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Vol. 79. (In progress)
(January - December 2024)
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Vol. 79. (In progress)
(January - December 2024)
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Mental health and sleep quality issues in adolescents with chronic conditions during and after COVID-19 quarantine
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Renan Andrews de Sousa, Levi Medeiros Vieira Paradelas, Livia Lindoso, Reinan Tavares Campos, Rafaela Mendes Battiferro, Beatriz Oliveira Leão Carneiro, Jean Paulo Veronesse de Souza, Marianna Ribeiro de Menezes Freire, Maria Paula Ribeiro Cardoso, Claudia Alejandra Ayala Strabelli, Clovis Artur Silva
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Instituto da Criança e Adolescente, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
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Table 1. Demographic data, Strengths and Difficulties Questionnaire (SDQ), Pittsburgh Sleep Quality Index (PSQI) and Pediatric Quality of Live Inventory 4.0 (PedsQL4.0) scores reported by adolescents during COVID-19 quarantine and after COVID-19 quarantine.
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The COVID-19 pandemic was considered a catastrophic event for physical and mental health in adolescents.1,2 A systematic review showed an increased incidence of psychiatric issues for this population during this period,3 and the World Health Organization (WHO) also categorized adolescents with chronic conditions as a high-risk group during the pandemic.4

The authors demonstrated in a cross-sectional study that one-third of both chronic immunocompromised conditions and healthy teens had severe psychosocial dysfunction during COVID-19 quarantine. Female sex, fear of underlying disease activity or complication, and household members working outside of the home were relevant factors associated with adolescents with chronic immunocompromised conditions.5 The authors also showed poor sleep quality frequencies in both groups (38 % and 48 %) in another report.6 Another cross-sectional study of our group identified emotional, hyperactivity and inattention problems in up to one-third of immunocompromising chronic disease teens during this emergent period.7 All these researches were performed before the COVID-19 vaccination period for adolescents.5-7

A prospective study evaluated emotional issues during the COVID‐19 pandemic in Brazil, and showed fluctuations in mental symptoms of non-vaccinated children and adolescents. Lowest socio-economic status, chronic condition demanding treatment and family members with COVID-19 have increased these mental issues over time.8

A recent meta-analysis study showed that the prevalence of mental health issues increased during the COVID-19 pandemic progression, even though recovery and stabilization of these were also evidenced. However, this report did not include subgroup analysis of immunocompromising chronic conditions, precluding a definitive conclusion of longitudinal mental health impact for this population.9 Therefore, the objective of this prospective study was to evaluate mental health and sleep quality issues in the teen population in two distinct moments: during the COVID-19 pandemic (non-vaccinated adolescents) and after the COVID-19 pandemic (vaccinated adolescents).

Between June and December 2022, a follow-up online survey was sent for the same subject's population (n = 504) of previous studies,5-7 using the validated instruments to assess prospectively: mental health (Strengths and Difficulties Questionnaire [SDQ]), Health-related quality of life (HRQL) (Pediatric Quality of Live Inventory 4.0 [PedsQL4.0]) and sleep quality [Pittsburgh Sleep Quality Index (PSQI)]. The survey was sent using the REDCAP© platform at least six times to each subject, and contained a consent form signed by the guardians, an assent form signed by the adolescents, a semi-structured socioeconomic questionnaire, and the validated instruments.

During recruitment, n = 38 (35.2 %) of healthy adolescents and n = 86 (25.1 %) patients signed assent form. However, only n = 27 participants (6.0 %) (n = 18 patients and n = 9 healthy controls) finished the follow-up survey and had previously answered the questionnaires during the COVID-19 pandemic. According to diagnosis, rheumatologic conditions occurred in n = 4 (22.2 %), gastrointestinal conditions in n = 8 (44.4 %), and renal conditions in n = 6 (33.3 %).

Further comparison between adolescents during versus after COVID-19 quarantine showed that vaccinated against COVID-19 (≥ 2 shots; 0 vs. 96 %, p = 0.0001), vaccinated against COVID-19 (3 shots; 0 vs. 55 %, p = 0.001) and COVID-19 diagnosis confirmed by test (0 vs. 41 %, p = 0.0003) were significantly higher in the former group. Online school activities were significantly reduced after COVID-19 quarantine (p < 0.0001) (Table 1).

Table 1.

Demographic data, Strengths and Difficulties Questionnaire (SDQ), Pittsburgh Sleep Quality Index (PSQI) and Pediatric Quality of Live Inventory 4.0 (PedsQL4.0) scores reported by adolescents during COVID-19 quarantine and after COVID-19 quarantine.

