Mental Health Crisis in Children and Adolescents with COVID-19: A Retrospective Cohort Study of Over Seven Million Youth from Electronic Health Records

Background: There is extensive research on the negative effects of the COVID-19 pandemic on mental health due to lockdowns and quarantine, but there is significantly less research on the effects of the disease itself on mental health, especially among youth.Methods: In this study, we investigated the psychiatric sequelae of the SARS-CoV-2 infection in 4,199,075 children and 3,155,463 adolescents who had no prior mental health histories. We used de-identified medical records from the TriNetX Research Network to examine the effect of the SARS-CoV-2 infection on subsequent diagnoses of psychiatric disorders, suicidal behavior, and all-cause mortality on these youth. Using Kaplan-Meier survival analysis, the cumulative incidence of new psychiatric diagnoses in the two years following SARS-CoV-2 infection was compared with propensity-score matched groups of children and adolescents who either had, or did not have COVID-19.Findings: Both children and adolescents with SARS-CoV-2 infection had a significantly increased risk of acquiring any mental disorder diagnosis (ICD-10-CM codes F01-F99) with higher hazard ratio (HR) in children (7·2, 95% CI: 6·9-7·5) than adolescents (4·7, 95% CI: 4·5-4·9)). The HRs for all sub-categories of mental disorder diagnoses, as well as suicidal behavior and all-cause mortality were also significantly elevated in both age groups. Patients with confirmed COVID-19 diagnoses had significantly higher risks than those who had only tested positive for the virus (chi2(1) = 17·8, p< 0.0001). Further comparisons between patients admitted to the hospital and patients treated in the emergency room, or outpatient facilities showed that although hospitalization itself increased the risk of mental disorder diagnoses, SARS-CoV-2 infection further increased the risk.Interpretation: Overall, our results highlight the ongoing mental health crisis among children and adolescents following SARS-CoV-2 infection, and underscore an urgent need to support at-risk youth.Funding: Dr. Faraone is supported by the European Union’s Horizon 2020 research and innovation programme under grant agreement No 965381; NIMH grants U01AR076092-01A1, 1R21MH1264940, R01MH116037; 1R01NS128535 – 01; Oregon Health and Science University, Otsuka Pharmaceuticals, Noven Pharmaceuticals Incorporated, and Supernus Pharmaceutical Company. Dr. Zhang-James is supported by the European Union’s Horizon 2020 research and innovation programme under grant agreement No 965381.Declaration of Interest: Dr. Faraone has received income, potential income, travel expenses continuing education support and/or research support from Aardvark, Aardwolf, Akili, Atentiv, Corium, Genomind, Ironshore, Medice, Noven, Otsuka, Sandoz, Sky Therapeutics, Supernus, Tris, and Vallon. With his institution, he has US patent US20130217707 A1 for the use of sodium-hydrogen exchange inhibitors in the treatment of ADHD. In previous years, he received support from: Alcobra, Arbor, Aveksham, Axsome, CogCubed, Eli Lilly, Enzymotec, Impact, Janssen, KemPharm, Lundbeck/Takeda, Shire/Takeda, McNeil, NeuroLifeSciences, Neurovance, Novartis, Pfizer, Rhodes, Shire, and Sunovion. He also receives royalties from books published by Guilford Press: Straight Talk about Your Child’s Mental Health; Oxford University Press: Schizophrenia: The Facts; and Elsevier: ADHD: Non-Pharmacologic Interventions. In addition, he is the program director of www.adhdinadults.com. Other authors have no conflicts of interest to report.