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Trends in Positive Depression and Suicide Risk Screens in Pediatric Primary Care During COVID-19

  • Author Footnotes
    ⁎ Contributed equally as co-first authors.
    Chloe Hannan
    Footnotes
    ⁎ Contributed equally as co-first authors.
    Affiliations
    Clincial Futures (A Research Institute Center of Emphasis) and The Possibilities Project, Children's Hospital of Philadelphia (C Hannan, SL Mayne, MK Kelly, M Powell, G Dalembert, KE McPeak, BP Jenssen, and AG Fiks), Philadelphia, Pa
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  • Author Footnotes
    ⁎ Contributed equally as co-first authors.
    Stephanie L. Mayne
    Correspondence
    Address correspondence to Stephanie L. Mayne, PhD, MHS, Childrens Hospital of Philadelphia, 2716 South St, 10-471, Philadelphia, PA 19146
    Footnotes
    ⁎ Contributed equally as co-first authors.
    Affiliations
    Clincial Futures (A Research Institute Center of Emphasis) and The Possibilities Project, Children's Hospital of Philadelphia (C Hannan, SL Mayne, MK Kelly, M Powell, G Dalembert, KE McPeak, BP Jenssen, and AG Fiks), Philadelphia, Pa

    Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania (SL Mayne, G Dalembert, KE McPeak, BP Jenssen, and AG Fiks), Philadelphia, Pa
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  • Mary Kate Kelly
    Affiliations
    Clincial Futures (A Research Institute Center of Emphasis) and The Possibilities Project, Children's Hospital of Philadelphia (C Hannan, SL Mayne, MK Kelly, M Powell, G Dalembert, KE McPeak, BP Jenssen, and AG Fiks), Philadelphia, Pa
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  • Molly Davis
    Affiliations
    Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, and PolicyLab, Children's Hospital of Philadelphia (M Davis and JF Young), Philadelphia, Pa

    Penn Implementation Science Center at the Leonard Davis Institute of Health Economics ([email protected]), University of Pennsylvania (M Davis and AG Fiks), Philadelphia, Pa
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  • Jami F. Young
    Affiliations
    Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, and PolicyLab, Children's Hospital of Philadelphia (M Davis and JF Young), Philadelphia, Pa

    Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania (JF Young), Philadelphia, Pa
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  • Maura Powell
    Affiliations
    Clincial Futures (A Research Institute Center of Emphasis) and The Possibilities Project, Children's Hospital of Philadelphia (C Hannan, SL Mayne, MK Kelly, M Powell, G Dalembert, KE McPeak, BP Jenssen, and AG Fiks), Philadelphia, Pa
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  • Alisa Stephens-Shields
    Affiliations
    Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (A Stephens-Shields), Philadelphia, Pa
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  • George Dalembert
    Affiliations
    Clincial Futures (A Research Institute Center of Emphasis) and The Possibilities Project, Children's Hospital of Philadelphia (C Hannan, SL Mayne, MK Kelly, M Powell, G Dalembert, KE McPeak, BP Jenssen, and AG Fiks), Philadelphia, Pa

    Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania (SL Mayne, G Dalembert, KE McPeak, BP Jenssen, and AG Fiks), Philadelphia, Pa
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  • Katie E. McPeak
    Affiliations
    Clincial Futures (A Research Institute Center of Emphasis) and The Possibilities Project, Children's Hospital of Philadelphia (C Hannan, SL Mayne, MK Kelly, M Powell, G Dalembert, KE McPeak, BP Jenssen, and AG Fiks), Philadelphia, Pa

    Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania (SL Mayne, G Dalembert, KE McPeak, BP Jenssen, and AG Fiks), Philadelphia, Pa
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  • Brian P. Jenssen
    Affiliations
    Clincial Futures (A Research Institute Center of Emphasis) and The Possibilities Project, Children's Hospital of Philadelphia (C Hannan, SL Mayne, MK Kelly, M Powell, G Dalembert, KE McPeak, BP Jenssen, and AG Fiks), Philadelphia, Pa

    Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania (SL Mayne, G Dalembert, KE McPeak, BP Jenssen, and AG Fiks), Philadelphia, Pa
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  • Alexander G. Fiks
    Affiliations
    Clincial Futures (A Research Institute Center of Emphasis) and The Possibilities Project, Children's Hospital of Philadelphia (C Hannan, SL Mayne, MK Kelly, M Powell, G Dalembert, KE McPeak, BP Jenssen, and AG Fiks), Philadelphia, Pa

    Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania (SL Mayne, G Dalembert, KE McPeak, BP Jenssen, and AG Fiks), Philadelphia, Pa

    Penn Implementation Science Center at the Leonard Davis Institute of Health Economics ([email protected]), University of Pennsylvania (M Davis and AG Fiks), Philadelphia, Pa
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  • Author Footnotes
    ⁎ Contributed equally as co-first authors.
Published:December 26, 2022DOI:https://doi.org/10.1016/j.acap.2022.12.006

      Abstract

      Objective

      Adolescent mental health concerns increased during COVID-19, but it is unknown whether early increases in depression and suicide risk have been sustained. We examined changes in positive screens for depression and suicide risk in a large pediatric primary care network through May 2022.

