Earthquakes, economic crisis and, now, COVID-19: the cry of yell of Central Italy.

On 6 April 2009, the city of L'Aquila (in the region of Abruzzo, Central Italy) was stricken by an earthquake that caused the death of 309 people, with more than 70000 displaced, and about 7500 inhabitants becoming homeless. The psychiatric consequences were terrifying: an increase in rates of mental disorders (especially anxiety disorders and PTSD), suicide attempts, substance abuse, and psychiatric admissions (Carmassi et al., 2017; Stratta et al., 2016). Contemporarily, Italy was suffering from the consequences of the economic crisis that, per se, impacted mental health (Odone et al., 2018), and this crisis was more struggling in Central and South Italy due to previous and historical economic conditions. In August 2016, another destructive earthquake struck Central Italy (in the regions of Lazio, Marche, Umbria and Abruzzo), devastating Amatrice and several other towns again, causing almost 300 deaths and leaving more than 30000 people homeless (Massazza et al., 2019). Considering the proximity of Amatrice to L'Aquila, Rieti, Norcia, Teramo, and other cities of Central Italy that were directly or indirectly impacted by the earthquake of 2009, as a consequence, the psychiatric situation worsened again with a recrudescence of psychiatric disorders (Carmassi et al., 2020; Pacelli et al., 2016). Moreover, the ongoing economic crisis of Central Italy worsened again after this event, with a rise in suicide rates (De Vogli et al., 2019).

Now Central Italy, and, in particular, the regions of previous earthquakes (Abruzzo, Marche, Umbria, and central Lazio) were struck by the COVID-19 with more than 18000 confirmed cases and 1900 deaths.

Consequently, because of this pandemic, several psychiatric facilities in such regions were temporarily closed or reduced the availability for hospital beds or transformed in COVID-19-only psychiatric facilities. Therefore, the bed availability for psychiatric inpatients was massively reduced during the COVID-19 pandemic. Now, in Central Italy, even before the lockdown loosening of the 4 May 2020, we started to see a new "psychiatric" pandemic on a territory yet devastated by previous catastrophic events and economic crisis. We are now re-experiencing a considerable increase in PSTD cases (even in those who had recovered after having developed it because of the earthquakes), suicide attempts and deaths (more than ten completed suicide were observed only regarding May 2020), depressive episodes, increased substance abuse, etc. We have observed that several subjects with severe emerging psychiatric symptoms were not known before. As well, many known patients are experiencing a recrudescence of symptoms even if, before lockdown, they were recovered (Cowan, 2020).

In many psychiatric facilities of Central Italy, telepsychiatry and teleworking were firmly improved (using Skype, Zoom, Meet etc.) and well accepted by the team and patients. In Teramo and Giulianova (two cities of Abruzzo), a dedicated toll-free hotline to listen to people's psychological needs was activated, with hundreds of calls received. Moreover, the long-acting antipsychotic administration was offered in appropriate cases and assured when possible. We have also organized calls and videoconferences to educate subjects with severe psychiatric disorders to follow recommended hygiene norms (i.e., washing hands, avoiding handshakes, wear face masks, respect the safe distance, measuring temperature once daily, etc.).

However, in Central Italy, there is great difficulty in finding a hospital bed in the case of necessary or involuntary admission, and this may significantly influence psychiatric care in the next future. Moreover, we firmly believe that, together with telemedicine, also territorial medicine should be substantially improved first to detect at-risk cases. To date, we know the consequences on the mental health of the SARS epidemic (a dramatic increase of any psychiatric diagnoses of 3%) (Lam et al., 2009), the economic crisis (Merzagora et al., 2016), and the earthquakes in Central Italy (Ripoll Gallardo et al., 2016). As well, we are observing that many colleagues and healthcare workers in different divisions are facing remarkable work and psychological difficulties, and some of them have been also affected by COVID-19 with psychiatric sequelae after recovery.

In conclusion, the "dark triad" (earthquakes, economic crisis, and COVID-19) has hit, during the time and in a massive way, Central Italy. Every effort must be made especially in Central Italy to devise solutions that will be acceptable to all the subjects suffering from or with emerging psychiatric disorders. Shortly, the current "intensive care" can indeed evolve into a "psychiatric" intensive care, and the Italian government and all authorities should consider this. We must be ready and prepared because "better safe than sorry."

Declaration of Competing Interests

None.