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. 2022 Dec 10;166:107381. doi: 10.1016/j.ypmed.2022.107381

The intersection of internalizing symptoms and alcohol use during the COVID-19 pandemic: A prospective cohort study

Mahmood R Gohari a,⁎, Thepikaa Varatharajan a, Karen A Patte b, James MacKillop c, Scott T Leatherdale a
PMCID: PMC9737513  PMID: 36513170

Abstract

Given the well-established relationship between alcohol and internalizing symptoms, potential increases in depression and anxiety during the COVID-19 pandemic may lead to increases in alcohol consumption and binge drinking. This study examines this association from before to during two phases of the pandemic in a cohort of Canadian youth. We used linked data from a sub-sample of 1901 secondary school students who participated in three consecutive school years of the Cannabis use, Obesity, Mental health, Physical activity, Alcohol use, Smoking, and Sedentary behaviour (COMPASS) study between 2018/19 and 2020/21. Separate multilevel logistic regression models examined the association between depression and anxiety symptoms with odds of escalation and reduction (vs. maintenance) and initiation (vs. abstinence) of alcohol consumption. Results show that depression and anxiety symptoms significantly increased over the three years, and these changes were moderated by changes in alcohol consumption and binge drinking. Students with increased depression symptoms were less likely to reduce their alcohol consumption in the early pandemic (Adjust odds ratio [AOR] 0.94, 95% CI:0.90–0.98), more likely to initiate alcohol consumption in the ongoing pandemic period (AOR 1.03, 95% CI: 1.01–1.05), and more likely to initiate binge drinking in both periods. The depression-alcohol use association was stronger among females than males. This study demonstrates a modest association between internalizing symptoms and alcohol use, particularly for depression symptoms and in females. The identified depression-alcohol use association suggests that preventing or treating depression might be beneficial for adolescent alcohol use and vice versa.

Keywords: Depression, Anxiety, Binge drinking, Longitudinal study, COVID-19

1. Introduction

Alcohol use and binge drinking among youth are prominent high-risk health behaviours and important public health issues (Canadian Centre on Substance Use and Addiction, 2019). Results from the 2019 Canadian Student Tobacco, Alcohol and Drugs Survey indicated that by grade 12, 63.5% of youth reported ever using alcohol and 38.5% engaged in binge drinking in the past 12 months (Health Canada, 2019). The use and misuse of alcohol during adolescence is linked to an array of negative risk behaviours and health outcomes later in life, such as the development of substance use and mental disorders, insomnia, academic underachievement, criminal and violent behaviours, and strained relationships with family and friends (Caldwell et al., 2002; MacArthur et al., 2012).

Adolescents are also at a greater risk for developing internalizing psychiatric disorders (Hanna et al., 2001) and the relationship between alcohol and depression and anxiety is well-established among both clinical and population-based studies (Dyer et al., 2019; Esmaeelzadeh et al., 2018; Johannessen et al., 2017; Kim et al., 2019). Depression and/or anxiety have been linked to an earlier initiation of alcohol use and more frequent and heavy alcohol consumption in adolescents (Johannessen et al., 2017; Kim et al., 2019). Increased alcohol consumption levels may be reflective of adolescents' attempt to cope with or self-medicate during stressful circumstances (Torikka et al., 2017). Thus, understanding how symptoms of depression and anxiety relate to alcohol use and binge drinking among youth can facilitate early identification of at-risk youth and inform future prevention efforts, including during global crises.

After the onset of the COVID-19 pandemic, a growing public health concern is that youth will use alcohol as a strategy to cope with the lockdowns and physical distancing measures (Glowacz and Schmits, 2020; Smith et al., 2020; Wardell et al., 2020). Being confined at home and dealing with loneliness, boredom, and the uncertainties of daily life may instigate psychological distress (Schmits and Glowacz, 2021). Findings from a 2021 meta-analysis indicated that the global prevalence of depression and anxiety for children and adolescents doubled; with the percentage of youth experiencing symptoms increasing from 12.9% to 25% for depression and from 11.6% to 20% for anxiety (Racine et al., 2021). The study, in consensus with other research, also reported relatively higher rates of depression and anxiety among girls and older adolescents (Minhas et al., 2021; Racine et al., 2021). This sex difference in drinking patterns of male and female students (Cheng et al., 2016; Danzo et al., 2017) and different responses to the pandemic with was also reported by past research (Dumas et al., 2020).

