). Antipsychotic prescription rates fell by 4.6% in London and increased by 12.5% in Cornwall in populations with ADHD,15 though the statistical significance of these findings is unclear. In contrast, a Canadian study of nursing home residents found a significant increase in the prescribing trend of this drug (B=0.051, SE=0.010, p<0.01). In this sample, the absolute difference in observed vs projected in the final week of the pandemic period was greatest for antipsychotics.31 Italy likewise observed an increase in prescriptions for this medicine, with a 5.2% (p<0.001) increase during the lockdown and a 3.9% (p=0.01) increase after the lockdown in face-to-face settings. Though this study was not conducted in nursing homes.26

    Changes in antidepressant prescribing rates

    During and after the peak of the pandemic, the majority of studies indicated decreases in antidepressant prescribing patterns (online supplemental table 1); 5 out of 11 studies reported an increase in overall prescribing,15 17 19 26 31 while 6 studies report an increase.15 26 27 29 34 36 A study in the USA observed a 1.5% (p<0.001) increase in weekly antidepressant prescribing. Hirschtritt et al also found that antidepressant fills increased significantly in this North California population between mid-February and late March compared with the previous year’s time period. Older individuals showed to have fewer antidepressant fills when compared with other adult age groups.17 According to Naqvi et al’s study on the impact of the pandemic on psychotropic prescribing in adults with intellectual disabilities, antidepressant prescription rates increased by 10.9% among those living with autism residing in London but decreased by 0.5% in those with autism residing in Cornwall. The study also found that prescribing patterns for this medication in individuals without intellectual disabilities increased by 9.4% and decreased by 4.2% in London and Cornwall, respectively.15

    Two studies that examined prescribing trends in face-to-face settings revealed that this medicine was being prescribed less frequently. The study by Balestrieri et al discovered a 3.1% decrease in the annual prescribing rate of antidepressants in Italy during the lockdown, though statistically insignificant. Interestingly, data retrieved from Lombardy’s mental health departments during the lockdown period revealed a significant decline in psychiatric visits, although post-lockdown prescription patterns were comparable to the previous year.26 Ferro Uriguen et al study employing data from a Spanish population indicated a 5.2% (p<0.001) decline in monthly antidepressant prescriptions in geriatric units, whereas prescribing rates for the drug surged by 3.2% (p<0.001) in psychogeriatric units. The study also found that trazodone and SSRIs were the most prescribed antidepressants in these settings. One study found variations in monthly prescribing trends in remote settings.29 Wolfschlag et al found that antidepressant prescription rates in Sweden also continued to decrease after the pandemic was declared (β=+22 053±14805, p=0.146).19

    Prescribing trends in remote, face-to-face and mixed approach settings

    Here we evaluated whether there was obvious difference in prescribing trends and behaviours in face-to-face consultations and remote consultations or both (mixed-approach settings). All studies in the USA reported decreases in prescription fills for hypnotics in addition to benzodiazepines (p<0.001), while a single study in the UK reported increases in antipsychotics and antidepressants in settings where remote and face-to-face consultations were used in tandem.15 Other studies conducted in Europe reported statistically significant increases and decreases in benzodiazepines in face-to-face setting, respectively.26 29 There was no significant variation in prescribing trends between remote, face-to-face and mixed approach settings, and no evident trend for a specific group of psychiatric medicines was found.

    Discussion

    Summary of principal findings

    To the authors’ knowledge, this is the first systematic review assessing the impact of the pandemic on psychotropic prescribing trends across different healthcare settings and geographical context. The findings show varying results among studies examining changes in benzodiazepine, antipsychotic and antidepressant prescribing patterns, with geographical location within and between countries, healthcare context and consultation mode contributing to these discrepancies. There was also no significant variation in prescribing patterns between remote, face-to-face and mixed approach settings and no distinctive trends were detected for a specific group of psychiatric medicines. Despite the WHO publishing a ‘wake up call’ to encourage countries to strengthen their mental health services due to an increase in the global prevalence of anxiety, depression and insomnia during the pandemic,37 the majority of studies showed a drop in antipsychotic and antidepressant prescriptions.

