Edited by: Dinesh Kumar Bhugra, King’s College London, United Kingdom
Reviewed by: Andres Ricardo Schneeberger, Albert Einstein College of Medicine, United States; Michaela Pascoe, Victoria University, Australia
*Correspondence: Valentina Socci,
This article was submitted to Public Mental Health, a section of the journal Frontiers in Psychiatry
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
The psychological impact of the COronaVIrus Disease 2019 (COVID-19) outbreak and lockdown measures on the Italian population are unknown. The current study assesses rates of mental health outcomes in the Italian general population three to 4 weeks into lockdown measures and explores the impact of COVID-19 related potential risk factors.
A web-based survey spread throughout the internet between March 27th and April 6th 2020. Eighteen thousand one hundred forty-seven individuals completed the questionnaire, 79.6% women. Selected outcomes were post-traumatic stress symptoms (PTSS), depression, anxiety, insomnia, perceived stress, and adjustment disorder symptoms (ADS). Seemingly unrelated logistic regression analysis was performed to identify COVID-19 related risk factors.
Endorsement rates for PTSS were 6,604 (37%), 3,084 (17.3%) for depression, 3,700 (20.8%) for anxiety, 1,301 (7.3%) for insomnia, 3,895 (21.8%) for high perceived stress and 4,092 (22.9%) for adjustment disorder. Being woman and younger age were associated with all of the selected outcomes. Quarantine was associated with PTSS, anxiety and ADS. Any recent COVID-related stressful life event was associated with all the selected outcomes. Discontinued working activity due to the COVID-19 was associated with all the selected outcomes, except for ADS; working more than usual was associated with PTSS, Perceived stress and ADS. Having a loved one deceased by COVID-19 was associated with PTSS, depression, perceived stress, and insomnia.
We found high rates of negative mental health outcomes in the Italian general population 3 weeks into the COVID-19 lockdown measures and different COVID-19 related risk factors. These findings warrant further monitoring on the Italian population’s mental health.
The psychological impact of the COronaVIrus Disease 2019 (COVID-19) outbreak and related lockdown measures among the Italian population are unknown. The COVID-19 pandemic is a global health emergency that could potentially have a serious impact on public health, including mental health (
As previously reported, health emergencies such as epidemics can lead to detrimental and long-lasting psychosocial consequences, due to disease related fear and anxiety, large-scale social isolation, and the overabundance of (mis)information on social media and elsewhere (
Concerning the COVID-19 pandemic, a study on 1210 respondents in China found rates of 30% of anxiety and 17% of depression (
Together, these findings strongly suggest the need to accurately and timely assess the magnitude of mental health outcomes in the general population exposed to COVID-19 pandemic, with particular regard to the implementation of preventive and early interventions strategies for those at higher risk. However, no study to date has investigated mental health outcomes and associated risk factors in the Italian population. This could be of additional relevance considering the implementation of the strict lockdown and social distancing measures imposed on the entire national territory.
The aim of the current study was to assess rates of mental health outcomes in the Italian general population three to 4 weeks into lockdown measures and to explore the impact of COVID-19 related potential risk factors. This study aims at providing evidence that could potentially inform subsequent research strategies and mental health delivery in Italy and Europe. Our hypothesis is that specific COVID-19 related risk factors could show a relevant association with mental health in the general population.
A cross-sectional web-based survey design was adopted. Approval for this study was obtained from the local IRB at University of L’Aquila. On-line consent was obtained from the participants. Participants were allowed to terminate the survey at any time they desired. The survey was anonymous, and confidentiality of information was assured.
Data on mental health were collected between March 27th and April 6th 2020 using an on-line questionnaire spread throughout the internet, using sponsored social network advertisement together with a snowball recruiting technique. Questionnaires were evenly distributed across the national territory. The investigated timeframe corresponds to the contagion peak in Italy, according to epidemiological data confirmed by the World Health Organization (
All Italian citizens ≥ 18 years were eligible. A total of 18,147 individuals completed the questionnaire, of which 14,447 (79.6%) women, median age was 38 (IQR=23). Because of the web-based design, no response rate could be estimated as it was not possible to estimate how many persons were reached by social network advertisement.
