Impact of the COVID-19 Pandemic on Child and Adolescent Psychiatric Emergencies

ABSTRACT

Objective: By forcing closure of schools, curtailing outpatient services, and imposing strict social distancing, the COVID-19 pandemic has abruptly affected the daily life of millions worldwide, with still unclear consequences for mental health. This study aimed to evaluate if and how child and adolescent psychiatric visits to hospital emergency departments (EDs) changed during the pandemic lockdown, which started in Italy on February 24, 2020.

Methods: We examined all ED visits by patients under 18 years of age in the 7 weeks prior to February 24, 2020, and in the subsequent 8 weeks of COVID-19 lockdown at two urban university hospitals, in Turin and Rome, Italy. ED visits during the corresponding periods of 2019 served as a comparison using Poisson regression modeling. The clinician’s decision to hospitalize or discharge home the patient after the ED visit was examined as an index of clinical severity.

Results: During the COVID-19 lockdown, there was a 72.0% decrease in the number of all pediatric ED visits (3,395) compared with the corresponding period in 2019 (12,128), with a 46.2% decrease in psychiatric visits (50 vs 93). The mean age of psychiatric patients was higher in the COVID-19 period (15.7 vs 14.1 years). No significant changes were found in hospitalization rate or in the prevalence distribution of the primary reason for the psychiatric ED visit (suicidality, anxiety/mood disorders, agitation).

Conclusions: In the first 8 weeks of the COVID-19–induced social lockdown, the number of child and adolescent psychiatric ED visits significantly decreased, with an increase in patient age. This decrease does not appear to be explained by severity-driven self-selection and might be due to a reduction in psychiatric emergencies or to the implementation of alternative ways of managing acute psychopathology.

J Clin Psychiatry 2021;82(3):20m13467

To cite: Davico C, Marcotulli D, Lux C, et al. Impact of the COVID-19 pandemic on child and adolescent psychiatric emergencies. J Clin Psychiatry. 2021;82(3):20m13467.
To share: https://doi.org/10.4088/JCP.20m13467

© Copyright 2021 Physicians Postgraduate Press, Inc.

aDepartment of Public Health and Pediatric Sciences, Section of Child and Adolescent Neuropsychiatry, University of Turin, Turin, Italy
bDepartment of Human Neuroscience, Section of Child and Adolescent Neurology and Psychiatry, “Sapienza” University, Rome, Italy
cEmergency Pediatrics, Department of Child Care, Regina Margherita Hospital, Turin, Italy
dChild Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University, Via Montpellier 1, 00133 Rome, Italy.
eDepartment of Neuroscience, University of Turin, Turin, Italy
‡Drs Davico and Marcotulli are co-first authors of this article.
*Corresponding author: Chiara Davico, MD, Department of Public Health and Pediatric Sciences, Section of Child and Adolescent Neuropsychiatry, University of Turin, Piazza Polonia 94, 10100, Turin, Italy (chiara.davico@unito.it).


 

The coronavirus SARS-CoV-2 pandemic has dramatically changed life throughout the world. Since being first identified in Wuhan, China, in December 2019, the virus rapidly spread to other parts of Asia and to Europe.1,2 In February 2020, Italy saw the first large outbreak of coronavirus disease 2019 (COVID-19) outside Asia.3 On February 23, 2020, in an effort to contain the pandemic, the Italian government started enacting a series of decrees that closed schools and nonessential businesses; cancelled all cultural, entertainment, recreational, and sport events; and imposed strict social distancing with severe limitation to freedom of movements and personal interaction.4 All routine health care was suspended as medical services were limited to essential needs and urgent care, including outpatient and day hospital center services for psychiatric patients.

While these measures were deemed necessary to contain the spread of the virus, the mental health implications of the pandemic itself as a life-threat and of its consequences, such as curtailment of health care, disruption of therapeutic contacts, school closure, social distancing, and general societal lockdown, are unknown. Concerns have been raised that quarantine could have unfavorable psychological effects.5,6 Limited information can be derived from other recent viral outbreaks because of the unprecedented nature of the COVID-19 pandemic. Unlike during previous events such as the SARS outbreak in 2003 in Singapore and Canada, a large proportion of the world population has been directly threatened and subjected to extreme measures of social isolation that have disrupted interpersonal contacts at all levels. In particular, little is known about the possible mental health implications for children and adolescents, especially with respect to the development of severe symptoms requiring emergency evaluation.

