The Coronavirus disease 2019 (COVID-19) pandemic represents an unprecedented health emergency affecting healthcare systems worldwide, with serious socioeconomic consequences (1). In the complex scenario that arose from the infection spread, mental health was prioritized because of the high psychological distress caused by social distancing and isolation (2, 3). Indeed, an increasing prevalence of anxiety, depression, irritability, and insomnia has been documented among the general population after the COVID-19 outbreak (4). The COVID-19 pandemic hit Italy consistently, and data from the epidemiological register of the Umbria region, in the center of the country, also reported a dramatic increase in the curve since the beginning of the pandemic spread (5). The rise in contagions forced the regional council to adopt severe restrictive measures to preserve the proper functioning of the hospital and healthcare network, with high psychopathological distress for the population. Indeed, previous reports underlined that the mental health of the general population in central Italy was significantly impacted by the pandemic, as also demonstrated by the increase of psychiatric consultations in emergency services (6).

However, the risk of developing COVID-19-related psychological distress was particularly high in vulnerable populations, such as in subjects aged 16–24 years old, who represented one of the groups most affected by the pandemic emergency (7–10). Lockdown measures had an unfavorable impact on adolescents and young adults, and a large amount of literature highlighted a greater risk for the occurrence of psychiatric symptoms due to a change in their lifestyles and habits (11) as well as lower levels of post-traumatic growth (12). For instance, the closure of schools has imposed distance learning as an alternative to maintain continuity in the education of children and adolescents (13). The subsequent prolonged social isolation threatened the psycho-physical wellbeing of youths, worsening or unmasking psychopathology (14). During the pandemic, there has been a widespread increase in depression, anxiety, irritability among children, and adolescents, and suicidal behaviors (8, 15, 16). Studies conducted in Italy already demonstrated a high prevalence of moderate or severe anxiety among youths (17), as well as a higher risk for developing problematic internet use in this population during the pandemic (18).

Furthermore, limitations due to infection imposed an adaptation in the availability of psychiatric and psychosocial interventions in dedicated settings, which were pointed out as critical needs for this population (19–21). For this reason, implementing telepsychiatry and integrating interventions to maintain regular and emergency child and adolescent psychiatric treatment during the pandemic was identified as a significant challenge that could be necessary for limiting long-term consequences on mental health (22). In fact, integrated intervention programs (medical intervention, psychotherapy, psychoeducation to family members, social intervention) seem to have a considerably better impact than treatment-as-usual in the youth population, especially at disease onset (23).

Several countries had already allocated tailored funding for the mental health of adolescents and young adults before the pandemic (24) and conducted specific campaigns to address children and young people’s mental health in the COVID-19 era (25). To this end, the European Year of Youth 2022 presents an opportunity for countries and organizations to enhance health promotion initiatives and focus on mitigating mental health problems in this population (26).

Within this scenario, the Italian Umbria region had already decided to allocate specific funds to widen the possibility of mental health departments supporting youths with psychopathological distress. The Addiction Service (SerD) of Local Mental Health 2 (USL Umbria 2) in Foligno agreed with the Umbria region to expand its curative offer by implementing an outpatient service dedicated to adolescents and young adults who present psychological distress.

Based on these premises, the present study aimed to investigate the pandemic’s impact on adolescents and young adults, analyzing data from the abovementioned outpatient youth mental health service. Notably, changes in access to mental health care, clinical and treatment features of patients in charge of the service before the pandemic were furtherly analyzed. A secondary analysis was performed to evaluate access to care and changes in clinical and treatment features of subjects suffering from psychiatric disorders. Particularly, we expect to detect significant changes in diagnostic and treatment (both psychopharmacological and psychosocial) features after the COVID-19 outbreak, possibly reflecting differences in pathways to care and patterns of care for this population.

After the COVID-19 outbreak, there was a significant increase in the number of interventions supplied to subjects who first accessed the service in the “pre-COVID-19” period. We found an increase in the mean age of subjects who accessed the service in the “during-COVID-19” period, a higher prevalence of anxiety disorders, and an increase in the use of anxiolytics and mood stabilizers. A reduction in the prevalence of opioids use disorder and in the use of substitution therapy for opioid dependence was also observed. Furthermore, we observed a highly significant increase in digital mental health interventions in the “during-COVID-19” period, as well as a decrease in family therapies, both provided by digital tools and in-person, with a high significance of the difference in the subpopulation of subjects suffering from psychiatric disorders. Treatment features of people who were already followed by the service before the COVID-19 outbreak did not significantly change, except for the number of supplied interventions and the already mentioned increase of digital interventions.

New accesses to the service after the COVID-19 outbreak were stable, which is in line with the literature on the topic. Indeed, previous studies highlighted that the number of admissions to psychiatric care facilities showed trends similar to the pre-COVID-19 outbreak period (39). This result could be due to an adaptation of mental services to give help during the pandemic, especially implementing digital mental health services (40), while it is in contrast with other findings, e.g., those concerning the decrease of new accesses to psychiatric emergency units (41–43). Based on the stated above, access to care during the COVID-19 emergency should be further investigated since it represents a complex issue that relies on several possible determinants (44). Future research on the topic should thus consider these determinants, such as socio-economic factors (45, 46).

