Mental health and suicide among adolescents in the United States in the wake of the COVID-19 pandemic: a narrative review

Introduction

Background

Suicide, suicidal ideation (SI), and mental health (MH) amongst children and adolescents have become a public health crisis over the last decade. Over the past two decades, suicide rates in this population have increased by over 50%, which has resulted in suicide emerging as the second leading cause of death in individuals aged 10 to 24 years (1-5). The Youth Risk Behavior Survey (YRBS) is a cross-sectional survey conducted biennially by the Centers for Disease Control and Prevention (CDC) collecting data from adolescents in grades 9–12 as a nationally representative sample and comparing the responses to the 10 preceding years. Prior to the pandemic in 2019, the YRBS reported that 18.8% of students said they had seriously considered suicide and 8.9% had attempted suicide, both of which were significantly increased from 2009 (6). There are also several important trends and statistics regarding SI, suicide attempts, and deaths to consider. Suicide attempts are more common in females, but males are more likely to die by suicide. For teens, the most common method of suicide is by firearms, followed by suffocation/hanging, then overdose/poisoning. The majority of teenagers who consider, plan, or attempt suicide have a preexisting diagnosis of depression, anxiety, or other MH diagnosis. Non-suicidal self-injury such as cutting, scratching, or burning is a strong predictor of death by suicide. Adolescents who use drugs or alcohol are also at a higher risk of suicide. While the majority of youth suicide attempts and deaths prior to the pandemic were by non-Hispanic white individuals, there are several populations at higher risk compared to their peers including children with intellectual disabilities, immigrants, teens in rural areas, the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community, youth in foster care or the juvenile justice system and American Indian/Alaskan Native youth (4).

The coronavirus disease 2019 (COVID-19) pandemic and the mitigation efforts to prevent the spread have had a profound effect on society. State-wide lockdowns, shelter-in-place mandates, school closures and virtual learning, pausing of extracurricular activities, virtual learning, and social isolation resulted in disruption of social and emotional support networks for individuals of all ages (7,8). Early research shows that youth are particularly vulnerable to this social isolation which has resulted in a decline of MH and increased suicide behaviors (9,10). These findings prompted the American Academy of Pediatrics (AAP), Children’s Hospital Association and the American Academy of Child and Adolescent Psychiatry (AACAP) to declare a National State of Emergency in children’s MH because of the COVID-19 pandemic in October 2021 (4,11,12). The US Surgeon General issued a public health advisory in December 2021 regarding the pediatric MH crisis (13). In 2024, almost 4 years since the pandemic began, providers are still coping with the ongoing MH crisis, despite children having returned to their normal activities (4). Many researchers have investigated if there is a correlation between the COVID-19 pandemic and pediatric MH diagnoses, suicidal behaviors and deaths by suicide, as well as proposed explanations for their findings. This research has provided new guidance for pediatric providers, teachers, parents, and peers on how to best identify and address these sensitive topics with youth at risk.

Objectives

This narrative review aims to describe and summarize the impact the COVID-19 pandemic has had on adolescents in the US and investigate a possible relationship between the pandemic and suicide rates and MH diagnoses in the pediatric population. It also seeks to identify continued and emerging trends, provide explanations to the findings, and describe solutions and important considerations moving forward. It will also describe the role of pediatricians in the prevention of suicide amongst children and adolescents as well as improving overall MH in this vulnerable population. We present this article in accordance with the Narrative Review reporting checklist (available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-35/rc).

Methods

We performed a literature search using PubMed and the AAP journal. These databases were searched for articles published after March 2020 up until January 2024 when the search was conducted. Search terms included COVID, COVID-19, Adolescents, Teens, Suicide and Mental Health. Due to the high number of search results, studies were excluded if they were not in English, conducted outside the United States, or included data pertaining to adults. Focus was also turned to cross-sectional analyses and interrupted time-series analyses, however reviews and meta-analyses were not excluded. The two authors conducted the literature review. Table 1 provides additional information about the literature review. The authors acknowledge that there is extensive research on this topic which made it difficult to narrow the search criteria.

