Debate: Emergency mental health presentations of young people during the COVID-19 lockdown

SARS-CoV-2 and Adolescent Psychiatric Emergencies at the Tübingen University Hospital: Analyzing Trends, Diagnoses, and Contributing Factors

Psychiatric emergencies have increased in recent decades, particularly with the onset of the SARS-CoV-2 pandemic, and far too little is known about the backgrounds of these emergencies. In this study, we investigated the extent to which the number of psychiatric emergencies changed during and in the aftermath of the SARS-CoV-2 pandemic at the Child and Adolescent Psychiatry (CAP) Tübingen. We considered age and psychiatric diagnoses. Additionally, we evaluated the backgrounds of the emergencies. We applied a mixed- (quantitative and qualitative) methods approach to data on emergency presentations at the CAP Tübingen from the pre-SARS-CoV-2 pandemic period (October 2019-January 2020) to Restriction Phase 1 (October 2020-January 2021), Restriction Phase 2 (October 2021-January 2022), and endemic phase (October 2022-January 2023). The total number of emergencies and those with eating disorders and affective disorders increased, while obsessive-compulsive disorders, expansive disorders and anxiety disorders decreased. The patients presenting in the pre-SARS-CoV-2 pandemic period were younger than those in the subsequent periods. We content-coded the reasons behind the emergency presentations. We also identified four areas of stressors and personality characteristics associated with the emergency presentations. In light of the increasing number of psychiatric emergencies, the long-term aim should be to meet the growing demands and create options for prevention.

One year of psychiatric presentations to a hospital emergency department during COVID-19

OBJECTIVES

To examine the impact of the first full year of the COVID-19 pandemic and its associated restrictions on the volume and nature of psychiatric presentations to an emergency department (ED) in a large academic hospital.

METHODS

Anonymised clinical data on psychiatric presentations to the ED were collected for the 52-week period from the start of the COVID-19 pandemic and compared with corresponding 1 year periods in 2019 and 2018.

RESULTS

There was a significant increase in psychiatric presentations overall to the ED during the first year of the COVID-19 pandemic compared to previous years, in contrast to a reduction in total presentations for all other specialties. There was a marked increase in psychiatric presentations of those below 18 years, and in the 30-39 years and 40-49 years age groups, but a decrease in the 18-29 years group. There was a significant increase in anxiety disorder presentations but a decrease in alcohol related presentations. There was no significant change observed in the rates of presentations for self-harm or suicidal ideation.

CONCLUSIONS

Psychiatric presentations to the ED have increased during the first year of the COVID-19 pandemic in contrast to a decrease in presentations for other medical specialties, with this increase being driven by out-of-hours presentations. The fourfold increase in presentations of young people below the age of 18 years to the ED with mental health difficulties is an important finding and suggests a disproportionate burden of psychological strain placed on this group during the pandemic.

Liminality and insecurity: A qualitative study of young adults’ vulnerabilities during the first 12 months of the COVID-19 pandemic in Australia

COVID-19 has disrupted the normative social order, particularly for young adults. Their deteriorating mental health over 2020 has been associated with the economic and social conditions during the COVID-19 lockdowns. We conducted 19 semi-structured interviews with young adults aged 8 and 29 most of whom lived in Victoria, Australia. The interviews explored participants' experiences and responses to COVID-19, covering areas such disrupted everyday practices and future plans, impacts on their physical and mental health, and interactions community and services. Young adults were concerned about loss of social connectedness, their mental health and the complex interplay of issues such as employment, income, education and housing. They developed routines to protect their physical and mental health while in lockdown and some made the most of opportunities. However, the pandemic may have had a profound effect by disrupting some young adults’ plans for the future, thus contributing to a sense of ontological insecurity.

Excess healthcare costs of mental disorders in children, adolescents and young adults in the Basque population registry adjusted for socioeconomic status and sex

BACKGROUND

Mental illnesses account for a considerable proportion of the global burden of disease. Economic evaluation of public policies and interventions aimed at mental health is crucial to inform decisions and improve the provision of healthcare services, but experts highlight that nowadays the cost implications of mental illness are not properly quantified. The objective was to measure the costs of excess use of all healthcare services by 1- to 30-year-olds in the Basque population as a function of whether or not they had a mental disorder diagnosis.

METHODS

A real-world data study was used to identify diagnoses of mental disorders and to measure resource use in the Basque Health Service Registry in 2018. Diagnoses were aggregated into eight diagnostic clusters: anxiety, attention deficit hyperactivity disorder, conduct disorders, mood disorders, substance use, psychosis and personality disorders, eating disorders, and self-harm. We calculated the costs incurred by each individual by multiplying the resource use by the unit costs. Annual costs for each cluster were compared with those for individuals with no diagnosed mental disorders through entropy balancing and two-part models which adjusted for socioeconomic status (SES).

