Samantha Gordon, OMS-IV, outlines the importance of screening for depression and anxiety in adolescents and young adults, especially amid the pandemic, and offers tips for providing individuals and their families with appropriate resources.
Samantha Gordon, OMS-IV | Touro University College of Osteopathic Medicine in California 2022 Namey/Burnett Preventive Medicine Writing Award Submission
Sponsored by the ACOFP Foundation, with winners selected by the ACOFP Health & Wellness Committee, the Namey/Burnett Preventive Medicine Writing Award honors the memory of Joseph J. Namey, DO, FACOFP, and John H. Burnett, DO, FACOFP—dedicated advocates for osteopathic medicine—and recognizes the best preventive medicine blog posts submitted by osteopathic family medicine students and residents.
The COVID-19 pandemic has changed the landscape of the world in innumerable ways. One example of this is the increasing levels of anxiety and depression among adolescents and young adults. Factors contributing to this include social isolation, uncertainty of the future, worry about loved ones getting sick and increased stress for both the patients themselves and their family members. It is essential that primary care providers are aware of this increasing trend and are able to screen and treat appropriately.
Adolescents and young adults are unique in their relationship to the pandemic. They have lost their previous ability to grow and develop their unique sense of self by interacting with peers normally, living on their own, going to college and/or starting their careers. Due to virtual schooling, students have lost their usual everyday interactions with peers and access to social support separate from their families. The loss of this social support can cause patients to lose coping skills they have developed to handle feelings of anxiety and depression. Although technology has allowed adolescents to connect with their peers virtually, it also brings up concerns such as online bullying and body image distortions with the widespread use of filters and Photoshop online.
Several studies have demonstrated increased feelings of anxiety and depression among adolescents during the COVID-19 pandemic.1–6 This seems to be a worldwide trend, given that these findings are being discovered in the United States, China, Sweden, India and Australia. Knowing that adolescence is a time of exponential growth and discovery, it stands to reason that the loss of normal milestones would lead to complex emotions and feelings, potentially leading to anxiety and depression. Further, social isolation, loneliness and increased stress contribute to these feelings.
Studies have demonstrated that women have had increased rates of anxiety and depression during COVID-19, which is consistent with previous research performed during other outbreaks, such as Zika virus.7 For young adults, women are more likely than men to have increased childcare responsibilities during COVID-19, causing women to leave the workforce to care for children now at home during virtual school. This adds to increased stress and decreased satisfaction from being forced to leave their careers. Further, it was found that women are more likely to experience domestic violence during COVID-19.8 Being in lockdown with their abuser without means to leave the home for their safety or to confide in social support led to more abuse. Lastly, changes in access to reproductive and sexual health (e.g., access to birth control or abortion) added increased stress to women.7
Sexual and gender minority patients have noted increased rates of anxiety/depression during the pandemic.9 This population already has a higher baseline rate of these diagnoses; however, the disparity seems to be increasing during the pandemic. This could be due to loss of social support from peers and increased time being spent with family members who may not be supportive or accepting. Further, for transgender patients, decreased in-person visits could cause patients to delay gender-affirming treatment, worsening their mental health.
Finally, socially disadvantaged groups—such as racial/ethnic minorities or those of a lower socioeconomic status—face disparities in care to lead to them having increased risk of psychiatric comorbidities due to COVID-19, a trend that was true with previous public health emergencies.10 This in turn leads to increased stressors on minorities, resulting in increased anxiety/depression. These populations may also have decreased access to mental health resources due to finances and/or location.
Role of the Provider
It is essential that healthcare providers are aware of these trends and that adolescents and young adults have mental health screenings at appointments. They should also be encouraged to continue annual visits with a provider, especially given that young people may be tempted to skip appointments due to their good overall health. Providers should also be aware of protective factors against worsening depression/anxiety, including social support and coping skills. At the same time, they should be aware of risk factors including female gender and family conflict. As referenced above, females were demonstrated to have increased depression/anxiety; however, males should not be ruled out as they may feel less comfortable being honest on questionnaires given social constructs and perceived gender roles. Additionally, males are more likely to exhibit atypical signs of depression, including irritability and aggression.11 Young men and women should be screened for domestic violence and be directly asked if they feel safe at home. Additional consideration should be given to at-risk populations, including racial/ethnic minorities, individuals of lower socioeconomic status, and sexual/gender minority patients.