      Methods

      Using an observational repeated cross-sectional design, we examined changes in depression and suicide risk during the pandemic using electronic health record data from adolescents. Segmented logistic regression was used to estimate risk differences (RD) for positive depression and suicide risk screens during the early pandemic (June 2020-May 2021) and late pandemic (June 2021-May 2022) relative to before the pandemic (March 2018-February 2020). Models adjusted for seasonality and standard errors accounted for clustering by practice.

      Results

      Among 222,668 visits for 115,627 adolescents (mean age 15.7, 50% female), the risk of positive depression and suicide risk screens increased during the early pandemic period relative to the prepandemic period (RD, 3.8%; 95% CI, 2.9, 4.8; RD, 2.8%; 95% CI, 1.7, 3.8). Risk of depression returned to baseline during the late pandemic period, while suicide risk remained slightly elevated (RD, 0.7%; 95% CI, −0.4, 1.7; RD, 1.8%; 95% CI, 0.9%, 2.7%).

      Conclusions

      During the early months of the pandemic, there was an increase in positive depression and suicide risk screens, which later returned to prepandemic levels for depression but not suicide risk. Results suggest that pediatricians should continue to prioritize screening adolescents for depressive symptoms and suicide risk and connect them to treatment.

      Keywords

      What's New
      Adolescent mental health concerns have increased during the COVID-19 pandemic, but it is unknown whether early pandemic increases in depression and suicide risk among adolescents have been sustained. We found sustained increases for suicide risk but not depression.
      Adolescent mental health concerns have increased during the COVID-19 pandemic,
      • Jones EAK
      • Mitra AK
      • Bhuiyan AR
      Impact of COVID-19 on mental health in adolescents: a systematic review.
      ,
      • Mayne SL
      • Hannan C
      • Davis M
      • et al.
      COVID-19 and adolescent depression and suicide risk screening outcomes.
      with abrupt changes including physical distancing, distance learning, and family health and economic concerns disrupting daily routines and adding significant stress. Mental health concerns may be especially high for racially minoritized and lower income adolescents due to systemic racism and differential access to care.
      • Assari S
      • Gibbons FX
      • Simons R
      Depression among black youth; interaction of class and place.
      • Alegria M
      • Vallas M
      • Pumariega AJ.
      Racial and ethnic disparities in pediatric mental health.
      • Abrams AH
      • Badolato GM
      • Boyle MD
      • et al.
      Racial and ethnic disparities in pediatric mental health-related emergency department visits.
      The pediatric primary care office is an ideal place to screen for depression and suicide risk due to recommendations that adolescents visit annually for a well visit.

      American Academy of Pediatrics. Recommendations for Preventive Pediatric Health Care. 2021. Updated March 2021. Available at: https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf. Accessed March 9, 2022.

      Both the American Academy of Pediatrics (AAP) and the US Preventive Services Task Force (USPSTF) recommend routinely screening adolescents for depression

      American Academy of Pediatrics. Addressing Mental Health Concerns in Pediatrics: A Practical Resource Toolkit for Clinicians, 2nd ed. Available at: https://publications.aap.org/toolkits/pages/Mental-Health-Toolkit. Accessed March 3, 2022.

      ,

      U.S. Preventive Services Task Force. Depression in Children and Adolescents: Screening. 2016. Available at:https://www.uspreventiveservicestaskforce.org/uspstf/document/RecommendationStatementFinal/depression-in-children-and-adolescents-screening. Accessed March 9, 2022.

      ; depression screeners often include questions about suicidality. In a prior report comparing early pandemic levels of depressive symptoms and suicide risk to prepandemic levels (prepandemic: June-December 2019; pandemic: June-December 2020), early pandemic increases in depression and suicide risk were documented among adolescents cared for in a large pediatric primary care network.
      • Mayne SL
      • Hannan C
      • Davis M
      • et al.
      COVID-19 and adolescent depression and suicide risk screening outcomes.
      However, it is unknown whether these increases have been sustained over time. We examined changes in depression and suicide risk during the COVID-19 pandemic through May 2022.

