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.
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 reason-for-visit (chief complaint), and administrative diagnosis codes
(determined using codes from the International Classification of Diseases, Ninth Edition,
Clinical Modification; International Classification of Diseases, Tenth Edition, Clinical
Modification; and the Systematized Nomenclature of Medicine) (Supplementary Table,
https://stacks.cdc.gov./view/cdc/127852), and did not differentiate by the primary
or secondary diagnosis when multiple medical conditions were present as part of the
visit record. CDC calculated percent change in mean weekly ED visits overall and by
sex.
¶
Changes were classified as decreased (≤−10%), stable (>−10% to <10%) or increased
(≥10%) to support meaningful change identification and reduce identification of changes
resulting from normative national ED visit fluctuations. Visit ratios (VRs)** with
95% CIs were calculated to describe the proportion of ED visits of interest among
all adolescent ED visits in the surveillance versus comparison periods. Analyses were
conducted using R software (version 4.1.2; The R Foundation). This activity was reviewed
by CDC and conducted consistent with applicable federal law and policy.
††
During January 2019–February 2023, adolescent ED visits for MHCs (overall and specific),
suicide-related behaviors (including suspected suicide attempts), and drug overdoses
(including opioid-involved overdoses) varied over time and by school semester (Figure)
(Supplementary Figure, https://stacks.cdc.gov./view/cdc/127853). Mean weekly ED visits
for MHCs overall, suicide-related behaviors, and drug overdoses were stable during
spring and summer 2022 compared with those during 2021 (Table 1). By fall 2022, mean
weekly adolescent ED visits were decreasing for MHCs overall (−11%), suicide-related
behaviors (−12%), and drug overdoses (−10%) compared with fall 2021; trends for females
mirrored overall patterns, whereas visits among males were stable for each of these
outcomes (−7% to 3%). With some exceptions,
§§
visits for MHCs overall, suicide-related behaviors, and all drug overdoses accounted
for a smaller proportion of ED visits during 2022 compared with 2021.
FIGURE
Mean weekly number (A) and percentage (B) of emergency department visits*
,
†
for mental health conditions overall,
§
all suicide-related behaviors,
¶
and all drug overdoses** among persons aged 12–17 years — National Syndromic Surveillance
Program, United States, January 2019–February 2023
††
Abbreviations: ED = emergency department; ICD-9-CM = International Classification
of Diseases, Ninth Edition, Clinical Modification; ICD-10-CM = International Classification
of Diseases, Tenth Edition, Clinical Modification; MHC = mental health condition;
NSSP = National Syndromic Surveillance Program; SNOMED = Systematized Nomenclature
of Medicine.
* 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 any mental health-related ED visits, including
those for 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.
** The drug overdose classification identifies acute drug poisonings from any type
of drug.
†† The time series displays data from epidemiologic week 1 for 2019 (December 30,
2018) through epidemiologic week 5 for 2023 (February 4, 2023).
The figure consists of two panels showing the mean weekly number and percentage of
emergency department visits for mental health conditions overall, all suicide-related
behaviors, and all drug overdoses among persons aged 12–17 years in the United States
during January 2019–February 2023, according to data provided by the National Syndromic
Surveillance Program.
