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Sex differences Among
Children, Adolescents, and
Young Adults for Mental Health
Service Use Before and During
the COVID-19 Pandemic

John Sina Moin (PhD) – He/Him

March 9, 2023

Photos by Unknown Author(s) are licensed under CC BY-SA-NC

COI – Declaration

• I do not have any conflict of interest to disclose.

Funding Acknowledgments

Thank you CIHR!

Funding: Sponsor: 303157 CIHR grants, reference WI2-179943.
Funding Acknowledgments

• Postdoctoral Fellowship funding provided by the University of Toronto Institute for

Pandemics (IfP), an academic center dedicated to public health research and
education on pandemic readiness, resilience, and recovery, at the Dalla Lana School of
Public Health

• Additional funding was provided by the Better Access and Care for Complex Needs
(BeACCoN) that was Ontario’s response to the Canadian Institutes for Health
Research (CIHR) Strategy for Patient Oriented Research (SPOR) for Primary and
Integrated Health Care Innovations
Other Acknowledgments

• This study contracted ICES Data & Analytic Services (DAS) and used de-
identified data from the ICES Data Repository, which is managed by ICES with
support from its funders and partners: Canada’s Strategy for Patient-Oriented
Research (SPOR), the Ontario SPOR Support Unit, the Canadian Institutes of
Health Research (CIHR) and the Government of Ontario. The opinions, results
and conclusions reported are those of the authors. No endorsement by ICES
or any of its funders or partners is intended or should be inferred
• Parts of this material are based on data and information compiled and
provided by CIHI. However, the analyses, conclusions, opinions, and
statements expressed herein are those of the author, and not necessarily
those of CIHI
Poll Question 1

• Among the attendees today, how would you describe your primary
role?

• Multiple choice (moderator please facilitate Zoom poll)

• 30-seconds to 1-minute
Learning Objectives for Today

• Describe current trends related to mental health among children, adolescents and
young adults, post-COVID-19

• Discuss how these trends were affected by the COVID-19 pandemic with regards to
sex and age, and the implications for practice

• Identify opportunities to improve mental health surveillance data, particularly with

respect to critical indicators that may affect public health response
Poll Question 2

• What do you think was most disruptive for children and youth
during the pandemic?

• Multiple Choice (moderator please facilitate Zoom poll)

• 30-seconds to 1-minute
Background
Background (the pandemic)

COVID-19 – Wuhan, COVID-19 Pandemic –

China – Fall 2019/Winter WHO - March 11, 2020
2020
Lockdowns Begin –
Public Health - March
15, 2020
Background (the pandemic)
Background (total lockdown)

CBC, 2020; StatsCan, 2020

Background (lockdown schools)

Gallagher-Mackay et al., 2021

Background (other restrictions)

• Using the COVID-19 restrictions index, we

know that other sectors were closed which
would have further impacted children, youth
and young adults

• Canceling of Public Events

• Gyms closed
• Restrictions on indoor dining/events
• Restrictions on indoor/outdoor gathering

Dekker & Macdonald, 2022

Background (remote learning & work)

This Photo by Unknown Author is licensed under CC BY-SA-NC

Mental Health Frameworks

• Pre- and Post-covid stressors

• Despair framework (Shanahan et al., 2019)

• Social & Economic Impact of COVDI-19 (Statistics Canada, 2022)
• Hypothesized pathways between social media use and depressive symptoms in young people
(Kelly et al., 2018)
• Adolescent wellbeing framework (McGushin et al., 2022)
• Positive Mental Health (PHAC, 2016)
• COVID-19 strain on daily life (CDC, 2021)
Despair Framework (parents/adults)

Pre-COVID Lockdown/school Theorized MHA & Outcomes of Despair

economic closure, familial job and pathways
stressors, post- income loss, high cost of
COVID stressors, living + rapid
(background) inflation
(context/predictors)
Shanahan et al., 2019
 2+ years of
On & Off
Lockdown
Measures

Cases, death, job losses More cases, deaths, job recovery Inflation and rising costs
(economic hardships cont.)

Statistics Canada, 2022

“Compare and Despair”

Kelly et al., 2018

Climate Change (children/youth/young adults)

• Climate change has huge implications

for human society and bio-diversity
(natural disasters, the economy, food
supply, prospects for the future, etc.)