Post-Traumatic Stress Symptoms (PTSS), depression symptoms, anxiety symptoms, insomnia, perceived stress and adjustment disorder symptoms (ADS) were assessed using the Italian versions of the following instruments and cut-offs or scoring:
The Global Psychotrauma Screen, post-traumatic stress symptoms subscale (GPS-PTSS) (
the 9-item Patient Health Questionnaire (PHQ-9) (
the 7-item Generalized Anxiety Disorder scale (GAD-7) (
the 7-item Insomnia Severity Index (ISI) (
the 10-item Perceived Stress Scale (PSS) (
the International Adjustment Disorder Questionnaire (IADQ) (
Standardized age, gender, and region of residence (Northern Italy: Aosta Valley, Piedmont, Liguria, Lombardy, Trentino-Alto Adige, Veneto, Friuli-Venezia Giulia, Emilia-Romagna; Central Italy: Tuscany, Umbria, Marche, Lazio; Southern Italy: Abruzzo, Molise, Apulia, Campania, Basilicata, Calabria, Sicily, and Sardinia) were inserted as independent variables. Region of residence was inserted in order to account for the different incidence of COVID-19 among Italian regions. COVID-19 related independent variables were:
being under quarantine either because infected or in close proximity to infected people;
any changes in working activity compared to “working as usual” (e.g., smart-working, working activity discontinued due to lockdown measures, higher workload due to COVID-19);
having a loved one infected, hospitalized or deceased due to COVID-19;
any stressful events comprised in the IDAQ checklist, purposely modified in order to capture only stressful events due to COVID-19. The IADQ checklist comprises eight questions about any potential stressful life event occurred in the recent past, with a yes/no response, including financial, working, educational, housing, relationship, own or loved one’s health and caregiving problems. In order to separate COVID-19 related stressful life events from non-COVID-19 related events, responses to the checklist were modified as follows: “no”; “yes”; “yes, due to COVID-19”. Responses were collapsed in a binary variable where 1=“any stressful life evet only if due to COVID-19” and 0=“no stressful life events or presence of a stressful life event not due to COVID-19”.
A history of childhood trauma and any previous mental illness, as assessed by the dedicated GPS module; education level, occupation (employed, unemployed, student, retired) and being in a relationship.
Frequency analysis were performed in order to ascertain the prevalence of each outcome, separately for Northern, Central, and Southern Italy.
A seemingly-unrelated multivariate logistic regression model was fitted in order to explore the impact of the proposed covariates and confounders on the selected outcomes. Seemingly unrelated regression models are systems of equations that allow to jointly model several outcomes, assuming correlation among their errors. Because of the very low missing data rates (<3%), missing data were treated with listwise deletion in regression analysis.
Data analysis was performed using Stata v. 16® (StataCorp). Seemingly unrelated logistic regression was performed using the -suest- postestimation command after running a panel of logistic regressions.
Socio-demographic characteristics of the sample, along with rates of mental health outcomes, are reported in
Demographic characteristics and rates of mental health outcomes in the sample.
Total | North | Centre | South | |
---|---|---|---|---|
38 (23) | 38 (23) | 38 (24) | 38 (31) | |
|
14207 (79.5) | 6310 (79) | 3729 (79.4) | 4168 (80.6) |
3653 (20.5) | 1681 (21) | 966 (20.6) | 1006 (19.4) | |
|
8538 (47.8) | 3770 (47.2) | 2243 (47.8) | 2525 (48.8) |
|
7674 (43) | 3411 (42.7) | 2112 (45) | 2151 (41.6) |
1649 (9.2) | 810 (10.1) | 340 (7.2) | 499 (9.6) | |
|
1139 (6.4) | 367 (4.6) | 244 (5.2) | 528 (10.2) |
|
2094 (11.7) | 793 (9.9) | 484 (10.3) | 817 (15.8) |
|
10881 (60.9) | 5349 (66.9) | 2867 (61.1) | 2665 (51.5) |
|
291 (1.6) | 124 (1.6) | 77 (1.6) | 90 (1.7) |
|
3456 (19.3) | 1358 (17) | 1023 (21.8) | 1075 (20.8) |
141 (0.8) | 101 (1.3) | 21 (0.5) | 19 (0.4) | |
|
2320 (13.5) | 977 (12.6) | 633 (14) | 710 (14.5) |
|
6688 (38.9) | 3088 (39.9) | 1847 (40.9) | 1753 (35.7) |
|
7500 (43.7) | 3347 (43.2) | 1870 (41.4) | 2283 (46.5) |
|
665 (3.9) | 335 (4.3) | 168 (3.7) | 162 (3.3) |
|
16312 (91.8) | 6987 (87.6) | 4431 (94.7) | 4894 (95.5) |
|
789 (4.4) | 519 (6.5) | 139 (3) | 131 (2.6) |
|
253 (1.4) | 183 (2.3) | 30 (0.6) | 40 (0.8) |
|
424 (2.4) | 284 (3.6) | 80 (1.7) | 60 (1.2) |
6604 (37) | 2876 (36) | 1560 (33.2) | 2168 (41.9) | |
3084 (17.3) | 1349 (16.9) | 703 (15) | 1032 (20) | |
3700 (20.8) | 1613 (20.2) | 854 (18.3) | 1233 (23.9) | |
1301 (7.3) | 542 (6.8) | 280 (6) | 479 (9.3) | |
3895 (21.8) | 1720 (21.5) | 918 (19.6) | 1257 (24.3) | |
4092 (22.9) | 1900 (23.8) | 1032 (22) | 1160 (22.4) |
GPS, Global Psychotrauma Screen; PHQ, Patient Health Questionnaire; GAD, Generalized Anxiety Disorder scale; ISI, Insomnia severity Index; PSS, Perceived Stress Scale; ADS, Adjustment Disorder Symptom; IQR, Interquartile range.
