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

Key Points

Question  How did utilization of acute mental health care change during the second year of the COVID-19 pandemic for youth aged 5 to 17 years?

Findings  In this cross-sectional study comparing pandemic year 2 with a baseline year, the fraction of youth with mental health emergency department visits increased 7%, the percentage of emergency department visits that resulted in inpatient psychiatric admission increased 8%, and the mean length of inpatient psychiatric stay increased 4%. Prolonged boarding before inpatient stays increased 76%; all were statistically significant.

Meaning  Interventions are needed to increase inpatient child psychiatry capacity and reduce strain on emergency departments.

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.

Before the COVID-19 pandemic, youth emergency department (ED) use for mental health problems was increasing, and boarding (waiting in an ED or medical inpatient unit) before inpatient psychiatric care was common.^1-3 The pandemic exacerbated stressors among youth, including social isolation, school disruptions, and parental unemployment,⁴ and rates of depression and anxiety have doubled since the start of the pandemic.⁵ In 2021, 20% of high school students seriously considered suicide, and 9% attempted suicide.⁶ The American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association declared a national emergency in children’s mental health.⁷ The US Surgeon General has called for a “swift and coordinated response to this crisis.”⁸

EDs and inpatient psychiatric units provide care for youth in crisis. However, there are limited data on how ED and inpatient use for mental health has changed in the context of this children’s mental health emergency. Research from single hospital systems shows an initial drop in ED visits followed by a return to or increase above prepandemic levels.^9-13 One tertiary children’s hospital reported that the median inpatient psychiatric length of stay increased by 3.4 days.¹¹ Over three-quarters of pediatric hospitalists reported an increase in the frequency and duration of boarding.¹⁴

We extend this work to quantify national trends in mental health ED use, inpatient length of stay, and boarding among commercially insured youth into the second year of the pandemic.

This retrospective, cross-sectional study used deidentified health insurance claims data from March 2019 to February 2022 for members of commercial health plans spanning all 50 states (OptumLabs Data Warehouse).¹⁵ In the US, 62% of youth 18 years and younger have commercial insurance¹⁶; those who do are more likely to be Asian or White and have higher family income than youth with public insurance.¹⁷ These data include all care paid for by the health plan, including ED, hospital, and outpatient visits, and have been used in many prior analyses to describe care patterns in the US.^18-21 We included youth aged 5 to 17 years enrolled in both medical and behavioral health coverage in a given month. To maximize representativeness of our sample, we did not require continuous enrollment in the plan for the full study period. On average, our sample included 2.2 million youth per month. This study was deemed exempt by the Harvard Institutional Review Board and follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.²²

First, we identified youth with an ED visit using the following codes: revenue codes (0450-0459), Current Procedural Terminology codes (90500, 90505, 90510, 90515, 90517, 90520, 90530, 90540, 90550, 90560, 90570, 90580, 99281-5, G0383-4), or place of service (23). Mental health–related ED visits were defined as ED visits with a primary diagnosis of a mental health condition on the first ED claim (diagnoses listed in eMethods in Supplement 1). We categorized diagnoses as (1) depression; (2) suicidal ideation, suicide attempt, or intentional self-injury; (3) bipolar, schizophrenia, or related disorder; (4) anxiety disorder; (5) adjustment or trauma disorder; (6) conduct or impulse control disorder; (7) attention-deficit/hyperactivity disorder; (8) autism spectrum disorder (ASD); (9) eating disorder; or (10) other. ED visits with a primary diagnosis of substance use disorder (SUD) were not included.

Second, we identified mental health ED visits resulting in inpatient psychiatric stays: hospitalizations with inpatient psychiatry revenue codes (0114, 0116, 0124, 0126, 0134, 0136, 0144, 0146, 0154, 0156, 0204) and a primary mental health diagnosis. The ED visit and inpatient psychiatric stays were linked if they were on consecutive days or with a 1-day gap between the ED claim and the inpatient psychiatry stay claims. This allowed us to follow up youth transferred from an ED in one hospital to an inpatient psychiatric stay in another, which is common in psychiatry.²³

Third, we captured length of inpatient psychiatric stay (reported as the number of midnights postadmission) for psychiatric unit admissions that started in the ED.

Fourth, when a mental health ED visit resulted in admission to inpatient psychiatry, we identified prolonged boarding where youth waited for 2 or more midnights before admission.²⁴ Since claims data only include date, not time of arrival or discharge, boarding time was calculated as the date of psychiatric inpatient care minus the date for the ED visit. Boarding time included time in an ED or a nonpsychiatric medical inpatient unit.