Our study also observed a significant increase in the number of follow-up interventions of subjects that were already being treated in the “pre-COVID-19” period. This has been made possible by the highly significant increase of digital mental health interventions (47–51). Indeed, digital mental health interventions, such as those delivered via mobile and web-based platforms, offer the potential to improve access to care while avoiding many existing barriers to receiving face-to-face intervention, including stigma and time (52–54). The evidence base for digital mental health interventions in the general population is rapidly accumulating (55, 56), and many studies on the topic reported that such interventions were either effective or partially effective in producing beneficial changes in the main psychological outcome variables, also among youngsters (50, 57, 58).

Dropouts from the therapeutic project did not face a statistically significant increase and were similar to those detected in studies conducted on similar populations before the pandemic spread (59). Despite this, an increasing trend in dropouts was evidenced after the COVID-19 outbreak and a positive, strong association was highlighted in the psychiatric disorders’ subgroup. To our best knowledge, literature concerning drop-out rates from outpatient psychiatric services during the pandemic is scant, especially for the youth population. Data from the present research are thus expected to be further clarified by future prospective studies, since adequate access to care represents a crucial issue in the field of early intervention (60).

The results have shown an increase of medium significance in the mean age of subjects accessing the service in the “during-COVID-19” period. We hypothesized that this finding could be due to better social support given by belonging to a group, such as schoolmates for adolescents, representing a protective factor against loneliness that can lead to anxiety and depressive symptomatology (61). Therefore, having finished school, with a consequent reduction in the sense of belongingness, may have a synergistic effect with the isolation linked to the pandemic and lockdown measures themselves. Many studies reported that loneliness threatens mental health (7, 62), leading to sleep disturbances and increased inactivity (63, 64). Greater severity of depressive symptomatology may also had been caused by loneliness, along with poor self-perceived overall health quality, impaired functional status, and a perceived negative change in the quality of life (65).

Concerning people who first sought help to the service after the COVID-19 outbreak, we found a higher prevalence of anxiety disorders in this population when compared to those referred before the pandemic spread. An increase in prescriptions of antidepressants and mood stabilizers was also highlighted, both for subjects suffering from psychiatric disorders and those who did not. Interestingly, the significance of the phenomenon was higher in the second group. Several studies confirmed our findings by detecting the increase in the prevalence of anxiety and depressive disorders in young adults during the COVID-19 pandemic (66, 67). Scientific papers that have evaluated the differences in the prescriptions of psychopharmacological treatments during the pandemic are scant. However, some studies showed an increasing trend (68). It should also be noted that the choice of pharmacological treatments in youth populations represents a critical issue, as demonstrated by the high prescription rates of off-label treatments in this population (69). In our sample, when a clear-cut diagnosis according to the DSM-5 criteria was not possible to be performed, pharmacological treatments were based on symptom dimensions. Indeed, the absence of a full-blown diagnosis does not necessarily mean the absence of an at-risk state, namely a totipotent condition that could hesitate in different exit syndromes (70–72). This could also explain higher rates of mood stabilizer prescription in the sample, even though the diagnosis of bipolar disorders did not significantly change. To this extent, it should be noted that the emergence of SUD or anxiety symptoms during youth may be the expression of a bipolar diathesis in young people, and this may partially explain the higher mood stabilizer prescription rate (73). Furthermore, we should consider that adjustment disorders may also manifest with disturbed conduct, which may more frequently benefit from mood stabilizers or antipsychotics in youths (74, 75). Due to the risk of dependence associated with benzodiazepines assumption, especially in a population of subjects accessing an addiction service, low-dose atypical antipsychotics and mood stabilizers were preferred for anxiety symptoms or anxiety disorders (76, 77).

As demonstrated by some reviews (10, 78), the COVID-19 pandemic and the lockdown measures may have negatively impacted youths’ mental health. First, school closure may have significantly impacted children and adolescents, particularly those aged between 5 and 18 (79). Lack of regular contact with friends may more frequently result in loneliness during adolescence and is not necessarily mitigated using phones or other communication forms (80). This context predisposes adolescents to psychopathological vulnerability, leading to an increasing trend in diagnoses of depressive and anxiety disorders (81). Accordingly, the prevalence of depression in young people across studies conducted in this period ranged from 22.6% to 43.7%, according to previous studies (66, 67), and an increase in the severity of pre-existing depression was detected (82). A survey conducted in China among 8,079 adolescents aged 12–18 revealed a high prevalence of symptoms of depression (43%), anxiety (37%), and combined depression and anxiety (31%) during the COVID-19 pandemic (83). Several risk factors, such as relatives suffering from COVID-19, were identified for the development of affective symptoms (84). These findings are considerable since youths suffering from psychiatric disorders represent an extremely vulnerable population, among which significant consequences could also emerge after the pandemic outbreak (85).

