key: cord-0947952-lwn7q1kw authors: Hawke, Lisa D.; Monga, Suneeta; Korczak, Daphne; Hayes, Em; Relihan, Jacqueline; Darnay, Karleigh; Cleverley, Kristin; Lunsky, Yona; Szatmari, Peter; Henderson, Joanna title: Impacts of the COVID‐19 pandemic on youth mental health among youth with physical health challenges date: 2020-10-12 journal: Early Interv Psychiatry DOI: 10.1111/eip.13052 sha: db022fe740422b77b3f4dbce2c2e5a5317448418 doc_id: 947952 cord_uid: lwn7q1kw AIM: To examine mental health in conjunction with physical health during the COVID‐19 pandemic among youth with physical health conditions compared to those without. METHODS: A cross‐sectional survey of 622 youth aged 14 to 28 was conducted. Analyses were conducted to understand the changes in mental and physical health among youth in four groups: (a) participants with a friend or family member diagnosed with COVID‐19, (b) participants with symptoms associated with COVID‐19, (c) participants with atopic conditions (asthma and allergies), and (d) participants with other preexisting physical health conditions. RESULTS: Many participants with physical health concerns met screening criteria for an internalizing disorder, which was significantly higher than the rate found among participants without physical health conditions. Significantly greater declines in self‐reported mental health were observed during the COVID‐19 period compared to 3 months earlier among youth reporting physical health concerns compared to those without physical health concerns. Substance use does not appear to have been affected. CONCLUSIONS: Mental health concerns are highly prevalent among youth with physical health concerns, and also appear to be exacerbated by the COVID‐19 pandemic. Physical health concerns appear to constitute risk factors for heightened mental health responses to the pandemic situation. System planners striving to adapt mental health services to meet social/physical distancing recommendations are urged to consider youth with physical health conditions and ensure that adequate integrated mental health and physical health supports are available to them. Mental health is a key concern during the COVID-19 pandemic, as expressed in a plethora of commentary and opinion articles emerging (Duan & Zhu, 2020; Ho, Chee, & Ho, 2020; Holmes et al., 2020; Yao, Chen, & Xu, 2020) . Emerging research from China has found appreciable negative mental health impacts during the COVID-19 pandemic (Wang et al., 2020) , and that mental health impacts may be more severe among adults under the age of 35 (Huang & Zhao, 2020) . Another Chinese study found high rates of mental health impacts among children confined to their home due to the pandemic (Xie et al., 2020) . Our study, conducted in Canada, found that youth aged 14 to 28 with and without preexisting mental health challenges experienced an increase in mental health concerns in the early phases of COVID-19, but did not experience increases in substance use . Mental health service disruptions were substantial, as was the unmet need for mental health support. Youth are a particularly vulnerable group during public health crises, including youth with preexisting mental health concerns (Holmes et al., 2020; Perrin, McCabe, Everly Jr., & Links, 2009) . Mental health and substance use disorders are highly prevalent among youth, affecting about 20% of youth in Canada (Boyle & Georgiades, 2009) , and many adult mental health disorders developing initially during adolescence (Kessler et al., 2007) . This developmental period is also the peak age of onset for substance use, which can lead to substance use disorders in adulthood (Boak, Elton-Marshall, Mann, & Hamilton, 2020; Young et al., 2002) . In the context of COVID-19, key developmental milestones facing youth, such as school completion, labour market engagement, social relationships, and autonomous decision-making (Arnett, 2004) have been disrupted. This may place young people at particular risk for the development of mental health and substance use concerns during this time. The impacts of pandemic response strategies on youth mental health therefore require research and any necessary subsequent mitigating action. The relationship between mental and physical health during the COVID-19 period also merits attention. A recent study in China found higher rates of depression among those who had been infected with COVID-19 and recovered, but not in people under quarantine or the general public . Another study found more vicarious trauma among the general public than among medical teams providing direct care for patients with COVID-19, who thereby were at risk of exposure to the virus . Numerous reports have raised concerns about mental health and anxiety during COVID-19 among individuals with preexisting physical health conditions (Hao et al., 2020; Kosir et al., 2020; Mukhtar & Mukhtar, 2020; Tsamakis et al., 2020) . It is promising that emerging research demonstrates less susceptibility to COVID-19 infection among youth, and less susceptibility to severe outcomes when infected (Lee, Hu, Chen, Huang, & Hsueh, 2020; Liao et al., 2020) . Nevertheless, youth with preexisting physical health conditions may be more concerned about COVID-19, potentially increasing the risk for mental health challenges in this group. Health anxiety may be more prevalent during the pandemic (Asmundson & Taylor, 2020) . This study examines mental health, substance use, and physical health among youth during the COVID-19 pandemic. The study focuses on the pandemic's impacts on both young people with preexisting physical health conditions and on those who have COVID-19-related symptoms or who know someone with a diagnosis of COVID-19. This cross-sectional survey evaluated self-reported mental