TABLE 1
Changes in mean weekly number and percentage of emergency department visits*
,
†
involving overall
§
and specific mental health conditions, suicide-related behaviors including suspected
suicide attempts,
¶
and all drug overdoses including opioid-involved overdoses** among persons aged 12–17
years, by school semester — National Syndromic Surveillance Program, United States,
2021–2022
††
,
§§
Mental and behavioral health indicator/Sex
Surveillance period
Comparison period
Spring semester, 2022 (weeks 1–23)††
Spring semester, 2021 (weeks 1–23)
Summer, 2022 (weeks 24–36)††
Summer, 2021 (weeks 24–36)
Fall semester, 2022 (weeks 37–53)††
Fall semester, 2021 (weeks 37–53)
Mean weekly ED visit counts, surveillance period
Absolute change in mean weekly ED visit counts¶¶ (%)
VR (95% CI)***
Mean weekly ED visit counts, surveillance period
Absolute change in mean weekly ED visit counts¶¶ (%)
VR (95% CI)***
Mean weekly ED visit counts, surveillance period
Absolute change in mean weekly ED visit counts¶¶ (%)
VR (95% CI)***
Overall mental health conditions
All
7,083
273 (4)
0.83
(0.83–0.84)
5,031
−385 (−7)
0.97 (0.96–0.98)
6,441
−767 (−11)
0.82 (0.81–0.82)
Female
4,572
70 (2)
0.83 (0.82–0.84)
3,166
−337 (−10)
0.96 (0.95–0.97)
4,057
−616 (−13)
0.81 (0.80–0.82)
Male
2,493
200 (9)
0.85 (0.84–0.86)
1,850
−51 (−3)
0.99 (0.97–1.01)
2,366
−155 (−6)
0.84 (0.82–0.85)
Anxiety disorders
All
2,104
−4 (—)
0.80 (0.79–0.81)
1,697
−140 (−8)
0.96 (0.95–0.98)
1,874
−263 (−12)
0.80 (0.79–0.81)
Female
1,486
−16 (−1)
0.81 (0.80–0.82)
1,181
−122 (−9)
0.96 (0.94–0.99)
1,303
−206 (−14)
0.81 (0.79–0.82)
Male
609
11 (2)
0.80 (0.78–0.82)
508
−20 (−4)
0.98 (0.95–1.01)
562
−60 (−10)
0.80 (0.78–0.83)
Depressive disorders
All
3,055
−66 (−2)
0.78 (0.78–0.79)
1,801
−330 (−15)
0.88 (0.87–0.90)
2,584
−581 (−18)
0.74 (0.74–0.75)
Female
2,202
−102 (−4)
0.78 (0.77–0.79)
1,284
−287 (−18)
0.87 (0.85–0.89)
1,824
−475 (−21)
0.74 (0.73–0.75)
Male
844
35 (4)
0.82 (0.80–0.83)
511
−43 (−8)
0.94 (0.91–0.97)
751
−106 (−12)
0.78 (0.76–0.80)
Attention-deficit/Hyperactivity disorders
All
794
−16 (−2)
0.79
(0.77–0.80
622
−52 (−8)
0.96 (0.93–0.99)
737
−97 (−12)
0.81 (0.79–0.83)
Female
318
−18 (−5)
0.77(0.75–0.80)
245
−22 (−8)
0.98 (0.93–1.02)
291
−47 (−14)
0.80 (0.77–0.83)
Male
472
1 (—)
0.79 (0.76–0.81)
372
−32 (−8)
0.94 (0.90–0.97)
442
−51 (−10)
0.80 (0.77–0.82)
Trauma and stressor-related disorders
All
803
82 (11)
0.89 (0.87–0.91)
562
−17 (−3)
1.01 (0.98–1.05)
744
−51 (−6)
0.85 (0.83–0.88)
Female
533
41 (8)
0.88 (0.86–0.91)
371
−21 (−5)
1.01 (0.97–1.05)
481
−48 (−9)
0.85 (0.82–0.87)
Male
265
40 (18)
0.92 (0.89–0.96)
187
3 (2)
1.04 (0.98–1.10)
260
−2 (−1)
0.88 (0.85–0.92)
Disruptive behavioral and impulse disorders
All
514
45 (10)
0.88 (0.86–0.90)
391
−18 (−4)
1.00 (0.96–1.04)
458
−50 (−10)
0.82 (0.80–0.85)
Female
230
17 (8)
0.88 (0.85–0.92)
178
−4 (−2)
1.04 (0.98–1.10)
209
−18 (−8)
0.86 (0.82–0.90)
Male