Results

MH diagnoses

Early research has suggested that social isolation as a result of stay-at-home orders and school closures during the pandemic had a negative impact on the MH of children and adolescents (9,10). A study conducted in Illinois found that during the pandemic, teens were 84% more likely to be hospitalized for SI if the principal diagnosis was a severe mental illness including substance use disorder, anxiety or depression (1). This emphasizes why identifying trends in MH goes hand in hand with the discussion of suicidal behaviors and why it is important to consider both. It is also important to note that prior to the pandemic, depression, anxiety, alcohol, and substance use disorders were increasing among adolescents (14). Several studies have been conducted supporting the negative impact of the COVID-19 pandemic on adolescent MH and the lasting, lingering effects despite resumption of normal activities.

A study by Bittner Gould et al. in 2022 investigated the impact of the pandemic on primary care visits for children for seven different MH diagnoses including alcohol and substance use disorders, anxiety disorders, attention deficit hyperactivity disorder (ADHD), behavior disorders, eating disorders, mood disorders including depression, and stress/trauma disorders before and during the pandemic. They found significantly increased visits for eating disorders and mood disorders, from 9.3 to 18.3 per 1,000 patients and 65.3 to 94.0 per 1,000 patients, respectively. While they found no changes in visits for anxiety, ADHD, stress/trauma disorders or behavior disorders, they found significant decreases for alcohol and substance use disorders. This contrasts research in adults, which has shown increased substance and alcohol use during the pandemic. They hypothesized that this may be secondary to different coping mechanisms utilized by adults and children, decreased access to substances due to less peer interaction, or more time spent at home with adult supervision (14).

New York City (NYC) was one of the US cities greatest affected by the pandemic, and in turn it imposed some of the strongest restrictions for longer time periods. A time-series analysis by Levine et al. analyzed pediatric MH visits to Emergency Departments (EDs) across five COVID-19 waves in NYC. They adjusted for seasonal changes based on data from 2016 to 2020 and compared five distinct COVID-19 waves based on prevalence of the disease from March 2020 to June 2022. They found consistent seasonal patterns of MH visits peaking in April and November and with nadirs in January and July, which persisted during the pandemic. There was an overall decrease in ED pediatric census during the first wave, likely due to strict stay-at-home orders. There were increases in census in waves 2 and 3 and a return to baseline for waves 4 and 5. After adjusting for the seasonal patterns, the researchers found that visits to the ED for MH diagnoses were higher during each of the five waves compared to predicted values from pre-pandemic. They found increases in eating disorder visits across all five waves, anxiety in all except wave 3, depressive disorders in wave 2, and substance use disorders in waves 2, 4 and 5. There were higher proportions of visits among females and children with high child opportunity index. They also noted that despite the return to baseline census in waves 4 and 5, the higher prevalence of MH visits persisted, highlighting the continued crisis despite resumption of normal activity (12).

Another consistent finding is the profound effect the pandemic has had on eating disorders among adolescents. Like other MH diagnoses, the prevalence of eating disorders in the pediatric population has been increasing over the last three decades (15). Researchers have additionally found a significant increase in adolescents seeking care for eating disorders during the pandemic (14,15). A study by Rappaport et al. analyzed a population of adolescents aged 12 to 21 years who were hospitalized for eating disorders including binge eating, anorexia nervosa, bulimia nervosa, avoidant/restrictive food intake disorder and other disordered eating behaviors from 2010 to 2022. They analyzed clinical characteristics, demographic data, and coexistence of other psychiatric conditions. They found that while there was a gradual increase in hospitalizations prior to the pandemic, there was a large and significant increase beginning in 2020. There was an average increase of around 131 hospitalizations per year throughout the study period, with over 500 additional hospitalizations from 2020 to 2021. Most patients were female (85.9%) and white (71.8%). Another important consideration is that almost 1 in 4 patients required rehospitalization for treatment within 1 year, highlighting the difficulty and complexity of treating eating disorders (15). These findings support the proposed negative impact the COVID-19 pandemic has had on severe and dangerous MH diagnoses such as eating disorders in adolescents.

Suicide and suicidal behaviors

Suicide is the second leading cause of death among individuals aged 10 to 24 years and suicidal behaviors including SI and attempts amongst adolescents have been increasing before the pandemic (1-5). Early research suggests that stay-at-home restrictions, school closures, social isolation and disruption of daily activities negatively impacted MH in adolescents (9,10). As suicide rates in adolescents were already on the rise in previous years, the cumulative effects of the pandemic have created a public health crisis (1,2). This has prompted many researchers to investigate and quantify these effects, as well as identify trends in order to better inform providers which adolescents may be at higher risk.