Domains  Adolescents during COVID-19 quarantine(n = 27)  Adolescents after COVID-19 quarantine(n = 27)  p 
Semiestructured socioeconomical questionaire       
Demographic data       
Current age  14 (10‒17)  16 (12‒19)  0.001 
Female sex  13 (48)  13 (48)  1.000 
Use of daily medication  17 (63)  13 (50)  0.500 
Psychological or psychiatric care  2 (7)  7 (26)  0.142 
COVID-19 diagnosis and vaccination       
Vaccinated against influenza  16 (59)  19 (70)  0.393 
Vaccinated against COVID-19 (≥ 2 shots)  0 (0)  26 (96)  0.0001 
Vaccinated against COVID-19 (3 shots)  0 (0)  15 (55)  0.0001 
COVID-19 diagnosis confirmed by test  0 (0)  11 (41)  0.0003 
Hospitalization due to COVID-19  0 (0)  3 (11)  0.236 
Sleep time       
Sleep after midnight  19 (70)  14 (52)  0.163
Sleep before midnight  8 (30)  13 (48) 
Sleeping disorder  9 (33)  7 (26)  0.551 
Online school activities       
Without  0 (0)  17 (63)  <0.0001
≥ 3 h/day  14 (52)  5 (19) 
< 3 h/day  13 (48)  5 (18) 
Housework       
None  7 (26)  7 (26)  0.788
≤1 hour/day  5 (18)  7 (26) 
>1 hour/day  15 (56)  13 (48) 
Screen time       
≤ 2 h/day  0 (0)  3 (11)  0.134
3‒6 h/day  16 (59)  11 (41) 
> 6 h/day  11 (41)  13 (48) 
Family financial status       
Did not change  19 (70)  17 (63)  0.820
Worsen  7 (26)  8 (30) 
Improved  1 (4)  2 (7) 
SDQ       
SDQ score       
SDQ total score (0‒40)  12.7 ± 6.3  11.6 ± 5.8  0.350 
Abnormal SDQ, (total score 20‒40)  5 (18.5)  4 (14.8)  0.715 
SDQ domains scores       
Prosocial (0‒10)  7.04 ± 2.3  7.37 ± 2.0  0.431 
Hyperactivity (0‒10)  4.41 ± 3.0  4.04 ± 2.7  0.464 
Emotional (0‒10)  3.48 ± 2.5  3.48 ± 2.5  1.000 
Conduct (0‒10)  2.52 ± 2.0  1.85 ± 2.0  0.077 
Peers (0‒10)  2.30 ± 1.8  1.85 ± 2.0  0.389 
Internalizing (0‒20)  5.78 ± 3.6  5.97 ± 3.6  0.877 
Externalizing (0‒20)  6.93 ± 4.4  5.89 ± 3.9  0.148 
SDQ domains abnormal scores       
Prosocial disorders, (score 0‒4)  11 (40.7)  8 (29.6)  0.393 
Hyperactivity disorder, (score 7‒10)  8 (29.6)  5 (18.5)  0.340 
Emotional disorder, (score 7‒10)  5 (18.5)  5 (18.5)  1.000 
Conduct disorder, (score 5‒10)  5 (18.5)  4 (14.8)  1.000 
Peers problems, (score 6‒10)  5 (18.5)  4 (14.8)  1.000 
Internalizing disorder, (score 11‒20)  5 (18.5)  5 (18.5)  1.000 
Externalizing disorder, (score 13‒20)  6 (22.2)  4 (14.8)  0.484 
PSQI score       
PSQI score       
PSQI total score (0‒21)  5.65 ± 2.6  3.48 ± 3.0  0.038 
Good sleep quality, total score ≤5  9 (39.1)  20 (70.4)  0.013 
PSQI domains scores       
Overall sleep quality (0‒3)  0.69 ± 0.88  0.74 ± 0.62  0.285 
Sleep latency (0‒3)  1.13 ± 0.97  0,91 ± 0.90  0.347 
Sleep duration (0‒3)  0.13 ± 0.63  0.26 ± 0.54  0.479 
Sleep efficiency (0‒3)  0.50 ± 0.89  0.88 ± 1.26  0.304 
Sleep disturbances (0‒3)  1.26 ± 0.45  1.17 ± 0.39  0.328 
Sleep medication use (0‒3)  0.78 ± 1.24  0.61 ± 1.20  0.590 
Day dysfunction due to sleepiness (0‒3)  0.96 ± 0.93  0.83 ± 1.15  0.613 
PedsQL4.0 score       
Total score (0‒100)  77 (35‒95)  77 (44.5‒100)  0.440 
Physical health summary score (0‒100)  84 (31‒100)  81 (38‒100)  0.792 
Psychosocial health summary score (0‒100)  73 (20‒92)  78 (45‒100)  0.203 
Emotional functioning (0‒100)  65 (30‒95)  75 (25‒100)  0.114 
Social functioning (0‒100)  93 (20‒100)  90 (65‒100)  0.715 
School functioning (0‒100)  65 (0‒100)  75 (15‒100)  0.189 

Results are presented in median (minimum‒maximum values), mean ± standard deviation and n (%).

Importantly sleep quality of adolescents improved after the COVID-19 quarantine. The mean PSQI total score was significantly higher in adolescents during versus after COVID-19 quarantine (5.65 ± 2.6 vs. 3.48 ± 3.0, p = 0.038), whereas the frequency of good sleep quality was significantly lower before COVID-19 quarantine (39.1 vs. 70.4, p = 0.013).

Abnormal SDQ score was high and similar in both groups (18.5% vs. 14.8 %, p = 0.715). No differences were observed before and after COVID-19 quarantine in all parameters of mental health score (SDQ) and HRQL (PedsQL) (p > 0.05).

The main limitation of the present study was low adherence to questionnaire responses. This finding may be related to tiredness, possibly due to fatigue by the information overload of the COVID-19 quarantine. Low response rates in research also have been described during SARS-CoV-210 and may be related to subjects feeling undervalued, and media overexposed of adolescents during and after this emergency crisis.

In conclusion, the present study showed psychosocial dysfunction in approximately 15 % of adolescents with chronic immunocompromised conditions and healthy teens after the COVID-19 pandemic, with longitudinal improvement in sleep quality. This report highlights the necessary implementation of future programs to protect the mental health of teens from other public health disasters or emergencies.

Acknowledgments

The authors thank the colleagues for including their patients. This study was supported by grants from Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) (#2015/03756–4 to CAS), Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq 304984/2020–5 to CAS), and by Núcleo de Apoio à Pesquisa “Saúde da Criança e do Adolescente” da USP (NAP-CriAd) to CAS.

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