Introduction
The COVID-19 pandemic declared by the World Health Organisation in February 2020 and stepped down in May 2023 led to three and a half years of significant societal disruption with unprecedented changes in social behaviour, economic structures, and healthcare working. The immediate concern was of managing medical risk and reducing mortality. As of July 2023, over 6.9 million deaths have occurred globally due to COVID-19 (World Health Organisation 2023).
Previous pandemics have alerted us to pandemic-related mental health (MH) repercussions, often longer lasting and with greater impact than medical sequelae (Gunnell et al., Reference Gunnell, Appleby, Arensman, Hawton, John, Kapur, Khan, O’Connor, Pirkis, Appleby, Arensman, Caine, Chan, Chang, Chen, Christensen, Dandona, Eddleston, Erlangsen, Gunnell, Harkavy-Friedman, Hawton, John, Kapur, Khan, Kirtley, Knipe, Konradsen, Liu, McManus, Mehlum, Miller, Moran, Morrissey, Moutier, Niederkrotenthaler, Nordentoft, O’Connor, O’Neill, Page, Phillips, Pirkis, Platt, Pompili, Qin, Rezaeian, Silverman, Sinyor, Stack, Townsend, Turecki, Vijayakumar and Yip2020). Current international evidence confirms adverse MH outcomes internationally, with higher risk among females and younger age (Holmes et al., Reference Holmes, O’Connor, Perry, Tracey, Wessely, Arseneault, Ballard, Christensen, Cohen Silver, Everall, Ford, John, Kabir, King, Madan, Michie, Przybylski, Shafran, Sweeney, Worthman, Yardley, Cowan, Cope, Hotopf and Bullmore2020; Santomauro et al., Reference Santomauro, Mantilla Herrera, Shadid, Zheng, Ashbaugh, Pigott, Abbafati, Adolph, Amlag, Aravkin, Bang-Jensen, Bertolacci, Bloom, Castellano, Castro, Chakrabarti, Chattopadhyay, Cogen, Collins, Dai, Dangel, Dapper, Deen, Erickson, Ewald, Flaxman, Frostad, Fullman, Giles, Giref, Guo, He, Helak, Hulland, Idrisov, Lindstrom, Linebarger, Lotufo, Lozano, Magistro, Malta, Månsson, Marinho, Mokdad, Monasta, Naik, Nomura, O’Halloran, Ostroff, Pasovic, Penberthy, Reiner, Reinke, Ribeiro, Sholokhov, Sorensen, Varavikova, Vo, Walcott, Watson, Wiysonge, Zigler, Hay, Vos, Murray, Whiteford and Ferrari2021).
Ireland too saw an increase in MH presentations. Paediatric emergency departments nationally saw a disproportionate rise in acute MH referrals for suicidal thoughts and self-harm. (McDonnell et al., Reference McDonnell, Conlon, McNicholas, Barrett, Barrett, Cummins, Hensey, McAuliffe and Nicholson2022) aligning with international experience (Wong et al., Reference Wong, Cross, Zavaleta-Ramírez, Bauda, Hoffman, Ibeziako, Nussbaum, Berger, Hassanian-Moghaddam, Kapornai, Mehdi, Tolmac, Barrett, Romaniuk, Davico, Moghraby, Ostrauskaite, Chakrabarti, Carucci, Sofi, Hussain, Lloyd, McNicholas, Meadowcroft, Rao, Csábi, Gatica-Bahamonde, Öğütlü, Skouta, Elvins, Boege, Dahanayake, Anderluh, Chandradasa, Girela-Serrano, Uccella, Stevanovic, Lamberti, Piercey, Nagy, Mehta, Rohanachandra, Li, Tufan, Mirza, Rozali, Baig, Noor, Fujita, Gholami, Hangül, Vasileva, Salucci, Bilaç, Yektaş, Cansız, Aksu, Babatunde, Youssef, Al-Huseini, Kılıçaslan, Kutuk, Pilecka, Bakolis and Ougrin2023).
