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Coronavirus (COVID-19)

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

Educational Objective
To identify the key insights or developments described in this article

1 Credit CME

JAMA Psychiatry

Published Online: March 16, 2022

Original Investigation

Article Information and Disclosures

Author Affiliations

¹National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia
²Center for Surveillance, Epidemiology, and Laboratory Services, US Centers for Disease Control and Prevention, Atlanta, Georgia
³National Center for Chronic Disease Prevention and Health Promotion, US Centers for Disease Control and Prevention, Atlanta, Georgia
⁴Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee
⁵Epidemic Intelligence Service, US Centers for Disease Control and Prevention, Atlanta, Georgia
⁶National Center on Birth Defects and Developmental Disabilities, US Centers for Disease Control and Prevention, Atlanta, Georgia
⁷Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, Georgia
⁸ICF International, Atlanta, Georgia
⁹InductiveHealth Informatics, Ottawa, Kansas
¹⁰Deloitte, Atlanta, Georgia
¹¹Office of Minority Health and Health Equity, US Centers for Disease Control and Prevention, Atlanta, Georgia

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Key Points

Question How have adult mental health (MH)–related emergency department (ED) visits changed during the COVID-19 pandemic?

Findings In this cross-sectional study of 107 761 319 eligible ED visits, MH-related visit count findings depended on the COVID-19 pandemic period examined, whether this was compared with other periods in the pandemic or prepandemic period, and which mental disorder was examined. There was between- and within-group variation in ED visits by race and ethnicity, which varied by pandemic period examined, and there were increases in some disorders after COVID-19 case peaks for adults aged 18 to 24 years.

Meaning Results of this study suggest that EDs may have increases in MH-related visits after COVID-19 surges, especially for young adults and some racial and ethnic minoritized subpopulations.

Abstract

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.

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Article Information

Accepted for Publication: January 24, 2022.

Published Online: March 16, 2022. doi:10.1001/jamapsychiatry.2022.0164

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

Corresponding Author: Kayla N. Anderson, PhD, National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention, 4770 Buford Hwy, MS S106-10, Atlanta, GA 30341 (kanderson5@cdc.gov).

Author Contributions: Mr Sheppard and Dr Adjemian had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Njai and Thomas contributed equally to this work as co–senior authors.

Concept and design: Anderson, Radhakrishnan, Lane, Hartnett, Adjemian, Rodgers, Njai.

Acquisition, analysis, or interpretation of data: Anderson, Radhakrishnan, Sheppard, DeVies, Azondekon, Smith, Bitsko, Hartnett, Lopes Cardozo, Leeb, van Santen, Carey, Crossen, Dias, Wotiz, Adjemian, Thomas.

Drafting of the manuscript: Anderson, Radhakrishnan, Lane, Leeb, Adjemian, Njai.

Critical revision of the manuscript for important intellectual content: Anderson, Radhakrishnan, Sheppard, DeVies, Azondekon, Smith, Bitsko, Hartnett, Lopes Cardozo, Leeb, van Santen, Carey, Crossen, Dias, Wotiz, Adjemian, Rodgers, Njai, Thomas.

Statistical analysis: Sheppard, DeVies, Azondekon, Smith, van Santen, Crossen, Dias, Wotiz, Adjemian.

Obtained funding: Adjemian.

Administrative, technical, or material support: Anderson, Radhakrishnan, Lane, Azondekon, Lopes Cardozo, Crossen, Adjemian, Rodgers, Njai.

Supervision: Anderson, Radhakrishnan, Hartnett, Adjemian, Rodgers, Thomas.

Conflict of Interest Disclosures: None reported.

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the US Centers for Disease Control and Prevention.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.