Potential increases in depression and anxiety during the pandemic may lead to increases in alcohol consumption and binge drinking. The current study aims to further understand changing patterns of alcohol consumption over the pandemic and associations with depression and anxiety symptoms among adolescents. We hypothesized that there is a positive association between alcohol use and depression and anxiety symptoms. We used survey data from an ongoing prospective cohort study of Canadian secondary school students. Given sex differences in alcohol use and internalizing symptoms (Minhas et al., 2021), a secondary purpose of this paper is to consider whether associations differ between males and females.

2. Methods

This study used longitudinal student data from the ongoing Cannabis use, Obesity, Mental health, Physical activity, Alcohol use, Smoking, and Sedentary behaviour (COMPASS) study (2012–2027), 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 I-V in Quebec). Participating schools are recruited if they permit using an active-information passive-consent parental permission protocol (Leatherdale et al., 2014).

2.1. Design and participants

We used 3-year linked student data from a convenience sample of 49 schools (n = 26 Quebec, n = 21 Ontario, n = 2 British Columbia) that participated in COMPASS during the 2018/19 school year (T1; pre-pandemic), May to June 2020 (T2; early pandemic), and the 2020/21 school year (T3; ongoing pandemic). Student data in T1 were collected using a paper-based survey completed during one classroom period by whole-school samples (Reel and Leatherdale, 2020). As schools closed to in-person learning in March 2020, T2 data were collected online from May to June 2020 using the Qualtrics XM survey software (Qualtrics, Provo, UT, USA). Each participating school emailed a survey link to all eligible students, followed by a reminder email one week after (Reel et al., 2021). Online data collection continued in T3 given the ongoing pandemic response (see Fig. 1 ). Data from students that completed the paper-based survey from September 2019 to March 2020 before schools closed due to COVID-19 were not included in this study, as the goal was to examine change from before the pandemic to the early pandemic, and from the early pandemic to the ongoing pandemic response.

Fig. 1.

Fig. 1

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Data collection periods and longitudinal data linkage. aData collected from September 2019 to March 20, 2020 (pre-pandemic) were not included in the analysis.

Five items from the beginning of the questionnaire were used to generate unique identification codes as a means to link data across years anonymously. In total, data from 1901 participants who provided 3-year linked data were analyzed. A large proportion of the non-linked data was attributed to students who did not complete the online survey after the survey switched from paper to online. we described this as a limitation in the Discussion section. Supplementary Table A1 compares characteristics of linked and unlinked participants.

2.2. Measures

Alcohol consumption: Consistent with national surveillance measures used for substance use among Canadian youth (Elton-Marshall et al., 2011) and previous research (Gohari et al., 2021), students reported their frequency of drinking by responding to the question “In the last 12 months, how often did you have a drink of alcohol that was more than just a sip?” on a 10-option measure from “I have never drunk alcohol” to “every day”.

Binge drinking: The frequency of binge drinking was assessed by the question “In the last 12 months, how often did you have 5 drinks of alcohol or more on one occasion?” with an 8-option response measure from “I have never done this” to “2-5 times a week or daily”.

Changes in frequency from T1 to T2 and from T2 to T3 of alcohol consumption and binge drinking were categorised as abstinence (no use at both time points), maintained (use reported at both time points with frequency remaining constant), reduced (use reported at baseline with frequency decreasing/non-use reported at follow-up), escalated (use reported at both time points with frequency increasing from baseline to follow-up), and initiated (no use reported at baseline with any level of use reported at follow-up).