A study by Brewer et al. investigated ED visits from 2016 to 2021 coded for SI to identify differences potentially related to COVID-19 by comparing three equal 22-month periods before and during the pandemic. The researchers found that while there was slow increase in ED visits for SI from 2016–2018, there was a sharp spike in the fall of 2019 (before the pandemic) and a similar spike in the fall of 2020 (during the pandemic). ED visits for SI overall increased by 59% comparing 2016 to 2020. Twenty-five percent of these ED visits resulted in inpatient hospitalization, with overall hospitalizations increasing 57% since the start of the pandemic. In addition, the study found that children were more likely to be hospitalized if the principal diagnosis for the visit was depression, anxiety or substance use disorder and the child also had SI. This demonstrates the importance of addressing preexisting MH diagnoses when considering suicide risk (1). A similar study in Texas pulled data from suicide-risk screenings completed at ED visits during January to July of 2019 and 2020 to identify if there was an increase in suicide-related behaviors secondary to the pandemic. They found significantly higher rates of SI in March and July in 2020 compared to the same months in 2019, as well as higher rates of suicide attempts during February, March, April, and July comparing 2020 to 2019. They found that months with higher SI and suicide attempts corresponded with periods in which restrictions in Texas were re-imposed, with lower rates corresponding with restrictions being lifted (2).

Death by suicide was also hypothesized to be impacted by the pandemic. A cross-sectional analysis by Bridge et al. modeled trends in previous years to extrapolate expected numbers of suicide deaths in 2020 by month. They found that there were an estimated 212 excess deaths by suicide during the pandemic compared to their modeled expected values (3). In addition, the CDC’s 2021 YRBS reported that comparing data from the 2019 and 2021 survey, female students reported increased prevalence of seriously considering attempting suicide by 6%, having a suicide plan by 4%, and suicide attempts by 2% (16).

There are several persistent trends as well as new emerging trends to consider from research investigating suicidal behaviors during the pandemic. Higher proportions of females reported SI, but more males died by suicide, which has remained consistent (3,7). The most common method of death was by firearm, which is also consistent with pre-pandemic trends (3,4). The study conducted by Bridge et al. highlights that death by firearm is increasing in female adolescents, which demonstrates a concerning shift among females to more lethal means (3). Youth living in rural areas are more likely to have access to firearms, which could explain why this method is most common among this population (4). While deaths by suicide are still more prevalent in rural settings, there was an increase in suicide in urban areas during the pandemic. In these areas, there are higher proportions of deaths by hanging and poisoning. It is particularly concerning that death by hanging is increasing as hanging is a highly lethal and effective means of suicide and can done with common household items such as shoelaces, belts, and electrical cords (5). Additionally, there are important racial differences in suicide risk. Although the vast majority of deaths by suicide occurs in non-Hispanic white teenagers, there have been increasing proportions of deaths among non-Hispanic Black, non-Hispanic American Indian/Alaskan Native (AI/AN) before and during the pandemic (3,4). According to the 2021 YRBS, 19.4% of AI/AN female youth participants reported that they had made a suicide attempt in the past year, an increase from 13.4% in the 10 years prior, to the highest rate among all ethnic groups (16). The increase in suicide among minority groups is concerning as these populations experienced disproportionate disparities as a result of COVID-19 including higher levels of unemployment, less access to internet to facilitate virtual learning, difficulty accessing childcare, food insecurity, eviction rates and less access to quality healthcare (17). Adolescents who identify as lesbian, gay, bisexual or questioning (LGBQ) community are also known to be a vulnerable population at higher risk of suicide; this may be especially true if they live in unsupportive environments (18). Forty-six percent of students in grades 9–12 who identified as lesbian, gay, or bisexual had seriously considered attempting suicide when surveyed in 2019, compared to 15% of their heterosexual peers (6). The 2021 YRBS found that the prevalence ratio of attempted suicide among LGBQ youth was 1.5–3.9 compared to their heterosexual peers (16). Transgender youth also had a higher prevalence of suicidal behaviors than their cisgender peers prior to the pandemic (19). However, this narrative review did not uncover any data newer than 2019 in this population; the effect of the COVID-19 pandemic on suicide rates among transgender youth is not yet known.

