Beyond Averages: The Hidden Surge in Severe Emotional Distress Among Adolescents After COVID-19

How new nationally representative data from six countries reveal a sharp rise in the most severe cases. What do we need to do next?

By Caio Borba Casella, Clinical Data Analyst
Stavros Niarchos Foundation (SNF) Global Center for Child and Adolescent Mental Health

• New Lancet study maps widespread rise in high levels of emotional distress among young people post COVID-19 across six countries and territories from 2018-2020 across six countries and territories
• Girls consistently reported higher distress than boys
• Implications for health systems include strained workforce, more adolescents meeting thresholds for clinical concern and danger of chronic mental health problems
• Young people who are already vulnerable are now at greater risk.
• Investment in youth mental health, and disaster and pandemic planning must be a core priority

Most of the early answers came from convenience samples, such as online surveys, that, although valuable, are not designed to represent an entire country. That means we have had limited capacity to quantify how widespread the problem is and to plan services accordingly.

In a new study published in The Lancet Child & Adolescent Health, titled “Emotional distress in adolescents in 2018 and 2022: a comparison of cross-sectional national probabilistic samples from six countries, our team set out to address this gap. While leading the study, I worked with contributors including Giovanni Salum, senior vice president of Global Programs; Zeina Mneimneh, vice president of Global Epidemiology and Evidence-Based Interventions; and leading epidemiologists Guilherme Polanczyk, Kathleen Merikangas, and Ronald Kessler.

We used nationally representative data from the Programme for International Student Assessment (PISA) regarding six countries and territories (Hong Kong, Ireland, Mexico, Panama, Spain, and the United Arab Emirates) to compare emotional distress among 15-year-olds in 2018 (pre-pandemic) and 2022 (post-pandemic onset). Although the focus of PISA is on academic assessment, its questionnaire also includes items addressing other domains, such as socioeconomic and behavioral aspects (e.g., socialization and physical activity) and emotional distress (e.g., anxiety, depression, and somatic stress responses), that we used for this analysis.

What we found challenges the idea that “things got only a little worse.” On average, emotional distress increased modestly. However, behind that modest average lies a much more troubling story: evidence suggests the number of adolescents experiencing very high levels of emotional distress appears to have risen substantially.

Most studies on mental health trends focus on how the average symptom level changes over time. This is important, but it can also be misleading.

Imagine a classroom where most students feel roughly the same as before, but a smaller group at the back of the room is struggling much more than they used to. If you only look at the class average, you might conclude that “not much has changed,” when in reality, a growing subset of students is in serious distress.

To avoid this blind spot, we used quantile regression, a method that allows us to examine changes across the entire distribution of emotional distress, from those with mild symptoms to those with very severe symptoms.

Across the six countries and territories, we found:

• A modest increase in emotional distress between 2018 and 2022 at the median (the “middle” adolescent).
• Much larger increases of emotional distress at the upper end of the distribution, among adolescents with the highest symptom levels.

When we translated these shifts into population-level estimates, we found that:

• The proportion of adolescents scoring above the median pre-pandemic level increased by about 15%.
• The proportion scoring above the 95th percentile, that is those with very high levels of distress, increased by around 137%.

Put simply: the overall average increased a little, but the number of adolescents in severe distress seems to have more than doubled. When we apply these proportions to national population estimates, this corresponds to roughly an additional 200,000 adolescents aged 15 years in the severe distress range across the six countries and territories we studied. We explore the far-reaching consequences of this population-level shift and its implications for mental health systems later in this analysis.

Our study also examined how emotional distress is related to key social and demographic factors, and how those relationships changed between 2018 and 2022.

We found that:

• Girls consistently reported higher distress than boys, and the gap widened over time.
• Bullying was one of the strongest correlates of higher emotional distress, and its association with distress became even stronger in 2022.
• Lower sense of belonging at school, fewer days spent with friends, and lower perceived parental support were all linked to higher distress, again with stronger associations after the pandemic began.
• More frequent electronic contact with friends was also associated with higher distress, underscoring the complex relationship between digital communication, social connection, and mental health.

Taken together, these patterns suggest a “vulnerability amplification” effect: young people who were already exposed to risk factors, such as bullying, weak social ties, or limited family support, seem to have been hit hardest by the pandemic context and its aftermath.

Our findings add to a growing body of evidence that adolescent mental health has worsened over recent years, in ways that reflect both pre-existing trends and pandemic-related exacerbation. Crucially, this worsening is not evenly distributed: young people who are already vulnerable are now at even greater risk. This rise in mental health distress has important implications for health systems that were already operating under strain before the pandemic:

• More adolescents may now meet thresholds for clinical concern, increasing demand for assessment and treatment.
• Specialist services alone cannot absorb this surge, especially in countries with limited child and adolescent mental health infrastructure.
• Without timely support, severe distress in adolescence can evolve into chronic mental health problems, academic failure, social exclusion, and elevated suicide risk.

To respond effectively to the rise in severe adolescent distress, systems must adopt scalable, layered solutions that match support to need. Policies must also focus on environments where adolescents live, learn, and connect, including schools, families, digital spaces, and communities, rather than relying solely on clinic-based models of care. This includes:

• School-based prevention and early response, such as anti-bullying efforts, mental health literacy, and access to brief psychological interventions.
• Integration of mental health into primary care, ensuring earlier detection and intervention closer to families.
• Digital and telehealth pathways that expand reach and reduce barriers, particularly where specialist capacity is limited.
• Stepped-care models that provide the least intensive effective support first and allow young people to “step up” to more intensive care when needed.
• Task-sharing approaches, training non-specialists to deliver evidence-based interventions under supervision—especially crucial in low- and middle-income contexts.

Many of our current initiatives, within the Stavros Niarchos Foundation Global Center for Child and Adolescent Mental Health at the Child Mind Institute from school-based assessment tools to telehealth Cognitive Behavioral Therapy and single-session interventions, are designed precisely to address this growing gap between need and available care. We remain committed to partnering with governments, schools, communities, and young people themselves to translate evidence like this into meaningful, equitable change.