Increase in depression and anxiety disorder diagnoses during the Covid-19 pandemic among children and adolescents

Ulrike Ravens-Sieberer investigated the mental health and quality of life of children and adolescents during the pandemic and found that a total of 711,300 children and adolescents felt burdened by the pandemic and reported a stressful school day, less contact with their friends, and more arguments within the family. Furthermore, the prevalence of mental health problems increased from 181,300 before the COVID-19 pandemic to 301,300 during the crisis (12).
Berger et al. identified 11 publications addressing the mental health of children and adolescents in the context of coronavirus outbreaks. Children and adolescents reported fear and anxiety, but were also able to demonstrate resilience during the outbreak with the right support (13).
Although published studies investigating the impact of the pandemic on the mental health of children and adolescents are of great interest, most are based on relatively small sample sizes and are therefore not representative. To date, no database- or register-based studies have been published in Germany that empirically examine the impact of the coronavirus lockdown on the prevalence of depression and anxiety disorders in children and adolescents documented in pediatric practices. This study aims to fill this gap. The objective of this study was to investigate, quantify, and critically discuss the impact of the coronavirus lockdown and other measures implemented in response to the coronavirus pandemic on consultations for psychiatric problems in children and adolescents.
methods
This retrospective cross-sectional study is based on data from the Disease Analyzer database (IQVIA), which compiles drug prescriptions, diagnoses, and general medical and demographic data obtained directly in anonymized form from computer systems in the practices of general practitioners and specialists (14). This database has already been used for a number of studies on COVID-19 (15, 16).
This study included all children and adolescents aged 2-17 years who visited at least one of 168 German pediatric practices between April 2019 and December 2019 or between April 2020 and December 2020. The database used has a coverage of approximately 3.51 million pediatric practices. These practices provide complete information on consultations and diagnoses of the children and adolescents treated there.
The first outcome was the number of children and adolescents diagnosed with depression (ICD-10: F32, F33) and anxiety disorder (ICD-10: F41) per practice. The number of children and adolescents with these diagnoses per practice was compared between April 2020 and December 2020 versus April 2019 and December 2019 using a Wilcoxon signed-rank test. This analysis was also performed for new depression and anxiety disorder diagnoses, defined as diagnoses not previously documented in the database, to identify patients who were diagnosed with depression or anxiety disorder for the first time during the coronavirus pandemic.
The second outcome of the study was the change in the prevalence of depression and anxiety disorder diagnoses between April 2020 and December 2020 compared to April 2019 and December 2019. Prevalence was defined as the number of children and adolescents diagnosed with depression or anxiety disorder during the selected period, divided by the total number of children and adolescents with at least one visit during the same period. Chi-squared tests were used to compare prevalence between the two periods.
A p-value of <0.05 was considered statistically significant in all analyses. Analyses were performed using SAS 9.4 (SAS Institute, Cary, USA).
Results
study population
This study included 454,741 pediatric patients between April 2019 and December 2019, and 417,979 patients between April 2020 and December 2020. Baseline characteristics are shown in Table 1. There were significant differences in age between 2019 and 2020, but these were very small in absolute terms.

Changes in consultations per practice
Table 2 shows the differences by sex and age in the number of patients with at least one visit per practice between April 2019 to December 2019 and April 2020 to December 2020. The number of patients per practice was lower in the period April to December 2020 than in the period April 2020 to December 2019 (2,488 vs. 2,707, -8%, p=0.037). These differences were observed for both girls and boys as well as for different age groups. The most striking differences (-10%) occurred in the 2-5 year age group.

Changes in depression and anxiety patients per practice
The number of children and adolescents diagnosed with depression and anxiety per practice increased between April 2020 and December 2020 compared to the same period in 2019 (anxiety: +91 TP3T, depression: +121 TP3T, Table 3). The increase was significantly greater in girls than in boys (anxiety: +131 TP3T vs. +51 TP3T; depression: +191 TP3T vs. +11 TP3T). The increase in both anxiety (+161 TP3T) and depression (+291 TP3T) was most pronounced in the 10-12 year age group. Although none of the observed differences met the criteria for statistical significance due to the small number of practices included, they nevertheless provide a clear picture of the changes caused by the pandemic in Germany. This trend was also observed in new diagnoses (+131 TP3T for anxiety, +181 TP3T for depression). The increase in depression in girls was significant at +29% (p=0.010) (Table 3).