Monitoring psychiatric visits to hospital emergency departments (EDs) can inform on trends in acute psychopathology and may help identify specific clinical needs of the most vulnerable patients. A general decrease in ED visits was reported with the onset of the COVID-19 pandemic.7 A decrease in adult psychiatric ED visits has been reported by some,8,9 but not others.10 Recently, reductions in pediatric general and mental health ED visits have also been reported.11,12

The aim of this study was to examine child and adolescent ED visits for mental health concerns during the COVID-19 pandemic at two large urban university hospitals, respectively in the North and Center of Italy. It was expected that, on one hand, fear of possible contagion would lead families to avoid, whenever possible, hospital settings, but that, on the other hand, restricted access to outpatient services and stress from social distancing would increase the likelihood of acute behavioral and emotional disturbances requiring emergency intervention. Thus the a priori hypothesis was that the COVID-19 pandemic would be associated with a reduction in the total number of psychiatric ED visits, but with more severe clinical presentations.

METHODS

We examined all of the ED visits by patients under age 18 years at two urban university hospitals in Italy (Regina Margherita Pediatric Hospital, University of Turin, and Policlinico Umberto I Hospital, University of Rome) in the 7 weeks prior to the onset of the COVID-19–induced lockdown, which began on February 24, 2020, and in the first 8 weeks of lockdown. The ED visits during the corresponding time periods in 2019 were similarly examined. From the hospital electronic databases, all ED visits that involved a psychiatric evaluation were identified. For these visits, the data were manually extracted from the hospital clinical records. The primary psychiatric reason for the ED visit was categorized, in decreasing order of severity, into suicide attempt, suicidal ideation, psychomotor agitation, psychosis, non-suicidal self-injury (NSSI), mood disorder, eating disorder, anxiety, or somatic symptom disorder. If more than one category applied, the most severe category was selected. The attributions were done independently by two raters, who agreed or reached consensus in case of disagreement.

The decision by the clinician at the end of each ED visit to discharge the patient home or to admit her/him to the hospital was recorded as an index of severity. When applicable, data on previous psychiatric diagnosis, ongoing psychiatric treatment, therapeutic interventions, and interruption of therapeutic interventions within the last 2 months were obtained.

The study consisted in examining hospital records and collection and analysis of anonymized clinical data without active recruitment of patients. The study was approved by the Institutional Ethics Committee.

Statistical Analysis

Statistical analyses were performed using the statistical programming language R (version 3.5.1).13 Descriptive statistics was applied to sociodemographic and clinical data. Continuous variables were described by median and interquartile range, and categorical data as percentages.

The periods of observation consisted of a total of 15 weeks in 2020 (7 weeks prior to February 23 and 8 weeks starting February 24) and the corresponding periods in 2019. Weekly ED visit counts were modeled using a Poisson regression model. A dichotomous (dummy) covariate that represented COVID-19–related lockdown measures was used. Specifically, the COVID-19–related covariate assumed the value of 0 until February 23 and the value of 1 thereafter for the within-year comparison. A similar dummy covariate was used to model COVID-19–related lockdown measures between the second interval of 2020 and the corresponding interval of 2019. Since a decline in psychiatric visits was also observed in the second interval of 2020, the Poisson model used to analyze psychiatric ED visits observed in 2019 had a factitious COVID-19 covariate equivalent to the one used for 2020, as a control that the reduction observed in 2020 was not due to a seasonal effect. A hospital-related factor was used in all models to control for site effects. The same models with an offset equivalent to the logarithm of the number of all ED visits per week were used to evaluate the trend in psychiatric visits while adjusting for total ED visits.

Then, a 2-step procedure was used to predict the number of ED visits from February 24, 2020, based on the 2019 observed visits trend. Observed ED visits from January 6 until February 23, 2020, were analyzed with a Poisson regression model using ED visits during the corresponding weeks of 2019 as covariate. The resulting model was used to predict number of ED visits in the second interval of 2020, using the visits count in the second interval of 2019 as an additional predictor.

Possible effects of sex and clinical severity (ie, discharged home vs hospitalized) on changes in ED use during the COVID-19 lockdown (ie, before vs after February 23, 2020, as compared with the corresponding period in 2019) were evaluated using the Pearson χ2 test. Age effects were assessed by means of a 2-tailed Mann-Whitney U test. A χ2 test, with the William correction as appropriate, was used to analyze the distribution of clinical reasons for the ED visits. Statistical significance was set at 2-tailed P < .05.

RESULTS

In the 7 weeks ending with February 23, total pediatric ED visits were 10,844 in 2020 (6,803 in Turin and 4,041 in Rome) and 10,888 in 2019 (6,765 in Turin and 4,123 in Rome). Psychiatric ED visits were 131 in 2020 (69 in Turin and 62 in Rome) and 101 in 2019 (53 in Turin and 48 in Rome) (Table 1). Male sex accounted for 37% of psychiatric ED visits in 2020 and 45% in 2019, a statistically nonsignificant difference.

