Mental Disorders in Minors During the COVID-19 Pandemic

An Analysis of Nationwide Hospital Treatment Data

The COVID-19 pandemic and the measures to contain it affected the mental health of children and adolescents (1). Affective disorders in minors have increased, which was also seen in the outpatient setting (2). At the start of the pandemic, strong reductions in case numbers in the inpatient sector were reported on the one hand, and lacking treatment capacity on the other hand (3).

We investigated how under pandemic conditions:

• Trends in the nationwide case numbers in inpatient care for mentally ill minors developed, and
• Whether the diagnostic spectrum changed.

Methods

We analyzed on the basis of nationwide hospital treatment data (dataset according to §21 German Hospital Financing Act [KHG], Institut für das Entgeltsystem im Krankenhaus [the institute for the remuneration system in hospitals, InEK] with permission from the Federal Ministry of Health) data each for the first six months of 2019 (pre-pandemic) and of 2021 (during the pandemic) changes in the numbers of cases with psychiatric diagnoses treated on an inpatient basis in child and adolescent psychiatric and psychotherapeutic settings and in pediatrics. We included the diagnoses F1x.0, F F50.0–1, F32–34, F93.0–2, F40–41, F93.0–2, F42, F43.0–1, and X 84.x from the ICD-10. Trends in the length of hospital stay and emergency rates (by timing of admission and emergency admission mode) were studied. For reasons of data protection, the InEK analyzed the data at a highly aggregated level. Significance calculations were determined as simple frequency distributions by applying the Chi square test (www.socscistatistics.com/tests/chisquare2) and the Welch test (two-sample location testing). For the diagnoses relating to the respective half yearly data we calculated odds ratios (OR) and percentage changes relative to the OR.

Results

In child and adolescent psychiatry and psychotherapy, a fall in case numbers was seen in the analyzed diagnoses during the pandemic by 2.6%, and by 17.8% in pediatrics (Table). Scrutiny of the association between the trend in case numbers and the specialty (child and adolescents psychiatry and psychotherapy versus pediatrics) showed a clear association (Χ₂[1] = 123.81, p < 0.001).

Table

Case numbers, length of inpatient stay, and ICD-10 F-diagnoses in hospitals before and during the pandemic

The absolute and percentage changes were very different relating to diagnoses and specialties, and increases as well as decreases were seen for individual diagnoses. In patients with anxiety disorders or obsessive-compulsive disorders, no change was seen in child and adolescent psychiatry and psychotherapy (2019 vs 2021: n=1112 vs n=1113), but it was seen for pediatrics (2019 vs 2021: n=368 vs n=452). The comparison of child and adolescent psychiatry and psychotherapy with pediatrics showed clear differences between groups in the change of diagnoses in alcohol intoxication, eating disorders, and deliberate self harm (Table).

The in-hospital stay in child and adolescent psychiatric and psychotherapeutic settings fell by a mean total of 1.7 days between 2019 and 2021, with a high standard deviation of 41.1 days before the pandemic and 40.8 days during the pandemic (t[48/164]=4604, p<0.001). In pediatrics it increased by 1.4 days (Table).

Emergencies in the respective observation period accounted for 48.86% of inpatients in child and adolescent psychiatry and psychotherapy before the pandemic (n=11,926), with no change during the pandemic (38.8%, n=11,619). Before the pandemic 27.96% of cases (n=6824) in child and adolescent psychiatry and psychotherapy were admitted outside regular office hours and during the pandemic, 28.83% (n=6855).

Discussion

The hospital data highlight nationwide an unchanged and high demand of child and adolescent psychiatric and psychotherapeutic services, with a changing diagnostic spectrum and a notably shorter length of stay. The length of stay showed a large standard deviation even before the pandemic and a reduction by two days does not seem clinically relevant. The rate of emergencies in child and adolescent psychiatry and psychotherapy settings rose only slightly. But more differentiated analyses seem to confirm regional effects with raised emergency rates associated with less inpatient capacity (4). Notably more common affective disorders showed a rising trend in minors even before the pandemic (5). The falling case numbers of depressive conduct disorders probably mark a demand effect.

