Emergency Department Visits Involving Mental Health Conditions, Suicide-Related Behaviors, and Drug Overdoses Among Adolescents — United States, January 2019–February 2023

The U.S. adolescent mental and behavioral health crisis is ongoing,* with high pre-COVID-19 pandemic baseline rates† (1) and further increases in poor mental health (2), suicide-related behaviors (3), and drug overdose deaths (4) reported during 2020-2021. CDC examined changes in U.S. emergency department (ED) visits for mental health conditions (MHCs) overall and for nine specific MHCs,§ suicide-related behaviors (including suspected suicide attempts), and drug-involved overdoses (including opioids) among children and adolescents aged 12-17 years (adolescents) during January 2019-February 2023, overall and by sex. Compared with fall 2021, by fall 2022, decreases in weekly ED visits were reported among all adolescents, and females specifically, for MHCs overall, suicide-related behaviors, and drug overdoses; weekly ED visits among males were stable. During this same period, increases in weekly ED visits for opioid-involved overdoses were detected. Mean weekly ED visits in fall 2022 for suicide-related behaviors and MHCs overall were at or lower than the 2019 prepandemic baseline, respectively, and drug overdose visits were higher. Differences by sex were observed; levels among females were at or higher than prepandemic baselines for these conditions. These findings suggest some improvements as of fall 2022 in the trajectory of adolescent mental and behavioral health, as measured by ED visits; however, poor mental and behavioral health remains a substantial public health problem, particularly among adolescent females. Early identification and trauma-informed interventions, coupled with expanded evidence-based, comprehensive prevention efforts, are needed to support adolescents' mental and behavioral health.

The U.S. adolescent mental and behavioral health crisis is ongoing,* with high pre-COVID-19 pandemic baseline rates † (1) and further increases in poor mental health (2), suicide-related behaviors (3), and drug overdose deaths (4) reported during 2020-2021. CDC examined changes in U.S. emergency department (ED) visits for mental health conditions (MHCs) overall and for nine specific MHCs, § suicide-related behaviors (including suspected suicide attempts), and druginvolved overdoses (including opioids) among children and adolescents aged 12-17 years (adolescents) during January 2019-February 2023, overall and by sex. Compared with fall 2021, by fall 2022, decreases in weekly ED visits were reported among all adolescents, and females specifically, for MHCs overall, suicide-related behaviors, and drug overdoses; weekly ED visits among males were stable. During this same period, increases in weekly ED visits for opioid-involved overdoses were detected. Mean weekly ED visits in fall 2022 for suicide-related behaviors and MHCs overall were at or lower than the 2019 prepandemic baseline, respectively, and drug overdose visits were higher. Differences by sex were observed; levels among females were at or higher than prepandemic baselines for these * Multiple declarations related to the adolescents' mental and behavioral health crisis have been issued by federal authorities (https://www.hhs.gov/sites/default/ files/surgeon-general-youth-mental-health-advisory.pdf) and national health care organizations (https://www.aap.org/en/advocacy/child-and-adolescenthealthy-mental-development/aap-aacap-cha-declaration-of-a-nationalemergency-in-child-and-adolescent-mental-health/). † CDC data on adolescent mental and behavioral health can be queried online, including data on fatal and nonfatal overdoses and suicide-related behaviors (https://www.cdc.gov/injury/wisqars/index.html) and self-reported data on mental health, suicide-related behaviors, and substance use (https://nccd.cdc. gov/youthonline/App/Default.aspx). § Anxiety, attention-deficit/hyperactivity disorders, bipolar disorders, depression, disruptive behavioral and impulse-control disorders, eating disorders, obsessivecompulsive disorders, tic disorders, and trauma and stressor-related disorders.
conditions. These findings suggest some improvements as of fall 2022 in the trajectory of adolescent mental and behavioral health, as measured by ED visits; however, poor mental and behavioral health remains a substantial public health problem, particularly among adolescent females. Early identification and trauma-informed interventions, coupled with expanded evidence-based, comprehensive prevention efforts, are needed to support adolescents' mental and behavioral health.
