Discussion
Our study confirms that during the COVID-19 pandemic there was an increase in MH disorders in adolescents, and highlights that the associated use of health services occurred especially in girls.1 6 8 15
In our sample, we observed an increase in the use of health services for conditions related to MH, both in boys and in girls, during the pre-pandemic period, which was particularly evident for the prevalence of psychotropic drug prescriptions. It is, therefore, likely, as observed by other researchers, that the pandemic exacerbated an already existing emergency concerning paediatric MH.33 34
In the first few months of the pandemic, there was a 30% drop in the attendance for MH conditions. After the first wave of the pandemic (March to May 2020), the ratio between the observed versus expected cases returned to 1, and further decreased during the second wave (October 2020 to January 21).
In this period, the attendance at CAMH outpatient services was only slightly affected, with a 10% reduction, while the main impact was observed on ED attendance (−40%). The impact was similar between genders, with the only exception of hospital admission, for which the decrease was more pronounced in boys than in girls.
The situation was completely different in the second pandemic period: the prevalence of observed cases remained lower than expected for boys, while the opposite occurred for girls.
Adolescent girls used health services for mental conditions more frequently than predicted on the basis of the trend in the pre-pandemic period, with a relative increase of 24% in the case of psychotropic drug prescriptions and of 18% in the case of ED attendance.
Despite the existing differences among countries regarding geographical, cultural and socioeconomic characteristics, and the differences in the public health measures adopted to tackle COVID-19, the impact of the pandemic on adolescent MH appears similar in different settings.1 4–7 9–12 21 24
Gender differences in the impact of the pandemic on MH were documented in several studies.6 7 13 20 21 23 24 Adolescent females suffered the consequences of COVID-19 and related lockdown measures more than males, resulting in symptoms of anxiety and depression,16 20 24 35 and this finding is consistent with the greater prevalence of internalising mental disorder in women compared with men.36
Eating disorders, mood disorders and self-harm were the conditions associated with ED attendance with the highest increase in girls during 2021. In boys, the access due to the same disorders decreased compared with the pre-pandemic period. Similar findings were reported in the UK.23
An increased utilisation of healthcare resources for eating disorders, more pronounced in adolescent girls, was observed in several Italian and international studies.37–41 Numerous stressors could trigger eating disorders during the pandemic, including increased time at home, easier access to food, social isolation, changes to routines and physical activity, and increased online media use.17–19 37 Differences in symptomatology of eating disorders were observed over time, with an increasing risk related to the dimensions of body concerns, dissatisfaction, asceticism and fear of maturity in the 2/3 years following the onset of the pandemic.38
The fact that the rise in ED visits for eating disorders, mood disorders and self-harm, was mainly observed in the second year of the pandemic, however, when social restrictions were at least partially eased, may indicate a long-term impact of the pandemic and/or that there was a lag-time between the onset of the disorders and the help-seeking. In the case of some disorders (eg, eating disorders), it is hypothesised that the effects of the pandemic on MH may be predominantly delayed rather than immediate, with a deterioration of symptoms during the period of lockdown that became apparent later on, when the relaxation of the restrictive measures exposed adolescents to a resumption of normal routines and to new risks such as social confrontation.38 39 Furthermore, lockdown restrictions had different levels of impact on people’s daily routines, both those with and without a medical diagnosis, on the difficulties experienced in performing daily tasks or in accessing healthcare and mental healthcare services.42 The aforementioned triggering environment can create additional challenges for patients with eating disorders, thereby exacerbating conditions that are not adequately addressed by online treatment or family support.
Findings from this study underline the need to monitor adolescent mental well-being beyond the conclusion of the ‘acute phase’ of the pandemic. For doing so, healthcare services should be potentiated and adapted to tackle new challenges,43 and people with different roles (parents, primary care physicians, professionals involved in child and adolescent mental healthcare, teachers) should be involved with the aim to identify and support adolescents with psychological distress.33 34
The treatment of mental disorders, regardless of the patient’s age and the type of disorder, requires multidimensional interventions involving community-based social and health services, families, and patients.44 The pandemic has shown that there is a need for innovative, holistic and comprehensive community-based support models, particularly in the areas of MH and healthcare for children and adolescents.34 45 We have also learnt that too little has been done so far for prevention, including in the context of MH. So adequate resources (human, economic and training) should be allocated to improve treatment and prevention pathways at the community level. This should be accompanied by the conduct of appropriate efficacy studies and the implementation of positive results.
Finally, in our study, the greatest relative increase was observed for psychotropic drug prescriptions in adolescent girls, and concerned both antidepressants and antipsychotics. In the first case, it is consistent with the increase in anxiety and depressive symptoms, while antipsychotic prescriptions refer to medium-severe disorders and other conditions and comorbidities. It could be hypothesised that there was an increase in episodes of psychomotor agitation, bipolar disorder or psychotic onset. This hypothesis is at least partially supported by data on ED visits.
This study has some limitations. We had the possibility to monitor outpatient visits and drug prescriptions reimbursed by the Italian NHS. Private visits and medicines paid out-of-pocket were not evaluated. Moreover, anxiolytics are not reimbursed by the NHS in Italy, and it is, therefore, likely that the prevalence of psychotropic drug use is underestimated and that the increase observed in girls during the pandemic period is greater than reported.
The socioeconomic conditions of the family are considered one of the main risk factors for experiencing greater negative MH effects due to the pandemic,46 but findings on healthcare utilisation are conflicting, with studies reporting a greater healthcare use in youths living in areas of higher socioeconomic status6 47 48 or a reduced attendance of subjects with lower socioeconomic conditions.49 Unfortunately, healthcare administrative databases do not collect information concerning socioeconomic variables, (which are in any case limited in terms of reliability), so we were not able to analyse the influence of these factors.