The immediate physical risks of the COVID-19 pandemic may have decreased significantly, but its effects continue to linger.Reference Pearson-Stuttard, Caul, McDonald, Whamond and Newton1 Across the world, services are still working to contain the secondary crisis of psychological distress and mental health system spillover.Reference Choi, Heilemann, Fauer and Mead2 Public health measures introduced during the COVID-19 pandemic to limit the spread of the virus, such as lockdown, quarantine and school closures and subsequent re-openings, disproportionately affected children and young people, increasing their emotional distress, mental health disorder symptoms and associated risks.Reference Ashwin, Cherukuri and Rammohan3–Reference Sayal, Partlett, Bhardwaj, Dubicka, Marshall and Gledhill6
In the early months of the pandemic, a survey of child and adolescent mental health service (CAMHS) in-patient wards found discharge delays and restrictions surrounding visits and time off the ward, but also some relaxation to rules around mobile telephones and video calling.7
At that time, there had been a significant drop in referrals to CAMHS in-patient services;Reference Tsiachristas, Holland, Guo, Chitsabesan, Sayal and Pari8 since then, there has been an increase in the number of referrals to CAMHS, as well as a rise in the acuity and severity of symptoms.9 Research into the pandemic needs to not only focus on the early months, but cover the whole period, since the nature of the threat and associated restrictions will have had differential effects throughout.
Data from the ‘Far Away from Home’ study
The ‘Far Away from Home’ study, a multi-methods programme of research investigating admissions of patients aged <18 years to CAMHS and adult in-patient wards, collected quantitative and qualitative data from February 2021 to September 2022.Reference Holland, Roe, Guo, Dasilva-Ellimah, Burn and Dubicka10,Reference Roe, Holland, Burn, Hopkin, Wild and Fisher11 Findings from this research showed that at-distance or out-of-region admissions affect 13.7–16.9 per 100 000 young people aged 13–17 years in England, and the most common reason for these admissions was a lack of local CAMHS beds.Reference Holland, Roe, Guo, Dasilva-Ellimah, Burn and Dubicka10
Underpinned by an interpretivist approach, this paper presents a multi-methods study of the effects of the COVID-19 pandemic on experiences during this period. It uses two different data-sets: free-text responses to questionnaires and interviews. These data are from overlapping (some healthcare professionals (HCPs) completed the questionnaires and participated in interviews) and distinct (interviews with young people, parents/carers and HCPs who only gave responses in one part of the study) samples.
Method
Participants and data collection
The Far Away from Home study, through the Child and Adolescent Psychiatry Surveillance System (CAPSS), conducted a 13-month surveillance period from February 2021 to February 2022, with 6-month follow-up data collected until September 2022.Reference Holland, Roe, Guo, Dasilva-Ellimah, Burn and Dubicka10 During this period, consultant child and adolescent psychiatrists across England who reported seeing an eligible case were asked to complete two questionnaires for each case, at baseline (as soon after admission as possible) and at 6-month follow-up. Eligible cases were defined as adolescents (aged 13–17 years) who were admitted to a general adolescent unit (a psychiatric ward for young people aged 13–17 years) far away from home (more than 50 miles (80 km) from their home address or outside of their National Health Service (NHS) commissioning region), or to an adult psychiatric ward for psychiatric care. The questionnaires included a mixture of closed and open-ended questions. This paper focuses on free-text comments offered about the effects of COVID-19 on the admission, and the responses to other questions are presented elsewhere.Reference Holland, Roe, Guo, Dasilva-Ellimah, Burn and Dubicka10
The Far Away from Home qualitative interview study purposively recruited young people, parents/carers and HCPs through local participating NHS Trusts in five large regions in England. All young people and parents/carers had experience of at least one of the following: admission to a local CAMHS ward, admission to a far-away CAMHS ward or admission to an adult psychiatric ward. Across the five regions, 30 young people and 21 parents/carers were interviewed; two further young people and one parent consented to participate, but withdrew before the interview.
Alongside this, using purposive sampling through clinical networks, healthcare leaders and respondents from the surveillance study, HCPs working in CAMHS in-patient or CAMHS community settings, adult mental health services or private mental health services across England were approached to be interviewed about their experiences. In total, 68 HCPs were interviewed; three additional HCPs consented to participate, but withdrew before the interview.
The topic guides for all interviews are included in the Supplementary Material available at https://doi.org/10.1192/bjo.2024.783.
