Impact of the Coronavirus Disease 2019 Pandemic on Mental Health Visits in Pediatric Primary Care Free

The Pediatric Physicians’ Organization at Children’s (PPOC) is an independent practice association affiliated with Boston Children’s Hospital. The PPOC is comprised of over 500 pediatric primary care physicians, nurse practitioners, and physician assistants in 77 primary care practices across Massachusetts. We analyzed electronic health record data to understand the impact of the COVID-19 pandemic on visit frequency for pediatric mental health conditions. This project was reviewed by the Boston Children’s Hospital Committee on Clinical Investigation and deemed exempt from the requirement for individual informed consent.

The population for this study includes over 310 000 patients from all 73 PPOC practices that were continuously in the network throughout the study period (11 other practices either joined or left the network during the study period and thus were excluded from the analysis). The study practices consist of 499 primary care providers (69% physicians and 31% nurse practitioners or physician assistants); the majority of practices have 3 or more primary care providers (72%) and are located in suburban towns (63%).¹⁵  As compared with the pediatric population of Massachusetts, patients seeking care at these practices were more likely to be commercially insured (71% vs 64%), equally likely to be male (both 51%), and less likely to be white (55% vs 63%), or Hispanic (9% vs 19%)^16,17  (Table 1).

Patients included in this sample were limited to ages 5 to 17 years (as calculated at each monthly time point). The analysis included visits, conducted in-person or via telehealth, with a physician, nurse practitioner, or physician assistant between January 1, 2019 and September 30, 2021 where any mental health visit diagnosis was assigned by the provider using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). Seven mental health diagnosis categories were defined: alcohol and substance use disorders (F10.×−F19.×); anxiety disorders (F40.×−F42.×); attention-deficit hyperactivity disorders (ADHD) (F90.×); behavior disorders (F63.×, F91.×,); eating disorders (F50.×); mood disorders (depressive and bipolar disorders) (F30.×−34.×, F39.×); and stress or trauma disorders (F43.×). As every billable encounter in our network is required to have an associated ICD-10 code, there were no encounters with missing data.

We conducted an interrupted time series analysis examining the impact of the COVID-19 pandemic on visit frequency for each of the 7 mental health categories.¹⁸  To compare data before and during the pandemic, we defined 3 time periods: the prepandemic period from January 2019 through February 2020; the emergency pandemic period from March 2020 through May 2020 (state of emergency declared, business closures, and stay-at-home advisory); and the pandemic period from June 2020 through September 2021. Monthly in-network visitation rates were annualized for each diagnostic category and analyzed for changes in level and slope from the prepandemic to pandemic period. Autocorrelation among data points was assessed using the Durbin-Watson statistic; when significant autocorrelation was found, autoregressive parameters were included in the model. All data were analyzed using SAS statistical software, version 9.4 (SAS Institute, Cary, North Carolina).

Data from the immediate emergency pandemic period (March–May 2020) were excluded from the analysis as it is common practice in ITS analyses to exclude periods of time with unstable, temporary changes.¹⁸  Medical visit frequency during this time period was down across all conditions, likely because of the stay-at-home advisory and fears of contracting COVID-19 from a healthcare setting; it was not until the summer that we saw in-person visits start to normalize.

As compared with visit frequency in the prepandemic period, visit frequency in the pandemic period differed for 3 of the 7 mental health visit categories (Table 2 and Fig 1). Significant decreases in both level and slope (both P < .001) were observed for alcohol and substance use disorder visits, where the annualized visit rate decreased from an average of 5.8 visits per 1000 patients per year in the prepandemic period to 5.5 in the pandemic period. A significant increase in slope (P < .001) was observed for eating disorder visits, with the visit rate increasing from an average of 9.3 visits per 1000 patients a year to 18.3. A significant increase in slope (P < .001) was also observed for mood disorder visits, where the visit rate increased from 65.3 visits per 1000 patients per year to 94.0. No significant changes were observed for anxiety disorder visits or for stress or trauma disorder visits between the prepandemic and pandemic periods; however, an increasing secular trend, which started before the pandemic, was observed over time in both visit categories. For anxiety, the average visit rate of 156.1 visits per 1000 patients per year in the prepandemic period increased to 210 in the pandemic period, and for stress or trauma, the average visit rate of 28.2 visits per 1000 patients per year in the prepandemic period increased to 39.3 in the pandemic period for stress or trauma. No significant changes were observed for ADHD visits, with an average visit rate of 211.1 visits per 1000 patients per year in the prepandemic period and 216.5 in the pandemic period. There was also no significant change in behavior disorder visits; the visit rate remained effectively unchanged from 10.1 visits per 1000 patients per year in the prepandemic period to 10.0 in the pandemic period.

