Child and Adolescent Mental Health during the COVID-19 Pandemic: Challenges of Psychiatric Outpatient Clinics

Background: Worldwide national surveys show a rising mental health burden among children and adolescents (C&A) during COVID-19. The objective of the current study is to verify the expected rise in visits to psychiatric outpatient clinics of C&A, especially of new patients. Methods: a cross-sectional study focusing on visits as recorded in electronic medical records of eight heterogeneous C&A psychiatric outpatient clinics. The assessment was based on visits held from March to December of 2019 (before the pandemic) in comparison to visits held in 2020 (during the pandemic). Results: The number of visits was similar for both periods. However, in 2020, 17% of the visits used telepsychiatry (N = 9885). Excluding telepsychiatry reveals a monthly decrease in traditional in-person activities between 2020 and 2019 (691.6 ± 370.8 in 2020 vs. 809.1 ± 422.8 in 2019, mean difference = −117.5, t (69) = −4.07, p = 0.0002, Cohen's d = −0.30). Acceptation of new patients declined during 2020, compared to 2019 (50.0 ± 38.2 in 2020 vs. 62.8 ± 42.9 in 2019;Z = −3.12, p = 0.002, r = 0.44). Telepsychiatry was not used for new patients. Conclusions: The activity of C&A psychiatric outpatient clinics did not rise but was guarded due to the use of telepsychiatry. The decline in visits of new patients was explained by the lack of use of telepsychiatry for these patients. This calls for expanding the use of telepsychiatry, especially for new patients.

A 16-Month Longitudinal Investigation of Risk and Protective Factors for Mental Health Outcomes Throughout Three National Lockdowns and a Mass Vaccination Campaign: Evidence from a Weighted Israeli Sample During COVID-19

Background COVID-19 is an ongoing global crisis, with a multitude of factors that affect mental health worldwide. We explored potential predictors for the emergence and maintenance of depression, anxiety, and posttraumatic stress symptoms (PTSS) in the general population in Israel. Methods Across the span of 16 months, 2,478 people completed a repeated self-report survey which inquired psychiatric symptoms and pandemic related stress factors (PRSF). We applied mixed-effects models to assess how each stressor contributes to depression, anxiety and PTSS at each time point, and longitudinally assessed participants who completed at least two consecutive surveys (n=400). Results Fatigue was the strongest predictor for depression, anxiety and PTSS at all time points, and predicted deterioration overtime. Financial concerns associated with depression and anxiety at all time points, and with their deterioration overtime. Health related concerns were uniquely associated with anxiety and PTSS at all time points and their deterioration, but not with depression. Improvement in sense of protection overtime associated with decrease in depression and anxiety. Hesitancy towards vaccination was associated to higher financial concerns and lower sense of protection by the authorities. Conclusions Our findings accentuate the multitude of risk factors for psychiatric morbidity during COVID-19, and the centrality of fatigue in determining mental health outcomes.

A 16-month longitudinal investigation of risk and protective factors for mental health outcomes throughout three national lockdowns and a mass vaccination campaign: Evidence from a weighted Israeli sample during COVID-19.

BACKGROUND: COVID-19 is an ongoing global crisis, with a multitude of factors that affect mental health worldwide. We explored potential predictors for the emergence and maintenance of depression, anxiety, and posttraumatic stress symptoms (PTSS) in the general population in Israel. METHODS: Across the span of 16 months, 2478 people completed a repeated self-report survey which inquired psychiatric symptoms and pandemic related stress factors (PRSF). We applied mixed-effects models to assess how each stressor contributes to depression, anxiety and PTSS at each time point, and longitudinally assessed participants who completed at least two consecutive surveys (n = 400). We weighted our sample to increase representativeness of the population. RESULTS: Fatigue was the strongest predictor for depression, anxiety and PTSS at all time points, and predicted deterioration overtime. Financial concerns associated with depression and anxiety at all time points, and with their deterioration overtime. Health related concerns were uniquely associated with anxiety and PTSS at all time points and their deterioration, but not with depression. Improvement in sense of protection overtime associated with decrease in depression and anxiety. Hesitancy towards vaccination was associated to higher financial concerns and lower sense of protection by the authorities. CONCLUSIONS: Our findings accentuate the multitude of risk factors for psychiatric morbidity during COVID-19, and the centrality of fatigue in determining mental health outcomes.

