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Association between co-occurring anxiety and depression with drug overdose encounters in the emergency department among adolescents and young adults in the era of COVID-19

      Abstract

      Purpose

      COVID-19 risk mitigation efforts could have negatively impacted anxiety, depression, and substance use among adolescents and young adults (AYA).

      Methods

      We analyzed 45,223 emergency department visits from April 2018–March 2022 of patients aged 12-21 in Pinellas County, Florida.

      Results

      Frequency of overdose, anxiety, and depression significantly increased from the pre-COVID-19 to the COVID-19 period. Anxiety (adjusted odds ratio [aOR]: 1.49, 95% Confidence Interval [CI]: 1.11, 1.98), and depression (aOR: 2.89, 95% CI: 2.15, 3.88) were associated with significantly higher odds of overdose during COVID-19.

      Conclusion

      Mental health and overdose among AYA worsened during COVID-19, necessitating greater screening and treatment in primary care.

      Key Words

      Abbreviation:

      ED (Emergency Department), AYA (Adolescents and Young Adults)

      Introduction

      Since mid-March 2020, risk mitigation interventions including physical and social distancing were implemented to reduce transmission of COVID-19 in the United States. A consequence of these public health interventions resulted in greater isolation [
      • Le K.
      • Nguyen M.
      The psychological consequences of COVID-19 lockdowns.
      ]. Despite lower risk of developing severe COVID-19 disease compared to adults, the pandemic response has deleteriously impacted the social, physical, and mental well-being of adolescents and young adults (AYA) [
      • Scott S.R.
      • Rivera K.M.
      • Rushing E.
      • Manczak E.M.
      • Rozek C.S.
      • Doom J.R.
      “I Hate This”: A Qualitative Analysis of Adolescents’ Self-Reported Challenges During the COVID-19 Pandemic.
      ]. Emergent findings indicate that mental health related emergency department (ED) visits increased significantly from the pre-pandemic to pandemic periods among AYA [
      • Chadi N.
      • Spinoso-Di Piano C.
      • Osmanlliu E.
      • Gravel J.
      • Drouin O.
      Mental Health–Related Emergency Department Visits in Adolescents Before and During the COVID-19 Pandemic: A Multicentric Retrospective Study.
      ]. Further, aggregate-level weekly overdose rates in the ED increased from 691 per 100,000 ED visits pre-COVID to 899 per 100,000 ED visits during the first 41 weeks after COVID-19 [
      • Holland K.M.
      • Jones C.
      • Vivolo-Kantor
      • et al.
      Trends in US Emergency Department Visits for Mental Health, Overdose, and Violence Outcomes Before and During the COVID-19 Pandemic.
      ]. While these data provide insight on the temporal trends in overdose and other mental health outcomes, individual-level data are needed to assess risk factors and identify intervention targets. Further, the interaction between worsening mental health, particularly anxiety and depression, and substance use among AYA has not been evaluated over the various waves of the COVID-19 pandemic, especially in settings that enacted minimal COVID-19 preventative measures, such as Florida. Given that limited social interactions could have disproportionately affected AYA compared to adults, we aimed to describe the temporal trends in anxiety, depression and overdose encounters before COVID-19 and during the different variant waves of the COVID pandemic (initial phase, delta, and omicron). Secondly, we determined if co-occurring anxiety and depression diagnoses were associated with drug overdose among AYA receiving care in the ED during COVID-19.

