Abstract
Background: The impact of the COVID-19 pandemic on mental health is complex and affects a broad segment of the population. Several studies indicate that depressive, anxious and post-traumatic symptoms are common in people exposed to SARS-Cov2.
Methods: 458 subjects were recruited during their first consultation in outpatient psychiatric services between June 2020 and October 2021. Post-traumatic, depressive and anxious symptoms were assessed using the Impact of Event Scale-Revised (IES-R), the Beck Depression Inventory Scale-second edition (BDI-II), and the Self Rating Anxiety Scale (SAS). A specific set of questions was developed, with the aim of evaluating socio-demographic variables and work, environmental and personal characteristics related to the pandemic.
Results: Prevalence rates of clinically significant depressive, anxious and post-traumatic symptoms were 57.6%, 63.5% and 54.8%, respectively. Female gender, worsening of relationship status and financial consequences due to the pandemic were the conditions most strongly associated with the presence of psychopathology.
Limitation: The cross-sectional design of the study doesn't allow an evaluation over time of the sample. No assumption of causality can be made due to the lack of pre-pandemic assessments for the investigated variables.
Conclusions: The impact of the pandemic involves depressive, anxious and post-traumatic dimensions. The investigated psychopathology correlates with several variables expressing the personal and environmental changes that occurred in the population due to the COVID-19 emergency. The study is multicentric and the recruitment of participants was held in a clinical setting, providing a realistic picture of the consequences of the pandemic in clinical practice within mental health services.
Keywords: Depression, Anxiety, post-traumatic, COVID-19, Pandemic, Mental health services
1. Introduction
A national lockdown represented the Italian Government's response to the rapid spread of COVID-19 cases in Italy since February 2020. Following the first peak in cases, further “waves” of the pandemic hit Italy and, as a consequence, non-therapeutic public health interventions such as quarantine and restriction in social and community movements have been cyclically reintroduced. During the COVID-19 outbreak many people became unemployed and experienced financial strain, which led to higher rates of mental instability in the population (Sultana et al., 2021). Given the persistence of the health emergency, a growing literature examined the impact of the pandemic on mental health, both short- and long-term. Data confirmed that negative effects on mental health may be outlasting the pandemic itself (Manchia et al, 2022). Anxiety and depressive symptoms were the most common mental health issues reported in the studies and meta-analyses (Bueno-Notivol et al., 2021; Robinson et al., 2022; Morganstein et al., 2020; Salari et al., 2020). During lockdown, patients with general anxiety disorders and OCD were more likely to access consultations in the emergency department (Capuzzi E et al., 2020; Ramadan M et al., 2022). The comparison of COVID-19 pandemic with natural disasters, such as earthquakes or tsunamis (Morganstein et al., 2020), led to the hypothesis of considering the spread of COVID-19 as a novel form of traumatic experience (Fiorillo and Gorwood, 2020). Thus, some studies evaluated post-traumatic psychopathology, finding substantial PTSD prevalence rates among the general population compared to the average global prevalence pre-COVID-19 (Yunitri et al., 2022) and significant associations with several pandemic-related conditions (Castellini et al., 2021).
Within mental health centers, the majority of psychiatric consultations were required by patients already treated and cared for by the outpatient services (Di Lorenzo et al., 2021), but also among the general population many studies outlined mental health issues arising de novo during the pandemic (Cullen et al., 2020). Studies in the general population often used online surveys, which lead to several selection biases of the sample; while research conducted in outpatient psychiatric settings focused on participants with a previous diagnosis of mental illness (Fleischmann et al., 2021). People who accessed mental health services for a first specialistic consultation represent a specific group of patients. In literature, there is a lack of data regarding the characteristics of this particular population during COVID-19 pandemic.
To our knowledge, this is the first study conducted in psychiatric public services that investigated the characteristics of psychological needs of patients who accessed the mental health services for a first specialistic evaluation. Our study took place after the first wave of COVID-19 outbreak and has a multicenter design.
