Young people's mental health suffered amid COVID pandemic, 3 new studies suggest

Troubled young man

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The COVID-19 pandemic and related lockdowns harmed the mental health of Canadian and US youth, exacerbating depression, anxiety, and eating disorders among certain groups, according to a trio of new studies published in JAMA journals.

Eating-disorder hospitalizations rose 65% amid pandemic

One of two studies from the Pediatric Outcome Improvement through Coordination of Research Networks (POPCORN) published today found that the rate of hospitalizations for mood disorders and substance use declined among male and females aged 6 to 20 years from before to during the COVID-19 pandemic. 

But admissions for eating disorders rose for both sexes, and admissions for anxiety, personality disorders, suicide, and self-harm increased significantly among females.

For the study, published in JAMA Network Open, the researchers analyzed public health administrative data on all Canadians aged 6 to 20 years and from April 2016 to March 2023. 

Of 6.3 million Canadian youths, there were 218,101 hospitalizations for mental illness (ages 6 to 11 years, 5.8%; 12 to 17, 66.9%; and 18 to 20, 27.3%; 66.0% female). Overall, hospitalizations for mental disorders fell from 51.6 to 47.9 per 10,000 person-years from before the pandemic to the pandemic among both males and females.

But hospitalizations rose among both sexes for anxiety (11%), personality disorders (21%), suicide or self-harm (10%), and eating disorders in females (66%) and males (47%). For both sexes, hospitalizations declined for mood disorders (-16%), substance use (-17%), and other mental disorders (-22%).

The proportion of hospitalizations for mental conditions climbed in the 12- to 17-years-old age-group, from 65.8% before the pandemic to 68.4% during the pandemic. During the same periods, hospitalizations decreased from 6.2% to 5.3% for participants aged 6 to 11 years and 18 to 20 (28.0% to 26.3%). 

These findings suggest that services geared to females, specifically screening for eating disorders, anxiety, personality disorders, and suicidality, will be important to maintain in future pandemics.

Females made up 63.8% of hospitalizations for mental disorders before COVID-19, increasing to 69.0% during the pandemic. Prepandemic, hospitalizations of patients in the most materially deprived quintile accounted for a larger share of hospitalizations (24.4%) than the least deprived (16.9%). During the pandemic, this difference narrowed to 21.9% and 18.6%, respectively.

Residence in a rural area was linked to a higher rate of mental disorder hospitalizations for all conditions but eating disorders.

There were 881,765 emergency department (ED) visits for mental health conditions during the study period. Females made up a greater proportion of available ED visits during the pandemic (65.8%) than before (60.0%), along with participants aged 12 to 17 (52.7% vs 46.0%).

"Understanding how the pandemic affected children, adolescents, and young adults in Canada is crucial to inform public health policy, and these findings suggest that services geared to females, specifically screening for eating disorders, anxiety, personality disorders, and suicidality, will be important to maintain in future pandemics," the authors wrote.

Lockdown stringency tied to hospitalizations

In JAMA Pediatrics, POPCORN researchers conducting a separate study of 8,726 hospitalizations for eating disorders among Canadian youths of the same age over the same period found that, among girls 12 to 17 years old, a 10% jump in pandemic-lockdown stringency was tied to significant rises in hospitalizations for eating disorders that varied by region.

To measure lockdown stringency, the researchers used 12 indicators, such as office and school closures, public-event cancellations, travel restrictions, and stay-at-home orders.

During the study period, there were 11,289 eating-disorder hospitalizations in Canada, 90.4% of them among girls, of which 77% were for 12- to 17-year-olds. A 10% increase in lockdown stringency was linked to a significant climb in hospitalization rates in Quebec and Ontario (5%), the Prairie provinces (Alberta, Saskatchewan, and Manitoba; 8%), and British Columbia (11%). 

Excess hospitalizations were highest at the 1-year pandemic mark, with increases in Quebec (117%), Ontario (144%), the Prairies (139%), and British Columbia (102%).