Individual-level age and biological sex were provided in enrollment data. We stratified by ages 5 to 12 years and 13 to 17 years, as inpatient beds are often divided by age group and the impact of the pandemic could vary by age group.¹² Given the data do not include self-reported race, ethnicity, or family income, we stratified youth by county-level percentage of individuals who were Asian, Black/African American, Hispanic, Native Hawaiian or other Pacific Islander, multiracial, and other race and ethnicity and median household income (divided into quartiles) using 2018 US census data.²⁵ Rurality was defined at the county level using the rural-urban commuting area classifications of rural and small towns.^26,27

Prior research suggests that youth with ASD^28,29 or SUD^30,31 may have longer boarding times. To test this, we identified youth with co-occurring ASD or SUD based on diagnosis codes in the ED or inpatient claims (see the eMethods in Supplement 1 for codes). We restricted to diagnoses given within the acute care episode to limit possible bias from less care access for diagnosing ASD³² or SUD during the pandemic.

To evaluate changes over the COVID-19 pandemic, we used 3 time periods: baseline (March 2019 to February 2020), pandemic year 1 (March 2020 to February 2021), and pandemic year 2 (March 2021 to February 2022). Because mental health ED use varies widely by season,^33,34 we plotted our 4 outcomes by month for each year of the study period.

For each outcome, we measured relative change from baseline to pandemic year 1 and baseline to pandemic year 2, overall and stratified by sex, age group, rural vs nonrural, county not White (Asian, Black/African American, Hispanic, Native Hawaiian or other Pacific Islander, multiracial, and other race and ethnicity) percentage, and county income. We also assessed changes across the 3 years in the fraction of youth with at least 1 ED visit for each diagnostic group, stratified by sex. To understand whether youth had received care prior to the ED visit, we captured what fraction of ED visits were preceded by an outpatient mental health visit in the 30 days prior.

Confidence intervals for differences between years were calculated using a linear regression with standard errors clustered at the individual level. All statistical tests were 2-sided with a P value less than .05 considered significant. Analyses were conducted in SAS version 9.4 (SAS Institute).

Our sample of 4.1 million youth was 51% male, and 41% were aged 13 to 17 years. The steps in creating our cohort and exclusion criteria are shown in eFigure 1 in Supplement 1. Youth in our cohort lived in counties with higher income and more White residents compared with national averages (Table 1 and eTable 1 in Supplement 1).²⁵ The fraction of our study sample insured for all 12 months in each of the 3 study years was stable (64.7%, 68.0%, and 64.8% at baseline, pandemic year 1, and pandemic year 2, respectively).

We identified 88 665 youth mental health ED visits. Compared with the baseline year, the fraction of youth with at least 1 mental health ED visit decreased 17.3% (95% CI, −19.6% to −15.1%; from 59 to 49 per 10 000) in pandemic year 1 but increased 6.7% (95% CI, 4.7%-8.8%; from 59 to 63 per 10 000) in year 2 (Figure 1A and Figure 2). The relative percentage of youth with 1 vs multiple ED visits in a year was similar over time (eTable 2 in Supplement 1).

Changes in the fraction of youth having a mental health ED visit from baseline to pandemic year 2 varied by age and sex: the fraction of females aged 13 to 17 years with visits increased 22.1% (95% CI, 19.2%-24.9%), the fraction for males aged 5 to 12 decreased 15.0% (95% CI, −21.2% to −9.2%), and the fraction for males aged 13 to 17 years decreased 9.0% (95% CI, −13.2% to −5.1%).

Changes in fraction of youth having a mental health ED from baseline to pandemic year 2 also varied by diagnosis and sex (Table 2). Among females, suicidal ideation, suicide attempt, or self-injury increased 43.6% (95% CI, 39.4%-47.5%; 19 to 28 per 10 000), and eating disorder increased by 120.4% (95% CI, 116.1%-123.6%; 2 to 4 per 10 000). Among males, ED visits across all diagnostic groups decreased or stayed the same except for a statistically nonsignificant 15.7% increase for eating disorder (95% CI, −31.0% to 42.8%). The fraction of youth with an ED visit for conduct or impulse control disorders decreased 30.0% (95% CI, −42.4% to −19.2%) for males and 19.9% (95% CI, −38.1% to −5.1%) for females.

In the baseline year, the fraction of youth with a mental health ED visit was lower in counties with more residents who were Asian, Black/African American, Hispanic, Native Hawaiian or other Pacific Islander, multiracial, and other race and ethnicity and similar across county income quartiles (Figure 2). From baseline to pandemic year 2, this fraction increased more among enrollees from counties with more residents who were Asian, Black/African American, Hispanic, Native Hawaiian or other Pacific Islander, multiracial, and other race and ethnicity.

In the baseline year, 78.1% of mental health ED visits were preceded by an outpatient visit with a primary mental health diagnosis within the prior 30 days. This decreased to 76.3% in pandemic year 1 and 72.2% in pandemic year 2 (eTable 3 in Supplement 2).

