As Canada reviews the lessons of the global COVID-19 pandemic, one thing has become abundantly clear: It's time to bolster efforts to address the country's mental health crisis. Canada is not alone in this predicament. More than 2 years ago, the World Health Organization reported a 25% pandemic-related increase in the prevalence of anxiety and depression across the globe.
For Canadian youth (ie, children and adolescents) and young adults, these increases were simply the tip of the iceberg; findings from two related studies published this month in JAMA Network Open and JAMA Pediatrics highlighted increased rates of hospitalizations for anxiety, personality disorders, and suicide and self-harm. According to these data, hospitalizations were also especially high for eating disorders in girls aged 12-17 years, who accounted for more than three in four admissions across the country between April 2020 and March 2023.
Nadia Roumeliotis, MD, PhD, a pediatric critical care physician at CHU Sainte-Justine in Montreal, Quebec, Canada, and lead author of both studies, told Medscape Medical News that "females seem to have fared worse over the course of the pandemic regarding anxiety disorders, suicide and self-harm, personality disorders, and eating disorders. It's interesting because there's something in the sex-based differences in how male and female adolescents have lived through it."
Hospitalization Rates, Eating Disorders Soar
Roumeliotis and her colleagues conducted a cross-sectional study evaluating pre-pandemic and COVID-19 prevalent periods (April 1, 2016, to March 31, 2023) to estimate differences in crude hospitalization rates for mental health conditions in 6.3 million youth and young adults (ages 6-20 years) in every Canadian province and territory.
Of the 218,101 mental health hospitalizations they identified, relative increases across study periods were most notable in youths aged 12-17 years (ranging from 65.8% in the 4 previous years to 68.4% in the 3-year COVID prevalence period). Women accounted for most of these hospitalizations, with the proportion increasing from 63.8% to 69.0%, from the pre-COVID to the COVID-prevalent period (vs 36.2%-31.0% in men, P < .001).
"It's really the high schoolers that we saw presenting to most hospitals; they made up 85%-90% of the hospitalizations, which is not surprising, because this tends to be where deteriorations in mental health show up, again, mostly in females," said Roumeliotis. "This age group is very vulnerable to loss of social interaction and loss of team and peer interactions," she added.
In the second study, the investigators examined the association between hospitalizations for eating disorders and the stringency of public health measures in school-aged youth and young adults, aged 6-20 years, between April 1, 2016, and March 31, 2023. To better understand if hospitalizations were new or recurrent, the researchers looked back as far as April 1, 2014, for mental health presentations, including eating disorders.
Overall, there were 11,289 hospitalizations for eating disorders among 6.3 million youth across Canada. In both study periods (ie, the pre-COVID and COVID-prevalent periods), more than half of hospital admissions (58.6%) were in patients who had not been previously hospitalized for the condition. And women accounted for 90.4% of all hospitalizations (9.6% were men), 77% of which occurred in patients aged 12-17 years.
These study findings echo those of a meta-analysis published in February in the Journal of the American Academy of Child & Adolescent Psychiatry that explored child and adolescent eating disorder-related visits to health settings across 15 countries, including Canada.
"We found a 54% increase in eating disorders in children and adolescents during the pandemic," said coauthor Tracy Vaillancourt, PhD, Canada Research Chair in School-Based Mental Health and Violence Prevention at the University of Ottawa, Ottawa, Ontario, Canada, and Canadian Institutes of Health Research. Vaillancourt is also chair of the COVID-19 Task Force at the Royal Society of Canada. Larger rate increases were seen in girls (rate ratio [RR], 1.48; 95% CI, 1.28-1.71) than in boys (RR, 1.24; 95% CI, 1.06-1.45) and in adolescents between the ages of 12 and 19 years (RR, 1.53; 95% CI, 1.29-1.81).
Eye to the Future
An important factor driving these figures is the control component, said Vaillancourt, who was not involved in the cross-sectional studies. "Maybe you're subclinical. But now you can't go to the gym, to soccer, the media is saying you're going to gain weight," she said. "All of these things are not good for somebody who's at risk for an eating disorder."
Another factor is Canada's regional stringency (ie, government policy and restrictions measured systematically over time and place), which were among the highest and longest in the G10 nations.
"With increased stringency, there was an increase in eating disorder presentation, and I think that there's a lot to be inferred from that," said Rachel Hana Mitchell, MD, a child and adolescent psychiatrist at Sunnybrook Health Sciences Centre in Toronto and assistant professor of psychiatry at the University of Toronto, Toronto, Ontario, Canada, who was also not involved in the cross-sectional study. "Clinically, I've seen so much of it in the course of the pandemic, and I believe that the signal is real. We have to pay attention to this signal in future pandemic planning," she added.
Prevention and capacity issues might have also played a role. "I was the chair of the Children in Schools COVID report for the Royal Society, and one thing we argued for was prevention, such as having a universal school-based mental health program," said Vaillancourt. "We could also increase capacity in terms of program delivery," she added, noting understaffing and a lack of funding for training programs.
"The time between now and the next pandemic is a time to think about delivery of care, how to make sure that we build resilience in kids so we don't end up where we are with a mental health crisis," she said.
Fortunately, the Canadian government is making preparations. In a statement to Medscape Medical News, representatives from Health Canada and Public Health Agency of Canada said that it is making concerted efforts to fund new and existing programs.
"Through the 2024 budget, the government is investing $500 million over 5 years into a new Youth Mental Health fund to help younger Canadians access mental healthcare and $7.5 million over 3 years to support Kids Help Phone to provide 24/7 mental health, counseling, and support to young people, including reaching those impacted by structural inequities, such as indigenous youth, racialized minorities, 2SLGBTQ+ youth, and newcomers."
The government is also "investing in strengthening the Integrated Youth Services model of care, which offers youth rapid access to integrated and culturally safe youth-targeted services, including mental health and substance use supports, meeting youth where they are: In the community," they wrote.
In the interim, it's critical to catch early warning signs.
Maintaining screening for eating disorders in adolescents is important, regardless of sex, sociodemographic class, weight, or race, said Roumeliotis. "It's also important to maintain community, clinical, and parental supports [in coordination] with family clinicians. Should there be another pandemic, services for adolescents, especially those at risk for eating disorders, anxiety, and self-harm, need to be maintained so we can treat them at home and in the community before they get sick enough to be hospitalized."
Vaillancourt offered one more piece of advice: "It's important that general practitioners, parents, and teachers know how to talk to kids about mental health issues. If the kid is in distress, listen, make sure that they feel validated, be present in the moment, and then move forward with an appropriate plan to deal with it," she said.
"Every single interaction is an opportunity," added Mitchell.
The studies were supported by the Canadian Institutes for Health Research (CIHR). Roumeliotis reported grants from Fonds de Recherche du Québec — Santé, Junior 1 Research Scholar, and CIHR outside the current work. Vaillancourt and Mitchell reported no relevant financial relationships.
Liz Scherer is an independent health journalist based in the United States.