282
28 (11)
0.87 (0.84–0.90)
211
−14 (−6)
0.95 (0.90–1.00)
247
−33 (−12)
0.79 (0.75–0.82)
Bipolar disorders
All
229
−23 (−9)
0.73 (0.70–0.75)
183
−29 (−14)
0.90 (0.85–0.95)
201
−32 (−14)
0.79 (0.75–0.82)
Female
148
−12 (−7)
0.76 (0.72–0.79)
114
−20 (−15)
0.91 (0.84–0.97)
130
−20 (−13)
0.81 (0.76–0.86)
Male
80
−12 (−13)
0.68 (0.64–0.72)
68
−10 (−12)
0.89 (0.82–0.98)
70
−12 (−15)
0.75 (0.70–0.82)
Eating disorders
All
141
4 (3)
0.83 (0.79–0.87)
104
−21 (−17)
0.86 (0.80–0.93)
115
−29 (−20)
0.73 (0.69–0.77)
Female
124
0 (—)
0.82 (0.78–0.86)
91
−20 (−18)
0.87 (0.81–0.94)
100
−28 (−22)
0.73 (0.68–0.78)
Male
15
4 (34)
1.05 (0.89–1.23)
12
−1 (−9)
0.92 (0.74–1.15)
14
−1 (−6)
0.84 (0.70–1.01)
Tic disorders
All
42
−24 (−36)
0.51 (0.47–0.55)
30
−10 (−25)
0.78 (0.69–0.89)
34
−19 (−36)
0.59 (0.53–0.65)
Female
27
−23 (−46)
0.44 (0.40–0.49)
19
−9 (−32)
0.72 (0.61–0.84)
19
−16 (−46)
0.50 (0.44–0.58)
Male
15
−1 (−9)
0.72 (0.62–0.83)
11
−1 (−7)
0.95 (0.75–1.20)
14
−2 (−14)
0.77 (0.64–0.91)
Obsessive-compulsive disorders
All
49
−5 (−10)
0.72 (0.67–0.78)
41
−5 (−11)
0.93 (0.83–1.04)
43
−8 (−16)
0.77 (0.69–0.85)
Female
29
−2 (−8)
0.75 (0.68–0.84)
24
0 (—)
1.06 (0.91–1.24)
26
−3 (−9)
0.85 (0.74–0.97)
Male
20
−3 (−11)
0.70 (0.61–0.79)
17
−5 (−23)
0.78 (0.66–0.94)
17
−6 (−26)
0.66 (0.57–0.78)
Suicide-related behaviors
All
4,699
328 (8)
0.86 (0.85–0.87)
2,967
−196 (−6)
0.98 (0.96–0.99)
4,219
−570 (−12)
0.80 (0.80–0.81)
Female
3,329
131 (4)
0.85 (0.84–0.86)
2,080
−203 (−9)
0.97 (0.95–0.98)
2,943
−478 (−14)
0.80 (0.79–0.81)
Male
1,360
195 (17)
0.92 (0.90–0.93)
880
6 (1)
1.03 (1.00–1.05)
1,267
−91 (−7)
0.83 (0.81–0.85)
Suspected suicide attempts
All
1,213
−36 (−3)
0.78 (0.77–0.79)
843
−96 (−10)
0.94 (0.91–0.96)
1,038
−220 (−17)
0.75 (0.74–0.77)
Female
954
−58 (−6)
0.77 (0.76–0.78)
660
−95 (−13)
0.93 (0.90–0.96)
814
−185 (−19)
0.76 (0.74–0.78)
Male
256
23 (10)
0.86 (0.83–0.89)
181
−1 (−1)
1.01 (0.96–1.07)
222
−34 (−13)
0.77 (0.74–0.81)
Drug overdoses overall
All
961
40 (4)
0.84 (0.82–0.85)
704
−47 (−6)
0.98 (0.95–1.01)
862
−97 (−10)
0.82 (0.80–0.84)
Female
690
4 (1)
0.82(0.80–0.84)
496
−53 (−10)
0.96 (0.93–0.99)
604
−104 (−15)
0.80 (0.77–0.82)
Male
269
36 (15)
0.90 (0.87–0.94)
207
5 (3)
1.05 (0.99–1.10)
258
7 (3)
0.92 (0.88–0.96)
Opioid-involved overdoses
All
36
2 (7)
0.86 (0.78–0.95)
38
4 (12)
1.17 (1.03–1.33)
40
8 (27)
1.16 (1.03–1.30)
Female
17
2 (17)
0.96 (0.83–1.11)
16
1 (6)
1.12 (0.92–1.37)
16
1 (10)
1.03 (0.86–1.22)
Male
19
0 (−1)
0.78 (0.68–0.88)
22
3 (16)
1.18 (1.00–1.40)
23
7 (41)
1.25 (1.07–1.47)
Abbreviations: ED = emergency department; ICD-9-CM = International Classification
of Diseases, Ninth Edition, Clinical Modification; ICD-10-CM = International Classification
of Diseases, Tenth Edition, Clinical Modification; MHC = mental health condition;
NSSP = National Syndromic Surveillance Program; SNOMED = Systematized Nomenclature
of Medicine.
