Global Health Journal 7 (2023) 78–86

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Global Health Journal

journal homepage: https://www.keaipublishing.com/en/journals/global-health-journal/

REVIEW

Risk factors and strategies for prevention of depression, anxiety and eating
disorders among adolescents during the coronavirus disease 2019
(COVID-19) pandemic: a review
Rea Pillai, Isha Patel, Rajesh Balkrishnan∗
Department of Public Health Sciences, University of Virginia School of Medicine, P.O. Box 800717 Charlottesville, Virginia, VA 22908, USA

a r t i c l e i n f o a b s t r a c t
Article history: The purpose of this review is to identify prevalent trends and risk factors in depression, anxiety, and eating
Received 29 January 2023 disorders in the adolescent population in the post coronavirus disease 2019 (COVID-19) scenario. We examined
Received in revised form 19 April 2023
the literature published on adolescent mental health since the COVID-19 pandemic. We chose to summarize
Accepted 21 April 2023
studies published from 2019 to 2022, using bibliographic search tools. We developed criteria for selecting articles
Available online 23 April 2023
for our review using diagnostic indicators and keywords. Mental health conditions such as depression, anxiety
Keywords: and eating disorders are commonly prevalent in this population and have shown increasing rates in the past
Coronavirus disease 2019 (COVID-19) three years. Some risk factors associated with these diagnoses include reduction in social interaction, increased
Mental health
workloads, routine shifts, sleep quality, social media usage and parental involvement. Routines, sleep cycles,
Teenagers
physical activity, and social media should all be considered as a part of prevention in this population. Approaches
Impact of mental health
that seem to be successful include maintaining social ties and avoiding negative social media usage with harmful
content. Increased global public awareness, as well as parental awareness, through media campaigns, is critical
to slowing the spread of mental health challenges in adolescents and teenagers in the post-COVID-19 era.

1. Introduction amplified pressures due to the stressful workload in e-learning.3 Also,

The global coronavirus disease 2019 (COVID-19) pandemic has
brought forth innumerable obstacles, on an individual and situational
basis. With the virus spreading at an expeditious rate, governing bodies
have attempted to contain the virus through quarantine and protective
measures or policies of social distancing, self-isolation and lockdowns.
While effectively lowering the risk of contracting the virus, these mea-
sures have remodeled societal norms and consequently acted as a cata-
lyst for those who already have mental health conditions. The pandemic
has led to worsened mental health and increased rates of anxiety, de-
pression and stress among the general population.1
One of the most afflicted groups by this predicament remains ado-
lescents (namely, individuals between the ages of 10‒19).2 Data col-
lected by Centers for Disease Control, United States in 2021 illuminated
that 37% of high school teenagers experienced poor mental health, and
44% experienced hopelessness and sadness over the course of a year.
Mental health has remained a prominent area of concern with regards
to the overall well-being of the population of adolescents. With pre-
pandemic depression and anxiety rates among adolescents estimated to
be at 12.9% and 11.6%, respectively, a reduction in social interaction
an inability to cope with a rapidly changing environment could only
exacerbate negative emotions within a population already dealing with
hormonal and genetic development.
As of 2021, depression and anxiety rates among adolescents are esti-
mated to have nearly doubled. The prevalence of clinically elevated de-
pression and anxiety symptoms were 25.2% and 20.5%, respectively.4
The pandemic has also created an abrupt shift in routine for adolescents.
Moreover, when the routines of meeting social circles nearly every day,
displaying physical affection, and being physically and mentally present
in the classroom at all times are disrupted, the pandemic has altered
routine circumstances for this group of individuals. By altering various
factors surrounding adolescent mental health and thus expediting men-
tal illness rates within the population, the pandemic has influenced the
mental health of teenagers to a large degree. Many states within the
United States for example, have faced an increase in suicide rates by
adolescents after the pandemic began. While the proportion of suicide
rates have subsided for adults ages 35 or over, states such as Arkansas,
California, Georgia, Indiana, New Jersey, Virginia and Vermont have
faced an increase in levels of adolescent suicide in the post-pandemic
period.5 In addition to anxiety and depression, there has been an in-

∗
Corresponding author: rb9ap@virginia.edu.

https://doi.org/10.1016/j.glohj.2023.04.004
2414-6447/Copyright © 2023 People’s Medical Publishing House Co. Ltd. Publishing service by Elsevier B.V. on behalf of KeAi Communications Co. Ltd. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
Pillai R, Patel I and Balkrishnan R
crease in the gravity and implications of eating disorders within the
general population. As compared to pre-pandemic levels (2019), eat-
ing disorders within adolescents have increased, highlighting issues of
nutritional restriction and functional impairment.6 Globally, the preva-
lence of mental health conditions has registered a huge increase. With
40% of those surveyed specifying the COVID-19 pandemic as the trigger
for the onset of the disorder, post-pandemic monthly cases of new-onset
anorexia nervosa or atypical anorexia nervosa increased by more than
60% and monthly hospitalizations nearly tripled. This is particularly
noted in teen and adolescent respondents.7
With these afflictions on the rise and the risk of adolescents re-
maining untreated, it could interfere with their education, self-image,
lifestyle and well-being. Furthermore, without proper protocols and in-
terventions in place, these conditions can worsen and result in a de-
motivated population, affecting literacy rates, quality of life, and sui-
cide rates. This paper aims to summarize the impact of the COVID-19
pandemic on the mental health of teenagers and adolescents globally
as well as take stock of the preventive measures and interventions that
have been put in place to counteract the worsening mental health among
teenagers. These are important first steps in addressing the challenges
posed by the pandemic on this vulnerable population.