Our findings describe the associations between the COVID-19 pandemic and mental health visit frequency for children and adolescents to pediatric primary care providers across Massachusetts. Visit frequency changes during the study period varied markedly by mental health disorder. Notably, the prepandemic baseline visit frequencies for anxiety disorders, alcohol and substance use disorders, and stress or trauma disorders were not stable and, for all conditions, were rising before the pandemic.

The most dramatic change in visit patterns occurred for eating disorders. In the year before the pandemic, the annualized rate for eating disorders was quite steady at ∼9 visits per 1000 patients per year, but began to rise precipitously during the pandemic period, essentially doubling in annualized frequency. These findings concur with other recent studies showing an increase in adolescent hospital care for eating disorders,^19,20  as well as a survey study where mostly adult respondents attributed the exacerbation to triggering environments (specifically COVID-19 stockpiling of high-risk foods with resultant weight gain), lack of social supports, and lack of structure.²¹  A meta-analysis on eating disorders among adults during COVID-19 also found studies ascribing the increase to a lack of access to care, reduced ability to exercise, and excessive exposure to triggering messages in social media.⁹  Another potential explanation, especially for a pediatric population, is that greater time spent at home with parents and caregivers could have led to greater detection of disordered eating patterns that might have otherwise remained hidden.

A similar pattern of change to that of eating disorders was also observed among mood disorders with a fairly level baseline before the pandemic and a nearly 50% increase in visits for such conditions during the pandemic period. This finding concurs with multiple studies among youth showing increased depression during COVID-19 presumably because of social isolation and a disruption to daily activities, as well as studies showing an increase in psychological distress for adults with bipolar disorder.^22–25 

We detected a significant change in the opposite direction for alcohol and substance use disorder visits, where the average visit rate significantly decreased during the pandemic period. We hypothesize that because of emergency pandemic measures, the pediatric and adolescent population may have lost access to substances because of a decrease in peer social interactions. It is also possible that, beyond access to substances, pediatric use of alcohol and substances was reduced because of an increase in time at home with supervision and interaction with parents and caregivers; indeed, a recent study among college students found lower alcohol use with perceived social support.²⁶  Alternatively, since this was the only category of visits where we detected a significant decrease, it is possible that the prevalence of substance use itself did not actually decrease but the detection and diagnosis by primary care clinicians did. Interestingly, our finding of a decrease in substance use diagnoses among children and adolescents is contrary to findings in adults. Studies have reported significant increases in alcohol and drug use during COVID-19, highlighting possible differences in coping mechanisms for adults versus youth and the potential protective family factors for youth throughout the pandemic.²⁷ 

Potential inverse explanations can be offered for alcohol and substance use disorders and eating disorders: although both conditions are associated with disordered consumption, home time and a restrictive environment may have been protecting against alcohol and substance use disorders while exacerbating eating disorders or, at least, the detection of them by observing caregivers. Additional research is needed to confirm these inverse relationships and more broadly disentangle the intricacies of each disorder in this unique circumstance, specifically the exacerbating versus protective factors.

Our analysis did not indicate the same significant increases in anxiety disorder visits and stress or trauma disorder visits throughout the pandemic period that have been reported in other studies.^8,28  However, many of these studies present cross-sectional data collected at the onset of the pandemic and/or soon after specific events, such as a return to school, whereas our analysis includes longitudinal data reflecting 16 months of the pandemic period. Many other studies also rely on visit data from other sources, such as emergency departments and hospitals. Primary care presentations likely represent the milder (eg, less detectable) end of the spectrum of mental health problems, whereas hospitalizations and emergency department visits likely represent the more severe end. Moreover, the primary behavioral health screening tool used by our medical clinicians is the Pediatric Symptom Checklist,²⁹  which is geared more toward identifying behavior and attention problems and depression, as opposed to anxiety.