• “Many feel the threat to their future, are

overwhelmed by the scale of the
problem, and are disillusioned by
inadequate action of those in power”
(McGushin et al., 2022, p.1)
Positive Mental Health
Surveillance Indicator Framework
• Positive Mental Health and various
determinants developed by PHAC
(2016)

• All 4 levels impacted (individual, family,

community, society) play a role

Public Health Agency of Canada, 2016

Covid Challenges (children/youth/young adults)

Challenges Impact
Changes in routines having to physically distance from family, friends, worship and other social
communities
Breaks in continuity of switching from in-person to virtual learning, missing out on supplementary and
learning early education opportunities, access limitations to personal workspace,
technology, and connectivity at home
Breaks in continuity of missed well-child and immunization visits, limited access to mental, speech,
health care and occupational health services

Missed significant life missing celebrations, family vacations, prom, graduations, dating, frosh-week
events and in-person college activities, and other milestone life events
Lost security and safety housing and food insecurity, increased exposures to domestic violence and
online harms, threats of physical illness, and uncertainty for the future

CDC, 2021
Studies on the MH of Youth Post-Covid19

• In England over a quarter of children and young people reported sleep disruptions, and high
cases of isolation, feeling lonely and fearful of leaving home because of COVID-19 early in the
pandemic (Vizard et al, 2020)
• Another study found increases in depressive symptoms among youth (Bignardi et al., 2021)
• The socioeconomic impact on parents due to job losses, working from home, and social
isolation also impacts children, particularly when there was job loss in the family and social
isolation, showing elevated stress and cortisol levels among parents and their children (Perry et
al., 2022)
• Another study in Ontario, found that there was a major increase in the use of mental health
care services during the pandemic, particularly among adolescent females (Saunders et al.,
2022)
• In Ontario, Canada, there are indications that acute care services were up for eating disorders
during the pandemic (ICES, 2022; Toulany, 2022)
Greater need for Mental Health Promotion and
Surveillance

• Evidently, there has been measurable impacts of COVID-19 pandemic on the mental
health of children, youth and young adults warranting greater focus in this area and
expanding mental health promotion and surveillance efforts as we look to build back
stronger
Advancing Mental Health
Surveillance and Data
Advancing Mental Health of Canadians
• According to MHCC – Advancing mental health of Canadians will require:

1. Leadership and Funding

2. Promotion and prevention

3. Access and services

4. Data and research

Mental Health Commission of Canada, (2016)

Advancing Mental Health of Canadians (cont.)

• Currently:

• No clear vision for mental health information as a whole

• Organizations and research groups conduct health data analysis and mental health reporting
primarily in silos (e.g., ICES, CAMH, PHO, arms-length agencies, clinicians/researchers,
etc.), however, there is no dedicated organization with a sole mandate to collect, analyze and
disseminate mental health information at the provincial level
• OH Announced - The Mental Health and Addictions Centre of Excellence (too early to
comment on their impact)

Mental Health Commission of Canada, (2016)

Epidemiological Surveillance
• Public health surveillance is defined by the World Health Organization (WHO) as:

• the continuous, systematic collection, analysis, and interpretation of health-related data

needed for the planning, implementation, and evaluation of public health practice. Such
surveillance can
(1) serve as an early warning system for impending public health emergencies
(2) document the impact of an intervention, or track progress towards specified goals
(3) monitor and clarify the epidemiology of health problems, to allow priorities to be set and
to inform public health policy and strategies

Bovbjerg, 2020
Data to Support Surveillance and Prevention
• Explore MH across the lifespan to help us ask the right
questions.
• How do people of different age-groups, sex, gender,
etc. interact/socialize? We are social beings.

• Better understand the causes of mental illness

• Is it genetics, built and natural environments?

• Make mental illness preventable.

• What puts people at risk? What interventions really
work and for who?

Russ Et al., (2017)

Data to Support Surveillance and Prevention (cont.)
• Improve detection screening and diagnosis.
• What are early warning signs? How do we improve
the accuracy of diagnostic tools?

• Support people living with existing mental health

conditions.
• Can we better monitor lifestyle and symptoms?
• How can we empower patients to be in control of their
care?

Russ Et al., (2017)

Data to Support Surveillance and Prevention (cont.)
• Driving improvements in health and social care.
• How can we create benchmarks and agreed
upon standard measures for tracking progress?
• Can AI and predictive analytics help improve
access to care and available services?

