Journal of Adolescent Health 74 (2024) 36e43

www.jahonline.org

Original article

Adolescents’ Depression and Anxiety Symptoms During the

COVID-19 Pandemic: Longitudinal Evidence From COMPASS
Mahmood R. Gohari, Ph.D. a, *, Karen A. Patte, Ph.D. b, Mark A. Ferro, Ph.D. a, Slim Haddad, M.D., Ph.D. c,
Terrance J. Wade, Ph.D. b, Richard E. Bélanger, M.D. d, Isabella Romano a, and
Scott T. Leatherdale, Ph.D. a
a
School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
b
Faculty of Applied Health Sciences, Department of Health Sciences, Brock University, St. Catharines, Ontario, Canada
c
Department of Social and Preventive Medicine, Université Laval, Quebec City, Quebec, Canada
d
Faculty of Medicine, Department of Pediatrics, Université Laval, Quebec City, Quebec, Canada

Article history: Received November 15, 2022; Accepted July 21, 2023
Keywords: Internalizing symptoms; Adolescents; Natural experiment; Mental health

A B S T R A C T
IMPLICATIONS AND
CONTRIBUTION
Purpose: There is concern over the potentially detrimental impact of the COVID-19 pandemic on
adolescents’ mental health. We examined changes in depression and anxiety symptoms from
This study provides pro-
before (2018-19) to the early (2019-20) and ongoing pandemic (2020-21) responses among spective evidence that
Canadian adolescents in the context of a natural experiment. internalizing symptoms
Methods: We used linked survey data from 5,368 Canadian secondary school students who participated increased over time in a
in three consecutive waves of the cannabis use, obesity, mental health, physical activity, alcohol use, large adolescent sample,
smoking, and sedentary behaviour study during the 2018-19, 2019-20, and 2020-21 school year. Separate particularly during the
fixed effects models examined whether changes in depression (Center for Epidemiologic Studies ongoing pandemic period.
Depression Scale Revised-10) and anxiety (General Anxiety Disorder-7) symptoms differed between two The pandemic does not
cohorts. The cohorts differed in the timing of their second data collection wave; one cohort participated appear to account for this
before the pandemic and the other cohort participated in the early pandemic (spring 2020). increase in the early
Results: Depression and anxiety symptoms increased during the early and ongoing pandemic COVID-19 period. Ongoing
periods in the overall sample and both cohorts. The two cohorts experienced similar elevations in evaluation of the ongoing
their symptoms. Females and younger respondents presented greater elevations over time. The pandemic and recovery
proportion of adolescents with significant depressive (29.4%) and moderate-to-severe anxiety periods is needed.
(17.6%) symptoms at baseline increased by 1.5 times, reaching 44.8% and 29.8% in the ongoing
pandemic period, respectively.
Discussion: Findings suggest that internalizing symptoms have consistently increased since before
the onset of COVID-19, particularly in the ongoing pandemic period; however, we found no
evidence of the increase being due to the pandemic in the early COVID-19 period when comparing
the two cohorts. Ongoing evaluation of adolescents’ mental health is necessary to capture
potentially dynamic impacts over time.
Ó 2023 Society for Adolescent Health and Medicine. Published by Elsevier Inc. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Conflicts of interest: The authors have no conflicts of interest relevant to this article to disclose.
* Address correspondence to: Mahmood R. Gohari, Ph.D., School of Public Health Sciences, University of Waterloo, 200 University Avenue West, Waterloo, Ontario,
Canada N2L 3G1.
E-mail address: mgohari@uwaterloo.ca (M.R. Gohari).

1054-139X/Ó 2023 Society for Adolescent Health and Medicine. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
https://doi.org/10.1016/j.jadohealth.2023.07.024