The aim of the study was to evaluate the prevalence of depressive, anxious and post-traumatic symptoms in a population requiring a first psychiatric or psychological consultation. As a second goal, we investigated the correlation between psychopathological symptoms and a set of social, economic and clinic variables related to COVID-19 pandemic.
2. Methods
2.1. Procedures and study participants
The study is multicenter and cross-sectional, involving three public mental health services located in the north, center and south of Italy. The study was conducted at the Department of Mental Health of San Carlo Hospital in Milan (MI, Lombardy, Italy), the Department of Mental Health of Prato (PO, Tuscany, Italy), and of Caltagirone-Palagonia (CT, Sicily, Italy). The present study was carried out in a real-life clinical setting. Patients who accessed the mental health outpatient services for a first psychiatric or psychological evaluation were recruited for the study and given self-report questionnaires. Enrollment was held between June 2020 and October 2021. Exclusion criteria included poor knowledge of the Italian language or other limits to verbal communication, being cognitively impaired or underage. The recruitment was contextual to the clinical evaluation made by the psychiatrist or psychologist during the consultation. Suitable subjects were asked to provide written informed consent after receiving a complete description of the study, having the opportunity to ask questions. All the recruited subjects were included in the study as they met the inclusion criteria on the basis of a clinical evaluation. No data was collected on subjects who were identified as non-suitable by clinicians.
The study was conducted in accordance with the Declaration of Helsinki and approved by the local Ethics Committees (Milano Area 1, Protocol number 2021/ST/105; Regione Toscana, Azienda Unità Sanitaria Locale Toscana Centro-Protocol number 2251).
2.2. Measures
Data on socio-demographic variables were collected from each participant, including age, gender, marital status, occupation, education level. A specific set of questions investigated information regarding variables related to COVID-19 emergency, including work-related, environmental, personal and clinical features (Table 1 ). Recruited subjects were assessed using self-report questionnaires: post-traumatic stress, depressive as well as anxious symptoms were measured using the Impact of Event Scale-Revised (IES-R), the Beck Depression Inventory Scale-second edition (BDI-II), and the Self Rating Anxiety Scale (SAS), respectively.
Table 1.
Socio-demographic, work-related, environmental, personal, and clinical COVID-related characteristics in the overall sample (N=458)
| - | Variable | Total Sample N(%) |
|---|---|---|
| Gender | Male | 205 (44.8%) |
| Female | 253 (55.2%) | |
| Nationality | Italian | 421 (92.1%) |
| Not italian | 36 (7.9%) | |
| Educational level | Elementary school | 34 (7.4%) |
| Secondary school | 170 (37.1%) | |
| High school | 197 (43%) | |
| College | 57 (12.4%) | |
| Occupation | Freelance | 33 (7.2%) |
| Employed or retired | 253 (55.2%) | |
| Unemployed | 172 (37.6%) | |
| Marital status | Single or widower | 186 (40.6%) |
| Engaged non-cohabiting | 44 (9.6%) | |
| Married or cohabiting | 228 (49.8%) | |
| Spent quarantine with | Alone | 71 (15.5%) |
| With family members | 379 (82.7%) | |
| With roommates | 5 (1.1%) | |
| Previous psychiatric visits | Yes | 192 (41.9%) |
| No | 266 (58.1%) | |
| Change in work characteristics due to COVID-19 | Yes | 209 (45.6%) |
| No | 249 (54.4%) | |
| Loss of income due to COVID-19 | Yes | 129 (28.2%) |
| No | 329 (71.8%) | |
| Change of workplace due to COVID-19 | Yes | 147 (32.1%) |
| No | 311 (67.9%) | |
| Reduction of working hours due to COVID-19 | Yes | 114 (24.9%) |
| No | 344 (75.1%) | |
| Losing employment due to COVID-19 | Yes | 48 (10.4%) |
| No | 410 (89.5%) | |
| Worsening of financial situation due to COVID-19 | Yes | 170 (37.1%) |
| No | 288 (62.8%) | |
| Worsening of relationship status due to COVID-19 | Yes | 106 (23.1%) |