As regards the increase in the number of patients with eating disorders it needs to be investigated whether this is a sustained trend and why many patients received only brief treatment in pediatric wards. The high numbers in the pediatric setting are unlikely to be the result of transfers between specialties (for example, regionally practiced transfers from a child and adolescent psychiatric and psychotherapeutic settings for the purpose of enteral nutrition). Because of a lack of codability, the rates of suicide attempts was not studied. Self harm increased only in pediatric settings.

It is a limitation of our study that we cannot draw conclusions about the severity of the treated disorders. The definition of emergencies is subject to possible overlaps on the basis of the available data. Possible transfers between pediatrics and child and adolescent psychiatry and psychotherapy in patients with eating disorders may have led to double counting. Because of the data structure, a sex specific and regional analysis was not possible.

The relatively constant case numbers imply that the healthcare system in general was able to react to the requirements for care. For the future, monitoring is needed regarding possible changes in the diagnostic spectrum and potentially rising treatment needs, so as to manage the care delivery for mentally ill minors in Germany and if needed react by means of flexibility and new treatment approaches. This is needed on a cross-sectoral level. Especially a backlog of untreated children and adolescents after the pandemic cannot be ruled out, since increasing outpatient and inpatient waiting times are seen, with sustained shorter inpatient stays. In this context, children who are socially disadvantaged and display abnormal behaviors with agitation and aggression, who were not focused on during the pandemic need to be considered, who run the risk of becoming disadvantaged in the longer term (1).

Michael Kölch, Olaf Reis, Lisa Ulbrich, Renate Schepker

Conflict of interest statement
Prof Kölch was the president of the German Society for child and adolescent psychiatry, psychosomatic medicine, and psychotherapy in 2020–2022 (DGKJP).

Prof Schepker is the deputy for political affairs of the DGKJP.

The remaining authors declare that no conflict of interest exists.

Manuscript received on 24 October 2022, revised version accepted on 12 January 2023.

Translated from the original German by Birte Twisselmann, PhD.

Cite this as:
Koelch M, Reis O, Ulbrich L, Schepker R: Mental disorders in minors during the COVID-19 pandemic—an analysis of nationwide hospital treatment data. Dtsch Arztebl Int 2023; 120: 362–3. DOI: 10.3238/arztebl.m2023.0010

References

1. Kölch M: Die COVID-19-Pandemie und psychische Störungen bei Minderjährigen. Nervenheilkd 2022; 41: 340–5

2. Berg G: F-Diagnosen bei 0- bis 20-Jährigen in der ambulanten Behandlung im ersten Jahr der COVID-19-Pandemie. Nervenheilkd 2022; 41: 335–9

3. RWI – Leibniz-Institut für Wirtschaftsforschung, Technische Universität Berlin: Analysen zum Leistungsgeschehen der Krankenhäuser und zur Ausgleichspauschale in der Corona-Krise: Ergebnisse für den Zeitraum Januar bis Dezember 2020 Im Auftrag des Bundesministeriums für Gesundheit; 30.04.2021. www.bundesgesundheitsministerium.de/fileadmin/Dateien/3_Downloads/C/Coronavirus/Analyse_Leistungen_Ausgleichszahlungen_2020_Corona-Krise.pdf (last accessed on 17 January 2023).

4. Kölch M, Reis O, Ulbrich L, Schepker R: COVID-19 und psychische Störungen bei Minderjährigen: Veränderungen der Behandlungen nach der Krankenhausstatistik. Z Kinder Jugenpsychiatr; submitted.

5. Greiner W, Witte J, Batram M: DAK Kinder- und Jugendreport 2019: Gesundheitsversorgung von Kindern und Jugendlichen in Deutschland. Schwerpunkt: Ängste und Depressionen bei Schulkindern. 1st ed. Heidelberg, Neckar: medhochzwei Verlag; 2019.