The SARS-CoV-2 pandemic is associated with worsening mental health among young adults, but further research is necessary to quantify the associations with depression and anxiety. Available evidence suggests that depressive and anxious symptoms increased among adults during the course of the pandemic, with the highest increases among adults ages 18 to 29.¹ Depressive and anxious symptoms among young adults increased in the presence of educational, financial, and other pandemic-related stressors,² and meta-analytic estimates suggest that 34% and 32% of young adults have reported depressive and anxious symptoms, respectively, during the pandemic.³ However, the specific domains of depressive or anxious symptoms most directly affected by the pandemic are a gap in the literature that can inform intervention efforts. Similarly, it remains unclear the extent to which highly prevalent depressive and anxious symptoms are primarily related to the pandemic, rather than symptoms that would arise regardless of the pandemic. Understanding the specific symptoms and individuals most directly affected by pandemic-related stressors provides important context for future mental health interventions.

The COVID-19 pandemic has disrupted young people’s social, educational, and occupational practices, at times leading to isolation, remote learning and employment, and changes to work hours or compensation. Job insecurity in the pandemic predicts higher depression and anxiety symptoms among young adults in the US,⁴ and pandemic-related academic disruptions and uncertainty can lead to psychological distress that results in young adults reducing or stopping their engagement with education.⁵ These, along with other pandemic-related experiences, including economic hardship and resource scarcity, have worsened young adults’ mental health, though further study is necessary to understand the full magnitude of their link with clinically significant levels of depressive or anxious symptoms. Additionally, while understanding the role of the COVID-19 pandemic for these symptoms is important, it is perhaps more crucial to identify and implement effective coping strategies against pandemic-related stressors. While some techniques, such as connecting socially with others⁶ and maintaining a healthy diet,⁷ have been reported by young adults for improved mental wellbeing, others strategies, such as substance use to cope with pandemic-related stress, are potentially damaging and can lead to future substance use problems.⁸ Furthermore, less is known about the extent to which coping behaviors vary between those with pandemic-related depressive and anxious symptoms and those with similar symptoms not attributed to the pandemic.

In order to understand the role of COVID-19 pandemic-related experiences in young adults’ depressive and anxious symptoms, this study had the following aims: (1) Estimate the distribution of depressive and anxious symptoms in this population and determine the extent to which these symptoms are attributed by young adults to the COVID-19 pandemic; (2) Disentangle the demographic risk profiles for depressive and anxious symptoms that are attributed to pandemic-related experiences vs. not; (3) Understand the extent to which specific pandemic-related experiences have elevated risk for depressive and anxious symptoms; and (4) Link patterns of depressive and anxious symptoms to various coping behaviors to recognize potential areas for intervention.

Monitoring the Future (MTF), an ongoing study of adolescent beliefs and behaviors,⁹ included a unique supplemental study in Fall 2020 that featured items relating to the COVID-19 pandemic.⁸ The MTF Vaping Supplement collected data between September and November 2020. Participants were recruited from grade 12 students participating in the Spring 2019 MTF survey. Of 13,713 MTF participants in grade 12, there were 7,850 eligible for the Vaping Supplement. Ineligibility criteria included missing contact information or random selection into MTF’s longitudinal study. Of eligible participants, 4,358 were selected at random, oversampling those who reported vaping or other substance use. Of these participants, 1,244 (28.5%) participated in a 1-year follow-up survey, which provides the data for these analyses. These participants ranged in age from 18 to 24, though the vast majority (93%) were 19 or 20. The Institutional Review Board of University of Michigan approved this study. This supplement’s baseline survey captured a broad array of internalizing symptom items, as well as information on coping behaviors, educational trajectories, and economic outcomes related to the COVID-19 pandemic. This sample oversampled 12^th grade students who vaped, but survey weights accounted for selection probabilities.

Sample characteristics for the 1,244 young adults in this study are reported in Table 1. This sample was predominantly male sex assigned at birth (55.4%), white (57.2%), had a parent who completed college (55.2%), and were most likely to be found in an urban setting compared to suburban or rural settings (41.2% in cities of any size).

Depressive symptoms were highly prevalent in this sample (Figure 1), ranging from 20.6% prevalence in the past two weeks (moving or speaking slowly or being fidgety and restless) up to 67.6% (feeling tired or having little energy). Six out of eight symptoms were prevalent in a majority of respondents (little interest or pleasure in things, feeling down/depressed/hopeless, sleep issues, feeling tired, poor appetite or overeating, and feeling bad about yourself). Dividing those with symptoms based on whether the symptoms were attributed more than somewhat to the pandemic, results showed that pandemic-attributed depressive symptoms were most common for little interest/pleasure in things (14.7% of respondents had this symptom attributed more than somewhat to the pandemic) and feeling down, depressed, or hopeless (18.8% had this symptom attributed more than somewhat to the pandemic).