health, substance use, physical health, and other concerns among youth. Youth were defined as adolescents and young adults between the ages of 14 and 29 years (Statistics Canada, 2019). A sample of 622 youth (age range 14-28 years; M = 20.6, SD = 2.4) participated in the study. The sample was recruited from existing participant pools in four studies operating out of the Centre for Addiction and Mental Health in Toronto, Ontario, Canada. This included a clinical cohort of youth participating in mental health and substance use research in Toronto, Ontario (Hawke, Koyama, & Henderson, 2018; Henderson et al., 2017 ; N = 276) and a nonclinical cohort of youth participating in a longitudinal cohort study across Ontario N = 346) . More details on the participants and procedures can be found in the companion manuscript presenting the initial mental health and substance use findings . An email invitation was sent to youth between 8 and 29 April 2020, containing a web link directing them to the survey in REDCap software (Harris et al., 2009) . After providing informed consent, participants completed a series of self-report questionnaires (20 min). The recruitment period began approximately 3 weeks after a state of emergency was declared in Ontario, Canada. Reminder emails were sent approximately every 2 days. An honorarium of $15 was provided. Research Ethics Board approval was obtained from the Centre for Addiction and Mental Health. Self-report questionnaires included demographic information and the questionnaires described below. The NIMH-developed CRISIS tool, Youth Self-Report Baseline version 0.1, was used. Questions included perceived emotional health, substance use, and physical health retrospectively at 3 months prior to the COVID-19 pandemic and in the past 2 weeks. Participants also reported on preexisting physical health conditions, the experience of symptoms associated with COVID-19 and COVID-19 diagnoses. Ten mental health items on a five-point Likert scale were averaged into a mental health subscale (Cronbach's alpha = .88). Eight substance use items on a five-point Likert scale were averaged into a substance use subscale (Cronbach's alpha = .64). Physical health was a single question answered on a five-point scale (excellent to poor). Participants endorsing any symptoms associated with COVID-19 (fever, shortness of breath, cough, or sore throat) were categorized into a COVID-19 symptoms group. One item regarding fatigue was removed due to the association between fatigue and depression. This was not intended to be diagnostic of COVID-19, but rather was used to explore the hypothesis that COVID-19 related anxiety would be increased in this population. The preexisting physical health conditions checklist in the CRISIS survey included endorsement of heart problems, kidney problems, allergies, asthma, immune disorder, diabetes or high blood sugar, cancer, arthritis, epilepsy or seizures, serious stomach or bowel problems, or obesity. The allergies and asthma items were analysed separately from other physical health symptoms as atopic symptoms, given the association of respiratory symptoms with COVID-19 (Centres for Disease Control and Prevention, 2020). Youth with physical health concerns were defined as either (a) having COVID-19-related symptoms (COVID-19 symptoms group); (b) reporting a physical health concern (physical health group); (c) reporting allergies and/or asthma (atopic group); (d) having knowledge of a friend or family member with a COVID-19 diagnosis (COVID-19 diagnosis group; Merikangas et al., 2020). The GAIN-SS, version 3, is a brief self-report screener that identifies the likelihood of meeting criteria for an internalizing disorder, externalizing disorder, or substance use disorder, or requiring services for crime/and violence issues (Dennis, Feeney, & Titus, 2013; Dennis et al., 2013) . Ratings range from never (0) to past month (3); 3 pastmonth endorsements indicate a high likelihood of meeting diagnostic criteria or requiring services in that domain. The GAIN-SS is validated among youth (Dennis, Chan, & Funk, 2006 ). Demographic characteristics are presented in Table 1 There was no significant difference in ethnicity, or whether they were born in Canada, spoke English as a first language, or were a student. The rate of mental health and substance use challenges across the clinical and nonclinical cohorts is described in detail in a companion manuscript . and 52 participants (8.4%) reported having a friend or family member who was diagnosed with COVID-19. There was no significant difference between the clinical and nonclinical samples for asthma/allergies, χ 2 (1) = 0.419, P = .517, φ = .03, a preexisting physical health condition χ 2 (1) = 3.560, P = .059, φ = .08, or reporting that a friend or family member had a diagnosis of COVID-19, χ 2 (1) = 2.063, P = .151, φ = .06.However, participants in the clinical sample were significantly more likely to report experiencing at least one symptom associated with COVID-19, χ 2 (1) = 13.449, P < .001, φ = .15. In terms of demographic characteristics, atopic symptoms were reported significantly more often by participants who were born in Canada (χ 2 (1) = 6.820, P = .009, φ = .11) and who spoke English as a first language (χ 2 (1) = 6.474, P = .011, φ = −.10); the remaining demographic characteristics were not significant. Other preexisting health conditions were associated with older age (t[614] = 2.303, P = .021), a gender outside of the binary (χ 2 (2) = 13.110, P = .001, φ = .15), and not being a student (χ 2 (1) = 7.812, P = .005, φ = .11).There were no differences in demographic characteristics of youth who were in the COVID-19 diagnosis group vs those who were not, with the exception of marginally more youth reporting a