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“Mr Brown” is a 55-year-old Caucasian male with a 30-year history of schizophrenia, hypertension, and hyperlipidemia. His illness has been stable for over 25 years on clozapine. He was fully vaccinated against COVID-19 5 months ago. However, 1 month ago, he tested positive for COVID-19. Although he had no known infected contacts, his teenaged son had fatigue and rhinorrhea the preceding week. Mr Brown’s primary symptoms included loss of taste and smell, fatigue, and an occasional dry cough, which resolved within 7 days. He did not have any fever or shortness of breath, nor did he require emergency department or inpatient services. He continued taking clozapine under the advisement of his psychiatrist without complication. Other than over-the-counter analgesics and antitussives, he did not take any medications for COVID-19. Mr Brown quarantined for 10 days, and then resumed his usual activities without further sequelae.

Clozapine, the “gold-standard” antipsychotic for treatment-resistant schizophrenia, may affect the innate immune system and is associated with increased risk of neutropenia and agranulocytosis.

 may also affect the adaptive immune system, given associations with reduced levels of immunoglobulins.

 There is evidence for an increased risk of infections, including viral infections pneumonia, in patients treated with clozapine versus other antipsychotics.

 Severe COVID-19 infection can cause pneumonia, acute respiratory distress syndrome, and death. Furthermore, several risk factors for severe 

, including older age, diabetes, and cardiovascular disease, are more prevalent in patients treated with clozapine.

 investigated whether patients treated with clozapine are at increased risk of more severe COVID-19 infection, as indexed by inpatient treatment, intensive care unit (ICU) care, or death, compared to other antipsychotics, using a regional health care register. They included all residents in the Stockholm, Sweden region (approximately 2 million total inhabitants) aged 18 or older by March 1, 2020, who had: 1) a diagnosis of a psychotic disorder (in the preceding 14 months), and 2) been prescribed and dispensed antipsychotic medication during 2020. Exposure was defined as clozapine treatment, and those prescribed other antipsychotics were unexposed. The primary outcomes were inpatient or ICU care or death due to COVID-19 between March 1, 2020, and January 14, 2021. Data were analyzed using Cox proportional hazard ratios, controlling for effects of age, sex, residence, country of birth, socioeconomic status, number of care visits, and 

A total of 8233 persons in Stockholm County met study inclusion/exclusion criteria, of whom 966 (12%) had received clozapine treatment. The mean subject age was 51, and 53% of subjects were male. Overall, 1.9% of clozapine-treated patients and 2.7% of other antipsychotic-treated patients experienced COVID-19-related inpatient care, ICU, or death during the study period. After controlling for potential confounding factors, the hazard ratios (HRs) for inpatient care (HR=0.96, 95% CI 0.54-1.70), ICU care (HR=1.69, 95% CI 0.48-5.93), and death (HR=0.86, 95% CI 0.26-2.8) were not significantly different for patients treated with clozapine versus other 

The authors found no indications that clozapine treatment was associated with a more severe course of COVID-19 infection. Findings are consistent with other case series that did not find an association between COVID-19 infection and reduced neutrophil counts in patients treated with clozapine. Study strengths included the use of register data with comprehensive measures of many potential risks for severe illness. However, results should be interpreted with caution, given the small number of severe cases, which raises the possibility of inadequate study power. Data on length of antipsychotic treatment, and whether antipsychotics were withheld upon diagnosis of 

Findings support existing recommendations for sustained treatment with clozapine during the COVID-19 pandemic. Adverse psychiatric risks of discontinuing clozapine treatment likely outweigh the risks of continued treatment with careful monitoring.

is a professor in the Department of Psychiatry and Health Behavior, Augusta University, Augusta, Georgia. He is on the Editorial Board and serves as the schizophrenia section chief for 

The author reports that he receives research support from Augusta University, the National Institute of Mental Health, and the Stanley Medical Research Institute.

The prevalence of agranulocytosis and related death in clozapine-treated patients: a comprehensive meta-analysis of observational studies.

2. Ponsford MJ, Steven R, Bramhall K, et al. 

Clinical and laboratory characteristics of clozapine-treated patients with schizophrenia referred to a national immunodeficiency clinic reveals a B-cell signature resembling common variable immunodeficiency (CVID).

Second-generation antipsychotic medications and risk of pneumonia in schizophrenia.

