Post-COVID 19 Pandemic Evolution of Suicide Ideation and Self-harm Behaviour Rates among Children and Adolescents Attending an Accident and Emergency Department

doi:10.21203/rs.3.rs-3875169/v1

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Research Article

Post-COVID 19 Pandemic Evolution of Suicide Ideation and Self-harm Behaviour Rates among Children and Adolescents Attending an Accident and Emergency Department

https://doi.org/10.21203/rs.3.rs-3875169/v1

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Background

Lockdowns and other health protective measures, such as social distancing, imposed during the COVID-19 pandemic nurtured unprecedented levels of stress and social isolation around the world. This scenario triggered an increase of suicidal thoughts and self-harm behaviours among children and young people. However, the longer-term impact of the pandemic on the children´s and adolescents´ mental health, especially with regards to self-harm, is still to be fully discovered.

Methods

We carried out a retrospective study where we collected data related to suicidal ideation and self-harm behaviours in all patients aged under-18 that required on call psychiatric services at the Accidents and Emergency (A&E) department in Salamanca, Spain, during 2019 (pre-pandemic) and in both 2021 and 2022, to capture possible variation at different time points during the post-pandemic period.

Results

A total of 316 patients under-18 were seen by on call psychiatric services at the A&E department during the three time periods: 78 in 2019, 98 in 2021 and 140 in 2022. The mean age was 15.12 (SD 2.25) and females represented more than twice the number of males each year. More than half of all patients assessed during 2022 disclosed suicidal thoughts, whilst in 2019 was near 25%. This increase in suicide ideation rates was more marked among females (p=0.001), those aged over-15 (p<0.001), and/or with previous history of mental health problems (p<0.001). We identified an increase in the proportion of males with suicidal ideas, especially between 2021 and 2022 (p=0.015).

Conclusions

Our study suggests that post-COVID 19 pandemic young people under-18 demand for psychiatric urgent care and the rates of these presentations in A&E departments with suicidal thoughts and/or self-injuries are not declining but increasing with the passage of time. More research is warranted to understand possible factors involved in this sustained trend.

Suicide

suicide ideation

self-harm

self-injury

children

adolescents

emergency.

On March 11, 2020, the World Health Organization (WHO) declared the COVID-19 pandemic (1), which required an urgent, unprecedented adaptation of healthcare systems (2). Lockdowns and other measures, such as social distancing, were imposed around the world to stop the spread of the disease-causing virus SARS-CoV-2, save the lives of those that were considered more vulnerable, such as the elderly, and prevent the collapse of healthcare services. Lockdown measures included social distancing, ‘stay-at-home’ and ‘work-from-home’ policies (3) that nurtured unprecedented levels of social isolation. This scenario gradually raised psychological distress, or worsened previous mental health problems, in our communities, especially among children and young people (4), which eventually triggered suicidal thoughts and self-harm behaviours that required urgent attention by medical emergency services (5).

In 2020, at the climax of the COVID-19 pandemic, 3941 people committed suicide in Spain. This represented a 7.4% increase from the previous year and was the highest ever reported annual figure since the Spanish collection of suicide data began in 1906 (6)(7). Fourteen suicides out of the 3941 were attributed to children aged under-15, doubling the cases reported in 2019 for that age group (7). In 2021, suicides of people under-18 increased by 57% compared to 2020, reaching a total of 22 cases (8). However, despite being the first non-disease related cause of death in people under-30, Spain still does not have a national strategy for suicide prevention (7).

Whilst the immediate impact of the pandemic on children´s and adolescents´ suicide rates and acts have been acknowledged and widely reported, little is known about the prevalence of acute self-harm ideation and attempts that may precede suicide when the pandemic began to tail off and lockdown measures were relaxed (mostly late 2020 and 2021), or, more recently, at the beginning of what could be called the post-pandemic era (2022). Indeed, the reported effects of the pandemic and associated confinements on suicidality in acute, hospital settings may have been biased by the imposed movement restrictions or more contained help-seeking behaviours due to fears to get infected in healthcare settings, and, therefore, may manifest later, or worsen over time (9)(10)(11).

With this study we aimed to explore the post-pandemic trend in suicidality and self-injuries in children and adolescents by comparing suicidal ideation and self-harm behaviour rates that required psychiatric assessment and/or intervention in an accident and emergency (A&E) department before and at different time points after the most severe COVID-19 pandemic outbreaks in Spain.