Descargado para Anonymous User (n/a) en Northern Private University de ClinicalKey.es por Elsevier en mayo 08, 2024. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados.
 M.R. Gohari et al. / Journal of Adolescent Health 74 (2024) 36e43
The COVID-19 pandemic has had a substantial impact on
adolescents across nearly every aspect of daily life. To contain the
spread of infectious severe acute respiratory syndrome
coronavirus-2 (SARS-CoV-2), countries around the world
implemented public health measures, including emergency
lockdown protocols and stay-at-home orders. In Canada, schools
first closed to in-person learning in March 2020, with partial and
online learning modes continuing over the 2020-21 school year.
There is concern that pandemic restrictions and school closures
have had detrimental impacts on adolescents’ mental health and
well-being [1e3]. Schools are typically a source of routine, social
interaction, extracurricular activities, positive adult role models,
and a primary context for public health promotion and preven-
tion interventions.
Adolescence is a critical developmental period with respect to
the onset of mental disorder, as most adult cases first emerge
during adolescence and early adulthood [4]. On average,
subclinical anxiety and depression symptoms tend to increase
over time during this age period [5e7]. From a psychosocial
development perspective, adolescents become increasingly
autonomous from their parents [8], yet physical distancing and
stay-at-home orders led to home-based confinement that
prohibited in-person social interaction with peers. Evidence from
earlier in the pandemic suggests greater mental health implica-
tions of COVID-19 among older adolescents, who typically spend
more time with their peers than younger adolescents [9].
Adjustment for developmental changes in mental health across
adolescence [10] is necessary to robustly evaluate the impact of
COVID-19-related restrictions over time [11].
While most of the evidence emerging over the past two
years comes from cross-sectional designs, a handful of studies
have leveraged longitudinal data to better understand the
impact of COVID-19-related restrictions on adolescents’
mental health [12e15]. Using linked data collected before and
3e4 months into the pandemic, we previously examined the
early COVID-19-related impact on Canadian youths’ mental
health, at which point mental health deterioration was no
greater than changes seen before the pandemic [12]. In
contrast, other studies have found a negative impact on ado-
lescents’ mental health during this same period and later into
the ongoing pandemic period as restrictions persisted [16,17].
To help inform the ongoing pandemic response and recovery,
as well as future pandemic readiness, there is a continued
need for prospective research to better understand the im-
pacts of COVID-19-related restrictions on adolescents’ mental
health over time.
It has also been a concern that COVID-19-related restrictions
might exacerbate existing inequities among adolescents and
their families [18]. Some emerging evidence suggests that
females may be more susceptible to COVID-19-related impacts
on their mental health than males [13,14]. For example, Ferro
et al. (2021) found a sex difference in changes in psychological
distress from pre-to during pandemic among children with
chronic physical illness. Families from racialized or marginal-
ized ethnic groups are also disproportionately impacted by
COVID-19 [19], but its impact on their mental health is not clear.
One recent study found that, despite experiencing greater
pandemic-related stressors, poorer mental health outcomes
among racialized participants were not observed [20]. Among
adolescents, however, a recent U.S. study found differences in
the risk of increases in levels of both anxiety and depression
according to self-identified race or ethnicity [16].
Descargado para Anonymous User (n/a) en Northern Private University de ClinicalKey.es por Elsevier en mayo 08, 2024. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados.
37
This study builds upon our previous research [12] by
leveraging data collected before and during the COVID-19
pandemic in a large prospective study with repeated
assessments of internalizing symptoms among two cohorts of
adolescents. Our primary objective is to examine changes in
internalizing symptoms (i.e., depression and anxiety symptoms)
from before (2018-19) to the early pandemic period (2019-20)
and from the early to the ongoing pandemic (2020-21). We
compared two cohorts of students that differed in the timing of
their second data collection wave: one cohort was assessed in the
early pandemic period in spring 2020, and the comparison
cohort was assessed immediately before the pandemic onset
between September and February of the 2019-2020 school year.
Our secondary objective is to examine whether any change in
adolescents’ mental health during the pandemic period differed
by age, gender, and race or ethnicity.
Methods
This study uses longitudinal data from the ongoing cannabis
use, obesity, mental health, physical activity, alcohol use, smoking,
and sedentary behaviour (COMPASS) study (2012e2027).
COMPASS is a school-based learning system in which survey data
are collected annually from a rolling cohort sample of Canadian
students in grades 9 through 12 (secondary IeV in Quebec) [21].
Students attending a convenience sample of participating
schools are recruited using an active-information, passive-con-
sent, and parental permission protocol.
Design and participants
We have used three-year linked data from students attending
a convenience sample of 81 schools (n ¼ 37 Quebec, n ¼ 38
Ontario, n ¼ 6 British Columbia) that participated in COMPASS
during school years 2018-19 (T1), 2019-20 (T2), and 2020-21 (T3)
(see Figure 1). Student data in T1 were collected using a paper-
based survey completed during one classroom period by
whole-school samples (Reel et al., 2020). In T2, data collection
was done prepandemic (from September 2019 to February 2020,
T2a) and postpandemic (from May to June 2020, T2b), creating
two cohorts to disaggregate changes in mental health due to
age-related factors from period-related factors. T2a data were
collected as in T1. As the COVID pandemic was declared in
Canada in March 2020 and schools were closed to in-person
learning, T2b data were collected online using the Qualtrics XM
survey software (Qualtrics, Provo, UT, USA). All eligible students
attending participating schools were emailed a link to complete
