Patterns of Youth Inpatient Psychiatric Admissions Before and After the Onset of the COVID-19 Pandemic

Abstract

To slow the spread of severe acute respiratory syndrome coronavirus 2, the virus causing 2019 novel coronavirus disease (COVID-19), many state authorities enforced extreme social distancing measures, such as closing schools, implementing online instruction, canceling major events, and limiting social contact outside families. Such measures have promoted safety but also have severely disrupted the lives of children of all ages. Many youths have missed seminal milestones; have struggled with the challenges of virtual schooling; and have isolated at home with their families, which has eroded opportunities for peer social support, relaxation, and enjoyment. While the consequences of COVID-19 on mental health are still unfolding, the psychological toll of these prolonged social distancing measures in combination with economic hardships and increased parental stress has led to worldwide reports of increased rates of mental health problems,^1,2 trauma, abuse,^3,4 and predicted increases in suicide⁵ in youths.

To the Editor:

To slow the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus causing 2019 novel coronavirus disease (COVID-19), many state authorities enforced extreme social distancing measures, such as closing schools, implementing online instruction, canceling major events, and limiting social contact outside families. Such measures have promoted safety but also have severely disrupted the lives of children of all ages. Many young people have missed seminal milestones; have struggled with the challenges of virtual schooling; and have isolated at home with their families, which has eroded opportunities for peer social support, relaxation, and enjoyment. While the consequences of COVID-19 on mental health are still unfolding, the psychological toll of these prolonged social distancing measures in combination with economic hardships and increased parental stress has led to worldwide reports of increased rates of mental health problems,^{1 , 2} trauma, abuse,^{3 , 4} and predicted increases in suicide⁵ in children and adolescents.

To begin to understand how COVID-19 may have affected mental health and help-seeking behaviors of minors, the authors examined patterns of admissions of children and adolescents to an acute academic psychiatric hospital in a major metropolitan area. Two time periods were compared: the COVID-19 period (March 11 to August 31, 2020) and the same time period 1 year previously (March 11 to August 31, 2019). March 11 was selected as the start of the pandemic because it was the day the mayor declared a local state of disaster owing to a public health emergency; residents were strongly encouraged to shelter in place and avoid crowded areas and places where people may be ill. Differences in age, sex, number of psychiatric hospitalizations, suicidality, history of abuse, length of admission, and primary diagnoses at discharge were analyzed retrospectively from hospital records. Given the myriad possible diagnoses, the diagnoses were clustered and analyzed based on the broad diagnostic categories of DSM-5.

The psychiatric hospital provides a combination of pharmacotherapy, psychotherapy, and supportive care aimed at stabilization of acute psychiatric conditions. The acute child and adolescent unit has a maximum capacity of 21 patients (10 double-occupancy rooms and 1 single-occupancy room). Patients range in age from 4 to 17 years. There are no exclusionary diagnostic criteria; however, patients must be medically stable before they are admitted to the hospital. The treatment team comprises 2 child psychiatrists (C.P.Z.), 1 child psychologist (A.M.U.), 1 child psychiatry fellow, 1 psychiatry resident, 1 psychology intern, 2–3 nurses, 3 psychiatric nurse technicians, and 2 social workers. During the pandemic, the unit capacity was not decreased, and no limitations were placed on patient age or admission diagnosis. Staffing was based on the number of patients on the unit, and there was no shortage of staff on the unit.

The total sample consisted of 516 patients ranging in age from 4 to 17 years. The majority of patients were 14 years old, female (57%), Hispanic/Latino (38%), uninsured (90%), and endorsed “high” risk for suicide (45%). Given the skewness of data, differences between the time periods were analyzed using Mann-Whitney U and Pearson χ² tests.

Results indicated a 41% reduction in the number of young people presenting to the hospital as self-referrals and a 36.5% reduction in the number of patients transferred from other hospitals, which accounted for an overall 40% reduction in admissions during the COVID-19 period. When comparing the 2 cohorts, significant differences were found for age (U = 27861.5, p = .041), length of stay (U = 24459, p = .000), and substance use disorders (χ² ₁ = 11.22, p = .001). No differences were found for sex, number of previous hospital admissions, suicidality, history of abuse, or any other diagnoses. A comparison of the 2 cohorts is presented in Table 1 .