Depression: Depression was measured in each wave using the 10-item Center for Epidemiologic Studies Depression Scale Revised (CESD-R-10) scale (Andresen et al., 1994). Item responses are scored 0–3 and summed to create a composite score. Scores were calculated only if a maximum of two items were missing based on the available responses, otherwise the score was set to missing. Scores have possible range from 0 to 30; higher scores indicating higher depression symptoms. In this study, internal consistency across CESD-R-10 items measured by Cronbach's alpha were 0.71, 0.71, 0.71 over the three years.

Anxiety: Anxiety was measured in each wave using the Generalized Anxiety Disorder 7-item (GAD-7) scale (Spitzer et al., 2006). Items are scored from 0 to 3 and summed, with a possible total score ranging from 0 to 21; greater scores indicate higher anxiety symptoms. Similar to depression score, the anxiety score was set to missing if there were more than two missing items. The internal consistency for the GAD-7 scale was 0.89, 0.90, and 0.91 across the three years of the study.

The validity and reliability of both the CESD-R-10 and GAD-7 scales in adolescents' population are documented (Haroz et al., 2014; Mossman et al., 2017) and their measurement invariance by sex and grade in the COMPASS study are shown (Romano et al., 2022).

Clinically relevant symptoms: The binary status of having clinically-relevant depression symptoms was defined as 1 (if the CESD-R-10 score was ≥10) and 0 (otherwise). Clinically-relevant anxiety was also defined as a binary status of 1 (if a GAD7 score was ≥10) and 0 (otherwise) {Andresen, 1994 #40}.

Covariates: The COMPASS student questionnaire includes demographic questions to assess age, race/ethnicity (White, Black, Asian, Latin American/Hispanic, and Other, including “other”, First Nations, Métis, Inuit, and multiracial or mixed identity), and sex (male, female). Due to the low frequency of responses, race/ethnicity responses were coded as White and Non-white.

Missing values: Of the total 5703 (1901*3) records, the proportion of records with complete data is 93.3% (n = 5320), and 6.7% (n = 383) records has missing. Of them, 81 had only one, 95 had two, and 207 had more than two missing values. The rates of missing depression data were 2.7% (T1), 8.2% (T2), and 6.9% (T3) and missing anxiety data rates were 1.7% (T1), 7.6% (T2), and 6.5% (T3). The missing rates for alcohol use across the three years of the study were < 0.01%, 0.06%, and 0.05% and binge drinking were < 0.01%, <0.01%, and 0.05%. Because of low missing rates we did not use any imputation methods and used pairwise deletion approach (Peugh and Enders, 2004).

Analysis: Statistical analyses were conducted using SAS software, Version 9.4. We first identified the prevalence of each alcohol change group in the sample overall and by sex. We compared the demographic and behavioural characteristics of students who changed their alcohol use behaviour to students that did not. We used a series of separate multilevel logistic regression models to examine the association between depression and anxiety scores with odds of escalation and reduction (vs. maintenance) and initiation (vs. abstinence) of alcohol consumption from T1 to T2 and from T2 to T3. The models controlled for race/ethnicity, sex, age at baseline, and the nested structure of students' data within schools. The same models were used to examine the association between depression and anxiety with odds of change in binge drinking. We examined possible sex differences by separate models for males and females.

Sensitivity analysis: To investigate possible impact of the characteristics difference between participants with linked data and participants with unlinked data on estimation of odds ratios, we conducted a sensitivity analysis. We used inverse probability weighting method to give extra weight to subjects who provided linked data. In this method, each participant is weighted by the inverse of an estimate of the conditional probability of being linked for three years. A logistic regression was used to estimate conditional probability of having three-year linked data given baseline data on sex, race, depression, anxiety, levels of drinking and binge drinking.

