Emergency Department Visits Involving Mental Health Conditions, Suicide-Related Behaviors, and Drug Overdoses Among Adolescents - United States, January 2019-February 2023.

The U.S. adolescent mental and behavioral health crisis is ongoing,* with high pre-COVID-19 pandemic baseline rates† (1) and further increases in poor mental health (2), suicide-related behaviors (3), and drug overdose deaths (4) reported during 2020-2021. CDC examined changes in U.S. emergency department (ED) visits for mental health conditions (MHCs) overall and for nine specific MHCs,§ suicide-related behaviors (including suspected suicide attempts), and drug-involved overdoses (including opioids) among children and adolescents aged 12-17 years (adolescents) during January 2019-February 2023, overall and by sex. Compared with fall 2021, by fall 2022, decreases in weekly ED visits were reported among all adolescents, and females specifically, for MHCs overall, suicide-related behaviors, and drug overdoses; weekly ED visits among males were stable. During this same period, increases in weekly ED visits for opioid-involved overdoses were detected. Mean weekly ED visits in fall 2022 for suicide-related behaviors and MHCs overall were at or lower than the 2019 prepandemic baseline, respectively, and drug overdose visits were higher. Differences by sex were observed; levels among females were at or higher than prepandemic baselines for these conditions. These findings suggest some improvements as of fall 2022 in the trajectory of adolescent mental and behavioral health, as measured by ED visits; however, poor mental and behavioral health remains a substantial public health problem, particularly among adolescent females. Early identification and trauma-informed interventions, coupled with expanded evidence-based, comprehensive prevention efforts, are needed to support adolescents' mental and behavioral health.

Trends in Stimulant Prescription Fills Among Commercially Insured Children and Adults - United States, 2016-2021.

Prescription stimulant use, primarily for the treatment of attention-deficit/hyperactivity disorder (ADHD), has increased among adults in the United States during recent decades, while remaining stable or declining among children and adolescents (1,2). MarketScan commercial claims data were analyzed to describe trends in prescription stimulant fills before and during the COVID-19 pandemic (2016-2021) by calculating annual percentages of enrollees aged 5-64 years in employer-sponsored health plans who had one or more prescription stimulant fills overall and by sex and age group. Overall, the percentage of enrollees with one or more prescription stimulant fills increased from 3.6% in 2016 to 4.1% in 2021. The percentages of females aged 15-44 years and males aged 25-44 years with prescription stimulant fills increased by more than 10% during 2020-2021. Future evaluation could determine if policy and health system reimbursement changes enacted during the pandemic contributed to the increase in stimulant prescriptions. Stimulants can offer substantial benefits for persons with ADHD, but also pose potential harms, including adverse effects, medication interactions, diversion and misuse, and overdoses. Well-established clinical guidelines exist for ADHD care, but only for children and adolescents* (3); clinical practice guidelines for adult ADHD could help adults also receive accurate diagnoses and appropriate treatment.

Rapid onset of functional tic-like behaviors among adolescent girls-Minnesota, September-November 2021.

Background: On October 15, 2021, the Minnesota Department of Health began investigating a school cluster of students experiencing tic-like behaviors thought to be related to recent COVID-19. The objective of this report is to describe the investigation, key findings, and public health recommendations. Methods: Affected students and proxies were interviewed with a standardized questionnaire including validated depression and anxiety screens. Results: Eight students had tic-like behaviors lasting >24 h after initial report with onset during September 26-October 30, 2021. All eight students were females aged 15-17 years. All students either had a history of depression or anxiety or scored as having more than minimal anxiety or depression on validated screens. Four students previously had confirmed COVID-19: the interval between prior COVID-19 and tic symptom onset varied from more than a year prior to tic symptom onset to at the time of tic symptom onset. Conclusion: The onset of tic-like behaviors at one school in Minnesota appeared to be related more to underlying mental health conditions than recent COVID-19. These findings highlight the need to better understand functional tic-like behaviors and adolescent mental health.

Rapid onset of functional tic-like behaviors among adolescent girls—Minnesota, September–November 2021

Background On October 15, 2021, the Minnesota Department of Health began investigating a school cluster of students experiencing tic-like behaviors thought to be related to recent COVID-19. The objective of this report is to describe the investigation, key findings, and public health recommendations. Methods Affected students and proxies were interviewed with a standardized questionnaire including validated depression and anxiety screens. Results Eight students had tic-like behaviors lasting >24 h after initial report with onset during September 26–October 30, 2021. All eight students were females aged 15–17 years. All students either had a history of depression or anxiety or scored as having more than minimal anxiety or depression on validated screens. Four students previously had confirmed COVID-19: the interval between prior COVID-19 and tic symptom onset varied from more than a year prior to tic symptom onset to at the time of tic symptom onset. Conclusion The onset of tic-like behaviors at one school in Minnesota appeared to be related more to underlying mental health conditions than recent COVID-19. These findings highlight the need to better understand functional tic-like behaviors and adolescent mental health.

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

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.

Pediatric Emergency Department Visits Associated with Mental Health Conditions Before and During the COVID-19 Pandemic - United States, January 2019-January 2022.