Interview schedules for each stakeholder group were developed in collaboration with the study professional, young person and parent/carer advisory groups. Interviews were conducted either virtually through Microsoft Teams for Windows or face to face. All interviews were 20–60 min long and audio recorded. Reponses to other interview questions are presented elsewhere;Reference Roe, Holland, Burn, Hopkin, Wild and Fisher11 this paper focuses on themes found within comments about the impacts of the COVID-19 pandemic specifically.
Positionality statement
J.H. (White British, female) and K.S. (Indian British, male) are clinical academics in child and adolescent psychiatry, M.D.-S.-E. (Black British African, female) is a clinical academic in paediatrics, R.M. (White British, male) is a clinical academic in adult psychiatry and J.R. (White British, male) is an academic researcher in mental health.
Content analysis of questionnaire responses
The qualitative data about the impact of the COVID-19 pandemic, provided through free-text responses, were analysed using conventional content analysis as described by Hsieh and Shannon.Reference Hsieh and Shannon12 Two researchers (J.H. and M.D.-S.-E.) completed the following steps: familiarisation with the data, initial coding, grouping the codes into categories and then combination of categories until main categories emerged. Any comments that did not include any content were excluded. Where comments contained relevant content, but did not have enough detail to interpret the meaning with certainty, two study team members reviewed these comments alongside the other questionnaire responses, to resolve ambiguity.
Thematic analysis of interview responses
All interviews were transcribed verbatim and initially coded with NVivo 12 for Windows (Lumivero, Denver USA; https://lumivero.com/products/nvivo/) by the Far Away from Home research team. The interview data were thematically analysed using the five stages of framework analysis, as described by Ritchie and Spencer: familiarisation, identifying a thematic framework, indexing, charting, and mapping and interpretation.Reference Ritchie, Spencer, O'Conner, Ritchie and Lewis13 When coding was completed, the matrix framework was exported into Microsoft Excel, Microsoft 365 for Windows, with a row for each interviewee, column for each code and data within the cells. Concise summaries of the verbatim text were then produced in each matrix cell. The summaries were then grouped into overarching themes.
Comparison and combination of themes/categories
The identified categories from the content analysis were treated as themes. The identified themes from both data sources, along with the initial codes and the data within them, were compared. Where the themes significantly overlapped, they were combined. Themes that were only present in one data source are also presented.
Ethics statement
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2013. All procedures involving patients were approved by the South Birmingham Research Ethics Committee (approval numbers 20/WM/0265 and 20/WM/0314) and Section 251 Health Research Authority Confidentiality Advisory Group permission (20/CAG/0127).
Consent statement
Within the Far Away from Home surveillance study, consultant child and adolescent psychiatrists reported information about young people. Participants did not specifically consent for their data to be shared, and so approval by the confidentiality advisory group (CAG) was applied for and granted. Medical records held by the NHS keep a record of whether a parent of a child does not want their medical notes to be used for research purposes. Parents/carers of young people can inform their respective consultant psychiatrist that they do not want their child's notes to be used in this sense. If any parent/carer had indicated such dissent, we did not use their data. The national data opt-out also enables patients to opt out of the use of their data for research purposes. Written informed consent was obtained from all interview participants.
Results
Questionnaire free-text responses
A total of 79 free-text comments were provided by 51 respondents to the surveillance study (child and adolescent psychiatry consultants, no further demographic information was collected). Eleven comments were excluded because they did not contain any relevant content; 68 were included in further analysis. The comments from the baseline and follow-up surveys were combined and analysed together. All extracts have been quoted verbatim.
Interview data
All 119 interviewees, see Table 1 for demographic details, spoke about the impact of the COVID-19 pandemic on their experiences. All comments were included in the analysis.
Table 1 Demographic details of interview participants
Themes generated in both data-sets
Theme: how the COVID-19 pandemic affected young people's contact with others
COVID-19 affected young people's contact with others in a number of ways, including changes in access to the ward, self-isolation, visiting and leave rules (see Table 2 for quotations).
Table 2 Quotations to illustrate the theme: how the COVID-19 pandemic affected young people's contact with others
P/C, parent/carer; YP, young person; HCP, healthcare professional by interview; HCP QR, healthcare professional by questionnaire response.
Parents/carers unable to enter wards
Parents/carers talked about how already high anxiety levels when their child was admitted were worsened by being unable to see their young person's room (Q1).
