Age-specific determinants of psychiatric outcomes after the first COVID-19 wave: baseline findings from a Canadian online cohort study

GAD, depression and OCD symptoms were identified via validated measures: the Generalized Anxiety Disorder Scale (GAD-7) [36, 55], Patient Health Questionnaire for Depression (PHQ-9) [29, 46] and the Obsessive–Compulsive Inventory–Revised (OCI-R) and -Child Version (OCI-CV) [15, 16], with clinical threshold scores of 10, 10, 21 and 11, respectively. “How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?” queried impact required for GAD and depression. Item 2 from adult/child versions of the Yale-Brown Obsessive Compulsive Scale [24, 52] queried impact required for OCD. Above-threshold scores with concurrent impairment, or a reported COVID-19-era suicide attempt provided a dichotomous indicator of clinically relevant psychiatric problems.

Those reporting one or more lifetime psychiatric diagnoses by a health professional were asked for each disorder whether its severity changed during COVID-19, using a 5-point Likert scale with item scoring from “much worse” to “much better”.

Unmet MH support needs were captured by asking respondents if they had needed but not received support for their MH, with response choices of “yes” or “no”.

Prevalence of components of outcome #1 as reported at baseline across age groups are detailed in Table 2. Associated factors differed across age groups (Fig. 1).

Figure 1A presents results of multivariable logistic regression models pertaining to selected psychiatric problems (with binary dependent variable indicating the presence of one or more of probable GAD, depression, OCD or suicide attempt) in children (0–7 years) and youth (8–18 years). Figure 1B presents associated factors among young adults (19–29 years) and adults over 29 years.

Data on lifetime psychiatric diagnoses, rates of increased severity since the onset of COVID-19, and attribution of increased severity to COVID-19 is provided in Table 3.

Regression models for increased diagnostic severity were not constructed for children or youth due to limited sample sizes of those with lifetime diagnoses. Figure 2 shows regression results for the young adult and adults over 30 years age groups.

Table 4 provides descriptive data on pandemic-era MH support across age groups as reported following the first wave.

Determinants of unmet MH support needs during the COVID-19-era are shown in Fig. 3a (for children and youth) and Fig. 3b (for young adults and adults 30 years and older.

Rates of GAD, depression, OCD and unmet MH support needs were multiple-fold of those reported by Canadian pre-pandemic studies including the 2014 Ontario Child Health Survey [21, 42] and the 2012 Canadian Community Health Survey [57] (see Additional file 3). As noted, feelings of sadness and worry and washing behaviors are all expected during an infectious pandemic, and as such, caution was required to not pathologize or label individuals based upon these singular symptoms. The use of validated psychiatric measures and the requirement for associated impairment add confidence to our conclusion that prevalence remained markedly amplified compared to pre-pandemic Canadian rates. Moreover, while Aknin et al. [2] reported on resolution of anxiety and depression symptoms beyond early 2020, our study found that these continued Aknin at least until mid-2021.

The age-specific patterns parallel separate results of Canadian child [9, 51] and adult [11, 41] studies and those from other countries [10, 19]. Specifically, older adolescents and young adults report highest levels of common or high lethality psychiatric problems. Emergence of mental illness generally occurs between 14 and 25 years [54], representing a sensitive period of development into mature adulthood. As such, it follows that pandemic impacts on social isolation, educational environments, job loss and MH service availability disproportionately affected youth and young adults [59]. Amplifying challenges, this life phase also aligns with lapse of service between child and adult MH systems that exist in Canada and globally [39, 53].

Relative to males, female youth and non-binary young adult participants were at increased risk for poor MH outcomes. This generally tracks with risk for mental illness outside the pandemic experience [21, 49]. Given that gender-specific expectations and stressors have disproportionately affected females during the pandemic [4], it is clear why female gender was predictive in youth but less clear why it was not a determinant among adults in our study.

Non-binary individuals had greater risk for increased severity of psychiatric diagnoses in this study. Unfortunately, this group has been particularly avoidant of healthcare professional contact during the pandemic [58]. As such, MH care systems should optimally provide multiple options such as digital, telehealth and in-person sessions to accommodate individual preference and needs [37].

LGBTQ2S + status was a determinant of poor MH among Canadian youth and young adults. Potential explanations include exacerbated isolation in a previously socially isolated group [32], being quarantined with unsupportive parents [13] or in abusive environments [18] and increased peer victimization [22]. As such, targeted resources and support for Canadians in the LGBTQ + community are warranted. This may include provision of LGBTQ-affirming virtual extracurricular activities [25], social media MH resources such as the Trevor Project [18] and safe spaces [56]. It is advised to be particularly aware of intersectionally marginalized LGBTQ + groups such as those living in poverty who may not have access to digital technology [50].

Living in poverty increased risk for selected mental illness and for unmet support needs across youth and adult groups, doubling risks among adults over 30 years. Association between financial difficulties and poor MH was noted in Canadian first wave COVID-19 studies of children and adolescents [9, 47] and adults [44]. Exacerbation of negative impacts of poverty on MH have also been demonstrated globally [30], with amplification in those living with food insecurity [67]. However, to our knowledge, the link between poverty and failure to access MH support among Canadians during COVID-19 is novel. While this result may be unsurprising given pre-COVID-19 patterns, it is also particularly concerning given that Canada’s healthcare system aims to be universal. These results may reflect challenges in the system's capacity to either adapt to increased needs or maintain prior level of services in the context of the pandemic (particularly given inequities at baseline). Other identified socioeconomic determinants include limited educational attainment in adults, which relates to income potential, and ‘homemaker/caregiver’ occupational status among adults over 30 years old, which may limit financial autonomy and/or opportunities for social interaction. Regardless, it appears that COVID-19 exacerbated the role of poverty as a pre-existing disparity and action is needed to improve the availability and delivery of MH services to low-income populations.

Across all age groups, the lifetime diagnosis of a psychiatric illness was a determinant for current psychiatric problems and/or unmet MH support needs during the pandemic. This is generally consistent with the conceptualization that psychiatric illness can be exacerbated by stressful events [18]. Other conditions selectively conferred risk for current psychiatric problems and unmet MH support needs in either the youngest or oldest age group.

Children with special educational needs were significantly more vulnerable to negative outcomes. This may reflect the general vulnerability of these populations to stressful events or relate more specifically to the impacts of COVID-19 related changes (e.g, youth with special needs were less able to adapt to changes in school delivery). A Canadian study by Gonzalez et al. [23] found that while children with special educational needs received fewer clinical services during COVID-19, those who were also living in poverty, or who had parents with limited education or less than a full-time job were especially unlikely to receive services. As such, it is critical that these multiply disadvantaged families be targeted to receive tailored and individualized services to enable continuity of care throughout this and future pandemics. Moreover, support for their parents and caregivers is necessary to prevent burnout and their own MH challenges [1].

Medical illness was found to be a determinant of poor MH and unmet support needs in adults. These individuals were likely most directly impacted by delays or changes to health service provision as the system pivoted to prioritize COVID-19 patients. Indeed, McElroy-Heltzel et al. [35] found that among adults with illness, COVID-related loss of services was associated with mental distress, which was only partially buffered by the presence of social support. Maintenance of usual daily activities including exercise and social contacts is a recommended mitigation strategy to build psychological resilience and prevent mental illness onset among the medically ill during COVID-19 [31].