key: cord-0276594-eezfcfek authors: Bilu, Y.; Flaks-Manov, N.; Bivas-Benita, M.; Akiva, P.; Kalkstein, N.; Yehezkelli, Y.; Mizrahi-Reuveni, M.; Aka-Zohar, A.; Shapiro Ben David, S.; Lerner, U.; Bodenheimer, G.; Greenfeld, S. title: Mental health assessment of Israeli adolescents before and during the COVID-19 pandemic date: 2022-01-06 journal: nan DOI: 10.1101/2022.01.06.22268809 sha: f5df5c2628f6e2b13062e6fd89e4a41257c26140 doc_id: 276594 cord_uid: eezfcfek The measures used to contain the COVID-19 pandemic caused severe disruption to the lives of children and adolescents, compromising their mental health and wellbeing. In this study we assessed the incidence rates of psychiatric diagnoses and drugs in Israeli adolescents before and during the COVID-19 pandemic. Analysis of health records data of over 200,000 12-17 years old adolescents identified a significant increase in all mental health diagnoses and most psychiatric drugs dispensation during the COVID-19 period compared to a corresponding pre-COVID period. A gender sub-analysis revealed that most of this increase was associated with adolescent girls. Girls exhibited increases of 68% in depression, 67% in eating disorders, 42% in anxiety and 29% in stress-related diagnoses during the COVID-19 period, which are significantly higher rates than those seen in boys and in the pre-COVID period. Sector sub-analysis showed that the increase was mainly in the general Jewish sector with almost no significant increases in the Arab and ultra-orthodox sectors. Our study highlights the mental health burden of Israeli adolescents during the pandemic and suggests that careful consideration should be given to it while deciding on measures to mitigate the pandemic. The COVID-19 pandemic and the measures taken to control its spread have transformed the lives of adolescents, raising concern regarding their mental health. Although children and adolescents mostly represent a milder course of COVID-19 compared to adults 1 , the measures taken to contain the disease, such as school closures and social isolation, have negatively impacted the mental health and wellbeing of this young population 2 . Current reports have indicated that depression, anxiety and eating disorders have increased significantly during the pandemic and higher prevalence rates were measured in girls [3] [4] [5] , increasing gradually with age between the ages of 12 and 17 years (up to their 18 th birthday) 6 . As Israel is getting prepared to contain the fifth coronavirus wave, the additional burden on children and adolescents' mental wellbeing should be weighed. In this study we assessed updated incidence of Israeli youth mental illness before and during the COVID-19 pandemic based on electronic health records (EHR). Maintenance Organization (HMO) in Israel, which includes 2.3 million insured citizens. We performed a retrospective cohort study design of adolescents, 12-17 years old (up to their 18 th birthday) between November 1 st , 2016, and November 1 st , 2021. The outcomes included four categories of mental health diagnoses: depression (ICD10 F32, F34); anxiety and OCD disorders (ICD10 F41, F42); adjustment and emotional problems and stress-related conditions (ICD10 F43, F93.9; denoted as "stress") and eating disorders (ICD10 F50) and three drug categories of antidepressants (ATC code N06A), anxiolytics (ATC code N05B) and antipsychotics (ATC code N05A) dispensed during those years. Incidence was computed by considering the cohort of all MHS members 12-17 years old at the beginning of the year, who did not previously receive a diagnosis, or a medication of the type being considered. Then the number of members from this cohort who received such a diagnosis or medication during the year was counted and normalized by the size of the cohort. Relative Risks (RRs) per 1,000 members and 95% confident intervals (CIs) were computed to measure the changes in mental illness trends between two time periods is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 6, 2022. ; https://doi.org/10.1101/2022.01.06.22268809 doi: medRxiv preprint results of the RRs and CIs we used forest plots. Statistical analyses were conducted using Python version 3.7.1. This report is a sub-analysis of a larger research studying the long-term effects of COVID-19 infection. The study was carried out in accordance with relevant guidelines and regulations. The protocol was approved, and informed consent was waived by Maccabi Health Services' institutional review board (MH6-0006-21). The study included retrospective, de-identified data therefore, presented minimal risk and did not adversely affect the rights and welfare of the subjects. All investigators that were involved in the current study performed GCP training for human subjects' studies and had a completion certificate in effect. We evaluated the EHR data of 12-17 years old adolescents to assess mental health outcomes before and during the pandemic. The population numbers differed between outcomes as we excluded those with a history of the specific outcome, therefore an average population size was 211,404 in 2017, 218,906 in 2019 and 229,528 in 2021. On average, 51.1% were male, 80.2% were general Jews, 12.4% ultra-orthodox Jews, and 7.5% were Arabs. Diagnoses and medication incidence rates for mental health increased over time, however the rise was higher during the COVID-19 period than the pre-COVID period (Table 1) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2022. ; https://doi.org/10.1101/2022.01.06.22268809 doi: medRxiv preprint (RR=1.28; 95% CI: 1.18-1.39). The exception was a non-significant increase in the dispensation of anxiolytics (RR=1.13; 95% CI: 0.99-1.29). In the gender-stratified analyses, most of the increase in the incidence rates of psychiatric diagnoses and medications was associated with girls, while boys presented risk rates that were not significantly different from previous years ( Figure 1A ). The incidence rates of antidepressants in girls increased by 42% during the COVID pandemic vs 14% in the prepandemic period (RR=1.42; 95% CI: 1.31-1.53 vs RR=1.14; 95% CI: 1.04-1.24, respectively). The sector-stratified analyses showed that most of the increase in the incidence rates of psychiatric diagnoses and medications dispensation was associated with the general Jewish sector, while in the Arab and ultra-orthodox sectors there were no significant increases in incidences of most of the diagnoses and medications dispensation during the COVID-19 pandemic ( Figure 1B ). The incidence rates of anxiety among ultra-orthodox Jews increased by 28% during pandemic period (COVID period RR=1.28; 95% CI: 1.02-1.62 vs pre-COVID RR=0.81; 95% CI: 0.64-1.04) and among Arabs by 56% (COVID period RR=1.56; 95% CI: 1.07-2.27 vs pre-COVID RR=0.81; 95% CI: 0.61-1.08). . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2022. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2022. Horizontal (solid) lines denote the 95% confidence interval for the RR. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2022. ; https://doi.org/10.1101/2022.01.06.22268809 doi: medRxiv preprint The COVID-19 pandemic has taken a toll on the mental health and wellbeing of children and adolescents. While most recent studies used surveys to obtain current status of mental health in kids 6,7 , we have approached the issue from a quantitative perspective and evaluated psychiatric diagnoses and drug dispensation in adolescents before and during the COVID-19 pandemic. Consistent with studies showing a sharp increase in reports of mental health problems 3,6,8 , we observed a significant increase in diagnosis of depression, anxiety, stress and eating disorders during the COVID-19 era compared to previous years. These observations can be attributed to anything from fear of the new unknown illness to extended lockdowns and school closures causing prolonged social isolation, lack of physical activity and inadequate healthy daily routines 9,10 . Closures and extended contact with the parents at home may also increase parental awareness and there may also be an increase in legitimacy to discuss mental distress during these times 11 . Our analysis emphasizes the significant higher risk of girls aged 12-17 years suffering a mental disorder for the first time during the pandemic. While this could imply that girls are more sensitive to the effects of the pandemic, this can also be attributed to higher tendency of girls sharing their mental distress with their parents or physicians and getting the diagnosis and treatment for their condition. Indeed, stay-at-home policies and school closures may have given teenagers more opportunity to share such problems with their parents, and for parents to observe such difficulties even if they were not verbally communicated. The lack of increase among boys might be because generally they are more frequently referred to mental health services by their school following behavioral issues. Since schools were closed during large parts of the analyzed period, potential increase due to the pandemic may have been offset by the decrease in school referrals. Comparing the sectors in the Israeli population interestingly shows that different circumstances and lifestyle during the coronavirus period affect mental health outcomes in adolescents. Ultra-orthodox Jews that were less exposed to the media, were less inclined to close their schools and leaned heavily on their faith and community, did not show the increase in mental health diagnoses and medication dispensation as the general sector did. While the findings in this report are clear and consistent with other studies, we are aware that they probably under-represent reality. A large population of adolescents is diagnosed and . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2022. ; https://doi.org/10.1101/2022.01.06.22268809 doi: medRxiv preprint treated by mental health professionals in private clinics outside their HMO, and then their diagnoses are not recorded in their EHR. Psychiatric drugs prescribed outside the HMO are also not recorded and were not included in this analysis. Furthermore, mental health services lines are long and on average, adolescents wait 3 months for mental health services, so not all those who seek and need help are included in this study. Our analysis addressed these limitations by comparing the risk ratios of the outcomes, measuring the difference in new mental health diagnoses and dispensation within the HMO in different time periods. Overall, we estimate that there are higher incidence rates than those presented here. As the fifth coronavirus wave led by the Omicron strain is starting, these results should be considered when deciding on policies for containing it. Our findings highlight that together with the risk of a new strain infecting the population, attention should be given to the mental health of adolescents -especially secular girls -and measures to safeguard their mental health and wellbeing should be weighed. No external funding was used for this study Why is COVID-19 less severe in children? A review of the proposed mechanisms underlying the age-related difference in severity of SARS-CoV-2 infections COVID-19 in children: I. Epidemiology, prevention and indirect impacts International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity Risk and Protective Factors for Prospective Changes in Adolescent Mental Health during the COVID-19 Pandemic Mental Health of Children and Adolescents Amidst COVID-19 and Past Pandemics: A Rapid Systematic Review Depressive symptoms, mental wellbeing, and substance use among adolescents before and during the COVID-19 pandemic in Iceland: a longitudinal, population-based study Global Prevalence of Depressive and Anxiety Symptoms in Children and Adolescents During COVID-19: A Meta-analysis Mental Health Implications of the COVID-19 Pandemic Among Children and Adolescents: What Do We Know so Far? Mostly worse, occasionally better: impact of COVID-19 pandemic on the mental health of Canadian children and adolescents Challenges and burden of the Coronavirus 2019 (COVID-19) pandemic for child and adolescent mental health: a narrative review to highlight clinical and research needs in the acute phase and the long return to normality COVID-19 pandemic impact on children and adolescents' mental health: Biological, environmental, and social factors The authors declare they have no conflict of interest Due to data privacy regulations, the raw data used in this study cannot be shared publicly. It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)The copyright holder for this preprint this version posted January 6, 2022. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2022. ; https://doi.org/10.1101/2022.01.06.22268809 doi: medRxiv preprint