Discussion

Researchers have hypothesized several explanations to their findings; however, the majority acknowledge that the impact of the pandemic on adolescent MH and suicide is complex and multifactorial. Among MH diagnoses, eating disorders have emerged as one of the most negatively impacted by the pandemic. Researchers have hypothesized that this could be a result of lack of access to care, decreased access to gyms, or more social media (SM) attention (14). Additionally, it has been proposed that more time at home with caregivers has increased detection of disordered eating habits leading to caregivers seeking care for their teenagers in crisis (14). There have also been recent changes in hospitalization criteria for disordered eating behaviors, which could have contributed to the increased prevalence over the last several years (15). For mood disorders such as depression, there are clear and obvious associations between increase in prevalence and social isolation, school closures, cessation of sports and extracurricular activities, and decreased interaction with peers (14). One study suggested several possible explanations for the increase in both MH and suicide prevalence including recent reduced stigma leading to increased willingness for teens to seek help, increased academic pressure as being a college graduate has become a standard, and exposure to toxic online environments and cyberbullying (1). Additionally, much of the youth in these studies grew up during the 2008 economic crisis and socioeconomically disadvantaged children were previously 2 to 3 times more likely to experience MH problems (1). This is in contrast to the study conducted in NYC which found that prevalence of MH diagnoses was higher in children of higher socioeconomic status (12). This study acknowledges that populations living in poverty were disproportionately affected by the pandemic and that their results were inconsistent with this finding and they discuss that closure of private outpatient services may have required more affluent families to seek public health care in EDs (12). Substance use disorders seem to have decreased prevalence among teens during the pandemic despite evidence to the contrary in adults during this time. Reduced youth use of alcohol and illicit substances during the pandemic may have resulted from less access to these items if the adults that likely made the purchases or supervised use of finances by the youth became more aware of what their young ones were doing and disapproved (14). The contrast between the trends in youths and adults may also stem from youth having more opportunities to see firsthand the effects of alcohol and substance use in adults and consequently choosing to abstain. While hospitalizations and ED visits for MH increased over the pandemic period, one study found no significant change in anxiety or ADHD diagnoses. The writers proposed that in teens with primarily social anxiety, virtual learning and decreased social interaction may have relieved their anxiety. Similarly for ADHD, less time at school may have been protective for these adolescents as ADHD symptoms are often most pronounced and even first detected at school (14).

SI, suicide attempts and death by suicide have increased over the course of the pandemic. Several preexisting and new emerging trends in the demographics of affected adolescents have been identified during this period. There are important racial differences in suicide trends since the pandemic began. There is an increased prevalence of suicidal behaviors of non-Hispanic Black teenagers, which could be explained by the disproportionate affect the pandemic has had on urban and disadvantaged areas, or due to recent societal unrest within the Black community secondary to events unrelated to the pandemic (3). It is also possible that increased suicidality could be due to disparate death rates from COVID-19 infection in the Black community (20). Non-Hispanic AI/AN male youth had the highest suicide attempt rate among all ethnic groups in 2019 and the 2021 YRBS data (16). There were also disproportionately high transmission rates of COVID-19 among this population, which could be associated with negative cultural, social, and economic consequences leading to increasing rates of suicide (3). Another important ethnic group to consider is Asian/Pacific Islander adolescents, where suicide has been the number one cause of death since 2017. This population experienced increased discrimination and physical assault during the pandemic which could have contributed to worsening MH and increased suicide rates (3). Another emerging trend since 2020 is the increased proportion of deaths by firearm among teenagers. Researchers proposed spending more time at home or increased suicide rates in rural areas where teens are more likely to have access to firearms could explain this (3,4). In urban areas, suicide rates are also increasing and there are higher proportions of death by hanging or poisoning within these communities (5). Urban areas were disproportionally affected by COVID-19 including decreased access to MH services. It is important to note that 24% of COVID-impacted youth suicide deaths in the Schnitzer et al. study were linked to disruptions in MH care in the 12 months prior to their deaths compared to only 4% of those suicide deaths not impacted by COVID. This emphasizes that disruptions in medical and MH services as a result of pandemic-related restrictions could have contributed to the MH and suicide crisis (5). There is additionally an acute shortage of child psychiatrists, particularly in areas with higher poverty rates (21). There also continues to be higher rates of suicide among LGBQ adolescents compared to their heterosexual peers both before and after the pandemic (16,19). Further research into transgender youth will be needed to identify trends in suicidal behaviors affected by the pandemic.