* 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).
†† School semester surveillance periods during 2022 were as follows: spring, calendar
weeks 1–23 (Jan 2–Jun 11, 2022); summer, calendar weeks 24–36 (Jun 12–Sep 10, 2022);
and fall, calendar weeks 37–53 (Sep 11–Dec 31, 2022). Corresponding school semester
comparison periods during 2021 were as follows: spring, calendar weeks 1–23 (Jan 3–Jun
12, 2021); summer, calendar weeks 24–36 (Jun 13–Sep 11, 2021); and fall, calendar
weeks 37–53 (Sep 12, 2021–Jan 1, 2022).
§§ Individual values for females and males might not add up to the total values because
of rounding.
¶¶ Percent change in visits per week during each surveillance period was calculated
as the difference in mean weekly visits between the surveillance period and the comparison
period, divided by the mean weekly visits during the comparison period, x 100% ([{mean
weekly ED visits with condition of interest during surveillance period − mean weekly
ED visits with condition of interest during comparison period} / mean weekly ED visits
with condition of interest during the comparison period] x 100%).
*** VR is the proportion of ED visits with condition of interest during the surveillance
period, divided by the proportion of ED visits with condition of interest during the
comparison period ([ED visits with condition of interest {surveillance period} / all
ED visits {surveillance period}] / [ED visits with condition of interest {comparison
period} / all ED visits {comparison period}]). Ratios >1 indicate a higher proportion
of ED visits with the condition of interest during the surveillance period compared
with the comparison period; ratios <1 indicate a lower proportion during the surveillance
period compared with the comparison period.
From school semesters in 2021 to those in 2022, variation in ED visits for specific
MHCs, suspected suicide attempts, and opioid-involved overdoses overall and by sex
were observed (Table 1). By fall 2022, compared with fall 2021, mean weekly ED visits
for opioid-involved overdoses increased among both females (10%) and males (41%).
Compared with the same periods, ED visits for specific MHCs and suspected suicide
attempts among females generally mirrored trends in visits for overall MHCs and suicide-related
behaviors. Among males, mean weekly ED visits were stable for MHCs overall (−6%) and
suicide-related behaviors (−7%), but decreased for some specific MHCs (e.g., anxiety
[−10%], depression [−12%], and many less common conditions) and suspected suicide
attempts (−13%). Among all adolescent ED visits, those for specific MHCs and suspected
suicide attempts accounted for a smaller proportion (VRs = 0.59–0.85 and 0.75, respectively),
and opioid-involved overdoses for a larger proportion (VR = 1.16) during fall 2022
compared with fall 2021. With some exceptions, sex-stratified findings were generally
similar to these overall trends.