Providers should screen patients to recognize early signs of increased anxiety and depression in order to provide treatment when necessary. Preexisting constraints to mental health treatment—including stigma, insurance and finances—are still present; however, there are now new constraints, including availability, lack of home technology for effective telemedicine, and burnout among providers. Despite these challenges, referrals should be provided to therapists so that adolescents can learn to process these complex emotions early before they are profoundly anxious/depressed.
Additionally, providers should encourage open communication among teens and their families, given increased family stressors, and provide referrals to family therapy when indicated. Parents are dealing with increased stressors as well, and lockdowns and loss of income may lead to increased tension at home; they should be encouraged to seek out treatment for themselves when indicated. Telehealth visits for therapy provide a safe option for patients to meet with their therapist while allowing social distancing and infection control. These visits can also be convenient for families, as they can attend from the comfort of their own home.
Several novel telehealth services have been developed due to COVID-19.12 While these are not intended to replace therapy, there are several tools that can help track symptoms and learn coping skills. These services can help people feel like they have a source of support while they await an appointment. Examples include:
These applications can be especially useful for adolescents, given that they are generally technology savvy and accustomed to using different mobile phone applications.
Further, providers should prescribe medications when necessary and help work with patients if they have any fears of stigma regarding mental health medication. The long-term mental health effects of the continued pandemic should continue to be studied.
Teens and young adults have unique mental health considerations at baseline, especially in the landscape of COVID-19. Their unique developmental milestones and stages in life leave them in a particularly vulnerable position to be affected by anxiety and/or depression. Healthcare providers have an essential role to identify these symptoms by early screening and providing treatment when necessary. The need for social distancing and infection control requires creative solutions to continue to provide high quality mental health care to all of those who need it. Despite these many difficulties, adolescents and young adults are incredibly resilient and able to adapt to change if they are provided with appropriate tools and assistance.
Elmer T, Mepham K, Stadtfeld C. Students under lockdown: Comparisons of students’ social networks and mental health before and during the COVID-19 crisis in Switzerland. PLoS One. 2020;15(7):e0236337. doi:10.1371/journal.pone.0236337
Li HY, Cao H, Leung DYP, Mak YW. The psychological impacts of a COVID-19 outbreak on college students in China: A longitudinal study. Int J Environ Res Public Health. 2020;17(11):3933. doi:10.3390/ijerph17113933
Saraswathi I, Saikarthik J, Senthil Kumar K, Madhan Srinivasan K, Ardhanaari M, Gunapriya R. Impact of COVID-19 outbreak on the mental health status of undergraduate medical students in a COVID-19 treating medical college: A prospective longitudinal study. PeerJ. 2020;8:e10164. doi:10.7717/peerj.10164
Magson NR, Freeman JYA, Rapee RM, Richardson CE, Oar EL, Fardouly J. Risk and protective factors for prospective changes in adolescent mental health during the COVID-19 pandemic. J Youth Adolesc. 2021;50(1):44–57. doi:10.1007/s10964-020-01332-9
Lee CM, Cadigan JM, Rhew IC. Increases in loneliness among young adults during the COVID-19 pandemic and association with increases in mental health problems. J Adolesc Health. 2020;67(5):714–717. doi:10.1016/j.jadohealth.2020.08.009
Hawes MT, Szenczy AK, Klein DN, Hajcak G, Nelson BD. Increases in depression and anxiety symptoms in adolescents and young adults during the COVID-19 pandemic. Psychol Med. 2021;1–9. doi:10.1017/S0033291720005358
Wenham C, Smith J, Davies SE, et al. Women are most affected by pandemics—lessons from past outbreaks. Nature. 2020;583(7815):194–198.
Roesch E, Amin A, Gupta J, García-Moreno C. Violence against women during covid-19 pandemic restrictions. BMJ. 2020;369:m1712. doi:10.1136/bmj.m1712
Moore SE, Wierenga KL, Prince DM, et al. Disproportionate impact of the COVID-19 pandemic on perceived social support, mental health and somatic symptoms in sexual and gender minority populations. J Homosex. 2021;68(4):577–591. doi:10.1080/00918369.2020.1868184
Purtle J. COVID-19 and mental health equity in the United States. Soc Psychiatry Psychiatr Epidemiol. 2020;55(8):969–971. doi:10.1007/s00127-020-01896-8
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