1. Introduction
COVID-19 changed the status-quo on psychiatric admissions and evaluations throughout the world, with outpatient experiences being the most affected (D’Agostino et al., 2020; Fiorillo and Gorwood, 2020; Gavin et al., 2020; Öğütlü, 2020). Anxiety induced by uncertainty, morbidity, and mortality associated with the disease and a marked disruption in daily routines have created an unprecedented burden on mental health with the potential to create a parallel outbreak of mental health crises (Choi et al., 2020; Dong and Bouey, 2020). However, psychiatric emergencies remained a staple of psychiatric care, due to the pandemic’s deleterious effects on mental health. The present study aims to detect the early effects of the pandemic on child and adolescent psychiatric emergency admissions.
2. Materials and methods
Electronic patient records of child and adolescent emergency admissions with subsequent consultations to child and adolescent psychiatry during the designated three-month periods of March11-June11,2020 where the effects of the pandemic were observed, December11,2019-March10,2020, preceding the pandemic; and periods coinciding with these dates of the previous year March11-June11,2019 and December11,2018-March10,2019 were retrospectively collected. March 11, 2020, on which the documentation of the index case of COVID-19 in our country (Öğütlü, 2020) and the declaration of COVID-19 as a pandemic took place, was selected the cut-off date. The collected data included the age, sex, length of stay and presenting psychiatric symptoms. Each admission was grouped into eight distinct categories: Suicidal ideation/attempt (further divided into suicidal ideation without attempt, suicide attempt with low, intermediate and high acute risk for suicide reattempt), agitated/aggressive behavior, anxiety/panic/conversion symptoms, alcohol/substance intoxication, psychotic symptoms, psychotropic medication side effects, suspected abuse and non-emergency psychiatric consultations.
Kruskal-Wallis test was used for the assessment of continuous variables, with further analysis via Dunn’s multiple-comparison test and Bonferroni correction to determine intergroup differences. Categorical variables were assessed with Pearson’s Chi-Square.
The total number of psychiatric consultations and presenting psychiatric symptoms on admission, coded to eight distinct diagnostic categories were recorded as count data in one-week intervals and were analyzed by means of log-linear Poisson regression after assumption testing revealed that the data followed a Poisson distribution. The presented study was approved by the local ethics committee (Decision no:20-6 T/44,Date:10.06.2020).
3. Results
The study included 427 patients presenting to the ED during the March11–June11,2020 (n= 66), December11,2019-March10,2020 (n=140), March11-June11,2019 (n=128) and December11,2018-March10,2019 (n=93) periods. No significant differences in age, sex and outcome have been observed. Hovewer, the length of stay during the pandemic period March2020-June2020 (87,[7–985]) and pre-pandemic period December2019-March2020 (480,[3–3840]) was statistically significant with an 81.7 % reduction in median length of stay in minutes during the COVID-19 pandemic (p<0.001).
Poisson regression analysis results of psychiatric consultations in each period are presented in Table 1 . The total number of psychiatric presentations to the emergency department during the pandemic period was found to be significantly reduced compared to the previous year March2019-June2019 with an incident risk ratio (IRR,95 %CI) of 1.94 (1.44−2.80, p=0.000), and the preceding 3-month period of December2019-March2020 with an IRR = 2.12 (1.47−3.05, p=0.000) corresponding to 48.45 % and 52.83 % reductions in admission, respectively. Separate subgroup analyses revealed the incident risk ratio to be IRR = 11.0 (1.30−93.05, p=0.028) during March2019-June2019; translating to a 90.90 % reduction in the pandemic period admissions for suicidal ideation without suicide attempt compared to the previous year, and IRR = 14.0 (1.69−116.18, p=0.015) during December 2019-March 2020; a 92.85 % reduction from the pre-pandemic period in the same year. A significant 70.58 % reduction was observed in low-risk suicide attempts in the pandemic period compared to December2018- March2019 IRR = 3.40 (1.39−8.31, p=0.07); with an 82.14 % and 75.00 % reduction, both significant, in comparison to the pre-pandemic period in the same year IRR = 5.6 (2.39−13.13, p < 0.000) and the same period in the previous year IRR = 4.0 (1.66−9.62, p=0.002), respectively. There was no significant reduction in the number of patients presenting with intermediate or high-risk suicide attempts during the pandemic period in addition to no significant change being observed in the presenting psychiatric symptoms of agitation/aggression, anxiety/panic, conversion, psychotropic medication side effects, psychosis, suspected abuse. However, a significant increase in incidence rate ratio in March2019-June2019 IRR = 3.50 (1.25−9.82, p=0.017) and December2019-March2020 IRR = 4.75(1.75−12.93, p=0.002) was detected for patients presenting with alcohol or substance intoxication compared to the pandemic period of March2020-June2020; translating to a 71.42 % reduction from the previous year and a 78.94 % reduction from the preceding pre-pandemic period.
Table 1.