Compared with those during 2019 school semesters, visits for MHCs overall, suicide-related
behaviors, and drug overdoses 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.
TABLE 2
Mean weekly number and percentage of emergency department visits*
,
†
involving overall
§
and specific mental health conditions, suicide-related behaviors including suspected
suicide attempts,
¶
and all drug overdoses including opioid-involved overdoses** among persons aged 12–17
years — National Syndromic Surveillance Program, United States, 2019
††
and 2022
§§
Mental and behavioral health indicator/Sex
Surveillance period
Comparison period
Spring semester, 2022 (weeks 1–23)††
Spring semester, 2019 (weeks 1–23)
Summer, 2022 (weeks 24–36)††
Summer, 2019 (weeks 24–36)
Fall semester, 2022 (weeks 37–53)††
Fall semester, 2019 (weeks 37–53)
Mean weekly ED visit counts, surveillance period
Absolute change in mean weekly ED visit counts¶¶ (%)
VR
(95% CI)***
Mean weekly ED visit counts, surveillance period
Absolute change in mean weekly ED visit counts¶¶ (%)
VR
(95% CI)***
Mean weekly ED visit counts, surveillance period
Absolute change in mean weekly ED visit count)¶¶ (%)
VR
(95% CI)***
Overall mental health conditions
All
7,083
252 (4)
1.13 (1.13–1.14)
5,031
−279 (−5)
0.97 (0.96–0.98)
6,441
−943 (−13)
0.87 (0.86–0.88)
Female
4,572
462 (11)
1.22 (1.21–1.23)
3,166
8 (—)
1.04 (1.03–1.05)
4,057
−343 (−8)
0.93 (0.92–0.94)
Male
2,493
−213 (−8)
1.01 (1.00–1.02)
1,850
−294 (−14)
0.88 (0.87–0.89)
2,366
−606 (−20)
0.79 (0.78–0.80)
Anxiety disorders
All
2,104
159 (8)
1.18 (1.17–1.20)
1,697
−94 (−5)
0.98 (0.96–0.99)
1,874
−331 (−15)
0.85 (0.84–0.86)
Female
1,486
164 (12)
1.23 (1.21–1.25)
1,181
−28 (−2)
1.01 (0.99–1.04)
1,303
−192 (−13)
0.88 (0.86–0.89)
Male
609
−8 (−1)
1.08 (1.06–1.11)
508
−69 (−12)
0.90 (0.87–0.93)
562
−145 (−20)
0.79 (0.77–0.81)
Depressive disorders
All
3,055
156 (5)
1.15 (1.14–1.16)
1,801
−116 (−6)
0.97 (0.95–0.98)
2,584
−528 (−17)
0.83 (0.82–0.84)
Female
2,202
232 (12)
1.22 (1.21–1.24)
1,284
−32 (−2)
1.01 (0.99–1.03)
1,824
−278 (−13)
0.87 (0.86–0.89)
Male
844
−80 (−9)
1.00 (0.98–1.02)
511
−86 (−14)
0.87 (0.85–0.90)
751
−251 (−25)
0.74 (0.73–0.76)
Attention-deficit/Hyperactivity disorders
All
794
−236 (−23)
0.84 (0.83–0.86)
622
−290 (−32)
0.70 (0.68–0.72)
737
−445 (−38)
0.62 (0.61–0.64)
Female
318
−55 (−15)
0.93 (0.90–0.96)
245
−92 (−27)
0.75 (0.72–0.79)
291
−139 (−32)
0.68 (0.66–0.71)
Male
472
−181 (−28)
0.79 (0.77–0.81)
372
−200 (−35)
0.66 (0.64–0.69)
442
−308 (−41)
0.58 (0.57–0.60)
Trauma and stressor-related disorders
All
803
69 (9)
1.20 (1.17–1.22)
562
−2 (—)
1.03 (0.99–1.06)
744
−64 (−8)
0.92 (0.90–0.94)
Female
533
69 (15)
1.26 (1.22–1.29)
371
6 (2)
1.06 (1.01–1.10)
481
−26 (−5)
0.95 (0.93–0.98)
Male
265
−3 (−1)
1.08 (1.05–1.12)
187
−10 (−5)