| No | 352 (76.9%) | |
| Having a house with open spaces | Yes | 329 (71.8%) |
| No | 129 (28.2%) | |
| Family quarrels due to COVID-19 | Yes | 113 (24.7%) |
| No | 345 (75.3%) | |
| Undergone testing for COVID-19 | Yes | 154 (33.6%) |
| No | 304 (66.4%) | |
| Got sick with COVID-19 | Yes | 28 (6.1%) |
| No | 430 (93.9%) | |
| Hospitalized for COVID-19 | Yes | 12 (2.6%) |
| No | 446 (97.4%) | |
| Acquaintances got sick with COVID-19 | Yes | 175 (38.2%) |
| No | 283 (61.8%) | |
| Acquaintances died with COVID-19 | Yes | 88 (19.2%) |
| No | 370 (80.8%) | |
| Loved ones got sick with COVID-19 | Yes | 104 (22.7%) |
| No | 354 (77.3%) |
The Impact of Event Scale-Revised (IES-R) (Weiss et al., 1997; Craparo et al., 2013) is a 22-item scale measuring three core symptomatological characteristics of PTSD: intrusion, avoidance and hyperarousal. The questionnaire has good internal consistency (Cronbach's α for each subscale: intrusion = 0.87 to 0.94, avoidance = 0.84 to 0.97, hyperarousal = .79 to .91), and high test-retest reliability (r = 0.93). Each item is rated on a five-point likert-like scale (0-4). Total score range from 0 to 88. A score over 33 represents a cutoff for the presence of clinically significant post-traumatic stress symptoms. According to the aim of the study, the items referred to subjective traumatic experiences of lockdown and COVID-19 emergency.
The Beck Depression Inventory Scale-second edition (BDI-II) (Beck et al., 1996) is a 21-item scale, used to measure the cognitive, motivational, affective, and somatic symptoms of depression. Each item is rated on a four-point likert-like scale, ranging from 0 to 3. A total score over 14 indicates at least a mild condition, while higher scores indicate more severe symptoms. Both the original (internal consistency: α = 0.92 in a community sample) and the Italian version (internal consistency: α = 0.87 in community patients) demonstrated excellent psychometric properties (Beck et al., 1996; Sica and Ghisi, 2007).
The Self-Rating Anxiety Scale (SAS) (Zung, 1971; Conti, 2000) is a 20 item scale. The raw scores range from 20 to 80. SAS items measure both affective and somatic symptoms. The raw score of 40 is considered the cut-off for clinically significant anxiety (Zung, 1980; Dunstan and Scott, 2020). The SAS has been shown to have good internal consistency with a Cronbach's alpha of 0.82 (Tanaka-Matsumi et al., 1986).
2.3. Statistical analysis
All statistical analyses were performed using the STATA software (version 13.0). Descriptive analyses were carried out in order to evaluate the distribution of socio-demographic, work-related, environmental, personal and clinical characteristics. Chi-square test was used for comparison between groups for categorical variables and Student's t-test for continuous variables. Multivariate logistic regression analyses were implemented in order to evaluate the correlation between psychopathology (DV) expressed as binary variables (presence or non-presence of clinically significant depressive, anxious and post-traumatic symptoms) and the socio-demographic, work-related, environmental, personal and clinical variables (IV) resulted as statistically significant in the descriptive analysis (chi-square, t-test). Odds ratio (OR) with 95% confidence intervals were used for the observed associations.
3. Results
The study included a total sample of 458 subjects, of which 233 (50.8%) enrolled in Prato, 121 (26.4%) enrolled in Milan, and 104 (22.7%) enrolled in Caltagirone. All subjects were asked if they ever had access to psychiatric consultations prior to that visit: approximately 58% of the subjects (266) indicated that they never had psychiatric visits before. We correlated this finding with the presence of depressive, anxious and post-traumatic symptoms and found no significant associations (p=0.41; p=0.70; p=0.40, respectively). Distribution of socio-demographic variables and work-related, environmental, personal, and clinical characteristics related to COVID-19 pandemic in the sample is shown in Table 1.