Challenges associated with periods of self-isolation
Self-isolation periods were felt to be negative by all who commented (Q2–Q8). Parents’ worries about being unable to see their child's room were compounded with the knowledge the young person would be confined to it during their initial days (Q2). Young people talked of the loneliness and dark thoughts they experienced during this period (Q3–Q6). HCPs echoed concerns about young people during these periods (Q7, Q8), including the delays to assessment (Q9), and some felt that these periods of isolation were actively harmful for young people.
Changes to arrangements around visiting
Another way in which young people's contact with others was reduced was through changes to visiting. Parents and young people frequently discussed how visits were changed in several ways, including limits to their frequency, duration, who could visit (Q10), the number of people who could visit (Q11) and where they could occur (Q12, Q13), with families having to be coordinated to ensure visits were staggered (Q14).
Changes to arrangements around leave
A third way in which young people's contact with others was affected was through changes in leave. The closure of nearby businesses meant sometimes local leave periods were hard to fill during bad weather because there was little to do (Q13). When someone tested positive for COVID-19 on the ward, all visits and leave would be suspended for a period, which caused frustration to all involved (Q15, Q16). HCPs questioned why overnight leave had to be followed by a self-isolation period, and how this disincentivised it (Q17); young people (Q18) and parents also echoed this (Q19).
Theme: how the COVID-19 pandemic affected discharge planning
COVID-19 affected discharge planning in several ways (see Table 3 for quotations). Overall, the use of online discharge planning meetings was felt to make the process feel more collaborative (Q1). However, isolations after overnight leave meant fewer trials of overnight leave were completed before discharge, leaving some young people, parents and HCPs concerned that discharge was earlier or less tested than it should be (Q2, Q3). For others, the need for periods of isolation and less access to overnight leave meant that discharges were delayed (Q4). A third way in which discharge was affected was when young people were discharged because they tested positive for COVID-19, a situation that parents/carers found very stressful both because of concerns about the young person passing the virus to others at home and the worry about the alternative of having to isolate on the ward while unwell (Q5–Q7).
Table 3 Quotations to illustrate the theme: how the COVID-19 pandemic affected discharge planning
HCP, healthcare professional by interview; HCP QR, healthcare professional by questionnaire response; P/C, patient/carer.
Themes generated only in questionnaire data
Theme: how the COVID-19 pandemic delayed admission and transfer
Within the questionnaire data but not the interviews, HCPs commented on the effect of COVID-19 on admission and transfer between wards (see Table 4 for quotations). Questionnaire respondents detailed several ways admission or transfer were delayed, including the ward being closed because of COVID-19-positive cases (Q1), delays getting negative tests before transfer, and young people testing positive for COVID-19 and therefore not being permitted to transfer (Q2).
Table 4 Quotations to illustrate the theme: how the COVID-19 pandemic delayed admission and transfer
HCP QR, healthcare professional by questionnaire response.
A subtheme generated within this theme was that ‘COVID-19 reduced the availability of beds’. The questionnaire respondents described how paediatric or psychiatric wards were sometimes being used for adult COVID-19 patients, and one reported the general adolescent unit was shut down (Q3).
Themes generated only in interview data
Theme: the effect of the COVID-19 pandemic on working practices
See Table 5 for quotations.
Table 5 Quotations to illustrate the theme: the effect of the COVID-19 pandemic on working practices
HCP, healthcare professional by interview; P/C, parent/carer; YP, young person.
Introduction of the use of virtual meetings
The effect of the COVID-19 pandemic on the introduction of virtual meetings was the most commonly coded theme within the interview data, with 46 participants referring to it. Most of those who commented were HCPs, for whom the introduction of virtual meetings meant community teams and other professionals, as well as parents, were able to be present in more meetings, increasing the collaborative feel of decision-making and reducing the impact of admissions far away from home (Q1–Q3). Some HCPs did offer some negative viewpoints, discussing how it may decrease the quality of interactions (Q4, Q5). Young people and parents echoed some of these negatives, talking about how it can be difficult to build rapport over a screen, and complex interventions such as family therapy may feel more awkward online (Q6).
Difficulties around staffing
A further effect on working practices that was highlighted by young people, parents and HCPs was the effect of the pandemic on ward staffing. The pressures of the pandemic affected both the availability and the resilience of staff, causing higher reliance on temporary staff, which was felt to be negative (Q7, Q8).
