The epidemiological trend of neuropsychiatric disorders has been constantly growing in the last decade [26, 27]. A new social and sanitary scenario due to SARS-CoV-2 infection outbreak was inserted in the context of this alarming trend. Social distancing, numerous limitations, changes in daily routine, and a sense of anxiety and uncertainty for health and for the future affected negatively the psychological wellbeing of both adults and children. In the field of mental health, this study aimed to observe the way in which the COVID-19 sanitary emergency affected the clinical features and the management of patients hospitalised for neuropsychiatric problems, comparing the first COVID year with the previous one.
Patients appeared generally similar regarding sociodemographic and family variables. The majority of inpatients were female adolescents between 12 and 17 years. This result is widely documented by the literature, according to which before puberty males and females presented the same rate of mental illness, while this rate rises for the female sex in adolescence [28, 29]. According to the fact that more than half of inpatients were adolescents, it was observed that almost half of them attended high school, while a quarter of them attended middle school. It should be kept in mind that high school students suffered more from containment measures (e.g., suspension of the educational offline activities for longer periods). In this sense, different studies questioned the school closure’s efficacy as anti-contagion measure, assuming that the damages, at a psychological level, for children and adolescents, will exceed over time the benefits related to contagion [30, 31].
Data related to bullying, peer socialisation, and time use of devices were similar in the pre-COVID and COVID samples. As we know from the literature, there was a strong association between being a victim of bullying and psychosocial functioning impairment, as well as physical and psychopathological symptoms [32,33,34]. Similarly, the association between excessive internet use (more than three hours per day), already increased in the pre-COVID era [35, 36], and internalising mental health problems (specifically anxiety, depression, and mixed mental disorders) is well known [37]. Our data, which did not show substantial differences between the two years, should be interpreted in the light of psychopathology symptoms, which are themselves associated with the abovementioned factors (difficult socialisation, bullying, and internet addiction) [38].
Regarding the use of substances, such as alcohol and tobacco, an increase was observed, especially for alcohol and tobacco. This result could be controversial: on one hand, mental health disease due to forced social distancing and other COVID 19 related limitations and changes could facilitate increase in alcohol, other substances, and tobacco consumption, and, on the other hand during the most restrictive period of COVID-19 epidemic in which it was forbidden to move without demonstrable need, the availability of these substances was limited, especially for adolescents. In any case, there was a stronger association between emotional–behavioural vulnerability and substance abuse, from adolescence to adulthood [39]. Data reported by Italian National Health Institute during the COVID-19 epidemic, show a change in the consumption typology and modality: on one side, a reduction in substances consumed, usually a stimulant (amphetamine and/or cocaine) that in the pre-COVID-19 era could be consumed in social contexts (e.g., café, discotheque, etc.,) and, on the other side, an increase in substances consumed with a calming effect (opioid, benzodiazepines, and cannabinoid). Moreover, the COVID-19 group of inpatients showed an increase in tobacco smoking three times more than the pre-COVID-19 group. An Italian study on the adult population highlighted that tobacco smokers increased by 9.1% from 27 April to 3 May 2020. [40]. In terms of other vulnerability factors on the development of psychiatric pathologies, the results were similar for both years: the majority of inpatients had psychiatric familiarity, had parents or first-degree relatives who suffered from another pathology, had previously accessed neuropsychiatric services or requested other forms of assistance (e.g., psychological, psychotherapeutic, or psychiatric support). About 40% of inpatients reported at least one traumatic life event and were also affected by one or more non psychic chronic pathologies.
Special attention was drawn to suicidal and non-suicidal self-injury, because of the increase in self-harming related accesses to mental health services, as detected in clinical daily practice and in the scientific literature [41]. COVID-19 year inpatients reported more suicidal ideation than pre-COVID-19 era inpatients; nevertheless, inpatients of the COVID-19 group attempted suicide more or less with the same frequently as the pre-COVID-19 inpatients. Among COVID-19 year patients with a suicide attempt, poisoning and wrist-cutting were increased compared to other suicidal methods. Literature relating to COVID-19 epidemic effects on suicidal behaviour, although limited to date, highlighted a significant increase in both suicidal ideation and attempts among adolescents in the COVID-19 period compared to the previous year, specifying that rates of suicide ideation and attempts were higher during some months of 2020 as compared with 2019 but were not universally higher across this period [19]. Our data showed a larger suicidal ideation increase than suicidal attempts, suggesting the possibility of higher suicide rates in the future. According to that, a recent first meta-analysis estimate of suicidal ideation based on a large sample from different countries and populations has shown the rate of suicidal ideations during COVID-19 pandemic was higher than that reported in studies on the general population prior to the pandemic [20]. The increase in suicidal ideation in the COVID-19 year is coherent with the rise of anxiety, stress, and depression, related to the protracted period of lockdown and the interruption of educational and sport activities, known risk factors for the development of self-injury and suicidal behaviours [42, 43]. The relative reduction in suicide attempts could be due to limiting/ protective actions of the lockdown on children and adolescents, who were more supervised by parents. In line, it is the variation of percentage related to suicidal methods in the COVID-19 year: substance and drug poisoning and wrist-cutting were reported as the more feasible methods in the domestic context. When globally reading this data, it must be also said that the absence of significant differences in the percentages of suicidal ideation and suicide attempts between two years is consistent with the trend of these behaviours already rising before the COVID-19 epidemic. Indeed, a study conducted in the U.S.A. had already shown an alarming growth of hospitalisations for suicidal ideation and for suicide attempts among children and adolescents from 2008 to 2015, where the percentage was almost doubled between the first and the last year [44]. Even in Italy this phenomenon occurred in some hospitals of both central and north areas [45].