Design and sample

To achieve our aim, we carried out a retrospective, observational study where we collected data related to presence or absence of acute suicidal ideation and self-harm behaviours in all children and adolescents under-18 that required psychiatric assistance at the Salamanca University Hospital (Hospital Universitario de Salamanca (HUS)) A&E department, in Salamanca, Spain, during 2019 (pre-pandemic) and in both 2021 and 2022, in order to capture possible variation at different time points during the post-pandemic period.

We did not include data related to 2020 given the difficulties we could encounter tracking these presentations in healthcare records during such an unprecedented public health crisis that involved an urgent reorganization, both functionally and structurally, of local health services, which were gradually restored to their former functions and settings by the end of 2020 and beginning 2021. In addition, attendance to emergency services in 2020 may have been affected by several factors, such as the imposed public movement restrictions or the fear of becoming infected in hospital settings, amongst others.

Setting

As stated above, the study was performed at the HUS A&E department. This hospital provides healthcare to the population residing in the University city of Salamanca and its province (2), situated in Northwest Spain (12). The latest Spanish National Institute of Statistics (Instituto Nacional de Estadística (INE)) census data (13), indicates that this province has a total population of 327,338 (168,464 women and 158,874 men), with 49,995 (24.309 women and 25.646 men) of these being under the age of 18 (14).

According to healthcare referral protocols at HUS, any patient attending the A&E department that discloses suicidal ideas, committed any form of self-harm, or presented with a suspicion of such behaviour, either with suicidal intentions or not, must be referred to the psychiatry on-call service for a mental health assessment. This protocol implies that every patient, regardless of their age, who presents to emergency services with suicide ideas and/or signs of self-harm is seen by a clinical psychiatrist.

Study variables and data collection

We collected all information related to suicidal thoughts and self-harm behaviours for all patients aged under-18 that attended the HUS A&E department for the three years under study. Following current scientific consensus, suicidal ideation referred to thoughts aiming at one’s own death (15), and self-harm behaviours included attempted and completed suicide, but also intentional self-injuries, regardless of the motives behind them (10)(16). We adopted this definition to avoid difficulties discerning suicidal attempts or intentions in some self-harm manifestations in children and adolescents, especially in cross-sectional diagnostic evaluations performed in emergency departments.

In addition, we collected basic sociodemographic information for all patients, specifically age and sex, and information related to psychiatric history and mental health services use, such as number of contacts with the A&E department for psychiatric reasons within the previous 12 months, and the level of follow-up that was prescribed by the on call psychiatrist after the assessment, differentiating between ‘non-intensive’ (or the standard mental health care provided by child and adolescents community mental health services in Salamanca), and ‘intensive’, such as admission to a psychiatric ward or request for urgent follow-up appointments by the community services within a week to monitor risk closely.

All this information was obtained from the HUS electronic clinical record system, Jimena 4, and exported to an anonymised database purposely designed for the study.

Statistical analysis

We distributed all the study variables categorically for a clearer reporting, using both absolute and relative frequencies. We used chi-square test to make comparisons for the different study variables and considered there was statistical significance if the p-value was below 0.05. We carried out the analyses with the statistical software package SPSS version 15.

Sociodemographic characteristics and mental health services use

A total of 316 under-18 patients were seen by psychiatrists on call at the HUS A&E department during the three study periods: 78 in 2019, 98 in 2021 and 140 in 2022, showing a remarkable increase in urgent psychiatric service demand over time.

The mean age for the whole sample was 15.12 (SD 2.25), with no difference in the distribution of under- and over-15 across the three years. The female sex was the most prevalent, representing more than twice the number of male patients every year. We did not find significant differences in distributions for either age and gender between the three years, or for the presence of psychiatric history and number of visits to A&E services for other mental health assessments within the previous 12 months. However, the intensity of care prescribed after attendance to the emergency department varied significantly, with a higher proportion of patients receiving ‘intensive’ follow-ups post-pandemic, especially among those seen in 2021 (See Table 1).