0.97 (0.92–1.02)
260
−40 (−13)
0.86 (0.82–0.90)
Disruptive behavioral and impulse disorders
All
514
−66 (−11)
0.97 (0.95–0.99)
391
−102 (−21)
0.82 (0.79–0.85)
458
−148 (−24)
0.75 (0.73–0.78)
Female
230
−16 (−6)
1.02 (0.99–1.06)
178
−33 (−16)
0.87 (0.83–0.92)
209
−46 (−18)
0.82 (0.79–0.86)
Male
282
−49 (−15)
0.93 (0.90–0.96)
211
−69 (−25)
0.77 (0.73–0.81)
247
−102 (−29)
0.70 (0.67–0.73)
Bipolar disorders
All
229
−61 (−21)
0.86 (0.83–0.90)
183
−86 (−32)
0.70 (0.67–0.74)
201
−116 (−37)
0.63 (0.61–0.66)
Female
148
−26 (−15)
0.93 (0.89–0.98)
114
−50 (−30)
0.72 (0.68–0.77)
130
−61 (−32)
0.69 (0.65–0.72)
Male
80
−35 (−31)
0.76 (0.71–0.80)
68
−37 (−35)
0.66 (0.61–0.72)
70
−55 (−44)
0.55 (0.52–0.60)
Eating disorders
All
141
75 (114)
2.34 (2.20–2.49)
104
44 (72)
1.77 (1.62–1.93)
115
41 (55)
1.55 (1.44–1.66)
Female
124
68 (121)
2.42 (2.27–2.58)
91
39 (75)
1.82 (1.65–2.00)
100
36 (57)
1.57 (1.46–1.70)
Male
15
6 (61)
1.76 (1.49–2.09)
12
4 (46)
1.49 (1.16–1.90)
14
4 (37)
1.36 (1.11–1.67)
Tic disorders
All
42
13 (44)
1.57 (1.43–1.74)
30
5 (20)
1.24 (1.07–1.43)
34
2 (8)
1.07 (0.95–1.21)
Female
27
14 (108)
2.27 (1.98–2.61)
19
9 (93)
2.00 (1.62–2.47)
19
7 (56)
1.57 (1.31–1.88)
Male
15
−2 (−9)
0.99 (0.85–1.15)
11
−4 (−29)
0.73 (0.59–0.90)
14
−5 (−24)
0.75 (0.63–0.89)
Obsessive-compulsive disorders
All
49
1 (2)
1.12 (1.03–1.22)
41
−1 (−3)
1.00 (0.89–1.13)
43
−10 (−19)
0.81 (0.73–0.90)
Female
29
6 (28)
1.40 (1.25–1.58)
24
3 (16)
1.20 (1.02–1.41)
26
0 (−2)
0.99 (0.86–1.13)
Male
20
−5 (−21)
0.86 (0.76–0.98)
17
−4 (−21)
0.80 (0.67–0.96)
17
−10 (−36)
0.63 (0.54–0.74)
Suicide-related behaviors
All
4,699
1,008 (27)
1.39 (1.38–1.40)
2,967
505 (20)
1.24 (1.22–1.26)
4,219
292 (7)
1.07 (1.06–1.08)
Female
3,329
867 (35)
1.48 (1.46–1.49)
2,080
446 (27)
1.32 (1.30–1.34)
2,943
363 (14)
1.15 (1.13–1.16)
Male
1,360
137 (11)
1.22 (1.20–1.24)
880
56 (7)
1.09 (1.06–1.12)
1,267
−74 (−6)
0.94 (0.92–0.95)
Suspected suicide attempts
All
1,213
328 (37)
1.50 (1.47–1.53)
843
165 (24)
1.28 (1.24–1.32)
1,038
121 (13)
1.13 (1.11–1.15)
Female
954
285 (43)
1.56 (1.53–1.59)
660
150 (30)
1.34 (1.30–1.39)
814
131 (19)
1.20 (1.17–1.23)
Male
256
41 (19)
1.30 (1.25–1.35)
181
14 (8)
1.10 (1.04–1.17)
222
−12 (−5)
0.94 (0.90–0.98)
Drug overdoses overall
All
961
208 (28)
1.40 (1.37–1.42)
704
96 (16)
1.19 (1.16–1.23)
862
78 (10)
1.10 (1.07–1.12)
Female
690
180 (35)
1.48 (1.45–1.52)
496
87 (21)
1.26 (1.21–1.30)
604
84 (16)
1.17 (1.13–1.20)
Male
269
27 (11)
1.22 (1.17–1.26)
207
8 (4)
1.06 (1.01–1.12)
258
−7 (−3)
0.97 (0.92–1.01)
Opioid-involved overdoses
All
36
15 (73)
1.89 (1.69–2.12)
38
21 (123)
2.30 (1.96–2.69)
40
12 (44)
1.44 (1.28–1.63)
Female
17
7 (70)
1.86 (1.58–2.20)
16
8 (103)
2.11 (1.66–2.67)
16
4 (32)
1.32 (1.10–1.59)
Male
19
8 (75)
1.91 (1.64–2.23)
22
13 (137)
2.42 (1.96–3.00)