In the first year of the pandemic, referrals to five child and adolescent mental health services (CAMHS) increased by 50% compared to previous years (McNicholas et al., Reference McNicholas, Kelleher, Hedderman, Lynch, Healy, Thornton, Barry, Kelly, McDonald, Holmes, Kavanagh and Migone2021). Research by this group failed to show any increase in general practitioner (GP) referrals but reported a change in clinical profile: a higher proportion of referrals for females (57% compared to 43% pre-pandemic) presenting with internalising disorders (86% v.70%) and/or self-harm or suicidal ideation (56% v. 42%) (FitzPatrick et al., Reference FitzPatrick, Antczak, Lynch, Lynch and McNicholas2023). Fewer referrals were received for ADHD (11% post COVID-19 compared to pre-pandemic rates of 21%) and ASD (16% v. 26%). As this study was limited to the first ten months of the pandemic, it is not clear whether this change in profile has persisted.
Aims
To compare characteristics of GP referrals to CAMHS prior to and over the entire pandemic.
Methods
Using CAMHS electronic health records (Mental Health Information System; MHIS), all referrals received and accepted by one specialist geographically defined CAMHS in Dublin were examined. This CAMHS covered a catchment area of about 20,000 youths under eighteen years. The study time period spanned 54 months, from January 1st 2019 to 30th June 2023. Referrals received after March 2020, or time 2, were categorised as post COVID-19. Referrals received that did not meet criteria for CAMHS were excluded.
A proforma was designed to assist with data extraction from the GP letter. The presence or absence of various clinical symptoms referenced by the GP were recorded using a tick-box system. This included mention of possible mood, anxiety, psychotic or eating disorder, ADHD, ASD, behavioural or conduct disorder, substance abuse disorder, suicidal ideation, and self-harm. Reasons for referral and clinical features mentioned were extracted and aligned with possible clinical diagnoses. Data was collected by the team psychiatry registrars. A medical student attached to the team during a summer research project also assisted with data extraction. Training and ongoing supervision were provided by the senior clinical members. Data extracted from MHIS was de-identified at source and analysis conducted using Statistical Package for Social Sciences (SPSS).
Descriptive statistics were used to categorise the sample. Mean and standard deviations (SD) were used to describe age, with frequencies and percentages used to describe sex, education, symptoms and diagnosis, actions, and thoughts of self-harm. Referrals marked urgent by GP or clinician post review were categorised as priority.
Cases were subsequently categorised as either internalising (reserved for any mention to symptoms of anxiety or depression) or externalising (where reference was made to ADHD, behavioural, or conduct problems) for ease of analysis. Other presentations, such as psychosis, eating disorders, substance use disorder, and self-harm, were listed separately.
Results
An average of 17.8 referrals were accepted per month during time 1 compared to 18.7 time 2 post COVID-19, representing a 5% increase (see Table 1).
Table 1. Clinical characteristics of GP referrals pre and post COVID-19*
* Full data on N = 249 pre and N = 713 post COVID-19.
The age of referral showed a significant increase from 13.1 to 13.64 (p = .010). During T1, 125 cases (50.2%) were females (average of 8.9 per month), compared to 443 (62.1%) in T2 (average 11.1/month) (p < .001). There was also a difference in clinic prioritisation, with 152 (41%) being prioritised by CAMHS as urgent at T1 compared to 391 (54.8%) at T2 (p < .001).
There was a significant increase in the proportion of referrals with internalising disorders post COVID-19 (68.7% v. 78.7%, p = .001), reflected by an increase in referrals for anxiety (43.0% v. 78.2% p = .004), where monthly referrals increased significantly from 7.6 to 9.6/m. The proportion of referrals for eating disorders (0% v. 6.2%, p < .001) and self-harm (18.5% v. 36.3%, p < .001) also increased (Table 1). Monthly referrals for self-harm increased from 3.3 to 7.5/m. In contrast, the proportion of referrals for psychosis (8.4% v. 4.8%, p = .032) and ASD (26.5% v. 18.7%, p = .008) decreased significantly. Monthly referrals for ADHD also decreased, from 7.7 per month to 5.6, but this did not reach clinical significance. (p = .061).