2. Methods
2.1. Information sources
The Information used for this research paper was extracted from vari-
ous sources. We used online databases of Google and PubMed, to search
for publications published in 2019 to 2022. We utilized keywords of
COVID-19, anxiety, depression, young adults, adolescents, teenagers,
Mental health, prevention, treatment, anorexia, eating disorder, and
limited criteria to papers written in English, and Human studies.
The population comprised of adolescents who are experiencing men-
tal health conditions (namely: depression, and anxiety), during the
COVID-19 Pandemic. Studies that discussed the mental health of ado-
lescents, or discussed a prevalent trend amongst the general population
were included. Fig. 1 describes the study selection process for the re-
view.
2.2. Study abstraction and evaluation
This systematic review employed data extraction strategy based on
the preferred reporting items for systematic reviews and meta-analyzes
(PRISMA) and followed PRISMA guidance (Fig. 1). 223 records and ar-
ticles were initially yielded through online databases and websites. We
removed any duplicates found and articles that did not meet specific
criteria (e.g. studies on animals, studies that are not written in English,
and studies that had no mention of the adolescent cohorts). A remain-
ing 193 articles were retained before the screening process as they did
not meet the aforementioned criteria. The full-text screening removed
101 articles based on irrelevances (if the article was not pertinent to
the population, key topics, or did not meet the inclusion/exclusion cri-
teria). The remaining 92 studies were checked for eligibility, which led
to the exclusion of approximately 62% of the articles, thereby resulting
in the inclusion of the 34 remaining articles. Studies were eligible for
inclusion if they met the following inclusion criteria: (1) study popu-
lation was adolescents/teenagers (few studies were included which did
not meet these criteria if they provided general trends of mental health
in the post-COVID-19 environment); (2) main idea was relevant to the
concept of the article (patterns of mental health in adolescents and/or
possible methods to prevent and treat mental health conditions during
the COVID-19 pandemic); (3) articles must be published after 2019; (4)
articles written in English.
Data from the studies were then organized to be able to compare
varying scientific resources (Table 1). Features of the various studies
79
Global Health Journal 7 (2023) 78–86
were analyzed and briefly explained. Table 1 shows the key character-
istics of the studies used for the review paper.
3. Findings
3.1. Post-COVID-19 trends in adolescents—factors associated with
depression and anxiety
3.1.1. Perception of the pandemic
The Pandemic has created a strong link between its growing presence
and adolescent mental health. As cited previously, with the rates of anx-
iety and depression increasing at an expeditious rate, nearly doubling
in numbers, adolescents have experienced a multitude of psychologi-
cal effects. With individuals commonly experiencing stress, depression
and anxiety, which can be attributed to the social distancing, quaran-
tine and isolation measures, most individuals largely perceived the pan-
demic as negative, and conversely produced negative outcomes (namely
post-traumatic stress disorder, rage, emotional disturbance, irritability,
insomnia, fear, confusion, depressive symptoms, and stress.). Individu-
als who perceived the pandemic positively, presented the situation as
an opportunity and experienced positive psychological effects due to
the minimization of the risk of contracting the virus, thus reducing the
pressures/stress experienced.8
3.1.2. Sleep quality
The sleep cycles of adolescents are one such factor that has been in-
fluenced as a result of the pandemic. Whilst students have experienced
an improved sleep schedule and duration over the course of the pan-
demic many students believed that school closures, restrictive measures
etc. have deteriorated their sleep cycles, within the UK alone. More-
over, anxiety and depression have been observed to be stable within
adolescents in China for the past three waves, but sleep quality ap-
peared to be deteriorating, which could have dangerous consequences
in the future.9 Due to increased restrictions and decreased in-person
communication, time spent travelling has nearly been eliminated, al-
lowing adolescents to sleep for longer periods. Since COVID-19, 85%
of high school students have reported increased sleep duration and a
2.9-hour mean delay in weekday wake time, with high school students
being the most affected. While most adolescents perceived an improve-
ment in sleep quality, some believed it had deteriorated. Moreover,
with sleep quality acting as a predictor of subsequent depression and
anxiety above the age of 15, and being significantly (negatively) cor-
related to interpersonal functioning of teenagers during the lockdown,
sleep quality can manipulate levels of mental wellbeing within the
population.10
3.1.3. Social media usage
In addition to the reduction in sleep quality, adolescents have turned
to social media and electronics during their spare time. A study con-
ducted in five countries, showcased a 41.7% increase in social media us-
age compared to pre-pandemic figures among adolescents, to maintain
social connections.11 Disaster-related social media content consumption
was significantly related to negative mental health among adolescents.
Additionally, the pandemic has led to an emphasis on "news avoidance".
Information overload due to COVID-19 (prominent especially during
the first wave) has led individuals to avoid watching the news. News
can often act as triggers for stress and anxiety and thereby with an
abundance of content to view, individuals may consciously or uncon-
sciously take breaks from the same to preserve their mental health.12
Passive usage of social media (without direct involvement) has been as-
sociated with an increased ill-being, namely depression, anxiety, lone-
liness, and low self-esteem. Social media content with idealistic body
types may lead to body comparison and eating disorders. These issues
were more prevalent in populations who had experienced psychopatho-
logical problems beforehand. Furthermore, increased time spent in front
Pillai R, Patel I and Balkrishnan R
Table 1
Summary of studies utilized for review.