Ward rule changes
Some of the ward rules changed during the COVID-19 pandemic, young people welcomed some changes such as being able to smoke on the hospital site, but others, such as cancelled trips and group activities, were felt to have a negative impact (Q9).
Theme: general population effects of the COVID-19 pandemic
Another theme among the HCP interviewees (that did not emerge from the questionnaire data) focused on the effects of the COVID-19 pandemic on the wider population and those presenting to CAMHS (see Table 6 for quotations). Several interviewees commented on how the COVID-19 pandemic had an overall detrimental effect on everyone (Q1), and in some young people prompting a deterioration in some that led to the need for admission (Q2). There was a consensus that since the beginning of the pandemic there were fewer presentations with psychotic symptoms, but a higher percentage of presentations involving eating disorders and autism spectrum disorder (Q3–Q5). HCPs also discussed how referral rates during the early part of the COVID-19 pandemic went down, but then increased; there were concerns that changes in community practice with online mental health reviews had led to some presentations being more florid and severe when they were admitted (Q6, Q7).
Table 6 Quotations to illustrate the theme: general population effects of the COVID-19 pandemic
P/C, parent/carer; HCP, healthcare professional by interview.
Discussion
This study used two methodologies to investigate experiences of CAMHS in-patient admissions during the COVID-19 pandemic, gathering information from many participants and bringing together multiple perspectives. It is known that restrictions introduced during the COVID-19 pandemic placed a limit on the social interactions of young people within the general population. However, our findings starkly show how restrictions were amplified for young people who required psychiatric admission, with requirements for periods of total isolation in their room, limits to visits with family and loved ones, and disruption to leave. The imposition of these restrictions caused distress for young people, parents and HCPs, as well as additional complications for care transitions such as admissions, transfers and discharges. There was additional strain on units during the pandemic, with difficulties in staffing noted by all involved.
However, some positive changes resulted from the COVID-19 pandemic: the introduction of virtual meetings has increased collaboration and joint decision-making, and also mitigated some of the negative effects of admissions far away from home. These findings are in keeping with other studies published during the pandemic that found more positive than expected reports from clinicians about remote consultations.Reference Bhardwaj, Moore, Cardinal, Bradley, Cross and Ford14 However, online reviews are not perceived as universally beneficial or practical, and there are concerns relating to access equality.Reference McCarron, Moore, Foreman, Brewis, Clarke and Howes15 Some argue for a need to co-produce guidelines for best practice in remote working, and to ensure that practitioners are adequately trained.Reference Newlove-Delgado, Mathews, Cross, Wooding, Ford, Hove and De Vries16
Studies have shown a significant negative effect of isolation and loneliness on symptoms of mental disorders.Reference Loades, Chatburn, Higson-Sweeney, Reynolds, Shafran and Brigden17,Reference Groarke, Berry, Graham-Wisener, McKenna-Plumley, McGlinchey and Armour18 Our findings highlight how this effect of the pandemic was particularly pronounced for young people admitted to psychiatric hospitals, since they experienced isolation from even their close family during these periods, which is particularly worrying because this population is already significantly vulnerable and unwell.Reference Douglas, Katikireddi, Taulbut, McKee and McCartney19 A study by Hanss and colleaguesReference Hanss, Carcana and Rice20 suggested that content-restricted devices may be a way that technology could be safely used to combat the effects of self-isolation on patients admitted to adolescent in-patient psychiatric units. The feasibility of such devices in these settings needs further investigation.
Large surveys have shown an increase in the prevalence of probable mental disorders in young people since the pandemic,Reference Panagi, White, Pinto Pereira, Nugawela, Heyman and Sharma21,Reference Newlove-Delgado, Russell, Mathews, Cross, Bryant and Gudka22 and our findings add to the literature, focusing on how it affected this unique group. The change in population being referred for in-patient care is also supported by wider research that has found lockdowns were associated with increased levels of depression and anxiety among adolescents and exacerbated eating disorders.Reference Zipfel, Schmidt and Giel23,Reference Huang and Ougrin24
The introduction of virtual meetings, and the positives and negatives of this,Reference Bhardwaj, Moore, Cardinal, Bradley, Cross and Ford14–Reference Newlove-Delgado, Mathews, Cross, Wooding, Ford, Hove and De Vries16,Reference Proulx-Cabana, Segal, Gregorowski, Hargreaves and Flannery25–Reference Worsley, Hassan, Nolan and Corcoran27 have been discussed. A survey by Bentham et al found that staff at a UK community CAMHS service perceived the lack of face-to-face visits during the pandemic as hindering their ability to build rapport with young people and undertake core aspects of their role, as well as creating delays.Reference Bentham, Driver and Stark28 The role of virtual meetings may differ between the in-patient setting (where the young person is reviewed in-person, but some therapies and meetings may be conducted online) and an out-patient setting (where reviews may be conducted online). For the population within our study, who have complex needs and often require multi-agency working, online meetings appear to provide a helpful way to promote collaboration across networks.