3. Results

From pre-pandemic (T1) to the early pandemic period (T2), nearly half of students (45.4%) continued abstinence from drinking, 9% reduced consumption, 13.2% reported escalation, and 12.6% had no change (Table 1 ). The proportion of females that were maintaining, initiating or escalating their consumption was higher than males, while higher proportions of males reported abstaining than females (48.9% vs. 43.4%). The same patterns of changes are observed during the ongoing pandemic period (T3), where females were more likely to maintain or increase their alcohol consumption from T2 than males. Rates of reduced consumption were similar among males and females from T1 to T2 and T2 to T3.

Table 1.

Demographic characteristics and changes from before to the early and ongoing COVID-19 pandemic periods in alcohol use, and depression and anxiety symptoms, among students attending 49 secondary schools that participated in the COMPASS study across three study waves (2018/19, Spring 2020, 2020/21).

Overall (n = 1,901a) Female (n = 1234, 65.3%) Male (n = 655, 34.7%)
Age at baseline
 12–13 747 (39.5) 482 (39.1) 264 (40.3)
 14 603 (31.9) 398 (32.3) 204 (31.1)
 15–18 542 (28.6) 353 (28.6) 187 (28.5)
 Race (white) 1533 (80.6) 989 (80.1) 543 (82.9)
Change in alcohol consumption from pre (T1) to early (T2) pandemic period
 Abstained 809 (45.4) 505 (43.4) 296 (48.9)
 Initiated 351 (19.7) 235 (20.2) 114 (18.8)
 Maintained 225 (12.6) 162 (13.9) 62 (10.2)
 Reduced 161 (9.0) 105 (9.0) 54 (8.9)
 Escalated 236 (13.2) 157 (13.5) 79 (13.1)
Change in alcohol consumption from early (T2) to ongoing (T3) pandemic period
 Abstinence 618 (36.1) 377 (34.4) 226 (39.2)
 Initiated 226 (13.2) 138 (12.6) 83 (14.4)
 Maintained 333 (19.5) 230 (21.0) 96 (16.7)
 Reduced 257 (15.0) 170 (15.5) 81 (14.1)
 Escalated 278 (16.2) 182 (16.6) 9 (15.6)
Change in binge drinking from pre (T1) to early (T2) pandemic period
 Abstained 1327 (70.0) 842 (68.4) 470 (72.5)
 Initiated 259 (13.7) 185 (15.0) 73 (11.3)
 Maintained 102 (5.4) 70 (5.7) 31 (4.8)
 Reduced 128 (6.7) 79 (6.4) 49 (7.5)
 Escalated 80 (4.2) 55 (4.5) 25 (3.9)
Change in binge drinking from early (T2) to ongoing (T3) pandemic period
 Abstinence 1071 (59.7) 673 (58.6) 369 (61.0)
 Initiated 269 (15.0) 170 (14.8) 98 (16.2)
 Maintained 175 (9.8) 124 (10.8) 46 (7.6)
 Reduced 175 (9.8) 121 (10.5) 51 (8.4)
 Escalated 104 (5.7) 61 (5.3) 46 (6.8)
Clinically-relevant depression symptoms
 T1: Pre-pandemic 567 (30.8) 447 (37.0) 120 (19.0)
 T2: Early pandemic 633 (36.5) 493 (43.2) 140 (23.6)
 T3: Ongoing pandemic 808 (46.7) 611 (53.8) 197 (33.2)
Clinically-relevant anxiety symptoms
 T1: Pre-pandemic 347 (18.7) 279 (22.9) 68 (10.6)
 T2: Early pandemic 393 (22.5) 312 (27.2) 81 (13.6)
 T3: Ongoing pandemic 556 (32.0) 457 (40.1) 99 (16.5)
Depression symptoms, mean (sd)
 T1: Pre-pandemic 7.8 (5.9) 8.6 (6.0) 6.2 (5.2)
 T2: Early pandemic 8.6 (6.0) 9.5 (6.2) 6.7 (5.1)
 T3: Ongoing pandemic 10.3 (6.7) 11.3 (6.8) 7.9 (5.7)
Anxiety symptoms, mean (sd)
 T1: Pre-pandemic 5.3 (5.0) 6.2 (5.1) 3.8 (4.2)
 T2: Early pandemic 6.0 (5.3) 6.8 (5.4) 4.1 (4.5)
 T3: Ongoing pandemic 7.6 (5.9) 8.7 (5.9) 5.1 (4.8)
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a

Due to missing data, male and female numbers (n) do not add up to overall sample size; sd: Standard deviation.

