Comparison of paediatric emergency department visits for attempted suicide, self-harm, and suicidal ideation before and during the COVID-19 pandemic: a systematic review and meta-analysis

Abstract

Background: There is a lack of consensus about the effect of the COVID-19 pandemic on the mental health of children and adolescents. We aimed to compare rates of paediatric emergency department visits for attempted suicide, self-harm, and suicidal ideation during the pandemic with those before the pandemic.

Methods: For this systematic review and meta-analysis, we searched MEDLINE, Embase, and PsycINFO for studies published between Jan 1, 2020, and Dec 19, 2022. Studies published in English with data on paediatric (ie, those aged <19 years) emergency department visits before and during the COVID-19 pandemic were included. Case studies and qualitative analyses were excluded. Changes in attempted suicide, self-harm, suicidal ideation, and other mental-illness indicators (eg, anxiety, depression, and psychosis) were expressed as ratios of the rates of emergency department visits during the pandemic compared with those before the pandemic, and we analysed these with a random-effects meta-analysis. This study was registered with PROSPERO, CRD42022341897.

Findings: 10 360 non-duplicate records were retrieved, which yielded 42 relevant studies (with 130 sample-estimates) representing 11·1 million emergency department visits for all indications of children and adolescents across 18 countries. The mean age of the samples of children and adolescents across studies was 11·7 years (SD 3·1, range 5·5-16·3), and there were on average 57·6% girls and 43·4% boys as a proportion of emergency department visits for any health reasons (ie, physical and mental). Only one study had data related to race or ethnicity. There was good evidence of an increase in emergency department visits for attempted suicide during the pandemic (rate ratio 1·22, 90% CI 1·08-1·37), modest evidence of an increase in emergency department visits for suicidal ideation (1·08, 0·93-1·25), and good evidence for only a slight change in self-harm (0·96, 0·89-1·04). Rates of emergency department visits for other mental-illness indications showed very good evidence of a decline (0·81, 0·74-0·89), and paediatric visits for all health indications showed strong evidence of a reduction (0·68, 0·62-0·75). When rates for attempted suicide and suicidal ideation were combined as a single measure, there was good evidence of an increase in emergency department visits among girls (1·39, 1·04-1·88) and only modest evidence of an increase among boys (1·06, 0·92-1·24). Self-harm among older children (mean age 16·3 years, range 13·0-16·3) showed good evidence of an increase (1·18, 1·00-1·39), but among younger children (mean age 9·0 years, range 5·5-12·0) there was modest evidence of a decrease (0·85, 0·70-1·05).

Interpretation: The integration of mental health support within community health and the education system-including promotion, prevention, early intervention, and treatment-is urgently needed to increase the reach of mental health support that can mitigate child and adolescent mental distress. In future pandemics, increased resourcing in some emergency department settings would help to address their expected increase in visits for acute mental distress among children and adolescents.

Funding: None.

Figure 1

Study profile

Figure 2

Changes in child and adolescent emergency department visits for (A) attempted suicide, (B) self-harm, and (C) suicidal ideation expressed as ratios of rates during the COVID-19 pandemic to those before the pandemic Ratios are plotted on a log axis. The grey area represents slight changes (RR 0·90 to <1·11). Vertical dashed lines indicate thresholds for large (0·10 to <0·50 or 2·00 to <10·00) and extremely large (<0·10 or ≥10·00) reductions and increases. Error bars represent 90% CIs. When numbers of visits are not reported (ie, NA for Kemerer and colleagues⁴⁹), RRs and their corresponding CIs were extracted directly from the study. A value of 0·5 replaced counts of zero (ie, for Bothara and colleagues³⁸). RR=rate ratio. NA=not applicable.

Figure 3

Meta-analysed mean changes in child and adolescent emergency department visits expressed as ratios of rates during the COVID-19 pandemic to those before the pandemic Ratios are plotted on a log axis. Grey area represents slight changes (rate ratio 0·90 to <1·11). Horizontal dashed lines indicate thresholds for reductions (moderate reduction 0·50 to <0·70; large reduction <0·50) and increases (moderate increase 1·43 to <2·00; large increase ≥2·00). Thick error bars represent 90% CIs for means and thin error bars represent 90% CIs for individual settings.