We examined the suicidality phenomena within the hospitalised patients’ sample during the COVID-19 epidemic, in order to verify any change between the first wave (from March 2020 to September 2020) and the second wave (from October 2020 to March 2021). Results showed a slight increase in suicidal ideation (from 50.9% to 57.8%) and a more marked increment of suicide attempts (from 14.5% to 25.6%) from the first to the second wave. Comparing percentages of suicide attempts among patients with suicidal ideation, we observed a greater increase along the two years (from 28.6% to 45.5%). This result is consistent with a Japanese study that reported a reduction of 14% in suicide rates during the first five months of epidemic and an increase of 16% in suicide rates in the subsequent four months, especially among females (37%) and children and adolescents (49%) [46]. We then suppose that the lower rate of suicide attempts during the first wave could depend not only on major monitoring by the parents but even more on the temporary reduction in social and performance stress burden linked to school closure. Moreover, it should be kept in mind that in Italy a special Decree-Law was approved for the academic year 2019–2020 in order to promote the inclusion of the more vulnerable subjects, which facilitated the transition to higher class for students with poor academic performance (Decree-Law 8 April 2020, n. 22). This measure certainly reduced school related anxiety and stress in many adolescents. On the contrary, the increase in suicide attempts during the second wave of the epidemic could be mainly induced by what is called “back-to-school stress”. Returning to school with new rhythms and rules, in addition to social and test anxiety in many students, together with the uncertainty due to constant routine changes caused by contagion curve raising, could have a rebound effect on the psychological state of young people.
As for what concerns non-suicidal self-injury, this occurred in more than one third of inpatients and, among these, more than half self-injured more than five times. We observed an opposite trend for the number of self-injured body parts, which decreased in the COVID year compared with the previous period.
This result could be related to a greater possibility of child monitoring by caregivers, thanks to lockdown and social restrictions. A significant raising of the NSSI onset age was registered, from a mean of 12.2 years in the pre-COVID-19 year to a mean of 13.8 years in the COVID-19 year. These data, which are different from the trend reported by literature about a reduction in the NSSI onset’s mean age in adolescents [47, 48], could be linked to teenagers’ greater suffering because of major restriction measures compared to younger subjects during the COVID-19 pandemic.
Also concerning non-suicidal self-injury, we observed a significant increase from the first (29.1%) to the second wave (48.8%), which was in line with the literature that highlighted an increase in NSSI behaviours in adolescents during the COVID-19 pandemic compared to the pre-COVID-19 era [49]. Other studies reported a “wave trend”, with an initial decrease in self-harming during the first months of COVID-19 pandemic, followed by a strong rise during subsequent months [50].
We classified hospitalisation modality into urgent and scheduled, showing a reduction in scheduled hospitalisations from 12.7% in the pre-COVID-19 year to 6.3% in the COVID-19 year, and, on the contrary, an increase in urgent hospitalisations. This result is in accordance with the generalised interruption of scheduled hospitalisations at the peak of COVID-19 epidemic due to institutional rules on one side and to the increase in COVID-19 issue-related acute psychiatric conditions on the other side. Interesting differences emerged by comparing the different paths to access to hospitalisation. In particular, we saw an increase in hospital admission following a visit to our outpatient service (from 5.9% to 24.0%) and a reduction in hospitalisation following Emergency Department access (from 51.0% in the pre-COVID-19 year to 43.8% in the COVID-19 year). These results are similar to those obtained from a study conducted in the Emergency Department (ED) of two of Modena’s hospitals, which compared urgent ED psychiatric consultations during the first six months of the COVID-19 pandemic with ones during the corresponding period of the previous year. The authors found a general reduction in ED consultations, probably due to contagion fear and to lockdown-related rules [51]. The increased percentage in our hospitalisation admissions after an outpatient examination could be explained by both the interruption of scheduled recoveries and the restriction imposed to territorial mental health services, so that patients were referred to outpatient service at a hospital. Moreover, Modena’s study recorded an increase in care requests by those people who already suffered from psychiatric disorders and/or were already treated by psychiatric territorial services, compared to 2019.