Discussion
Findings of this study, conducted over 40 months post-pandemic onset, concur with and extend findings from a study examining GP referrals to CAMHS in the first ten months of COVID-19 (FitzPatrick et al., Reference FitzPatrick, Antczak, Lynch, Lynch and McNicholas2023). Average monthly referrals for females increased from 8.9 to 11.1 per month, and the average age increased from 13.1 to 13.6 as the pandemic progressed. This observation resonates with a systematic review reporting adolescents and girls experienced a more pronounced deterioration in MH post-pandemic (Samji et al., Reference Samji, Wu, Ladak, Vossen, Stewart, Dove, Long and Snell2022). Existing literature suggests that during crises, girls rely more on social networks for support than boys. Hence, pandemic disruptions to these networks may have disproportionately affected females, increased distress, and prompting referrals to CAMHS.
This study found that GP referrals for internalising disorders and/or self-harm or suicidal ideation were also higher than pre-pandemic rates. This was predominantly driven by a sustained increase in anxiety-related referrals, where the average monthly referral rose from 7.6/month pre-pandemic to 9.6. This increased rate of referrals with self-harm to CAMHS aligns with international data (Ougrin et al., Reference Ougrin, Wong, Vaezinejad, Plener, Mehdi and Romaniuk2022).
A pandemic-related increase in demand for eating disorder (ED) services has been reported in specialist services both in Ireland (Campbell et al., Reference Campbell, Maunder, Lehmann, McKeown and McNicholas2022; Rafferty et al., Reference Rafferty, O’Donnell, Campbell, Sun, King, Ali, Lynch, Barrett, Richardson, Clifford and McNicholas2024) and internationally (Branley-Bell and Talbot Reference Branley-Bell and Talbot2020). The earlier study (FitzPatrick et al., Reference FitzPatrick, Antczak, Lynch, Lynch and McNicholas2023) noted little change in GP referrals of EDs in the initial stages of COVID-19. However, this service has historically low rates of ED referrals. However, as the pandemic progressed, ED referrals increased. A potential delayed effect on ED psychopathology has also been reported by others (Lin et al., Reference Lin, Hartman-Munick, Kells, Milliren, Slater, Woods, Forman and Richmond2021).
COVID-19 related social isolation, time home alone, and stressful home environments were viewed as risk factors for depression in this age group (Chen et al., Reference Chen, Zheng, Liu, Gong, Guan and Lou2020). Higher rates of depression have been reported internationally (Ludwig-Walz et al., Reference Ludwig-Walz, Dannheim, Pfadenhauer, Fegert and Bujard2022) and in qualitative interviews with a cohort of 48 Irish families (O’Sullivan et al., Reference O’Sullivan, Clark, McGrane, Rock, Burke, Boyle, Joksimovic and Marshall2021). Given Ireland had one of the longest periods of school closure compared to other countries, it might be expected that rates of depression would be higher (OECD 2021). Contrary to expectations, our study did not show any increase in referrals for depression. Monthly referral rates remained stable at between 9.4 and 9.8/month. Other researchers have highlighted a rebound effect of anxiety symptoms with the easing of lockdown restrictions and re-integration back to school and society (Huang and Ougrin Reference Huang and Ougrin2021). It is possible that our lack of any increase in depression may be due to diagnostic overshadowing with anxiety.
