Impact of the COVID-19 pandemic on utilization of mental health services among children and adolescents using an interrupted time series analysis

This study aimed to examine the impact of the COVID-19 pandemic and SOE on the utilization of mental health services among children and adolescents in Japan. We performed an interrupted time series analysis using Japanese medical claims data stratified by sex and age group. The results of this analysis yielded several important findings. We found that the NOV for health care services and mental health services decreased during the SOE, with similar findings across age/sex groups. Moreover, after the second wave of COVID-19 cases, there was an increase in the NOV and AIE for initial visits for mental health services among girls and adolescent females.

The NOV for health care services and mental health services declined significantly during the SOE (April to May 2022), with a particularly large negative impact among young people. A systematic review based on 81 studies across 20 countries identified a significant decrease in health care service visits that was due to the COVID-19 pandemic (− 42.3%; IQR, − 52.8% to − 31.5%), although there was a large degree of heterogeneity across the studies¹³. By contrast, in our study, the decrease in the NOV for health care services during the SOE (− 20.7%) was relatively small, even in the month with the largest decrease (May 2020). These findings may be explained by the facts that the SOEs implemented in Japan were noncompulsory and modest, and the government recommended proceeding with visits to medical institutions if necessary.

In each age/sex group, the decrease in the NOV for initial visits for mental health services during the SOE was larger than that for health care services, whereas the decrease in the NOV for the follow-up visits for mental health service was smaller than that for health care services. This finding suggests that although patients previously diagnosed with mental disorders were less likely to refrain from visiting medical services, potential patients with mental disorders were more likely to refrain from accessing medical services during the SOE, suggesting that the provision of mental health care that could have reduced foregone care among potential patients may have been insufficient during this period.

In Japan, where mental health care is primarily provided by psychiatric specialists rather than primary care physicians, having a usual source of primary care has been identified as a contributor to maintaining opportunities for medical consultation during the COVID-19 pandemic, although these reports indicated that the rate of uptake for screening for mental disorders was very low during this period²². Meanwhile, studies from countries other than Japan have found that patients’ satisfaction with telehealth services for mental health treatment during the pandemic was comparable to levels of satisfaction with face-to-face and telephonic treatment^23,24. Furthermore, studies have suggested that replacing face-to-face care with telehealth services has mitigated the reduction in consultation opportunities during the pandemic²⁵ and that implementing telehealth for mental health services may have reduced overall medical costs, including costs associated with non–mental health diseases²⁶. Therefore, enhancing telehealth capacity for mental health services in primary care in Japan could contribute to early detection and treatment of mental disorders, potentially leading to improved health care access and cost containment, not only during pandemics. This approach has strong potential to improve access for groups such as young people and those living in remote areas who may not have received adequate care through traditional face-to-face consultations. In the future, it will be important to develop a system of telehealth mental health services that is suitable for Japan’s health care system, to verify the effectiveness and safety of this new approach to mental health services, and to introduce it gradually. Simultaneously, it is necessary to promote the environment required to expand the scope of telemedicine, including education and technical support for health care providers and improving patients’ digital literacy.