RESULTS

Of the 609,381 individuals included, 96,671 (15.9%) had ≥ 1 mental disorder diagnosis. The annual cost per person was two-fold higher in the group diagnosed with mental disorders (€699.7) than that with no diagnoses (€274.6). For all clusters, annual excess costs associated with mental disorders were significant. The adjustment also evidenced a social gradient in healthcare costs, individuals with lower SES consuming more resources than those with medium and higher SES across all clusters. Nonetheless, the effect of being diagnosed with a mental disorder had a greater impact on the mean and excess costs than SES.

CONCLUSIONS

Results were consistent in showing that young people with mental disorders place a greater burden on healthcare services. Excess costs were higher for severe mental disorders like self-harm and psychoses, and lower SES individuals incurred, overall, more than twice the costs per person with no diagnoses. A socioeconomic gradient was notable, excess costs being higher in low SES individuals than those with a high-to-medium SES. Differences by sex were also statistically significant but their sizes were smaller than those related to SES.

Increase of depression among children and adolescents after the onset of the COVID-19 pandemic in Europe: a systematic review and meta-analysis

BACKGROUND

Research points to a high depression burden among youth during the COVID-19 pandemic; however, a lack of systematic evidence exists. We determine the change in depression symptoms among children and adolescents during COVID-19 compared to pre-pandemic baselines. By using country differences in pandemic-related restrictions and school closures in Europe as quasi-experimental design, we evaluate policy impacts on depression.

METHODS

In this systematic review and meta-analysis, following the PRISMA statement, we searched six databases (MEDLINE, EMBASE, PsycINFO, Cochrane Central, Web of Science, WHO COVID-19) using a peer-reviewed search string up until March 18, 2022 with citation tracking and grey literature searches. No limitations regarding language and effect measures existed. We included studies that compared (1) general depression symptoms or (2) clinically relevant depression rates in children and adolescents (≤ 19 years) before and during the COVID-19 pandemic in Europe. The validated Oxford Stringency Index was used as indicator for pandemic-related restrictions. Screening for eligibility, extracting data from published reports and from unpublished data requested directly from study authors, assessing the study risk of bias and grading certainty of evidence using the GRADE approach, were all done in duplicate. Data were pooled in a random-effects model.

PROSPERO

CRD42022303714.

RESULTS

Of 7,422 nonduplicate records, 22 studies with data from 868,634 participants pre-pandemic and 807,480 during pandemic, met full inclusion criteria. For the comparison of depression symptoms before and during the COVID-19 pandemic, moderate certainty of evidence was observed for general depression symptoms (standardized mean difference, 0.21 [95%CI, 0.12-0.30]; I2 = 94%) and low certainty of evidence for clinically relevant depression rates (odds ratio, 1.36 [95%CI, 1.05-1.76]; I2 = 95%) for total population. Increase in general depression symptoms was higher for male adolescents, whereas increase in clinically relevant depression rates was higher for females. Effect estimates were significantly higher when pandemic-related restrictions were more stringent or school closure occurred.

CONCLUSION

An increase in depression symptoms occurred in a pre-pandemic vs. during-pandemic comparison within the COVID-19 pandemic, whereby pandemic-related restrictions (such as school closures) resulted in a considerable effect increase. Ensuring adequate supply of mental health recovery services and long-term monitoring is of high public health relevance.

Pediatric ICU Admissions After Adolescent Suicide Attempts During the Pandemic

BACKGROUND AND OBJECTIVES

The worldwide severe acute respiratory syndrome coronavirus 2 pandemic challenges adolescents' mental health. In this study, we aim to compare the number of pediatric ICU (PICU) admissions after suicide attempts during the first German lockdown and one year later during a second, prolonged lockdown with prepandemic years.

METHODS

A retrospective multicenter study was conducted among 27 German PICUs. Cases <18 years admitted to the PICU because of accidents or injuries between March 16 and May 31 of 2017 to 2021 were identified based on International Classification of Diseases, 10th Revision codes (German modification) and patient data entered into a database. This study is a subset analysis on suicide attempts in adolescents aged 12 to 17.9 years. The Federal Statistics Office was queried for data on fatal suicides, which were available only for 2020 in adolescents aged 10 to 17.9 years.