      Methods

      Study Population

      Using an observational repeated cross-sectional design modeled after an interrupted time series,
      • Bernal JL
      • Cummins S
      • Gasparrini A.
      Interrupted time series regression for the evaluation of public health interventions: a tutorial.
      electronic health record (EHR) data from Children's Hospital of Philadelphia's (CHOP) pediatric primary care network were examined for changes in depression and suicide risk during the pandemic. The network includes 31 practices in urban, suburban, and semirural areas of Pennsylvania and New Jersey and provides care for approximately 300,000 patients.
      • Fiks AG
      • Grundmeier RW
      • Margolis B
      • et al.
      Comparative effectiveness research using the electronic medical record: an emerging area of investigation in pediatric primary care.
      CHOP routinely screens for depression and suicide risk at annual well visits starting at age 12, following guidelines from the AAP's Bright Futures and the USPSTF.

      American Academy of Pediatrics. Addressing Mental Health Concerns in Pediatrics: A Practical Resource Toolkit for Clinicians, 2nd ed. Available at: https://publications.aap.org/toolkits/pages/Mental-Health-Toolkit. Accessed March 3, 2022.

      ,

      U.S. Preventive Services Task Force. Depression in Children and Adolescents: Screening. 2016. Available at:https://www.uspreventiveservicestaskforce.org/uspstf/document/RecommendationStatementFinal/depression-in-children-and-adolescents-screening. Accessed March 9, 2022.

      Adolescents aged 12 to 21 years who were screened for depression and suicide risk during at least one preventive care visit between March 2018 to May 2022 were included in the study population.

      Outcomes

      Depressive symptoms and suicide risk were assessed using the Patient Health Questionnaire-Modified (PHQ-9-M).
      • Mayne SL
      • Hannan C
      • Davis M
      • et al.
      COVID-19 and adolescent depression and suicide risk screening outcomes.
      ,
      • Davis M
      • Rio V
      • Farley AM
      • et al.
      Identifying adolescent suicide risk via depression screening in pediatric primary care: an electronic health record review.
      ,
      • Farley AM
      • Gallop RJ
      • Brooks ES
      • et al.
      Identification and management of adolescent depression in a large pediatric care network.
      The PHQ-9-M retains the 9 core items of the PHQ-9, which has been validated with adolescents, with slight modifications to increase the PHQ-9’s relevance for youth depression. The PHQ-9-M also includes an additional 4 supplemental items, 2 of which are focused on suicidality.
      • Aggarwal S
      • Taljard L
      • Wilson Z
      • et al.
      Evaluation of modified patient health questionnaire-9 teen in South African adolescents.
      • Nandakumar AL
      • Vande Voort JL
      • Nakonezny PA
      • et al.
      Psychometric properties of the patient health questionnaire-9 modified for major depressive disorder in adolescents.
      GLAD-PC Toolkit Committee
      Threshold depressive symptoms were established by a PHQ-9-M score of 11 to 27, indicating moderate-to-severe depression.
      • Richardson LP
      • McCauley E
      • Grossman DC
      • et al.
      Evaluation of the patient health questionnaire-9 item for detecting major depression among adolescents.
      For the primary analysis, suicide risk was assessed by a positive endorsement of either or both of the following 2 suicide risk PHQ-9-M questions: (item 9) “Thoughts that you would be better off dead, or of hurting yourself in some way?” (scored from 0 to 3, where a score of 1 or more was considered a positive endorsement); and (item 12) “Has there been a time in the past month when you have had serious thoughts about ending your life?" (scored as yes/no, where a “yes” response was considered a positive endorsement).
      • Mayne SL
      • Hannan C
      • Davis M
      • et al.
      COVID-19 and adolescent depression and suicide risk screening outcomes.
      We conducted several sensitivity analyses using alternative outcome definitions: 1) examining a more severe level of depressive symptoms (PHQ-9-M score of 15–27), 2) assessing suicide risk including the other supplemental suicidality item (item 13, “Have you ever, in your whole life, tried to kill yourself or made a suicide attempt?”) in addition to item 9 and item 12, and 3) assessing suicide risk using only item 12 (past-month serious suicidal thoughts).