Contribution of Risk and Resilience Factors to Suicidality among Mental Health-Help-Seeking Adolescent Outpatients: A Cross-Sectional Study.

BACKGROUND: Peer victimization is an established risk factor for youth suicidal thoughts and behavior (suicidality), yet most peer-victimized youth are not suicidal. More data are needed pertaining to factors that confer resilience to youth suicidality. AIM: To identify resilience factors for youth suicidality in a sample of N = 104 (Mean age 13.5 years, 56% female) outpatient mental health help-seeking adolescents. METHODS: Participants completed self-report questionnaires on their first outpatient visit, including the Ask Suicide-Screening Questions, a battery of risk (peer victimization and negative life events) and resilience (self-reliance, emotion regulation, close relationships and neighborhood) measures. RESULTS: 36.5% of participants screened positive for suicidality. Peer victimization was positively associated with suicidality (odds ratio [OR] = 3.84, 95% confidence interval [95% CI] 1.95-8.62, p < 0.001), while an overall multi-dimensional measure of resilience factors was inversely associated with suicidality (OR, 95% CI = 0.28, 0.11-0.59, p = 0.002). Nevertheless, high peer victimization was found to be associated with a greater chance of suicidality across all levels of resilience (marked by non-significant peer victimization by resilience interaction, p = 0.112). CONCLUSIONS: This study provides evidence for the protective association of resilience factors and suicidality in a psychiatric outpatient population. The findings may suggest that interventions that enhance resilience factors may mitigate suicidality risk.

Child and Adolescent Mental Health during the COVID-19 Pandemic: Challenges of Psychiatric Outpatient Clinics.

BACKGROUND: Worldwide national surveys show a rising mental health burden among children and adolescents (C&A) during COVID-19. The objective of the current study is to verify the expected rise in visits to psychiatric outpatient clinics of C&A, especially of new patients. METHODS: a cross-sectional study focusing on visits as recorded in electronic medical records of eight heterogeneous C&A psychiatric outpatient clinics. The assessment was based on visits held from March to December of 2019 (before the pandemic) in comparison to visits held in 2020 (during the pandemic). RESULTS: The number of visits was similar for both periods. However, in 2020, 17% of the visits used telepsychiatry (N = 9885). Excluding telepsychiatry reveals a monthly decrease in traditional in-person activities between 2020 and 2019 (691.6 ± 370.8 in 2020 vs. 809.1 ± 422.8 in 2019, mean difference = -117.5, t (69) = -4.07, p = 0.0002, Cohen's d = -0.30). Acceptation of new patients declined during 2020, compared to 2019 (50.0 ± 38.2 in 2020 vs. 62.8 ± 42.9 in 2019; Z = -3.12, p = 0.002, r = 0.44). Telepsychiatry was not used for new patients. CONCLUSIONS: The activity of C&A psychiatric outpatient clinics did not rise but was guarded due to the use of telepsychiatry. The decline in visits of new patients was explained by the lack of use of telepsychiatry for these patients. This calls for expanding the use of telepsychiatry, especially for new patients.

Pediatric psychiatric emergency rooms during COVID-19: a multi-center study.

BACKGROUND: The COVID-19 (SARS-CoV-2) pandemic has been a major stressor for the mental health and well-being of children and adolescents. Surveys and reports from hotlines indicate a significant rise in mental health problems. As the psychiatric emergency room (ER) is a first-line free-of-charge facility for psychiatric emergencies, we expected to see a significant increase in visits, specifically of new patients suffering from anxiety, depression, or stress-related disorders. METHODS: Data from two psychiatric hospital ERs and one general hospital were included. All visits of children and adolescents from the computerized files between March and December of 2019 were analyzed anonymously and compared to the same months in 2020, using multilevel linear modeling. RESULTS: There was a significant decline in the total number of visits (p = .017), specifically among those diagnosed as suffering from stress-related, anxiety, and mood disorder groups (p = .017), and an incline in the proportion of visits of severe mental disorders (p = .029). DISCUSSION: The limited use of child and adolescent psychiatric emergency facilities during the pandemic highlights the importance of tele-psychiatry as part of emergency services. It also suggests the importance of the timeline of the emergence of clinically relevant new psychiatric diagnoses related to the pandemic. Future studies are needed to establish the long-term effects of the pandemic and the expeditious use of tele-psychiatry.