Fig. 2a shows that students who reduced their alcohol consumption from T1 to T2 reported lower depression (Δ = −1.7, 95% CI: −2.7, −0.6) and slightly lower anxiety (Δ = −0.4, 95% CI: −1.3, 0.4) in T2 compared to T1, while escalated, initiated, and abstained groups reported increased depression and anxiety symptoms. Adjusted odds ratios from multilevel logistic regressions (Table 2 ) suggest that students with increased depression scores in T2, relative to T1, were less likely to reduce their alcohol consumption in T2 (OR 0.94, 95% CI: 0.90–0.98) than to maintain their behaviours from T1. Supplementary Tables A2 and A3 indicate that point estimates of odds ratios from linked and unlinked data are equal or very close.

Fig. 2.

Fig. 2

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Changes in depression and anxiety scores stratified by alcohol consumption change groups among students attending 41 secondary schools that participated in the COMPASS study across three study waves (2018/19, Spring 2020, 2020/21).

Table 2.

Odds of reporting a change in the frequency of alcohol use by changes in depression and anxiety symptoms from pre to early and ongoing pandemic periods among students attending 49 COMPASS secondary schools across three study waves (2018/19, Spring 2020, 2020/21).

Pre (T1) to early pandemic (T2)
 Early (T2) to ongoing pandemic (T3)
Depression Anxiety Depression Anxiety
Overall
 Odds of escalation/reduction (vs. maintenance)
 Escalation 1.02 (0.97, 1.06) 1.00 (0.95, 1.06) 1.03 (0.99, 1.07) 1.00 (0.96, 1.05)
 Reduction 0.94 (0.90, 0.98) 1.02 (0.96, 1.07) 1.0 (0.96, 1.04) 0.97 (0.93, 1.01)
 Odds of initiation (vs. abstinence)
 Initiation 1.03 (0.99, 1.06) 1.02 (0.99, 1.06) 1.05 (1.01, 1.09) 1.00 (0.96, 1.05)
Females
 Odds of escalation/reduction (vs. maintenance)
 Escalation 0.99 (0.95, 1.05) 1.04 (0.98, 1.11) 1.02 (0.97, 1.06) 1.00 (0.96, 1.05)
 Reduction 0.94 (0.89, 0.99) 1.05 (0.99, 1.12) 1.01 (0.96, 1.05) 0.96 (0.91, 1.00)
 Odds of initiation (vs. abstinence)
 Initiation 1.04 (1.00, 1.08) 1.02 (0.97, 1.06) 1.05 (1.01, 1.10) 0.99 (0.94, 1.04)
 Males
 Odds of escalation/reduction (vs. maintenance)
 Escalation 1.07 (0.95, 1.19) 0.86 (0.76, 0.98) 1.07 (0.99, 1.16) 1.01 (0.92, 1.11)
 Reduction 0.94 (0.85, 1.03) 0.89 (0.77, 1.02) 0.98 (0.91, 1.06) 1.01 (0.93, 1.11)
 Odds of initiation (vs. abstinence)
 Initiation 1.00 (0.94, 1.06) 1.04 (0.98, 1.12) 1.04 (0.98, 1.11) 1.02 (0.95, 1.11)
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Significant odds ratios are bolded.

As seen in Fig. 2b, the average scores of depression and anxiety symptoms were more in T3 than T2, with the smallest increase among the group of students who reduced their consumption from T2 to T3 (depression Δ = 0.8 [95% CI: 0.1, 1.6], anxiety Δ = 0.9 [95% CI: 0.3, 1.6]) and the largest increase among students who initiated drinking in T3 (depression Δ = 2.8 [95% CI: 2.0, 3.6], anxiety Δ = 2.2 [95% CI: 1.6, 2.7]). Fig. 2a and 2b indicate that, overall, students' depression has increased more than their anxiety across both periods. We obtained consistent results from regression models on binary variables of clinically-relevant depression and anxiety symptoms (see Supplementary Table A2).