In the subsequent 8 weeks, total pediatric ED visits were 3,395 in 2020 (2,326 in Turin and 1,069 in Rome) with a 72.0% decrease compared with the corresponding period in 2019 (12,128, 7,630 in Turin and 4,498 in Rome), and psychiatric ED visits were 50 (26 in Turin and 24 in Rome) in 2020, a 46.2% decrease compared with 2019 (93, 47 in Turin and 46 in Rome) (Table 1). The decline in psychiatric ED visits paralleled the decrease in total ED visits (Figure 1A). Weekly psychiatric ED visits declined after February 23, 2020, compared with the corresponding period of 2019 (Figure 1B), with consistent time trends at the two sites (Turin and Rome) (Figure 1C).

In a Poisson regression model with COVID-19 lockdown period coded as dichotomous covariate (positive after February 23), the lockdown period was associated with a 67% decrease in psychiatric visits compared to the within-year control period (P < .001) (Figure 2, Table 2).

The proportion of total of pediatric ED visits accounted for by the psychiatric visits increased from 2019 to 2020. This was evident in the 2 time periods, before and after the COVID-19 lockdown date (Table 1). In the generalized linear model, the COVID-19 lockdown factor was not associated with the proportion of psychiatric referrals among the total of ED visits in the within-year comparison (Table 2).

No statistically significant differences in the distribution of the reason for psychiatric ED visit were detected (Table 1 and Figure 3). In particular, suicidality (defined as suicide attempt or ideation) accounted for 18% of psychiatric ED visits during the COVID-19 lockdown period as compared with 17% in the corresponding period in 2019. The prevalence of anxiety, somatic symptom, and mood disorder was 26% in the second interval of 2020 versus 42% in the second interval of 2019, and that of psychosis 3% in the second interval of 2020 versus 4% in the second interval of 2019.

No statistically significant difference was found in the rate of clinician-recommended hospitalization as the outcome of the ED visits during the COVID-19 lockdown as compared to the corresponding interval in 2019.

No significant sex effect was found in the number of psychiatric ED visits in the observed time periods. Patient age during the 2020 COVID-19 period was higher (15.74 years) than in the corresponding period of 2019 (14.12 years, P < .05) (Table 1).

To test for possible site effects, we also independently analyzed the psychiatric ED visits in Rome and Turin, without finding significant differences in sex or hospitalization rate. In Turin, but not in Rome, psychiatric ED patients were older (median [IQR] age = 15.48 [12.92–16.45] years) during the COVID-19 lockdown period than during the corresponding period of 2019 (median [IQR] age = 13.58 [10.75–15.42] years, P ≤ .05).

DISCUSSION

By examining the ED visits at two urban university hospitals in Italy, we found a sudden decrease in the number of child and adolescent psychiatric visits in the first 8 weeks of the COVID-19 lockdown. The decrease was evident when compared with both the 7 weeks prior to the onset of the lockdown and the corresponding time period in 2019. However, the decline in the number of psychiatric ED visits was less marked than that observed in all pediatric ED visits and was not accompanied by significant changes in the reason for ED visit. The steepest decline in number of ED visits occurred during the first weeks of lockdown, when the rate of viral infections was rapidly increasing to reach a peak in the incidence of new infections in mid-March 2020.14

An ED visit can result in the decision by the examining clinician to hospitalize the patient or to discharge her/him home, typically based on the severity of the condition. Thus, the decision of the clinician to hospitalize or to discharge the patient was taken as an index of severity. Contrary to the expectation, however, we found no increase in the rate of hospitalization as disposition of psychiatric ED visits during the COVID-19 lockdown. No involuntary hospitalization was recorded during the periods of observation in 2020 and 2019. These data do not support the hypothesis that the decrease in ED visits could be accounted for by severity-driven self-selection, with individuals with less severe cases avoiding the ED.

Our data are consistent with a recent report of a 61% decrease in pediatric mental health ED visits12 and a decrease in adult psychiatric and suicide-related ED visits.9,15 Another recent report10 that the number of adult psychiatric ED visits did not change during the pandemic despite a substantial decrease in general ED visits is in part consistent with our finding that, in children, psychiatric ED visits declined less than did the general pediatric ED visits, thus accounting for a larger proportion of the overall ED use.