In 2021, a national emergency* for children's mental health was declared by several pediatric health organizations, and the U.S. Surgeon General released an advisory† on mental health among youths. These actions resulted from ongoing concerns about children's mental health in the United States, which was exacerbated by the COVID-19 pandemic (1,2). During March-October 2020, among all emergency department (ED) visits, the proportion of mental health-related visits increased by 24% among U.S. children aged 5-11 years and 31% among adolescents aged 12-17 years, compared with 2019 (2). CDC examined changes in U.S. pediatric ED visits for overall mental health conditions (MHCs) and ED visits associated with specific MHCs (depression; anxiety; disruptive behavioral and impulse-control disorders; attention-deficit/hyperactivity disorder; trauma and stressor-related disorders; bipolar disorders; eating disorders; tic disorders; and obsessive-compulsive disorders [OCD]) during 2019 through January 2022 among children and adolescents aged 0-17 years, overall and by sex and age. After declines in weekly visits associated with MHCs among those aged 0-17 years during 2020, weekly numbers of ED visits for MHCs overall and for specific MHCs varied by age and sex during 2021 and January 2022, when compared with corresponding weeks in 2019. Among adolescent females aged 12-17 years, weekly visits increased for two of nine MHCs during 2020 (eating disorders and tic disorders), for four of nine MHCs during 2021 (depression, eating disorders, tic disorders, and OCD), and for five of nine MHCs during January 2022 (anxiety, trauma and stressor-related disorders, eating disorders, tic disorders, and OCD), and overall MHC visits during January 2022, compared with 2019. Early identification and expanded evidence-based prevention and intervention strategies are critical to improving children's and adolescents' mental health (1-3), especially among adolescent females, who might have increased need.

Mental Health-Related Emergency Department Visits Among Children Aged <18 Years During the COVID-19 Pandemic - United States, January 1-October 17, 2020.

Published reports suggest that the coronavirus disease 2019 (COVID-19) pandemic has had a negative effect on children's mental health (1,2). Emergency departments (EDs) are often the first point of care for children experiencing mental health emergencies, particularly when other services are inaccessible or unavailable (3). During March 29-April 25, 2020, when widespread shelter-in-place orders were in effect, ED visits for persons of all ages declined 42% compared with the same period in 2019; during this time, ED visits for injury and non-COVID-19-related diagnoses decreased, while ED visits for psychosocial factors increased (4). To assess changes in mental health-related ED visits among U.S. children aged <18 years, data from CDC's National Syndromic Surveillance Program (NSSP) from January 1 through October 17, 2020, were compared with those collected during the same period in 2019. During weeks 1-11 (January 1-March 15, 2020), the average reported number of children's mental health-related ED visits overall was higher in 2020 than in 2019, whereas the proportion of children's mental health-related visits was similar. Beginning in week 12 (March 16) the number of mental health-related ED visits among children decreased 43% concurrent with the widespread implementation of COVID-19 mitigation measures; simultaneously, the proportion of mental health-related ED visits increased sharply beginning in mid-March 2020 (week 12) and continued into October (week 42) with increases of 24% among children aged 5-11 years and 31% among adolescents aged 12-17 years, compared with the same period in 2019. The increased proportion of children's mental health-related ED visits during March-October 2020 might be artefactually inflated as a consequence of the substantial decrease in overall ED visits during the same period and variation in the number of EDs reporting to NSSP. However, these findings provide initial insight into children's mental health in the context of the COVID-19 pandemic and highlight the importance of continued monitoring of children's mental health throughout the pandemic, ensuring access to care during public health crises, and improving healthy coping strategies and resiliency among children and families.

COVID-19 Mitigation Behaviors by Age Group - United States, April-June 2020.

CDC recommends a number of mitigation behaviors to prevent the spread of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19). Those behaviors include 1) covering the nose and mouth with a mask to protect others from possible infection when in public settings and when around persons who live outside of one's household or around ill household members; 2) maintaining at least 6 feet (2 meters) of distance from persons who live outside one's household, and keeping oneself distant from persons who are ill; and 3) washing hands often with soap and water for at least 20 seconds, or, if soap and water are not available, using hand sanitizer containing at least 60% alcohol (1). Age has been positively associated with mask use (2), although less is known about other recommended mitigation behaviors. Monitoring mitigation behaviors over the course of the pandemic can inform targeted communication and behavior modification strategies to slow the spread of COVID-19. The Data Foundation COVID Impact Survey collected nationally representative data on reported mitigation behaviors during April-June 2020 among adults in the United States aged ≥18 years (3). Reported use of face masks increased from 78% in April, to 83% in May, and reached 89% in June; however, other reported mitigation behaviors (e.g., hand washing, social distancing, and avoiding public or crowded places) declined marginally or remained unchanged. At each time point, the prevalence of reported mitigation behaviors was lowest among younger adults (aged 18-29 years) and highest among older adults (aged ≥60 years). Lower engagement in mitigation behaviors among younger adults might be one reason for the increased incidence of confirmed COVID-19 cases in this group, which have been shown to precede increases among those >60 years (4). These findings underscore the need to prioritize clear, targeted messaging and behavior modification interventions, especially for young adults, to encourage uptake and support maintenance of recommended mitigation behaviors to prevent the spread of COVID-19.