3.1. Depressive symptoms
The prevalence of significant depressive symptoms (DEP), expressed by the BDI-II score ≥ 15, in the overall sample was 57.6%. The mean age of the depression group (DEP) was 45.2 (±15.7), the mean age of the non-depression group (nDEP) was 46.6 (±16.5). Being female (62.9% vs 55.2%, p=0.01, X²=6.27) and being single or in a non-cohabiting relationship (60.8% and 70.5% vs 40.6% and 9.6%, p=0.05, X²=6.04) were more frequently associated with depressive symptoms. Participants reporting change in work characteristics (64.1% vs 45.6%, p=0.01, X²=6.60), loss of income (66% vs 28.2%, p=0.01, X²=5.99), financial strain (70.6% vs 37.1%, p=0.00, X²=18.55), family quarrels (69.9% vs 24.7%, p=0.00, X²=9.25) and a worsened relationship status (80.2% vs 23.1%, p=0.00, X²=28.71) due to COVID-19 were more likely to experience significant depressive symptoms. After logistic regression analysis (see Table 2 ) the variables most strongly associated with the presence of significant depressive symptoms were having a worsened financial situation (p=0.005; OR 2.20 [1.27-3.80]), having a worsened relationship status (p=0.000; OR 3.22 [1.85-5.57] and being female (p=0.049; OR 1.48 [1.00-2.20].
Table 2.
Logistic regression analyses of socio-demographic factors and COVID-related variables on the presence of depressive symptoms (BDI-II score ≥ 15)
| Variables in equations | OR | p | 95%CI |
|---|---|---|---|
| Female gender | 1.48 | 0.049 | 1.00-2.19 |
| Change in work characteristics due to COVID-19 | 1.13 | 0.588 | 0.72-1.76 |
| Loss of income due to COVID-19 | 0.81 | 0.501 | 0.45-1.47 |
| Worsening of financial situation due to COVID-19 | 2.2 | 0.005 | 1.27-3.80 |
| Worsening of relationship status due to COVID-19 | 3.2 | 0.000 | 1.86-5.58 |
| Family quarrels due to COVID-19 | 1.28 | 0.328 | 0.78-2.10 |
3.2. Anxiety symptoms
The prevalence of significant anxious symptoms (ANX), expressed by the SAS score ≥ 40, in the overall sample was 63.5%. The mean age was similar in the two groups resulting in 45.8 (±16.1) in the anxiety group (ANX) and 45.7 (±16) in the non-anxiety group (nANX). Female gender was more frequently associated with significant anxiety symptoms (73.1% vs 55.2%, p=0.00, X²=22.41). The anxiety group (ANX) more frequently reported changes in work characteristics (70.3% vs 57.8%, p=0.006, X²=7.66), financial strain (70% vs 59.7%, p=0.027, X²=4.87), a worsened relationship status (81.1% vs 58.2%, p=0.00, X²=18.43) and family quarrels (74.3% vs 60%, p=0.006, X²=7.55) due to COVID-19. Subjects with anxiety were more likely to have undergone tests for COVID-19 (70.1% vs 60.2%, p=0.037, X²=4.35). After logistic regression analysis (see Table 3 ) the variables most strongly associated with the presence of significant anxious symptoms were female gender (p=0.000; OR 2.46 [1.64-3.68] and having a worsened relationship status (p=0.002; OR 2.42 [1.38-4.26].
Table 3.