diagnosis in their circles if their first language is not English (χ2(1) = 4.754, P = .029, φ = .09). The COVID-19 symptoms group was only associated with less current employment if symptoms were present (χ 2 (1) = 6.126, P = .013, φ = −.10). The current mental health, substance use, and physical health of the four physical health groups are reported in physical health (P < .001) than those without physical health conditions. There were no differences between youth in the COVID-19 diagnosis group and those who were not, in terms of mental health (P = .558), substance use (P = .819), or physical health ratings (P = .727). However, youth in the COVID-19 symptoms group reported significantly more mental health concerns (P < .001), higher substance use (P = .002), and poorer self-rated mental health (P = .001) than those without COVID-19-related symptoms. T A B L E 3 Logistic regression prediction of health group membership based on mental health, substance use, and physical health, controlling for pre-COVID-19 status and sample In the atopic group, a greater mental health impact was found compared to youth without atopic symptoms (P = .0168, OR = 1.321 (1.051, 1.660). In the physical health group, a significant association was found between self-rated mental health (P = .002, OR = 1.510 GAIN-SS results demonstrate high rates of internalizing disorders in the sample as a whole. Significant associations were found between internalizing disorders and preexisting physical health conditions (P = .012), as well as COVID-19-related symptoms (P < .001; Table 4 ). Internalizing disorders were marginally associated with atopic symptoms, but this association was not statistically significant after the Bonferroni correction (P = .024). Externalizing disorders were also more frequent among those in the COVID-19 symptoms group. Substance use disorders were not associated with the identified groups. Anxiety, depression, and medical trauma are highly prevalent among youth with chronic medical conditions, with some studies suggesting that anxiety might in fact worsen the course of the medical condition (Cobham et al., 2020; Goodwin, Bandiera, Steinberg, Ortega, & Feldman, 2012; Greenley et al., 2010; Katon et al., 2007; Kovacs, Goldston, Obrosky, & Bonar, 1997) . Several studies report that youth with physical health conditions and co-occurring mental health challenges experience longer hospitalizations and more service utilization (Doupnik et al., 2016; Richardson, Russo, Lozano, McCauley, & Katon, 2008) . The current study confirms the existence of mental health challenges in physically ill youth, which may be further exacerbated by the COVID-19 pandemic. The importance of evaluating mental health in youth with preexisting physical health conditions (Cobham et al., 2020) has increasingly become apparent; however deterioration in their mental health during the COVID-19 period, as noted in this study, highlights the need for greater attention to mental health. Study results further support the bidirectional relationship between mental and physical health. During the COVID-19 pandemic, even one symptom typically associated with the common cold was associated with a significant deterioration in mental health, as well as reporting of poorer physical health by youth, thus suggesting the heightened levels of health anxiety in this cohort of our sample (Asmundson & Taylor, 2020) . Higher rates of generalized anxiety disorder have also been noted during COVID-19 times, with higher rates among younger adults (<35 years of age) (Huang & Zhao, 2020 (Hetrick et al., 2017; Settipani et al., 2019) . The integration of physical and mental healthcare has been shown to provide substantial benefits for this population (Asarnow, Rozenman, Wiblin, & Zeltzer, 2015) . Indeed, the Lancet Psychiatry Commission proposes the integration of physical and mental health services as a priority policy and service direction moving forward, acknowledging the importance of primary prevention and early intervention in low-barrier settings (Firth et al., 2019) . Physical health service integration should continue to be prioritized as integrated service models adapt their service delivery mechanisms to respect social/ physical distancing requirements during pandemic times and beyond, acknowledging the interplay between mental and physical health in the context of the COVID-19 pandemic. This was a cross-sectional survey with retrospective reports of pre-COVID-19 mental and physical health, which may be subject to recall bias. Larger, more diverse, and longitudinal samples are required for future analyses, as are samples of youth diagnosed with COVID-19 to examine mental health impacts among those who have acquired the disease. Data collection took place exclusively online and therefore would have been more likely to reach youth with more internet use, which may also affect COVID-19 responses given the proliferation of online information about the pandemic; similarly, the online recruitment method may have reduced the likelihood of reaching youth with the greatest mental and physical health challenges during the recruitment period. Mental health concerns are highly prevalent among youth with physical health concerns, and this relationship appears to be exacerbated in the context of the COVID-19 pandemic. Physical health concerns appear to constitute risk factors for heightened mental health responses to the pandemic situation. System planners striving to adapt mental health services to meet social/physical distancing recommendations are urged to consider youth with physical health conditions as a vulnerable population and ensure the adequate integration of mental health and physical health support. 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