Management of clozapine treatment during the COVID-19 pandemic.

5. Ohlis A, Wallin AS, Sarafis A, et al. 

Clozapine treatment and risk of severe COVID-19 infection.

Does clozapine increase the risk of severe COVID-19 infection? Researchers performed a larger register-based cohort study of this association.

Clozapine and Severe COVID-19 Infection

From preparing for the holiday season to clinical updates and psychiatric perspectives on social issues and contemporary events, 

 covered important topics this week. Top articles included:

Holidays are joyous for some, but not for everyone. How can you help patients with mood disorders navigate the difficulties of the holidays?

COVID-19, Cognition, and Dementias: What Role Has the Pandemic Played?

How does COVID-19 contribute to cognitive impairment in older adults and future cases of dementia?

Shedding Light on the Shadow Brain Pandemic: The Devastating Effects of Gendered Violence-Related Acquired Brain Injury

In honor of the International Day for the Elimination of Violence against Women, let’s consider the impact of IPV on the neuropsychiatric health of women.

A Humanity Lesson From the Mouths of Babes

A child’s perspective, innocent and honest, serves as a good reminder of our biases.

Be sure to stay up-to-date by subscribing to the 

Do you have a comment on any of these or other articles? Have a good idea for an article and want to write? Interested in sharing your perspectives? Write to us at 

It’s been a full week of interesting stories, commentaries, and more on a variety of topics at psychiatrictimes.com.

In Case You Missed It: November 22 to 26

 was characterized as a pandemic, it was clear that older adults in general, and those with 

 (ADRD) in particular, would be severely impacted both directly by the virus and indirectly by the social consequences and responses.

 Now, approaching 2 years since SARS-CoV-2 emerged, we are starting to measure the impact of COVID-19 on older patients with cognitive impairment and ADRD. Further, we can begin to review neurobiological issues associated with COVID-19 in older adults, and consider how COVID-19 may contribute to cognitive impairment and future cases of dementia.

The demographics of COVID-19 cases have shifted over time, with older adults being most impacted early in the pandemic, and later waves involving younger individuals.

 Similarly, risk varied by setting, with an early wave of COVID-19 cases in congregate settings including nursing homes, retirement homes, and hospitals. These frequent and widespread outbreaks were associated with significant morbidity and mortality. Despite campaigns to vaccinate nursing home residents, they still account for a large proportion of the total deaths due to COVID-19.

The severity of COVID-19 spans the spectrum from asymptomatic carrier state to severe illness and death, with age being the strongest demographic risk factor for a more severe illness: Age has an exponential relationship with infection fatality rate, reaching 15% at age 85.

 Older adults with cognitive impairment are doubly at risk, with age and cognitive impairment independently contributing to illness severity.

 Cognitive impairment has been associated with double the risk of COVID-19 mortality in nursing homes.

 Even when controlling for residence in a nursing home, those with dementia had twice the risk of acquiring COVID-19.

We had anticipated that rates of behavioral and psychologic symptoms associated with dementia (BPSD) would increase as a result of indirect factors such as disruption to care, social isolation, and disruption to routine.

 Unfortunately, this has been borne out, with studies reporting increases in BPSD including anxiety, depression, insomnia, wandering, and agitation.

Alongside the risk of mortality, the pandemic is also affecting mental health negatively, both via the direct effect of the virus and indirectly via the massive disruption to society in response to the pandemic. Early and ongoing mental health consequences of the pandemic include increased rates of symptoms of depression, anxiety, substance use, and suicidal ideation. However, paradoxically, younger individuals may be more impacted than older ones.

 Similarly, while the pandemic may have increased BPSD in some individuals with dementia, this has not been universally true. For example, in New Brunswick, Canada, despite a marked reduction in family visits and periods of lockdown (mitigated by virtual visits and volunteer services), there was no change in rates of agitation, and a reduction in rates of depression among nursing home residents, with more than half of them having dementia.

The availability of safe and effective COVID-19 vaccines is thought to be a key element to ending the pandemic. Early on, in the context of limited supply, governments prioritized vaccination for high-risk groups such as the elderly and those living in long-term care (LTC) facilities. Thus, most individuals with dementia were prioritized for vaccination. For example, in Ontario, Canada, despite only 0.5% of the population living in LTC facilities, vaccination initially was reserved for LTC residents and health professionals when vaccines first became available in December 2019.