Logistic regression analyses of socio-demographic factors and COVID-related variables on the presence of anxious symptoms (SAS score ≥ 40)
| Variables in equations | OR | p | 95%CI |
|---|---|---|---|
| Female gender | 2.46 | 0.000 | 1.64-3.68 |
| Change in work characteristics due to COVID-19 | 1.41 | 0.127 | 0.90-2.21 |
| Undergone testing for COVID-19 | 1.37 | 0.166 | 0.88-2.12 |
| Worsening of financial situation due to COVID-19 | 1.16 | 0.533 | 0.73-1.84 |
| Worsening of relationship status due to COVID-19 | 2.4 | 0.002 | 1.38-4.26 |
| Family quarrels due to COVID-19 | 1.35 | 0.250 | 0.80-2.26 |
3.3. Post-traumatic stress symptoms
The prevalence of significant post-traumatic stress disorder symptoms, expressed by the IES-R score ≥ 32, in the overall sample was 54.8%. The mean age was similar in the two groups resulting in 45.8 (±15.9) in the PTSD group (PTSD) and 45.8 (±16.1) in the non-PTSD group (nPTSD). Female gender was more frequently associated with significant PTSD symptoms (58.5% vs 50.2%, p=0.038, X²=1.76). Participants reporting change in work characteristics (63.1% vs 47.8%, p=0.000, X²=3.29), loss of income (65.1% vs 50.7%, p=0.0027, X²=2.78), job loss (68.7% vs 53.17%, p=0.021, X²=2.05), financial strain (62.9% vs 50%, p=0.0036, X²=2.69) and relationship status (76.4% vs 48.3%, p=0.000, X²=5.10), and family quarrels (68.1% vs 50.4%, p=0.0005, X²=3.28) due to COVID-19 were more likely to experience significant post-traumatic symptoms. Participants who underwent COVID testing (64.3% vs 50%, p=0.002, X²=2.9), got sick (71.4% vs 53.7%, p=0.03, X²=1.82), and were hospitalized (83.3% vs 54%, p=0.021, X²=2.01) for COVID-19 or whose loved ones got sick with COVID-19 reported more frequently significant post-traumatic symptoms. After logistic regression analysis (see Table 4 ) the variable most strongly associated with the presence of PTSD was having a worsened relationship status (p=0.000; OR 2.66 [1.57-4.5].
Table 4.
Logistic regression analyses of socio-demographic factors and COVID-related variables on the presence of post-traumatic symptoms (IES-R score ≥ 32)
| Variables in equations | OR | p | 95%CI |
|---|---|---|---|
| Female gender | 1.27 | 0.229 | 0.85-1.88 |
| Change in work characteristics due to COVID-19 | 1.19 | 0.441 | 0.75-1.88 |
| Loss of income due to COVID-19 | 1.25 | 0.472 | 0.68-2.29 |
| Losing employment due to COVID-19 | 1.17 | 0.685 | 0.54-2.55 |
| Worsening of financial situation due to COVID-19 | 1.14 | 0.610 | 0.67-1.94 |
| Worsening of relationship status due to COVID-19 | 2.66 | 0.000 | 1.58-4.50 |
| Family quarrels due to COVID-19 | 1.44 | 0.138 | 0.88-2.35 |
| Undergone testing for COVID-19 | 1.43 | 0.124 | 0.90-2.26 |
| Got sick with COVID-19 | 0.82 | 0.735 | 0.27-2.54 |
| Hospitalized for COVID-19 | 3.41 | 0.211 | 0.49-23.34 |
| Loved ones got sick with COVID-19 | 1.44 | 0.094 | 0.93-2.23 |
4. Discussion
We set out to assess the prevalence of psychopathological outcomes in response to the COVID-19 pandemic, reporting prevalence rates of significant depressive, anxious and post-traumatic symptoms of 57.6%, 63.5% and 54.8%, respectively.
In the existing literature, studies carried out in outpatient psychiatric settings always include patients already known by the mental health services. These studies highlighted the relevant impact of pandemic in groups of patients with specific diagnosis, such as personality disorders, OCD and schizophrenia (Caldiroli A et al., 2022).