The percent of mental health ED visits that resulted in an inpatient psychiatry admission was 20.9% in the baseline year and increased 13.1% (95% CI, 10.1%-16.1%) from baseline to pandemic year 1 and 8.4% (95% CI, 5.5%-11.2%) from baseline to pandemic year 2 (Figure 1B and eFigure 2 in Supplement 1). Depression was the only diagnostic group with a statistically significant increase in likelihood of admission in pandemic year 2 relative to baseline (14.0% [95% CI, 9.4%-18.2%]). In the baseline year, females were more likely than males to be admitted (26.1% vs 15.9%), and this difference grew during the pandemic (change baseline to year 2, female percentage increased 6.8% [95% CI, 3.3%-10.2%]; male percentage decreased 0.3% [95% CI, −5.8 to 4.6%]) (eFigure 2 in Supplement 1).

The mean (SD) length of inpatient psychiatric stay following mental health ED visits was 9.2 (10.3) midnights in the baseline year (Figure 1C). Mean length of stay was 10.6% longer (95% CI, 6.6%-14.3%) from baseline to pandemic year 1 and 3.8% longer (95% CI, 1.8%-5.7%) from baseline to pandemic year 2. The only diagnostic group with a statistically significant change in inpatient length of stay from the baseline year to pandemic year 2 was suicidal ideation/suicide attempt/self-harm, with a 5.4% increase (95% CI, 2.6%-8.1%). Females had a longer mean (SD) length of stay in the baseline year (9.4 [10.5] vs 8.8 [9.8] midnight); changes in mean length of stay were similar for males and females (eFigure 3 in Supplement 1).

In the baseline year, 11.0% of ED visits that resulted in admission to inpatient psychiatry included prolonged boarding (≥2 midnights). Boarding increased consistently over the pandemic (Figure 1D). Compared with baseline, prolonged boarding increased by 27.1% (95% CI, 17.9%-35.0%) from baseline to pandemic year 1 and 76.4% (95% CI, 71.0%-81.0%) from baseline to pandemic year 2. In pandemic year 2, prolonged boarding increased more for age 13 to 17 years (87.2% [95% CI, 82.0%-91.5%]) than for age 5 to 12 years (35.9% [95% CI, 15.6%-50.9%]). Changes in prolonged boarding were not significantly different between males and females. The increase in prolonged boarding was most pronounced for those in counties above the median income and in counties with more residents who were Asian, Black/African American, Hispanic, Native Hawaiian or other Pacific Islander, multiracial, and other race and ethnicity (Figure 3).

At baseline, youth with ASD had higher rates of prolonged boarding (18.4% vs 10.3% for youth without ASD), and this difference widened by pandemic year 2 (27.0% boarding rate for youth with ASD; 18.8% for those without).

In the context of a national emergency in children’s mental health, we observe a 7% increase in the fraction of youth with any mental health ED visits from baseline to pandemic year 2. Among adolescent females, there was a notable 22% increase. Into pandemic year 2, the percentage of mental health ED visits that resulted in a psychiatric admission increased by 8%, and there was a striking 76% increase in prolonged boarding.

The fraction of youth with a mental health ED visit was lower during the entire pandemic year 1. This is consistent with the larger decline in all ED visits due to fear of going to the hospital in the early phase of the pandemic³⁵ but contrasts with the experience in single hospital systems and tertiary children’s hospitals where visits returned to baseline and even increased.^10,11,13 This difference may be due to our national sample and inclusion of community hospitals. Community hospitals account for the majority of pediatric ED visits^36,37 and may have experienced different trends than tertiary hospitals due to a shift from community hospital to tertiary hospital EDs. The percentage of youth who had an outpatient visit with a mental health diagnosis in the 30 days preceding a mental health ED visit decreased from 78.7% in the baseline year to 72.7% in pandemic year 2, suggesting that in pandemic year 2 fewer youth were connected with the health care system prior to an ED visit.

We observed very different trends in ED visits among adolescent females vs males. By pandemic year 2, the fraction of adolescent females who had a mental health ED visit increased 22% while decreasing substantially among adolescent males. This contrast is consistent with prior literature showing adolescent females have been more negatively impacted by the pandemic than males.^38,39 Multiple factors likely contribute to females’ increase in mental distress⁴⁰ including higher pandemic-related stress,^4,39,41 more pandemic-related disruptions to school, and emotional abuse in the home.⁴⁰ This may explain why the increase in ED visits for females was primarily driven by suicidal ideation, suicide attempt, and self-harm. There was also a doubling in the fraction of adolescent females with an ED visit for an eating disorder. This may be a continuation of a prepandemic trend of worsening eating disorder symptoms.^42,43 Some have hypothesized that the worsening of symptoms during the pandemic was due to more screen time and seeing oneself on camera.^44,45 However, if this was the mechanism, then we would have expected a reduction in ED visits with a return to in-person learning, which we do not observe.⁴⁶

