Changes and Inequities in Adult Mental Health-Related Emergency Department Visits During the COVID-19 Pandemic in the US

Abstract

Importance: The COVID-19 pandemic has negatively affected adult mental health (MH), with racial and ethnic minoritized groups disproportionately affected.

Objective: To examine changes in adult MH-related emergency department (ED) visits into the Delta variant pandemic period and identify changes and inequities in these visits before and during COVID-19 case surges.

Design, setting, and participants: This epidemiologic cross-sectional study used National Syndromic Surveillance Program data from US adults aged 18 to 64 years from 1970 to 2352 ED facilities from January 1, 2019, to August 14, 2021. All MH-related ED visits and visits related to 10 disorders (ie, anxiety, depressive, bipolar, schizophrenia spectrum, trauma- and stressor-related, attention-deficit/hyperactivity, disruptive behavioral and impulse, obsessive-compulsive, eating, and tic disorders) were identified.

Exposures: The following periods of MH-related ED visits were compared: (1) high Delta variant circulation (July 18-August 14, 2021) with a pre-Delta period (April 18-May 15, 2021), (2) after a COVID-19 case peak (February 14-March 13, 2021) with during a peak (December 27, 2020-January 23, 2021), and (3) the Delta period and the period after a COVID-19 case peak with the respective corresponding weeks during the prepandemic period.

Main outcomes and measures: ED visits for 10 mental disorders and all MH-related visits.

Results: This cross-sectional study included 107 761 319 ED visits among adults aged 18 to 64 years (59 870 475 [56%] women) from January 1, 2019, to August 14, 2021. There was stability in most MH-related ED visit counts between the Delta and pre-Delta periods (percentage change, -1.4% to -7.5%), except for eating disorders (-11.9%) and tic disorders (-19.8%) and after a COVID-19 case peak compared with during a peak (0.6%-7.4%). Most MH-related ED visit counts declined in the Delta period relative to the prepandemic period (-6.4% to -30.7%); there were fluctuations by disorder when comparing after a COVID-19 case peak with the corresponding prepandemic period (-15.4% to 11.3%). Accounting for ED visit volume, MH-related ED visits were a smaller proportion of visits in the Delta period compared with the pre-Delta period (visit ratio, 0.86; 95% CI, 0.85-0.86) and prepandemic period (visit ratio, 0.80; 95% CI, 0.79-0.80). After a COVID-19 case peak, MH-related ED visits were a larger proportion of ED visits compared with during a peak (visit ratio, 1.04; 95% CI, 1.03-1.04) and the corresponding prepandemic period (visit ratio, 1.11; 95% CI, 1.11-1.12). Of the 2 510 744 ED visits included in the race and ethnicity analysis, 24 592 (1%) were American Indian or Alaska Native persons, 33 697 (1%) were Asian persons, 494 198 (20%) were Black persons, 389 740 (16%) were Hispanic persons, 5000 (0.2%) were Native Hawaiian or Other Pacific Islander persons, and 1 172 683 (47%) were White persons. There was between- and within-group variation in ED visits by race and ethnicity and increases in selected disorders after COVID-19 peaks for adults aged 18 to 24 years.

Conclusions and relevance: Results of this cross-sectional study suggest that EDs may have increases in MH-related visits after COVID-19 surges, specifically for young adults and individual racial and ethnic minoritized subpopulations. Public health practitioners should consider subpopulation-specific messaging and programmatic strategies that address differences in MH needs, particularly for those historically marginalized.

Figure 1.. US Mental Health–Related Emergency Department (ED) Visit Counts for Adults Aged 18 to 64 years, Overall and by Disorder

This figure includes data from January 1, 2019, through August 14, 2021. Shaded areas of the graph depict time periods included in the analytic index or comparison periods, which are as follows: the prepandemic comparison periods (February 10-March 9, 2019, and July 14-August 10, 2019), the COVID-19 case peak comparison period (December 27, 2020-January 23, 2021), the period immediately after a COVID-19 case peak index period (February 14-March 13, 2021), a COVID-19 pandemic comparison period with low circulation of the Delta variant, called the pre-Delta period (April 18-May 15, 2021), and a COVID-19 pandemic index period with high circulation of the Delta variant, called the Delta period (July 18-August 14, 2021). To accommodate differences in counts of all mental health–related visits and specific disorders, results for high-prevalence (A), medium-prevalence (B), and low-prevalence (C) disorders are presented.

Figure 2.. Mental Health–Related, Anxiety, and Depressive Disorder US Emergency Department (ED) Visits, by Race and Ethnicity, December 27, 2020, to August 14, 2021

This figure includes data for all mental health (A), anxiety disorders (B), and depressive disorders (C). Shaded areas of the graph depict time periods included in analytic index or comparison periods: a COVID-19 case peak comparison period (December 27, 2020-January 23, 2021), the period immediately after a COVID-19 case peak index period (February 14-March 13, 2021), a COVID-19 pandemic comparison period with low circulation of the Delta variant (the pre-Delta period; April 18-May 15, 2021), and a COVID-19 pandemic index period with high circulation of the Delta variant (the Delta period; July 18-August 14, 2021). These windows were used in the temporal comparisons displayed in Table 2 (eAppendix 1 in the Supplement).

Figure 3.. Bipolar, Schizophrenia Spectrum, and Trauma- and Stressor-Related Disorders US Emergency Department (ED) Visits, by Race and Ethnicity, December 27, 2020, to August 14, 2021

This figure includes data for bipolar disorders (A), schizophrenia spectrum disorders (B), and trauma- and stressor-related disorders (C). Shaded areas of the graph depict time periods included in analytic index or comparison periods: a COVID-19 case peak comparison period (December 27, 2020-January 23, 2021), the period immediately after a COVID-19 case peak index period (February 14-March 13, 2021), a COVID-19 pandemic comparison period with low circulation of the Delta variant (the pre-Delta period; April 18-May 15, 2021), and a COVID-19 pandemic index period with high circulation of the Delta variant (the Delta period; July 18-August 14, 2021). These windows were used in the temporal comparisons displayed in Table 2 (eAppendix 2 in the Supplement).