An overall decrease in ED visits during the pandemic has been reported for both children and adults.8,11,16,17 This decrease could be generally explained by the tendency to avoid hospital settings for fear of contagion.18,19 While hospital EDs are usually considered relatively safe places to obtain prompt medical attention, during a pandemic hospitals can become dangerous containers of COVID-19–infected patients, to be avoided if at all possible.18 A number of factors could influence the use of EDs for psychiatric reasons among children during a pandemic lockdown.

On one side, school closure can reduce academic stress and the risk of negative interpersonal contacts such as bullying, all factors that could decrease the risk for acute psychiatric symptoms.6 The suspension of many work activities and greater reliance on remote work from home can provide more opportunity for parental involvement and supervision. Greater family cohesion may result in reduced risk for acute psychopathology, especially in younger children. Moreover, social distancing, home confinement, and suspension of most activities might temporarily alleviate psychological pain in children and adolescents suffering from separation anxiety, social anxiety, and school refusal. Youths in general may be protected from the loss of direct personal contacts by their reliance on remote technology for social interaction and the tendency to privilege virtual connections over real-life contacts.20 In addition, a general social lockdown, with early curfew, may decrease opportunities for substance abuse.

On the other side, fear of infection and uncertainty about future could increase anxiety in both parents and children, with negative impact on psychological well-being,5 and especially for those with preexisting mental health conditions.21 Reduced opportunities for social recreational activities and outside physical exercise may also contribute to worsening of mental health.22,23 The closure of outpatient and day hospital services, except for the most urgent cases, with abrupt interruption of psychotherapies and other routine therapeutic contacts, may increase the risk of clinical deterioration. Moreover, the reduced availability of community mental health and social services, including child protective services, may increase the risk of domestic conflict and child maltreatment.

This study was conducted in the initial phase of the pandemic, at a time when in Italy there were no established standards of telehealth psychiatric care for children and adolescents and telehealth services were largely insufficient to fulfill patients’ needs. We think that it is unlikely that telehealth would have attenuated the need for psychiatric ED visits.

We found that the number of psychiatric ED visits decreased, but their proportion among the total ED visits increased. The increase in the proportion of psychiatric visits was evident in 2020, both before and during the COVID-19 lockdown, over the corresponding time periods in 2019. This finding is consistent with reports of increasing proportion of psychiatric ED visits by children and adolescents, documented even prior to 2019.24–27

This study has several limitations. Analyses were based on data from two university hospitals in Italy and did not rely on nationwide data. However, the participating hospitals are the main child and adolescent inpatient resource serving areas with a cumulative population of more than 6 million people. The clinical data were obtained from medical records and not systematically collected through standardized rating scales or interviews. Consequently, the reasons for the ED visits could be grouped only into rather general and likely heterogeneous categories. It also cannot be excluded that the clinician’s decision to hospitalize or not hospitalize the patient after the ED visit, although based on psychiatric severity, might have been biased by not wanting to put a child in the hospital because of possible COVID-19 infection and/or wanting to preserve hospital resources for COVID-19 patients.

In conclusion, the societal lockdown consequent to the COVID-19 pandemic was accompanied by an abrupt and marked decrease in the number of child and adolescent psychiatric visits to the ED of two urban hospitals in Italy, without evidence of significant changes in type or severity of psychopathology. Such an abrupt decline in ED use is unlikely to be due to a sudden reduction in psychopathology but may reflect alternative ways of dealing with acute psychiatric needs. Further research on psychiatric needs during emergency situations such as the COVID-19 pandemic may help identify more efficient approaches to managing acute psychopathology than resorting to hospital ED.

Submitted: May 14, 2020; accepted February 12, 2021.
Published online: April 6, 2021.
Potential conflicts of interest: In last 2 years, Dr Vitiello has received consultant fees or honoraria from Medice, Lundbeck, and Angelini Pharmaceuticals, and from law firms Goodwin & Procter, and Haynes & Boone. The remaining authors have no potential conflicts of interest relevant to the subject of this article.

Funding/support: None.

Clinical Points:

  • During the early phases of the COVID-19 pandemic, a decrease in general pediatric emergency department (ED) visits was reported, but few data were available on child and adolescent psychiatric emergencies.
  • This study found a 46% decrease in psychiatric ED visits by children and adolescents during the COVID-19 social lockdown at two university hospitals in Italy, suggesting that there were alternative ways of managing acute psychiatric needs.

Editor’s Note: We encourage authors to submit papers for consideration as a part of our Focus on Childhood and Adolescent Mental Health section. Please contact Karen D. Wagner, MD, PhD, at kwagner@psychiatrist.com.

Volume: 82

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