Study
1
Salari et al., 2020
Nearchou et al., 20202
Fawaz et al., 20213
Racine et al., 20214
Charpignon et al., 20225
Spettigue et al., 20216
Agostino et al., 20217
Bozdağ, 20218
Wang et al., 20229
Illingworth et al., 202210
Kerekes et al., 202111
Condition studied
Anxiety, depression
Anxiety, depression
Anxiety, depression
Anxiety, depression
Depression
Eating disorder
Anxiety, depression, eating
disorder
Depression
Anxiety, depression
Anxiety, depression
Anxiety, depression
Population studied
Systematic review of stress and anxiety prevalence
during the COVID-19 pandemic
Systematic review of 12 studies regarding
youth/adolescent mental health during the
COVID-19 pandemic
Survey of 520 undergraduate students using
quantitative cross sectional analyzes, regarding
e-learning and mental health
Meta-analysis of 29 studies (80 879 youth
globally). Measured prevalence of depression and
anxiety during the COVID-19 pandemic
Cross sectional study of adolescent suicide
patterns, before and after the COVID-19 pandemic
Retrospective chart review of 48 adolescents
during the pandemic, and one year previously.
Patients were assessed at a pediatric tertiary eating
disorder program
Cross sectional study of 1 883 children and
adolescents with newly diagnosed anorexia
nervosa or atypical anorexia nervosa
Analyzes of 96 women and 80 men ages 18‒57
regarding individual perception of staying at home
during the COVID-19 pandemic and mental health
conditions
Survey of 1 952 middle- and high school students
(from grade 7‒10)
Utilised the OxWell school survey, about the
impact of COVID-19, on 18 642 respondents aged
8‒19 years
Self reports were collected from 5 114 high school
students (aged 15‒19 years)
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Main findings
(1) COVID-19 has increased rates of depression,
anxiety, and distress in the general population. (2)
News about COVID-19 can exacerbate anxiety, and
aging (particularly in the 21–40 age group) can
exacerbate depression, anxiety, and stress. (3) Women
are more likely to suffer from a stress disorder.
(1) During the COVID-19 epidemic, psychological
distress, depression, and other mental disabilities are
still prevalent in adolescent age groups. (2)
Adolescents who use social distancing techniques may
experience anxiety.
(1) Students who use online learning methods are
dissatisfied because of increased workloads,
inefficiency during online classes, and various
expenses. (2) These issues have resulted in an increase
in anxiety and depression symptoms. Counselling and
mental health treatment plans for these students are
suggested.
(1) Adolescent depression and anxiety have nearly
doubled in the last year. (2) The female gender in this
population has been more vulnerable to poor mental
health, with higher rates of depression among older
children/adolescents.
(1) Adolescent suicide rates are rising in Arkansas,
California, Georgia, Indiana, New Jersey, Virginia,
and Vermont. (2) Adolescent suicide rates have
increased in the population after aggregating all rates.
(1) The COVID-19 pandemic was cited by 40% of
adolescents as a direct cause of their eating disorder.
(2) There is increased nutritional restriction and
functional impairment in the population. (3) There
was also an increase in mental instability and the need
for hospitalization.
(1) Monthly cases of anorexia nervosa have increased
by more than 60% since the beginning of the
pandemic, as have monthly hospitalizations. (2)
Adolescents who have an eating disorder are more
likely to have comorbid psychopathology, such as
depression, anxiety, or OCD.
(1) Individuals were more likely to perceive the
pandemic as a negative event that resulted in negative
outcomes such as PTSD, rage, emotional disturbance,
irritability, insomnia, fear, confusion, depressive
symptoms, and stress. (2) Those who saw the
pandemic as a positive opportunity experienced
positive psychological effects. (3) Attempts at social
distancing had a negative psychological impact on the
population.
(1) School closures, restrictive measures, and other
factors have disrupted some students’ sleep cycles. (2)
Anxiety and depressive symptoms have remained
stable in Chinese adolescents over the last three
waves. (3) Sleep quality has deteriorated following
three months of lockdown and school closure due to
the COVID-19 pandemic.
(1) Some students believed that during the pandemic,
sleep quality had deteriorated. (2) Teenagers’ mental
health may suffer as a result of sleep deprivation,
which is a predictor of subsequent anxiety and
depression and has a negative correlation with
interpersonal functioning. (3) Females and older
children/adolescents were the most affected.
(1) When compared to the pre-pandemic figure,
adolescents spent 41.7% more time on social media.
(2) They have also reported a decrease in time spent
outside, meeting friends, and school performance. (3)
Additionally adolescent have faced an increase in
stress post-pandemic.