Table 1

Sociodemographic and clinical characteristics of patients under-18 seen at HUS A&E department due to mental health problems in 2019, 2021 and 2022.
Categories			2019 (N = 78)	2021 (N = 98)	2022 (N = 140)	Statistical Study
Age Median 15.38 Mean 15.12 (SD 2.25)	Under 15 years N (%)		31 (39.7%)	42 (42.9%)	55 (39.3%)	X² = 0.330 p = 0.848
Age Median 15.38 Mean 15.12 (SD 2.25)	Over 15 years N (%)		47 (60.3%)	56 (57.1%)	85 (60.7%)	X² = 0.330 p = 0.848
Sex	Female N (%)		53 (67.9%)	67 (68.4%)	100 (71.4%)	X² = 0.392 p = 0.822
Sex	Male N (%)		25 (32.1%)	31 (31.6%)	40 (28.6%)	X² = 0.392 p = 0.822
Previous Psychiatric History N (%)			51 (65.4%)	68 (69.4%)	110 (78.6%)	X² = 5.042 0.080
Number of psychiatric emergency visits		One visit N (%)	60 (76.9%)	69 (70.4%)	98 (70%)	X² = 1.330 p = 0.514
Number of psychiatric emergency visits		More than one visit N (%)	18 (23.1%)	29 (29.6%)	42 (30%)	X² = 1.330 p = 0.514
Type of management		Non-intensive N (%)	64 (82.1%)	64 (65.3%)	102 (72.9%)	X² = 6.149 p = 0.046
Type of management		Intensive N (%)	14 (17.9%)	34 (34.7%)	38 (27.1%)	X² = 6.149 p = 0.046
Suicidal thoughts N (%)			19 (24.4%)	42 (42.9%)	79 (56.4%)	X² = 20.998 p < 0.001
Suicidal behaviour N (%)			26 (33.3%)	43 (43.9%)	67 (47.9%)	X² = 4.351 p = 0.114
X²: chi-square significance test; p: p-value.

Suicide ideation and self-harm behaviour rates

The increase in A&E service demand was also reflected in the number of children and adolescents with suicide risk assessed every year in that clinical setting. For instance, in 2022 sixty more patients disclosed suicidal ideas than in 2019 (79 vs. 19 patients). The evolution of this service demand is graphically represented in Fig. 1.

The proportion of patients with suicidal ideation within each year increased significantly over time; for example, more than half of the under-18 assessed in the A&E department during 2022 expressed acute suicidal thoughts, whilst in 2019 was just near 25%. Interestingly, the significant rise in the percentage of patients with suicidal ideation per year was not mirrored in a statistically significant increase in self-harm behaviours. Nonetheless, almost 48% of the patients seen in A&E in 2022 had self-harmed, versus 33% three years earlier (See Table 1).

To date, there has not been suicides reported for any of the patients included in the study.

-Table 1 about here-
-Figure 1 about here-

Distribution of suicide ideation and self-harm behaviour rates depending on sociodemographic characteristics and mental health services use

The proportion of adolescents aged over-15 with suicidal thoughts within each year showed a statistically significant increase in 2021 and 2022, reaching 62.4% of all patients seen in 2022. This increase in rates was also found in patients under-15, but, in that case, with no statistical significance.

With regards to sex, both, male and female patients, suffered a significant post-pandemic increase in the proportion of those interviewed in the A&E department with suicidal thoughts. Notably, we found out a sharp increase in the percentage of male patients with suicidal ideas between 2021 and 2022. Also, during the post-pandemic period, especially in 2022, we identified a higher proportion of patients with previous psychiatric history that disclosed lethal ideas. The same happened for this group and self-harm behaviours. Also, despite not being statistically significant, patients that attended A&E post-pandemic disclosing self-harm ideation were more likely to have previously visited such department due to mental health problems (27% (2019) vs 43% (2021) & 36% (2022)), suggesting that some of those previous attendances could have been preludes for self-harm crises. The same pattern was found for the prescription of ‘intensive’ vs. ‘non-intensive’ follow-up after the A&E assessment, being the former slightly more frequent in the patients interviewed during 2021 (48%), returning to pre-pandemic rates (34%) in 2022 (See Table 2).

