COVID-19 Linked to Rise in Suicide-Related ED Visits Among Youth

Ted Bosworth

September 10, 2021

After a steep decline in the first months of the COVID-19 pandemic, youth with suicidal thoughts and behaviors visiting an emergency department (ED) resurged with an overrepresentation among girls and children without a prior psychiatric history, according to a cross-sectional study conducted at Kaiser Permanente Northern California.

The latest findings, published in JAMA Psychiatry, are highly consistent with Centers for Disease Control and Prevention data published a few months earlier in the Morbidity and Mortality Weekly Report that looked at these trends among young people aged 12-25 before and during the pandemic. In addition, the new data suggest that prevention efforts might be particularly helpful for these young people and their families.

"As suicide-related encounters have made up more ED volume during the pandemic, increasing ED-based interventions, staff trained in addressing emergency mental health needs, and aftercare resources may also be valuable in addressing the needs of this population," wrote Kathryn K. Erickson-Ridout, MD, PhD, first author of the more recent study and an adjunct investigator with the Kaiser Permanente Division of Research, Oakland, Calif.

"While these results suggest many of our youth are coping well through the pandemic, we need to be vigilant as health care workers," she said in an interview.

Ridout and associates evaluated suicide-related ED visits among children aged 5-17 years presenting to EDs in the Kaiser Permanente Northern California system. Four periods in 2020 were compared with the same four periods in 2019.

In the first period, March through May 2020, the incidence rate ratio (IRR) of suicide-related ED visits among children and adolescents fell more than 40% (IRR, 0.53; P < .001) relative to the same months in 2019. This is consistent with a broader decline in other types of ED visits during the beginning of the COVID-19 pandemic.

In the periods of June through August and September to Dec. 15, suicide-related ED visits increased, reaching prepandemic levels overall but with differences between genders. In girls, an increase in the first period reached significance (IRR, 1.19; P = .04) and then climbed even higher in the second (hazard ratio, 1.22; P < .001).

Youth Present With No Prior Psychiatric History

Among boys, the increase relative to 2019 in the first period was modest and nonsignificant (IRR, 1.05; P = .26) In the second period, suicide-related ED visits fell and the difference relative to the same period in 2019 reached statistical significance (IRR, 0.81; P = .02).

Other characteristics of suicide-related ED visits during the pandemic were also different from those observed in 2019. One was an increase in visits from youth with no prior history of mental health or suicide-related outpatient visits.

"This finding may suggest that a youth's first presentation to the ED for suicidal thoughts and behaviors differed during the pandemic, compared to prior to the pandemic," Erickson-Ridout explained. "Mental health comorbidities first diagnosed at the ED encounter may suggest an increased complexity at first presentation."

These data are remarkably similar to ED visits for suicide attempts that were reported by the CDC several months earlier. The CDC data were drawn from the National Syndromic Surveillance Program, which captures data from 71% of the EDs in the United States.

Measured from March 29 to April 25, 2020, ED visits for a suicide attempt declined by more than 25% in both girls and boys, but by early May, those visits were already starting to return to prepandemic levels, particularly among girls, according to the CDC report. When evaluated from July 26 through Aug. 22, 2020, the mean weekly ED visits for suspected suicide attempts had increased 26.2% among girls but only 10.8% among boys, compared with the same period in 2019.

"More Severe Distress" Found Among Girls

In the most recent period evaluated, starting Feb. 21, 2021, and extending to March 20, there was a 50.6% increase among girls in the mean number of weekly ED visits for suspected suicide attempts, compared with the same period in 2019. For boys, the increase was 3.7%.

Higher rates of suicide attempts among girls have been reported by others independent of the COVID-19 pandemic, but the CDC investigators led by Ellen Yard, PhD, a researcher in the CDC's National Center for Environmental Health, Chamblee, Ga., reported that others have also found greater suicide ideation and attempts by girls during the pandemic. This new report "suggests more severe distress among young females than has been identified in previous reports during the pandemic."

Neither study was designed to isolate the reason or reasons for an increase in suicide-related ED visits overall or among girls specifically, but Yard and her coinvestigators speculated that social distancing and isolation during the COVID-19 pandemic might be affecting girls more.

The faster increase in suicide attempts among girls compared with boys "speaks to the importance of upstream prevention to prevent this group from becoming suicidal in the first place as well as improving suicide care both during and after ED visits," said Yard, who was interviewed about this research.

For clinicians, she recommended "scaling up adoption of evidence-based best practice." She cited two such resources from the National Action Alliance for Suicide Prevention (NAASP). One resource is the Best Practices in Care Transitions for Individuals with Suicide Risk: Inpatient Care to Outpatient Care; the other is called Recommended Standard Care. Both are available online for free from the NAASP.

Erickson-Ridout and Yard reported no potential conflicts of interest.

This article originally appeared on, part of the Medscape Professional Network.