(continued on next page)
Pillai R, Patel I and Balkrishnan R
Table 1 (continued)
Study
12
de Bruin et al., 2021
Marciano et al., 202213
Ellis et al., 202014
Wang et al., 202215
Otto et al., 202116
Fernández-Aranda et al.,
202017
Matthews et al., 202118
Ravens-Sieberer et al., 202119
Yard et al., 202120
Kouzy et al., 202021
Cauberghe et al., 202122
Waselewski et al., 202023
Condition studied
Anxiety
Anxiety, depression
Depression
Anxiety, depression
Depression, eating disorder
Eating disorder
Eating disorder
Anxiety, depression
Depression
Anxiety, depression
Anxiety
Anxiety, depression
Population studied
2 panel surveys conducted over 2 months in the
Netherlands
Systematic review and meta-analysis of 30 studies
regarding digital media usage and adolescent
mental health
Survey of 1 054 adolescents (aged 14‒18 years) in
Canada. Respondents had a mean age of 16.68 and
comprised on mainly female cohorts (76.4%)
Survey of 692 middle school students and their
parents in Bejing in May 2020
Chart review of children and adolescents aged 10
to 23 years who were admitted to a children’s
hospital for eating disorders, from March 2017 to
March 2021
Review regarding COVID-19 and its impact on
eating disorders within adolescent populations
Retrospective chart review of children and
adolescents (aged 8‒18 years) with acute medical
complications of anorexia nervosa or atypical
anorexia, before, during and after the COVID-19
lockdown
Survey of 1 586 families with children aged 7 to
17 years, from May 26 to June 10
Analysis of emergency department visit of
individuals aged 12‒25 years before and during
the COVID-19 pandemic
Analysis of social media content (twitter) using 14
keywords/hashtags.
Survey conducted on 2 165 Belgian adolescents,
aged 13‒19 years.
Survey of 1 174 youth aged 14‒24 years on 20
March 2020 regarding coping behaviors during the
COVID-19 pandemic
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Main findings
(1) The COVID-19 pandemic has created a need for
people to stay up to date on current events. (2) This,
however, may cause people to avoid the news due to
upsetting information. (3) This has increased stress
and anxiety in the population, creating a conflicting
choice between preserving mental health and being
informed.
(1) Individuals who used social media during the
pandemic experienced both positive and negative
outcomes (although most garnered worsened mental
wellbeing). (2) The use of social media without direct
participation, as well as content related to idealistic
body types, has resulted in worsened mental
health.(3) Negative news articles about COVID-19 can
have a negative impact.
(1) Post-COVID-19, adolescents have reported using
social media to a greater extent. (2) Increased time
spent remaining socially connected with friends, on
the other hand, has resulted in worsened mental
health via increased depressive symptoms. (3) Physical
activity, time spent on schoolwork, and time spent
with family have all shown to improve mental health.
(1) Parents are unable to strike a balance between
work and personal life, negatively impacting their
mental health. (2) As a result, some parents have used
harsher disciplinary methods or increased parental
control, which has had a negative impact on
adolescent mental health.
(1) Within the adolescent population, there is an
increase and emergence of eating disorder symptoms.
(2) Aside from routine changes that alter behavior,
adolescents who experience depressive symptoms are
more likely to develop an eating disorder.
(1) Negative consequences for increased consciousness
during video calls, as well as further enforcement of
the “thin” body type on social media platforms, have
acted as a trigger for eating disorders. (2) Individuals
with eating disorders have a greater need for
self-management due to a decrease in the availability
of psychological support, particularly in the
“face-to-face” medium.
(1) Adolescent inpatient census, daily admission, and
rapid readmission rates have all increased
significantly since COVID-19. (2) Protective measures
such as social isolation, quarantine, and so on have
made it increasingly difficult to seek in-person
psychiatric help and treatment, which may exacerbate
the existing symptoms.
(1) When compared to pre-pandemic data, adolescents
have experienced increased feelings of burden and
have become more susceptible to mental illness. (2)
The pandemic has resulted in an increase in mental
and psychosomatic health problems, as well as a
decrease in health-related quality of life.
Suicide rates among adolescents increased by 31%
compared to the previous year’s figures, with girls
being the most affected (up by approximately 51%).
(1) There have been an alarming number of social
media posts about COVID-19 that are either false or
cannot be verified. (2) Increase amounts of
data/emotional content associated with the pandemic
can overwhelm populations, leading to an increase in
anxiety and depression.
Adolescents with anxiety use social media to better
cope with situations, stay socially connected to
friends/family (which is unrelated to feelings of
happiness), and alleviate feelings of distress and
anxiety.
(1) Adolescents’ mental health has suffered as a result
of the Pandemic, which prompt them to use methods
to cope with these feelings, such as social connection,
relaxation, staying busy, and routine. (2) Telehealth
appears to be a potential solution to the population’s
deteriorating mental health.
(continued on next page)
Pillai R, Patel I and Balkrishnan R
Table 1 (continued)
Study
Türk et al., 202124
Temple et al., 202225
Kang et al., 202126
Ashworth et al., 202227
Gray et al., 202028
Meng et al., 202129
Schleider et al., 202230
Ding et al., 202031
Bonardi et al., 202232
Carey, 202033
Binagwaho et al., 202134
COVID-19: coronavirus disease 2019; OCD: obsessive-compulsive disorder; PTSD: post-traumatic stress disorder.
Condition studied
Anxiety, depression
Anxiety, depression
Depression
Anxiety, depression
Depression
Anxiety, depression
Anxiety, Depression, Eating
Disorder
Anxiety, depression
Anxiety, depression
Anxiety, depression
Anxiety, depression
Population studied
Survey of 3 058 students (2 080 females and 978
males) who are studying in secondary and high
school in Sahinbey District in Gaziantep
Randomized controlled trial of 1 188 adolescents
from 12 Texas public middle schools
4 898 adolescents were surveyed from middle
schools in 13 urban and rural areas in China using
two questionnaires.