In our study, all subjects accessed the territorial mental health services for the first time and about 58% of the sample never had a previous psychiatric consultation prior to that visit. Our recruitment selected a subgroup of subjects in the general population who required specialistic help because of a self need. To our knowledge, available studies do not recruit populations with characteristics similar to our sample. As conceivable, in our research, the prevalence of psychopathology resulted significantly higher than those reported in studies in community samples. In particular, the prevalence of depression in our sample (57.6%) was higher than those reported in the meta-analyses by Luo et al. (2020) (28%), Arora et al. (2022) (22%) and by Salari et al. (2020) (34%) and in the large study of Georgieva et al. (2021) (30.3%).
Around 63.5% of the patients in our study reported clinically significant anxiety symptoms. This rate was higher than those reported in meta-analyses in the general population (32% and 28%) (Luo et al., 2020; Arora et al., 2022).
Regarding traumatic symptoms, we reported a prevalence of 54.8%, that was higher than those estimated in meta-analyses in the general public (33%) (Arora et al., 2022).
Unemployment was found to be one of the main determinants of perceived stress (Codagnone et al., 2020), leading people to require mental health support (Allume et al., 2021; Menculini et al., 2021). This finding is consistent with our results showing a significant correlation between worsened financial condition and the manifestation of depressive, anxious, and traumatic symptoms.
According to previous studies (Mazza et al., 2021; Moccia et al., 2020; Wang et al., 2020), our results indicated that the female gender was a determinant for higher levels of depression, anxiety and PTSD symptoms.
Worsening of relationship status due to the pandemic was shown to be the variable most strongly correlated with the presence of significant depressive, anxious as well as traumatic symptoms. These results are consistent with literature showing the correlation between loneliness and social isolation and the vulnerability to the psychological distress of COVID-19 (Lei et al., 2020; Holmes et al., 2020).
Our data also showed that factors directly associated with COVID-19 infection such as undergoing testing, getting sick and being hospitalized for COVID-19 were only associated with PTSD symptoms.
One of the strengths of our research was the recruitment of participants in a real-life clinical setting which led to a greater heterogeneity of the sample in terms of age, ethnicity, education and economic level than in most clinical studies, providing a realistic picture of the consequences of the pandemic in clinical practice.
The results of the present study are also affected by some limitations. First, it is a cross-sectional study so it is unable to track the psychopathological impact over time of the pandemic in the participants. Second, no assumption of causality can be made due to the lack of pre-pandemic assessments for the investigated variables.
Furthermore, to collect social, environmental, relational and clinical characteristics we used a questionnaire created by the authors specifically for the purpose of this study but non validated in literature, and we only used self-report questionnaires for assessing the presence of psychopathology.
5. Conclusions
The COVID-19 emergency impacted on mental health services, given the need to guarantee care to patients with pre-existing psychiatric disorders, but also to provide prompt response to the general population seeking specialistic support for the first time. In this context, a better understanding of the population's psychological needs is crucial. As confirmed by the results of the present study, the impact of the pandemic involves depressive, anxious as well as post traumatic dimensions. In our clinical sample, psychopathology correlates with several variables expressing personal and environmental changes due to the COVID-19 emergency. Being directly exposed to COVID-19 is associated with the presence of post-traumatic symptoms, while economic and social variables correlate with depressive, anxious as well as post-traumatic dimensions. Particularly, worsening of relationship status is strongly associated with all the investigated psychopathology. This should be taken into consideration in order to include specific interventions aimed at improving social and relational support within mental health services.
Contributors
EP, EF and AC designed the study. EP, EF, EG, AC and CN recruited the participants. CN, EP, EF and EG created the dataset. AL analyzed the data. EP and AC interpreted the data and wrote the manuscript. PAFM, RB, and GC revised the manuscript. All authors read the manuscript and approved the submission to Journal of Affective Disorders.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Declaration of Competing Interest
The Author(s) declare(s) that there is no conflict of interest.
Acknowledgements
The authors would like to thank Dr. Sara Candotti, Dr. Gloria Faraci, Dr. Rebecca Ranieri, and Dr. Fabio Salvaggio for their help in participant recruitment.
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