Here in the U.S., we’re in the middle of Mental Health Awareness Month (MHAM), which we observe every year in the month of May. That’s many of our articles this month focus on mental health awareness, the connection between mental health and substance use disorder (SUD), and how we can all work together to improve the mental health of all of our citizens, including our youth and teens.
To learn more about MHAM, please navigate to the blog section of our website and read this article:
May is Mental Health Awareness Month
That article presents a comprehensive overview of MHAM and the importance of mental health as a fundamental component of overall health and wellbeing. It recognizes the impact of environmental and community factors on mental health, and shares action steps we can all take to improve our communities and optimize the social, community, and environmental factors in our lives to improve our mental health.
This article is about a recent radical change in our community, social, and environmental factors that had a direct impact on our collective mental health: the COVID-19 pandemic. There are several direct connections between our work as SUD treatment providers, the COVID-19 pandemic, and mental health.
First, the presence of a mental health disorder – particularly anxiety or depression – can increase the risk of developing an SUD. Second, the phenomenon of co-occurring disorders – when a person has a mental health disorder and an SUD at the same time – is a partial driver of the current phase of the opioid overdose epidemic in the U.S. Third, overdose rates increased during the pandemic, partially due to the increase in pandemic-related stress. Finally, policymakers have embraced the concept of harm reduction to address the opioid crisis, which, among other things, prioritizes a whole-person, integrated, comprehensive approach to treatment – including a renewed focus on the role of mental health disorders in SUD/addiction.
It’s all connected: that’s why we’re taking the time to explore the data on changes in rates of anxiety and depression in children and adolescents during COVID-19
COVID-19 and Mental Health in the U.S.: How Did it Impact Children and Teens?
It’s now been three full years since the pandemic began and two full years since vaccines became available to most of us. That means it’s time for us to settle into our new normal – and it also means scientists have had time to examine all the data from 2020 and 2021 and arrive at evidence-based conclusions about the impact of the pandemic on mental health.
In March 2020, when the pandemic arrived in the United States, we organized a national strategy to mitigate the potential harm experts predicted the pandemic might cause. While our response varied from state to state and community to community, it’s safe to say that the pandemic changed daily life for millions of people across the country. Many businesses had to completely change the way they operate. Schools went virtual. People in various professions made the switch to working from home and engaging with coworkers via videoconference. Many others, unfortunately, experienced job loss or reduced hours that led to significant financial insecurity, and for some, food and housing instability as well.
Those factors increased default stress levels across the board – even in places where the COVID-19 prevention measures were not as extreme as others. They also prompted mental health experts to predict significant increases in rates of mental health disorders for adults. Experts in child and adolescent development warned the cumulative stress and changes would have a disproportionate effect on children and adolescents.
Here’s why they thought our youth were most at-risk of negative mental health outcomes associated with COVID-19.
Mitigation Measures: Potential to Disrupt Child and Teen Mental Health
- Previous research showed social isolation/quarantine increased risk in stress-related symptoms among children and adolescents by close to 400%
- Daily life changed dramatically in 2020-2021. Changes included:
- More screen time
- School closures and disruptions
- Widespread cancellation of extracurricular activities
- Widespread cancellation of milestone events like prom and graduation
- Decreased direct contact with peers, resulting in an increase in isolation and loneliness
- Decreased physical activity, resulting in decreased physical health and increased risk of mental health problems
- Reduced access to support at school, including:
- Breakfast, lunch, and snack programs
- Tutoring
- Academic counseling
- Mental health support
- Changes in family life included:
- Increases in anxiety and depression among parents
- Increased family violence
- Job loss
- Financial instability
- Housing instability
- Food insecurity
- Increased alcohol consumption among adult family members
In 2020, it seemed almost guaranteed that the combination of all these factors would create a perfect storm for increased mental health problems for everyone, including children and teens. However, long-range studies that analyzed data from before and during the pandemic did not yield consistent results. For example, see below.