Concerns around pediatric inpatient psychiatric bed capacity and ED boarding existed before the pandemic.^1,28,47 We found that boarding dramatically worsened in the pandemic with a striking 76% increase by pandemic year 2. During time spent boarding, youth receive little care to facilitate recovery: only 14% of pediatric hospitalists reported that youth boarding at their institutions received medication management and 18% that they received psychotherapy.¹⁴ Parents of boarding youth frequently likened the environment to incarceration and experienced significant distress during boarding.⁴⁸ Clinicians often find it morally distressing to care for boarding youth.⁴⁸

What is driving the increase in boarding is less clear. An increase in need is one factor as we observed an increase in the likelihood of admission among ED visits. The modest increase in inpatient length of stay also decreases the number of available beds. However, the increase in boarding was disproportionately larger than both of these changes. We believe another key factor is restricted inpatient child psychiatry capacity. The number of inpatient child psychiatry beds may be decreased due to staffing challenges,⁴⁹ pandemic precautions that restricted use of double occupancy rooms,⁵⁰ and closure or repurposing of inpatient child psychiatry units.⁵¹

Several policy interventions could address the changes we observe. Addressing a shortage of clinicians and clinician burnout would allow more inpatient units to run at capacity. Supporting primary care professionals in providing mental health care^52,53 and triage of outpatient care for youth who need it most⁵⁴ could reduce mental health ED visits. Given more children are boarding, a shift in practice may be needed where treatment begins in the ED instead of waiting to admission to the inpatient unit. Brief therapeutic interventions in the ED, possibly via telemedicine, may even reduce the need for admission. Long-term, increased reimbursement rates for mental health care could help incentivize hospitals to prioritize psychiatric inpatient care. In the meantime, it is critical to continue monitoring trends in boarding and to improve the experiences of boarding youth by prioritizing active, collaborative treatment in a healing environment.^55,56

Our study was limited to commercially insured youth. While we expect our findings are representative of the 62% of youth with commercial insurance,¹⁶ they may not generalize to those who are publicly insured or uninsured. Claims data only include date, not time of arrival or discharge. Midnights boarded is a crude measure of time spent boarding. We could not differentiate time spent boarding from time being medically stabilized though we excluded ED visits primarily focused on SUD to minimize the risk that medical stabilization is biasing our findings. As with most commercial claims data sets, we had information on biological sex but did not have individual-level information on gender identity, race, ethnicity, or income. We did not assess boarders who were ultimately discharged without an inpatient psychiatric stay, as we were unable to reliably identify this group in the data. Lastly, while concerns about the youth mental health crisis are international, we do not know if our findings generalize to other countries.

In this study of acute mental health care utilization among commercially insured youth over the first 2 years of the pandemic, mental health ED visits notably increased among adolescent females, and we observed a 76% increase in prolonged boarding of youth awaiting inpatient care. These data can help inform the continuing debate about how to best address the mental health crisis and reduce ED boarding.

Accepted for Publication: April 21, 2023.

Published Online: July 12, 2023. doi:10.1001/jamapsychiatry.2023.2195

Corresponding Author: Haiden A. Huskamp, PhD, Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115 (huskamp@hcp.med.harvard.edu).

Author Contributions: Mss Overhage and Hailu had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Overhage, Hailu, Busch, Mehrotra, Huskamp.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Overhage.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Hailu, Michelson.

Obtained funding: Mehrotra, Huskamp.

Administrative, technical, or material support: Busch, Mehrotra, Huskamp.

Supervision: Mehrotra, Michelson, Huskamp.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by the National Institute of Mental Health (NIMH) (grants R01 MH112829 and T32 MH019733), Agency for Healthcare Research and Quality (grant K08HS026503), and National Institute of Aging (grant T32AG51108).

Role of the Funder/Sponsor: Funding agencies were not involved in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; nor decision to submit the manuscript for publication. OptumLabs, the data provider, reviewed the manuscript to confirm compliance with the data use agreement but did not contribute otherwise to the study.

Meeting Presentation: This work was presented as an oral abstract at the Pediatric Academic Societies 2023; April 29, 2023; Washington, DC.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality, the National Institute of Mental Health, National Institute on Aging, or the National Institutes of Health.

Data Sharing Statement: See Supplement 2.

Additional Contributions: We are grateful to Nicole Benson, MD, MBI (McLean Hospital and Harvard Medical School), for help contextualizing the results of this study and editing the manuscript. No compensation was received.