Increasing paediatric emergency visits for suicide-related concerns during COVID-19

Suicidal ideation and suicide attempts are common during adolescence, with an international prevalence of 14–23% for suicidal ideation, and 5–17% for suicide attempts among people younger than 22 years.¹ Despite this high prevalence, only a minority of adolescents seek medical help for suicide-related concerns.² Yet, when they do, rapid interventions are often necessary given the acute risks for health and safety.

In a systematic review and meta-analysis of 42 studies, Sheri Madigan and colleagues³ compared paediatric emergency department visits for suicidal ideation, suicide attempts, and self-harm before the COVID-19 pandemic with those during the pandemic, among adolescents younger than 19 years. They identified an increase in visits for attempted suicide during the pandemic (rate ratio 1·22, 90% CI 1·08–1·37). Among older adolescents (mean age 16·3 years), emergency department visits for self-harm increased (1·18, 1·00–1·39), but they did not for younger adolescents (mean age 9·0 years). When considering emergency department visits for suicidal ideation, there was an increase (1·08, 0·93–1·25). These findings are striking given that the authors found that rates of emergency department visits for all health concerns in this age group decreased during the period (0·68, 0·62–0·75), including for other mental health problems (0·81, 0·74–0·89). Their search identified data from 18 countries (78% of studies were conducted in North America or Europe), representing more than 11 million emergency department visits.

Trends in paediatric emergency department visits for suicide-related concerns need to be monitored in real time, in parallel with suicide deaths, to inform data-driven decisions. Even during the COVID-19 pandemic, following trends across time is important given that the increase in mental illness symptoms among young people described in the early stages of the pandemic⁴ might evolve as humanity begins to cope and live with the virus. The published data available to Madigan and colleagues³ largely focus on the situation in 2020 (35 of 42 studies reported data from 2020, and seven of 42 from 2021). More up to date surveillance data are needed to obtain a more current understanding of the situation.

Notably, the increase in emergency department visits for either suicidal ideation or suicide attempt, described by the authors, was higher among females (rate ratio 1·39, 90% CI 1·04–1·88) than among males (1·06, 0·92–1·24). The reasons for such a discrepancy are certainly multifactorial, but a few studies have shown a more pronounced worsening of psychological symptoms from before to during the pandemic in girls versus boys, which might have played a contributing role.⁴ Greater use of services is to be expected when mental illness burden and symptom severity are on the rise, but whether increases in paediatric emergency department visits during the COVID-19 pandemic were primarily driven by factors related to sex and gender remains unclear. Nonetheless, stigma around mental illness and a lack of sex-and-gender-inclusive services could represent substantial barriers to care, for example among males and gender-diverse young people who might not feel at ease receiving care in paediatric emergency departments.⁵ Although suicide rates are higher among males than females across the globe, males might be less likely to seek professional help for mental illness concerns and to disclose suicidal ideation and attempts than females.⁶ Such disparities raise questions about the role of stigma surrounding young men's mental health, which could prevent them from disclosing symptoms and accessing necessary help and support.

Young people who have attempted suicide are at increased risk for a range of consequences that persist during adulthood, including poor physical and mental health, and social and economic outcomes, underscoring the importance of offering treatment options that go beyond immediate suicide risk assessment and management.⁷ There is a high demand placed on mental health services worldwide. As such, young people might have to wait several weeks, or even months, before receiving the care they need for suicide-related concerns. The development of virtual care services, which accelerated during the pandemic, might help to reduce waiting times and to improve access, but recent work suggests that online services might not always be equivalent to in-person services.⁸

Given the high rates of emergency department visits for suicide-related concerns during adolescence, paediatric health-care providers need to receive adequate training in therapeutic risk assessment, formulation, and management, and they need to conduct appropriate safety planning.⁹ Although most paediatric residency programme directors and paediatric chief residents practising in the USA rate suicide prevention training during residency as extremely or very important, only a minority report being adequately prepared to conduct suicide risk assessments.¹⁰

The accelerated increase in emergency department visits for suicide-related concerns observed in young people, especially young girls, since the beginning of the COVID-19 pandemic should be considered as an urgent call to action. It is now up to professional and governing bodies to take appropriate steps to offer appropriate preventive services and care to those in need.

We declare no competing interests. M-CG holds a Canada Research Chair in Youth Mental Health and Suicide Prevention and NC is supported by a Junior 1 salary award from the Fonds de recherche du Québec–Santé. M-CG and NC are supported by the Observatory for Children's Education and Health.