The COVID-19 pandemic may negatively influence mental health as a consequence of the distinctive blend of the public health crisis, social isolation and economic crises [22]. Measures to contain the virus have reshaped many facets of daily life, such as income, employment, schooling, and social interactions. Considering the direct impact of the virus and related consequences, researchers anticipated an increase in anxiety, depression, and their aftermath, including suicide [23]. Results of the current study revealed that depression and anxiety were almost always present with different severities. This high percentage agrees with a Chinese survey among adolescents aged 12–18; as symptoms of depression and anxiety during the COVID-19 outbreak were highly prevalent [24]. Similarly, in a study in Spain [25], during the first weeks of COVID-19 confinement, large numbers of students experienced moderate to extremely severe scores of anxiety and depression.
In comparing the results of the present study to other studies during COVID-19 pandemic, the current sample PHQ-9 mean score for depression (11.21 ± 6.58) was higher than that of Lin’s et al. [26], who studied 5641 Chinese individuals across the different age groups, as the average PHQ-9 score of their participants was 6.10 ± 5.97. Also, in the same study, the anxiety scores assessed using GAD-7 had an average score of 4.97 ± 5.25 [26], while the current sample GAD-7 mean score was (9.31 ± 6.30) which is higher.
Furthermore, with a mean ISI score of 12.36 ± 6.41, the prevalence of clinical insomnia was 73.8%. This is much higher than reported before in a Chinese study; the average ISI score was 5.93 ± 5.88 and the prevalence of clinical insomnia was 20.05% [26]. While in other studies, insomnia was identified in 23% of 11,835 young adults [27]. Youth experienced distress, lack of energy, irregular naps, more screen time, and unrestricted online social media. A well-recognized feature of Egyptian sleep practice is biphasic sleep distributed in afternoon and late night bouts. Also, most of Egyptians eat the main meal of the day around mid-afternoon, and then nap in the late afternoon. In the evening, activity picks up again. The night bout of sleep begins sometime after midnight and ends after dawn [28]. These disruptive effects of social disorganization can affect bedtime, sleep quality, and sleep/wake patterns constancy directly or collectively [29].
Evidence found that depression and mental states among Arab adolescents are constructed and expressed differently than among adolescents in other cultures [30]. Culture may play a role in differences in frequency of disorders in different groups [31]. Also, socio-cultural factors may also play a part in how distress is expressed [32]. Hence, the differences across different population studies may emerge.
The present study showed significant associations between symptoms of depression, anxiety, and insomnia. Previous studies shown that symptoms of anxiety and depression are risk factors for insomnia and are associated and cyclically related [27, 33]. The relationship between sleep disturbance and depression is complex from the level of shared neurobiology to manifestation in clinical symptoms. Sleep duration and depressive symptoms appear to be related concurrently in a curvilinear manner [34]. Given the higher mean score of PHQ-9 in the current study, this might contribute to the higher prevalence of insomnia in comparison to other studies. Studies found that almost 75% of children and adolescents with depression manifested sleep disturbances, with over 50% experiencing insomnia [35]. Social distance and isolation that follows long-term lockdowns can be a risk factor for anxiety and mood disorders [36]. Variations in sleep during the COVID-19 pandemic may exacerbate or even contribute to psychopathology. Poor sleep can have a detrimental effect, leading to heightened vulnerability to mood and anxiety disorders [37].
An accumulating body of evidence indicated that females are at higher risk of depression and anxiety symptoms [24, 38], sleep problems [39], and negative psychological impact in general [7]. These results also matched the findings of this study, where female gender has significant associations with depression, anxiety, and insomnia. On the other hand, a study by Xie et al. reported no effect of gender [40].
Notably, youth between 14 and 19 had more severe scores on depression, anxiety but not insomnia, when compared to the older youth. Other studies revealed that younger persons reported higher psychological impacts [7, 26]. These results are contradicting with a study Zhou et al. that found prevalence of symptoms of insomnia was higher among senior high school and college students [27]. The inverse correlation between respondents' age and the prevalence of depressed mood, anxiety, and insomnia was recorded in another study [41]. In the studied population, age has no significant association with insomnia. The timing and amount of sleep are largely determined by direct and interactive effects of gender, age, and sleeping arrangements [28].
It appears that the residence may give an idea about the circumstances in which the person lives and hence on his social conduct [42]. The result of the current study reveals that residence had no effect on association with psychopathology. This was in contrast to studies in China that found that depression and anxiety symptoms in cities were lower than in rural areas [24, 43]. A Greek study also found that people in urban areas were more vulnerable to sleep problems [39], while an Egyptian study found rural residency had a negative impact on mental health during COVID-19 [7]. This might be implied by the fact of urbanization of the countryside and ruralization of cities is taking place [44]. Considerably, the association of psychopathology and residence may change based on the population studied.