the online survey. Online data collection continued for both
cohorts in T3 given the ongoing pandemic response.
An anonymous student-generated identification code was
created from five measures asked at the beginning of the
questionnaire to link student data across study waves [22]. As
shown in Figure 1 and consistent with previous research
(Leatherdale S.T., unpublished data, 2023), data were linked be-
tween three years to construct two cohorts: the pre-COVID
cohort includes students who provided linked data in T1, T2a,
and T3 (n ¼ 1,872), and the COVID cohort includes students who
provided linked data in T1, T2b, and T3 (n ¼ 3,447). Given our
focus on changes in internalizing symptoms, we removed 49
students who had more than two years of missing depression
and anxiety symptoms. This left a sample of n ¼ 5,319
participants.
38 M.R. Gohari et al. / Journal of Adolescent Health 74 (2024) 36e43
Figure 1. Data collection periods and longitudinal data linkage. The pre-COVID cohort consists of adolescents who provided linked data in T1, T2a, and T3 (n ¼ 3,447),
and the COVID cohort consists of students who provided linked data in T1, T2b, and T3 (n ¼ 1,872).
Measures
Depression was assessed using the Center for Epidemiologic
Studies Depression Scale Revised (CESD-R-10) scale [23]. The
CESD-R-10 is a 10-item scale that offers participants a 4-response
option for describing the degree to which item statements are
true. Scores across the items are summed to create a total score
ranging from a possible 0 to 30; higher scores indicate higher
depression symptoms. In this study, the internal consistency
across CESD-R-10 items was 0.72 in each year over the three
years.
Consistent with past research [24,25], the binary status of the
likelihood of having significant depressive symptoms was
defined as 1 (if the CESD-R-10 score was 10) and 0 (otherwise).
Anxiety was measured through the Generalized Anxiety
Disorder 7-item (GAD-7) scale [26]. Scores on the four-response
scale are summed to create a composite score, with a higher
score representing more anxiety symptoms. The internal
consistencies for the GAD-7 scale in the three studied years were
respectively 0.89, 0.89, and 0.91.
Consistent with past research [24,26], this measure was
defined as a binary status of 1 (if a GAD-7 score was 10) and
0 (otherwise) showing moderate to severe anxiety symptoms.
The validity and reliability of both CESD-R-10 and GAD-7
scales in adolescent populations have been documented
[27,28], including measurement invariance by sex and grade in
the COMPASS study [29].
Covariates
The covariates included to reduce potential confounding are
as follows: grade; self-identified sex (female, male); and self-
identified race or ethnicity (White, persons of colour). Partici-
pants could indicate their race or ethnicity by selecting all that
apply from the following provided response options: Asian,
Black, Latin American or Hispanic, White, and other. Due to the
low frequency of responses other than White, and consistent
with previous research [3], we dichotomized race or ethnicity as
White (participants that selected white only) and persons of
colour (all other participants). Participants that selected more
than 1 option were categorized as persons of colour.
Statistical analysis
The average changes in depression and anxiety symptoms
over two years of the intrapandemic periods were compared to
pre-COVID-19 scores. We used longitudinally linked student-
Descargado para Anonymous User (n/a) en Northern Private University de ClinicalKey.es por Elsevier en mayo 08, 2024. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados.
level data to examine changes in the two cohorts’ scores using
a fixed effect regression model [30]. This study design measured
pre-post changes in depression and anxiety symptoms within
individuals. The fixed effect model minimizes characteristic
differences between the two cohorts and controls for all
measured and unmeasured time-invariant characteristics of our
analysis sample [30].
Changes in the proportion of students with significant
depressive symptoms and/or anxiety symptoms over time were
described. Separate multilevel transition logistic regression
models then examined the odds of significant depressive and
anxiety symptoms between the two cohorts. In these models,
repeated measures over the waves (level 1) were nested within
students (level 2), and students were nested within schools (level
3). Transition models correlate current symptoms and those in
previous assessments of individuals [31]. Thus, the odds of
significant depressive or moderate-to-severe anxiety symptoms
at T2 (T2a and T2b) are adjusted for the symptom status at T1,
and the odds of symptoms at T3 are adjusted for the symptom
status at both T1 and T2. Odds ratios are adjusted for baseline
sex, age, race or ethnicity, and the nested structure of student
data within schools. All statistical analyses were carried out using
SAS (SAS Studio, SAS Inc.).
Attrition analysis
We examined whether participant characteristics differed
between those that were included in the study compared to
those that were excluded because their data were not linked over
the three years. The results of the attrition analysis indicated that
the analytic sample comprised slightly more participants who
identified as females and White, and with higher depression and
anxiety symptoms than the excluded participants (See
Supplementary Table A1). Since we are modeling within-person
changes, we only included data from participants who provided
linked data.
Missing values
The rates of missing depression symptoms were 3.0% (T1),
4.5% (T2), and 7.3% (T3), and missing anxiety symptoms were
2.1% (T1), 3.7% (T2), and 6.8% (T3). For both depression and
anxiety scales, we calculated total scores for each time point only
if a maximum of two items per scale were missing; otherwise,
the score for that individual was set to missing and was excluded
from the analysis. If there were one or two items missing, we
imputed missing values with a person-mean of responses [32].
 M.R. Gohari et al. / Journal of Adolescent Health 74 (2024) 36e43
Sensitivity analysis
We compared the results from fixed effect models with the
results of a difference-in-difference model. Similar to the fixed
effect model, the difference-in-difference model measured
pre-post changes in depression and anxiety symptoms within
the COVID cohort (as the exposed group) and the pre-COVID
cohort (as the comparison group) and then examined possible
differences between average changes in the two groups. In a
