The literature showed how the restrictive measures taken due to the ongoing health emergency have affected several emotional and psychological areas3,7,8,9. In continuity with a previous study28, we used an online survey to evaluate the psychological and emotional impact of the COVID-19 pandemic on adolescents during the third lockdown in Italy (March–June 2021). We enrolled 481 participants that do not differ in gender, nation of birth, region of residence, and personal experience of virus infection. In the sample, almost 8% stated that were already in therapy before the pandemic, with half of them continuing it, and 5% claim to have started treatment during the COVID-19 health emergency. This data confirms how the pandemic and quarantine influenced psychological health and the need for greater support for Italian adolescents 9.
As the first outcome, we aimed to find the prevalence rate of depressive, anxious, panic, and psychotic symptoms and COVID-related stress disorders, according to DSM-5 criteria, during the third lockdown in Italy. We found that adolescents reported feeling that they experienced a higher level of psychotic symptoms (not due to substance abuse) than in the pre-pandemic period (+ 4%). In line with the literature1,2, the survey also revealed that more than half of the population presented anxiety symptoms, with almost 47% of them with suprathreshold symptoms. About panic, we found that 39% of adolescents experienced panic symptoms, 25% of them with suprathreshold severity. Regarding depression, results showed that 34% exhibited subthreshold symptoms and almost 19% suprathreshold. In contrast to some studies showing a prevalence of depressive disorders, followed by anxiety ones8,10 our study shows a higher frequency of anxiety disorders than depressive disorders, in fact, unpredictability, the climate of uncertainty, and general instability appear to be fertile substrates for the onset of anxiety disorders. Finally, we aimed to evaluate the prevalence of COVID-related stress disorders, excluding those who had experienced previous trauma. Among them, traumatic news and abuse of a friend represented the most frequent traumas, and some of the participants reported multiple experienced traumas. In the rest of the sample, we discovered that almost 20% presented stress symptoms: seven adolescents (1.85%) met the criteria for a PTSD diagnosis according to DSM-5 and 11 participants (2.91%) met the criteria for ASD. Moreover, 18% experienced subthreshold PTSD symptoms. These data are alarming when compared to an earlier survey in which only 2 out of 1251 (0.16%) participants met the criteria for a PTSD diagnosis and 1 (0.08%) for ASD28. The increase in PTSD and ASD diagnoses may be due to the continuation of restrictive measure. The reduction of social relations, the interruption of routines, social isolation, distancing, and other restrictive measures adopted are therefore confirmed as precipitating factors for the onset of stress disorders33. Moreover, also school closures and e-learning affected adolescents’ health in fact, not only did they suffer from the lack of classmates, but they also suffered from the considerable study load required.
As the second objective, we investigated the perception of personal stress level, sleep problems, dysfunctional eating behaviors, substances abuse, perceived social withdrawal, and suicidal ideation and self-harm during the third lockdown in Italy. We noticed that 41% of the sample indicated that they had a perception that their stress levels had increased since the first lockdown, and literature confirms that stress levels follow a trend, increasing during the closing phases and decreasing near re-openings3. Moreover, it is interesting to learn that more than half of adolescents reported sleep disorders, especially difficulty falling asleep, night awakenings, and daytime naps. As shown by the studies of Uccella and colleagues9 on the Italian population during the pandemic, sleep disorders occupy a significant place both in the adolescent population and in children under 6 years of age. Significant changes were also reported in eating disorders. More than half of adolescents manifested changes in eating behavior, and a relevant percentage reported variations in body weight. In this regard, Rodgers and colleagues17 described some important precipitating factors such as limited access to support networks, increased symptoms of self-evaluation about one’s body due to social isolation, and experiences of anxiety related to food, exercise, and weight due to the influence of social media. We also found that 6% of adolescents that reported regular use of drugs and/or alcohol in the last 6 months. Furthermore, the study sample reported a higher level of withdrawal symptoms during the pandemic compared to the pre-COVID period (+ 15%). This finding overlaps with the literature stating that withdrawal was likely used during the pandemic as a strategy to reduce perceived psychological stress20. Lamblin and colleagues26 then found that interactions between brain maturation and external stimuli might increase the risk of mental illness or promote resilience. A great concern is also aroused by the presence of active suicidal ideation (almost 30%), higher than in literature18. Our findings confirm what Hill and colleagues15 said about the alarming increase in the discomfort experienced by adolescents during the pandemic. Moreover, also non-suicidal self-harm ideations and acts such as cutting, burning, and branding must be considered as an “alert bell” among adolescents (25.7%) with even 9% of adolescents reporting actual mild or severe self-harm gestures.
For third aim, in line with the literature10,18,19, we found that female participants exhibited a higher frequency of anxiety (57% suprathreshold), panic (33% suprathreshold), and depressive symptoms (almost 25% suprathreshold and 39% subthreshold). Moreover, male adolescents showed fewer pre-pandemic psychotic symptoms (either due to drugs or not) than females, but they do not differ in regular substance use. Female adolescents also experienced more symptoms of ASD and PTSD than males and expressed a higher level of suicidal ideation (37%) and non-suicidal self-harm (almost 33%). Then, in line with previous data34,35, we found a higher level of expressed sleep problems and problems related to eating behavior in the female population. The prevalence of psychiatric symptoms in the female population is not unambiguous, however these data would seem to reflect a higher prevalence of symptoms such as anxiety, depression and eating disorders in females. Consistent with other studies, psychological symptoms were found to be significantly more common among females, and this finding is not surprising because, regardless of the pandemic, anxiety and depressive symptoms are generally more common in females, even in adolescence36.
Regarding limitations, the online survey was accessible from April to July 2021; therefore, the brief period that coincides with the final phase of the third lockdown in Italy did not encourage compilation to a greater number of adolescents, but to limit biases, we still decided to stop data collection before the end of restrictions. Moreover, we cannot generalize the data to the entire Italian adolescent population because the answers to the questionnaire came mainly from northern Italy, and only adolescents who had technological devices and an internet connection were able to access the survey.
Since the high frequency and severity of symptoms, it appears necessary to ensure valid and continuous assistance and not to overlook the signs of this “latent pandemic” that involves above all the most fragile and emotionally vulnerable in a critical growth phase, that of adolescence. The increased frequency of symptoms associated with various psychiatric disorders triggered by the ongoing pandemic has inevitably resulted in a significant impact on clinical practice. Several epidemiological investigations have established a disproportionate increase in admissions to child neuropsychiatry wards and an increase in emergencies. In our opinion, it is therefore essential to provide appropriate and prompt conditions of care, maybe creating networks among services to intercept distress at an early stage. Moreover, as other studies suggested, rather than talking about “social distancing”, measures should be planned to allow “physical distancing” while preserving “social connection”37. Therefore, it is necessary to listen to adolescents and accept their discomfort, taking time to talk about their emotional well-being, especially under the most difficult conditions and in the contexts in which they spend the most time, such as school. To some extent, telemedicine has facilitated access to care, but the demand for care from young people is still very strong and resources need to be used to provide better care and recognize psychological and social distress. To end, in the final part of our questionnaire, we asked young people to express themselves freely and give their suggestions on what changes adults should make to the current level of care. In several comments, the adolescents asked adults to give them a space to listen, to include them more, and make them more responsible, but at the same time leave them a space for physiological growth and search for independence (Figure S1).
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