CDC examined ED visit data for adolescents from facilities consistently reporting data to the National Syndromic Surveillance Program (NSSP) during January 2019-early February 2023. A collaboration among CDC, local, and state health departments, and federal, academic, and private sector partners, NSSP receives anonymized medical record data from approximately 75% of EDs nationwide, although fewer than 50% of facilities from California, Hawaii, Minnesota, and Oklahoma currently participate. To reduce artifactual impact from changes in reporting patterns, analyses were restricted to facilities with a coefficient of variation for ED visits of ≤40 and average weekly informative discharge diagnosis ≥75% complete throughout the study period. In addition to displaying continuous trends, school semester surveillance periods in 2022 (spring included calendar weeks 1-23; summer, weeks 24-36; and fall, weeks 37-53) were compared with corresponding periods in 2021 and 2019 to monitor recent changes in ED visits and differences from the prepandemic baseline, respectively. School semester surveillance periods were used after visual inspection of visits related to MHCs, suicide-related behaviors, and drug overdoses for adolescents, which indicated substantial seasonal variation in visit patterns that mirrored U.S. K-12 education semesters (spring semester, summer vacation, fall semester). ED visits of interest were identified using a combination of free-text reasonfor-visit (chief complaint), and administrative diagnosis codes (determined using codes from the  during 2022 varied (Table 2). By fall 2022, compared with fall 2019, mean weekly ED visits were lower than the prepandemic baseline for MHCs overall (-13%) and comparable to baseline for suicide-related behaviors (7%); visits for drug overdoses were higher during fall 2022 (10%) than during fall 2019. Mean weekly ED visits among females were stable for MHCs overall (−8%) but increased for suicide-related behaviors (14%) and drug overdoses (16%) during fall 2022 compared with fall 2019. Among males, mean weekly ED visits in fall 2022 for MHCs overall were lower (−20%) than those during fall 2019, but were stable for suicide-related behaviors (−6%) and drug overdoses (−3%). Among all adolescent ED visits during fall 2022, those for MHCs overall accounted for a lower proportion (VR = 0.87), and those for suicide-related behaviors and drug overdoses for a higher proportion (VRs = 1.07 and 1.10, respectively) than during fall 2019. In fall 2022, VR findings by sex generally mirrored broader trends, especially for females; among males, the proportion of suicide-related behaviors was lower (VR = 0.94) and for drug overdose (VR = 0.97) was similar, compared with fall 2019. Adolescent ED visits for specific MHCs, suspected suicide attempts, and opioid-involved overdoses, overall and by sex, varied by school semester in 2022 compared with 2019 ( Table 2). As of fall 2022, ED visits for eating disorders increased overall (55%; VR = 1.55) and for both sexes, and tic disorders increased among females only (56%; VR = 1.57). ED visits for other specific MHCs were lower than or comparable with visits during fall 2019. Patterns for suspected suicide attempts and opioid-involved overdoses generally followed the broader directional trends for suicide-related behaviors and drug overdoses, respectively.      * NSSP receives anonymized medical record information from approximately 75% of nonfederal EDs nationwide. NSSP collects free-text reason-for-visit (chief complaint), discharge diagnosis, and patient demographic details. Diagnosis information is collected using ICD-9-CM, ICD-10-CM, and SNOMED codes. † To reduce artifactual impact from changes in reporting patterns, analyses were restricted to facilities with a coefficient of variation for ED visits ≤40 and average weekly informative discharge diagnosis ≥75% complete throughout the study period. § The overall MHC classification identifies all mental health-related ED visits, including the nine MHCs included in this analysis (anxiety, attention-deficit/hyperactivity disorders, bipolar disorders, depression, disruptive behavioral and impulse-control disorders, eating disorders, obsessive-compulsive disorders, tic disorders, and trauma and stressor-related disorders), schizophrenia spectrum disorders, additional low-prevalence MHCs (e.g., delusional disorders and reactive attachment), and general mental health terms and codes. ¶ The suicide-related behaviors classification identifies ED visits related to suicidal ideation, self-harm, and suspected suicide attempts, whereas the suspected suicide attempt classification only includes suspected suicide attempts. ** The drug overdose classification identifies acute drug poisonings from any type of drug, whereas the opioid-involved overdose classification includes acute drug poisonings from illicit (e.g., heroin) or prescription opioids (e.g., oxycodone).