difference-in-difference analysis, each subject serves as their
own control, so the model accounts for any age-related changes.
Unlike the fixed effect approach, to minimize characteristic dif-
ferences between the two cohorts, we used weighted propensity
scores in the modeling. Propensity scores were created based on
age at baseline, sex, and race or ethnicity of participants, and
weights were considered the inverse of the propensity scores.
For the stratified models, the propensity scores were calculated
based on the variables that were not stratified.
Results
Table 1 provides the demographic characteristics of our
sample, which consists of 60.2% females and an approximately
even distribution across age groups. COVID cohort adolescents
were younger and more likely to be female and White than their
pre-COVID cohort counterparts.
Before comparing changes in the two cohorts, we explored
the changes in the overall sample. Table 1 indicates that the
overall depression score at T1 (7.6) significantly increased to 8.2
at T2 (p < .001) and continued to significant increase from T2 to
T3 (9.9, p < .001). Similarly, the overall anxiety score from T1
(5.2) to T2 (5.9) and from T2 to T3 (7.2) shows significant
increases (p < .001). Prepandemic, we identified that 29.4%
(n ¼ 1,520) of adolescents had significant depressive symptoms
and 17.6% (n ¼ 920) had moderate-to-severe anxiety symptoms
(Table 1). In T2, these proportions increased to 33.5% and 21.4%,
and to 44.8% and 29.8% in T3, respectively.
The results of Table 1 show changes in the proportion of
adolescents with significant depressive symptoms in the two
cohorts. From T1 to T2, the proportion in the COVID cohort rose
from 31.3% (n ¼ 573) to 36.9% (n ¼ 645) compared to the
proportion in the pre-COVID cohort that increased from 28.3%
(n ¼ 941) to 31.7% (n ¼ 1,070). Estimated odds of having signif-
icant depressive symptoms in T2, after controlling for previous
symptom status and other covariates, suggest no significant
difference between the two cohorts (1.16, 95% CI: 0.96e1.40).
Consistently, the likelihood of either cohort having moderate-to-
severe anxiety symptoms in T2 was not different (1.02, 95% CI:
0.84e1.24).
Figure 2A and B compare changes in depression and anxiety
scores between the two cohorts. From T1 to T2, the fixed effect
model identified that the between-cohort change in depression
score was nonsignificant (p ¼ .082), although within-cohort
changes were significant. The average depression score of 7.8
among COVID cohort students in T1 significantly increased to 8.5
in T2b (D ¼ 0.7, p < .001), whereas in pre-COVID cohort students,
the score increased from 7.5 to 8.0 in T2a (D ¼ 0.5, p < .001).
Similarly, the between-cohort difference in anxiety score was not
significant (p ¼ .329), while within-cohort changes indicate
significant increases in T2 in both cohorts.
In T3, both cohorts were assessed during the pandemic.
Although each cohort reported significantly higher depression
Descargado para Anonymous User (n/a) en Northern Private University de ClinicalKey.es por Elsevier en mayo 08, 2024. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados.
39
and anxiety scores than T2, changes were not significantly
different between the two cohorts (p > .05), suggesting
internalizing symptoms increased in both cohorts similarly.
COVID cohort adolescents reported an increase of D ¼ 0.74 in
their depression scores compared to pre-COVID cohort adoles-
cents, who reported D ¼ 0.50 changes. The average anxiety score
of both cohorts increased from T2 to T3 (D ¼ 0.56 COVID cohort
vs. D ¼ 0.73 pre-COVID cohort 2). The adjusted likelihoods of
members of the two cohorts having significant depressive
symptoms (1.02, 95% CI: 0.84e1.24) and/or moderate-to-severe
anxiety symptoms (1.17, 95% CI: 0.95e1.43) in T3 were not
significantly different. The results of the sensitivity analysis
suggest that the difference-in-difference method for comparing
the two cohorts confirms the results of the fixed effect models
(Supplementary Figure A1).
Stratified analyses
Figure 2C and D identify that females had higher depression
and anxiety symptoms across the three years. Females in the
COVID cohort reported significantly greater increase in their
depression than those in the pre-COVID cohort (p ¼ .042) from
T1 to T2. However, the two cohorts reported similar changes in
their scores from T2 to T3. In comparison, males in both cohorts
experienced similar changes in depression across the three years
(Figure 2C). Female and male anxiety changes among the two
cohorts were similar over time.
Age group analyses in Figure 2E and F show that changes in
depression symptoms of the two cohorts were similar, except
that the 15e18-year-olds in the COVID cohort reported greater
depression increases from T1 to T2 than their younger peers in
the pre-COVID cohort (p ¼ .005). It appears that changes in the
anxiety symptoms of age groups between the two cohorts were
similar across the three years (Figure 2F).
Figure 2G and H indicate that students identifying as White
reported lower depression and anxiety symptoms than persons
of colour across the study period, although the pre-COVID and
COVID cohorts reported similar changes.
Discussion
This natural experiment study explored the ongoing impact of
the COVID-19 pandemic on within-person changes in the mental
health of Canadian adolescents using prospective data linked
across three waves of the COMPASS study. Results suggest
consistent increases across the three years in both anxiety and
depression symptoms during the early and ongoing pandemic
periods. Elevations in symptoms of pre-COVID and COVID
cohorts from baseline to the first follow-up wave were similar,
and thus, the results do not support a negative impact of the
early pandemic but instead a gradual increase in symptoms from
early to later adolescence. Both cohorts had significant increases
in depression and anxiety symptoms from the second wave to
the ongoing pandemic period, to a greater extent than the
increases from the pre-to early pandemic periods. Increases in
symptoms were again similar across cohorts. The stratified
analyses indicated that females and younger students experi-
enced higher elevations than their male and older peers, while
there was no difference by race/ethnicity.
Our results show that the increases in symptoms during the
ongoing pandemic were approximately twice the increases in
the early pandemic. Because both cohorts were exposed to the
40 M.R. Gohari et al. / Journal of Adolescent Health 74 (2024) 36e43

