The present paper is one of the first reports to follow up on the COPSY-study on quality of life and mental health in adolescents after approximately 1.5 years of living with the COVID-19 pandemic. All in all, the results suggest a change of psychological stress in youths during the course of the pandemic. Whereas COPSY and other authors show an increase in mental health problems and a decrease of HRQoL after onset of the pandemic (8,18), the present results show a similar level as in pre-pandemic times. The cross-sectional design prevents identifying causal attributions, but it can be discussed if stress adaptation processes, better pandemic management, and improved medical knowledge, as well as coping strategies and a significant reduction of lockdown measures during the summer have led to an increased capability of living with the virus and a more ‘back to normality’ feeling in the population. In addition, the prospect of imminent vaccination may have had a positive influence on the psychological well-being.
Health-related quality of life (HRQoL)
The HRQoL reported by adolescents and parents is similar, both scores are in the range of an average score (T=50, SD=10), which means that HRQoL is not limited in the present sample in general. However, age and sex differences in HRQoL occur, as it was assessed significantly higher in the younger than in the older group and higher in boys vs. girls. These results are in accordance with many former findings from population-based studies, that show an decrease of HRQoL in older adolescents and especially in girls (19–22). Explanations for these differences can be found in an earlier onset of puberty and hormonal changes in girls, which lead to a physical and social transition period, challenges with new behavior, coping with the environment and can therefore decrease perceived well-being. Further, the vulnerability for psychological symptoms is increased in female adolescents which may impact psychological well-being (7).
Regarding changes of HRQoL after onset of the COVID-19 pandemic, comparable data is rare. In a systematic review about the effect of COVID-19 on HRQoL in children and adolescents, only six studies from different countries worldwide were included (18). Three studies reported a decrease of HRQoL, among them the German COPSY study (23). Two did not find a significant change, and another did not report a change. The authors conclude that different aspects of COVID-19, e.g. lockdown and quarantine measures, social isolation/distancing, school closures, had negatively impacted the quality of life in children and adolescents (18). The difference to the present data is that the cited studies all were performed at the beginning of the pandemic, at the time when more strict arrangements were enforced in most countries. The current study was performed in summer 2021 in Germany, when infection numbers were low, restrictions were loosened, schools were open, and a vaccination was already available. The impact of COVID-19 on adolescent life was not so strong as the year before, which could have led to an increase in quality of life again. Therefore, our data indicate a partial reversibility of negative first impacts of lockdown on children.
Mental health problems
The present results show a moderate frequency of clinically relevant psychological symptoms in total (18.5% by self-report) which is similar to the pre-pandemic comparison rates used in the COPSY study and are also consistent with results from a meta-analysis finding a pooled prevalence of psychological disorders in 17.6% (9,24). Other findings promote lower rates using stricter criteria (25). One must consider that the present evaluation used only questionnaire data and a less strict cut-off in the SDQ (80th percentile) to enable comparison with the COPSY data, which could have overestimated the real prevalence. Further, our data only report symptoms, not rates of manifest psychiatric disorders.
Age and sex-specific differences are shown, as older adolescents report significantly more internalizing symptoms, but less externalizing symptoms than the younger ones, girls report more internalizing symptoms, and parents report more externalizing symptoms in boys than girls. This is in line with known data, e.g. that externalizing symptoms e.g. ADHD or hyperactivity are more common in younger children and decrease with age (26). On the other hand, internalizing symptoms as anxiety or depression have a higher incidence in females (27).
The rates of mental health problems in the present study are lower than reported in other publications after the outbreak of COVID-19. In the German COPSY study prevalence rates increased to over 30% after wave 1 and 2 (8,23). Also, first meta-analyses support the data and report increased rates especially of depression (25-29%), anxiety (20-26%), sleep problems (44%) and post-traumatic stress symptoms (48%) (6,7).