To examine sex difference in the association between internalizing symptoms and alcohol use behaviours, interaction terms, which were not significant (p > .05), were included in the models. Changes in depression and anxiety scores stratified by sex are shown in Fig. 2c-f. Depression and anxiety symptoms increased more in females than in males, particularly from T2 to T3. Both males and females who reduced their alcohol consumption in T2 had lower depression than T1 (Fig. 2c and e). Females' depression scores in T3 are significantly higher than those in T2, males' scores do not significantly change from T2 (Fig. 2d, f). In comparison to T2, female and male students who reduced their consumption in T3, showed increased depression and anxiety, and these increases among females were more than double than the changes reported by males. Furthermore, depression and anxiety increased the most from T2 to T3 among the Initiated alcohol group, with females showing a higher increase than males (Fig. 2c, d).

The stratified analysis shows female students with increased depression from T1 to T2 were more likely to initiate drinking and less likely to reduce their alcohol consumption, while this association was not observed in male students (Table 2).

Fig. 3 shows change in depression and anxiety by subgroups of the population who changed their binge drinking. Consistent with the patterns of changes on alcohol consumption, students who reduced their binge drinking in T2 reported lower depression and students who initiated binge drinking in T2 reported the greatest increase in depression and anxiety; although odds of initiation and reduction were not significantly different from others (Table 3 ). In T3, students with increased depression symptoms from T2 were more likely to initiate binge drinking.

Fig. 3.

Fig. 3

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Changes in depression and anxiety scores stratified by binge drinking change groups among students attending 49 secondary schools that participated in the COMPASS study across three study waves (2018/19, Spring 2020, 2020/21).

Table 3.

Odds of reporting a change in the frequency of binge drinking by changes in depression and anxiety symptoms from pre to early and ongoing pandemic periods among students attending 49 COMPASS secondary schools across three study waves (2018/19, Spring 2020, 2020/21).

Pre (T1) to early (T2) pandemic
 Early (T2) to ongoing (T3) pandemic
Depression Anxiety Depression Anxiety
Overall
 Odds of escalation/reduction (vs. maintenance)
 Escalation 1.06 (0.98, 1.15) 0.93 (0.85, 1.01) 1.01 (0.95, 1.07) 1.03 (0.97, 1.10)
 Reduction 0.99 (0.94, 1.06) 0.96 (0.89, 1.03) 0.97 (0.93, 1.02) 1.01 (0.95, 1.06)
 Odds of initiation (vs. abstinence)
 Initiation 1.06 (1.03, 1.09) 1.01 (0.97, 1.04) 1.03 (1.00, 1.06) 1.02 (0.98, 1.06)
 Females
 Odds of escalation/reduction (vs. maintenance)
 Escalation 1.05 (0.96, 1.14) 0.98 (0.89, 1.08) 1.01 (0.95, 1.07) 1.04 (0.97, 1.11)
 Reduction 0.98 (0.91, 1.06) 0.99 (0.91, 1.08) 0.99 (0.94, 1.05) 0.99 (0.93, 1.05)
 Odds of initiation (vs. abstinence)
 Initiation 1.06 (1.02, 1.10) 1.01 (0.96, 1.06) 1.03 (0.99, 1.07) 1.0 (0.98, 1.03)
 Males
 Odds of escalation/reduction (vs. maintenance)
 Escalation 1.08 (0.85, 1.37) 0.77 (0.59, 1.00) 1.0 (0.88, 1.14) 0.99 (0.87, 1.14)
 Reduction 1.03 (0.91, 1.16) 0.88 (0.76, 1.03) 0.90 (0.78, 1.02) 1.09 (0.95, 1.26)
 Odds of initiation (vs. abstinence)
 Initiation 1.05 (0.98, 1.11) 0.99 (0.91, 1.07) 1.03 (0.98, 1.10) 0.99 (0.92, 1.06)
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Significant odds ratios are bolded. Different subsamples were used for each subgroup.