11- to 14-year-olds across north west england were
surveyed online, from September 2020 to
December 2020, concerning their lockdown
experiences and mental health
Cross sectional survey of 2 020 participants using
five instruments to gather data on the population
Survey and Cross-sectional study of 3 351 college
students in China, in relation to sociodemographic
and COVID-19 characteristics, the needs of school
support and mental wellbeing
Randomised control trial testing online-single
session interventions on 2 452 adolescents aged 13
to 16 years old.
Survey of 1 200 adolescents from provinces if
Hunan and Guangxi in China, from February to
April 2020.
Systematic review of interventions that aim to
address mental health symptoms of COVID-19,
from 31 December 2019 to 22 March 2021.
Not reported
Review of adolescent and children mental health
and its possible outcomes during the COVID-19
pandemic
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Main findings
(1) Adolescents who had high levels of depression and
anxiety used more avoidant and negative coping
strategies. (2) Adolescents who use active coping
strategies (such as problem-solving) have less anxiety
and depression. (3) Other factors, such as sex, parental
education level, school grade, and social media usage,
have been identified as predictors of anxiety and
depression in the population.
(1) Stress has been linked to increased usage of
marijuana, alcohol and e-cigarettes among the
adolescent population. (2) Family related relationship
difficulties, and increased social interaction, have been
linked to increased misuse of substances. (3) Food
bank usage has been linked to depressive symptoms.
(1) Adolescents have adopted a sedentary lifestyle as a
result of routine changes brought about by the
introduction of COVID-19. (2) This lifestyle has
resulted in a deterioration of mental health. (3) As a
result, there must be an increase in physical activity,
which can alleviate feelings of rage, exhaustion, and
depression.
(1) Adolescent mental health can benefit from
increased social support and positive experiences. (2)
Greater adherence to government guidance,
community and school connection act as protective
factors for internalizing difficulties and wellbeing
only, while family keyworker status, family
connection, and the number of parents at home act as
protective factors for externalizing difficulties and
wellbeing only. (3) Peer support and knowledge of
Covid-19 among family members were protective
factors for wellbeing.
(1) Individuals with a higher perceived sense of social
support had a lower risk of depression and poor sleep
quality. (2) Individuals who isolate themselves have
higher rates of depression, irritability, and loneliness.
(1) Students are increasingly reliant on schools for
psychological and informational support. (2) Using
methods to learn about the COVID-19 pandemic, such
as online curricula and books, can help to reduce
anxiety and depression.
(1) 20 to 30 min online interventions that use
behavioral activation and personality growth mindset
to help with mood regulation and adopting a belief of
flexible character can help improve one’s agency. (2)
It reduced the population’s depression, anxiety,
restrictive eating, hopelessness, and COVID-19-related
trauma.
(1) Peer education, which promotes open
communication in a public setting, has been shown to
reduce depression, anxiety, and improve sleep quality
in adolescents. (2) When combined with physical
exercise, this intervention has resulted in significantly
improved mental health in the population.
(1) Various interventions that use evidence-based
strategies to address mental health problems within
populations can be a promising solution. (2)
Self-guided online intervention can help reduce the
mental health challenges that different populations
face.
(1) The University of Chicago has developed an online
intervention called “Path 2 Purpose”, which is aimed
at adolescents suffering from depression or anxiety.
(2) The intervention, which teaches stress
management, mindfulness, and relationship building
skills, is a promising example of possible large-scale
solutions to combat deteriorating mental health.
(1) Adolescents and children who have psychological
problems are rarely treated on time. (2) This can result
in impaired daily functioning as well as increased
comorbity. (3) Long-term solutions to help diagnose
and treat mental health conditions in adolescents must
be implemented by governing bodies.
Pillai R, Patel I and Balkrishnan R
Fig. 1. PRISMA diagram of study selection for inclusion in review.
on the screen is associated with increased sleep problems, further con-
tributing to anxiety. However, the discernible outcomes of social media
on adolescents’ mental health are dualistic. Providing teenagers with a
medium of staying connected during social isolation, may deplete the
feelings of isolation experienced.13 Increased time spent on social me-
dia and remaining socially connected with peers, virtually has revealed a
worsened mental health (increased loneliness and depression). To coun-
teract this, time spent on school work and with the family has proved the
opposite.14
3.1.4. Parent work-life conflict
Links between adolescent mental health and parental work-life con-
flict can be found. With parents unable to find a sufficient balance be-
tween work and life and facing conflicts, parental mental health has
significantly deteriorated, and as a result of the increased work-family
demands experienced by parents, adolescent mental health has simulta-
neously decreased. Parents and adolescents, themselves, have reported
decreased adolescent mental health, alongside facing academic difficul-
ties and lowered vitality. This may be due to the increase in harsher
disciplinary/parenting methods used by parents due to the work-family
conflicts which can thereby lead to depleting adolescent mental health.