 By March 2020, more than 92% of LTC residents had received at least 1 dose of a COVID-19 vaccine, which was estimated to have reduced mortality by 96%.

 The recent approval by the US Food and Drug Administration of booster shots for older persons (ie, a third dose) may offer them further protection and also deepen current inequities when vaccination remains unavailable due to supply constraints in some jurisdictions.

COVID-19 is transmitted person to person via inhalation of respiratory droplets and their deposition on mucous membranes, and to a lesser extent by contaminated hands contacting mucous membranes.

 The virus enters cells via the angiotensin-converting enzyme 2 receptor, present not only in the respiratory and gastrointestinal tract but also in other organs, including the brain and blood vessels.

 Thus, COVID-19 can potentially lead to neuropathology via systemic and inflammatory indirect effects and by its direct action on the nervous system.

Although most cases of COVID-19 are classified as mild, severe cases occur in individuals of all ages, most commonly in older adults. Common acute symptoms include cough, fever, fatigue, headache, myalgias, and diarrhea.

 Symptoms can progress and involve hypoxemia and acute respiratory distress syndrome.

 In addition, injury to all organ systems due to severe inflammation, thromboembolic events, and neurologic complications can occur.

The neurologic consequences of severe COVID-19 are common and involve both the central nervous system (CNS) and peripheral nervous system (PNS) (

 Dizziness and headache are the most common CNS manifestations, which can also include cerebrovascular disease (eg, ischemic stroke, hemorrhage), ataxia, and seizure. Delirium is a common presentation of older adults with COVID-19; it has a very poor prognosis and is associated with permanent cognitive impairment.

 Anosmia and ageusia are the most common PNS manifestations.

Neurologic manifestations can occur within the first days of illness and persist months after hospital discharge.

 Isolating the virus in cerebrospinal fluid is rare.

 Cognitive impairment is a commonly reported symptom in survivors of severe COVID-19 at 60 days post discharge.

 Although research is needed to confirm the neuropsychiatric sequelae of COVID-19, a broad spectrum of neuropsychiatric symptoms have been reported, including headaches, sleep disorders, encephalopathy, myalgia, and ageusia.

 The term long COVID refers to the persistence of symptoms after the resolution of the acute infection, and a broad range of symptoms have been reported, including neuropsychiatric symptoms such as cognitive impairment, insomnia, impaired concentration, posttraumatic symptoms, and headache.

 Long COVID is not always associated with the severity of acute COVID-19 or risk factors for severe COVID-19, and it may involve multiple organ damage by other direct mechanisms.

 Long COVID is thought to be relatively common, but estimates of its prevalence vary widely depending on definition and time since infection. It may also depend on the SARS-CoV-2 genetic variant.

There is evidence for both structural and functional brain changes following COVID-19, and these changes may be associated with the neurologic symptoms of long COVID. Various studies have reported heterogenous findings. A recent systematic review summarizing the neuroimaging findings associated with COVID-19 in older adults reported widespread neuropathological issues typically associated with cerebrovascular damage, most consistently in white matter, brainstem, and frontotemporal cortical areas.

 A case-control study of patients who recovered from COVID-19 found hypometabolism in frontotemporal regions, which was associated with neurological symptoms.

 A study of United Kingdom Biobank participants by Douaud et al found changes in 394 individuals who had brain imaging before and after a COVID-19 infection, compared with 388 matched controls without a history of COVID-19. Among those who had survived COVID-19, Douaud et al identified reductions in grey matter in the left parahippocampal gyrus, left lateral orbitofrontal cortex, and left insula.

Although it is staggering that approximately 1 in 500 Americans has died of COVID-19, mortality is the tip of the iceberg. The Centers for Disease Control and Prevention estimates that as of May 29, 2021, there had been more than 100 million individuals with symptomatic COVID-19 in the United States, 10 million of them 65 years or older.

 The sequelae from severe COVID-19 are risk factors for dementia, and they may increase the growing number of individuals living with dementia. Understanding the specific contribution of a past COVID-19 infection on future risks of dementia will require longitudinal studies. These risks may be substantial given the cerebrovascular changes associated with past infection. During the next few years, post-COVID-19 issues may occur mostly in older adults. However, COVID-19 may also increase the risk of future cognitive impairment and dementia in younger individuals, because early life experiences and exposures contribute to the risk of dementia, as is the case in other risk factors for dementia such as low level of education or depression early in life. The magnitude of the current and future human, financial, and societal cost of COVID-19 is unknown, but certainly worrisome.

