Kaiser Permanente study finds small uptick in suicide-related emergency room visits for teen girls in fall 2020
The number of teens being seen at Kaiser Permanente Northern California emergency departments (ED) for suicidal thoughts and behaviors did not increase significantly during the COVID-19 pandemic, though specific groups of teens may have sought care at higher rates during late 2020.
The findings were reported Sept. 1 in JAMA Psychiatry. The analysis found an overall reduction in number of suicide-related ED visits by patients aged 5 to 17 between 2019 and 2020, going from 2,339 to 2,123. About two-thirds of visits were by girls, and most were aged 13 to 17.
The findings are reassuring and provide guidance for focus on specific populations, said lead author Kathryn Erickson-Ridout, MD, PhD, a psychiatrist with The Permanente Medical Group (TPMG) and adjunct investigator with the Kaiser Permanente Division of Research. “There is widespread concern that there has been a big increase in mental health crises among teenagers because of the COVID-19 pandemic,” Erickson-Ridout said. “But these data suggest that the trends over time are generally consistent with the year prior to the pandemic, though there may be certain groups who need more attention.”
Increases were seen for a subset of patients during specific periods. Suicide-related visits for girls jumped 19% over 2019 levels between June and August 2020, and 22% between September and December 2020. By contrast, visits for boys remained below 2019 levels during fall 2020.
The researchers’ review included as “suicide-related visits” those coded for suicide attempts, suicidal ideation, and self-injurious behaviors.
The researchers also found higher risk of a fall 2020 ED mental health visit among 2 additional groups: young people who had no history of outpatient mental health diagnoses in the last 2 years and those diagnosed with mental health conditions in addition to suicidal thoughts and behaviors at the time of the ED visit.
Is teen mental health suffering?
Suicide is the second leading cause of death for Americans aged 10 to 17, and incidence has been on the rise for the past decade. There have been anecdotal reports that young people were suffering increased depression and suicidal thoughts during the pandemic. A June study from the Centers for Disease Control and Prevention found 22% and 39% more ED encounters for suicide attempts by adolescents aged 12 to 17 throughout the U.S. during the summer 2020 (July to August 2020) and winter 2021 (February to March 2021) compared with the corresponding weeks in 2019, with higher rates among girls driving the increase.
But the Kaiser Permanente figures suggest that for its members in Northern California, there may not have been a large increase in young people in crisis during 2020, the authors said. “Although the COVID-19 pandemic has been associated with a wide range of social economic, and health stressors in the lives of youth and their families…suicidal thoughts or behaviors may not emerge until later in the pandemic and not evenly among groups of youth,” they wrote.
The potential effects of stay-at-home orders and video-based schooling, along with stress of the COVID-19 pandemic itself, are complex when it comes to youth, said Erickson-Ridout, who is also a member of TPMG Physician Researcher Program. “There are many factors at play that could make mental health challenges either better or worse,” she said. “There’s a tradeoff between being online more and socially isolated versus being relieved of in-person bullying and the pressures of academic and sports performance. Medical records and statistics tell part of the story, but we will learn more in coming months and years as we work with our young patients.”
The researchers noted that overall numbers of ED visits for mental health in 2020 were likely lower because fewer patients were visiting hospitals during the shelter-in-place months of March to May 2020; visits fell by nearly half during this time but returned later in the year to levels seen pre-pandemic.
It’s heartening as it may show our youth are able to weather the pandemic with support of family or friends or just their internal resources.
Kathryn Erickson-Ridout, MD, PhD, psychiatrist, The Permanente Medical Group
The authors found that during the pandemic, youth ED visits were more likely to be suicide-related than due to other issues. However, this did not necessarily imply a rapid increase in suicidality. They found that suicide-related visits among youth were generally stable, but that overall ED visits decreased substantially — explaining the jump in proportion related to suicide. A similar jump in proportion was seen for appendicitis, a condition that would not be sensitive to COVID-19 .
“The fact that we see similar increases in the proportion of ED volume for appendicitis as for suicidal thoughts suggests both are conditions patients continue to seek care for, but may not be influenced by the pandemic,” Erickson-Ridout said. “It’s heartening as it may show our youth are able to weather the pandemic with support of family or friends or just their internal resources.”
The increase in mental health visits for girls later in the year could be related to the start of school and its attendant social complications, said senior author Esti Iturralde, PhD, a research scientist with the Kaiser Permanente Division of Research. “In adolescence social activities are so important developmentally,” Iturralde said. “So if we are seeing a little bit of a spike for girls toward the fall, that could be a signal suggesting something about girls being particularly sensitive to the social challenges of the pandemic.”
The emergency department is not the only place where young members of Kaiser Permanente would go for mental health assistance, the authors said, but it was the care setting where suicide-related encounters took place. Those seeking help could also be seen by a mental health provider in person, by phone or video, or attend a group counseling session. They may also have school-based or faith-based support that could have become less accessible during the pandemic.
The study was funded by The Permanente Medical Group Delivery Science and Applied Research program.
Co-authors included Samuel J. Ridout, MD, PhD, Maria T. Koshy, MD, Sameer Awsare, MD, and David R. Vinson, MD, of The Permanente Medical Group; Mubarika Alavi, MS, Constance M. Weisner, DrPH, and Stacy Sterling, DrPH, MSW, MPH, of the Division of Research; and Brooke Harris, PhD, of Kaiser Foundation Hospitals.
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About the Kaiser Permanente Division of Research
The Kaiser Permanente Division of Research conducts, publishes and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and society at large. It seeks to understand the determinants of illness and well-being, and to improve the quality and cost-effectiveness of health care. Currently, DOR’s 600-plus staff is working on more than 450 epidemiological and health services research projects. For more information, visit divisionofresearch.kaiserpermanente.org or follow us @KPDOR.