The COVID-19 pandemic has disrupted almost every aspect of our lives. So many people have died, jobs were lost, companies closed, lockdowns and quarantines resulted in social isolation, and healthcare delivery changed.
Many of these stressors affected the mental health of children and adolescents. An article published in Pediatric Annals discusses a survey revealing that over half of adolescents reported feeling depressed, over one-third experienced suicidal ideation, and almost one in 50 attempted suicide during summer 2020, very early in the pandemic. In addition, a Chicago study found a 27% increase in mental health visits by children and adolescents, also early in the pandemic, which increased 4% per month through February 2021. CDC data shows, in 2020, that among children ages 10-14, suicide was the second leading cause of death and the third leading cause for those ages 15-24. This situation greatly increased the number of patients seeking care for mental health and suicide versus before the pandemic.
I remember standing in the pediatric intensive care unit (PICU) in summer 2021, as we admitted another intentional overdose patient: the third in a matter of weeks. It was impossible to ignore the sheer number of patients we had been admitting over the course of the pandemic for suicide and suicide attempts. We were seeing firsthand what the articles mentioned above were finding: the decline in mental health of children and adolescents.
I was curious if other hospitals were experiencing similar trends, so I reached out to a colleague in the San Francisco Bay Area. She shared they were having a similar experience. They were seeing an uptick before the pandemic that skyrocketed with the pandemic. For them it wasn't the number of suicidal kids, but the potentially lethal nature of what they have tried. "They are taking a lot more pills, or hanging themselves, or trying way harder to die than they were before; it's been a big shift for us." While this is firsthand, anecdotal evidence at one hospital, she also shared that they had seen an increase in females attempting suicide. Her input tracks with an article that presented CDC data stating rates of suicides among adolescent girls increased 50.6%, compared with 3.7% in adolescent boys from February to March 2021. The shocking increase in the number of children and adolescents with suicidal ideation and/or suicide attempts during the pandemic helps explain why, in October 2021, the American Academy of Pediatrics and others issued a statement declaring a National State of Emergency in Children's Mental Health.
Are we ready to take on this crisis?
These trends are heartbreaking and support a need for better mental health screenings, access to comprehensive inpatient and psychiatric care and support for pediatric patients. However, are we as nurses ready to take on this role? Are organizations ready? Are patients and families ready? I was chatting with a nurse in the PICU and she said she was concerned not only with the attempts, but the number of children coming in after multiple attempts. In some cases, it seemed like some of the parents didn't seem to care. "These kids are screaming for help — tattoos all over, signs of self-harm, piercings, taking any pills they can find," yet some of the parents she has tried to talk to don't want to believe their child is unhappy and don't want to listen to what the staff have to say. On the flip side, you have parents deeply concerned, but their child has no interest in participating in getting better. I wondered if we as healthcare workers may be playing a role in this discomfort. A video from Nationwide Children's Hospital mentioned providers may have some anxiety in discussing suicide and may unconsciously avoid the topic. Maybe our own discomfort prevents us from fully engaging with patients and families in a way that helps them be more open to discussion.
But I'm not a psych nurse
Pediatric nurses are used to caring for patients with physical illnesses, giving medications, assessing them, etc., yet they may feel unprepared to meet the mental health needs of these patients. Some nurses have shared their feelings of anxiety and discomfort, feeling awkward or unqualified in these situations. One said, "I'm not a psych nurse!" I have even seen avoidance in some nurses and other healthcare workers when dealing with pediatric patients who have considered or attempted suicide. A recent doctoral study expands on the experience of nurses in the acute care setting who lack knowledge and have anxiety about caring for these patients, and provides a nursing toolkit to help care for them.
Often these patients have a sitter, usually unlicensed personnel, in the room with them 24/7 for the patient's safety, and they too have expressed feeling ill-equipped to care for them. Situations have occurred that illustrate both this discomfort and a need for more tools and training. A patient on a 72-hour involuntary hold left the unit when the nurse didn't have line of sight while the patient was in the restroom; the nurse may have wanted to give them some privacy. Similarly, a patient tried to hang themself in the emergency department's bathroom while a security guard was just outside the door. Nurses are taught to allow patients to have privacy and to care for their patient's physical needs, yet this contrasts with the care our potentially suicidal patients need. There needs to be a constant line of sight, they need someone to talk to and to listen to them, and they need a safe environment where they can't harm themselves.
What do patients and families need?
- Staff who are trained in comprehensive suicide prevention
- Suicide screenings
- Clinicians who are empathetic, curious and ask direct questions
- Better access to mental health providers
- Timely access to inpatient psych units when a referral is made
- Social connection and support
Our patients really need us to do better and improve the care we provide when they are in a suicidal state. With the increasing number of suicidal children and adolescents, the time is now. Better access to mental health providers is also important, because we have patients who have been medically cleared but then wait, sometimes a day or two, for psych to decide their disposition. When they are referred to an inpatient psych unit it can take days, even over a week, for a bed in a facility to become available; and when they do find a bed it can be hours from their home. There are not enough child psychiatrists and psychologists, or inpatient psych beds in the community, to care for these kids in a timely manner.
The increasing number of patients we are seeing admitted is only a fraction of this population. The patients who are admitted are the ones who must be medically cleared — from their overdose, asphyxia, etc. — before they can see a child psychiatrist or psychologist to decide their disposition. This does not include the number of patients seen in the emergency department for a primary mental health issue who are waiting for a bed in a psychiatric facility.
What can we do?
- Consider an organizational framework to improve care (e.g., Zero Suicide).
- Integrate suicide prevention strategies into the clinical setting.
- Elicit leadership support for this work.
- Provide tools and ongoing training for clinical staff.
- Provide support and resources for patients and families.
When my colleague from another hospital said they have been really stuck on how to deal with this situation, I was able to empathize. She said they have required more 14-day involuntary treatment holds than ever before, because they are unable to secure psych placement for children in the time frame of the 72-hour hold. They have also tried to support staff with education on suicidal ideation. When staff say, "We aren't psych nurses," she responds, "I'm not either, but this isn't a choice, these are our patients, this is what we do. We manage behavior every day and this is behavioral management."
When I heard this feedback and reflected on my own experiences, I thought we have to do better. She is right: This is not a choice, but it can't be up to individuals or single units to solve this problem. While suicide rates increased during the pandemic, so did research and resources on suicide prevention and treatment. We have a golden opportunity to shift our mindsets to caring for mental health like any physical illness we have trained for. It is my hope that the resources provided here can be a starting point to take on systematic, evidence-based approaches to suicide prevention in children and adolescents.
What are you doing in your unit to address the pediatric mental health crisis?