Changes in the prevalence of depression and anxiety
The sharp increase in the prevalence of anxiety and depression diagnoses is due to a decrease in the number of patients seeking consultations, while the number of patients with anxiety and depression diagnoses increased (Figure 1). The prevalence of anxiety disorder rose from 0.311 to 0.591 (p<0.001), and that of depression
from 0.23% to 0.47% (p<0.001). The largest increases were observed in girls (anxiety from 0.35% to 0.72% (+106%, p<0.001), depression from 0.28% to 0.72% (+132%, p<0.001).
discussion
This study, conducted in 168 pediatric practices in Germany, showed that the total number of children and adolescents with anxiety disorders and depression, and the prevalence of anxiety disorders and depression in children and adolescents, increased in the period April-December 2020 compared to April-December 2019.
Furthermore, this increase was most pronounced in girls and children aged 10-12 years. To our knowledge, this is one of the largest studies on this topic conducted in Germany to date, and it is also the first study to use pediatric diagnoses.
Anxiety disorder and depression diagnoses represent only the highest level of anxiety and depressive symptoms. Mohler-Kuo et al.
In their study of 1,146 children aged 12 to 17 years in Switzerland, Nearchou et al. reported that during the COVID-19 pandemic, the prevalence rates of anxiety symptoms were 13.61 TP3T in girls and 12.51 TP3T in boys, and the prevalence rates of depressive symptoms were 9.71 TP3T in girls and 4.61 TP3T in boys (17). Based on self-reported data from the children and adolescents aged 11 to 17 years included in their study, they found significantly higher levels of generalized anxiety during the COVID-19 pandemic than before (24.11 TP3T vs. 14.9 TP3T) (12). Nearchou et al. provided a systematic review of the evidence on the impact of the COVID-19 pandemic on the mental health of children and adolescents, based on 12 studies. They reported that the prevalence of anxiety symptoms ranged from 18.91 to 37.41 and that of depression symptoms ranged from 22.61 to 43.71 (18). Panda et al. analyzed 15 studies of 22,996 children and adolescents, in which 34.51 suffered from anxiety and 41.71 from depression (19). In our study, the prevalence rates for anxiety and depression were much lower because only confirmed medical diagnoses from pediatricians were used, and individual symptoms of mental disorders do not necessarily lead to diagnoses, even when these symptoms are reported to or observed by pediatricians.
Although the results of Ravens-Sieberer et al. indicated that children suffered from psychosomatic complaints during the pandemic, they found no increase in clinically relevant depressive symptoms (12). We observed a significant increase in the prevalence of both anxiety and depression during the COVID-19 pandemic, but the proportion of children with these mental health diagnoses was relatively small.
It is known that prevalence estimates based primarily on self-reported symptoms, as used in online surveys, differ from prevalence documented in medical practices (20). In this context, it is important to consider the specific conditions of pediatric practices in Germany. Pediatricians in Germany perform primary care functions. They are required to document diagnoses using ICD-10 codes and services according to fee schedules. The pandemic had far-reaching consequences for the provision of services in these practices (21): the frequency of contact and the intensity of services decreased, particularly the number of acute respiratory illnesses, fewer preventive check-ups, and fewer sick leave certificates for parents caring for sick children because many parents were working from home. Finally, many services were provided via telephone or video consultation (21). Practices may have had more time available to address mental health concerns more extensively.
On the other hand, there is considerable evidence that quarantine measures can be associated with negative psychological consequences (22). In children and adolescents, this particularly affects children living in cramped conditions where there is a chronic family conflict situation (e.g. divorce, separation, parental mental illness) (23).
In pediatric and adolescent medicine practices, patients are usually cared for over a very long period. In Germany, preventive medical check-ups are carried out at mandatory intervals—a practice that may make physicians particularly aware of patients' transitional phases. A particularly striking finding of these examinations is the development of mental disorders in schoolchildren aged 10–12 years. This age group is in an important transitional phase (24), which is generally characterized by the transition to secondary school, the onset of puberty, and an initial separation from the parental home and increased contact with the peer group. This is also usually a phase in which the resilience of schoolchildren and adolescents in the face of increasing responsibilities in life may differ from that of adults or older people (25, 26).
Although the data used for this study do not provide direct evidence for interventions to reduce or treat anxiety or depression in children and adolescents, several reviews already exist that present possible interventions (27). However, it has been noted that children and adolescents in pediatric practices are a particularly vulnerable group for developing mental health disorders such as anxiety and depression, and that certain subgroups, including female patients aged 10 to 12 years, are at higher risk. We do not currently know to what extent repeated hospital admissions will continue to lead to volatile situations with unpredictable consequences for children's mental health. Furthermore, it remains unclear to what extent mental health disorders will decrease or worsen after the pandemic ends. In light of this, child and adolescent psychiatrists are calling for a recovery plan for children, adolescents, and their families (28).
Unlike existing studies on mental health problems in children and adolescents during the COVID-19 pandemic that used surveys, our study employs a large cohort of children representative of the sociodemographic situation in Germany and uses retrospective data from pediatric practices. We acknowledge that this work is subject to several limitations. Firstly, misclassifications or omissions of individual diagnoses may have occurred due to the use of the ICD-10 coding system. Furthermore, the German Disease Analyzer database does not provide details on how the diagnoses were made, nor does it offer information on lifestyle or socioeconomic status, and the available data do not allow for an analysis of illness severity. Finally, this study is descriptive in nature and did not employ complex statistical methods such as time series analyses.
Nevertheless, the database provides a relevant overview of the diagnosis of depression and anxiety disorders in children and adolescents during the Covid-19 pandemic and shows an interesting trend in the number of pediatric diagnoses in the pandemic year 2020 compared to the previous year.