On the other hand, we expect that the pandemic will lead to numerous changes that benefit older adults. Specifically, the spotlight on nursing homes has revealed systemic flaws and inequities in many countries that now will be hard to ignore. The pivot to virtual care has spurred some innovation that may facilitate access to care going forward.

In our own experience, working at the Centre for Addiction in Mental Health in Toronto, we have had to pivot to providing care to older individuals despite multiple waves of COVID-19 cases in the community. Some of the changes in our practice and our environment will have long-lasting benefits. The heterogeneity of real-world experience, compared with averages often reported in research, is humbling. Some of our older patients have shown remarkable resilience through the pandemic and have adjusted their lifestyle to thrive during this time. Others have had their usual coping mechanisms totally disrupted and are suffering, needing additional mental health and social resources. In our geriatric mental health inpatient unit, technology (eg, internet-connected tablets) has been helpful to connect patients to family, activities, and entertainment. We have also noticed an improved access to specialist consultations with virtual care and additional physician-to-physician consultation options. In our outpatient setting, virtual care options introduced to reduce risk of COVID-19 have also reduced barriers for certain patients who prefer it or may have mobility issues.

The impact of the pandemic on older adults and those with dementia has been immense. Vaccination can dramatically reduce severe outcomes from COVID-19 in older adults. The indirect impact of the pandemic on individuals with dementia, such as isolation and disruption of care, can be pronounced, but they can also be mitigated. COVID-19 causes neurological damage that is not restricted to severe cases or older adults. A significant proportion of individuals infected by COVID-19 will experience long-term negative impact, including an increased risk of dementia. Research to better understand the neurobiology and the long-term neuropsychiatric impacts of COVID-19 is critical, as it will shift the understanding of the risk-benefit of population-level interventions to prevent COVID-19. The pandemic is not over. Efforts to protect everyone, including older adults, from COVID-19 are essential.

 is an assistant professor of psychiatry at the University of Toronto and a clinician scientist at the Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, in Toronto, Canada. 

 is an associate professor of psychiatry at the University of Toronto and chief of geriatric psychiatry at the Centre for Addiction and Mental Health. 

 is the Labatt Family Chair of the Department of Psychiatry in the Faculty of Medicine at the University of Toronto and a clinician scientist in the Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health.

Anticipating and mitigating the impact of the COVID-19 pandemic on Alzheimer’s disease and related dementias

2. Boehmer TK, DeVies J, Caruso E, et al. 

Changing age distribution of the COVID-19 pandemic – United States, May-August 2020

3. Panagiotou OA, Kosar CM, White EM, et al. 

Risk factors associated with all-cause 30-day mortality in nursing home residents with COVID-19

Nursing home care in crisis in the wake of COVID-19

5. Levin AT, Hanage WP, Owusu-Boaitey N, et al. 

Assessing the age specificity of infection fatality rates for COVID-19: systematic review, meta-analysis, and public policy implications

6. Tahira AC, Verjovski-Almeida S, Ferreira ST. 

Dementia is an age-independent risk factor for severity and death in COVID-19 inpatients

COVID-19 and dementia: analyses of risk, disparity, and outcomes from electronic health records in the US

Effectively caring for individuals with behavioral and psychological symptoms of dementia during the COVID-19 pandemic

9. Dellazizzo L, Léveillé N, Landry C, Dumais A. 

Systematic review on the mental health and treatment impacts of COVID-19 on neurocognitive disorders

10. Czeisler MÉ, Lane RI, Wiley JF, et al. 

Follow-up survey of US adult reports of mental health, substance use, and suicidal ideation during the COVID-19 pandemic, September 2020

11. McArthur C, Saari M, Heckman GA, et al. 

Evaluating the effect of COVID-19 pandemic lockdown on long-term care residents’ mental health: a data-driven approach in New Brunswick

12. Brown KA, Stall NM, Vanniyasingam T, et al. Early impact of Ontario’s COVID-19 vaccine rollout on long-term care home residents and health care workers. Science Table: COVID-19 Advisory for Ontario. March 8, 2021. Accessed October 5, 2021. 