Youth and Teen Mental Health: Contradictory and Conflicting Research
- Many studies showed depression and anxiety symptoms have increased significantly
- Many studies showed depression and anxiety symptoms have decreased slightly
- Other studies showed no change in depression and anxiety symptoms
- Still others showed inconclusive, inconsistent results: increases in depression for some but not others, increases in anxiety for some, but not other
This type of inconsistency in results from experts can result in doubt and confusion in the general public. But more importantly, variability in results – or even conflicting results – can cause doubt and confusion among policymakers that ultimately make decisions that have a real and lasting impact on the mental health and wellbeing of individuals, families, and communities. And in this case, the data will be used to make policy that affects our future – meaning our children and adolescents.
A New Study Reconciles Conflicting Data
To address these inconsistencies – now that researchers have had time to collect and verify the data – a group of scientists conducted a wide-range meta-analysis called “Changes in Depression and Anxiety Among Children and Adolescents From Before to During the COVID-19 Pandemic.” The research team collected and reviewed data from 53 longitudinal studies from 12 countries with data on over 40,000 children and adolescents.
Here’s their primary research question, i.e., the question that drove their analysis:
“Did depression and anxiety symptoms increase in children and adolescents during the COVID-19 pandemic?”
Rather than sharing the raw numbers of children and adolescents who reported symptoms of anxiety and depression before and during COVID-19, researchers use a metric called standardized mean changes (SMC). Using SMC allows researchers to collate and discuss results with accuracy when the studies they analyze address the same thing – in this example, anxiety and depression – but use different psychiatric metric tools to report their results. The SMC standardizes the original results using established and reliable statistical methods and creates uniformity among the new results that allow for easier and more accurate comparisons.
In this study, the subjects were children and adolescents, the intervention – or the event that may or may not have created change – was the COVID-19 pandemic, and the outcomes were symptoms of anxiety or depression, as expressed in the change in mean before and during COVID-119. Here’s how you can interpret the numbers we share below:
- Slight change: SMC of 0.2
- Small change: SMC of 0.6
- Moderate change: SMC of 1.2
- Large change: SMC of 2.0
Keep those figures in mind when we report the results below. Before we get to the data, though, let’s take a look at the key demographic features of the sample group.
Age of Participants:
- Depression studies: 13.5 years old
- Anxiety studies: 12.6 years old
Gender of Participants:
- Depression studies:
- 54% female
- 46% male
- Anxiety studies:
- 52% female
- 48% male
Type of Data:
- Self-reported symptoms: 87%
- Parent reported symptoms: 9%
- Parent and child/adolescent reported symptoms: 2%
- Unknown: 2%
Location of Studies:
- North America: 51%
- Europe: 24%
- Asia: 19%
- Australia: 4%
- Israel: 2%
Enough about the study: let’s take a look at those results.
Did Anxiety and Depression Symptoms Increase Among Children and Teens Because of COVID-19?
You may notice something in that heading.
The initial research question was simpler: did symptoms increase during COVID-19?
However, the comprehensive analysis used in this study allows researchers to answer the variation of the question that asks if they changed because of the pandemic, rather than simply asking if the prevalence of symptoms changed overall.
Here’s the data.
Depressive Symptoms Before and During COVID: Standard Mean Change (SMC)
- Overall change:
- 26 SMC, with a range of 0.19 to 0.33 SMC
- That’s a slight to small increase
- By gender:
- Females: 0.32 SMC, with a range of 0.21 to 0.42
- That’s a small increase
- Males: 0.10 SMC, with a range of -0.02 to 0.22
- That’s a slight to small increase
- Difference: 0.22 SMC
- Females: 0.32 SMC, with a range of 0.21 to 0.42
Females showed larger increases in depressive symptoms than males.
- By age group:
- Over age 12: 0.27, with a range of 0.19 to 0.34
- Under age 12: 0.21, with a range of 0.03 to 0.39
Adolescents showed larger increases in depressive symptoms than younger children.