Furthermore, increased parental control was associated with increased
mental health difficulties faced by the adolescents, contrary to some par-
ents’ reasoning of increasing support through involvement. Surprisingly
within the sample of the study, only 5.92% of adolescents reported open
communication between parents and teachers, which can only amplify
the issues.15
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Global Health Journal 7 (2023) 78–86
3.1.5. Eating disorders (ED)
Alongside elevated levels of anxiety and depression within various
adolescent cohorts, the COVID-19 pandemic has heightened the im-
pact of eating disorders within the population. Within the first wave
of COVID-19, an influx in the number of diagnoses and hospitalization
of anorexia nervosa or atypical anorexia nervosa within adolescents
was observed.7 Within which those suffering from these ailments si-
multaneously had comorbid psychopathology, wherein heightened anx-
iety, depression and obsessive-compulsive disorder were witnessed. The
pandemic might have served as a trigger for previously diagnosed pa-
tients, while simultaneously worsening the symptoms of the same due
to anxiety, social isolation, and reduced contact with their treatment
teams. Moreover, increased social media usage with harmful messages
regarding body image could have further exacerbated anorexia.16 Whilst
stressful events can act as a trigger for eating disorder patients, a lack of
a clear routine could have further aggravated this issue. The pandemic
has produced various possible triggers for those adolescents who show-
case symptoms of ED. With an increasing amount of teenagers spending
their spare time online due to the constant availability of electronics,
and the need to maintain social relationships virtually, media has cre-
ated a prominent role in the increasing number of ED cases within this
population. Video conferences for online classes may prompt adoles-
cents to question their self-image due to their appearance on the screen
during virtual interactions, thereby prompting a trigger for ED.17 More-
over, social media in its entirety further enforcing the "thin" body ideal
for teenagers can further add to this issue. In contrast to the increasing
need for medical help for ED patients, the protective measures imposed
Pillai R, Patel I and Balkrishnan R
have reduced the availability of in-person psychiatric help, and treat-
ment programs and made access to it increasingly difficult.18 In addi-
tion, compared to pre-pandemic cohorts, post-pandemic cohorts of ado-
lescents demonstrated higher levels of “restraint” (restricting intake),
higher levels of over-exercising, and higher levels of functional impair-
ment, mental instability and hospitalization. Plausible reasons for the
increased need for medical attention for eating disorders among adoles-
cents arise from the bases of a lack of clear structure within the routine
for adolescents. This phenomenon resulted in a lack of physical exercise,
increased spare time spent on social networking apps, and diminishing
social support and normative development.6
3.2. Outcomes and treatment/prevention strategies
3.2.1. Outcomes
The COVID-19 Pandemic has caused a reduction in mental health-
related quality of life (HRQOL), especially for adolescents. By reduc-
ing the overall standard of life of physical and mental health over this
period, the pandemic has caused a significant increase in mental and
psychosomatic health problems among adolescents, compared to pre-
pandemic figures. Adolescents who miss schools often, have less social
contact due to protective measures, and socially disadvantaged children
and children whose parents face mental illnesses are at increased risk of
a reduction in HRQOL. Alongside facing an increase in depression and
anxiety, distress rates have increased for this population.19
This culmination of worsened individual and situational factors can
result in threatening outcomes. As stated previously, many states have
witnessed an increase in adolescent suicide rates as compared to pre-
pandemic data. Moreover by May 2020, ED visits for suspected suicide
attempts increased by 31% for adolescents aged 12‒17 years, compared
to the previous year figures. From 21 February to 20 March 2021, ED vis-
its for girls and boys within this age group increased by approximately
50.6% and 3.7%, respectively.20
Given the toll on mental health compared to pre pandemic era, there
was a need towards effort of adequate mental health facilities. Unfor-
tunately, many countries fell short of accomplishing this. A report by
World Health Organization (WHO) highlighted the unfavorable real-
ity. Only 51% of WHO’s member states reported a mental health pol-
icy/plan that confirmed with international and regional human rights
instruments. 52% of countries were able to meet the targets regarding
mental health promotion and prevention programs. These dismal figures
missed the 80% mark set by WHO. Regrettably, government budgets for
mental health have remained mostly stagnant at around 2% even after
the pandemic began. Given the worsening condition of mental health
within the population, immediate and complete efforts are required by
governing bodies to counter this situation.
3.2.2. Coping mechanisms
Given the current state of well-being, adolescents consciously or un-
consciously have adopted various coping strategies. Adolescents have
also continued to use social media as a coping mechanism to counter-
act feelings of loneliness and anxiety. Often using social media to regu-
late one’s feelings it’s been observed that using social media to actively
face the pandemic, has relieved feelings of distress and anxiety. Further-
more, social media has been associated with higher feelings of loneliness
when used as a substitute for physical social interaction. The informa-
tion posted on social media related to COVID-19 can overwhelm the
population and emotional content related to COVID-19 can cause in-
creased feelings of anxiety and depression.21 Alternatively, there is a
beneficial outline of social media. Those adolescents who have anxiety
symptoms have benefited from social media to be able to face the cur-
rent situation.22 Few methods that adolescents may use to cope with
the circumstances include but are not limited to social connection, re-
laxation, staying busy and routine.23 While some may prove effective in
the short run, many methods to cope with the pandemic, are unhealthy
methods that may worsen adolescent mental health. Furthermore, it has
84
Global Health Journal 7 (2023) 78–86
been noted that adolescents who utilize negative (entailing individu-
als who exaggerate the effects of an issue and use blaming behavior)
and avoidant coping strategies experience a greater amount of depres-
sion and anxiety. Whereas adolescents who use active coping strategies,
such as utilizing problem-solving face lower rates of depression and anx-
iety,24 elevated levels of stress, due to COVID-19, have been linked to
increased misuse of substances in the form of alcohol, marijuana and
e-cigarettes, especially the latter. Lowered likeliness for usage of sub-
stances were witnessed with adolescents who had less social interaction
during the epidemic, and adolescents who did not face significant re-
lationship difficulties with their family.25 This highlights the extensive
evidence that coping methods have on manipulating adolescent mental
health, thus one must consciously attempt to choose healthy methods to
cope with circumstances.