The mind and mental health are influenced by the health of the body. This is observed in the present study where young people with chronic physical illness had significantly higher anxiety and insomnia scores but not depression. El-Zoghby et al. reported that those with chronic illnesses are more susceptible to psychological distress [7]. Furthermore, some of them may perceive themselves with poor health and more liable to get diseased [45, 46]. Even after controlling for confounders, strong cross-effects between physical and mental health are still valid [47].
Moreover, those who had a family member infected with COVID-19 had more significant distress in the form of depression, anxiety, and insomnia. These findings are corresponding to Cao et al., who found that having relatives or acquaintances with COVID-19 infection were risk factors for anxiety among Chinese undergraduate students [43]. Besides, all family members may have their COVID-19-related fears. Taken together, this response can lead to significant psychological distress for all family members, especially youth.
Economic recessions as during pandemic are accompanying with increased mental health problems for youth [22]. Family income has a significant impact on young people response to life stressors such as the COVID-19 crisis [48]. In a study among 7143 college students, family income stability was a protective factor against anxiety in the era of COVID-19 [43]. However, the results of the current study revealed that financial loss affected neither mood nor sleep. Although, low socioeconomic status is generally associated with high psychiatric morbidity, the nature of this association is not clear-cut [49]. Part of the difficulty is in disentangling other factors and their interactions, which are beyond the scope of current study.
Concerning changes in bodyweight during COVID-19 lockdown, 37.4% of the sample reported weight gain, 20.1% reported weight loss, while around half of the sample reported change in their number of daily meals. These are comparable to a study in Poland, in which around 30% and over 18% experienced weight gain and loss respectively, while over 43.0% and nearly 52% reported eating and snacking more [50]. Consistently, a study [51] on 3533 Italians found the sense of satiety and hunger altered for more than 50% of their population; 17.8% of them had less appetite, comparable to 16.8% of the sample. Phillipou et al. provided further support and reported increased restricting and binge eating behaviors among Australian population [52]. Notably, isolation leads to an increased sedentary behaviors and more physical inactivity which are expected to affect weight [53]. The excessive food exposure caused by the only freedom permitted was grocery shopping, which prompted people who were least successful in managing their diet to amplify the association between food consumption and feelings [41].
Furthermore, the current study is in line with an extensive body of evidence indicated that food consumption, eating patterns, food type, number of main meals, emotional and night, in addition to beverages consumption (caffeinated and carbonated), all were affected during confinement [54]. In addition to bodyweight, all described dietary changes have significant associations with depression, anxiety and insomnia. Previous studies reported increased scores of emotional and night eating in response to external stimuli with PHQ-9 and GAD-7 scores [55].
Pandemic-related anxiety may increase the difficulty of patients in managing their eating habits [56]. From another point of view, the consumption of palatable foods may have positive and reinforcing implications. The stress response can be sensibly controlled through its soothing effect [57]. However, the current study pointed out that around one-quarter of the sample improved their diet in consuming a more healthy diet and nearly the third decreased their intake of carbonated beverages. These findings were also reported by Di Renzo et al. but only 16.7% of their population improved their behaviors in the form of a decrease in consumption of snacks, savory food, carbonated, and sugary drinks [51].
Participants of both sexes reported various positive and negative coping strategies. In stress situation, coping mechanisms are used to control, mitigate, or tolerate stress and stressors such as those during COVID-19. A study involved 16 countries found that the most utilized coping strategies during COVID-19 were watching television for entertainment, social networking, listening to music, sleeping, performing household chores like cleaning and washing, eating well, and clearing/finishing piled-up work [58]. While the strategies used the most by participants of the current study were raising self-awareness regarding COVID-19, praying, communication with others, staying alone, and engagement in a hobby.
This study sheds important light on youth’s psychiatric morbidity and dietary habits during the COVID-19 pandemic. Up to our knowledge, this study is one of the first studies to address such matters in Egypt and the Middle East. However, there is no study without limitations. The cross-sectional design of the current study limits the possibility of establishing temporality. Additionally, the psychological status was assessed using a self-administered online survey. A systematic psychiatric evaluation through interviews of the participants would give a better assessment. Dietary habits and coping methods were assessed using designed questionnaires. Although these questionnaires were developed after a careful review of literature, the tools were new and could add to the limitations.