Discussion
These findings extend previous research that indicated worsening in some aspects of adolescent mental and behavioral health during the COVID-19 pandemic (2)(3)(4)(5) and suggest some improvements in the trajectory of adolescent mental and behavioral health, as measured by ED visits. Declines in adolescent ED visits for overdoses overall from 2021 to 2022 are consistent with other available nonfatal ¶ ¶ and provisional fatal overdose*** data, though comparable data beyond 2021 on mental health and suicidal behaviors are limited. Increases in opioid-involved overdoses warrant further investigation but might be related to the overall rarity of adolescent opioid-involved overdoses, such ¶ ¶ https://www.cdc.gov/drugoverdose/nonfatal/dashboard/index.html *** https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm  * NSSP receives anonymized medical record information from approximately 75% of nonfederal EDs nationwide. NSSP collects free-text reason-for-visit (chief complaint), discharge diagnosis, and patient demographic details. Diagnosis information is collected using ICD-9-CM, ICD-10-CM, and SNOMED codes. † To reduce artifactual impact from changes in reporting patterns, analyses were restricted to facilities with a coefficient of variation for ED visits ≤40 and average weekly informative discharge diagnosis ≥75% complete throughout the study period. § The overall MHC classification identifies all mental health-related ED visits, including the nine MHCs included in this analysis (anxiety, attention-deficit/hyperactivity disorders, bipolar disorders, depression, disruptive behavioral and impulse-control disorders, eating disorders, obsessive-compulsive disorders, tic disorders, and trauma and stressor-related disorders), schizophrenia spectrum disorders, additional low-prevalence MHCs (e.g., delusional disorders and reactive attachment), and general mental health terms and codes. ¶ The suicide-related behaviors classification identifies ED visits related to suicidal ideation, self-harm, and suspected suicide attempts, whereas the suspected suicide attempt classification only includes suspected suicide attempts. ** The drug overdose classification identifies acute drug poisonings from any type of drug, whereas the opioid-involved overdose classification includes acute drug poisonings from illicit (e.g., heroin) or prescription opioids (e.g., oxycodone). that even a 10% change actually represents a small absolute change in the number of overdoses. Still, any adolescent overdose is concerning, particularly as increased availability of highly potent and lethal counterfeit pills containing illicitly manufactured fentanyl among adolescents via social media platforms † † † has heighted awareness recently about increasing overdose risk among younger populations. Despite some recent declines in ED visits for MHCs, suicide-related behaviors, and drug overdoses, poor adolescent mental and behavioral health remains a notable public health problem (1-6), particularly because ED visits for these conditions remain similar to or higher than already concerningly high prepandemic baselines among females into 2022. † † † h t t p s : / / w w w. d e a . g o v / s t o r i e s / 2 0 2 1 / 2 0 2 1 -0 7 / 2 0 2 1 -0 7 -2 3 / counterfeit-drugs-social-media Multiple reasons might account for these findings. Many adolescents have returned to prepandemic-like school and community environments, which might have improved social engagement, reduced isolation, and supported mental and behavioral health for some adolescents (6,7). Familial or other stressors might also have declined, resulting in fewer adverse childhood experiences, § § § which are strongly associated with adolescent mental and behavioral health (8). CDC has released resources to guide states, communities, and schools in selecting strategies for prevention of suicide, ¶ ¶ ¶ overdose,**** and adverse childhood experiences, † † † † based on the best available evidence. Implementation of these strategies and approaches, § § § https://www.cdc.gov/injury/priority/aces.html ¶ ¶ ¶ https://www.cdc.gov/suicide/pdf/preventionresource.pdf **** https://www.cdc.gov/drugoverdose/pdf/pubs/2018-evidence-basedstrategies.pdf

Summary
What is already known about this topic?