RESULTS

Total admissions and suicide attempts declined during the first lockdown in 2020 (standardized morbidity ratio 0.74 (95% confidence interval; 0.58-0.92) and 0.69 (0.43-1.04), respectively) and increased in 2021 (standardized morbidity ratio 2.14 [1.86-2.45] and 2.84 [2.29-3.49], respectively). Fatal suicide rates remained stable between 2017 to 2019 and 2020 (1.57 vs 1.48 per 100 000 adolescent years) with monthly numbers showing no clear trend during the course of 2020.

CONCLUSIONS

This study shows a strong increase in serious suicide attempts among adolescents during the course of the pandemic in Germany. More research is needed to understand the relation between pandemic prevention measures and suicidal ideation to help implement mental health support for adolescents.

Impact of the First COVID Lockdown on Accident- and Injury-Related Pediatric Intensive Care Admissions in Germany—A Multicenter Study

Children’s and adolescents’ lives drastically changed during COVID lockdowns worldwide. To compare accident- and injury-related admissions to pediatric intensive care units (PICU) during the first German COVID lockdown with previous years, we conducted a retrospective multicenter study among 37 PICUs (21.5% of German PICU capacities). A total of 1444 admissions after accidents or injuries during the first lockdown period and matched periods of 2017–2019 were reported and standardized morbidity ratios (SMR) were calculated. Total PICU admissions due to accidents/injuries declined from an average of 366 to 346 (SMR 0.95 (CI 0.85–1.05)). Admissions with trauma increased from 196 to 212 (1.07 (0.93–1.23). Traffic accidents and school/kindergarten accidents decreased (0.77 (0.57–1.02 and 0.26 (0.05–0.75)), whereas household and leisure accidents increased (1.33 (1.06–1.66) and 1.34 (1.06–1.67)). Less neurosurgeries and more visceral surgeries were performed (0.69 (0.38–1.16) and 2.09 (1.19–3.39)). Non-accidental non-suicidal injuries declined (0.73 (0.42–1.17)). Suicide attempts increased in adolescent boys (1.38 (0.51–3.02)), but decreased in adolescent girls (0.56 (0.32–0.79)). In summary, changed trauma mechanisms entailed different surgeries compared to previous years. We found no evidence for an increase in child abuse cases requiring intensive care. The increase in suicide attempts among boys demands investigation.

[Child and Adolescent Psychiatric Emergencies During the Second Wave of the SARS-CoV2-19 Pandemic: Findings from the Tübingen University Hospital]

Child and Adolescent Psychiatric Emergencies During the Second Wave of the SARS-CoV2-19 Pandemic: Findings from the Tübingen University Hospital Abstract. Objective: Child and adolescent psychiatric emergencies during the SARS-CoV2-19 pandemic are part of a controversial discussion. This study investigates the volume of such emergencies, the age of the patients, and the diagnoses of eating disorders and obsessive-compulsive disorders (OCD) that occurred at the Child and Adolescent Psychiatric Center (CAP) Tübingen during the second wave of the pandemic compared to the year before. Methods: We evaluated data on all emergencies at CAP Tübingen (telephone calls, outpatients, patient admissions) from 10/2019-01/2020 (first time period) and 10/2020-01/2021 (second wave). Results: The volume of emergencies during the second wave (319 presentations) was 29.7 % higher than during the first time period, and the number of patients (172 presentations) increased by 10.3 %. Compared to the first time period, the number of inpatients was 27.9 % higher, and the emergency admissions increased by 27.8 %. Patients in the second wave were somewhat older, with an average age of 14.8 years (first period: 14.2 years). Eating disorders were more frequent during the second wave, whereas OCD were more frequent in the first time period. Conclusions: Almost 30 % more emergencies were recorded in the second wave of the pandemic, with especially eating disorders increasing. Systematic emergency records should be documented at all German CAPs to enable demand-oriented planning.

How well do children in the North East of England function after a mental health crisis during the COVID-19 pandemic: A service evaluation

The COVID-19 pandemic has affected millions of people, and some researchers postulate that a mental health crisis will follow. The immediate effects of the COVID-19 pandemic on children's mental health are now starting to be published, and results appear to be mixed. There is no research, to the authors' knowledge, that empirically examines the functioning of young people following intervention from Child and Adolescent Mental Health Services (CAMHS) Crisis Teams in the UK during the COVID-19 pandemic. This service evaluation aims to do this using data from an NHS trust that supports 1.4 million people in the North East of England. We compared functioning, as measured by the Outcome Rating Scale (ORS), before and after treatment for young people discharged from the CAMHS Crisis Team between December 2019 and December 2020. ORS scores were significantly higher at the end of treatment (t(420) = -57.36, p < 0.001) with a large effect size (d = -1.56). Fifty eight percent of patients exhibited significant and reliable change (i.e. functioning improved to a 'healthy' level). No patients significantly deteriorated in functioning after accessing the crisis service.