Seemingly unrelated logistic regression analyses are reported in
Seemingly unrelated logistic regression.
PTSS | Depression | Anxiety | Perceived Stress | Insomnia | ADS | |
---|---|---|---|---|---|---|
1.49*** [1.39,1.60] | 1.55*** [1.42,1.69] | 1.72*** [1.59,1.87] | 1.76*** [1.62,1.90] | 1.01 [0.97,1.05] | 1.05 [0.75,1.47] | |
|
1.00 (ref) | |||||
2.12*** [1.94,2.31] | 1.39*** [1.24,1.56] | 1.77*** [1.59,1.97] | 2.06*** [1.85,2.30] | 1.50*** [1.26,1.78] | 1.64*** [1.45,1.84] | |
1.00 (ref) | ||||||
0.93 [0.86,1.01] | 0.87* [0.78,0.97] | 0.90* [0.82,1.00] | 0.90* [0.82,0.99] | 0.9 [0.77,1.05] | 0.91 [0.81,1.02] | |
1.36*** [1.26,1.47] | 1.25*** [1.13,1.37] | 1.29*** [1.18,1.41] | 1.20*** [1.10,1.32] | 1.41*** [1.24,1.62] | 0.95 [0.85,1.06] | |
1.46*** [1.37,1.56] | 1.58*** [1.45,1.72] | 1.64*** [1.51,1.78] | 1.82*** [1.68,1.97] | 1.58*** [1.40,1.79] | n.a. n.a. | |
1.74** [1.21,2.49] | 1.49 [0.98,2.26] | 1.52* [1.05,2.22] | 1.42 [0.97,2.07] | 1.23 [0.69,2.18] | 2.28*** [1.44,3.61] | |
1.00 (ref) | ||||||
1.01 [0.91,1.12] | 0.99 [0.86,1.14] | 0.97 [0.85,1.10] | 1.02 [0.90,1.15] | 0.9 [0.74,1.10] | 1.07 [0.91,1.25] | |
1.15** [1.05,1.27] | 1.40*** [1.23,1.59] | 1.16* [1.03,1.31] | 1.19** [1.06,1.34] | 1.22* [1.03,1.46] | 1.1 [0.95,1.28] | |
1.42*** [1.18,1.71] | 1.26 [0.98,1.63] | 1.25 [1.00,1.57] | 1.71*** [1.38,2.12] | 1.29 [0.93,1.80] | 1.39* [1.04,1.87] | |
1.00 (ref) | ||||||
1.22* [1.05,1.42] | 1.05 [0.87,1.28] | 0.91 [0.75,1.10] | 0.88 [0.73,1.05] | 1.02 [0.77,1.35] | 0.96 [0.79,1.17] | |
1.68*** [1.30,2.16] | 1.41* [1.03,1.93] | 1.22 [0.91,1.65] | 1.34* [1.01,1.78] | 1.74** [1.18,2.54] | 1.21 [0.87,1.68] | |
1.22 [1.00,1.48] | 1.09 [0.84,1.41] | 1.25 [0.99,1.57] | 1.1 [0.87,1.39] | 1.1 [0.76,1.60] | 1.16 [0.91,1.49] | |
1.14*** [1.06,1.22] | 0.92 [0.84,1.00] | 1.11* [1.02,1.22] | 1.11* [1.02,1.21] | 1.08 [0.94,1.23] | 1.07 [0.97,1.19] | |
|
1.00 (ref) | |||||
|
1.12** [1.04,1.20] | 1.30*** [1.19,1.43] | 1.28*** [1.18,1.39] | 1.25*** [1.15,1.36] | 1.31*** [1.15,1.50] | 1.05 [0.95,1.16] |
|
1.25*** [1.11,1.41] | 1.62*** [1.40,1.87] | 1.51*** [1.32,1.74] | 1.47*** [1.28,1.69] | 1.76*** [1.46,2.13] | 1.21* [1.01,1.44] |
1.00 (ref) | ||||||
1.28*** [1.11,1.47] | 1.35** [1.12,1.63] | 1.31** [1.11,1.55] | 1.21* [1.03,1.44] | 1.39** [1.11,1.74] | 1.05 [0.83,1.32] | |
1.05 [0.94,1.17] | 1.59*** [1.40,1.80] | 1.39*** [1.23,1.57] | 1.22** [1.08,1.37] | 1.33** [1.12,1.58] | 1.09 [0.93,1.27] | |
0.9 [0.66,1.22] | 1.17 [0.79,1.75] | 1.02 [0.69,1.51] | 1.39 [0.96,2.01] | 0.88 [0.52,1.48] | 0.46* [0.22,0.97] | |
0.79*** [0.71,0.88] | 1.60*** [1.41,1.83] | 1.02 [0.90,1.16] | 1.28*** [1.13,1.44] | 1.02 [0.86,1.22] | 1.16 [0.84,1.62] | |
1.06 [0.99,1.13] | 1.41*** [1.30,1.54] | 1.29*** [1.19,1.39] | 1.01 [0.93,1.09] | 1.50*** [1.33,1.70] | 1.10* [1.01,1.21] | |
1.59*** [1.48,1.71] | 2.19*** [2.01,2.39] | 2.10*** [1.94,2.28] | 1.73*** [1.59,1.87] | 1.76*** [1.56,1.98] | 1.25*** [1.13,1.39] |
*p < 0.05; **p < 0.005; ***p < 0.001; n.a., Not Applicable; PTSS, Post-Traumatic Stress Symptoms; ADS, Adjustment Disorder Symptom; §Age is standardized and reversed, younger age has an OR>1 if associated with heightened risk.