Table 1
Distribution of baseline characteristics of two prospective cohorts of students attending 81 secondary schools across three waves (2018-19, 2019-20, and 2020-21) of the
COMPASS study

Overall sample Pre-COVID cohorta COVID cohort

(n ¼ 5,319) (n ¼ 3,447) (n ¼ 1,872)
N (%) N (%) N (%)

Sex (female) 3,206 (60.3) 1,980 (57.4) 1,226 (65.5)

Age at baseline (%)
12e13 1,960 (37.0) 1,221 (35.6) 739 (39.6)
14 1,928 (36.4) 1,332 (38.8) 596 (32.0)
15e18 1,409 (26.6) 880 (25.6) 529 (28.4)
Race/ethnicity (%)
White 4,251 (79.9) 2738 (79.4) 1,513 (80.8)
Black 92 (1.7) 45 (1.3) 47 (2.5)
Asian 331 (6.2) 231 (6.7) 100 (5.3)
American/Hispanic 54 (1.0) 37 (1.1) 17 (1.0)
Mixed/Others 591 (11.1) 396 (11.5) 195 (10.4)
Significant depressive symptoms (CESD-R-10 score 10, %)
Prepandemic (T1) 1,520 (29.4) 947 (28.3) 573 (31.3)
Early pandemic (T2) 1,715 (33.5) 1,070 (31.7) 645 (36.9)
Ongoing pandemic (T3) 2224 (44.8) 1,382 (43.1) 842 (47.8)
Moderate to sever anxiety symptoms (GAD-7 score 10, %)
Prepandemic (T1) 920 (17.6) 572 (16.9) 348 (18.8)
Early pandemic (T2) 1,108 (21.4) 705 (20.7) 403 (22.9)
Ongoing pandemic (T3) 1,491 (29.8) 900 (27.9) 591 (33.3)
Depression score (CESD-R-10), mean (sd)
Prepandemic (T1) 7.6 (5.8) 7.5 (5.7) 7.9 (6.0)
Early pandemic (T2) 8.2 (5.8) 8.0 (5.7) 8.6 (6.0)
Ongoing pandemic (T3) 9.9 (6.6) 9.6 (6.5) 10.3 (6.7)
Anxiety score (GAD7), mean (sd)
Prepandemic (T1) 5.2 (5.0) 5.1 (5.0) 5.4 (5.0)
Early pandemic (T2) 5.9 (5.2) 5.8 (5.2) 6.0 (5.3)
Ongoing pandemic (T3) 7.2 (5.9) 7.0 (5.9) 7.6 (5.9)

CESD ¼ Center for Epidemiologic Studies Depression Scale Revised; GAD ¼ generalized anxiety disorder; COMPASS ¼ cannabis use, obesity, mental health, physical activity,
alcohol use, smoking, and sedentary behaviour.
a
pre-COVID cohort includes students who provided linked data in 2018/19, 2019/20 before the pandemic, and 2020/21; COVID-cohort includes students who
provided linked data in 2018/19, 2019/20 immediately after the pandemic (spring 2020), and 2020/21.

pandemic restrictions in the third wave of the study, we cannot
separate the effects of the ongoing pandemic from other factors,
including age-related changes. This finding may reflect the
timing of the early pandemic assessments, which occurred
during the first school closures for in-person learning when
online schooling was minimal in Canada. For many students,
the early pandemic may have been a break from school-related
stressors. In the ongoing period, however, extended isolation
and confinement at home, returning to school with new pro-
tocols and schedules, more concentrated efforts to deliver on-
line learning, and the repeated closures and openings were
reported to be stressful among many students and may have
been associated with increased depression and anxiety symp-
toms. Another possible explanation, as Wade et al. (2020)
suggested, is that the responses of some adolescents to
pandemic-related stress could be immediately observed, while
for some others, they have unfolded over time. That is, the
pandemic may have altered adolescents’ stress responses,
affecting how they respond to stressors in the future, whether
COVID-19-related or otherwise [33]. Therefore, the escalation of
anxiety and depression symptoms in the ongoing pandemic can
be an indication of the starting point for subsequent mental
health problems in the adolescents’ population [33]. This
escalation, irrespective of whether due to the pandemic or the
typical increase seen from early to later adolescence, warrants
ongoing monitoring to determine any sustained impacts and
investigation into potential mechanisms, disparate impacts,
and interventions.
It is notable that the results of measuring change in inter-
nalizing symptoms on a continuous scale are consistent with
those on a binary scale of significant depressive and moderate-
severe anxiety symptoms. This finding is in line with past
research that reported a high association between mean symp-
tom scores and rates of clinically elevated symptoms [13]. This
observed deterioration during the three years is likely to result in
higher needs from a clinical perspective. The decline in mental
health during adolescence underscores the importance of
increased collaboration between health and education systems.
This can be achieved by incorporating mental health literacy into
school curricula, which has the potential to improve self-care
skills and facilitate early interventions. In addition, prevention
programs should take into consideration for unforeseen situa-
tions such as the pandemic, which may result in limited access to
mental health facilities for youth. As a result, one strategy would
be to develop and implement online resources as an effective and
efficient way of providing support and early-intervention
services to adolescents. Ongoing evaluation of students’ mental
health and further enhancement of clinical capacity are
necessary.
Our finding that females had higher symptoms across the
three years than males is consistent with past evidence sug-
gesting women’s depression and anxiety rates are higher than
males [34,35]. In addition to the higher depression and anxiety
symptoms at baseline, the results also show that females re-
ported a greater elevation in symptoms than males, which is in
line with evidence that females are more vulnerable to