Table 2

Prevalence of suicidal thoughts and self-harm behavior in patients under-18 seen at the HUS A&E department according to age, sex and PPH in 2019, 2021 y 2022.
Suicidal thoughts and self-harm behaviour according to age, gender and PPH		2019 (N = 78)	2021 (N = 98)	2022 (N = 140)	Statistical Study
Age		< 15 years N = 31	< 15 years N = 42	< 15 years N = 55
	Suicidal thoughts N (%)	7 (22.6%)	15 (35.7%)	26 (47.3%)	X² = 5.242 p = 0.073
	Self-harm behaviour N (%)	11 (35.5%)	16 (38.1%)	22 (40%)	X² = 0.172 p = 0.918
		> 15 years N = 47	> 15 years N = 56	> 15 years N = 85
	Suicidal thoughts N (%)	12 (25.5%)	27 (48.2%)	53 (62.4%)	X² = 16.437 p < 0.001
	Self-harm behaviour N (%)	15 (31.9%)	27 (48.2%)	45 (52.9%)	X² = 5.502 p = 0.064
Sex		Female N = 53	Female N = 67	Female N = 100
	Suicidal thoughts N (%)	15 (28.3%)	36 (53.7%)	61 (61%)	X² = 15.127 p = 0.001
	Self-harm behaviour N (%)	22 (41.5%)	36 (53.7%)	56 (56%)	X² = 3.055 p = 0.217
		Male N = 25	Male N = 31	Male N = 40
	Suicidal thoughts N (%)	4 (16%)	6 (19.4%)	18 (45%)	X² = 8.396 p = 0.015
	Self-harm behaviour N (%)	4 (16%)	7 (22.6%)	11 (27.5%)	X² = 1.155 p = 0.561
PPH		With PPH N = 51	With PPH N = 68	With PPH N = 110
	Suicidal thoughts N (%)	13 (25.5%)	31 (45.6%)	67 (60.9%)	X² = 17.823 p < 0.001
	Self-harm behaviour N (%)	15 (29.4%)	29 (42.6%)	60 (54.5%)	X² = 9.178 p = 0.010
		Without PPH N = 27	Without PPH N = 30	Without PPH N = 30
	Suicidal thoughts N (%)	6 (22.2%)	11 (36.7%)	12 (40%)	X² = 2.250 p = 0.325
	Self-harm behaviour N (%)	11 (40.7%)	14 (46.7%)	7 (23.3%)	X² = 3.776 p = 0.151
X²: chi-square significance test; p: p-value; PPH: Previous Psychiatric History.

-Table 2 about here-

The burden of the COVID-19 pandemic on the mental health of children and adolescents, and its consequence on the healthcare involvement of mental health professionals working in acute psychiatric settings has already been widely reported. For instance, Bortoletto et al. (17) found a significant increase in the number of children admitted to acute psychiatric wards due to suicidal ideation after the lockdown in Verona (Italy). In Zurich (Switzerland), Berger et al. (18) detected an increase of suicidal thoughts in child and adolescent populations that attended to their emergency departments. Sara et al. (19) also identified an increase of suicidal thoughts among children and adolescents living in New Gales (Australia); although they had already noticed a gradual increase of these symptoms amongst children over the last decade, which was more marked following the pandemic. Sivertsen et al. (20) also detected a surge of mental health problems, including suicidal thoughts, across Norwegian youngsters, especially among female patients. This sex association was also found by Du et al. (21), who reported an increase of self-harm behaviours in adolescent just after COVID-19 pandemic lockdowns in China. This group also highlighted single-parent families, loneliness and excessive mobile phone abuse as contributing factors to self-injuries in adolescents.

In Spain, immediately after the states of emergency declared by the Spanish government, Llorca-Bofí et al. (22) started to find out an increase, still non-statistically significant, of suicidal ideation among the children and adolescents residing in Lleida. Fernández et al. (11) also reported a gradual increase of attendances to A&E departments due to suicidal ideation of children and adolescents living in the Eastern province of Alicante during the 2018–2021 period, which, as in other countries, was mostly associated to female sex. In addition, Gracia-Liso et al. (23) in the North Eastern region of Catalonia noticed a decrease in the age of presentation to psychiatric emergency services with suicidal ideation. Gracia et al. (24) found, in the same region, an increase in suicide attempts among adolescents compared to pre-pandemic times, and, again, predominantly associated with the female sex. This evidence, also found in other countries as stated before, indicates that female adolescents with mental health problems may require a more careful assessment and care planning to avoid an increase in suicide risk over time.

Most of these studies analysed suicidal activity in children and adolescents during the pandemic have mainly focused on the lockdown periods (2020) or soon after (2020 and 2021). Whilst this information is utterly relevant, the effect of confinements on suicidal thoughts and self-harm behaviours reported from hospital sources might have been still affected by a decrease in visits to the emergency department during the initial pandemic outbreaks, mainly due to movement restrictions, uncertainty surrounding this unparalleled health crisis or, simply, fears of becoming infected in healthcare settings. In our study, we aimed to ameliorate this limitation by looking into the effect of the pandemic on the distribution of self-harm ideation and behaviour rates in children and adolescents evaluated in an A&E department in 2021, but also in 2022. In comparison with 2019 (pre-pandemic), during 2021, when the pandemic gradually faded away, and 2022, the first year that could be considered post pandemic, our study identified a remarkable upward trend in the number of children and adolescents seen by psychiatric emergency services in the city and province of Salamanca, Spain, that does not seem to be tempered by the passage of time. In parallel, we found an increase of children´s and adolescents´ attendance to A&E expressing suicidal ideation or having committed self-harm. Notably, the groups that showed a higher proportional increase in urgent mental healthcare attention for suicidal ideation or self-injuries were adolescents over-15 and patients with previous history of mental health problems. Curiously, although as previously reported the female sex was much more likely to be seen in A&E for psychiatric reasons, including those related to self-harm, in male patients we identified a steep surge of suicidal thoughts between 2021 and 2022. In general, the level of care required after A&E assessment during the post-pandemic period was more intensive than pre-pandemic, suggesting more severe psychiatric morbidity.