As expected, we observed a highly significant increase in telepsychiatry interventions in line with a large amount of literature. Several papers highlighted an increase in the prevalence of digital mental health interventions in young adults during the COVID-19 pandemic, and different psychological interventions were adapted to the online form (86, 87). We highlighted a decreasing trend in family therapies, with higher significance in the subgroup of subjects suffering from psychiatric disorders. Family therapies are psychotherapy interventions provided by a trained mental health professional (in our service, usually a psychologist) and oriented toward communication improvement and conflict solution in familiar contexts. This data is relevant since scientific literature demonstrated how the pandemic impacted the whole familiar system. Indeed, previous reports underlined that quarantine measures might influence depressive symptom severity among students and their family members (88). Studies focusing on the mental health of children, young adults and their parents showed considerable stressors that these populations perceived during the pandemic period. Children and adolescents were mainly stressed by the disruption of social life and important activities/events, whereas their parents were stressed by the uncertainty of the pandemic and the disease itself (89). These changes in habits suggest that specific risk factors for the development of psychological distress should be identified for both youths and their families in order to act on potentially modifiable stressors. Despite this, the readaptation of family therapy models to digital mental health settings, which was needed due to physical distancing protocols, required a huge effort, and several challenges were faced by both professionals and users (90). Indeed, the lack of adequate technology could represent a concern for families already coping with socio-economic problems before the pandemic due to the worsening of such problems in most cases (91).

Furthermore, the engagement with the therapist could become a concern for families that were not already in contact with the service in the “pre-COVID-19” period. This issue could explain the decrease in such interventions, possibly due to one or more members’ difficulties trusting the therapist and establishing a therapeutic alliance (92). A decreasing trend was not evidenced for social and educational interventions, usually requiring one-to-one relationships between social workers/professional educators and the user. This relationship does not happen in the context of a therapeutic process and does not undergo the rules of a psychotherapeutic setting, making it easier to adapt the intervention for a digital setting.

These considerations reinforce the need for integrated interventions in adolescents showing the onset of psychiatric symptoms during the pandemic (93). Integrated psychosocial interventions could avoid the detriments of more extended home-schooling periods, the loss of opportunities to meet peers, and the disruption of familiar daily routines (89). Accordingly, the finding concerning the reduction in access to residential facilities should be considered, even though the significance was low. This could be interpreted in consideration of significant challenges faced in youth residential care, where social distancing measures and the interruption of contacts with families of origin critically affected the possibility of providing integrative care (94).

Regarding substance use, in our study, we observed a reduction in opioid use in the “during-COVID-19” period of medium significance and, consequently, a reduction in the use of substitution therapy for drug addiction. This evidence could be related to the limitations produced by the lockdown measures during the pandemic period and confirms data from previous studies (95, 96).

However, our sample’s decrease in opioid consumption should be considered a part of a more complex, multi-facet situation. Indeed, due to reduced access to treatment and replacement pharmacology therapies and the lack of continuity in the intake of opioids, emergencies occurred more frequently in the pandemic period, as demonstrated by the increase in cases of opioid overdose (97).

Our study has limitations: first, the relatively small sample size may limit the generalizability of the findings. The issue is also due to the choice of a real-world setting relying on data from one service, since outpatient facilities dedicated to adolescents and young adults suffering from mental health problems are limited in our region. The sample size also hindered the possibility to perform further sub-analyses, e.g., stratifying subjects based on psychiatric diagnoses. Furthermore, it should be considered that data concerning the “during-COVID-19” period were collected during different pandemic phases, without, e.g., specifying whether new accesses happened during lockdown periods or not. To note, we could not analyze any increasing trends in the considered variables during the years preceding the COVID-19 outbreak, and the comparison between the pre-COVID-19 and the during-COVID-19 period assumed no increasing trends in the variables of interest.

Moreover, a specific psychopathological assessment was not systematically administered, and data collected in the usual clinical practice were instead used. This issue may limit the possibility to evaluate treatment response in the considered population. To this end, further studies should evaluate the outcomes of the administered interventions in youths suffering from psychological distress, particularly focusing on telepsychiatry and psychosocial treatments.

Data from the present study suggest that health professionals should accurately screen youths for the presence of psychological distress, both those that already suffered from a psychiatric disorder and those manifesting such distress for the first time. Youths represent a high-risk population for the development of mental disorders, and these were demonstrated to increase during the COVID-19 pandemic and could be expected to rise in the post-pandemic era. The increase of specific psychopathological features in this vulnerable group after the COVID-19 outbreak suggests that pathways to care should be reinforced, and targeted interventions should be proposed to improve the mental health of adolescents and young adults. Particularly, clinicians should further promote the adaptation of mental health services to the emerging historical and social context, e.g., extensively rethinking services under a digital mental health perspective. Furthermore, the proposed interventions should include tailored pharmacological treatments that could help achieve symptomatologic remission and psychosocial interventions that would progressively lead youths toward a full-functional recovery.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by the Ethics Committee of Umbria Region (protocol N° 23369/21/ON). Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.

GM and GP conceived the idea and designed the study. GP and AS collected the data. GM performed the statistical analysis. GM, GP, FB, AM, NM, and MD’A wrote the original draft. SB, EM, LO, UV, and AT revised the whole manuscript. LS supervised the study during all its phases. All authors contributed to the article and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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