Descargado para Anonymous User (n/a) en Northern Private University de ClinicalKey.es por Elsevier en mayo 08, 2024. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados.
 M.R. Gohari et al. / Journal of Adolescent Health 74 (2024) 36e43 41

Figure 2. Depression (CESD-R-10) and anxiety (GAD-7) scores in two prospective cohorts of adolescents over three years of the COMPASS study. Only significant
estimates at a ¼ 0.1 are reported, showing a significant difference between changes in pre-COVID cohort (who surveyed in Sept-Feb 2019-20 right before the start of the
pandemic) and COVID cohort (who surveyed in May-June 2020 right after the start of the pandemic). *T1:2018/19, T2:2019/20, T3:2020/21. CESD ¼ Center for
Epidemiologic Studies Depression Scale Revised; GAD ¼ generalized anxiety disorder; COMPASS ¼ cannabis use, obesity, mental health, physical activity, alcohol use,
smoking, and sedentary behaviour.

experiencing the mental health consequences of the pandemic
[13,15]. This sex difference could be due to the fact that females
are more likely to develop depression and anxiety after exposure
to stress and trauma than males [36].
Based on potential concerns related to changes in the
administration of our scales on account of the pandemic,
assessed the performance of the CESD-10 and GAD-7 scales in
different administration formats, namely online and paper-
based. Our research focused on the contextual changes experi-
enced by adolescents, which encompassed both changes in
modality (i.e., in-person, online) and the context of administra-
tion (i.e., in the classroom, at home). Previous studies have
yielded mixed findings in this area. For example, Cronly et al. [37]
found that online and paper-based screening for depression and
anxiety produced comparable scores among the adult popula-
tion. In contrast, Olino et al. [38] identified noninvariance in
measures based on scalar-invariant criteria among adolescents.
Our investigation indicated measurement invariance across the
two cohorts as well as longitudinal measurement invariance over
a 1-year period before and after the onset of the pandemic. The
complete results of our examination of the performance of the
two scales will be presented in a forthcoming manuscript.
Our study has four novel aspects. First, we used longitudinal
data from before the pandemic and two waves into the pandemic
that allowed us to explore ongoing changes. Existing longitudinal
studies are mainly limited to the first year of the pandemic. The

