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Association of Major Disease Outbreaks With Adolescent and Youth Mental Health in Low- and Middle-Income CountriesA Systematic Scoping Review

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Question  Are major disease outbreaks from 2009 to 2021 associated with the mental health of adolescents and youth in low- and middle-income countries?

Findings  In this systematic scoping review of 6 databases, a total of 57 studies of the influenza A (H1N1) and SARS-CoV-2 infections revealed that these outbreaks were associated with adolescent and youth mental health. Results suggest high rates of anxiety and depressive symptoms, in addition to posttraumatic stress disorder, general stress, and health-related anxiety among adolescents.

Meaning  Findings suggest that the H1N1 and SARS-CoV-2 outbreaks were associated with adolescent and youth mental health; future studies with improved measurement tools and the inclusion of a wider range of mental disorders and risk factors will help ascertain how epidemics affect adolescent mental health in low- and middle-income countries.


Importance  Adolescents and young people have been historically understudied populations, and previous studies indicate that during epidemics, these populations, especially in low- and middle-income countries (LMICs), are at high risk of developing mental disturbances.

Objective  To identify the existing evidence regarding the association of mental health with outbreaks of the influenza A (H1N1), Zika, Ebola, and SARS-CoV-2 virus in exposed youth and adolescents in LMICs.

Evidence Review  Across 6 databases (Embase, Cochrane Library, PubMed, PsycINFO, Scopus, and Web of Science), the mental health outcomes of adolescents and youth (aged 10-24 years) associated with 4 major pandemic outbreaks from January 2009 to January 2021 in LMICs were reviewed. A group of 3 authors at each stage carried out the screening, selection, and quality assessment using Joanna Briggs Institute checklists. The social determinants of adolescent well-being framework was used as a guide to organizing the review.

Findings  A total of 57 studies fulfilled the search criteria, 55 related to the SARS-CoV-2 (COVID-19) pandemic and 2 covered the H1N1 influenza epidemics. There were no studies associated with Zika or Ebola outbreaks that met screening criteria. The studies reported high rates of anxiety and depressive symptoms among adolescents, including posttraumatic stress disorder, general stress, and health-related anxiety. Potential risk factors associated with poor mental health outcomes included female sex; home residence in areas with strict lockdown limitations on social and physical movement; reduced physical activity; poor parental, family, or social support; previous exposure to COVID-19 infection; or being part of an already vulnerable group (eg, previous psychiatric conditions, childhood trauma, or HIV infection).

Conclusions and Relevance  Results of this systematic scoping review suggest that the COVID-19 pandemic and H1N1 epidemic were associated with adverse mental health among adolescents and youth from LMICs. Vulnerable youth and adolescents may be at higher risk of developing mental health–related complications, requiring more responsive interventions and further research. Geographically localized disease outbreaks such as Ebola, Zika, and H1N1 influenza are highly understudied and warrant future investigation.

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Article Information

Accepted for Publication: August 9, 2022.

Published Online: October 12, 2022. doi:10.1001/jamapsychiatry.2022.3109

Corresponding Author: Manasi Kumar, PhD, Brain and Mind Institute, Aga Khan University, 3rd Parklands Ave, Nairobi, Kenya (manasi.kumar@aku.edu).

Author Contributions: Drs Kumar and Akbarialiabad had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Kumar, Akbarialiabad, Taghrir, R. Shidhaye.

Acquisition, analysis, or interpretation of data: Kumar, Akbarialiabad, Forjoud Kouhanjani, Kiburi, P. Shidhaye, Taghrir.

Drafting of the manuscript: Kumar, Akbarialiabad, Forjoud Kouhanjani, Kiburi, Taghrir.

Critical revision of the manuscript for important intellectual content: Kumar, Akbarialiabad, Kiburi, P. Shidhaye, Taghrir, R. Shidhaye.

Statistical analysis: Kumar, Akbarialiabad, Kiburi, Taghrir.

Obtained funding: Kumar.

Administrative, technical, or material support: Kumar, Akbarialiabad.

Supervision: Kumar, Akbarialiabad, R. Shidhaye.

Conflict of Interest Disclosures: Dr Shidhaye reported receiving grant support from DBT-Wellcome Trust India Alliance Fellowship in Clinical and Public Health Research. No other disclosures were reported.

Additional Contributions: We thank Muhammad Rahman, BSc (University of Washington) for providing assistance in the first draft of this article and Vincent Nyongesa, BSc (University of Nairobi) for help with amending referencing in the final version of the paper. No one was financially compensated for their contribution.

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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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