      Statistical Analysis

      We examined 3 periods: March 2018 to February 2020 (prepandemic, 24 months), June 2020 to May 2021 (early pandemic, 12 months), and June 2021 to May 2022 (late pandemic, 12 months). March-May 2020 were excluded due to unusually low visit volume at the start of the pandemic. June 2021 was chosen as the split point between the early and late pandemic periods to correspond with the end of the 2020–21 academic year, during which much of the patient population was attending school remotely, and to enable inclusion of 12 months in each pandemic period. We first descriptively examined and graphed monthly proportions of positive screens in each period. Then, we conducted segmented logistic regression using Stata version 16 to estimate changes in the intercept (level) and slope (monthly trend) for positive depression and suicide risk screens during the early and late pandemic periods, relative to the prepandemic period. The model took the form: log odds (positive screen) = β0 + β1*(time in months) + β2*(pandemic period) + β3*(time in months × pandemic period) + β4*(season). Models included time in months as a continuous variable (estimating the prepandemic trend), a 3-level pandemic indicator variable (prepandemic, early pandemic, late pandemic; estimating the change in intercept), and the pandemic/time interaction term (estimating the change in trend). We accounted for seasonal variation by ensuring a consistent number of months (12 or 24) was included in each period and by including an indicator term for season in the models (coded as: winter: December-February, spring: March-May, summer: June-August, fall: September-November). Results were similar when we instead adjusted for calendar month (data not shown). Standard errors accounted for clustering by primary care practice to account for potential differences in screening practices across sites. Using Stata's “margins” package, results were translated into predicted proportions of adolescents screening positive for depression and suicide risk at the beginning and end of each pandemic period. We then calculated risk differences which compared the risk of positive depression and suicide risk screens predicted by the model in May 2021 (end of the early pandemic period) and May 2022 (end of the late pandemic period) compared to the expected risk, had the prepandemic trend continued unchanged.
      Changes in depression and suicide risk were examined overall, and by sex, payor (commercial, public), and race and ethnicity (black, white, other, where “other” includes Hispanic, Asian, and other race patients). Race and ethnicity was included as a marker for exposure to racism, which might impact mental health outcomes differentially given the disproportionate impact of the COVID-19 pandemic on minoritized populations.
      • Pierce JB
      • Harrington K
      • McCabe ME
      • et al.
      Racial/ethnic minority and neighborhood disadvantage leads to disproportionate mortality burden and years of potential life lost due to COVID-19 in Chicago, Illinois.
      Categories were based on classifications in the electronic health record. Hispanic, Asian, and other race patients were collapsed into a single category for statistical analysis due to small sample sizes. Children's Hospital of Philadelphia's IRB determined this study to be exempt from review.

      Results

      Our analysis included 222,668 visits for 115,627 unique adolescents (mean age: 15.7 years, 49.9% female, 26.6% black, 30.0% publicly insured). The proportion of all primary care visits among adolescents that were preventive visits was 38% in the prepandemic period, 51% in the early pandemic period, and 43% in the late pandemic period. The demographic composition of adolescents was similar across the 3 time periods (Table 1). In the prepandemic period, monthly rates of positive depression screens were stable (P value for prepandemic trend: .7) while monthly rates of suicide risk were declining slightly (P = .02) (Figure 1).
      Table 1Population Characteristics at Adolescent Preventive Visits
      Pandemic periods were as follows: Prepandemic: March 2018–February 2020; early pandemic: June 2020–May 2021; late pandemic: June 2021–May 2022.
      CharacteristicPrepandemic N (%)Early Pandemic N (%)Late Pandemic N (%)
      Total visits101,28858,93162,449
      Positive depression screen5738 (5.7)4520 (7.7)4263 (6.8)
      Positive suicide risk screen4961 (4.9)3401 (5.8)3628 (5.8)
      Age—Mean (SD)15.2 (2.1)15.2 (2.0)15.2 (2.1)
      Sex
       Female50,531 (49.9)29,546 (50.1)31,109 (49.8)
       Male50,750 (50.1)29,379 (49.9)31,333 (50.2)
      Race and ethnicity
       Non-Hispanic Black24,641 (24.3)13,917 (23.6)14,623 (23.4)
       Non-Hispanic White56,535 (55.8)31,873 (54.1)32,944 (52.8)
       Hispanic6813 (6.7)4575 (7.8)4956 (7.9)
       Asian4267 (4.2)2591 (4.4)3126 (5.0)
       Other race and ethnicity9032 (8.9)5975 (10.1)6799 (10.9)
      Insurance type
      Excluding 2322 visits with self-pay, other, or missing insurance information.
       Commercial73,709 (72.8)41,590 (70.6)43,827 (70.2)
       Public26,605 (26.3)16,759 (28.4)17,856 (28.6)
      Practice location
       Urban26,152 (25.8)13,997 (23.8)15,304 (24.5)
       Suburban/semirural75,136 (74.2)44,934 (76.2)47,145 (75.5)
      Pandemic periods were as follows: Prepandemic: March 2018–February 2020; early pandemic: June 2020–May 2021; late pandemic: June 2021–May 2022.
      Excluding 2322 visits with self-pay, other, or missing insurance information.
      Figure 1
      Figure 1Depression and suicide risk screening outcomes by month. Points reflect percentages of visits where adolescents screened positive for depression/suicidality. Solid lines reflect slopes/intercepts for pre-, early-, and late pandemic periods. Blue dashed lines present counterfactual scenario in which prepandemic trend continued. Vertical dashed lines note the start of the early and late pandemic. Blank area indicates where data were removed.

