The past decade has seen a worrisome increase in mental health crises among adolescents. A new study led by Patricia Ibeziako, MD, associate chief of clinical services in the Department of Psychiatry and Behavioral Services at Boston Children's Hospital, shows that the situation worsened with the onset of the COVID-19 pandemic. Findings appear in Hospital Pediatrics, a publication of the American Academy of Pediatrics.
Ibeziako and colleagues looked back at the Boston Children's own records over a two-year study period—the first pandemic year (March 2020 to February 2021) and the year just prior. During this time, nearly 3,800 children aged 4 to 18 were admitted to the emergency department (ED) or inpatient units for mental-health-related reasons. About 80% were adolescents aged 12 to 18.
In the year before the pandemic, 50% of admitted patients had suicidal ideation or had made suicide attempts. That jumped to 60% during the first pandemic year. The number of patients making actual suicide attempts rose from 236 to 369—going from 12% to 21% of all mental health admissions.
"The majority of suicide attempts were overdosing," says Ibeziako. "We were seeing patients without known mental health issues presenting for the first time with suicide attempts, as well as patients with pre-existing mental health diagnoses."
An Influx of Adolescents in Crisis
Aside from suicidality, mental health admissions at Boston Children's increased year over year for depressive disorders (from 63 to 70% of admissions), anxiety disorders (from 46 to 51%), eating disorders (from 7 to 14%), substance-related disorders (7 to 9%), and obsessive-compulsive related disorders (4 to 6%). Admissions rose especially for girls, whose share increased from 56 to 66%.
"Boarding"—caring for patients in the ED or in an inpatient unit while waiting for a psychiatric placement—increased dramatically during the first pandemic year. Fifty percent of admitted patients boarded for two or more days, versus 30% the prior year; the average boarding time rose from 2.1 to 4.6 days.
Boston Children's wasn't alone in this: In a March 2021 survey of 88 U.S. hospitals, 99% were boarding youth awaiting psychiatric placement.
"While boarding keeps patients safe, it is an inherently stressful process associated with a lot of uncertainty, anxiety, and unpredictability for families," says Ibeziako.
A Perfect Storm
COVID-19 has clearly exacerbated a perfect storm, says Ibeziako. It has also exposed major deficiencies in our pediatric mental health care system and a growing crisis that isn't going away.
"The increase in suicidal behavior among youth very much predates the pandemic," she says. "The pandemic did not alter this trend—it simply amplified it."
At a time when adolescents should be socializing and gaining independence, remote learning made them even more sedentary, more socially isolated, and more glued to screens. Add to that the stress COVID-19 placed on many families, loss of caregivers to the pandemic, cancelation or disruption of sports, proms, and graduation ceremonies, and increasing climate anxiety.
But the most common risk factor for adolescents has continued to be academic pressure: homework, making good grades, and getting into college. "For years, school pressure has been the number one stressor reported by adolescents presenting to the hospital in a mental health crisis," Ibeziako says. "We see a significant drop during the summer months when kids are out of school."
An Advocacy Agenda for Mental Health
Seeking to stem the tide, Boston Children's Neighborhood Partnership Program provides consultation, training, and early intervention services to promote the mental health and well-being of students in the Boston Public Schools. The hospital has also expanded its outpatient mental health services, at both the main hospital and its Waltham location. Waltham also houses a second inpatient psychiatry unit and the less-intensive residential Community-Based Acute Treatment program. Boston Children's is further expanding its behavioral health services through a recent affiliation agreement with Franciscan Children's.
On the policy level, Boston Children's has joined the Sound the Alarm for Kids campaign, together with the Children's Hospital Association, the American Academy of Child and Adolescent Psychiatry, and the American Academy of Pediatrics, to urge passage of H.R. 7236: Strengthen Kids' Mental Health Now by the U.S. House of Representatives.
Introduced in March, H.R. 7236 would boost investment in the nation's pediatric mental health infrastructure. A companion U.S. Senate bill is in the works. In Massachusetts, through the Children's Mental Health Campaign, Boston Children's is advocating for similar legislation being considered in the Massachusetts Senate.
"We have to address the decades-old underinvestment in health services," says Ibeziako. "This effort has to be multi-pronged, at every level of care: school mental health services, integration of behavioral health in primary care, outpatient services, and intensive inpatient and partial hospitalization services. And as a society, we need to address the growing pressures and expectations on our youth, from school curricula to the role of technology."