    Discussion of findings and implications of selected studies

    Despite the stated overall decreases in prescribing, women were prescribed more benzodiazepines, hypnotics and antipsychotics than males, demonstrating the possible existence of gender-specific disparities.34 These increases in prescriptions to women in both the Milani et al and Leong et al investigations warrant further exploration; in line with other literature, these findings could imply that the pandemic has heightened gender differences in mental health.13 34 A recently published paper (outside the time frame of this review) conducted a nationwide analysis in England, comparing the prescribing trends of psychotropic agents from different classes with major physical health medications before and after the onset of the lockdown periods. The authors revealed that psychotropic prescribing increased, with hypnotics/anxiolytics rising by 0.2% (EAG=−2.3%) and antidepressants decreasing by −0.2% (EAG=5.0%). There was no net difference for antipsychotics (EAG=2.8%), although a temporary increase in antipsychotic prescribing occurred in the early pandemic period. For the main antidepressants prescribed in England such as sertraline, mirtazapine, venlafaxine, fluoxetine and citalopram, prescribing decreased during the main pandemic period compared with historical trends. These findings are in keeping with this review. Analyses from this review also support the idea that regional segmentation may impact the likelihood of developing mental health conditions38–44 and consequently changes in prescribing patterns. Given the limited studies comparing the general population and other special groups, further research is warranted to explore the impact of segmentation A study in the UK presented data on prescribing trends in people without intellectual disabilities who lived in Cornwall and London; London experienced a significant increase in antidepressant prescriptions, while Cornwall observed the opposite.15 Though reasoning behind these differences need to be investigated thoroughly, these observed differences could be partly due to Cornwall having less strict social restrictions than London; patients and caregivers may have suffered less interruption in their everyday lives, allowing them to retain a stable mental state.44 All other included studies did not specifically address vulnerable populations, highlighting the need for further research, especially concerning intellectual disability.

    In addition, despite finding no significant differences in prescribing patterns between remote, face-to-face and mixed approachs, declines in benzodiazepine prescriptions19 34 and increases in stimulant prescriptions19 36 were documented in two out of three studies that evaluated remote prescribing. There was also a minimal decrease in general psychotropic prescribing in remote settings when compared with face-to-face settings, although studies on mixed healthcare consultations generally show no changes in prescribing. The observed decreases could be associated with the assumption that healthcare professionals were cautious to start new medications due to clinical safety concerns and the inability to detect side effects via telehealth consultations.44 45 The decline could also be attributed to the cancellation of routine office visits as well as concerns regarding accessing health institutions during the height of the pandemic, indicating a large care gap for patients who are unable to acquire their prescriptions. Managing the use of telehealth modalities beyond the pandemic will require an in-depth study and understanding of the effects of face-to-face and virtual consultations on prescribing patterns. The results of this study indicate that prescribing may be a crucial consideration when choosing a consultation modality, perhaps even more so with new prescription starts. It is crucial to note that the choice of telehealth modality may be influenced by a variety of intricate aspects that need to be researched in tandem with the impacts of the pandemic on the administration of psychotropic medications. Future studies may examine how decision-making criteria for psychotropic prescriptions in both face-to-face and remote contexts affect prescribing behaviour by physicians.46

    An interrupted time-series analysis examining the impact of the COVID-19 pandemic on mental health visits to primary care physicians in nine countries (Argentina, Australia, Canada, China, Norway, Peru, Singapore, Sweden and the USA) revealed a notable rise in visit rates following the onset of the pandemic. Variations in these trends were observed, particularly among European nations, Australia and other regions, reflecting likely influences from historical accessibility patterns. This study provides evidence for anxiety and depression as prominent factors which contributed to the escalation in mental health service consumption during the pandemic period.47 The literature surrounding the remote prescribing of psychotropics is insufficient to draw credible conclusions regarding its safety. Previous research evaluating the safety of remote prescribing of antibiotics report the quality and safety are equivalent to in-person consultations, with similar guideline-concordant prescribing between both methods of healthcare consultations.48 However, more evidence is needed to conclude the safety of remote prescribing for mental health patients and determine whether patient drug consumption management in remote consultations is as effective as in face-to-face consultations. Furthermore, it was observed that follow-up visits after remote consultations were not documented in the few studies that investigated remote prescribing of psychotropics. Follow-up visits after remote consultations are frequently required, depending on the advice of the physicians and the needs of the patients. Though it should be noted that a high follow-up rate does not immediately correspond with incompetent management during first consultations, this information could be used to begin discussions about the usefulness and cost-effectiveness of remote consultations.48 49 Future research should try to collect this data, as well as data on symptom resolution as an endpoint, to assess whether remote consultations and remote prescribing are viable modes of health consultation in specific geographical regions.

    Limitations

    The findings of this study aid the understanding of the potential impact of the pandemic on changes in prescribing patterns in different regions, as well as the factors that may have driven these changes. Given that COVID-19 is a new area of research, it was anticipated that significantly fewer studies would be obtained; nonetheless, we gathered comprehensive studies allowing for more meaningful analysis. Although this study has many strengths, its limitations must be acknowledged.

