Trends in Acute Care Use for Mental Health Conditions Among Youth During the COVID-19 Pandemic

Abstract

Importance: Understanding how children's utilization of acute mental health care changed during the COVID-19 pandemic is critical for directing resources.

Objective: To examine youth acute mental health care use (emergency department [ED], boarding, and subsequent inpatient care) during the second year of the COVID-19 pandemic.

Design, setting, and participants: This cross-sectional analysis of national, deidentified commercial health insurance claims of youth mental health ED and hospital care took place between March 2019 and February 2022. Among 4.1 million commercial insurance enrollees aged 5 to 17 years, 17 614 and 16 815 youth had at least 1 mental health ED visit in the baseline year (March 2019-February 2020) and pandemic year 2 (March 2021-February 2022), respectively.

Exposure: The COVID-19 pandemic.

Main outcomes and measures: The relative change from baseline to pandemic year 2 was determined in (1) fraction of youth with 1 or more mental health ED visits; (2) percentage of mental health ED visits resulting in inpatient psychiatry admission; (3) mean length of inpatient psychiatric stay following ED visit; and (4) frequency of prolonged boarding (≥2 midnights) in the ED or a medical unit before admission to an inpatient psychiatric unit.

Results: Of 4.1 million enrollees, 51% were males and 41% were aged 13 to 17 years (vs 5-12 years) with 88 665 mental health ED visits. Comparing baseline to pandemic year 2, there was a 6.7% increase in youth with any mental health ED visits (95% CI, 4.7%-8.8%). Among adolescent females, there was a larger increase (22.1%; 95% CI, 19.2%-24.9%). The fraction of ED visits that resulted in a psychiatric admission increased by 8.4% (95% CI, 5.5%-11.2%). Mean length of inpatient psychiatric stay increased 3.8% (95% CI, 1.8%-5.7%). The fraction of episodes with prolonged boarding increased 76.4% (95% CI, 71.0%-81.0%).

Conclusions and relevance: Into the second year of the pandemic, mental health ED visits increased notably among adolescent females, and there was an increase in prolonged boarding of youth awaiting inpatient psychiatric care. Interventions are needed to increase inpatient child psychiatry capacity and reduce strain on the acute mental health care system.

Figure 1.. Changes in Fraction of Commercially Insured Youth With Mental Health Emergency Department (ED) Visits, Likelihood of Admission, Psychiatric Length of Stay, and Likelihood of Prolonged Boarding, March 2019 to February 2022

Prolonged boarding was defined as 2 or more midnights. Baseline year is March 2019 to February 2020; pandemic year 1, March 2020 to February 2021; and pandemic year 2, March 2021 to February 2022.

Figure 2.. Changes in the Fraction of Youth With 1 or More Mental Health (MH) Emergency Department (ED) Visit (per 10 000 Youth), by Demographic Group

Fraction of enrollees per 10 000 with 1 or more MH ED visit in the baseline year (March 2019 to February 2020) and change in that fraction from baseline to pandemic year 1 (March 2020 to February 2021) and pandemic year 2 (March 2021 to February 2022). This figure includes youth aged 5 to 17 years enrolled in health insurance through a large national commercial insurer. Confidence intervals were calculated using clustered standard errors at the individual level. MH ED visits were identified by a primary MH diagnosis on the first ED claim. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes are available in the eMethods in Supplement 1. Blue indicates change from baseline to pandemic year 1, and orange indicates change from baseline to pandemic year 2. ^aAsian, Black/African American, Hispanic, Native Hawaiian or other Pacific Islander, multiracial, and other race and ethnicity.

Figure 3.. Changes in Percentage of Episodes With Prolonged Boarding (≥2 Midnights) Before Admission to Inpatient Psychiatry

Percentage of youth aged 5 to 17 years who waited greater than or equal to 2 midnights between an emergency department (ED) visit and admission to an inpatient psychiatric unit – baseline year rate (March 2019-February 2020) is shown, with percent change from baseline year to pandemic year 1 and baseline to pandemic year 2. Co-occurring conditions are defined by the presence of any claim with that International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis anywhere in the acute care episode, including individuals with a primary ED diagnosis of autism. Blue indicates change from baseline to pandemic year 1, and orange indicates change from baseline to pandemic year 2. ADHD indicates attention-deficit/hyperactivity disorder; SUD, substance use disorder. ^aAsian, Black/African American, Hispanic, Native Hawaiian or other Pacific Islander, multiracial, and other race and ethnicity.