The COVID-19 pandemic is having a psychological impact on individuals. The COVID-19 outbreak and lockdown may have multiple consequences on the lives of adolescents. Social relations are disrupted and the individuals are staying at home. Worry for their families, unexpected bereavements, sudden school break, and home confinement in many countries may contribute to acute and chronic stress modulated by an increased time of access to the Internet and social media.1 It is possible that pre-existing psychosocial vulnerabilities (child victimization, socioeconomic disadvantage, history of psychopathology) amplify the detrimental impact of the COVID-19 pandemic on the mental health of young people, thus widening the already evident risk inequalities among the population and increasing the complexity of the clinical presentation.2

Suicide attempts are undertaken most frequently by young people, especially by teenage girls and young women. In fact, suicide is the second leading cause of death in adolescents between the ages of 15 and 19.3 The ratio of suicide in this age group increased significantly in the last few years. Phenomena which are of special importance for the prevention of suicide among adolescents include suicidal thoughts, attempted suicide, and completed suicide.4 A mainstay in the identification and management of youth at risk for suicide is the use of suicide risk factors, such as past suicide attempts, past or current suicidal ideation, mood disorders, substance use disorders, psychosis, male gender, and lack of family support. A history of at least one medically serious suicide attempt or violent self-harm is a particularly important risk factor.5

Epidemics may be linked to increased suicide rates6 but there are few studies on suicidal behavior in young people in a pandemic situation in Spain.7 It is worth highlighting a study carried out in Catalonia between March 2020 and March 2021, an increase of 25% in suicide attempts in young people was observed, while in adults it decreased by 16.5%. The increase of suicide attempts in girls was especially prominent in the starting school period in the COVID-year (September 2020–March 2021), where the increase reached 195%.8

In short, the COVID 19 pandemic can impact the mental health of the youngest, being a prolonged sequel to the pandemic situation. The objective of this study is to evaluate the impact that the COVID 19 pandemic may have had on the reasons for the urgent care of patients youngest, comparing the reasons for care with those from a previous period and to assess whether there was an increase in suicidal behavior among the youngest.

This study shows higher changes in child and adolescent visits to the Psychiatry Emergency Department during the second state of alarm in Spain, suggesting a long-term effect of COVID19 pandemic in this vulnerable population. We found an increase in the psychiatric visits of young patients in the second state of alarm. In this period patients were younger, had less psychiatric history and their living conditions changed with an increase of those living with relatives and a decrease of institutionalized patients. Furthermore, we found a change in the clinical picture of the second state of alarm with more anxious decompensations and less behavioral disturbances in the chief complain and less patients with cluster B disorder in axis II, all in the second state of alarm. In axis I we found a decrease in childhood-onset disorders in both states of alarm. Analyzing suicidality, we found a trend to higher rates in both states of alarm with no statistical significance. Having a diagnosis of depression, live with relatives and being a woman were independent risk factor for suicidal behavior in our sample.

Our observations of an increase of young people visited in psychiatry emergency department with younger age and no previous psychiatric history, are consistent with the Center for Disease Control and Prevention data.14 They showed that mental health related visits in 2020 increased by 24% in ages 5–11 and 31% in ages 12–17 when compared to 2019 data.15 A preliminary review already warned that depressive and anxiety symptoms would increase in children and adolescents.15 Our results showed a change in the chief of complain with an increase in the of young people due to anxiety symptoms and a decrease in personality disorders and behavioral alterations. These results are consistent with those found in preliminary studies from Asia where a cross-sectional survey of 1784 primary school children (77% of 2330 surveyed) from Wuhan and Huangshi after 30 days of home confinement showed that symptom rates depression and anxiety were elevated compared to previous surveys.16 Other preliminary studies supported the emergence of anxiety and depression symptoms through another cross-sectional survey of 8079 middle and high school students (99% of 8140 respondents) from 21 provinces and autonomous regions, again showing high rates of depressive and anxiety symptoms. We did not find significant associations with regard to gender, but some authors have associated higher levels of anxiety and depression with young women.17

Young people in our study population were admitted to the hospital in a lower proportion during the first lockdown. The bibliography in this regard is limited without being able to establish the repercussion in the field of hospitalization.18 This aspect is probably related to the decrease in the total number of available beds, the imposition of greater restrictions on admission and the reduction in the duration of admission.19

In our study, we observed that patients who lived with relatives attended the emergency department more, especially during the second state of alarm. The literature is ambiguous on this. On the one hand, it is pointed out that the fact of having relatives and perceiving their proximity is a factor related to greater resilience to withstand the pandemic.20,21 In fact, some authors reported that children who were isolated or quarantined during pandemic illnesses were more likely to develop acute stress disorder, adjustment and bereavement disorder. 30% of the children who were isolated or quarantined met the clinical criteria for post-traumatic stress disorder.22 But, on the other hand, a novel study conducted in Canada on the psychological impact of the pandemic on families revealed that the majority experienced symptoms of anxiety above the threshold, depression and family dysfunction.23 Another Australian study also warned of far-reaching detrimental family impacts associated with the COVID-19 pandemic.24 Although we have not shown an increase in institutionalized adolescents or those at risk of social exclusion, some authors have pointed out the special vulnerability of specific groups.25

In our sample, both in the first and in the second state of alarm, visits to psychiatric emergencies due to suicidal ideation increased but no statistical significance was reached. Other studies have already shown that there was an increase in young patients who tested positive for suicidality and suicide risk.26 It is relevant to pay close attention to suicidal ideation in younger patients since the existing literature has not been able to accurately approximate the longitudinal trajectory of suicidal ideation in the young population.27 However, existing research indicates that suicidal ideation in adolescents is strongly related to age, with ideation increasing during early adolescence, with an average age of onset between 10 and 15 years.28

When we specifically analyze the young people who consulted for suicidal behavior, we observed that, after logistic regression, it was associated with being a woman, living with relatives and presenting a history of depression. Existing literature suggests that the prevalence rate of suicidal ideation varies by sex, so that more young women, compared to young men, experience more suicidal ideation during adolescence.28 However, it is young boys who are most likely to commit suicide.29 Despite this knowledge, there is little research examining the nature of these gender differences. Family functioning has also been identified as important to consider when quantifying the risk of suicidal ideation in this age group. Family dysfunction has been consistently correlated with suicidal ideation30 and many findings suggest that youth exposed to adverse, dysfunctional, or abusive home environments are at significantly increased risk of subsequent suicidal behavior, including suicidal ideation.31 As in our results, there are previous studies that indicate depression as a risk predictor of suicide attempt in adolescents who report suicidal ideation.28 In our study, the young people who attended due to suicidal behavior were admitted more to the psychiatric unit, this aspect being a consequence of the behavior referred to. There are not many studies on hospitalizations for suicide attempt during the pandemic, but a recent French study revealed that hospitalizations for suicidal behavior in adults in France decreased during 2020.32

Our findings highlight a long-term impact on child and adolescent mental health showing a change in the clinical picture of the population visited in the second state of alarm at the psychiatric emergency department. We see an increase of the visits of this population, getting younger and with les psychiatry history. Regarding care for suicidal behavior, these were associated with being a woman, living with relatives and presenting depression. Altogether, our findings call for the public health system and stakeholders to implement durable measures in youngsters focused on prevention, promotion and care during COVID-19 times.

The authors affirm that all the procedures that contribute to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Declaration of Helsinki of 1975, revised in 2008. This work was evaluated and approved by the Commission of Ethics and Clinical Research of the Arnau de Vilanova University Hospital.

All authors declare that they have no conflict of interest in relation to the performance of this work.