Anxiety Symptoms Before and During COVID: Standard Mean Change (SMC)
- Overall change:
- 10 SMC
- That’s very slight increase
- By gender:
- Females: 0.12 SMC, with a range of -0.03 to 0.27
- That’s a slight to small increase
- Males: 0.04 SMC, with a range of -0.12 to 0.21
- That’s a slight to small increase
- Difference: 0.22 SMC
- Females: 0.12 SMC, with a range of -0.03 to 0.27
- 10 SMC
Females showed larger increases in anxiety symptoms than males.
- By age group:
- Over age 12: 0.16, with a range of -0.21 to 0.17
- Under age 12: -0.02, with a range of -0.21 to 0.17
Adolescents showed larger increases in anxiety symptoms than younger children.
After controlling for variables such as time trends and other non-COVID factors that may result in increases, researchers concluded:
“Our comprehensive systematic review and meta-analysis showed evidence of an increase in depression symptoms during the COVID-19 pandemic compared to prepandemic estimates. The magnitude of this increase was more than what could be expected based on time trends and can therefore likely be attributed to the disruptions, restrictions, and stress imposed on children and adolescents and their families during the pandemic.”
That’s what we’ve been waiting for since the pandemic began: an exhaustive statistical analysis on mental health metrics before and during COVID-19. What this data tells us is that increases in depressive symptoms were small, but statistically significant, and that increases in anxiety – among adolescents – slight, but also statistically significant. We should also note that for symptoms of depression and anxiety, researchers observed more substantial increases in females than in males. Finally, we should also report that rates of depressive symptoms increased in significantly Europe and North America, but less significantly in Asia, while symptoms of anxiety showed only slight increases in Europe, North America, and Asia.
Next, let’s talk about how we can support the mental health of our children and teens.
The Surgeon General’s Advice on How to Support Youth Mental Health
In December 2021, the Surgeon General of the United States issued an advisory on child and teen mental health called Protecting Youth Mental Health. In that advisory, he cited data that showed startling increases in the rates of child and teen suicide and child and teen mental health disorders between 2007 and 2019. Rates of suicide during that period increased by 57 percent, and rates of high school students considering suicide increased by 36 percent. In addition, the rates of high school students feeling sad or hopeless increased by 40 percent, and mental health-related visits to the emergency room for children and teens increased by 28 percent.
That report also contained helpful information on how healthcare organizations and health professionals can support youth and teen mental health, in the form of the five action steps, which we list below.
For Health Professionals: Five Steps to Support Youth Mental Health
- Recognize that prevention is the best treatment. Health professionals can implement trauma-informed prevention strategies and practices for all youth and teens, especially those with a history of trauma or adverse childhood experiences (ACEs).
- Screen for mental health disorders in youth on a regular basis. This includes screening in primary care settings, at school, and in emergency departments, among others. Mental health screening should include screening for ACEs and occur during typical checkups, well-visits, and during routine vaccinations.
- Identify and support the mental health needs of parents and caregivers. It’s critical to address the entire support system surrounding youth. Identifying homes that are physically and emotionally unsafe – and offering support to remediate existing issues – is essential to overall youth mental health and wellbeing.
- Increase communication across life domains. Teachers, primary care providers, school counselors, parents, and sports coaches can all communicate with mental health providers to identify and address mental health issues in youth as soon as they arise – and offer support when needed sooner, rather than later.
- Create multidisciplinary, culturally competent treatment teams. These teams should recruit youth and their families to engage and participate in all stages of mental health support, from screening and evaluation through treatment and discharge. Healthcare professionals should focus on cultural competency and offer all information in ways that respect the home culture of the family, and whenever possible, in the native language of the primary decision-makers in the family unit.
We’re on board with all five of these action steps. We should point out that parents who think their child or teen needs professional support should arrange a full evaluation from a mental health professional as soon as possible: evidence shows that the earlier a person with a mental health disorder receives evidence-based treatment, the better the outcome.