Psychiatric symptoms and emotional impact of the COVID-19 pandemic on Italian adolescents during the third lockdown: a cross-sectional cohort study

The literature showed how the restrictive measures put in place due to the ongoing public health emergency have impacted multiple emotional and psychological domains3,7,8,9. In continuation of a previous study28we used an online survey to assess the psychological and emotional impact of the COVID-19 pandemic on youth during the third lockdown in Italy (March-June 2021). We enrolled 481 participants who did not differ in gender, country of birth, place of residence, and personal experience of viral infection. In the sample, nearly 8% said they were in therapy before the pandemic, half of whom were continuing it, and 5% said they started treatment during the COVID-19 public health emergency. These data confirm how the pandemic and quarantine have impacted mental health and the need for greater support for Italian youth 9.

As a first result, we wanted to determine the prevalence rate of depressive, anxious, panic and psychotic symptoms and COVID-related stress disorder according to the DSM-5 criteria during the third lockdown in Italy. We found that adolescents reported feeling they experienced higher levels of psychotic symptoms (not due to substance abuse) than they did before the pandemic (+4%). Consistent with the literature1.2, the survey also found that more than half of the population experienced symptoms of anxiety, with nearly 47% experiencing symptoms that were above the threshold. Regarding panic, we found that 39% of the adolescents had panic symptoms, 25% of them with above-threshold severity. Regarding depression, the results showed that 34% had subliminal and almost 19% supraliminal symptoms. Contrasted with some studies showing a prevalence of depressive disorders followed by anxiety disorders8.10 Our study shows a higher frequency of anxiety disorders than depressive disorders, indeed, unpredictability, the climate of insecurity and general instability seem to be fertile substrates for the occurrence of anxiety disorders. Finally, we aimed to assess the prevalence of COVID-related stress disorders, excluding those who had previously experienced trauma. Among them, traumatic news and the abuse of a friend were the most common traumas, and some of the participants reported having experienced multiple traumas. For the remainder of the sample, we discovered that nearly 20% exhibited symptoms of stress: seven adolescents (1.85%) met criteria for a DSM-5 diagnosis of PTSD, and 11 participants (2.91%) met criteria for ASD. In addition, 18% suffered from underlying PTSD symptoms. These data are alarming compared to a previous survey in which only 2 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 continued restrictive measures. The dismantling of social relationships, the disruption of routines, social isolation, distancing and other restrictive measures taken are therefore confirmed as triggering factors for the development of stress disorders33. In addition, school closures and e-learning also affected the health of the young people, who not only suffered from the lack of classmates, but also from the considerable study load.

As a second objective, we examined perceptions of personal stress levels, sleep problems, dysfunctional eating habits, substance abuse, perceived social withdrawal, and suicidal ideation and self-harm during the third lockdown in Italy. We found that 41% of the sample said they felt their stress levels had increased since the initial lockdown, and the literature confirms that stress levels follow a trend, increasing during periods of closure and decreasing just before reopening3. In addition, it is interesting to note that more than half of the adolescents reported problems sleeping, particularly difficulty falling asleep, nocturnal awakenings and daytime naps. As the studies by Uccella and colleagues show9 In the Italian population during the pandemic, sleep disorders occupy a significant place in both adolescents and children under 6 years old. Significant changes have also been reported in eating disorders. More than half of the adolescents showed changes in eating behavior and a relevant percentage reported fluctuations in body weight. In this regard, Rodgers and colleagues17 described some key precipitating factors such as limited access to support networks, increased symptoms of self-assessment of one’s body due to social isolation, and feelings of anxiety about eating, exercise, and weight due to social media influence. We also found that 6% of adolescents reported having used drugs and/or alcohol regularly in the past 6 months. In addition, the study sample reported higher levels of withdrawal symptoms during the pandemic compared to before COVID (+15%). This finding overlaps with literature stating that withdrawal was likely used as a strategy to reduce perceived psychological stress during the pandemic20. Lambline and colleagues26 then found that interactions between brain maturation and external stimuli could increase the risk of mental illness or promote resilience. Also of great concern is the presence of active suicidal ideation (almost 30%), which is higher than reported in the literature18. Our results confirm what Hill and colleagues didfifteen about the alarming increase in complaints from young people during the pandemic. Additionally, non-suicidal self-harm thoughts and actions such as cutting, burning, and branding must also be considered “alarm bells” in adolescents (25.7%), with as many as 9% of adolescents reporting actual minor or severe self-harm gestures.

For the third goal consistent with the literature10,18,19we found that female participants had higher frequencies of anxiety (57% supraliminal), panic (33% supraliminal), and depressive symptoms (almost 25% supraliminal and 39% subliminal). In addition, 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 had more symptoms of ASD and PTSD than males and demonstrated higher levels of suicidal ideation (37%) and non-suicidal self-harm (almost 33%). Then consistent with previous data34.35, we found higher levels of reported sleep problems and problems related to eating behavior in the female population. The prevalence of psychiatric symptoms in the female population is not clear, however these data appear to reflect a higher prevalence of symptoms such as anxiety, depression and eating disorders in women. Consistent with other studies, it has been found that mental health symptoms are significantly more common in women, and this finding is not surprising given that, regardless of the pandemic, anxiety and depressive symptoms are generally more common in women, even in adolescence36.

Regarding restrictions, the online survey was accessible from April to July 2021; Therefore, the short period of time, coinciding with the final phase of the third lockdown in Italy, did not encourage the collection of larger numbers of adolescents, but to limit bias, we nevertheless decided to stop data collection before the end of the restrictions. Furthermore, we cannot generalize the data to the entire Italian youth population as the questionnaire responses came mainly from northern Italy and only youth with technical devices and an internet connection could access the survey.

Given the high frequency and severity of the symptoms, it seems necessary to ensure valid and continuous assistance and not to ignore the signs of this “latent pandemic” that affects especially the weakest and most emotionally vulnerable in a critical period of growth, that is, adolescence. The increased incidence of symptoms associated with various psychiatric disorders triggered by the ongoing pandemic has inevitably resulted in significant implications for clinical practice. Several epidemiological studies have identified a disproportionate increase in admissions to child neuropsychiatric wards and an increase in emergencies. Therefore, in our opinion, it is essential to create appropriate and timely care conditions, if necessary to create networks between services in order to intercept emergency situations at an early stage. Additionally, as other studies have suggested, measures should be planned to allow for “physical distancing” while maintaining “social connection,” rather than speaking of “social distancing.”37. It is therefore necessary to listen to young people and to accept their discomfort and to take the time to talk about their emotional well-being, especially in the most difficult conditions and in the contexts in which they spend most of their time, such as B. at school. To some extent, telemedicine has improved access to care, but demand for care from young people is still very strong and resources need to be harnessed to provide better care and identify psychological and social distress. Finally, in the final part of our questionnaire, we asked young people to freely express themselves 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 involve them more, and to give them more responsibility, while leaving them a space for physiological growth and the search for independence (Figure S1).

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