SM: a special consideration

SM has become a daily part of most teenagers’ lives as 97% of adolescents have at least one SM platform (4). SM use has skyrocketed in the last few years, and there has been some inconsistent and highly variable data as to whether it has had a negative impact on adolescent MH. While some research shows small to moderate evidence that SM imposes negative impacts on teenagers, others describe the effect as “substantial” and “detrimental” (22). Negative impacts of SM include being distracting, disrupting sleep, exposing teens to inappropriate content, having access to talk to predators, oversharing of personal information, peer pressure and cyberbullying (4). Research has found that victims and perpetrators of cyberbullying are at higher risk of harming themselves, having suicidal thoughts, or attempting suicide (4). There is also a significant amount of harmful and persuasive content on the internet that is easily and sometimes even subconsciously accessed by teenagers. There is a significant focus on body presentation in SM including “pro-ana” and “pro-mia” blogs which provide readers with strategies for avoiding treatment for anorexia and bulimia as well as how to answer health care providers’ questions regarding eating habits as to not raise concern. This is particularly concerning in the setting of a significant increase in eating disorders in teenagers (15). Suicide clusters are more common among youth and young adults and are often brought on by events in the media, such as the suicide of Robin Williams and TV shows such as “13 Reasons Why” (4). SM use is complicated by the fact that teens can use these platforms with very little supervision from parents or caregivers, leading to decreased recognition when an adolescent is accessing inappropriate content or experiencing distress (22). While there are notable negative impacts of SM, it also can be beneficial when used appropriately. Some teenagers find social connections on SM with peers outside their local community with similar interests who can offer support and allow them to express themselves in healthy ways. In addition, SM platforms like Instagram have implemented machine-learning to flag suicide-related content and deploy resources to individuals who may be in distress. Instagram also allows “friends” to refer their peers to receive assistance and resources through the platform itself if the peer has concerns (4). These findings demonstrate that SM use can be both beneficial and harmful dependent upon the user and the content that users choose to access. It is important as providers, parents, and friends to identify teens at risk for detrimental SM use (22) and provide education regarding safe practices.

The role of a pediatrician amongst an MH crisis

The increase in prevalence of adolescent MH diagnoses and suicide in recent years is a major public health crisis. As most individuals who die by suicide have recently seen a health care provider, it is vital for pediatric providers to identify and support teens who need help (11,23). During the pandemic, several researchers investigated trends screening for MH diagnoses and suicide risk. One study conducted at Children’s Hospital of Philadelphia found that positive screens for depression and suicide risk both increased during the pandemic months (9). Another study by Lantos et al. found a higher rate of positive suicide screens in face-to-face visits during the pandemic than in telehealth visits, which is an important consideration as telehealth visits have become more prevalent even after restrictions have eased. The researchers hypothesized that this could be a result of better communication during face-to-face visits and increased willingness of adolescents to disclose suicidal thoughts (7). The AAP recommends routine universal screening all children 12 or older at least annually for depression and suicidal thoughts and screening at every ED visit and hospitalization as well as any visit presenting with a behavioral health concern (4,11). They also emphasize the importance of screening without caregivers present, while still informing the teen that if they disclose SI they are obligated to breach confidentiality (4). During a Virtual Summit on Youth Suicide Prevention, a Blueprint for Youth Suicide Prevention was created which provides support and information for providers regarding screening guidelines. If a teen screens positive for suicide risk, the provider should conduct a Brief Suicide Safety Assessment (BSSA) to triage necessity of a more comprehensive MH evaluation. They also stress the importance of assessing teens with positive screens for access to lethal means, including firearms, knives, and medications, and counseling the patient and family regarding safe storage or removal of these items. Teens with a positive screen should also develop a safety plan including a list of coping strategies for suicidal thoughts and a plan to reach out for help. They recommend against “no-suicide contracts” as there is a lack of efficacy data and teens can perceive them as coercive or be hesitant to disclose SI to the provider out of fear of disappointing them. While screening for depression alone is insufficient to assess suicide risk, the writers also stress the importance of assessing teenagers for anxiety and depression given the high proportion of co-existence of these conditions with suicidal behaviors. In addition, providers should also screen for substance use disorders, as they are often associated with depression and development of suicidal behaviors. Treating depression with medications or referring the teenager to therapy or psychiatry services can also help prevent suicide in those with SI. Finally, the Blueprint also provides additional resources for providers as well as patients and their families (4).