High baseline rates of poor adolescent mental and behavioral health were exacerbated by the COVID-19 pandemic.
What is added by this report?
By fall 2022, weekly ED visits among adolescents, and females in particular, for mental health conditions overall, suicide-related behaviors, and drug overdoses decreased compared with those during fall 2021; weekly ED visits among males were stable. Although sex differences were observed, as of fall 2022, weekly ED visits among females were at or higher than the prepandemic baseline for mental health conditions overall, suiciderelated behaviors, and drug overdoses.
What are the implications for public health practice?
Early condition identification and trauma-informed interventions, coupled with evidence-based, comprehensive prevention efforts, are needed to support adolescents' mental and behavioral health.
and others that support adolescents and their families § § § § might improve mental and behavioral health for some adolescents. For example, communication campaigns ¶ ¶ ¶ ¶ can improve the rapid identification of behavioral changes, improve adolescent help-seeking behaviors, and support early intervention by parents and trusted adults. Further, federal investments, such as the 988 suicide crisis line***** and improvements to accessible behavioral health care (e.g., telehealth) † † † † † might have improved families' ability to identify support before a crisis or get care outside EDs. Clinicians who work with adolescents being treated in EDs for opioid overdose might consider screening for opioid use disorder and providing timely, FDA-approved medications (9); clinicians might also consider screening for depression and anxiety when evaluating adolescents. § § § § § Continued promotion of policies and programs that improve access to † † † † https://www.cdc.gov/violenceprevention/pdf/preventingACES.pdf § § § § Essentials for Parenting is a free online resource for parents based on the best available evidence on parenting. There are two versions: one for parents of toddlers and preschoolers (https://www.cdc.gov/parents/essentials/index. html) and one for parents of adolescents (https://www.cdc.gov/parents/ essentials/teens/index.html). Other resources are also available, such as those from The National Academies of Sciences, Engineering, and Medicine (https://nap.nationalacademies.org/resource/other/dbasse/ wellbeing-tools/interactive/). ¶ ¶ ¶ ¶ Examples include those from CDC (https://www.cdc.gov/howrightnow/) and the Substance Abuse and Mental Health Services Administration (https://www.samhsa.gov/talk-they-hear-you). ***** https://www.samhsa.gov/find-help/988 † † † † † https://telehealth.hhs.gov/providers/policy-changes-during-thecovid-19-public-health-emergency/ mental and behavioral health services, coupled with primary prevention efforts that support adolescents and their families, might mitigate risk for mental and behavioral health problems before they begin (10). Further prevention, intervention, and response efforts can be implemented to continue improving adolescent mental and behavioral health. The findings in this report are subject to at least five limitations. First, NSSP data are not nationally representative and data quality variations across facilities could potentially lead to over-or underreporting, potentially affecting visit trends. Second, this analysis used percent change thresholds to support identification of meaningful changes; however, this might under-identify (in the case of common ED visits such as overall MHCs) or over-identify (in the case of rare ED visits such as opioid-involved overdose) concerning trends, because this metric depends upon number of visits for conditions of interest. Third, these data cannot be used to make causal inferences regarding trend changes. Fourth, this analysis could not differentiate between primary or secondary diagnoses when multiple conditions were addressed at the visit. Finally, data are from ED visits which do not represent the full spectrum of adolescent mental and behavioral health challenges; trends warrant confirmation with adolescent self-report data.
Prioritizing implementation of evidence-based prevention and trauma-informed early intervention and treatment strategies that promote mental and behavioral health among adolescents might help prevent MHCs, suicide-related behaviors, and drug overdoses, and improve overall health. CDC supports efforts to promote adolescent well-being and provides resources for clinicians, ¶ ¶ ¶ ¶ ¶ families,****** schools, † † † † † † and communities. § § § § § §