Youth Psychiatric Hospitalization in Israel during COVID-19: A Multi-Center Study.

During the COVID-19 pandemic there have been numerous reports of increases in psychiatric morbidity and a deterioration of status among existing patients. There is little information about how this increase has affected youth and rates of adolescent psychiatric hospitalization. Our study was aimed at examining trends in youth psychiatric hospitalization during the first year of the COVID-19 pandemic. Method: We used medical records to compare trends in hospitalization rates from 2019 to 2020, among psychiatric youth wards from five different centers in Israel. Results: The number of patients that were hospitalized in youth psychiatric wards decreased significantly from 2019 (Mean ± SD=52.2 ± 28.6 per month) to 2020 (M&nbsp;± SD = 40.8 ± 22.0; unstandardized B = -11.4, 95% CI = -14.4 to -8.3, p < 0.0001). There was a significant decrease in the number of patients that were hospitalized due to internalizing disorders from 2019 (M&nbsp;± SD = 22.3 ± 9.3 per month) to 2020 (M&nbsp;± SD = 16.8 ± 7.7; B = -5.5, 95% CI = -8.0 to -3.0, p = 0.0002) and a marginally significant increase in the number of restraints per month (2019: M&nbsp;± SD = 2.8 ± 6.8, 2020: M&nbsp;± SD = 9.0 ± 14.5; Z = -1.96, Rosenthal's r = 0.36, p = 0.07). Conclusions: There was a significant decline in psychiatric hospitalizations during the pandemic, specifically among patients suffering from internalizing disorders. The reasons for this decline, and the future impact these changes had on hospitalizations during the pandemic demand further research. Study limitations: This is a retrospective multicenter study from five medical centers in Israel, therefore generalizability of our findings is limited.

Increase in Referrals of Children and Adolescents to the Psychiatric Emergency Room Is Evident Only in the Second Year of the COVID-19 Pandemic-Evaluating 9156 Visits from 2010 through 2021 in a Single Psychiatric Emergency Room.

Introduction: The COVID-19 pandemic affected the wellbeing of children and adolescents. The psychiatric emergency room (ER) is the hub of psychiatric emergencies and reflects clinically significant mental problems. Previous studies compared 2019 and 2020 and observed a decline in ER referrals. The current study focused on the continuous trend of referrals from 2010 to the end of 2021. Method: In our observational retrospective study, we procured data from 9156 child and adolescent referrals to our psychiatric ER. The comparison was made based on similar months of each year. Results: There was a significant positive trend in monthly referrals between 2010 and 2021, representing a similar increase in referrals per month in comparison to that month in the preceding year (unstandardized ß = 4.21, 95% CI = 3.44 to 4.98, p < 0.0001). Between March 2020 and February 2021 (monthly visits = 72.5 + 16.6 [median = 79.5], annual referrals = 870), we observed no additive effect beyond this general trend after controlling for population growth. Conversely, between March and December 2021 (monthly referrals = 106.1 + 31.8 [median = 105.5], overall referrals = 1061) we observed a significant additive effect beyond the projected incline, as predicted by previous years (ß = 21.61, 95% CI = 12.12 to 31.06, p < 0.0001). Conclusions: The first year of the COVID-19 pandemic was no different from the continuous decade long rise of referrals to the children and adolescents' psychiatric ER. Conversely, the second year showed an additional incline beyond the general trend. The complexity in this rising need demands the awareness of clinicians and policy makers alike.