Young People's Use of Digital Tools to Support Their Mental Health During Covid-19 Restrictions

Young adulthood represents a sensitive period for young people's mental health. The lockdown restrictions associated with the COVID-19 pandemic have reduced young people's access to traditional sources of mental health support. This exploratory study aimed to investigate the online resources young people were using to support their mental health during the first lockdown period in Ireland. It made use of an anonymous online survey targeted at young people aged 18-25. Participants were recruited using ads on social media including Facebook, Twitter, Instagram, and SnapChat. A total of 393 respondents completed the survey. Many of the respondents indicated that they were using social media (51.4%, 202/393) and mental health apps (32.6%, 128/393) as sources of support. Fewer were making use of formal online resources such as charities (26%, 102/393) or professional counseling services (13.2%, 52/393). Different social media platforms were used for different purposes; Facebook was used for support groups whilst Instagram was used to engage with influencers who focused on mental health issues. Google search, recommendations from peers and prior knowledge of services played a role in how resources were located. Findings from this survey indicate that digital technologies and online resources have an important role to play in supporting young people's mental health. The COVID-19 pandemic has highlighted these digital tool's potential as well as how they can be improved to better meet young people's needs.

Following the Epidemic Waves: Child and Youth Mental Health Assessments in Ontario Through Multiple Pandemic Waves

Emerging studies across the globe are reporting the impact of COVID-19 and its related virus containment measures, such as school closures and social distancing, on the mental health presentations and service utilization of children and youth during the early stages of lockdowns in their respective countries. However, there remains a need for studies which examine the impact of COVID-19 on children and youth's mental health needs and service utilization across multiple waves of the pandemic. The present study used data from 35,162 interRAI Child and Youth Mental Health (ChYMH) assessments across 53 participating mental health agencies in Ontario, Canada, to assess the mental health presentations and referral trends of children and youth across the first two waves of the COVID-19 pandemic in the province. Wave 1 consisted of data from March to June 2020, with Wave 2 consisting of data from September 2020 to January 2021. Data from each wave were compared to each other and to the equivalent period one year prior. While assessment volumes declined during both pandemic waves, during the second wave, child and youth assessments in low-income neighborhoods declined more than those within high-income neighborhoods. There were changes in family stressors noted in both waves. Notably, the proportion of children exposed to domestic violence and recent parental stressors increased in both waves of the pandemic, whereas there were decreases noted in the proportion of parents expressing feelings of distress, anger, or depression and reporting recent family involvement with child protection services. When comparing the two waves, while depressive symptoms and recent self-injurious attempts were more prevalent in the second wave of the pandemic when compared to the first, a decrease was noted in the prevalence of disruptive/aggressive behaviors and risk of injury to others from Wave 1 to Wave 2. These findings highlight the multifaceted impact of multiple pandemic waves on children and youth's mental health needs and underscore the need for future research into factors impacting children and youth's access to mental health agencies during this time.

Increased paediatric emergency mental health and suicidality presentations during COVID-19 stay at home restrictions

Objective

Anecdotal reports indicate an increase in mental health presentations and acuity to EDs during the COVID‐19 pandemic and associated stay at home restrictions. Paediatric and adolescent data to confirm this are unavailable in the Australian setting.

Methods

Retrospective electronic medical record review of all ED patients with mental health discharge codes at a large tertiary children's hospital in Australia during the period of stay at home restrictions from 1 April to 30 September 2020 compared with the same dates in 2019.

Results

We found a 40% decrease in ED presentations (18 935–11 235) with a concurrent 47% increase in mental health presentations (809–1190) to ED during the study periods between 2019 and 2020. This resulted in an increase of 100 mental health admissions from ED. Diagnoses with greatest percentage increases were eating disorders, social issues and suicidality. We found suicidality presentation numbers were highest in June to September 2020 compared with 2019. Patients with a diagnosis of suicidality had a higher rate of re‐presentation in 2020 (1.83 presentations per patient) compared to 2019 (1.38 presentations per patient).

Conclusions

Despite an overall decrease in ED presentations, the absolute increase in mental health presentations for children and adolescents during the stay at home restriction period was pronounced. It is unclear how sustained this change and the impact on mental health resource use will be post‐pandemic.

Editorial: How in the world are we handling COVID-19?

These are not normal times. As an editorial team, we felt that there was an urgency to reflect on our global experiences of the COVID-19 pandemic with our international colleagues. Instead of our planned debate series, we therefore commissioned a series of reflections on the impact of the pandemic on child and adolescent mental health throughout the world. We hope that you will find these reflections informative, thought-provoking, and in some cases, inspirational.