https://covid19-sciencetable.ca/wp-content/uploads/2021/03/Science-Brief_LTC-and-Vaccine_20210308_version-1.1_published-1.pdf

13. Scientific brief: SARS-CoV-2 transmission. Centers for Disease Control and Prevention. Updated May 7, 2021. Accessed September 28, 2021. 

https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/sars-cov-2-transmission.html

14. Hamming I, Timens W, Bulthuis MLC, et al. 

Tissue distribution of ACE2 protein, the functional receptor for SARS coronavirus. a first step in understanding SARS pathogenesis

Long Covid – mechanisms, risk factors, and management

Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China

18. Marengoni A, Zucchelli A, Grande G, et al. 

The impact of delirium on outcomes for older adults hospitalised with COVID-19

19. Chopra V, Flanders SA, O’Malley M, et al. 

Sixty-day outcomes among patients hospitalized with COVID-19

20. García-Azorín D, Abildúa MJA, Aguirre MEE, et al; Spanish neuroCOVID registry group. 

Neurological presentations of COVID-19: findings from the Spanish Society of Neurology neuroCOVID-19 registry

21. Nalleballe K, Reddy Onteddu S, Sharma R, et al. 

Spectrum of neuropsychiatric manifestations in COVID-19

Long COVID or post-COVID-19 syndrome: putative pathophysiology, risk factors, and treatments

23. Manca R, De Marco M, Ince PG, Venneri A. 

Heterogeneity in regional damage detected by neuroimaging and neuropathological studies in older adults with COVID-19: a cognitive-neuroscience systematic review to inform the long-term impact of the virus on neurocognitive trajectories

24. Guedj E, Campion JY, Dudouet P, et al. 

F-FDG brain PET hypometabolism in patients with long COVID

25. Douaud G, Lee S, Alfaro-Almagro F, et al. 

Brain imaging before and after COVID-19 in UK Biobank

26. Estimated COVID-19 burden. Centers for Disease Control and Precention. Updated July 27, 2021. Accessed September 28, 2021. 

https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/burden.html

Six in 10 Americans support the vaccine mandates announced by President Joe Biden, although support is divided sharply along party lines, a survey finds.

According to the Axios-Ipsos poll, conducted September 10 to 13, 2021, 60% of Americans favor requiring 

 for federal employees and businesses and organizations with 100 employees or more. However, only about 30% of Republicans support the requirements compared with more than 80% of Democrats and 60% of independents.

From a political perspective, the support among independents is especially important, according to Cliff Young, president of Ipsos US Public Affairs. “The No. 1 issue for Biden has been COVID, and he’s been losing ground on it, especially among independents. This is an initiative that could help bolster him there,” Young said in a statement.

The poll also found that increasing numbers of Americans are experiencing vaccine and masking requirements at work and in public places. Twenty-five percent of respondents said their employers now require all employees be vaccinated compared with 16% in a survey conducted August 10 to 13.

Similarly, 58% of respondents said their employers require mask wearing at work, up from 51% in the August survey, and 43% said their state or local government requires masks to be worn in public places, up from just 33% in August.

Also, there is growing concern over the spread of the Delta coronavirus, with 53% of respondents saying they are “extremely” or “very” concerned compared with 35% in late June. A plurality of Americans (38%) said the federal government’s top priority should be getting more people vaccinated, rather than providing booster shots (28%) or sending vaccines to developing countries (19%).

Interestingly, support for school masking mandates has increased slightly; 70% of respondents supported them compared with 69% in mid-August. Similarly, support for childhood vaccination is up but still lukewarm; 44% of respondents, compared with 38% in mid-August, said they were “very” or “somewhat” likely to get their child vaccinated when a vaccine becomes available for the child’s age group. ❒

As we continue to struggle with the COVID-19 pandemic, a majority of Americans favor  the President's vaccine mandates. 

Majority of Americans Favor President’s Vaccine Mandate: Poll

While teenagers have been largely spared the ravages of COVID-19, the full picture of their experience is just beginning to emerge. The pandemic has exposed many teens to trauma and tested their fragile 

. The school closures, canceled proms, and separation from friends seemed a small price to pay to save the lives of thousands. But in exchange, the 14- to 18-year-olds who represent the younger side of Generation Z were robbed of the capstone of their formative years. It created an atmosphere of uncertainty and anxiety among some teens, about both the future and their place in it.