Sleep Difficulties Among COVID-19 Frontline Healthcare Workers.

Objective: To identify COVID-19 work-related stressors and experiences associated with sleep difficulties in HCW, and to assess the role of depression and traumatic stress in this association. Methods: A cross-sectional study of HCW using self-report questionnaires, during the first peak of the pandemic in Israel (April 2020), conducted in a large tertiary medical center in Israel. Study population included 189 physicians and nurses working in designated COVID-19 wards and a comparison group of 643 HCW. Mean age of the total sample was 41.7 ± 11.1, 67% were female, 42.1% physicians, with overall mean number of years of professional experience 14.2 ± 20. The exposure was working in COVID-19 wards and related specific stressors and negative experiences. Primary outcome measurement was the Insomnia Severity Index (ISI). Secondary outcomes included the Primary Care-Post Traumatic Stress Disorder Screen (PC-PTSD-5); the Patient Health Questionnaire-9 (PHQ-9) for depression; the anxiety module of the Patient-Reported Outcomes Measurement Information System (PROMIS); Pandemic-Related Stress Factors (PRSF) and witnessing patient suffering and death. Results: Compared with non-COVID-19 HCW, COVID-19 HCW were more likely to be male (41.3% vs. 30.7%) and younger (36.91 ± 8.81 vs. 43.14 ± 11.35 years). COVID-19 HCW reported higher prevalence of sleep difficulties: 63% vs. 50.7% in the non-COVID group (OR 1.62, 95% CI 1.15-2.29, p = 0.006), mostly difficulty maintaining sleep: 26.5% vs. 18.5% (OR 1.65, 95% CI 1.11-2.44, p = 0.012). Negative COVID-19 work-related experiences, specifically witnessing patient physical suffering and death, partially explained the association. Although past psychological problems and current depression and PTSD were associated with difficulty maintaining sleep, the main association remained robust also after controlling for those conditions in the full model. Conclusion and Relevance: COVID-19 frontline HCW were more likely to report sleep difficulties, mainly difficulty maintaining sleep, as compared with non-COVID-19 HCW working at the same hospital. Negative patient-care related experiences likely mediated the increased probability for those difficulties. Future research is needed to elucidate the long-term trajectories of sleep difficulties among HCW during large scale outbreaks, and to identify risk factors for their persistence.

Left alone outside: A prospective observational cohort study on mental health outcomes among relatives of COVID-19 hospitalized patients.

Hospitalization due to COVID-19 bears many psychological challenges. While focusing on infected patients, their relatives are being largely neglected. Here, we investigated the mental health implications of hospitalization among relatives, over a one-month course. A single center study was conducted to assess relatives of COVID-19 patients during the first month from their admission to the hospital, and elucidate risk and protective factors for mental health deterioration. Ninety-one relatives of the first patients to be hospitalized in Israel were contacted by phone and screened for anxiety, depression, and posttraumatic stress symptoms (PTSS) at three time points (25-72 hours, 7-18 days, and one month). We found that anxiety and depression decreased significantly during the first month from their admission. Risk factors for deteriorated mental health at one month included feelings of mental exhaustion, financial concerns, and social disconnection. Being an ultra-orthodox was a protective factor for anxiety and depression but not for PTSS. Our findings emphasize the importance of addressing the mental health status of close relatives and adjust support for the unique setting of COVID-19.

Association among income loss, financial strain and depressive symptoms during COVID-19: Evidence from two longitudinal studies.

