Changes in the Level of Depressivity in Self-Harming Adolescents After the First Wave of the COVID-19 Pandemic

The COVID-19 pandemic and its consequences have not only had a somatic effect but has also had a psychological effect. Apart from various studies that point to the negative effects of the pandemic on the population´s mental health, there are also those that have dealt with its positive impact and have identified possible protective factors whose intensity have increased during the pandemic. The presented study focuses on the level of depressivity in a sample of self-harming adolescents through a comparison of its prevalence before and after the first wave of COVID-19. The results imply that the changes and measures brought by the first wave of the pandemic did not increase the prevalence of depressivity. The discussion presents the limitations of the research and the possible protective effects of a non-pathological home environment on the mental health of adolescents at risk.


Introduction
The COVID-19 pandemic has changed the lives of people all over the world. The consequences can be identified in many areas -the SARS-Co-V-19 virus has directly affected the lives and health of individuals (Koçak et al., 2021), many have lost their relatives (Mortazavi et al., 2020) or become unemployed (Achdut & Refaeli, 2020). The measures adopted resulted in social isolation (Hwang et al., 2020) as well as restrictions on the provision of physical and mental health care services (Humer et al., 2020). The first statistics concerning the number of infected, hospitalised and dead have been published and doctors all over the world have also drawn attention to long-term health impacts after fighting off the disease (Ladds et al., 2020;Morley, 2020;van den Borst, 2021;Maltezou et al., 2021). Although research into the consequences of the disease, restrictions and life changes on the mental health of population is still on-going, experts have already documented an increase in the prevalence of anxiety (Ma et al., 2020), depression (Luo et al., 2020), uncontrolled fears (Serafini et al., 2020) as well as post-traumatic stress disorders (Xiong et al. 2020) and stress (Rajkumar, 2020). Adolescents may be a group that, in this context, has been particularly vulnerable. Meeting the need for contact with their peers and education (Orben et al., 2020), which have been limited to the greatest extent during this period, is extremely important for their healthy mental development. These measures were adopted very quickly in Slovakiasome secondary schools closed on the first working day that followed the announcement of the first COVID-19 case in Slovakia (6th March 2020) and the rest of them stopped face to face teaching within 10 days (Public Health Authority of the Slovak Republic, 2020). Thus, with the exception of a couple of days in June when teaching was resumed at several schools, the lockdown lasted until the end of the school year.
Besides studies that present findings of a deterioration in the mental health of adolescents (e.g. Octavius et al., 2020;Son et al., 2020;de Figueiredo et al., 2021), studies have also emerged that have presented findings that suggest a possible improvement of the situation, mainly in the context of the measures adopted during the first wave of COVID-19. For example, Tang et al. found that social support, positive coping skills, home quarantine, and parent-child discussions have had a positive impact on the mental health of adolescents. They claim that home quarantine and parent-child discussions have increased the level of satisfaction with life (Tang et al., 2021). We have found similar results in connection with the prevalence of self-harm (see Demuth & Demuthova, 2021) -neither the prevalence nor the degree of self-harming behaviour in adolescents was found to have grown after the first wave of the pandemic. Quite the opposite, a slight (but not statistically significant) drop has been recorded. The question is whether it was the result of increased parental supervision or whether a real decrease in the number of stressors (for instance, of psychosocial character - Bailey et al., 2016) or triggers for self-harming behaviour took place during the period of social isolation and the influence of the home environment.

Objective
Owing to the ambiguous conclusions related to the effects of the changes caused by the COVID-19 pandemic on the mental health of self-harming adolescents, the goal of the research was to analyse the level of depressivity in a sample of self-harming adolescents before the outbreak of the COVID-19 pandemic and after the first wave.