As if the pandemic was not enough, teens watched as 

 reached breaking points. They saw angry mobs take over cities and storm the Capitol. Then Mother Nature swept in with deadly wildfires and other natural disasters that underscored the threat of climate change.

Throughout COVID-19, the physical health needs of the most vulnerable often took priority over the mental health needs of others. But as the pandemic dragged on, health care providers expressed concern over its long-term mental effects on youth and teens. Against expectations, suicide rates for all ages dropped by 5.6% in 2020 compared to 2019.

 But this is not entirely unusual. Known as the “pulling together” effect, suicide rates tend to dip during shared experiences of catastrophe. Despite this decline, there are indications that the pandemic has triggered a ripple of mental health concerns across all age groups.

When the shelter-in-place measures went into effect in late March 2020, trips to the 

 (ED) for anything other than COVID-19 plummeted by 42% across all ages.

 Yet, while these non-COVID trips declined, the proportion of ED trips for psychosocial issues actually increased by 69%.

 Children and teens experienced increases of about 24% and 31%, respectively.

 Further, there were troubling indications that suicide-related ED visits by girls were significantly higher than boys.

As COVID-19 rolls through 2021, clinicians are in desperate need of a comprehensive public health strategy to manage the anticipated increase in demand for treatment. This will be particularly important when working with teens. Many are dealing with multiple issues, including trauma, the effects of isolation, and a shattered sense of security and safety. COVID-19’s unique conditions may have created a new kind of 

 (PTSD), one rooted in fear of what might happen instead of what has happened. As a result, how PTSD is defined and diagnosed in the DSM-5 will likely need to change.

Until then, clinicians would do well to use a trauma-informed approach to care—one that considers and addresses the causes of traumatic stress. This may help stave off future conditions and nurture a resilience that will serve teens a lifetime.

When the pandemic shuttered classrooms across the country, everyone scrambled to pivot. Schools were pressured to build remote-learning solutions from scratch. Families had to adjust their homes to create space and time for work and school. Kids and teenagers did their best to stay focused, engaged, and connected despite the uncertainty.

A September 2020 poll found that 59% of teenagers considered online school worse than in-person instruction, with 19% describing it as “much worse.”

 One national survey found that half of the teenagers were experiencing anxiety, trouble concentrating, and 

 Also in the survey, 31% of parents reported their child’s emotional health was worse than before the pandemic. About 53% worried their children would contract COVID-19 if they went back to school the following fall. Another 36% worried their mental health would suffer if they did not.

In 2019, almost 19% of high school students in the United States had seriously considered suicide, 15.7% made an attempt plan, and 8.9% reported attempting suicide at least once.

Interestingly, parents were more likely to notice new or worsening symptoms of depression and anxiety in teen girls.

 In July/August 2020, the number of girls admitted to the ED for suspected suicide attempts had increased 26.2% over a year prior.

 In February/March 2021, this rate was now 50.6% higher.

 Among boys, this rate had increased only 3.7%.

 These were troubling statistics, especially since suicide is the second-leading cause of death among youths aged 10 to 17.

 In 2019, almost 19% of high school students in the United States had seriously considered suicide, 15.7% made an attempt plan, and 8.9% reported attempting suicide at least once.

Mental health care providers scrambled to set up telehealth options in order to treat patients from afar. For many teens, COVID-19 took away coping strategies like going on a hike or visiting friends—things that have always had a positive impact on depression, anxiety, and chronic health conditions.

 Ironically, remote learning did provide some protections for teens, namely against bullying, which is more commonly done in person. One study noticed online searches for “school bullying” and “cyberbullying” dropped by 30% to 40% in spring 2020 and maintained this level through the following winter.

 As students gradually returned to school, however, internet searches about bullying increased.

Alcohol and marijuana consumption among 12th graders remained stable during 2020.

 This indicated that even though the pandemic created perceived barriers to access, teenagers could still 

 Nicotine vaping, however, declined from 24% before the pandemic compared to 17%.

A Centers for Disease Control and Prevention (CDC) report in October 2020 acknowledged that virtual education presented more risks to the mental and emotional wellbeing of both parents and children.

 Children spent less time outside, less time with friends, and less time exercising because of it.

Children in Black, Latino, and multiracial families were particularly impacted, as they were more likely to receive virtual instruction compared to White children.