      Depression

      Female, non-Hispanic black, and publicly insured adolescents had the highest risk of depressive symptoms in the prepandemic period (Table 2A). Adjusting for seasonality, the risk of positive depression screens at the end of the early pandemic period was greater than would be expected based on the prepandemic level and trend (Table 1; risk difference (RD), 3.8%; 95% CI, 2.9%, 4.8%). By the end of the late pandemic period, the risk of positive depression screens had returned to prepandemic levels (Table 2A, Figure 1A; RD, 0.7%; 95% CI, −0.4%, 1.7%). This pattern was observed across all demographic subgroups (Table 2A); however, the risk difference during the early pandemic period was largest in magnitude among female adolescents (RD, 6.1%; 95% CI, 4.7%, 7.5%). Patterns were similar for more severe depressive symptoms (PHQ-9-M score of ≥15, Supplemental Table 1).
      Table 2APositive Depression Screens at Preventive Visits During the COVID-19 Pandemic
      Prepandemic was defined as March 2018–February 2020. Data from March through May of 2020 were excluded due to low visit volume. The early pandemic period is June 2020–May 2021. The late pandemic period is June 2021–May 2022.
      Early Pandemic PeriodLate Pandemic Period
      Model-Based % Screening Positive in May 2021
      Estimated using logistic regression and marginal standardization. This represents the predicted percentage of adolescents screening positive for depression at the end of the early and late pandemic periods, adjusting for seasonality.
      Expected % Screening Positive in May 2021 If Prepandemic Trend Continued
      This represents the predicted percentage of adolescents who would have screened positive for depression at each time point, had the prepandemic trend continued.
      Risk Difference (95% CI)
      Risk differences for the early and late pandemic periods represent the difference between the percentage of adolescents estimated by the model to have screened positive at each time point and the percentage that would have screened positive, had the prepandemic trend continued unchanged.
      Model-Based % Screening Positive in May 2022
      Estimated using logistic regression and marginal standardization. This represents the predicted percentage of adolescents screening positive for depression at the end of the early and late pandemic periods, adjusting for seasonality.
      Expected % Screening Positive in May 2022 If Prepandemic Trend Continued
      This represents the predicted percentage of adolescents who would have screened positive for depression at each time point, had the prepandemic trend continued.
      Risk Difference (95% CI)
      Risk differences for the early and late pandemic periods represent the difference between the percentage of adolescents estimated by the model to have screened positive at each time point and the percentage that would have screened positive, had the prepandemic trend continued unchanged.
      Overall10.56.73.8 (2.9, 4.8)
      P < .05.
      7.46.70.7 (−0.4, 1.7)
      Sex
       Female15.59.46.1 (4.7, 7.5)
      P < .05.
      11.29.71.5 (−0.1, 3.1)
       Male5.54.11.4 (0.5, 2.4)
      P < .05.
      3.53.9−0.4 (−1.8, 0.8)
      Payor
       Commercial9.15.43.7 (2.6, 4.7)
      P < .05.
      6.25.40.8 (−0.4, 2.1)
       Public13.69.73.9 (2.5, 5.3)
      P < .05.
      10.19.90.2 (−1.9, 2.3)
      Race and ethnicity
       Non-Hispanic White9.15.63.5 (2.2, 4.7)
      P < .05.
      6.25.70.5 (−0.9, 1.8)
       Non-Hispanic Black12.78.74.0 (2.4, 5.7)
      P < .05.
      9.48.90.5 (−2.1, 3.1)
       Other race and ethnicity
      “Other race and ethnicity” patients include Hispanic, Asian, and other race patients.
      10.66.83.8 (2.2, 5.4)
      P < .05.
      7.86.81.0 (−1.2, 3.3)
      low asterisk P < .05.
      Prepandemic was defined as March 2018–February 2020. Data from March through May of 2020 were excluded due to low visit volume. The early pandemic period is June 2020–May 2021. The late pandemic period is June 2021–May 2022.
      Estimated using logistic regression and marginal standardization. This represents the predicted percentage of adolescents screening positive for depression at the end of the early and late pandemic periods, adjusting for seasonality.
      § This represents the predicted percentage of adolescents who would have screened positive for depression at each time point, had the prepandemic trend continued.
      Risk differences for the early and late pandemic periods represent the difference between the percentage of adolescents estimated by the model to have screened positive at each time point and the percentage that would have screened positive, had the prepandemic trend continued unchanged.
      “Other race and ethnicity” patients include Hispanic, Asian, and other race patients.