Consistent with the previous study (FitzPatrick et al., Reference FitzPatrick, Antczak, Lynch, Lynch and McNicholas2023) as the pandemic continued, fewer referrals were received relating to ASD and psychosis. This is at odds with the experience of families with children with ASD, where they reported increased MH difficulties during the pandemic, mostly due to educational closures and changes to routine. Concerns have been raised previously that presentations of psychosis have been overshadowed or masked by anxiety during the pandemic, contributing to delays in treatment (O’Donoghue et al., Reference O’Donoghue, O’Connor, Thompson and McGorry2021) and of relevance given the increase in anxiety-related referrals received. Research conducted in Australia showed a twofold increase in presentations during the later phase of restrictions compared to the initial phase (O’Donoghue et al., Reference O’Donoghue, Collett, Boyd, Zhou, Castagnini, Brown, Street, Nelson, Thompson and McGorry2022). This finding does not align with our study and highlights the importance of ongoing surveillance.
In our initial study, we found a significant decrease in ADHD referrals (FitzPatrick et al., Reference FitzPatrick, Antczak, Lynch, Lynch and McNicholas2023). An ADHD specialist CAMHS also reported an 80% reduction in referrals, attributing this to school closure and reduced teacher referrals (McGrath Reference McGrath2020). It stands to reason with the re-opening of schools and other facilities in the latter stages of the pandemic that referrals for ADHD would return to pre-COVID-19 levels. However, our study, covering 40 months after COVID-19 onset does not suggest this. Although there has been an increase in the proportion of referrals over the 40 months (29.9%), compared to the first 10 months post-COVID-19 (11.1%) (FitzPatrick et al., Reference FitzPatrick, Antczak, Lynch, Lynch and McNicholas2023) these have not yet reached levels seen before COVID-19 (43.4%), where the average monthly referral rates were 7.7/month compared to 5.6/month post COVID-19.
Disorder-specific differences and the variance in findings between countries prompt an exploration into potential mitigating factors. Country-specific responses and financial supports to COVID-19, adaptation and roll out of telehealth, use of online communication, extent of family connections may account for some of these differences. (Sean Murray Reference Murray2023, Tibbetts et al., Reference Tibbetts, Epstein-Shuman, Leitao and Kushlev2021).
The COVID-19 pandemic has critically impacted young peoples’ MH (Hossain et al., Reference Hossain, Nesa, Das, Aggad, Tasnim, Bairwa, Ma and Ramirez2022). Perhaps the most pertinent finding of this study is the increase in clinic perceived prioritisation of cases, which has persisted as the pandemic continued. What previously might have been viewed as an acute stress response to the pandemic is evident as persistent for many. Ongoing demand for CAMHS will require requires more resources and manpower – something that needs to be continually advocated and championed for.
Limitations
This study lacked a standardised method for data collection, and data extracted relied on details provided in GP referrals letters alone. Diagnostic proxies drawn from this information were not substantiated by post-assessment diagnosis. Triangulating GP referral letters with post assessment reports would have added credibility to the findings. The retrospective nature of the study and data retrieval from only one CAMHS limits the generalisability of the findings.
Conclusions
Initial increases in GP CAMHS referrals for anxiety, self-harm, and EDs have persisted over the 40 months of the pandemic. The initial decrease in referrals of ASD and psychosis have also persisted over time. Females and older adolescents showed increased referral rates, potentially highlighting a demographic more vulnerable to the pandemic’s MH effects. The persistence of heightened clinical prioritisation underscores the pandemic’s lasting impact on MH service demand. These shifts necessitate adaptable service delivery models and increased resources to address the evolving needs of young patients. The study also emphasises the importance of continuous monitoring and proactive planning to manage the ongoing impact on CAMHS effectively. While the study faced limitations, including reliance on GP referral details and data from a single CAMHS, it underscores the critical need for sustained vigilance and flexibility in MH services. Addressing these ongoing challenges requires enhanced resources and strategic planning to support the MH of young people in the post-pandemic era.
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Competing interests
None.
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.
Ethical approval was granted by St John of God Ethics Board ID 784.
