The impact of the COVID-19 school closure on adolescents’ use of mental healthcare services in Sweden
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Abstract
Background
School closures used to contain the COVID-19 pandemic may have negative impacts on students’ mental health but credible evidence is scarce. Sweden moved upper-secondary students to remote learning but, as the only country in the OECD, kept schools at lower levers open throughout the pandemic.
Methods
Using nationwide register data, we estimate the difference in the use of mental healthcare services between upper- and lower-secondary students during the pandemic, and relate this to the same group difference prior to the pandemic. For the main analysis, this difference-in-difference approach is applied to the period April-June 2020 when upper-secondary schools were fully closed. We also study the periods July-December 2020 when upper-secondary schools were largely open, and January-March 2021 when they were partially closed. We study the impact on all contacts with hospitals and specialist psychiatric care due to mental and behavioral disorder, as well as prescriptions for antidepressants, insomnia, and ADHD drugs.
Findings
Compared with expected rates, the use of mental healthcare services among upper-secondary students fell by -3.71 [CI95 -5.52 to -1.91] cases per 1000 during April-June 2020, largely due to a reduction in depression and anxiety-related diagnoses (-1.49; CI95 [-2.36 to -0.63]) and prescriptions (-1.80; CI95 [-2.93 to -0.68]). This reduction in the use of mental healthcare services corresponds to a 4.36% CI95 [-6.47 to -2.25]) decrease compared to the level prior to the pandemic. The decrease compared to expected rates persists through July-December 2020 (-3.55%; CI95 [-5.38 to -1.71]) and January-March 2021 (-5.23%; CI95 [-7.24 to -3.21]). The reduction is stronger among students in the 2 nd (-5.06%; CI95 [-8.02 to -2.09]) and 3 rd (-4.86%; CI95 [-8.19 to -1.53]) year of upper-secondary school. The decrease is concentrated to students who was not in contact with mental healthcare services earlier in the academic year (-16.70%; CI95 [-22.20 to -11.20]). The relative reduction is largest for unplanned care (-13.88%; CI95 [-19.35 to -8.42]) and care at emergency units (-18.19%; CI95 [-26.44 to -9.92]).
Interpretation
Closing upper-secondary schools in Sweden reduced use of mental healthcare services. There is no indication of this being due to reduced accessibility. In a setting with no strict lockdown, moving to online teaching for a limited period did not worsen mental health among students in upper-secondary schools.
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SciScore for 10.1101/2021.12.12.21267684: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Ethics not detected. Sex as a biological variable Students in upper-secondary school are slightly more likely to be male, have foreign background and have parents without university education and lower income. Randomization not detected. Blinding not detected. Power Analysis not detected. Table 2: Resources
No key resources detected.
Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).
Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:This study has some limitations. The outcome measure includes contacts with hospitals and specialized …
SciScore for 10.1101/2021.12.12.21267684: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Ethics not detected. Sex as a biological variable Students in upper-secondary school are slightly more likely to be male, have foreign background and have parents without university education and lower income. Randomization not detected. Blinding not detected. Power Analysis not detected. Table 2: Resources
No key resources detected.
Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).
Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:This study has some limitations. The outcome measure includes contacts with hospitals and specialized psychiatric care, and prescriptions from any prescriber of drugs in Sweden. However, it does not include information on contacts with primary care or personnel working with healthcare in schools. School closures may have reduced access to school nurses and counselors who may refer students to specialized mental healthcare services. Thus, although the evidence presented suggests otherwise, we cannot entirely rule out this explanation. Another limitation is that other disease containment measures, such as restrictions on nightlife and travels, may have differently affected on upper- and lower secondary students. A natural limitation is the focus on immediate and medium-term effects. School closures may have reduced learning and opportunities for social interactions that can have detrimental long-term implications.
Results from TrialIdentifier: No clinical trial numbers were referenced.
Results from Barzooka: We did not find any issues relating to the usage of bar graphs.
Results from JetFighter: We did not find any issues relating to colormaps.
Results from rtransparent:- Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
- Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
- Thank you for including a protocol registration statement.
Results from scite Reference Check: We found no unreliable references.
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