In 2020, schools around the world shuttered and social activities transitioned to online platforms due to the coronavirus disease 2019 (COVID-19) pandemic. Anticipating the ramifications, experts called on individuals to protect their mental health during the ensuing lockdown as early as March.
But 1 year into the pandemic, new data are emerging that underscore the toll COVID-19 has taken on large swaths of the American public, impacting the mental health of everyone from children to millennials to frontline workers of all ages.
Quantifying these trends, a new study published in JAMA Psychiatry found that emergency department (ED) visit rates for mental health conditions (MHCs), suicide attempts (SAs), drug and opioid overdoses (ODs), intimate partner violence (IPV), and suspected child abuse and neglect (SCAN) all increased between mid-March through October 2020, compared with the same time period in 2019.
In particular, opioid ODs “exhibited the most consistent increases in counts, with only a limited decrease observed during the period in 2020 when overall ED visits were low, never decreasing below weekly counts observed in the first 41 weeks of 2019,” the study found.
Economic stress, including financial hardship and job loss, can worsen mental health and contribute to increases in suicide, substance use, and violence, researchers explained. “Furthermore, the shutdown of businesses, schools, and other public entities resulted in reduced or modified access to mental health treatment, addiction and recovery support services, and services designed to support families experiencing or at risk for violence victimization,” they added.
Fear of infection with COVID-19 also inhibited individuals from seeking medical care or prompted them to delay care, potentially increasing the risk of poor outcomes. Studies have shown that large-scale natural disasters and disasters of human origin have been linked with short- and long-term increases in mental health problems, substance use, IPV, and child abuse.
To better understand the impact of COVID-19 on these conditions, investigators analyzed data from the National Syndromic Surveillance Program (NSSP) at the CDC. More than 3500 emergency facilities representing portions of 48 states contribute data to the program, accounting for about 70% of all EDs in the country.
The analyses included data from 3119 EDs that reported in 2019 and 3598 in 2020. Events were classified based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), ICD-10-CM, and Systematized Nomenclature of Medicine (SNOMED) codes.
Data, collected between December 30, 2018, and October 10, 2020, showed that total ED volume decreased soon after March 16, 2020, when COVID-19 mitigation measures were implemented in the United States. Within this window, 187,508,065 ED visits (53.6% female, 46.1% male) were recorded and 6,018,318 included at least 1 study outcome.
- Weekly ED visit counts for all 6 outcomes decreased between March 8 and 28, 2020 (March 8: MHCs, 42,903; SAs, 5212; all ODs, 14,543; opioid ODs, 4752; IPV, 444; and SCAN, 1090; March 28: MHCs, 17,574; SAs, 4241; all ODs, 12,399; opioid ODs, 4306; IPV, 347; and SCAN = 487).
- ED visit rates increased beginning the week of March 22 to 28, 2020.
- Compared with the same period in 2019, median ED visit counts from March 15 to October 10, 2020, were significantly higher for SAs (n = 4940 vs 4656; P = .02), all ODs (n = 15,604 vs 13,371; P < .001), and opioid ODs (n = 5502 vs 4168; P < .001).
- During the same window, counts were significantly lower for IPV ED visits (n = 442 vs 484; P < .001) and SCAN ED visits (n = 884 vs 1038; P < .001).
- Median rates during the same period were significantly higher in 2020 compared with 2019 for all outcomes except IPV.
- The rate of all ED visits for IPV in 2020 exceeded the 2019 week 1 to 41 mean (rate, 27.2) beginning in week 16 (April 12-18; rate, 29.0) and remained higher through week 28 (July 5-11; rate, 28.5), decreasing slightly thereafter.
“Of importance, this study demonstrates that people still visited EDs for these outcomes and that, for the most part, visits for these outcomes decreased to a lesser extent than overall ED visits, suggesting that MHCs, SAs, ODs, and violence remain a concern during the COVID-19 pandemic,” the researchers wrote. Findings also indicate that visits for these outcomes were likely of sufficient severity to warrant treatment at an ED, despite the potential risk of COVID-19 infection.
Because ED visits for all drug and opioid ODs did not decrease like those for other outcomes, authors noted that the data suggest an increase in OD burden during the pandemic. Changes in the illicit drug supply and opioid-using habits may have led to this increase, whereby individuals may have used opioids alone or in higher-risk ways, raising the risk of an OD. Decreased access to naloxone or other risk-reduction services as a result of social distancing measures may have also contributed to the trend.
ED visit counts and rates for all outcomes began to decrease toward the latter part of the study period, authors noted, as stay-at-home orders were relaxed across the country.
“Given that the ED visit counts for outcomes decreased while visit rates increased, caution is warranted in interpreting results, and findings may be indicative of increased burden or increased help-seeking behavior,” the researchers wrote.
In addition, data are not nationally representative and participation in the NSSP varied over time, marking limitations to the study. As weekly ED visit rates were calculated as a percentage of the total number of ED visits per 100,000, “rates could be influenced by characteristics of the populations served by EDs or changes in total ED visits, which decreased substantially during COVID-19.”
Reporting differences between facilities may have also contributed to under- or overestimations of ED visits, and diagnosis data may be incomplete when visits are first recorded. However, “these results likely underestimate the number of health care visits associated with study outcomes because many patients who experience MHCs, SAs, drug ODs, and violence incidents do not present to EDs,” the authors wrote.
The findings emphasize the need for implementation of evidence-based interventions and linkage to in-person or virtual behavioral health and social support services, the researchers concluded. Existing in-person services could also be adapted for virtual implementation.
Apart from individual-level strategies, implementation of broader societal- and community-level prevention efforts, such as mass media campaigns, strengthening economic support to minimize financial stress, and regulatory policies to support expanded access to telehealth and addiction treatment services, will be paramount to address the ongoing COVID-19 pandemic response and recovery efforts, they stressed.
“Past research on public health crises suggests it is likely that COVID-19 and associated mitigation measures will have impacts that far outlast the short-term emergency period and that may intensify during periods of increased transmission,” the researchers cautioned. “This study’s findings underscore the need for continued MHC, suicide, OD, and violence prevention messages, screening, and interventions at the individual, relationship, community, and societal levels, as well as longitudinal surveillance to track the long-term impacts of COVID-19.”
Holland KM, Jones C, Vivolo-Kantor AM, et al. Trends in US emergency department visits for mental health, overdose, and violence outcomes before and during the COVID-19 pandemic. JAMA Psychiatry. Published online February 3, 2021. doi:10.1001/jamapsychiatry.2020.4402