4. Discussion

Using three waves of prospective data spanning the pre-pandemic to ongoing pandemic period, we examined changes in adolescents' alcohol consumption and binge drinking in association with changes in their depression and anxiety symptoms over this period of time. One in five adolescents that previously had not used alcohol, initiated drinking in the early pandemic, while one in ten adolescents reduced their consumption. Our findings of increases in both anxiety and depression symptoms over the three years, are consistent with past research suggesting a consistent increase in substance use and internalizing symptoms during adolescence (Campbell et al., 2003; Colder et al., 2002; Lewinsohn et al., 1993). Although in our study, the levels of changes in depression and anxiety varied among different groups of alcohol use change. Results support an association between depression changes and changes in alcohol consumption during the early and ongoing pandemic, and these associations appear stronger in females than males. Despite pandemic restrictions that would have likely made it more difficult for underage youth to drink alcohol, we found that females with increases in depression symptoms were less likely than females with decreased or no change symptoms to reduce their alcohol consumption during early pandemic period, more likely to initiate alcohol consumption in the ongoing pandemic period, and more likely to initiate binge drinking in both periods.

It is notable that the results from internalizing changes on a continuous scale are consistent with those on a binary scale of clinically-relevant symptoms. Significant effects were also modest in size; indicating that internalizing symptoms account for only a small proportion of factors that contribute to adolescents' alcohol consumption. As Rose et al. suggested (Rose et al., 2008), small changes at the individual level of adolescents can produce large changes in alcohol use behaviours among the adolescent's population. Future research should examine the influence of other factors in predicting adolescents' drinking behaviours over the pandemic. Furthermore, study results did not present associations for anxiety symptoms, in males, or for all alcohol use change groups. The lack of associations found in males and some alcohol use changes groups can be explained in part by the small sample of individuals in each alcohol groups.

In this study we did not find a sex difference in the association between internalizing symptoms and changes in alcohol use behaviours. The stratified analysis shows that females with increased depression symptoms were less likely to decrease their levels of drinking than females with decreased or no change symptoms. This result aligns with evidence that females may use alcohol as a coping mechanism to diminish their experience of negative emotions and relieve distress or depression (Kenney et al., 2015; Martínez-Cao et al., 2021; McKEE et al., 1998; Tomlinson and Brown, 2012). Romano et al. (Romano et al., 2021) found that 13.4% of female Canadian high school students used alcohol to cope during the early months of the pandemic, particularly those with poorer psychosocial well-being. While potentially an effective coping mechanism in the moment, in the long-term, maintenance or escalation of alcohol consumption can result in a wide range of health and social consequences, including depression. The current study is unable to establish the temporal ordering of changes in depression/anxiety and changes in alcohol use. Further research is required to examine whether alcohol consumption was motivated by internalizing symptoms or alcohol use preceded increases in adolescents' internalizing symptoms (Schleider et al., 2019).

Our results are consistent with other studies that demonstrated stronger links between alcohol use and depression than anxiety in adolescents (Hussong et al., 2017; Schleider et al., 2019). For example, Schleider et al. (2019) found an association between depression severity and alcohol use in adolescents, but not between anxiety and alcohol use. This result supports the evidence that although depression and anxiety are highly correlated, they have their own distinct features that lead to different outcomes (Clark and Watson, 1991; Schleider et al., 2019). The high correlations between changes in depression and anxiety scores over time are observed in this study.

Patterns of changes alcohol consumption and the associations with depression and anxiety symptoms were similar to those for binge drinking. This finding might be partly because a considerable portion of drinking occasions may have been binge drinking. Past research indicates that binge drinking is the most common pattern of youth alcohol consumption (Miller et al., 2007). On the other hand, the high association between reported regular drinking and binge drinking shows that participants are more likely to report those situations of drinking that are binge drinking. If so, then the frequency of drinking might be underestimated.