Russ Et al., (2017)

Continuum of Care

• Ensure we use data to support:

• Positive mental health promotion
• Solutions to prevent mental health
conditions and possible comorbidities
• Addressing current needs for treatment,
root causes of relapse and recurrence
of mental health conditions
• Using the right methods, indicators and
data to set priorities, inform progress
and improve these initiatives where
possible

(Institute of Medicine, 1994)

Types of Data in Mental Health Surveillance
Administrative Data
• Data that is collected at the provincial level, hospital admissions/discharge, physician
billing, ambulatory care, and drug databases (DAD, NACRS, OHIP, ODB etc.).
(+) enormous volume of data, opportunity for creative research and follow-up through
linkage
(+) ability to provide nearly complete population coverage for all publicly funded services
is a major advantage
(+) high value for money
(-) limited scope (can be improved)
(-) lag time (delays in availability due to collection, cleaning, collation, privacy checks,
made available for research/monitoring, etc.) (can be improved)
(-) does not include those who do not seek care or receive care through private services
Types of Data in Mental Health Surveillance
Surveys
• Population-based, cross-sectional, identify a population, then administer data collection within the
sample population (e.g. CCHS, OSDUHS).
(+) Surveys are more flexible and can be designed to provide more comprehensive information compared
to administrative data
(+) Able to target a wide spectrum of MH and theorized determinants (social, emotional, etc.). Able to
capture persons who have not reached the point of requiring mental health services but may be at risk
(+) Can be tailored to the objectives at hand and the necessary information/data required and not restricted
to information captured by health admin data
(+) typically, good value for money
(-) Cross-sectional data (Inherent flaws)
(-) Different surveys may use different questions/instruments to measure the same concepts/diagnosis,
making cross-survey comparisons difficult
(-) high response rates are critical and declining in some cases. Sampling strategies, means of data
collection continue to need refinement to keep samples representative
(-) proxy responses by parents may be an issue among surveys targeting persons below 18
Types of Data in Mental Health Surveillance
Longitudinal/Cohort Studies
• Falls more within the domain of research, namely concerned with answering questions around which
risk factors or antecedent conditions are associated with the subsequent illness.
(+) Especially useful at studying phenomena that occur over time, in addition to including delivery of
services, evaluation of interventions and other outcomes.
(+) Able to target a wide spectrum of MH and determinants
(+) Can be tailored to the objectives at hand and the necessary information/data required. If thought out
well, they can address multiple objectives to maximize value-for-money and time
(+) Analysis need not happen at the end of study but can coincide with follow-up as data is collected
(-) Expensive and resource intensive to plan/execute and ensure complete follow-up
(-) The longer the study, the higher the risk of loss-to-follow-up which is further compounded when dealing
with younger populations and primary data collection
(-) privacy issues – compounded with linking data, elapsed time and increased datapoints on a person
Types of Data in Mental Health Surveillance
Other Data Sources
EMR/EHRs:
• A secure, integrated and comprehensive view of a person’s medical records based on information generated through
a person’s interactions with the health care system (e.g., POPLAR)
(+) In theory should be a rich resource for information on the delivery of care across multiple conditions and setting,
including health outcomes
(-) EMRs are more focused on acute-care, infectious and chronic diseases currently
(-) Some of the same limitations as health administrative data (requires access to care)
(-) Only highlight one care facility or network of providers, we need to work toward system-wide linkages
Case registries:
• Refers to a system of collected data covering all cases of a particular disease or other health condition in a defined
population (e.g. cancer, stroke – MH N/A)
Sentinel reporting systems:
• Involves a network of reporting sites (e.g. PHUs, FHTs, labs, etc.)
• Mental health applications are rare but do exists (e.g., UK – occupational physician networks and work-related MH
issues)
Selection Criteria for Indicators, Measures, and Research

Selection Criteria Description

• Relevant - information should be meaningful and relevant to target user(s)

“the so what’”
• Actionable - information should be informative, influential, and able to support
the change in public health practice and policy
• Accurate - information should reflect the best evidence of the day,
scientifically sound, valid, reliable, sensitive to change,
interpretable and complete
• Feasible - look to leverage available data, should be of sufficient quality to
report on or institute new data collection that is cost-effective and
of value
• Ongoing - data is collected and collated regularly, in a timely manner to allow
for comparisons over time.
Public Health Agency of Canada, 2016
Our Study