      Suicide Risk

      As with depression, non-Hispanic black, female, and publicly insured adolescents had the highest risk of screening positive for suicidality in the prepandemic period (Table 2B). The risk of positive suicide screens at the end of the early pandemic period was greater than would be expected relative to the prepandemic level and trend (Figure 1B, Table 2B; RD, 2.8%; 95% CI, 1.7%, 3.8%). However, unlike depression, suicide risk remained above the expected prepandemic levels by the end of the late pandemic period (RD, 1.8%; 95% CI, 0.9%, 2.7%). These patterns were seen for all demographic subgroups except non-Hispanic black adolescents, for whom suicide risk was not significantly elevated relative to the prepandemic trend during either pandemic period. In sensitivity analyses that 1) included the lifetime suicide attempt item from the suicide risk measure or 2) examined past-month serious suicidal thoughts alone, patterns were similar (Supplemental Tables 2–3).
      Table 2BPositive Suicide Risk Screens at Preventive Visits During the COVID-19 Pandemic
      Prepandemic was defined as March 2018–February 2020. Data from March through May of 2020 were excluded due to low visit volume. The early pandemic period is June 2020–May 2021. The late pandemic period is June 2021–May 2022.
      Early Pandemic PeriodLate Pandemic Period
      Model-Based % Screening Positive in May 2021
      Estimated using logistic regression and marginal standardization. This represents the predicted percentage of adolescents screening positive for suicide risk at the start and end of the early and late pandemic periods, adjusting for seasonality.
      Expected % Screening Positive in May 2021 If Prepandemic Trend Continued
      This represents the predicted percentage of adolescents who would have screened positive for suicide risk at each time point, had the prepandemic trend continued.
      Risk Difference (95% CI)
      Risk differences for the early and late pandemic periods represent the difference between the percentage of adolescents estimated by the model to have screened positive at each time point and the percentage that would have screened positive, had the prepandemic trend continued unchanged.
      Model-Based % Screening Positive in May 2022
      Estimated using logistic regression and marginal standardization. This represents the predicted percentage of adolescents screening positive for suicide risk at the start and end of the early and late pandemic periods, adjusting for seasonality.
      Expected % Screening Positive in May 2022 If Prepandemic Trend Continued
      This represents the predicted percentage of adolescents who would have screened positive for suicide risk at each time point, had the prepandemic trend continued.
      Risk Difference (95% CI)
      Risk differences for the early and late pandemic periods represent the difference between the percentage of adolescents estimated by the model to have screened positive at each time point and the percentage that would have screened positive, had the prepandemic trend continued unchanged.
      Overall7.34.52.8 (1.7, 3.8)
      P < .05.
      6.04.21.8 (0.9, 2.7)
      P < .05.
      Sex
       Female10.66.44.2 (2.9, 5.5)
      P < .05.
      8.36.12.2 (0.9, 3.6)
      P < .05.
       Male3.92.71.2 (0.2, 2.3)
      P < .05.
      3.52.31.2 (0.2, 2.2)
      P < .05.
      Payor
       Commercial6.23.62.6 (1.6, 3.6)
      P < .05.
      4.73.31.4 (0.5, 2.4)
      P < .05.
       Public9.56.72.8 (0.8, 4.7)
      P < .05.
      8.76.42.3 (0.3, 4.2)
      P < .05.
      Race and ethnicity
       Non-Hispanic White5.73.32.4 (1.3, 3.4)
      P < .05.
      4.82.91.9 (1.0, 2.7)
      P < .05.
       Non-Hispanic Black8.77.61.0 (−0.4, 2.4)8.17.90.2 (−1.3, 1.8)
       Other race and ethnicity
      “Other race and ethnicity” patients include Hispanic, Asian, and other race patients.
      9.04.05.0 (3.1, 6.9)
      P < .05.
      6.23.32.9 (0.8, 5.0)
      P < .05.
      low asterisk P < .05.
      Prepandemic was defined as March 2018–February 2020. Data from March through May of 2020 were excluded due to low visit volume. The early pandemic period is June 2020–May 2021. The late pandemic period is June 2021–May 2022.
      Estimated using logistic regression and marginal standardization. This represents the predicted percentage of adolescents screening positive for suicide risk at the start and end of the early and late pandemic periods, adjusting for seasonality.
      § This represents the predicted percentage of adolescents who would have screened positive for suicide risk at each time point, had the prepandemic trend continued.
      Risk differences for the early and late pandemic periods represent the difference between the percentage of adolescents estimated by the model to have screened positive at each time point and the percentage that would have screened positive, had the prepandemic trend continued unchanged.
      “Other race and ethnicity” patients include Hispanic, Asian, and other race patients.