Participants
The research sample for the first phase of data collection (pre-pandemic) was made up of 1,117 participants (average age of participants = 15.56; st. dev. = 1.45 years; 65.4% = female). Of these 546 participants (48.9%) met the criteria for self-harm. Due to the anonymous nature of the questionnaires and the fact that there was no intention, before the pandemic, to carry out long-term monitoring of the participants, the second phase of data collection (post-first wave) was done using another group of participants (N = 281).
To balance the two groups, the following steps were taken: 1. The post-first wave group of participants was analysed in terms of selected variables that had been identified (in former scientific studies) as important to the prevalence of selfharm in adolescence: the age of the participants (Ose et al., 2021), their gender (Demuthova & Doktorova, 2019), the clinical character of the sample (Horváth et al., 2020), and the school setting (Cippriano et al., 2017). 2. According to the results of this analysis (age range 11 -18 years, average age 14.04 years, 68% female, non-clinical sample, participants attending primary or secondary state schools) 114 matching students were selected from the pre-pandemic data set (age range: 11 -18 years, average age = 14.01 years; 69.2% female, non-clinical sample, participants attending primary or secondary state schools). 3. The absence of differences between the pre-pandemic and post-first wave samples, in age and gender, was tested using a Mann-Whitney´s U-test (age) and Spearman's correlation test (gender) (see Tables 1 and 2). The final statistical analyses (due to missing data regarding the depressivity levels) were executed on a sample of 103 pre-pandemic and 93 post-first-wave self-harming adolescents.

Materials
Self-harming adolescents in the general population were identified using the modified Self-Harm Inventory (SHI) by Sansone & Sansone (2010). The modified questionnaire (Demuthova & Doktorova, 2019) determines the frequency of prevalence of the 20 most frequent forms of self-harm; an adolescent is considered to be a self-harmer if they have displayed some of the forms of self-harming behaviour more than once in their lives or a combination of several forms of self-harm.
The level of depressivity was identified using the Children's Depression Inventory (CDI) (Kovacs, 1998). The questionnaire measures the current state of the participant on five subscales -anhedonia, bad mood, inefficiency, interpersonal problems, and a negative attitude towards oneself. The questionnaire also includes norms for the Slovak population.

Procedure
The data was collected at primary and secondary schools during the school day and in two phases -the first phase was carried out prior to the pandemic, between October 2019 and January 2020. The second phase of data collection took place in late June 2020 during a short period when restrictions were lifted, and some students and pupils could finally go to school. It was collected anonymously and in a standardised way by trained administrators. The participants (or their guardians) were informed of the research in advance and could opt out, or leave the research during any phase, there was no sanction or any impact on any form of student evaluation as a consequence of the refusal to participate or when leaving the study.

Statistical Processing
The statistical analysis was carried out using IBM SPSS, ver. 27, and the significance threshold was set to 0.05 for all tests. Since the monitored variables did not exhibit a normal distribution (the significance value of Shapiro-Wilk test = 0.000), non-parametric tests were used for the statistical analyses.

Results
The results of the non-parametric Mann-Whitney U-test that examined the differences in the level of depressivity in the pre-pandemic group of self-harming adolescents and the post first wave group (see Chart 1) shows that there are no statistically significant differences between the two groups (Mann-Whitney U = 4,330; Asymptotic sig. = 0.243).

Figure 1. Differences in the level of depressivity in self-harming adolescents from the pre-pandemic (left half) and post first wave (right half) groups (Mann-Whitney's U-test) Source. Authors´ own conception
Thus, it can be stated that the level of depressivity, as one of the indicators of the mental health of adolescents, showed no increase after the first wave of the pandemic.