    While additional subgroup analysis would have added further granularity to this review, this was not possible given the high heterogeneity (eg, differences in measured outcomes and the time of measured outcomes) of the included studies. Much of the included study data was derived from health administration and pharmaceutical databases, which combine prescribing data from nursing homes, hospitals, GPs and psychiatrists; changes in prescribing rates could not be traced back to the setting in which prescribing practises occurred. Moreover, we were unable to compare studies by certain time periods within the overall COVID-19 period as this varied for each study and country/region. Furthermore, in certain studies, it was difficult to determine what the psychiatric medicine was prescribed for. For example, SSRIs can be used to treat anxiety, depression or both in some circumstances; we were unable to identify whether there was a higher prevalence of some mental health conditions based on the volume of drug dispensations.50 Children/adolescents were not considered as it is beyond the scope of this review. This population group requires exploration, particularly around ease and ability in use of digital technologies. One in every seven 10–19 years old has a mental condition, accounting for nearly 13% of the global disease burden in this age range,51 excluding this population groups decreases the generalisability of these findings to those below 18 years of age.

    Furthermore, inclusion of studies written in English has an impact on the study’s external validity. Studies conducted in English are more likely to originate from western countries, thus studies from low-income and middle-income country (LMIC) which may have valuable insights may have been inevitably excluded.52 With an increasing rate of reported mental health disorders in LMICs and lower income countries,53 coupled with decreasing quality of care in these settings,54 it is critical that these countries become producers of research or secure the necessary funding to conduct research from national and international organisations. Finally, it is worth noting that, while high-income countries were obtained, many of these studies focused their research on a specific region of the respective country. Therefore, it might not be appropriate for the outcomes to be extrapolated to other regions, especially in countries that have an imbalance of urban and rural settings. The fact that there were no geographical constraints in our search acted as both a strength and a drawback. Geographical heterogeneity may necessitate regional follow-up evaluations. These reviews are necessary to make the findings more generalisable to the individual country or location.55 Furthermore, it should be noted that the data we currently have is interim in nature, given its short duration and unique relevance to the pandemic. To comprehend the complete impact of the pandemic on mental health and prescribing we will require in-depth observations. Lastly, as some studies simply explored internet delivered cognitive–behavioural therapy (CBT) in psychiatry, and others with head-to-head comparisons of internet versus face-to-face CBT, further research on the modes of delivery of CBT and prescribing is warranted.

    Concluding remarks

    The results of our study provide evidence for both increasing and decreasing trends in the utilisation of psychotropic medications across various healthcare settings, thereby preventing us from definitively asserting that alterations in healthcare delivery methods, such as the increased adoption of telehealth modalities, have exerted a substantial influence on prescribing patterns. In areas where remote consultations have yet to be implemented, extensive study is warranted to inform public health policies, encompassing the practical and suitable implementation of these services.

    Data availability statement

    All data relevant to the study are included in the article or uploaded as online supplemental information.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study does not involve human participants. The present work relied on already published aggregated data and ethics committee approval was unnecessary.

    Acknowledgments

    KID acknowledges support for a PhD Studentship from the National Institute for Health and Care Research (NIHR) Applied Research Collaboration Northwest London. AJV-V acknowledges support from the Programme 'Beatriz Galindo' from the Ministry of Universities, Spain, and University of Seville, Spain.

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    Supplementary materials

    Footnotes

    • Contributors NM is responsible for the overall content as guarantor and conceived the original study concept with input from RI. NM, AJV-V, RI and KID led the overall study design and supervised the subsequent steps of the study. SM designed the search strategy with supervision from the other authors and conducted the literature search, data extraction and quality assessment of studies together with MLEA and KID. SM wrote the first draft of the manuscript. All authors participated in the interpretation of data, have critically reviewed the manuscript and provided edits and comments and approved its final submission.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Disclaimer The views expressed in this publication are those of the authors and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care.

    • Competing interests RI and NM are employees of Oracle UK, a health technology organisation. AJV-V reports past or current participation in investigator-initiated research grants to Imperial College London from Pfizer, Amgen, Sanofi, MSD, Daiichi Sankyo and Regeneron, honoraria for lectures from Amgen, Mylan and Akcea, and steering committee/consulting fees from Radcliffe Cardiology and Bayer, all outside the submitted work. KID reports past or current participation in investigator-initiated research grants to Imperial College London from Amgen, Sanofi, MSD, Daiichi Sankyo and Regeneron and consulting fees from Bayer, all outside the submitted work.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.