      Discussion

      During the early months of the pandemic, there was an increase in positive depression and suicide risk screens overall and among most demographic subgroups. This increase coincides with the state of emergency that was declared in March of 2020,

      COVID-19 Disaster Declarations. Available at: https://www.fema.gov/disaster/coronavirus/disaster-declarations. Accessed January 14, 2022.

      which resulted in increased stress and uncertainty for many adolescents in the following months. In addition, national events including the murder of George Floyd and the 2020 US presidential election led to social and political turmoil over this period. Also, as of June 2021, over 140,000 children and adolescents in the United States had lost a primary or secondary caregiver to COVID-19, with greater proportional losses among black, Hispanic, and American Indian/Alaskan Native youth.
      • Hillis SD
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      • Mackey K
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      • Kondo KK
      • et al.
      Racial and ethnic disparities in COVID-19-related infections, hospitalizations, and deaths: a systematic review.
      This might be an additional stressor for adolescents navigating the illnesses and the deaths of family, friends, and community members.
      The return of depression rates to prepandemic levels by the end of 2021 aligns temporally with the return to in-person school for much of the study population. The return to in-person learning was markedly delayed for children in underserved and marginalized communities due to the disproportionate impact of both the COVID-19 pandemic and resource strains on minoritized school districts.
      U.S. Department of Education’s Office for Civil Rights
      However, we lacked individual-level data on school opening status and acknowledge that resource differences in marginalized communities might contribute to persisting disparities.
      • Williams DR
      • Collins C.
      Racial residential segregation: a fundamental cause of racial disparities in health.
      In contrast, suicide risk remained elevated through the late pandemic period, although not as high as in the peak of the early pandemic period. This period coincided with subsequent surges of SARS-COV2 variants and additional, temporary school closures during the Omicron wave.
      Prior to the pandemic, rates of adolescent depression and suicidality rose nationally over the past 2 decades,
      • Keyes KM
      • Gary D
      • O'Malley PM
      • et al.
      Recent increases in depressive symptoms among US adolescents: trends from 1991 to 2018.
      • Burstein B
      • Agostino H
      • Greenfield B.
      Suicidal attempts and ideation among children and adolescents in US emergency departments, 2007-2015.
      • Twenge JM
      • Cooper AB
      • Joiner TE
      • et al.
      Age, period, and cohort trends in mood disorder indicators and suicide-related outcomes in a nationally representative dataset, 2005-2017.
      potentially due to a complex set of factors such as declining sleep duration, digital media, online bullying, and economic and political upheaval.
      • Keyes KM
      • Gary D
      • O'Malley PM
      • et al.
      Recent increases in depressive symptoms among US adolescents: trends from 1991 to 2018.
      ,
      • Kaur N
      • Hamilton AD
      • Chen Q
      • et al.
      Age, period, and cohort effects of internalizing symptoms among US students and the influence of self-reported frequency of attaining 7 or more hours of sleep: results from the monitoring the future survey 1991-2019.
      ,
      • Twenge JM
      • Campbell WK.
      Associations between screen time and lower psychological well-being among children and adolescents: evidence from a population-based study.
      In the 2 years directly preceding the pandemic, the proportion of adolescents screening positive for depression was relatively stable in our network, while suicide risk was declining. Though depression and suicide risk did not remain elevated with respect to prepandemic trends among non-Hispanic black adolescents in our study, the higher baseline rates among these adolescents deserves focused attention.
      • Davis M
      • Jones JD
      • So A
      • et al.
      Adolescent depression screening in primary care: who is screened and who is at risk?.
      ,
      • Congressional Black Caucus Emergency Taskforce on Black Youth
      Persistent disparities in suicide risk between black and white adolescents warrant equity-focused exploration of drivers and targeted mitigation. Results point to the need for developing and implementing effective suicide prevention interventions for minoritized youth, with a particular emphasis on ensuring that these interventions are acceptable and available to adolescents and families from minoritized populations. Pediatric health care providers can continue to advocate for expanded funding support for pediatric mental health care, universal precautions in trauma-informed care, and ongoing training and hiring practices to support minoritized youth.
      The sustained increase in positive suicide risk screens during the pandemic is especially concerning. Given both the concerningly high risk of suicidality in racially minoritized and publicly insured adolescents and the sustained increases during the pandemic among white and commercially insured adolescents, adolescents will benefit from pediatricians continuing to routinely screen patients for both depressive symptoms and suicide risk and connecting them to treatment options. For primary care practices without routine screening procedures, incorporating the PHQ-9-M or another screener with embedded suicide risk questions may be beneficial, since adolescents may endorse suicide risk in the absence of threshold depressive symptoms. Connecting patients to treatment options through referrals is important. However, emerging data indicate that access to behavioral health declined in many parts of the country during the pandemic.
      Centers for Medicare and Medicaid Services
      Preliminary Medicaid & CHIP Data Snapshot.
      As such, practice-based strategies including conducting brief interventions and counseling in the primary care office at the time of the visit may be important strategies to implement when risk is identified and as continued advocacy efforts strive to increase access to behavioral health providers.
      GLAD-PC Toolkit Committee
      ,
      • Sisler SM
      • Schapiro NA
      • Nakaishi M
      • et al.
      Suicide assessment and treatment in pediatric primary care settings.
      ,
      • McDanal R
      • Parisi D
      • Opara I
      • et al.
      Effects of brief interventions on internalizing symptoms and substance use in youth: a systematic review.
      A strength of our study is that the CHOP primary care network has a large and diverse population of adolescents. However, there are several limitations to note. First, research has found that adolescents are less likely to attend primary care visits than younger children, and thus may be missed in our study population.
      • Rand CM
      • Goldstein NPN.
      Patterns of primary care physician visits for US adolescents in 2014: implications for vaccination.
      In addition to lower adolescent visits overall, there may also be disparities in visits by race and ethnicity, where racially and ethnically minoritized adolescents in underserved areas may be less likely to present for care.
      • Alegria M
      • Vallas M
      • Pumariega AJ.
      Racial and ethnic disparities in pediatric mental health.
      Our study population may reflect adolescents who are more easily able to access well-visit appointments. In addition, the proportion of all visits that were preventive varied across study periods, which might have biased results if access to care or other barriers changed across the population over time. Also, a limitation of the PHQ-9-M is that it screens for depressive symptoms instead of diagnosis. In addition, the relatively small sample size limited examination of Asian, Hispanic, and other race adolescents separately. Additionally, adolescents who have severe mental health concerns may also not be seen at primary care and go straight to the emergency department for treatment. Finally, there are inherent limitations to EHR data. We are unable to examine more nuanced reasons for the observed trends without more detailed individual-level data, such as language preference, gender identity, and qualitative data that involves adolescents reporting on their experiences during the pandemic. We also lacked information on contextual factors that may have varied between pandemic periods (eg, socioeconomic status, family composition).

