Female adolescents are vulnerable to depression [10]. The outbreak of COVID-19 had a significant negative impact on daily life and on the study of female adolescents, resulting in increased risk of depression. Chinese is the largest ethnic group comprising one-fifth of the world population and has a larger number of female adolescents than other countries. Early prevention, detection, and treatment are essential to protect female adolescents from depression and improve their mental health. In this national online cross-sectional survey, we found that 39.5% of the female adolescents suffered from depression during the COVID-19 outbreak, and the onset of depressive symptoms was significantly related to age, grade, distant learning, attitude toward COVID-19, sleep duration/day, and physical exercise duration. Furthermore, our results indicated that older age, participating in distant learning, concerned about COVID-19, sleep duration/day of < 6 h, and physical exercise duration/day of < 30 min represented the independent factors for suffering from depression. This fact maybe highly informative for all stakeholders, from parents to governments, to develop intervention efforts targeting high-risk groups.
A recent systematic review and meta-analysis of 144,060 Chinese secondary school students indicated that the pooled prevalence of depression was 24.3% (95% CI: 21.3–27.6) [3]. In this study, we found a higher depression prevalence, which means that the COVID-19 outbreak is a vital risk factor of depression for female adolescents. The emergence of COVID-19 has parallels with the outbreak of severe acute respiratory syndrome, which killed 349 of 5327 infected patients in China [15]. As an unpleasant experience, the COVID-19 outbreak led to mass quarantine; fears of infection; boredom; anger; frustration; lack of contact with friends, classmates, and teachers; and lack of family, finance, and personal space at home, all of which are associated with increased risk of depression [9, 16, 17]. Since the COVID-19 epidemic was no longer confined to China, problems related to school closure and home confinement also became relevant in other affected countries.
The Government of China ordered a nationwide school closure to prevent the spread of COVID-19 and public activities were discouraged. Millions of adolescents were confined to their homes, resulting in decreased visits to others and outdoor activities. Prolonged school closure and home confinement during the COVID-19 outbreak might have a negative impact on children’s mental health, although these efforts and measures were highly necessary and commendable. We also found that less physical exercise and sleep duration were significantly associated with higher risk of depression, which was consistent with the findings of previous studies. Physical exercise proved to be a promising antidepressant treatment for adolescents aged 13–17 years [18]. We found that light to moderate intensive exercise three times a week for 6–12 weeks could bring alleviate depression [18]. Existing studies suggested that the relationship between short sleep duration and depression was bidirectional [19]. Accumulating evidence suggested that short sleep duration might be a prospective predictor of depressive symptoms among adolescents [20].
Our results indicated that female adolescents aged 15–18 years had higher risk of depression and higher CES-D scores. Female adolescents aged 15–18 years old had higher risk of severe depressive symptoms, considering higher scores indicating a greater number and increased frequency of depressive symptoms. In this study, we found that senior secondary school students had higher risk of depression than junior secondary students. After graduating from junior secondary school, most students in China entered secondary schools. These adolescents faced enormous academic pressure due to college entrance examinations, which was described as a stampede of “thousands of soldiers and tens of thousands of horses across a single log bridge” [3]. This may have led to the findings.
In this survey, female adolescents concerned more about the COVID-19 outbreak had lower risk of depression. This is partly because clear communication and regular and accurate updates about COVID-19 could improve relevant knowledge of the pandemic and reduce the sense of uncertainty and fear [7]. Additionally, the National Health Commission of China released the national guideline of psychological crisis intervention for COVID-19, which could help female adolescents better understand COVID-19. In brief, concerns about the COVID-19 outbreak were related to lower risk of depression for decreased sense of uncertainty and fear. Interestingly, the participants from the provinces of lower number of reported COVID-19 cases were more likely to score high on depressive symptoms. Partly because female adolescents concerned less about the COVID-19 outbreak, resulting in increased sense of uncertainty and fear. Future studies focus on those so-called counterintuitive results are needed.
Several limitations should be noted in this study. First, this is an online study; therefore, those with no access to the Internet could not join. However, distance teaching has been used nationwide during the COVID-19 outbreak, and only very few adolescents had no access to the Internet. Second, some data pertaining to important factors associated with depression, such as physical health and social support, were not available due to logistical reasons. Finally, due to the cross-sectional study design, causality between variables could not be examined. Hence, a well-designed study of the prevalence of depression is necessary to complement epidemiological studies and provide more conclusive evidence regarding the incidence of depression and its correlative factors among female adolescents during the COVID-19 outbreak.