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Comparison of Self-harm or Overdose Among Adolescents and Young Adults Before vs During the COVID-19 Pandemic in Ontario

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  What was the risk of self-harm or overdose among adolescents and young adults in Ontario, Canada, during the SARS-CoV-2 pandemic compared with the 2 years preceding?

Findings  In this cohort study of 1 690 733 adolescents and young adults in all of Ontario, the rate of self-harm or overdose was lower during (39.7 per 10 000 person-years) than before (51.0 per 10 000 person-years) the pandemic.

Meaning  At least up to mid-2021, the COVID-19 pandemic has not been associated with an excess of self-harm requiring health care among adolescents and young adults.


Importance  Self-harm and deaths among adolescents and young adults are notably related to drug poisonings and suicide. With the emergence of the COVID-19 pandemic, there are projections about a greater likelihood of such events arising among adolescents and young adults.

Objective  To evaluate the risk of self-harm, overdose, and all-cause mortality among adolescents and young adults during the COVID-19 pandemic.

Design, Setting, and Participants  This population-based cohort study took place in Ontario, Canada, where a universal health care system captures all emergency department (ED) visits, hospitalizations, and deaths. The participants included all adolescents and young adults born in Ontario between 1990 and 2006, who were aged 14 to 24 years between March 1, 2018, and June 30, 2021.

Exposures  The COVID-19 pandemic era (April 1, 2020 to June 30, 2021), relative to the 2 years preceding the pandemic (March 1, 2018 to February 28, 2020).

Main Outcomes and Measures  ED encounters or hospitalizations for self-harm or overdose. A secondary outcome was self-harm, overdose, or all-cause mortality. Cause-specific hazard models to estimate hazard ratios (HR) and 95% CIs were used for the primary outcome. Follow-up started at March 1, 2018, or the individual’s 14th birthday, whichever was later, and age was used as the time scale.

Results  In this study, 1 690 733 adolescents and young adults (823 904 [51.3%] female participants) were included with a median (IQR) age of 17.7 (14.1-21.4) years at start of follow-up. After 4 110 903 person-years of follow-up, 6224 adolescents and young adults experienced the primary outcome of self-harm or overdose during the pandemic (39.7 per 10 000 person-years) vs 12 970 (51.0 per 10 000 person-years) prepandemic, with an HR of 0.78 (95% CI, 0.75-0.80). The risk of self-harm, overdose, or death was also lower during than before the pandemic (HR, 0.78; 95% CI, 0.76-0.81), but not all-cause mortality (HR, 0.95; 95% CI, 0.86-1.05).

Conclusions and Relevance  Among adolescents and young adults, the initial 15-month period of the COVID-19 pandemic was associated with a relative decline in hospital care for self-harm or overdose.

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Article Information

Accepted for Publication: November 16, 2021.

Published: January 12, 2022. doi:10.1001/jamanetworkopen.2021.43144

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Ray JG et al. JAMA Network Open.

Corresponding Author: Joel G. Ray, MD, MSc, Departments of Medicine and Obstetrics and Gynaecology, St Michael’s Hospital, University of Toronto, 30 Bond St, Toronto, ON M5B 1W8, Canada (

Author Contributions: Ms Park had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Ray, Guttmann, Park.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Ray, Aflaki, Park.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Ray, Aflaki, Park.

Obtained funding: Ray.

Other - Statistical input: Austin.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was funded by a grant from the Ontario Academic Health Sciences Centre AFP Innovation Fund. This study was also supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health (MOH) and the Ministry of Long-Term Care (MLTC). This study also received funding the Canadian Institutes of Health Research (CIHR). Dr Austin is supported by a Mid-Career Investigator Award from the Heart and Stroke Foundation.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The analyses, conclusions, opinions and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred.

Additional Information: Parts of this material are based on data and information compiled and provided by the MOH and Canadian Institute for Health Information. The dataset from this study is held securely in coded form at ICES. While legal data sharing agreements between ICES and data providers (eg, healthcare organizations and government) prohibit ICES from making the dataset publicly available, access may be granted to those who meet prespecified criteria for confidential access. The full dataset creation plan and underlying analytic code are available from the authors upon request, understanding that the computer programs may rely upon coding templates or macros that are unique to ICES and be either inaccessible or may require modification.

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