• Sex differences Among Children, Adolescents,

and Young Adults for Mental Health Service
Use Within In-patient and Outpatient Settings,
Before and During the COVID-19 Pandemic: A
Population-based Study in Ontario, Canada
Selection Criteria Applied to our Study

Selection Criteria Description

• Relevant - MH is a critical issue among youth, with serious consequences if

ignored
• Actionable - The study/methodology is informative and can be used to support
and inform change in public health practice and policy
• Accurate - information reflects the best evidence of the day, is
scientifically sound, valid, reliable, sensitive to change,
and interpretable
• Feasible - leverages existing, high-quality data, is cost-effective and of value

• Ongoing - data is collected and collated regularly, allowing for comparisons

over time

Public Health Agency of Canada, 2016

Study Objective

• The objectives of this study were to examine whether the rates of mental health
visits had changed during the pandemic versus pre-COVID-19 patterns, and to
identify possible variations by sex, provider type, and clinical diagnoses among
children, adolescents, and young adults
Methods

Study Design
• A population-based, repeated cross-sectional study, using existing health
administrative data, including all children (6-12 years of age), adolescents (13-
17 years) and young adults (18-24 years), living in Ontario, Canada and
eligible for provincial health insurance between March 2016 to November
2021
• A baseline measure of mental health rates of use was obtained from the pre-
pandemic period (March 2016 to February 2020)
• Rates of use during the pandemic are based on utilization starting from March
2020 till the end of November 2021
• Data quarterly format (23 cross-sectional measures)
Methods (Cont.)

• Exclusion criteria: persons with missing IKN (ICES Key Number - unique
encrypted identifier), birth date, sex, OHIP eligibility, non-residential status, or
who had died prior to index date were excluded

• Three cohorts: 1) children 6-12 years of age, 2) adolescents 13-17 years of age,
and 3) young adults 18-24 years of age

• Open cohorts and assessed time at risk for outcomes

Methods (Cont.)

Data Sources
• Ontario Registered Persons Database (RPDB): sex, age, postal code, dob
• Ontario Health Insurance Plan (OHIP): billing records for outpatient visits to
GP/FP and psychiatrists
• The National Ambulatory Care Reporting System (NACRS), Canadian Institute
for Health Information’s Discharge Abstract Database (DAD), and Ontario
Mental Health Reporting System (OMHRS): identify mental health-related
emergency department (ED) visits and hospitalizations (ICD-9 & ICD-10)
Study Outcome

Outcomes Children Adolescents Young Adults

6-12 13-17 18-24

Outpatient Mental Health

Mood and anxiety disorders X X X
Other non-psychotic disorders X X X
Alcohol/substance abuse X X
disorder
Social problems X X X
Study Outcome (cont.)

Outcomes Children Adolescents Young Adults

6-12 13-17 18-24
ED and Hospitalizations
Substance-related and addictive X X
disorders
Anxiety disorders X X X
Assault related injuries (victims of X X X
violence)
Deliberate self-harm X X
Eating disorders X X
Methods (cont.)

Statistical Analysis
• Negative binomial regression with time and season as predictor variables,
were used to model utilization trends before the pandemic (March 2016 –
February 2020)
• Residuals were modeled as an autoregressive AR(1) process to account for
serial correlation
• The fitted model was used to predict the expected rates of use from March
2020 to the end of November 2021
• All outcomes were stratified by sex, provider type and mental health diagnoses
Results

• Over 6 million youth between the ages of 6 to 24 years from Ontario, Canada were
included in this study
Results (cont.)
• Higher than expected rates for
outpatient MH visits among adolescent
and young female adults
• Little to no difference among males
Results (cont.)
• No difference in service use detected
among males
• Higher than expected rates among
females, driven largely by mood and
anxiety disorders
• Highest difference among young female
adults, followed by adolescent females
Results (cont.)
• ED visits and hospitalizations were down
among males in all 3 age groups

• ED visits and hospitalizations were down

or non-significant among female children
and young adults

• MH ED visits, ED visits requiring

hospitalizations and MH-related
hospitalizations were up among
adolescent females, despite being lower
in the other two age groups
Results (cont.)
Deliberate Self-Harm
• ED visits for DSH
• 42.8% higher than expected relative to pre-pandemic trends (CI: 22.4, 59.7; 258 vs.
181/100,000) in Sep/Nov-2021 (end of the study period)