Therefore, we have learnt that the increase in suicidal ideation and behaviours in children and adolescents in Salamanca has not been limited to the first year post-pandemic. On the contrary, these clinical presentations are still increasing, which should be a public health matter of concern. Further research and a profound analysis of the possible reasons behind what seems to indicate a long-term, and rising, negative evolution of the mental health and emotional wellbeing of our younger populations following the COVID-19 pandemic are warranted in order to develop and implement evidence-based suicide and self-harm prevention strategies to overturn this worrying trend. To date we know that possible causes related to the negative impact of the pandemic on the emotional wellbeing of children and adolescent population include the time they spend alone, lack of physical exercise, altered sleep patterns and the much greater use of videogames and social media (25). In addition, the closure of schools could have harmed students mental health, as these are not only teaching centers, but also providers of social interactions with other peers or adults than the immediate family members, physical exercise and regular meals, whilst safeguarding children and adolescents at risk of abuse or neglect (26). Nevertheless, the long term negative impact that we are witnessing may be related to a sum of these and other factors, added to behavioral patterns that already existed or were brewing before the pandemic, which could have been accelerated and/or sharpened by the irruption of SARS-CoV-2 and its consequences on a critical period of physical and social development as a human being (9)(10)(27).

Limitations

It should be noted that this work is limited by the fact that our sample only included evaluations carried out by on call psychiatric services in the HUS A&E department, not patients seen exclusively by HUS general emergency staff, which is assumed, as stated before, to be very infrequent at HUS given the existing A&E protocols for patients disclosing suicidal ideation or self-injury. Also, it did not include those assessed urgently by community mental health services, out of the acute care system. Furthermore, despite this being a real-world study, it is restricted to one site, therefore, our findings may need to be replicated elsewhere in order to test generalisability and rule out differences that could be attributed to socio-cultural contexts and/or healthcare systems.

Our study suggests that post-COVID 19 pandemic people under-18 demand for psychiatric urgent care and the rates of these presentations in A&E departments with suicidal thoughts and/or self-injuries have not plateaued, or declined, with the passage of time, but, on the contrary, are still increasing. More research is warranted to understand possible factors involved in this sustained upward trend, which may be related to or worsened by the long-term pandemic impact on our younger populations. This should help develop initiatives and adjustments in healthcare systems to prevent further children´s and young people´s mental health deterioration.

A&E (Accidents and Emergency)

HUS (Hospital Universitario de Salamanca)

INE (Instituto Nacional de Estadística)

p (p-value)

PPH (Previous Psychiatric History)

WHO (World Health Organization)

X² (Chi-square significance test)

Ethical approval and consent to participate

The study is being conducted in accordance with the protocol and principles of the current version of the Declaration of Helsinki (28). Permission to conduct the study was granted by the Research Ethics Committee at the Salamanca University Healthcare Complex (ref: 2023/09 1422).

Consent for publication

Not applicable.

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available due to ethical reasons and data protection but are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

There was no external funding to carry out this research.

Authors’ contributions

AMC and CR designed the original study. AMC and JP modified the original design to obtain longer-term data. AMC, JIL, LGU, CMC, JCM, BRM, SDT and VBM contributed to the study data collection and AMC analysed them. AMC and JP drafted the manuscript. All authors revised the final draft and approved the version submitted for publication.

Acknowledgments

Not applicable.

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No competing interests reported.

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Post-COVID 19 Pandemic Evolution of Suicide Ideation and Self-harm Behaviour Rates among Children and Adolescents Attending an Accident and Emergency Department

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Abstract

Figures

BACKGROUND

METHODS

Design and sample

Setting

Study variables and data collection

Statistical analysis

RESULTS

Sociodemographic characteristics and mental health services use

Suicide ideation and self-harm behaviour rates

DISCUSSION

Limitations

Conclusion

Abbreviations

Declarations

References

Additional Declarations

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