In addition to identifying warning signs for depression and suicidal behaviors, providers should also assess for protective factors (4). While many youths experienced detrimental impacts of the pandemic, a minority of adolescents reported improved well-being which provides insight into protective factors against declining MH. These factors include improved relationships, more family engagement, healthy family relationships, decreased bullying, increased social interactions and community involvement (4,8). In addition, suicide attempts are associated with poor eating habits, increased screentime, insufficient sleep and decreased aerobic activity. Thus, encouraging healthy diet, exercise, sleep hygiene and time outdoors can decrease risk of suicide (4). Addressing caregiver MH and encouraging family engagement in intervention strategies at well child visits has also been shown to be protective against adolescent suicide (3,4).

Pediatricians have a unique role in identifying both physical and MH concerns in a typically healthy population (23). Increasing cultural literacy to better understand cultural and socio-political concerns among their patients can help identify and support children at risk (3). Appropriate knowledge of language and terminology can also be important when speaking to patients and their families; for example, using the term “die by suicide” instead of “commit suicide” (4). Additionally, advocating for higher risk youth including at risk racial groups, LGBTQ youth and those living in rural areas for increased access to resources and services is vitally important (4). Finally, pediatricians can contribute to the cause by advocating for increased research on prevention strategies and informing policies regarding adolescent MH and suicide (4,23).

Strengths and limitations

The strengths of this review include the consistent evidence amongst researchers supporting the hypothesis that the pandemic had a negative impact on adolescent MH and suicide rates. While each individual study addresses its own limitations, limitations of this review include some inconsistencies in demographic data, and a lack of clear evidence to support causality given that MH and suicide are complex and multifactorial topics, and that these numbers were increasing and continue to be higher before and after the pandemic. We also acknowledge that there is significant limitation in the scope of this narrative review. As there is an incredible amount of scholarly research on this topic, it would be impossible to summarize the entirety of research into one narrative review. The authors did their best to keep the scope of the research broad while still attempting to summarize the data by selecting research articles that were investigating similar study outcomes. In addition, there are many confounding variables that may have contributed to increased suicide rates during the pandemic, as suicide is a multifactorial and complex topic. It would be difficult to find causality from the pandemic alone when considering all other variables.

Conclusions

The COVID-19 pandemic had profound impacts on society across the United States. Prevalences of adolescent MH diagnoses and suicide were on the rise even before the pandemic. Research has shown that the pandemic and the coinciding restrictions, stay-at-home orders, and lingering impacts have had a detrimental effect on MH in adolescents including increased prevalence of MH diagnoses like depression and eating disorders as well as suicidal behaviors. There are also populations that have been disproportionately affected including non-Hispanic Black, Asian/Pacific Islanders and American Indian and Alaskan native racial groups, individuals living in both urban and rural areas, and those with preexisting MH diagnoses. Lack of access to behavioral health care, increased academic pressure, school closings and transition to virtual learning, decreased stigma, and more time spent at home with parental supervision and increased prevalence of SM are among the many hypothesized explanations for the ongoing MH crisis.

Pediatric providers play a vital role in identifying children at risk and providing them support and resources. Universal screening for depression, anxiety, substance use, and suicidal behaviors is recommended by the AAP at least annually at well child visits, at every hospitalization or ED visit and at every visit relating to a behavioral health diagnosis. In addition, teens who screen positive should undergo additional questioning to assess imminent risk, need for acute intervention, and access to lethal means. They should also create a safety plan with their providers, and involving families in these discussions has been shown to improve outcomes. Pediatricians should also ask about protective factors such as social engagement, healthy family relationships, exercise and sleep habits, diet, and extracurricular activities to assess suicide risk. It is also important for providers to continually advocate for populations at risk and to help inform policy regarding adolescent MH. As the trends identified during the pandemic have persisted after return to normal life, it will be important to continue research regarding mitigation and prevention strategies and continue to increase access to services for adolescents at risk for MH disorders and suicide.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Public Health and Emergency for the series “Primary Care and Public Health in the Wake of the COVID-19 Pandemic”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-35/rc

Peer Review File: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-35/prf

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-35/coif). The series “Primary Care and Public Health in the Wake of the COVID-19 Pandemic” was commissioned by the editorial office without any funding or sponsorship. V.O.K. served as an unpaid Guest Editor of the series and serves as an unpaid editorial board member of Journal of Public Health and Emergency from April 2023 to March 2025. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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