In this study, we report for the first time on the mental health outcomes related to COVID-19 outbreak and related lockdown measures on the general population in Italy. To the best of our knowledge, this is the first study to report on mental health outcomes related to the COVID-19 outbreak in Europe on such a large sample size. This study shows relatively high rates of PTSS, Depression symptoms, Anxiety symptoms, Insomnia, Perceived stress and ADS, with young women having higher odds of endorsing a mental health outcome. These outcomes were associated with a number of COVID-19-related risk factors, including being under quarantine, having a loved one deceased by COVID-19, working activity discontinued due to lockdown measures, or experiencing other stressful events (i.e. working, financial, relationship, or housing problems) due to the pandemic or lockdown measures. These findings were adjusted for previous psychiatric illness and a history of childhood trauma, suggesting that the COVID-19 pandemic is exerting an independent effect on the population mental health.
Compared to previous reports on common mental disorders in the Italian population, our data suggest in increase in rates of common mental disorders such as depression symptoms and anxiety symptoms (
Compared to an early report on the mental health outcomes related to COVID-19 in China on 1210 respondents (
Coherently with previous reports from China, female gender (
Monitoring populations’ mental health is critical during a pandemic, as generalized fear and fear-induced over-reactive behaviour among the public could impede infection control (
This study has some important limitations due to the sampling technique. Relying on social networks voluntary recruitment and re-sharing could have introduced an important selection bias, firstly excluding people not on social networks, and secondly introducing a self-selection bias, as suggested by the highly unbalanced gender ratio observed. This latter bias could have affected also two other large web-based surveys in China, that reported on samples with a 64.7% and 67.3% proportion of woman (
This study has also several strengths, including a very large sample size and the sampling timeframe that corresponded to the pandemic peak in Italy.
Future studies will need to monitor the trajectory of mental health outcomes, in order to define mental health interventions at a population level.
Moreover, these results suggests that appropriate mental health care delivery should be at the centre of future re-organization healthcare management, anticipating the needs, planning, and delivering much needed mental health protection of the whole community as well as in special populations (i.e. healthcare workers, adolescents, older age).
We found high rates of negative mental health outcomes in the Italian general population three to 4 weeks into the COVID-19 pandemic and lockdown measures. COVID-19 related factors were associated with these outcomes independently from previous mental illness or childhood trauma. These findings warrant further monitoring on the Italian population’s mental health and could serve to inform structured interventions in order to mitigate the impact on mental health of the outbreak.
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 Internal review board, University of L’Aquila. The patients/participants provided their written informed consent to participate in this study.
Conceptualization: RR, VS, FP, GL. Methodology: RR. Formal Analysis: RR. Data Curation: RR, SM, GL. Writing—Original Draft: RR, VS. Writing—Review and Editing: RR, VS, DT, AM, FP, SM, CN, AR, AS, GL.
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.
This work is supported by Territori Aperti, a project founded by “Fondo Territori Lavoro e Conoscenza CGIL CISL UIL”.