3.2.3. Prevention strategies
Adolescent mental health can be maintained by consciously imple-
menting healthy lifestyle changes. Avoiding sedentary lifestyle, adher-
ing to government guidance, maintaining social ties and mental health
programs can help prevent any possible mental health problems within
adolescents. For instance, the pandemic has caused adolescents to adopt
a sedentary lifestyle, which is associated with worsening mental health
of the population. Physical activity has been significantly associated
with mood states in adolescents. An increase in physical activity can
help reduce adolescents’ anger, fatigue, and depression and produce
positive emotional states.26 Hence adolescents must attempt to adopt
a healthy lifestyle with ample physical activity to maintain mental well-
being. Apart from changes in routine activity, specific factors such as ad-
herence to government guidance have acted as a protective measure for
adolescents in internalizing difficulties and overall wellbeing. By avoid-
ing circumstances which may enable COVID-19 symptoms, and situa-
tions which can increase the risk of contracting the virus, anxiety can be
significantly reduced within the population by lowering the fear of con-
tracting the virus itself. Stronger peer support and greater family-level
knowledge of COVID-19 can act as a protective factor for general well-
being. Additionally, social ties such as community, school connections
and family connections can act as a protective factor for internalizing
and externalizing difficulties, respectively.27
Gray et al. found that compared to individuals with lower perceived
social support, individuals with higher perceived social support expe-
rienced a 63% lowered risk of elevated levels of depression as well as
a 52% lowered risk of poor sleep quality.28 This shows the increased
depression symptoms is directly related to the perceived level of social
support. These factors may actively contribute to diminishing mental
well-being. Adolescents can take precautionary steps towards improving
mental health by maintaining social ties and actively trying to adhere
to guidance.
Furthermore, increased psychological and informational support
from schools has shown an improvement in adolescent mental health.
Schools can attempt to maintain adolescents’ mental health by provid-
ing accurate information on COVID-19 and precautionary measures, as
well as counselling services to regulate emotional responses due to the
pandemic.29 However, as stated in the aforementioned text, an overload
of COVID-19-related information may compound the problem, so infor-
mation support must be provided with limitations to avoid increasing
anxiety among adolescents.
We can attempt to reduce the chances of further neglecting adoles-
cent mental health and instead contribute to implementing a positive
change in mental wellbeing. This can be done by enforcing individual,
such as parental guidance with steering adolescents away from a seden-
tary lifestyle, and community-based changes, such as increased mental
health programs and interventions within schools, to provide support
and prevent detrimental routine changes.
3.2.4. Treatments
One of the important solutions toward resolving the situation would
be to seek adequate psychiatric help; however, due to limited financial
Pillai R, Patel I and Balkrishnan R
resources, all adolescents may not be able to seek psychiatric help. Solu-
tions must be implemented on a larger scale to be able to create an effec-
tive change by allowing for the treatment of wider groups of individuals.
If not implemented previously, possible treatments through therapies
and intervention strategies must be implemented to negate or reduce
any potential consequences. Single session interventions can be utilized
amongst the adolescent population to enhance their cognitive wellbe-
ing. Studies implementing interventions based on behavioral activation
(the practice of controlling one’s mood by engaging in pleasurable activ-
ities) and growth mindset of personality (belief that personal character-
istics and symptoms could alter) have shown a reduction in symptoms
of depression, anxiety, restrictive eating, hopelessness and COVID-19-
related trauma in high-symptom adolescents while improving perceived
agency.30 This improves adolescent health-related knowledge. Another
beneficial intervention which reduced adolescent anxiety and depres-
sion and improves sleep quality, is peer education intervention, which
is used for communicating information and resources in natural settings,
can also be used to target depleting adolescent mental health. The same
has been found to reduce adolescent anxiety and depression as well as
improve sleep quality.31 Interventions such as peer education Interven-
tion, single-session interventions, and others such as self-guided internet
intervention, social support-based interventions et cetera,32 are possible
treatments that can be used to negate the prevailing declining mental
health of the population. Consequently, educational institutes can em-
ploy a person in permanent basis who can target mental health problems
in school as regularity of mental health care in adolescents are a neces-
sity to improve wellbeing. Thereby mental health problems can be tar-
geted for further improvement and a visible improvement in adolescent
mental health can be achieved.
Individual or group therapies guided by mental health profession-
als can be provided to correct the situation. Mental health issue issues
may continue to worsen even after the COVID-19 pandemic, thus timely
action is the need of the hour.