Discussion
The data collected implies that there was no increase observed in the prevalence or the level of depressivity in the post first wave group of self-harming adolescents in comparison to the prepandemic sample. In the context of the research two explanations can be offered. The first is that lockdown (through higher levels of parental interest and support, by spending more time together, an increase in their mutual interactions, improvements in communication, etc.) may have compensated for the negative consequences of the pandemic restrictions (that resulted in social isolation, an absence of possibilities of psycho-hygienic activities, higher stress levels, etc.). This is also supported by the findings of Tang et al. (2021) who found that social support, positive coping skills, home quarantine, and parent-child discussions during the crisis have had a positive impact on the mental health of adolescents. In particular, home quarantine with parent-child discussions on COVID-19 negatively correlated with psychopathological symptoms and positively correlated with satisfaction with life. It is therefore possible that a supportive home environment could have improved the relationships and state of mind of adolescents otherwise stressed by COVID-19 situation.
The second explanation works with the factors of the social environment outside the family. Lockdown substantially limited social contact, in particular, for young people, which is often perceived negatively (Lee el al., 2020;Loades et al., 2020;Rauschenberg et al., 2021). On the other hand, the restrictions on social interaction have not only resulted in the absence of the positive but also the negative consequences of interpersonal relationships. In this light the lockdown may also be viewed as lowering the intensity or quantity of some negative social pressures (removing academic and peer stressors ... etc). If the mental issues suffered by adolescents come from these areas, it is understandable that their absence could have improved the state of mental health. Considering that a common reason for mental problems in adolescence is psychosocial stressors (e.g., bullying or exam pressure) (Bailey et al., 2016), it may be assumed that their frequency and intensity may have decreased during the lockdown and as such compensated for other social influences that have a negative action due to pandemics. Of course, it is also possible that the absence of the expected increase in depressive symptoms after the first wave of the pandemic was not a result of these factors but was a consequence of the specificities of the post first wave research sample; these circumstances are discussed in detail in the section Limitations.

Limitations and Suggestions for Further Research
The interpretation of the results presented should be perceived in the context of the limitations of the study in two specific areas -the design of the research and the composition of the sample. As the research into self-harm in adolescents began before the pandemic, it was anonymous and there was no possibility to further contact the participants, it was not possible to continually follow changes in the degree of depressivity (in the same participants).
Although the selection of the participants in the two phases was carried out so that the important variables of the groups were identical, it is possible that they differed in a variable that we failed to identify, and which subsequently had a negative effect on the results. Therefore, we suggest, as a stimulus for further research, an analysis of cases from clinical practice where continuous and individual follow up is possible for each client/patient, to evaluate changes in the degree of depressivity during the pandemic. The disadvantage of this approach is that this would result in a very limited group of self-harming adolescents, as few self-harming adolescents seek professional help (Rowe et al., 2014).
It is also crucial to point out the limitations imposed by the size and nature of the post first wave sample of participants. Although students and pupils could return to their schools and attend the last week of the summer term, many institutions did not take up this opportunity due to the epidemic situation. At the same time, the return of students and pupils to school was not mandatory -parents had the right to choose. Therefore, it is possible that it was only adolescents with special characteristics (from regions who better managed the epidemic, from families with a supportive approach towards their children), which could be related to their mental health (and the prevalence of depressivity), that returned to schools. The validity and effect of this limitation cannot be verified as the collection of data from children who stayed at home was not possible and the pandemic situation has since changed.
The main objective of this research was to examine the changes in the level of depressive symptoms in adolescents due to the COVID-19 pandemic. The results did not show differences -it is questionable whether this variable is the one that was significantly affected by the changes caused by the pandemic restrictions during the first wave. This question then provides a suggestion for further research as it is possible that other areas -e.g. social phobias, anxieties -were more prone to an intensification of symptoms than depressivity.
In any case and even despite the limitations stated, it is necessary to replicate the research, as it is possible that the impact of recurrent long-term social isolation and lockdowns (after the second wave of the pandemic) on the mental health of adolescents will be different.

Conclusion
The SARS-CoV-2 pandemic brought radical changes to people's lives, including an impact on the mental health of the population. The interruption of face-to-face teaching, free time activities and especially the resultant social isolation had an exceptionally intense effect on the population of adolescents -this has not only been noted by research studies but also by the wide network of providers of psychological support and consultancy services. However, it is not possible to make generalisations about this trend based on the research performed with a focus on depressive symptoms or other studies. It is not necessarily true that there must have been a deterioration in all areas of mental health in all groups; there is the possibility that there are certain factors that had a positive impact on the well-being of the population under lockdown and these are currently under consideration. Research in this direction continues to be important -both due to the need to discover and verify the real impact of the pandemic restrictions on the various areas of the mental health of individuals, and also in order to identify those factors which may have mitigated or even neutralised those negative impacts.

Acknowledgment
This work was supported by the Slovak Research and Development Agency under Contract No. APVV-17-0123.