Descargado para Anonymous User (n/a) en Northern Private University de ClinicalKey.es por Elsevier en mayo 08, 2024. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados.
42 M.R. Gohari et al. / Journal of Adolescent Health 74 (2024) 36e43
majority of published COVID-19 research uses cross-sectional
designs, either by making comparisons to previous estimates
and unable to evaluate within-individual changes or by retro-
spective measures asking participants to evaluate whether their
mental health improved or declined since before the pandemic,
which is susceptible to error in recall. Second, the quasiexper-
imental design of our study with a demographic and time-
matched comparison group enables us to examine whether
internalizing symptom increases were related to the COVID-19
pandemic, adjusting for known age-related increases in the
symptoms. Third, depression and anxiety symptoms were
measured using well-validated scales, as opposed to studies that
have used single items for assessment (i.e., asking if symptoms
changed due to the pandemic). Finally, the passive-consent
protocol used in the study promotes robust results when
assessing adolescents’ mental health by mitigating possible
self-selection and social desirability biases [39].
Results should be interpreted within the context of the study
limitations. First, the COMPASS study was not intended to be
representative of the Canadian adolescent population; however,
consistent with past research [40], we expect that the results will
be similar to those of studies designed to be representative in
view of our sample’s diversity in rural, urban, and suburban areas
and the sample size. Second, transitioning from an in-person
classroom survey to an online survey may have introduced
participation bias; as the attrition analysis showed and previ-
ously reported [41], linked COMPASS students were less likely to
report depression and anxiety symptoms. However, the de-
mographics of participants in the ongoing pandemic wave were
closer to characteristics of the pre-COVID cohort than those of
participants in the early pandemic. Further, it is likely that
measurement errors across the two cohorts were similar and
therefore had no significant impact on the results. The use of a
binary racial-ethnic variable due to the low frequency of some
racialized and ethnic groups limited our ability to examine
possible differences in mental health changes. Lastly, the survey
at baseline asked participants whether they identified as male or
female, with no options provided for nonbinary gender or other
identities. Further research is needed to examine disparate
mental health changes caused by intersecting identity factors.
Conclusion
Our findings suggest that internalizing symptoms have
consistently increased over the three years of the study.
However, when changes were compared between the two
cohorts, we found no evidence of the increases were due to the
pandemic in the early COVID-19 period. Increases in anxiety and
depression symptoms during the ongoing pandemic period were
around double the increases in the early pandemic; however, we
are unable to attribute this change to the pandemic in the
absence of an unaffected comparison group. That is, we cannot
separate age-related from pandemic-related factors since both
cohorts were exposed to the pandemic. Deterioration in ado-
lescents’ mental health, irrespective of the reason, supports a
growing need for comprehensive responses to supporting
adolescent mental health, including providing resources in
schools and in community services that are overburdened to
facilitate access to community mental health support and to
develop and implement promoting programs at schools and
community. Ongoing evaluation of the impact of the pandemic
on mental health is necessary to capture the dynamic changes
Descargado para Anonymous User (n/a) en Northern Private University de ClinicalKey.es por Elsevier en mayo 08, 2024. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados.
and to inform health promotion, targeted prevention, and early
intervention strategies.
Funding Sources
The COMPASS study has been supported by a bridge grant
from the CIHR Institute of Nutrition, Metabolism and Diabetes
(INMD) through the “Obesity e Interventions to Prevent or Treat”
priority funding awards (OOP-110788; awarded to SL), an oper-
ating grant from the CIHR Institute of Population and Public
Health (IPPH) (MOP-114875; awarded to SL), a CIHR project grant
(PJT-148562; awarded to SL), a CIHR bridge grant (PJT-149092;
awarded to KP/SL), a CIHR project grant (PJT-159693; awarded to
KP), and by a research funding arrangement with Health Canada
(#1617-HQ-000012; contract awarded to SL),a CIHR-Canadian
Centre on Substance Abuse (CCSA) team grant (OF7 B1-PCPEGT
410-10-9633; awarded to SL), and a SickKids Foundation New
Investigator Grant, in partnership with CIHR Institute of Human
Development, Child and Youth Health (IHDCYH) (Grant No.
NI21-1193; awarded to KAP) funds a mixed methods study
examining the impact of the COVID-19 pandemic on youth
mental health, leveraging COMPASS study data. The COMPASS-
Quebec project additionally benefits from funding from the
Ministère de la Santé et des Services sociaux of the province of
Québec, and the Direction régionale de santé publique du CIUSSS
de la Capitale-Nationale.
Supplementary Data
Supplementary data related to this article can be found at
https://doi.org/10.1016/j.jadohealth.2023.07.024.
References
[1] Galea S, Merchant RM, Lurie N. The mental health consequences of COVID-
19 and physical distancing: The need for prevention and early intervention.
JAMA Intern Med 2020;180:817e8.
[2] Golberstein E, Wen H, Miller BF. Coronavirus disease 2019 (COVID-19)
and mental health for children and adolescents. JAMA Pediatr 2020;174:
819e20.
[3] Gohari MR, Dubin JA, Cook RJ, Leatherdale ST. Identifying trajectories of
alcohol use in a sample of secondary school students in Ontario and
Alberta: Longitudinal evidence from the COMPASS study. Health Promot
Chronic Dis Prev Can 2019;39:244e53.
[4] Kessler RC, Amminger GP, Aguilar-Gaxiola S, et al. Age of onset of mental
disorders: A review of recent literature. Curr Opin Psychiatry 2007;20:359.
[5] Boak A, Hamilton H, Adlaf E, et al. The mental health and well-being of
Ontario students, 1991-2017: Detailed findings from the Ontario student
drug use and health survey (OSDUHS) (CAMH research document series
No. 47). Toronto: Centre for Addiction and Mental Health; 2018.
[6] Kilburn K, Prencipe L, Hjelm L, et al. Examination of performance of the
center for epidemiologic studies depression scale short form 10 among
African youth in poor, rural households. BMC Psychiatry 2018;18:201.
[7] Ferro MA, Gorter JW, Boyle MH. Trajectories of depressive symptoms in
Canadian emerging adults. Am J Public Health 2015;105:2322e7.