4. Discussion
While the initial solution to improving adolescent mental health
should be prevention-based, by allowing adolescents to use a clear rou-
tine that includes regular physical exercise, regulating sleep cycles,10
and balanced schedules between school and personal life, the issue has
already escalated. The methods mentioned above promote adequate
psychological health by assisting adolescents in coping with new cir-
cumstances while not jeopardizing their mental health. Further preven-
tion strategies including maintaining social ties remain vital for reduc-
ing depression, and anxiety symptoms within adolescents.27 This may
be achieved by limiting social media use during this period, by adher-
ing to government protocols and garnering strong peer support. How-
ever excessive social media use can be potentially harmful as harsh mes-
sages involving “idealistic” body types, excessive information about the
COVID-19 pandemic, and so on can all negatively impact mental well-
being.18 Environmental factors surrounding the psychological and infor-
mational support of COVID-19 within schools can help students regulate
their emotions and thereby prevent/treat any mental health issues.29
This may be in the form of awareness campaigns, counseling services
and precautionary measures. Schools can attempt to implement inter-
vention strategies, which can further benefit the mental health of ado-
lescents by promoting active cognitive growth and well-being, and by
teaching adolescents methods to cope with the varying circumstances
healthily.
However, adolescents who are already experiencing depleting men-
tal health must be prompt to seek psychiatric help, if permissible in the
circumstances. By seeking psychological help as soon as possible, any
developing mental health issues can be resolved without causing fur-
ther harm to the individual. Unfortunately, circumstances have reduced
the population’s resources. Individuals may be hesitant to seek profes-
sional help due to increased restrictions and a lack of adequate funding.
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Global Health Journal 7 (2023) 78–86
This situation necessitates a broader solution, which must be initiated by
governing bodies. Implementing protocols and putting more emphasis
on this population’s deteriorating mental health should be prioritized.
Implementation of mental health plans, prevention programs, and in-
creased funding for mental health in government budgets are required
to address this issue.
Parents may need to be educated regarding the rise in mental
illnesses and imbalance amongst adolescents and possible preven-
tion/treatment strategies. By acknowledging various factors contribut-
ing to the declining psychological well-being of the population, parents
may be able to guide their children by taking preventative measures or
providing treatments, if necessary. Furthermore, by understanding the
link between parent-work life conflicts and their potential consequences,
such as decreased mental well-being for both parents and adolescents,
parents can promote open communication in order to reduce mental
imbalance.15
An increasing need for communication and media campaigns is also
witnessed. By focusing on possible preventative strategies and increas-
ing the awareness of the problem, action can be taken before affect-
ing a greater population. A public health initiative by the University
of Illinois, Chicago developed a program named “Path 2 Purpose” to
combat mental illnesses within teenagers, by targeting resilience, stress
reduction and relationship-building skills. This campaign utilizes online
portals able to reach wider audiences and aims to negate the declining
mental health faced by teenagers today.33 Such initiatives implemented
on a wider scale can help bring attention to and put solutions into action
for the adolescent population.
To combat the issue, government programs such as diagnosis and
treatment tools, interventions and awareness programs, and others may
be implemented on a large scale. For example, during the Ebola outbreak
in Liberia, a study used community-based expressive arts programs to
reduce mental stress among adolescents and children. Furthermore, ef-
forts made for intervention-based programs for children can be applied
to adolescents. Other interventions have also been successful previously.
Such as the storybook titled My hero is you: how kids can fight COVID-
19! Emphasized the importance of open communication amongst fam-
ilies to mitigate prevailing mental distress and create awareness.34 By
varying the mediums and structure, these strategies can be targeted and
implemented for adolescent populations as well. Using online websites
and apps to raise global awareness of adolescent mental health and the
troubling trends seen post-covid can start a conversation in the home.
Furthermore, demonstrating problem-solving strategies can provide par-
ents and teenagers with a clear and efficient way to resolve these issues.
Optimizing mental health is not only critical to the future function
of society and thus predictive of future functioning, but it is also critical
to the continued improvement in human life quality. Adolescent mental
wellbeing is critical for individuals to grow into healthy adults. How-
ever, the pandemic has created a schism that has disrupted the norma-
tive pattern of cognitive growth, putting adolescents’ mental wellbeing
at risk. Mental health conditions, suicide rates, and feelings of hopeless-
ness will continue to rise in the absence of optimal mental health. This
may have an impact on our future standard of living by putting our men-
tal health and beneficial opportunities at risk. Adolescent mental health
must be kept in check in order to build a promising future, and due to
the current circumstances, immediate action is required.
5. Conclusion
While studies have shown that there is an increasing need for inter-
vention strategies, potential preventive measures, and treatments for
adolescents, global implementation of the same must begin expedi-
tiously. Adolescent mental health in the post-Covid era globally can
be improved by encouraging adolescents to prioritize mental health
through preventive measures and governing bodies providing adequate
funds and emphasis on the mental health sector. Possible therapies and
intervention strategies can be implemented in educational institutes reg-
Pillai R, Patel I and Balkrishnan R
ularly to sustain teenagers’ mental health, alongside providing support,
information and assistance. Further research must be conducted look-
ing into sustainable interventions which have the potential to be imple-
mented on a wide scale. Moreover, by continuing the practice of sus-
taining adolescent mental health in the future, any further hinderances
in psychological wellbeing may be avoided. By executing these strate-
gies and alerting parents and educators over this prevailing issue, we
can help adolescents sustain ideal mental health and treat any possible
deviations from the same if witnessed.
Competing interests
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
CRediT author statement
Rea Pillai: Conceptualization, Methodology, Writing – original
draft. Isha Patel: Conceptualization, Writing – review & editing.
Rajesh Balkrishnan: Conceptualization, Writing – review & editing.
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