BACKGROUND: COVID-19 pandemic has major ramifications for global health and economy, with growing concerns about economic recession and implications for mental health. Here we investigated the associations between pandemic-related income loss with financial strain and mental health trajectories over a 1-month course, in two independent cohorts. METHODS: Two independent studies were conducted in the U.S and in Israel at the beginning of the outbreak (March-April 2020, T1; study I: N = 2904, study II: N = 1267) and at a 1-month follow-up (T2; study I: N = 1318, study II: N = 241). Mixed-effects models were applied to assess associations among COVID-19-related income loss, financial strain, and pandemic-related worries about health, with anxiety and depression, controlling for multiple covariates including pre-COVID-19 income. RESULTS: In both studies, income loss and financial strain were associated with greater depressive symptoms at T1, above and beyond T1 anxiety, worries about health, and pre-COVID-19 income. Worsening of income loss was associated with exacerbation of depression at T2 in both studies. Worsening of subjective financial strain was associated with exacerbation of depression at T2 in one study (US). CONCLUSIONS: Income loss and financial strain were uniquely associated with depressive symptoms and their exacerbation over time, above and beyond pandemic-related anxiety. In times when a myriad of stressors are affecting mental health worldwide, our findings reveal specific links between the economic impact of COVID-19 and psychiatric outcomes.

Trajectories of post-traumatic stress symptoms, anxiety, and depression in hospitalized COVID-19 patients: A one-month follow-up.

OBJECTIVES: Little is known about the mental health outcomes of hospitalized COVID-19 patients. The aims of the study were: (1) to examine the trajectories of anxiety, depression, and pandemic-related stress factors (PRSF) of COVID-19 hospitalized patients one-month following hospitalization; (2) to assess the presence of post-traumatic stress symptoms (PTSS) a month after hospitalization; (3) to identify baseline risk and protective factors that would predict PTSS one month after hospitalization. METHODS: We contacted hospitalized COVID-19 patients (n = 64) by phone, at three time-points: during the first days after admission to the hospital (T1); after ~two weeks from the beginning of hospitalization (T2), and one month after hospitalization (T3). At all time-points we assessed the levels of anxiety and depression symptoms, as well as PRSF. At T3, PTSS were assessed. RESULTS: The levels of depressive and anxiety symptoms decreased one-month following hospitalization. Moreover, higher levels of anxiety (standardized ß = 1.15, 95% CI = 0.81-1.49, p < 0.001) and depression (ß = 0.97, 95% CI = 0.63-1.31 p < 0.001) symptoms during the first week of hospitalization, feeling socially disconnected (ß = 0.59, 95% CI = 0.37-0.81 p < 0.001) and experiencing a longer hospitalization period (ß = 0.25, 95% CI = 0.03-0.47 p = 0.026) predicted higher PTSS scores a month post-hospitalization. CONCLUSIONS: We identified early hospitalization risk factors for the development of PTSS one month after hospitalization that should be targeted to reduce the risk for PTSS.

The association between witnessing patient death and mental health outcomes in frontline COVID-19 healthcare workers.

BACKGROUND: Healthcare workers (HCW) treating coronavirus disease 2019 (COVID-19) patients face high levels of psychological stress. We aimed to compare mental health outcomes, risk and protective factors for posttraumatic stress symptoms (PTSS), probable depression, and anxiety between HCW working in COVID-19 and non-COVID-19 wards. METHODS: A self-report survey, administered in a large tertiary hospital in Israel during the peak of the COVID-19 outbreak was completed by 828 HCW (42.2% physicians, 57.8% nurses. Patient-Reported Outcomes Measurement Information System; the Patient Health Questionnaire-9; the Primary Care-Post Traumatic Stress Disorder Screen for DSM-5 (PC-PTSD-5) were used for assessing anxiety, depression, and PTSS, respectively. Pandemic-related stress factors, negative experiences, and potential protective factors were also assessed. RESULTS: Median PC-PTSD scores differed significantly between study teams (χ2 [5] = 17.24; p = .004). Prevalence of probable depression and anxiety were similar in both groups. Risk factors for mental health outcomes included mental exhaustion, anxiety about being infected and infecting family. Overall, higher proportion of the COVID-19 team witnessed patient deaths as compared to the non-COVID-19 team (50.2% vs. 24.7%). Witnessing patient death at the COVID-19 wards was associated with a four-fold increased likelihood of PTSS (odds ratio [OR] = 3.97; 95% confidence interval [CI], 1.58-9.99; p = .0007), compared with the non-COVID-19 wards (OR 0.91; 95% CI, 0.51-1.61; p = .43). CONCLUSIONS: Witnessing patient death appears to be a risk factor for PTSS unique to HCW directly engaged in treating patients with COVID-19. Our findings suggest that helping HCW cope with COVID-19 related deaths might reduce their risk of posttraumatic stress.