Many of the cited authors see lockdown measures, social distancing and school from home to account for the increased rates, as they impact the social life and development of young people. This is supported by a recent study that found a negative association between lockdown measures and mental health of children (28). Although assessment tools differed between studies, the direction of the results is clear. Again, the difference to the current data lies in the date the studies were performed. All cited studies assessed mental health in the first year of COVID-19 outbreak where in nearly all countries exceptional circumstances and special regulations were introduced. The present data were collected at a time with less active regulations and when a vaccination was available to prospectively lower the restrictions.
Moreover, the reduced rates of psychological problems may be a result of an adaptation process to stress factors that has taken place. In the transactional stress theory of Lazarus, stress is defined as a relationship between an individual and the environment which can be influenced by two mediators, ‘cognitive appraisal’ and ‘coping’ (29). Whereas appraisal of a stressful situation (e.g. COVID-19 outbreak) is based on factors like expectancies, individual dispositions, predictability, controllability and influences the individuals’ stress reaction, coping includes cognitive and behavioral strategies to manage, tolerate, or reduce the stress reaction (29).
The increased rates of mental health problems and reduced HRQoL in the first year of COVID-19 can be interpreted as reaction to the stress induced by worrying about health, unpredictable changes in social, economic and private life of the population. This is consistent with the impact of phase 1 and 2 of an epidemic where restrictions in public and private life and closures of health services may increase psychological stress, but also lower the possibilities to receive help, e.g. from health care systems (5). Phase 3 is seen as the ‘return to normality’ phase, where re-organizing and re-establishing services and practices take place. In this phase, coping strategies and new rules (e.g. vaccinations, tests, wearing masks) have been developed and decrease perceived stress as they make the situation more predictable and controllable. This may have influenced the mental health and general quality of life of our sample. Further, the decision of getting vaccinated can be interpreted as an individual coping strategy which in turn may increase self-efficacy and lower psychological stress.
The present sample included adolescents aged 12-17 years from a specific German region who decided to receive a vaccination against COVID-19. Although vaccination willingness is relatively high in Germany overall (30), recent international studies show that the decision for a COVID-19 vaccination in children and adolescents depends on vaccine safety and efficacy, of the perceived risk of infection transmission, and specific socio-demographic variables (31–33). Willingness to receive a vaccination is increased in older adolescents, in those using more social media, and those having both parents vaccinated (32); the willingness is decreased in those with higher distress over the effects (31), and in families with a lower income and a migration background (33). This is in line with the results of the present sample, as parental education level was high (>80% had a high- or medium level of education) (15) suggesting a higher socio-economic status (SES) of the participating families. Further, 85-89% of the parents were already vaccinated (15) which increases the likelihood of their children getting vaccinated, as well.
Regarding these results, the sample does not represent a population-based group, which may have influenced the outcomes on HRQoL and mental health. Adolescents from families with a higher SES tend to have a higher quality of life and a lower risk of mental health problems (34), which may have underestimated the frequency of psychological symptoms in the population. In addition, the decision of getting vaccinated may lead to more positive thinking and optimism in adolescents, as they expect more normalization of daily life and less restrictions.
Strengths and limitations
This is one of the first study assessing HRQoL and mental health of adolescents in a large sample with over 1000 participants after the third wave of COVID-19 in a defined German region. The outcomes were measured as self- and proxy-report by valid and reliable, as well as internationally used questionnaires that allow comparison with other publications. The sample is not population-based, but representative regarding age and sex and comparable to the adolescent group tested in the COPSY study after wave 1 and 2. A limitation is the probably higher SES of the participants in the study, as only those willing to receive a vaccination were included. Therefore, our results can be generalized to samples that are vaccinated or intend to be, but not to the general population.
Moreover, one has to consider that mental health problems were assessed by questionnaires and not by clinical experts, which is why only psychological symptoms can be reported, not psychiatric diagnoses. Due to the cross-sectional study design causal attributions cannot be made.