      Methods

      We conducted a retrospective cohort study of electronic medical records (EMR) from a large, urban pediatric hospital in Pinellas County, Florida. We analyzed 45,223 pediatric ED visits from April 1, 2018 to March 18, 2022 among 23,282 unique patients aged 12-21 years. The Johns Hopkins School of Medicine IRB approved all study procedures. As risk mitigation efforts and severity of the pandemic changed over time due to emergent variants, we classified the COVID-19 era into four periods: pre-COVID: April 1, 2018 – March 14, 2020; initial: March 15, 2020 – July 14, 2021; delta: July 15, 2021 – December 14, 2021; omicron: December 15, 2021, March 18, 2022. Cutoffs used for delineating the different COVID-19 variant periods were approximate but informed by local epidemiological data from Pinellas County and CDC when these variants became the predominant (>75%) circulating strains [
      • Lambrou A.S.
      • Shirk P.
      • Steele M.K.
      • et al.
      Genomic Surveillance for SARS-CoV-2 Variants: Predominance of the Delta (B.1.617.2) and Omicron (B.1.1.529) Variants — United States, June 2021–January 2022.
      ].
      Clinical predictors of interest included anxiety and depression diagnoses, which were based on international classification of disease 10 (ICD-10) codes and could have been from a previous diagnosis or at the time of the encounter (Supplementary Table 1). Active alcohol abuse was documented if patients were intoxicated at the encounter or self-reported alcohol use. The outcome of interest, drug overdose, was based on ICD-10 codes classified by the CDC [
      • Vivolo-Kantor A.M.
      • Hoots B.E.
      • Scholl L.
      • Pickens C.
      • Roehler D.R.
      • Board A.
      • Mustaquim D.
      • Smith H.
      • Snodgrass S.
      • Liu S.
      Nonfatal Drug Overdoses Treated in Emergency Departments—United States, 2016–2017.
      ]. We generated descriptive statistics stratified by COVID-19 period and the Cochran-Armitage test was used to assess the linear trend of overdose rates over the pre-COVID and COVID-19 periods. Biweekly rates of overdose, anxiety, and depression diagnoses, per 1,000 ED visits were plotted using locally estimated scatterplot smoothing. Multivariable logistic regression with generalized estimating equations, clustered by patient, was used to assess risk factors during the COVID-19 period of experiencing drug overdose. Multivariable models were adjusted for age, sex, race, insurance status, inpatient utilization and having a primary care provider. P-values <0.05 were considered statistically significant. Statistical procedures were conducted in STATA and SAS v.9.4.

      Results

      The median age of patients was 15 (IQR: 13-17) years, 52% of patients were male, and 45% of patients were non-Hispanic White. Overall, the frequency of pre-COVID-19 ED visits with overdose (2.8%, 95% Confidence Interval [CI]: 2.6%, 3.0%), anxiety (4.5%, 95% CI: 4.3%, 4.8%), depression diagnoses (3.3%, 95% CI: 3.1%-3.6%) increased significantly compared to the frequency during the omicron period (4.4% (95% CI: 3.6%, 5.1%), 8.1% (95% CI: 7.1%, 9.0%), 5.9% (95% CI: 5.1%, 6.8%), respectively, p-value for linear trend<0.0001 for all associations, Figure 1, Supplementary Table 2). Frequency of opioid-related overdoses increased from 0.36% (95% CI: 0.29%,0.44%) in the pre-COVID period to 0.77% (95% CI: 0.65%,0.89%) during the COVID-19 period and nearly doubled from 0.61% (95%CI: 0.48%,0.76%) in the initial COVID-19 wave to 1.03% (0.71%,1.45%) during the omicron wave (p-value for linear trend =0.006).
      Figure thumbnail gr1
      Figure 1Locally estimated scatterplot smoothing and 95% confidence intervals of number of overdose (A), anxiety (B), and depression (C) events per 1,000 emergency department visits among adolescent and young adult patients, 12-21 years of age. Dashed lines represent different phases of the COVID-19 pandemic (initial, delta, omicron).
      Adjusted odds ratios [aOR] for patient characteristics associated with overdose during the COVID-19 pandemic are presented in Table 1. Black patients had higher odds (aOR: 1.25 [95% CI: 0.97, 1.60]), of overdose compared to non-Hispanic White patients, however this association did not retain statistical significance. Patients with active alcohol abuse were 4.19 (95% CI: 1.73-10.14) times as likely to experience a drug overdose during the COVID-19 risk period. Diagnosis of both anxiety (aOR: 1.49, 95% CI: 1.11, 1.98) and depression (aOR: 2.89, 95% CI: 2.15, 3.88) were associated with significantly higher odds of experiencing a drug overdose compared to not being diagnosed. During the COVID-19 period, the change in odds of overdose during the omicron period did not reach statistical significance (aOR: 1.20 (95% CI: 0.96,1.50)).
      Table 1Adjusted odds ratios of patient characteristics associated with drug overdose during the era of COVID-19 (March 15, 2020 – March 18, 2022).
      Covariateadjusted odds ratio (aOR)95% CIp-value
      Age per year increase1.051.00-1.090.042
      Sex
      MaleRef
      Female1.000.99-1.000.246
      Race/ethnicity
      White, Non-HispanicRefRef
      Black1.250.97-1.600.083
      Hispanic0.910.68-1.230.539
      Other1.130.75-1.690.555
      Active Alcohol Abuse
      NoRef
      Yes4.191.73-10.140.001
      Type of Insurance
      Publicly funded (Medicaid/Medicare)Ref
      HMO/Commercial0.990.79-1.220.901
      None/Self-pay/other0.530.31-0.920.024
      Anxiety diagnosis
      NoRef
      Yes1.481.11-1.980.007
      Depression diagnosis
      NoRef
      Yes2.892.15-3.88<0.001
      Inpatient Admission
      NoRef
      Yes8.196.71-10.01<0.001
      Has Primary Care Physician
      NoRef
      Yes0.950.75-1.200.653
      COVID-19 period
      InitialRef
      Delta1.180.98-1.430.086
      Omicron1.200.96-1.500.115
      *aOR- Adjusted Odds Ratio
      **95% CI- 95% Confidence Interval