[8] Karabanova OA, Poskrebysheva NN. Adolescent autonomy in parent-child
relations. Procedia Soc Behav Sci 2013;86:621e8.
[9] Duan L, Shao X, Wang Y, et al. An investigation of mental health status of
children and adolescents in China during the outbreak of COVID-19. J Affect
Disord 2020;275:112e8.
[10] Wade TJ, Cairney J, Pevalin DJ. Emergence of gender differences in
depression during adolescence: National panel results from three coun-
tries. J Am Acad Child Adolesc Psychiatry 2002;41:190e8.
[11] Guessoum SB, Lachal J, Radjack R, et al. Adolescent psychiatric disorders
during the COVID-19 pandemic and lockdown. Psychiatry Res 2020;291:
113264.
[12] Bélanger RE, Patte KA, Leatherdale ST, et al. An impact analysis of the early
months of the COVID-19 pandemic on mental health in a prospective
cohort of Canadian adolescents. J Adolesc Health 2021;69:917e24.
 M.R. Gohari et al. / Journal of Adolescent Health 74 (2024) 36e43
[13] Hawes MT, Szenczy AK, Klein DN, et al. Increases in depression and anxiety
symptoms in adolescents and young adults during the COVID-19
pandemic. Psychol Med 2022;52:3222e30.
[14] Magson NR, Freeman JY, Rapee RM, et al. Risk and protective factors for
prospective changes in adolescent mental health during the COVID-19
pandemic. J Youth Adolesc 2021;50:44e57.
[15] Ferro MA, Meyer SB, Yessis J, et al. COVID-19-Related psychological and
psychosocial distress among parents and youth with physical illness: A
longitudinal study. Front Psychiatry 2021;12:761968.
[16] Barendse M, Flannery J, Cavanagh C, et al. Longitudinal change in adoles-
cent depression and anxiety symptoms from before to during the COVID-
19 pandemic. J Res Adolesc 2023;33:74e91.
[17] De France K, Hancock GR, Stack DM, et al. The mental health implications
of COVID-19 for adolescents: Follow-up of a four-wave longitudinal study
during the pandemic. Am Psychol 2022;77:85e99.
[18] Van Lancker W, Parolin Z. COVID-19, school closures, and child poverty: A
social crisis in the making. Lancet Public Health 2020;5:e243e4.
[19] Raifman MA, Raifman JR. Disparities in the population at risk of severe
illness from COVID-19 by race/ethnicity and income. Am J Prev Med 2020;
59:137e9.
[20] Goldmann E, Hagen D, El Khoury E, et al. An examination of racial and
ethnic disparities in mental health during the Covid-19 pandemic in the US
South. J Affect Disord 2021;295:471e8.
[21] Leatherdale ST, Brown KS, Carson V, et al. The COMPASS study: A longi-
tudinal hierarchical research platform for evaluating natural experiments
related to changes in school-level programs, policies and built environ-
ment resources. BMC Public Health 2014;14:331.
[22] Battista KWQ, Bredin C. COMPASS Technical Report Series. In: Leatherdale ST, ed.
Student data linkage over multiple years, Vol. 6. Waterloo, Canada: University of
Waterloo; 2019. Available at:, https://uwaterloo.ca/compass-system/student-
data-linkage-over-multiple-years. Accessed August 10, 2022.
[23] Andresen EM, Malmgren JA, Carter WB, Patrick DL. Screening for depres-
sion in well older adults: Evaluation of a short form of the CES-D. Am J Prev
Med 1994;10:77e84.
[24] Battista K, Patte KA, Diao L, et al. Using decision trees to examine envi-
ronmental and behavioural factors associated with youth anxiety,
depression, and flourishing. Int J Environ Res Public Health 2022;19:10873.
[25] Bradley KL, Bagnell AL, Brannen CL. Factorial validity of the center for
epidemiological studies depression 10 in adolescents. Issues Ment Health
Nurs 2010;31:408e12.
[26] Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing
generalized anxiety disorder: The GAD-7. Arch Intern Med 2006;166:1092e7.
[27] Haroz EE, Ybarra ML, Eaton WW. Psychometric evaluation of a self-report
scale to measure adolescent depression: The CESDR-10 in two national
adolescent samples in the United States. J Affect Disord 2014;158:154e60.
Descargado para Anonymous User (n/a) en Northern Private University de ClinicalKey.es por Elsevier en mayo 08, 2024. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados.
43
[28] Mossman SA, Luft MJ, Schroeder HK, et al. The generalized anxiety disorder
7-item (GAD-7) scale in adolescents with generalized anxiety disorder:
Signal detection and validation. Ann Clin Psychiatry 2017;29:227.
[29] Romano I, Ferro MA, Patte KA, Leatherdale ST. Measurement invariance of
the GAD-7 and CESD-R-10 among adolescents in Canada. J Pediatr Psychol
2022;47:585e94.
[30] Allison PD. Fixed effects regression models. Thousand Oaks: SAGE publi-
cations; 2009.
[31] Fitzmaurice G, Molenberghs G. Advances in longitudinal data
analysis: An historical perspective. Longitudinal Data Analysis.
Hoboken: John Wiley & Sons, Inc.; 2009:3e30.
[32] Peugh JL, Enders CK. Missing data in educational research: A review of
reporting practices and suggestions for improvement. Rev Educ Res 2004;
74:525e56.
[33] Wade M, Prime H, Browne DT. Why we need longitudinal mental health
research with children and youth during (and after) the COVID-19
pandemic. Psychiatry Res 2020;290:113143.
[34] Kwong AS, Manley D, Timpson NJ, et al. Identifying critical points of tra-
jectories of depressive symptoms from childhood to young adulthood.
J Youth Adolesc 2019;48:815e27.
[35] Wiens K, Bhattarai A, Pedram P, et al. A growing need for youth mental
health services in Canada: Examining trends in youth mental health from
2011 to 2018. Epidemiol Psychiatr Sci 2020;29:e115.
[36] Tolin DF, Foa EB. Sex differences in trauma and posttraumatic stress dis-
order: A quantitative review of 25 years of research. Psychol Bull 2008;
132:959e92.
[37] Cronly J, Duff AJ, Riekert KA, et al. Online versus paper-based screening for
depression and anxiety in adults with cystic fibrosis in Ireland: A cross-
sectional exploratory study. BMJ Open 2018;8:e019305.
[38] Olino TM, Case JA, Hawes MT, et al. Testing invariance of measures of
internalizing symptoms before and after a major life stressor: The impact
of COVID-19 in an adolescent and young adult sample. Assessment 2022;
29:1371e80.
[39] Chartier M, Stoep AV, McCauley E, et al. Passive versus active parental
permission: Implications for the ability of school-based depression
screening to reach youth at risk. J Sch Health 2008;78:157e64.
[40] Butler A, King N, Battista K, et al. Mental health and cannabis use among
Canadian youth: Integrated findings from cross-sectional and longitudinal
analyses. Int J Drug Policy 2023;112:103926.
[41] Reel B, Battista K, Leatherdale ST. COMPASS Technical Report Series.
COMPASS protocol changes and recruitment for online survey imple-
mentation during the COVID-19 pandemic, Vol. 7. Waterloo, Canada:
University of Waterloo; 2020. Available at:, https://uwaterloo.ca/compass-
system/publications/compass-protocol-changes-and-recruitment-online-
survey. Accessed August 10, 2022.