Table 1.

Comparison of Demographic Variables, Hospital Admission Variables, and Discharge Diagnoses in Patients From COVID-19 Period and Control Period

	COVID-19 period March 11–August 31, 2020 (n = 193)	Control period March 11–August 31, 2019 (n = 323)
Number of self-referrals presenting to hospital	194	329
Number of patients admitted to hospital	193	323
Number of self-referrals admitted to hospital	68	126
Number of transfer patients admitted to hospital	125	197
Age, y, mean (SD)	14.60 (2.21)∗	14.09 (2.57)∗
Sex, female	111 (58%)	184 (57%)
Number of previous psychiatric hospitalizations, mean (SD)	1.34 (0.67)	1.37 (0.67)
Suicidality, mean (SD)
Suicidal ideation (0–5)	2.10 (2.00)	2.31 (2.01)
Suicidal behavior (0–4)	1.32 (1.23)	1.34 (1.27)
History of abuse, (%)	69 (36.5)	118 (35.8)
Length of hospital stay, days, mean (SD)	7.73 (5.78)∗	6.26 (4.74)∗
Primary discharge diagnoses
Schizophrenia spectrum and other psychotic disorders (%)	20 (10.4)	41 (12.7)
Bipolar disorders (%)	9 (4.7)	22 (6.8)
Depressive disorders (%)	89 (46.1)	138 (42.7)
Anxiety disorders (%)	9 (4.7)	9 (2.8)
Obsessive-compulsive disorders, (%)	2 (1.0)	2 (0.6)
Trauma- and stressor-related disorders, (%)	50 (25.9)	91 (28.2)
Gender dysphoria, (%)	3 (1.6)	2 (0.6)
Disruptive, impulse-control, and conduct disorders, (%)	32 (16.6)	55 (17.0)
SUDs, (%)	58 (30.1)∗	56 (17.4)∗
Neurodevelopmental disorders, (%)	45 (23.3)	80 (24.8)

Note: SUD = substance abuse disorders.

^∗p < .05.

As the COVID-19 pandemic continues, mental health professionals are discovering the psychological toll of COVID-19 social distancing measures on young people. While significantly fewer minors presented or were admitted to the hospital during the pandemic, children and adolescents who were admitted stayed in the hospital approximately a day and a half longer; this was possibly due to the adjustment of professionals to temporary telehealth procedures or due to the reduced availability of step-down programs and other outpatient services necessary for discharge. While patients in the COVID-19 period were a few months older, they did not differ markedly from their peers in the control period. Depressive and trauma-related disorders were the most prevalent diagnostic categories in both samples. The only diagnostic difference found between samples was the high prevalence of substance use disorders in the COVID-19 cohort, suggesting patients were nearly twice as likely to use substances during the pandemic. One explanation may be minors were more likely to use substances to cope with stress, anxiety, and depression because they could not access other coping skills (eg, spending time with friends, which violated social distancing requirements). This result concurs with published reports of adults.⁶ The lack of differences between the 2 cohorts may also be related to the high acuity of the patient population regularly served by the hospital. Regardless of the time period, the majority of patients are strained by low socioeconomic backgrounds, adverse life events, and/or involvement with police and protective services.

While few differences were found between patients in an acute psychiatric hospital, further research is needed to recognize how COVID-19 has influenced the mental health of young people. As this report analyzes only patterns of hospital admissions at the beginning of the health crisis in the United States, the challenging and constantly changing nature of the pandemic may yield different patterns of admission if the fall and winter months are examined too. Thus, patterns of mental health service use across the entire pandemic and in different practice settings (eg, private psychiatric hospitals, schools, and outpatient clinics) need to be studied. If the increase of substance use disorders is a generalized and persistent finding, clinical practice and public health policies should be developed to address this problem.