• ED visits for DSH requiring hospitalization

• 46.1% higher (CI: 26.5, 62.6; 110 vs. 80/100,000) in Sep/Nov-2021

• Hospitalizations for DSH

• 102.4% higher (CI: 76.4, 123; 354 vs. 175/100,000) in Sep/Nov-2021

• DSH was persistently higher in every quarter since the pandemic (ED, ED-Hosp, Hosp.).
Possible indication of greater severity.
Results (cont.)
Assault-Related Injuries
• ED visits for Assault-related injuries requiring hospitalization
• 493.4% (CI: 238.5, 565.2; 2 vs. 0.4/100,000) in Sept/Nov-2021

• Hospitalizations for Assault-related injuries

• 272.7% (CI: 151.2, 372.6; 3 vs. 1/100,000) in Sept/Nov-2021

• Higher on average by quarter and over the course of the study (esp. ED-Hosp, Hosp.)
Results (cont.)
Eating Disorders
• ED visits for eating disorders
• 225.1% (CI: 178.6, 256.9; 59 vs. 18/100,000 ) in Sep/Nov-2021

• ED visits requiring hospitalization

• 221.3% (CI: 162.4, 258.4; 27 vs. 8/100,000) in Sep/Nov-2021 and comparably in
Mar/May-2021

• Hospitalizations for eating disorders

• 139.7% (CI: 112.4, 161; 64 vs. 26/100,000) in Mar/May-2021

• Persistently higher in every quarter since the pandemic (ED, ED-Hosp, Hosp.)
Strengths and Limitations
• (+) Large population-based study, representative of the Ontario population
• (+) Well-established MH and quality indicators based on health administrative billing codes,
many have been validated and used in routine reporting and peer-reviewed studies
• (+) Strong methodological design and analysis over time

• (-) Studies with outcomes based on healthcare utilization, may underestimate the true
prevalence of those health outcomes, due to non-seeking of care, or the seeking of care in
other medical establishments such as private clinics
• (-) Did not account for characteristics beyond age and sex (e.g., race, ethnicity, sexual
orientation, disability, education, employment status, etc.)
• (-) While results are generalizable to the population of Ontario, Canada, may not be
generalizable to other jurisdictions where COVID-19 cases, containment policies, boundaries
and population characteristics are different
Study Conclusion
• Over 20-month into the COVID-19 pandemic, we observed a substantial increase in
use of physician services for mental health diagnoses relative to pre-pandemic levels,
predominantly among female adolescents and young adults
• Increase in utilization was largely driven by outpatient services for mood, anxiety, and
depressive disorders. Highest among young female adults, followed by female
adolescents
• We noted an increase in cases and severity for eating disorders, deliberate self harm,
and assault-related injuries among adolescent females in EDs and hospitals
• Our study raises concerns about growing mental health needs among female
adolescents and young adults during the pandemic, especially in critical areas such as
depression, anxiety, DSH, eating disorders, and assault-related injury
Discussion & Next Steps
• MH among youth is a growing issue, compounded by COVID-19 and other factors
• More emphasis is needed on monitoring mental health of children, youth and young
adults. Especially as we look to recover from the pandemic and build back stronger.
• We provided a brief outline as to the state of mental health surveillance in Ontario and
the challenges they face
• In support of these efforts, we need to ensure that the information being used are
relevant, accurate, actionable, feasible and ongoing
• We shared one possible approach which can be used to evaluate critical mental health
indicators at the population level and possible interventions in the future
Discussion & Next Steps (cont.)
• Over the course of the pandemic, we observed substantially higher use of physician
services for mood and anxiety disorders, among female adolescents and young adults
• We noted an increase in cases and severity for eating disorders, deliberate self harm,
and assault-related injuries among adolescent females in EDs and hospitals
• Our study raises concerns about sustained growth in mental health service needs
among female adolescents and young adults during the pandemic
• With major challenges and uncertainty around climate change, the economy and cost
of living, automation/technology, social media, misinformation, geo-politics,
COVID19/zoonotic diseases, and many others, it is critical that we have robust and
responsive surveillance systems, especially around mental health indicators for
children, youth and young adults as we venture forward in meeting these challenges
Thank you
Poll Question 3

• Based on our presentation today, do you think we need more

timely data and improved mental health surveillance, especially for
children, youth and young adults?

• Moderator please facilitate Zoom poll

• 30-seconds to 1-minute
Discussions/
Q&A

All Photo(s) by Unknown Author is licensed under CC BY-NC-ND