The aim of the present paper was to assess the burden of child and adolescent mental health problems on all levels of the Slovenian mental healthcare system and to compare that data with data from before the COVID-19 pandemic.

After an initial drop in 2020, we observed an increased demand across all three tiers of the Slovenian healthcare system. There was a 20% increase in initial visits for MDR in primary healthcare, a 23% increase in referrals to the secondary level, and a 41% increase in referrals to the tertiary level of care in the period 2020–2022 compared to the pre-pandemic period of 2018–2019. Secondary healthcare reported a four- and sevenfold increase in waiting times for initial assessments for regular and very fast referrals, respectively, from August 2019 to August 2023. The prolonged waiting times indicate a collapse of the outpatient CAP system in Slovenia, leading to an increase in very fast and urgent referrals and, therefore, overwhelming pressure on the 3 triage emergency centres within tertiary hospitals. Due to these extensive waiting times, triage centres staffed by hospital CAP specialists and trainees temporarily accommodated high-risk outpatients, operating perpetually beyond their capacity. Heads of the emergency centres reported a higher proportion of high-risk patients who need immediate treatment.

With the data for the primary healthcare level available from 2008 onwards, we were able to analyse longitudinal trends exclusively for this level of care. From 2008 to 2019, primary healthcare experienced a consistent increase in initial visits for MBD, with an average annual growth rate of 4.5%. The onset of the pandemic resulted in a temporary 18.7% reduction in visits in 2020. However, the subsequent years saw a dramatic surge in visits, yielding an average annual growth rate of 13.9% for the period 2020–2022. Recognizing that growth has been evident since 2008 but has accelerated in recent years, we sought to determine when this acceleration began. Segmented regression analysis revealed that the growth rate has accelerated since 2017 for the age group 0–5, with an extremely small standard error. For the age group 6–14 years, this acceleration began in 2020. Considering all available data, trends for the age group 15–19, as well as for the entire population aged 0–19, began increasing in 2020. Given the pandemic’s effect on people’s behaviour in seeking healthcare, we excluded 2020 data from the models generated by the computer program. This exclusion showed that steeper trends might have actually begun emerging as early as 2017 for the age groups 0–5, 15–19, and 0–19, but not for the 6–14 year-olds.

The reduction in visits and referrals at the beginning of COVID-19 pandemic was attributable to altered healthcare-seeking behaviours, exacerbated by a generally less accessible healthcare system, and was comparable to reports from other countries [8, 19, 26]. A meta-analysis of 42 studies from 18 countries concluded there was a reduction in paediatric emergency visits due to mental health problems; however, the vast majority of included studies compared data only from 2020 with the pre-pandemic year(s), so they probably captured the reduction from the start of the pandemic [8]. A later study observed a 53% initial drop in referrals in the Republic of Ireland in March-May 2020 compared with the same period in 2019. However, in the second half of 2020, referrals and visits due to mental health problems began to grow, culminating in a 180% increase in referrals in November 2020 compared to November 2019 [20]. A Finnish study on the population aged 15–24 years observed a 28% increase in primary healthcare visits due to MBD from 2019 to 2020 and a 102% increase from 2019 to 2021 [27]. In a survey, 84% of 454 Swiss child mental healthcare professionals stated there were more or many more treatment requests and patient registrations in January-March 2021 compared to normal. They also reported on prolonged waiting times [26]. Observations of heads of Slovenian hospital departments for child and adolescent psychiatry regarding the severity of pathology are consistent with other studies [8, 19, 20] and other clinicians’ observations [23]. A meta-analysis by Madigan et al. found good evidence for an increase in emergency department visits for attempted suicide during the pandemic– the majority of data applied to the first year of the pandemic (rate ratio 1.22, 90% CI 1.08–1.37) [8].

One explanation for the increasing trends in the use of primary healthcare due to mental health issues could be attributed to changes in the encryption of diagnoses or the expansion of a larger and more accessible network of primary healthcare services. However, neither of these has occurred since 2017. Increasing waiting times at the secondary level could hypothetically result from a reduction in the secondary-level CAP network. Nevertheless, the CAP network has, in fact, expanded, with new CAMH centres for 5–19 year-olds opening after 2020 and functioning within the secondary healthcare system [28]. The developmental outpatient services for children aged 0–5 that function within the primary healthcare system, however, were gradually increased from 21 teams in 2013 to 27 teams in 2022 (Appendix 4). Trends in healthcare indicators across all levels are consistently increasing. Based on primary healthcare data, we can infer that trends were also increasing for secondary and tertiary healthcare before the pandemic. Nevertheless, we cannot definitively determine what the needs would have been like without the pandemic.

A limitation of our study is the absence of secondary- and tertiary-level data prior to 2018. Nonetheless, we included two years pre-pandemic. Another limitation is that one of the three emergency triage centres also accepts patients without a referral [15], probably elevating the actual rate of urgent CAP assessments in Slovenia we didn’t capture in our data. However, the data on their assessments of suicidal children and adolescents also show an initial drop in assessments and hospitalizations at the beginning of 2020 and a gradual increase from the end of 2020 to the summer of 2021. They also show drops in assessments during the school-free months of summer break, which indicates that the pressures of school may be an important factor in the need for emergency child and adolescent psychiatric services [12]. Obtaining data for the year 2023 would greatly aid our analysis; however, despite our efforts, at the time of writing these data were still unavailable from the NIPH. The list of indicators measuring the burden of mental health issues is extensive [29]. For our analysis, we selected one or two indicators for each level of care that appeared most suitable for assessing the burden of MBD among children and adolescents. It is important to consider that this approach, while comprehensive, involves some simplification in interpreting the results.

Our study’s strength lies in the reliability and extensive duration (2008–2022) of the primary healthcare data, encompassing all children and adolescents in Slovenia, as primary healthcare is very accessible for this demographic. This extended timeframe allows for the identification of evolving trends in mental health problems since 2008. While numerous articles have highlighted an increase in MBD and the system overload after the beginning of the pandemic [8, 19, 20, 26, 30, 31], to our knowledge none have contextualised these data within a broader historical perspective. There has also been no similar analytic article on this topic published in Slovenia. Also, other data from the NIPH are very robust, as they encompass all referrals that were issued in Slovenia. Predicted waiting times, which were questioned by politicians in the Slovenian media [32], were confirmed by our cross-sectional study, encompassing 91% of Slovenian CAP outpatient providers, and thus they affirmed the reliability of the official NIPH data on waiting times (Appendix 3).

It would be valuable to compare international longitudinal data about the burden on healthcare systems and differentiate the effects of the pandemic and probable previous influential factors (e.g. social media use, screen time among infants and children, changes in family structures and family burdens, better recognition of mental disorders in children and adolescents, decreasing stigma, etc.). It is also important to continue monitoring the burden on the healthcare system, as the COVID-19 pandemic and its consequences might have a long-term effect on child, adolescent, and adult mental health [10].

In light of our findings, addressing the burgeoning mental health crisis among Slovenia’s young demographic requires a significant and targeted investment of resources in the mental healthcare system, including a targeted investment in human resources with the aim of increasing availability and strengthening the system for the future [30]. However, as it is difficult to find enough professionals to meet the demand with sufficient speed, we advocate for urgent, systemic national action [33, 34]. Slovenia should immediately intensify training in evidence-based programmes for children and families, ideally integrated into the health, social, and education systems. Changes at the national level that promote prevention, such as early attachment work, parent training, limited use of electronic devices, reduction of peer violence, and modernization of the school system to reduce stress and promote emotional and social skills, are urgently needed [18, 23, 30, 31].