Obsessive compulsive symptoms severity among children and adolescents during COVID-19 first wave in Israel .

Several current publications have considered persons with obsessive compulsive disorder (OCD) as particularly vulnerable during the COVID-19 period, and to require more frequent symptom monitoring. The purpose of this study was to evaluate whether OCD exacerbated during the first wave of COVID-19 in children and adolescents. Twenty-nine children and adolescents with OCD were evaluated in the midst of the first outbreak of the COVID-19 pandemic in Israel (April-May 2020). Obsessive-compulsive symptoms (OCS) were assessed using the Clinical Global Impression Scale (CGI), by means of a functional questionnaire and by the Obsessive-Compulsive Inventory-child version (OCI-CV) questionnaires. Obsessive-compulsive symptoms were not found to have exacerbated during the period investigated, as evident by a lack of change in CGI severity scores and by improvement rather than deterioration among more participants, based on the CGI improvement scores. Additionally, the children and adolescents reported better general functioning during the COVID-19 period and had relatively low scores on the OCI-CV scale. Our findings indicate that Israeli children and adolescents with OCD coped well with COVID-19 during the first two months of the pandemic and mostly did not experience exacerbation of OCS. However, due to the short duration of exposure to the pandemic at the time of the study, social isolation and lockdown might have masked OCS; thus, further longitudinal studies are needed.

Anxiety and Depression Symptoms in COVID-19 Isolated Patients and in Their Relatives.

Background: While focusing on the management and care of COVID-19 patients, the mental health of these patients and their relatives is being overlooked. The aim of the current study was to measure anxiety and depression, and to assess their association with socio-demographic and pandemic-related stress factors in COVID-19 patients and their relatives during the initial stage of hospitalization. Methods: We assessed isolated hospitalized patients (N = 90) and their relatives (adults and children, N = 125) by phone, 25-72 h following patients' admission. The quantitative measures included the Anxiety and Depression modules of the Patient-Reported Outcomes Measurement Information System (PROMIS) and pandemic-related stress factors. Qualitative measures included questions exploring worries, sadness, and coping modes. Results: Both patients and relatives suffer from high levels of anxiety and related pandemic worries, with lower levels of depressive symptoms. Compared to adult relatives, child relatives reported significantly lower anxiety. The multivariable logistic regression analysis revealed an increased risk for anxiety among females and a decreased risk among ultra-orthodox participants. While increased anxiety among patients was associated with feelings of isolation, increased anxiety among relatives was associated with a feeling of not being protected by the hospital. Conclusions: Patients and relatives experience similar high anxiety levels which are more robust in women and lower in ultra-orthodox participants. Our findings indicate that anxiety symptoms of both patients and adult relatives should be addressed.

Anxiety, pandemic-related stress and resilience among physicians during the COVID-19 pandemic.

BACKGROUND: Physicians play a crucial frontline role in the COVID-19 pandemic, which may involve high levels of anxiety. We aimed to investigate the association between pandemic-related stress factors (PRSF) and anxiety and to evaluate the potential effect of resilience on anxiety among physicians. METHODS: A self-report digital survey was completed by 1106 Israeli physicians (564 males and 542 females) during the COVID-19 outbreak. Anxiety was measured by the 8-item version of the Patient-Reported Outcomes Measurement Information System. Resilience was evaluated by the 10-item Connor-Davidson Resilience Scale. Stress was assessed using a PRSF inventory. RESULTS: Physicians reported high levels of anxiety with a mean score of 59.20 ± 7.95. We found an inverse association between resilience and anxiety. Four salient PRSF (mental exhaustion, anxiety about being infected, anxiety infecting family members, and sleep difficulties) positively associated with anxiety scores. CONCLUSIONS: Our study identified specific PRSF including workload burden and fear of infection that are associated with increased anxiety and resilience that is associated with reduced anxiety among physicians.