Poisson regression analysis of psychiatric consultations and assigned diagnostic categories as weekly count data.
| December 2018 -March2019 |
March 2019 – June 2019 |
December 2019 – March2020 |
March 2020 – June 2020 | ||||
|---|---|---|---|---|---|---|---|
| p-value | IRR (95 % CI) | p-value | IRR (95 % CI) | p-value | IRR (95 % CI) | (COVID-19) | |
| Total number of psychiatric consultations | .086 | 1.41 (0.95−2.09) | .000* | 1.94 (1.44−2.80) | .000* | 2.12 (1.47−3.05) | 1 (Reference) |
| Suicidal ideation/attempt | .001* | 2.53 (1.45−4.42) | .000* | 2.80 (1.61−4.85) | .000* | 3.53 (2.07−6.03) | 1 (Reference) |
| Suicidal ideation | .235 | 4.0 (0.41−39.33) | .028* | 11.0 (1.30−93.05) | .015* | 14.0 (1.69−116.18) | 1 (Reference) |
| Low-risk suicide attempt | .007* | 3.40 (1.39−8.31) | .002* | 4.0 (1.66−9.62) | .000* | 5.6 (2.39−13.13) | 1 (Reference) |
| Intermediate-risk suicide attempt | .068 | 2.80 (0.93−8.47) | .447 | 1.60 (0.48−5.37) | .596 | 1.40 (0.40−4.86) | 1 (Reference) |
| High-risk suicide attempt | .726 | 0.75 (0.15−3.74) | .726 | 0.75 (0.15−3.74) | 1.00 | 1.00 (0.23−4.43) | 1 (Reference) |
| Agitation/aggressive behavior | .408 | 0.67 (0.25−1.74) | 1.00 | 1.00 (0.42−2.36) | .483 | 1.33 (0.60−2.98) | 1 (Reference) |
| Anxiety/conversion | .738 | 0.87 (0.40−1.91) | .161 | 1.62 (0.82−3.20) | .128 | 1.68 (0.86−3.31) | 1 (Reference) |
| Anxiety/panic attack | .130 | 0.45 (0.16−1.26) | .418 | 1.36 (0.64−2.89) | .099 | 1.82 (0.89−3.70) | 1 (Reference) |
| Conversion | .344 | 1.80 (0.53−6.07) | .189 | 2.20 (0.68−7.13) | .606 | 1.40 (0.39−5.02) | 1 (Reference) |
| Alcohol/substance intoxication | .720 | 1.25 (0.37−4.24) | .017* | 3.50 (1.25−9.82) | .002* | 4.75 (1.75−12.93) | 1 (Reference) |
| Psychotic symptoms | .303 | 3.00 (0.37−24.30) | .540 | 2.00 (0.22−18.39) | .112 | 5.00 (0.69−36.37) | 1 (Reference) |
| Psychotropic agent side effect | .299 | 2.25 (0.49−10.39) | .143 | 3.0 (0.69−13.04) | .629 | 1.50 (0.29−7.76) | 1 (Reference) |
| Suspected abuse | .567 | 0.50 (0.46−5.38) | .567 | 0.50 (0.46−5.38) | .567 | 0.50 (0.46−5.38) | 1 (Reference) |
| Non-emergency psychiatric consultation | .265 | 1.83 (0.63−5.33) | .144 | 2.17 (0.77−6.12) | .779 | 0.83 (0.23−2.98) | 1 (Reference) |
p-values less than 0.05 were considered statistically significant.
4. Discussion
The present study highlights the effects of the pandemic on pediatric psychiatric emergency admissions and underlines its consequences concerning suicidal behavior and alcohol and substance use in children and youth.
The decrease in admissions attributable to suicidal ideation and low-risk suicide attempts in the early days of the pandemic are concerning as suicidal thoughts and attempts may evolve over time, with passive suicidal ideation giving way to active suicidal thoughts and plans, or suicide attempts becoming more severe and lethal as the chronic depressive state and unexcogitable problems persist (Joiner and Rudd, 2000; Sveticic and De Leo, 2012). In a time where access to mental health facilities and outpatient clinics were severely restricted, the children and adolescents with persistent suicidal thoughts or non-lethal low-risk suicide attempts, who would typically present to the emergency department but cannot for COVID-19 related concerns, remain at risk for an escalation in suicidality and suicide lethality. The underserved youth for whom early intervention is crucial in addressing suicidality and associated depressive symptoms, remain at-risk for suicide. An increase in intermediate and high-risk suicides among this group in the coming days remains a possibility that cannot be ignored. The stress caused by the COVID-19 outbreak was expected to increase alcohol and substance use in adults (Dubey et al., 2020) with a surge in alcohol sales reported in the USA (Sher, 2020). The dramatic reduction in presentation with alcohol and substance intoxication during the pandemic in the present study might be a consequence of mandated curfews for minors and increased overall parental supervision in lockdown.
Financial disclosure
The authors declare that the work reported in this manuscript was undertaken with their financial resources, and they did not receive any financial help from any individual, group, or agency.
Declaration of Competing Interest
The authors have no conflicts of interest to declare.
Acknowledgments
The authors would like to thank Gulden Hakverdi and Dr. Timur Kose for their valuable guidance in the statistical analysis of the data and interpretation of the results.
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