The Impact of the COVID-19 School Closure on Adolescents’ Use of Mental Healthcare Services in Sweden

Background: School closures used to contain the COVID-19 pandemic may have negative impacts on students’ mental health but credible evidence is scarce. Sweden moved upper-secondary students to remote learning but, as the only country in the OECD, kept schools at lower levers open throughout the pandemic.Methods: Using nationwide register data, we estimate the difference in the use of mental healthcare services between upper- and lower-secondary students during the pandemic, and relate this to the same group difference prior to the pandemic. For the main analysis, this difference-in-difference approach is applied to the period April-June 2020 when upper-secondary schools were fully closed. We follow the students into the academic year 20/21, when upper-secondary schools were partly open, and analyze outcomes until March 2021. We study the impact on all contacts with hospitals and specialist psychiatric care due to mental and behavioral disorder, and all prescriptions for psychiatric drugs.Findings: Compared to expected rates, the use of mental healthcare services among upper-secondary students fell by -3.71 [CI95 -5.52 to -1.91] cases per 1000 during April-June 2020, largely due to a reduction in depression and anxiety-related diagnoses (-1.49; [CI95 -2.36 to -0.63]) and antidepressants (-1.80; [CI95 -2.93 to -0.68]). This reduction corresponds to a 4.36% [CI95 -6.47 to -2.25] decrease compared to the level prior to the pandemic. The decrease persists through July 2020-March 2021 (-4.82% [CI95 -6.53 to -3.11]). The reduction is stronger among students in the 2nd and 3rd year of upper-secondary school. The decrease is concentrated to students who were not in contact with mental healthcare services earlier in the academic year. The reduction is largest for unplanned care, -13.88% [CI95 -19.35 to -9.92], and care at emergency units, -18.19% [CI95 -26.45 to -9.92].Interpretation: Closing upper-secondary schools in Sweden reduced use of mental healthcare services. There is no indication of this being due to limitation in access to care. In a setting with no strict lockdown, moving to remote teaching for a limited period did not worsen mental health among students in upper-secondary schools.Funding Information: No funding was provided for the specific study. Declaration of Interests: There are no conflicts of interest for any of the authors.Ethics Approval Statement: Ethical approval for the study was obtained from the Swedish Ethical Review Authority application 2020-06492.