As regard to reasons for hospitalisation, we recorded two main changes: the eating disorders’ increase (from 11.8% in the pre-COVID-19 year to 18.9% COVID-19 year) and the psychotic symptoms’ decrease (from 9.8% to 4.2%). The analysis between the first and the second COVID-19 pandemic wave, showed that hospitalisations for eating disorders more than tripled (from 9.1% to 31.7%), as well as hospitalisations for agitation and aggression. The rise in eating disorders is in accordance with findings from other international studies; in particular, an Australian one recorded an increment of restrictive and binge eating behaviours in the general population, which were associated with compensatory physical activities among those people who previously suffered from eating disorders [52]. A study conducted in Italy and France, describing the ways in which COVID-19 pandemic affected the risk for eating disorder development, emphasised both the increase in risk factors and the decrease in protective factors related to COVID-19 epidemic’s consequences (daily routine interruption, outdoor activities limitations, greater exposure to social media, special diets with health related intents, social distancing, greater difficulty in the access to care, and emotion regulation difficulties related to uncertainty and to contagion fear) [53].
As concerns the reduction in hospitalisations because of psychotic symptoms, we suppose the lockdown could have constituted a protective factor for children who suffer from this disorder. The smaller exposure to external stimuli and the constant care by a caregiver could create a protective context for these patients, preventing the exacerbation of a psychotic crisis, specifically paranoid type ones. The differences about ICD-10 diagnosis between the two considered periods are in accordance with the abovementioned findings related to reasons for hospitalisation. Specifically, we observed an increase in IC10 F50-F59 codes among first diagnoses, which include diagnoses related to eating disorders.
One of the most important differences concerns post-discharge relapses. The number of inpatients who were hospitalised again after the first discharge almost tripled during the COVID-19 year. This result indicates that more patients were already hospitalised at least once during the COVID-19 year. Moreover, in the pre-COVID-19 year, 89% of patients were hospitalised for the first time (no post-discharge relapse), while during COVID-19 year this percentage lowered to 65%. Differently, the percentage of patients with two hospitalisations doubled from 7.3% in the pre-COVID-19 era to 17.5% in the COVID-19 year; patients with four hospitalisations were 1.2% in the pre-COVID-19 year, while they increased to 8.8% in the COVID-19 year; patients with five or six hospitalisations were registered only during the COVID-19 year. These data agree with multiple studies, one of those conducted by World Health Organization (WHO), that emphasised COVID-19 pandemic as a risk factor for multiple psychiatric disorders’ exacerbation and relapses [2].
Moreover, other studies conducted in Italy and Spain are consistent with our findings, corroborating the hypothesis that the greater number of relapses could be explained by limitations imposed on neuropsychiatric territorial services, unable to guarantee the continuity of mental health assistance, and by the increase in psycho-behaviour distress in children and adolescents who already suffered from psychiatric disorder and who were particularly affected by the pandemic. [54, 55]. In fact, the paradox of the territorial clinical-assistance management of psychiatric patients was highlighted: services operating at a lower rate, precisely in a historical context in which the most vulnerable people were subjected to greater stress and therefore needing care.
Those aspects influenced the hospital and the high-intensive therapeutic residential structures’ burden, as well as the greater use of psychiatric drugs. In fact, we suppose that these last findings are related to the increase in psychiatric symptoms’ severity to a first extent and to the reduction in psychological and psycho-educational treatment availability to a lesser extent. Specifically, the greater use of neuroleptics correlates with the management of behavioural and emotional dysregulation disorders, frequently associated with self-harming conduct and more severe eating disorders, in particular, anorexia nervosa [56, 57]. Suicidal and non-suicidal dimensions along with eating disorders, then, were the most increased problems among inpatients during COVID-19 epidemic and, accordingly, we observed an increment of post-discharge access to residential care structure. Current studies seem to agree on the fact that the SAR COVID 2 infection outbreak constituted a predisposing factor for the development and exacerbation of eating disorders, which were associated with a quantitative increment of mental health service patients [5].
Limits of the study
Our study presented some limitations related to missing data and to patients’ heterogeneity in age and other correlated variables, due to the retrospective design. Another limitation is related to the limited sample size and the statistical comparison carried out between closed time periods (2019–2020 and 2020–2021). Moreover, the SARS-Cov-2 infection sanitary emergency is still ongoing, and for this reason it was not yet possible to obtain a complete overview of its effects.