A total of 58.6% of hospitalizations before and during the pandemic were for youths without a history of an eating-disorder hospitalizations. 

The increase in such hospitalizations likely had multiple causes, including more social isolation, loss of routines and extracurricular activities, more disordered eating, and increased compensatory physical exercise, the researchers said. 

The importance of social connectedness for youths (including support networks and parental education) should be promoted to help ensure that children, when experiencing restrictions, such as school closures, are as minimally socially isolated as possible.

"Given that most patients with eating disorders are treated as outpatients, the lack of outpatient services during the pandemic may have led to disease progression that, when left untreated or unacknowledged, was associated with a higher likelihood of hospital admission compared with other mental health disorders given the immediate medical health risk," they wrote. 

In future pandemics, they said pediatric healthcare providers should find ways to stay connected with patients for ongoing clinical assessment and psychosocial support at the hospital visits or via telehealth. 

"Health care practitioners should also be screening youths for new eating disorders regardless of weight, gender, or socioeconomic status," the authors wrote. "The importance of social connectedness for youths (including support networks and parental education) should be promoted to help ensure that children, when experiencing restrictions, such as school closures, are as minimally socially isolated as possible."

Low-income youth fared better amid COVID stress

Late last week in JAMA Network Openresearchers from Children's Hospital Los Angeles who hypothesized that COVID-19 lockdown-related mental health would be worse among US youth living in lower-income households instead found that children from wealthier families reported more depression and anxiety.

The research team used the Child Behavior Checklist (CBCL), the Family Environmental Scale (FES), and the income-to-needs ratio (INR) to assess mental health before and during the pandemic among 10,399 children aged 10 to 12 years participating in the multisite, 10-year Adolescent Brain Cognitive Development Study.

The prepandemic group had a 2-year follow-up visit before COVID-19 lockdowns (before March 2020), and the pandemic group had a 2-year follow-up visit after that date. The final sample was made up of 10,171 youths with 1-year-follow-up data (prepandemic, 7,343 youth; pandemic, 2,828) and 10,399 with 2-year follow-up data (prepandemic, 7,493; pandemic, 2,906. 

A total of 52.3% of participants were boys, 66.0% were White, 20.3% were Hispanic, 14.5% were Black, 12.2% were multiracial, 44.2% reported caregiver education levels below a 4-year college degree, and 26.2% had INR either below 100% (poverty) or 100% to less than 200% (near poverty).

There were no significant differences in average number of total problems on the CBCL between participants in the prepandemic and pandemic groups over time, and an increase of one unit in the INR corresponded to a reduction in the average rate of change in total problems.

Our research group previously published data demonstrating that families with more socioeconomic disadvantage may have taken more action to alleviate emotional distress related to the COVID-19 pandemic.

Of youth who differed by one unit in INR between the prepandemic and pandemic cohorts from 1- to 2-year follow-up, the expected difference in total problems was 0.79, with sex, age, caregiver education, and interstudy interval held constant, which the researchers said suggests that total problems tend to be lower among youths with lower INR in the pandemic group than those in the prepandemic group who had a follow-up visit before COVID-19.

For every one-unit difference in INR, the expected differences between the pandemic and prepandemic groups from 1- to 2-year follow-up were 0.19 for anxiety or depression, 0.17 for aggression, 0.09 for inattention; 0.08 for social problems; 0.06 for rule breaking, 0.12 for cognition problems, 0.27 for internalization issues, and 0.23 for externalization difficulties.

The researchers noted that a previous study's findings suggested that children in lower-income families may have better adapted to pandemic stressors. "Indeed, our research group previously published data demonstrating that families with more socioeconomic disadvantage may have taken more action to alleviate emotional distress related to the COVID-19 pandemic," they said.

"These results suggest that socioeconomic status may matter when considering the youth mental health outcomes of the COVID-19 lockdown, which may be important for targeted treatment approaches," they concluded.

They cautioned, however, that the study didn't provide insight into what drove the differences between the pandemic and prepandemic groups.

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