Anxious symptoms were also highly prevalent (Figure 2), ranging from 31.6% of respondents (being so restless that it’s hard to sit still) to 56.7% (feeling nervous, anxious, or on edge). Pandemic-attributed anxious symptoms were most common for worrying too much about different things (14.8% had this symptom attributed more than somewhat to the pandemic) and feeling afraid, as if something awful might happen (14.4% had this symptom more than somewhat due to the pandemic). Clinically high depressive symptoms were evident among 28.0% of respondents, while clinically high anxiety symptoms were seen among 20.8%. Relative to meta-analytic estimates in this population, studies using the PHQ-9 with the appropriate threshold for clinically high depression had an average prevalence of 28%, which matches our estimate precisely.³ While the meta-analytic estimate for GAD-7 studies predicting prevalence of anxiety still produced a relatively higher estimate (32% vs our estimate of 20.8%), several included studies featured an estimate in the low twenties, suggesting that our results fall within the natural heterogeneity of studies on this topic.³

Table 2 shows results for multinomial regressions predicting the three membership groups (those without high symptoms, those with high symptoms more than somewhat attributed to the pandemic, and those with high symptoms not attributed to the pandemic more than somewhat) by demographic factors of sex, race/ethnicity, parental education and urbanicity. For sex, the risk of depressive and anxious symptoms, either primarily attributed to the pandemic or not, was higher for female respondents (e.g., RRR for high depressive symptoms more than somewhat attributed to the pandemic [female vs. male]: 1.74 [95% CI: 1.08, 2.82]). For race and ethnicity, risk of membership in either high symptom group was particularly elevated for respondents in the “Other” group (e.g., American Indian, Alaskan Native, Pacific Islander, and Middle Eastern respondents) compared to Black peers who had the lowest rates of significant depressive or anxious symptoms. Depressive and anxious symptoms were also elevated for white, Hispanic/Latino, and Asian respondents compared to Black respondents. For urbanicity, risk of depressive and anxious symptoms, either attributed to the pandemic or not, was consistently highest in the “Can’t say”/mixed group.

The risk profile for high internalizing symptoms attributed to the pandemic across sex, race/ethnicity, and urbanicity was similar to the risk profile for high internalizing symptoms without major pandemic attribution. However, for parental education, there was evidence of heterogeneous risk profiles for depressive symptoms. Risk of depressive symptoms that were not/minimally COVID-attributed was lower for those with higher parental education (RRR [College or more vs. some college or less]: 0.67 [95% CI: 0.45, 0.98]). Risk for depressive symptoms that were highly COVID-related, however, was higher for those with higher parental education.

Table 3 demonstrates the amplified risk of depressive and anxious symptoms due to major shifts in education, employment, and other economic effects of the pandemic. Changes to student status and educational plans in both Spring 2020 and Fall 2020 were each associated with elevated risk for depressive and anxious symptoms, especially clinically high symptoms attributed more than somewhat to the pandemic. For instance, dropping classes or other major change to student status in Spring 2020 was linked to a demographic-adjusted RRR of 2.57 (95% CI: 1.37, 4.81) for depressive symptoms attributed more than somewhat to the pandemic. The RRR was even higher for those who experienced resource scarcity due to the pandemic, such as lacking a place to sleep or money for rent, gas, or food elevated risk of internalizing symptoms (aRRR for high depressive symptoms attributed more than somewhat to the pandemic: 4.43 [95% CI: 2.59, 7.55]). While these experiences posed a particularly major risk for anxious and depressive symptoms among young adults, these outcomes were also elevated among those who experienced more general changes to employment, such as shifts in hours worked or compensation (aRRR for high anxious symptoms attributed more than somewhat to the pandemic due to major effect on employment since March 2020: 2.24 [95% CI: 1.27, 3.94]).

Table 4 shows the associations between the utilization of coping practices and internalizing symptom outcomes. Notably, many forms of healthy coping rooted in physical or social behaviors were linked to a reduced risk of high symptoms (e.g., aRRR for “Taking care of your body, such as taking deep breaths, stretching, or meditating” predicting high depressive symptoms more than somewhat attributed to the pandemic: 0.57 [95% CI: 0.36, 0.92]). Meanwhile, coping methods rooted in substance use and dietary changes were typically linked to higher symptoms, especially for high symptoms more than somewhat attributed to the pandemic (e.g., aRRR for “Vaping more” predicting high anxious symptoms more than somewhat attributed to the pandemic: 4.76 [95% CI: 2.08, 10.93]).

While the link between coping strategies and internalizing symptoms was typically similar regardless of whether symptoms were primarily attributed to the pandemic, there were two notable coping strategies with heterogenous links to depressive symptoms based on whether those symptoms were pandemic-attributed. Taking breaks from watching, reading, or listening to news stories, including social media was associated with mildly decreased risk of depressive symptoms not attributed to the pandemic (aRRR for high depressive symptoms = 0.88 [95% CI: 0.59, 1.31]), but increased the risk for depressive symptoms attributed to the pandemic (aRRR for high depressive symptoms more than somewhat attributed to the pandemic: 1.60 [95% CI: 1.00, 2.57]). A similar dynamic occurred for the coping mechanism of contacting a healthcare provider. For anxious symptoms, contacting a healthcare provider was strongly linked to anxious symptoms attributed more than somewhat to the pandemic (aRRR = 2.14 [95% CI: 1.03, 4.47]) but not for anxious symptoms not/somewhat attributed to the pandemic (aRRR = 1.03 [95% CI: 0.47, 2.28]).