23
8 (54)
1.53 (1.30–1.80)
Abbreviations: ED = emergency department; ICD-9-CM = International Classification
of Diseases, Ninth Edition, Clinical Modification; ICD-10-CM = International Classification
of Diseases, Tenth Edition, Clinical Modification; MHC = mental health condition;
NSSP = National Syndromic Surveillance Program; SNOMED = Systematized Nomenclature
of Medicine.
* 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).
†† School semester surveillance periods during 2022 were as follows: spring, calendar
weeks 1–23 (Jan 2–Jun 11, 2022); summer, calendar weeks 24–36 (Jun 12–Sep 10, 2022);
and fall, calendar weeks 37–53 (Sep 11–Dec 31, 2022). Corresponding school semester
comparison periods during 2019 were as follows: spring, calendar weeks 1–23 (Dec 30,
2018–June 8, 2019); summer, calendar weeks 24–36 (June 9–Sept 7, 2019); and fall,
calendar weeks 37–53 (Sept 8–Dec 28, 2019).
§§ Individual values for females and males might not add up to the total values because
of rounding.
¶¶ Percent change in visits per week during each surveillance period was calculated
as the difference in mean weekly visits between the surveillance period and the comparison
period, divided by the mean weekly visits during the comparison period, x 100% ([{mean
weekly ED visits with condition of interest during surveillance period − mean weekly
ED visits with condition of interest during comparison period} / mean weekly ED visits
with condition of interest during comparison period] x 100%).
*** VR is the proportion of ED visits with condition of interest during the surveillance
period, divided by the proportion of ED visits with condition of interest during the
comparison period ([ED visits with condition of interest {surveillance period} / all
ED visits {surveillance period}] / (ED visits with condition of interest {comparison
period} / all ED visits {comparison period}]). Ratios >1 indicate a higher proportion
of ED visits with the condition of interest during the surveillance period compared
with the comparison period; ratios <1 indicate a lower proportion during the surveillance
period compared with the comparison period.
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.
Discussion
These findings extend previous research that indicated worsening in some aspects of
adolescent mental and behavioral health during the COVID-19 pandemic (
2
–
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 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.
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,
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 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.
§§§§§§
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, suicide-related
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.