A dangerous pandemic pair: Covid19 and adolescent mental health emergencies

The Covid19 pandemic continues to introduce uncertainty into many aspects of our lives. The mental health sequelae of discreet, time-limited disasters—earthquakes, hurricanes, fires—are well known. But the mental health sequelae of COVID-19, with its global, continuously waxing and waning presence, may look different. Studies examining the mental health toll of the pandemic in adults are now appearing from China, Spain and Italy, but little has been documented regarding adolescents.

Prior to the emergence of Covid19, children and adolescents were experiencing mental health crises at unprecedented rates. Approximately one in five children ages three through 17 has a diagnosable mental, emotional or behavioral disorder. The Center for Disease Control reports that among adolescents aged 10–19, suicides increased 56% between 2007 and 2016, making it the second‑leading cause of death [2]. Much of this meteoric rise has been chronicled by those in Emergency Medicine. A 2019 study in JAMA Pediatrics revealed that Pediatric Emergency Department visits for suicidal ideation in the US increased from 580,000 in 2007 to 1.12 million in 2015 [1]. Nationwide, this flood of adolescents in crisis has overwhelmed emergency departments and laid bare the inadequacies of our pediatric mental health system. As a result, Emergency Departments often assume the role of de facto psychiatric crisis units, struggling to treat and manage youth who would be far better served with specialized care.

As the COVID-19 pandemic arrived in the US, the Center for Disease Control anticipated increased emotional stress on children and adolescents, and published guidance to help families cope with these challenges [3]. Mental health systems and Emergency Departments braced for increased pediatric mental health emergencies, speculating that the loss of educational routine, peer groups, and supports within schools would increase isolation, depression, substance use and suicidality [4]. Unexpectedly, however, our hospital did not observe this increase during the early months of the pandemic and the number of adolescents presenting for acute mental health emergencies dropped precipitously. This radical shift in numbers raised many concerns regarding the state of adolescent mental health and wellbeing. Many of us worried that youth needing mental health support were not seeking help due to fear of COVID-19. These concerns have been substantiated; over the past month, the number of youth seeking emergent mental health care in our hospital and emergency department is twice normal for this time of year.

As the pandemic continues, communities will debate school operations and wrestle, ironically, to strike the right balance between safety and wellbeing. Periods of quiet in which people struggle at home may alternate with less restrictive periods during which pent-up anxiety, depression and suicidality will lead desperate individuals to America's emergency departments. We can ill afford a system that lurches between extremes of unmanaged suffering at home and explosive mental health crises. While Emergency Departments should provide acute care to patients with mental health emergencies, they cannot substitute for a mental health care system while also acting as frontline providers during an infectious disease pandemic.

For the foreseeable future, economic insecurity, and uncertainty regarding schools reopening will continue, leading to the question, ‘how much longer can we do this?’ Despite an uneven public health response to COVID19, hospitals and Emergency Departments have proven they will respond aggressively. We need to think similarly for the mental health crisis and develop a time-tiered response for the short- and long-term. We must do a better job with the surveillance and tracking of our youth's mental health needs. For many years, schools have functioned as the eyes and ears of our pediatric mental health system. Without them, suffering is ‘locked down’ and weakly broadcast through suicide hotlines that, in some regions, have seen 1000% increases in call volumes. We must identify ways of tracking youth's mental health struggles; this requires acknowledging the problem and targeting messaging (including through social media) about prevention, staying safe, and seeking care. In the short term, we must develop nimble, technologically-based tele-health resources to reach struggling youth through this crisis. In addition, we must provide rapid responses to event clusters; especially, suicides in discreet communities. Over the long term, we must invest in mental health resources to prevent mental health problems from becoming emergencies. We must explore new paradigms for crisis care to safely bridge high-risk youth from crisis centers and Emergency Departments back to the community. [5]

Covid19 will change many aspects of our society. However, the truth remains that we all experience childhood exactly once. This experience cannot be repeated, rewound, or rewritten. The risks of unattended mental health issues posed by Covid19 are clear: millions of damaged and stunted childhoods. This generation will be defined by this moment in history; it is up to us how to shepherd them through it. If we fail to act now, we will pay dearly as our adolescents, healthy or not, progress into adulthood.

Financial Support

No external funding for this manuscript.

Author Contributions

RLC and RM conceptualized the topic and ideas behind this Perspective paper with RLC drafting the initial manuscript and RM reviewing and revising the manuscript. RLC and RM both critically reviewed the manuscript for important intellectual content. Both authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Declaration of Competing Interest

None.