In the current SARS-CoV-2 pandemic, young adults have experienced high levels of depressive and anxious symptoms, and a portion of these symptoms could be attributed to the effects of the pandemic (e.g., educational, financial, housing-related). Risk of these symptoms was overall higher for female (vs. male) respondents, and for white, Hispanic/Latino, Asian, or “Other” race/ethnicity (vs. Black) respondents. Pandemic-related depressive symptoms specifically were slightly elevated for those with high parental education, while the opposite was true for depressive symptoms not attributed to the pandemic more than somewhat. Depressive and anxious symptoms, particularly when pandemic-attributable, were strongly predicted by significant changes to educational plans or practices, employment, or resource availability due to the pandemic. Healthy physical or social coping mechanisms were linked to reduced risk of these symptoms, while substance use and dietary changes were linked to elevated risk. Taking breaks from the news and contacting healthcare professionals were common coping behaviors highly prevalent among those whose depressive and anxious symptoms were mainly due to the pandemic. Ultimately, these findings reflect the need for urgent, major structural and social changes to improve the mental health of young adults in the pandemic.

Still, most people with each depressive or anxious symptom in this study reported that they were minimally attributable to the pandemic. These substantial symptoms unrelated to the pandemic reflect consistently increasing pre-pandemic trends in depressive and anxious symptoms.^19,20 However, adverse pandemic-related experiences were linked to elevated risk for clinically high depressive and anxious symptoms, regardless of whether young adults attributed their symptoms primarily to the pandemic. Thus, benefits of pandemic-related interventions and structural changes to address pandemic-related stressors may benefit all young people with clinically high depressive and anxious symptoms.

The expansion of accessible, affordable, equitable mental healthcare with remote telehealth options that address pandemic-related stressors would be useful, alleviating psychological distress for any number of young adults.²¹ Additionally, interventions are needed to support productive coping methods and address maladaptive coping approaches that are consequences of the pandemic. Based on the coping mechanism results of our analyses, public health professionals should work towards the promotion of physical wellness and social connection for those distressed by the pandemic, while still emphasizing the value of social distancing and protective measures. As pandemic-related clinically high depressive and anxious symptoms were linked to higher rates of contacting healthcare providers and taking breaks from the news, there may also be an unmet need for succinct, fact-based, readily accessible information on pandemic-related news and recommendations. Additionally, just as healthy coping behaviors should be promoted, we should also monitor elevated substance use and disrupted eating patterns which, in this study, were associated with elevated depressive and anxious symptoms, pandemic-related or not. Public health organizations should boost visibility for accessible resources to address those behaviors, such as text or video-based therapies or guided treatment plans from a connected, collaborative network of informed clinicians.^22,23

The suggestions described above would help young adults to healthily cope with the pandemic, but our results also highlight that young adults who report struggling with pandemic-related effects, like not having a place to sleep or money to buy gas or food, have greater risk for depressive and anxious symptoms. Therefore, there is also a need for stronger structural supports to address the socioeconomic and educational effects of COVID. Given the associations between educational changes and clinically high depressive and anxious symptoms, further research should examine whether the widespread implementation of specific policies, such as flexibility of coursework and grading, support for effective remote learning, and school-based support for mental health counselling, would have mental health benefits.^24,25 To address the harmful effects of employment/income shifts and resource scarcity, it is likely worthwhile to examine the potential benefits of increased governmental economic stimulus sent directly to citizens, as well as expansion of insurance coverage, unemployment benefits, housing support, and employment opportunities.^26-29 These economic resources are vital for the improvement of young adults’ mental health, though notably young people with higher parental education, a proxy for socioeconomic status, had higher pandemic-related depressive symptoms. Further research should examine this interplay of diverse socioeconomic metrics and depressive and anxious symptoms.

This study had several strengths, including the use of thorough, validated measures for depressive and anxious symptoms. In addition to these scales, the measures of pandemic-related educational, employment, economic experiences, and coping were thorough, covering a broad array of potential experiences and behaviors. Still, as with any study, there were limitations. This measure of pandemic attribution for each symptom was self-reported, and the true extent to which a depressive or anxious symptom is due primarily to the pandemic may not align with a respondent’s perception. Future research may include a clinician interview or more thorough questions that examine participant history, which may influence the perception of the extent to which symptoms were truly attributable to the pandemic. We were also unable to examine mental health treatment in this sample, which may impact the relationship between pandemic-related stressors and internalizing symptom outcomes. Given the cross-sectional nature of these data, we were unable to disentangle the directionality of associations or the durations of symptoms. These results do not necessarily apply to other age groups or countries, as pandemic-related experiences likely differ substantially. Additionally, people who reported substance use at baseline were oversampled, though survey weighting accounted for this oversampling and adjusted results accordingly.

The COVID-19 pandemic added to the already substantial depressive and anxious symptoms of young adults. This psychiatric harm warrants urgent interventions that not only support effective coping practices, but provide tangible socioeconomic resources.