      Conclusions

      Early in the pandemic, there was an increase in depression and suicide risk overall and among many demographic subgroups. Suicide risk remained elevated longer-term compared to prepandemic trends in the overall population and among most demographic subgroups. The sustained increase in suicide risk speaks to the need for routine screening for depression and suicide risk in primary care, referral to behavioral health treatment, and advocacy to build access to behavioral health care.

      Acknowledgments

      Financial Disclosure: The other authors have indicated they have no financial relationships relevant to this article to disclose.
      Role of Funder/Sponsor: The funders and/or sponsors 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 article; or decision to submit the article for publication.
      Financial Statement: Funding for this study was provided by the Children's Hospital of Philadelphia Possibilities Project.
      Authorship Statement: Dr Stephanie Mayne conceptualized the design of the study, contributed to the interpretation of the data, drafted the manuscript, and led the review and revision of the manuscript.
      Chloe Hannan drafted the manuscript, performed all data analyses, contributed to the interpretation of the data, and led the review and revision of the manuscript.
      Dr Alexander Fiks conceptualized the design of the study and reviewed and revised the manuscript.
      Mary Kate Kelly, Maura Powell, and Dr Molly Davis, Dr Jami Young, Dr Alisa Stephens-Shields, Dr George Dalembert, Dr Katie McPeak, Dr Brian Jenssen all provided substantial contributions to the conception, design, execution, and interpretation of the work, and revised the manuscript.
      All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

      Appendix. supplementary data

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