This study has several strengths. The majority of published COVID-19 research uses retrospective designs, lacks pre-pandemic data, and/or examined only the early pandemic period. The linked data used in the current analysis allowed examination of within-individual changes in alcohol consumption and associations with internalizing symptoms from before to the early the pandemic, and into the ongoing pandemic response. Examining changes across waves reduced bias introduced in retrospective reports, which are more likely to be influenced by current mood states and recall error. Further, the passive-consent protocol used in the study promotes robust results when assessing youth substance use and mental health, by mitigating possible self-selection and social desirability biases (Chartier et al., 2008).

Results should be interpreted within the context of the study limitations. First, the COMPASS students who could not be linked were more likely to report use of alcohol and other substances, leading to an underestimation of alcohol consumption. Second, transitioning from an in-person classroom survey to an online survey may have introduced selection bias, as previously was reported (Shield and Rehm, 2012), our attrition analysis showed that students with three-year linked data consumed less alcohol and had higher depression and anxiety symptoms than students with only baseline data. Third, the scoring of change is prone to error as it is a self-report data and change by a single category could be attributed to error rather than actual change. Our results may bias toward underestimating the proportion of youth who escalated/reduced alcohol consumption because there may be students who escalated or reduced the frequency of drinking use but are still captured by the same response category. Further, there might be an overlap between pre-pandemic and early pandemic data for the frequency of alcohol consumption, especially for less frequent drinkers (such as less than a month drinkers), as their change may have happened before the pandemic but they reported during the early pandemic which is not actually refer to the pandemic period. Last, various cultural/regional factors influence alcohol use behaviours and internalizing symptoms and our results should be interpreted in its specific context.

5. Conclusion

This study shows that adolescents with increases in depression during early pandemic period were less likely to reduce their alcohol consumption and binge drinking, whereas adolescents with increased depression during the ongoing pandemic period were more likely to initiate drinking. Pandemic recovery efforts should consider programs targeting alcohol use, in conjunction with depression, given their association in adolescents. Although this study is unable to establish temporal effects, results suggest that prevention and intervention programs for depressive symptoms might also be beneficial for adolescent alcohol use, especially for females. Similarly, targeting depression in alcohol programs might enhance their efficacy in the prevention, reduction, or cessation of drinking.

Authors contribution

MG, TV, KP, JM, and SL contributed to project conceptualization. MG and SL planned the methodology, and MG conducted the formal analysis. MG did the original draft preparation. SL acquired funding, managed resources, and provided supervision for the host study and corresponding data in this manuscript. MG, TV, KP, JM, and SL reviewed and edited the manuscript for critical content. All authors have read and agreed to the published version of the manuscript.

Declaration of Competing Interest

JM is a principal in BEAM Diagnostics, Inc. and a Consultant to Clairvoyant Therapeutics, Inc. The authors have no other conflicts of interest relevant to this article to disclose.

Acknowledgment

Funding: The COMPASS study has been supported by a bridge grant from the CIHR Institute of Nutrition, Metabolism and Diabetes (INMD) through the “Obesity – Interventions to Prevent or Treat” priority funding awards (OOP-110788; awarded to SL), an operating 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.

Footnotes

Appendix A

Supplementary data to this article can be found online at https://doi.org/10.1016/j.ypmed.2022.107381.

Appendix A. Supplementary data

Supplementary material

mmc1.docx (60.5KB, docx)

Data availability

The datasets generated and analyzed during this study will not currently be shared because this is an ongoing study; however, access to the data supporting the findings of the study can be requested

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary material

mmc1.docx (60.5KB, docx)

Data Availability Statement

The datasets generated and analyzed during this study will not currently be shared because this is an ongoing study; however, access to the data supporting the findings of the study can be requested

Articles from Preventive Medicine are provided here courtesy of Elsevier

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