After the second outbreak of COVID-19 in Japan, the impact of the pandemic on AIE for health care services and follow-up visits for mental health services was limited; whereas, both the NOV and AIE for initial visits for mental health services increased among girls and adolescent females. This finding suggests that the COVID-19 pandemic contributed to a deterioration in the mental health of girls and adolescent females, consistent with prior reports^{3,4,6,7,8,9,10}. Several factors may have contributed to this deterioration. First, the economic impact of the pandemic was particularly pronounced in industries with high proportions of women workers, with more severe employment losses among women¹. Ueda et al. also reported a surge in suicides among young women in October 2020, finding that young women workers were more likely to experience job and income loss than any other demographic group, suggesting economic factors may have contributed to mental health deterioration²⁸. Second, Ueda et al. noted education-related factors, including loss of educational opportunities and anxiety about graduation and future prospects²⁸. During the pandemic, school-age children and adolescents experienced mandatory home confinement lasting approximately 3 months until the SOE was lifted in late May. According to a survey administered in June and July 2020, approximately 72% of the participants exhibited symptoms of psychological distress, indicating that the extended period of school closures potentially had adverse effects on students’ mental health²⁸. For university students in particular, the shift to online classes beginning in April 2020 and continuing through both spring and fall semesters resulted in an isolated learning environment without in-person campus activities, potentially leading to accumulated stress. Their online survey also reported that 29.41% of university students were classified as being in a depressive state²⁸. These findings from multiple studies in Japan suggest that the pandemic had substantial effects on mental health among adolescents and young adults, as evidenced by the increased utilization of mental health services in this demographic group. In addition to being a young woman, other risk factors for worsening mental health during the pandemic included COVID-19 infection status, a high level of fear associated with COVID-19, and low socioeconomic status^2,3,5,6,9. Pierce et al. identified 2 patterns in the chronology of deteriorating mental health during the pandemic: one in which mental health declines in immediate response to the pandemic and the another in which mental health deteriorates gradually²⁷. During the first COVID-19 outbreak in Japan, the government granted cash benefits to each individual citizen, and the daily number of cases of COVID-19 was not yet particularly high¹. Thus, a significant negative impact on mental health may not have existed at that time. Later during the pandemic, however, several factors may have contributed to cumulative stress: the increased risk of infection during the second outbreak, the prolonged nature of the pandemic itself, and the termination of government cash benefits amid a worsening economy. For school-age children and adolescents, while schools had shifted to remote learning during the first COVID-19 outbreak, the subsequent transition back to in-person schooling may have presented additional challenges, such as difficulties in rebuilding relationships with teachers and peers, and anxiety about returning to school²⁹. For university students, the continued isolated learning environment through online classes may have further contributed to accumulated stress²⁸. Furthermore, the number of COVID-19 cases temporarily decreased after the second outbreak, possibly facilitating access to health care for patients who had been refraining from obtaining medical services. As a result of the combined effects of these factors, the increased NOV and AIE among girls and adolescent females may have finally become apparent after the second wave of COVID-19. The suicide rate in Japan decreased during the initial outbreak of COVID-19, relative to before the pandemic, but increased in the second outbreak, with the increased rate of suicide being most pronounced among young women^1,28. Notably, in our study, while the AIE did not show significant changes during the initial outbreak, suggesting that severe mental health deterioration had not yet progressed at this point, it increased substantially in the later phase of the pandemic. This temporal pattern of AIE may be attributed to two factors: the potential progression of symptoms due to delayed appropriate medical visits during the early pandemic, and the gradual deterioration of mental health due to the prolonged nature of the pandemic. Our study suggests that the mental health of girls and adolescent females deteriorated after the second outbreak, which would be consistent with the findings of prior studies on elevated suicide rates^1,28. Therefore, early detection and treatment of patients with potential mental disorders is needed to prevent increased suicides during a pandemic. Among vulnerable groups, particularly girls and adolescent females, more proactive screening and enhanced support systems could be beneficial. Additionally, it is important to establish systems for providing continuous care that is accessible even under pandemic conditions, for example by utilizing telemedicine and collaborating with local communities through training community volunteers to identify high-risk patients, provide psychological first aid, and coordinate between caregivers and mental health professionals²⁹. In this context, Japan has been developing the Disaster Psychiatric Assistance Team (DPAT) system to provide comprehensive mental health support during emergencies, including pandemics³⁰. Our findings suggest critical areas where DPAT’s functions could be enhanced: maintaining access to mental health services during the initial phase of a pandemic, developing targeted support strategies for vulnerable populations (particularly young women), and ensuring continuity of care for patients with mental disorders. These insights could contribute to building a more resilient mental healthcare system for future crises. Through such measures, it may be possible to minimize the adverse effects of a pandemic on mental health and to contribute to suicide prevention. Further research is needed to evaluate the effectiveness of these strategies in various pandemic-related contexts.

To the best of our knowledge, this is the first study in Japan to analyze the impact of the COVID-19 pandemic on the utilization of mental health services among children and adolescents, using a large cohort of over 3,000,000 individuals. Moreover, the study estimated counterfactual time series using a BSTS model and robustly analyzed the longitudinal impact of the COVID-19 pandemic. This study has several limitations. First, the data used in the study only included individuals enrolled in health insurance societies and thus is not representative of the entire population in Japan. Second, the database used in this study only contained data up to December 2020; therefore, the study could not assess the long-term impact of the pandemic on the outcomes of interest. Third, previous studies have suggested that demographic and socioeconomic factors are associated with mental health outcomes during the pandemic^{1,2,4,27,28,31,32}. However, our analysis could only stratify by sex and age due to data limitations and sample size constraints. Further studies incorporating more detailed demographic and socioeconomic variables are necessary for a comprehensive assessment of the differential impacts of the pandemic across population subgroups. Fourth, the major deregulation and expansion of telemedicine in Japan in April 2020 might have affected mental health care utilization patterns. However, this influence was likely minimal, as the proportion of medical institutions providing telemedicine for initial visits temporarily increased from 0.72 to 1.18% immediately after its implementation but subsequently decreased to 0.64% by October 2020, returning to pre-pandemic levels³³. Moreover, in-person continuity of care for mental health services was maintained for initial visits requiring the prescription of psychotropic medications as Japanese regulations prohibited the prescription of psychotropic medications through telemedicine for initial visit patients. Finally, although the Japanese government actively encouraged medical service utilization during the SOE, changes in psychiatric care delivery systems and mental health specialist availability during the pandemic might have had some slight influence on our findings.