      Discussion

      We found that rates of anxiety, depression, and overdose-related ED visits increased and remained elevated more than two years since the emergence of COVID-19. Although Florida’s lockdown period was shorter than many other states (only during the early months of COVID-19), frequency of anxiety, depression, and overdose-related ED encounters did not return to pre-COVID levels and continued to rise during the delta/omicron waves compared to the initial phase of the pandemic. Potential explanations for these trends include difficulty with readjusting to in-person interactions, continuation of familial stress, and lack of treatment for anxiety and depression that emerged during the initial COVID-19 period [

      Panchal, N., Kamal, R., Garfield, R., & Chidambaram, P. The Implications of COVID-19 for Mental Health and Substance Use. KFF. 2020.

      ]. Anxiety and depression are unlikely to resolve on their own and rates may remain elevated to due patients remaining untreated [
      • Lu W.
      • Bessaha M.
      • Muñoz-Laboy M.
      Examination of Young US Adults’ Reasons for Not Seeking Mental Health Care for Depression, 2011-2019.
      ].
      Strong and significant correlates of overdose during COVID-19 were anxiety or depression diagnosis and alcohol use. This lends further evidence that risk mitigation efforts for reducing transmission of COVID-19 could have worsened mental health and substance use related outcomes in AYA. Generalizability of findings are limited given that data are from one pediatric ED in Florida and findings might underestimate the association in other settings that enforced stricter COVID-19 related risk mitigation efforts [
      • Witkowski K.
      • Yeo J.
      • Belligoni S.
      • Ganapati N.E.
      • Corbin T.
      • Rivera F.
      Florida as a COVID-19 Epicenter: Exploring the Role of Institutions in the State’s Response.
      ]. Misclassification or lack of documented diagnosis in patients’ EMRs is another limitation. Increased routine mental health and substance use screening among AYA in primary care may help reduce overdoses and ED visits. These data also underscore the urgent need for increased efforts to improve access to treatment for mental health and substance use for AYA.

      Implications and Contributions

      Findings from a large pediatric hospital emergency department indicate an increase in overdose, anxiety, and depression among adolescents and young adults from pre-COVID-19 to the COVID-19 era. These results underscore the need to increase mental health and substance use screening in primary care settings.

      Supplementary Data

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