As mentioned, these data highlight the prepandemic trend toward increasing visits for anxiety disorder and stress or trauma disorder with a continued increase at essentially the same rate throughout the pandemic. We hypothesize, based on our clinical experience, that the pandemic has had varying effects depending on the type of anxiety suffered by different youth. For some, missing school and social interactions has increased anxiety-related symptoms (eg, “fear of missing out”), whereas for others who suffer primarily from social anxiety, virtual schooling and the cessation of social activities during the pandemic may have actually relieved some of their symptoms.³⁰  It appears in sum that these competing factors may have balanced one another out.

There were no significant changes in ADHD and behavior disorder visit frequencies between the prepandemic and pandemic periods. A recent study showed that adolescents with ADHD had less perceived stress surrounding COVID-19 than peers without ADHD and that the use of routines and an increase in coping behaviors were protective factors for adolescents with ADHD throughout 2020.³¹  Similarly to patients with anxiety, some patients with ADHD may have also experienced the protective benefits of virtual schooling with more time at home and less time at school, which may have included negative social experiences.³²  Alternatively, ADHD and behavior problems may have been underreported, as these disorders are often most problematic (and typically first detected) in the in-person school setting.

Our findings highlight the complex relationship between the COVID-19 pandemic and the mental health of children and adolescents. In addition to the direct impact of the pandemic, such as the closing of schools and isolation from peers, confounding factors that potentially contribute to the complexity of the relationship include vulnerabilities, such as low household income, racial injustice, and, perhaps most importantly, the quality of relationships at home. Indeed, high quality familial relationships have been shown to foster resilience and support children’s ability to cope with disasters.³³  However, many parents and caregivers, especially those deemed “essential workers,” were required to report to work throughout the pandemic and thus unable to stay home with their children, placing their children at heightened risk for adverse sequelae.

The results of this study underscore the importance of the primary care medical home as the first point of contact for children and adolescents suffering from mental health conditions, whether in the context of the current pandemic or otherwise.²⁵  Therefore, appropriate investment in building competence among primary care clinicians to identify and manage mental health conditions in children and adolescents would seem to be important.³⁴  Steps in this direction may include policy changes to elevate the minimum educational standards for medical students and residents in the recognition and management of mental health conditions and enhance professional development opportunities for currently-practicing primary care clinicians. Additionally, policy changes and financial investment are needed to expand mental health treatment options beyond the primary care setting for more severe cases of these disorders,³⁵  perhaps through more robust recruitment of mental health providers, tuition forgiveness programs, and/or investment in mental health facilities that can provide more intensive services to children and adolescents in need.

Our analysis has certain limitations: first, these data represent primary care visits within privately owned pediatric practices in Massachusetts, and our findings may not be generalizable to children and adolescents cared for in other settings or geographic regions. Second, mental health diagnoses were coded by medical providers using the ICD-10-CM, which may not directly align with other diagnostic systems, including the Diagnostic and Statistical Manual of Mental Disorders primarily used by mental health providers. Third, our network includes a robust integrated behavioral health program that has been in place for several years^36,37 ; it is possible that the visit patterns we observed would be different in settings without similar services in place. Finally, our network first launched telehealth virtual visits at the start of the emergency pandemic period (March 2020)—how the availability of virtual visits would have affected mental health encounters absent the pandemic is unknown; however, studies have generally shown that the introduction of telehealth visits has resulted in comparable or modestly increased frequency of visits.^38–40  Notably, a fundamental strength of our study includes the use of longitudinal data, which addresses one of the main limitations of many other studies.

The COVID-19 pandemic has resulted in significant changes in the pattern of visits to primary care offices for mental health conditions in children and adolescents: most notably, striking increases in visits for eating disorders and mood disorders. Conversely, visits for alcohol and substance use disorders declined during the pandemic period. Additional research analyzing longitudinal data are needed to further understand the long-term impact of COVID-19 on youth mental health.

COVID-19

coronavirus disease 2019