Strengths and limitations
A strength of this study is the multi-methods approach to data collection. The surveillance survey enabled participants to respond at any time that was convenient, and so allowed many responses to be collected in a relatively short period. This was combined with richer, more in-depth interview data, which allowed the interviewer to flexibly explore a participants’ responses. HCPs from every region of England were interviewed to ensure generalisability across the country. A limitation of this study is that it captured only experiences in England and did not feature those living and working in other parts of the UK. The free-text survey responses were able to capture comments from a large number of HCPs; however, this method of data collection does not allow the opportunity for the study team to respond to these comments either for clarification or to elicit more information. The large amount of data included in the analysis meant it was not possible to go into depth about individual experiences or capture the phenomenology of this topic in more specific detail. A further limitation, but also potential strength, was that responses were not segregated based on the time of capture; the questionnaire respondents were asked to comment on the effect of the COVID-19 pandemic on a particular case they were reporting, but some responded about the more general effects of COVID-19. Alongside this, the participants interviewed were asked to comment more generally on the effects of COVID-19, and therefore the data were able to capture not only specific effects on a person's admission, but also a more longitudinal view of how the COVID-19 pandemic had affected services.
Clinical implications
The COVID-19 pandemic and associated restrictions has had an overall negative effect on the mental health of young people, which was amplified for young people admitted to CAMHS wards. However, some of the changes resulting from the pandemic, such as virtual meetings, have provided a useful tool that will continue to be used in everyday practice. For future national emergencies, the unique situation of those admitted to CAMHS in-patient units, who are young and physically healthy but mentally extremely vulnerable, should be considered when deciding how and whether public health restrictions are applied in these settings.
Supplementary material
Supplementary material is available online at https://doi.org/10.1192/bjo.2024.783
Data availability
The data that support the findings of this study are available on reasonable request from the corresponding author, J.H.
Acknowledgements
We thank the CAPSS for facilitating the data collection, and the reporting psychiatrists, particularly those who reported cases and completed the questionnaires. Special thanks to the three advisory panels for this study: professionals, young people and parents, who have generously contributed their time regularly throughout. We also thank to the Maudsley Young People's Mental Health Advisory Group, who have given helpful feedback to the study team on multiple occasions. We acknowledge the input of the members of the CAPSS scientific committee: Professor Alka Ahuja, Dr Cornelius Ani, Dr Hani Ayash, Dr Joanne Doherty, Dr Priya Hodgins, Dr Siona Hurley, Dr Marinos Kyriakopoulos, Richard Lynn, Professor Fiona McNicholas, Dr Andrew McWilliams, Dr Tamsin Newlove-Delgado, Professor Dasha Nicholls, Dr Udo Reulbach, Dr Aditya Sharma, Dr Eleanor Smith, Dr Helen Smith, Dr Adele Warrilow and Professor Ian Wong.
Author contributions
J.H. was involved in formulating the research questions, designing the study, carrying it out, analysing the data and writing the paper. M.D.-S.-E. was involved in analysing and interpreting the data, and writing the first draft of the paper. J.R. and K.S. were involved in designing the work, the acquisition and interpretation of the data, and critically reviewing the draft paper for important intellectual content. R.M. contributed to the interpretation of the results and provided comments on the manuscript. All authors approved the final version of the paper. All authors agree to be 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.
Funding
This study is funded by the National Institute for Health Research (NIHR) Applied Research Collaboration East Midlands, East of England, West Midlands, ARC Oxford and Thames Valley and ARC Greater Manchester (NIHR200171). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. The study researchers acted independently of the funder.
Declaration of interest
The authors declare that they have no conflicts of interest. The views, opinions and/or conclusions expressed by the authors are their own and do not necessarily reflect the views, opinions and/or conclusions of either the funders or the Child and Adolescent Psychiatry Surveillance System or its constituent partners.
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