 Parents of these remote-learning children were also more likely to report loss of work, job stability concerns, child care challenges, emotional distress, and difficulty sleeping.

Among Latino families, adults reported a higher prevalence of stress in relation to food, housing, and job insecurity.

 Racial tension, protests, and riots added another layer of stress within Black, Indigenous, and people of color communities, where more than half of teens worried about dealing with racial justice issues at school.

Asian Americans and Pacific Islanders were experiencing their own version of racism, as many held them responsible for the spread of COVID-19.

 No less than 81% of Asian Americans and Pacific Islanders felt violence against them was increasing in 2020.

36% of teenagers found social media helped them cope with the pandemic.

The pandemic has affected just about every teenager in some way. Cut off from their peers, there was little opportunity to socialize and commiserate in person. It is only natural that young people turned to 

 to connect with others. In fact, 36% of teenagers found social media helped them cope with the pandemic.

Prior to March 2020, 26% of students spent 4 to 8 hours a day on social media.

 That shot up to 39% during the brunt of the pandemic.

 Aware that it was one of the few available ways to connect, many families relaxed their rules on screen time, with 81% saying it helped their children.

 Social media provided kids with comfort, inspiration, and something to do. Kids learned the latest TikTok dance, perfected making whipped coffee, and collectively laughed as school pranks easily transitioned to online platforms.

Among 14- to 22-year-olds, 43% said social media helped them feel better when they were depressed, stressed, or anxious—up from 27% in 2018.

A survey of teens from September to November 2020 revealed that 53% credited social media as “very important” to keeping them connected to friends and family.

 Among 14- to 22-year-olds, 43% said social media helped them feel better when they were depressed, stressed, or anxious—up from 27% in 2018.

 It was also where most of them got their news. A 2019 survey discovered that 54% of teens relied on social media and 50% on YouTube for information.

murder of George Floyd and the killing of Breonna Taylor

 by police ignited racial unrest, teens turned to their phones to keep up to date.

But there was also a dark side to social media. A month after police Floyd’s death, the “George Floyd Challenge” encouraged some teens to recreate scenes of the crime and post them on social media. For BIPOC youth, it was a stark reminder of how powerful and hurtful social media can be. According to a survey, 69% of Black youth and 67% of Hispanic youths reported encountering racist content online.

lesbian, gay, bisexual, transgender, and queer

 (LGBTQ) said they encountered homophobic content on social media. Gender and sexual identity were major topics of discussion in 2020, with almost a quarter of youths identifying themselves as some form of nonbinary gender.

 At 65%, LGBTQ youth were twice as likely to report symptoms of moderate to severe depression than non-LGBTQ youth.

 When 92% of them searched for health information online, the most common topics were COVID-19 and anxiety.

. Body dissatisfaction and body shaming played online, with 53% of girls exposed to at least 1 form of weight stigmatization.

 Eating disorders were also on the rise. The number of 12- to 18-year-olds admitted to a hospital for an eating disorder increased by 25% from March 2020. This was mainly attributed to girls, who experienced a 30% increase, compared to boys at 4%.

By fall 2021, the prevalence of depression and anxiety in children and adolescents around the world had doubled from pre-pandemic levels to 25.2% and 20.5%, respectively.

 Symptoms were noted at higher levels later in the pandemic, especially in girls and older teens.

With COVID-19 infection rates constantly fluctuating, schools and communities debated, hesitated, and grappled with the decision to reopen schools for in-person learning. The city of San Francisco had to sue its own school district in March 2021 to force it to open its doors to students, citing a loss in learning and mental health concerns.

When students returned to school earlier this fall, only 31% felt emotionally prepared to socialize in person, 20% felt they would succeed in school, and 28% felt they would be able to focus on learning.

 Adding to the back-to-school jitters, 1 survey found that 3 in 4 teens were worried about contracting COVID-19 during 

At least now, schools could fulfill their role identifying kids with mental health conditions as well as other situations, such as abuse and homelessness. In the meantime, federal and state governments are directing funds to provide training to schools and doctors to identify, treat, and refer children in need of mental health services.

The pandemic has exposed many teens to trauma and tested their fragile resilience. What can you, as a clinician, do to help?

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A Role for Psychiatry in Understanding and Overcoming Vaccine Hesitancy

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