**3. Results**

The descriptive statistics of the sample (Table 1), risk perception, negative mood, and social support (Table 2) are reported.

**Table 2.** Descriptive statistic of COVID information and risk perception, bad mood, and social support during the quarantine.


As shown in Table 3, we did not find statistically significant differences between the BPRS scores measured in November (T1; NoCoT) and April (T2; CoT). During lockdown, the patients showed a small increase in symptomatology (T1NoCoT M = 2.50, T2CoT M = 2.79) in terms of emotional isolation, but differences in other symptoms were not found. The MMSE also did not show a significant difference (Table 3).


**Table 3.** Between administration-time differences (ANOVA).

\* *p* < 0.05. \*\* *p* < 0.01; K\_Axis = Kennedy Axis V; PI = Psychological impairment; SS = Social skills; Vi = Violence; OI = ADL-Occupational Skills; SA = Substance abuse; CPC = Compromising of physical conditions: Medical impairment; AI = Ancillary impairment; GAF Eq = Global Evaluation Functioning Equivalent, a score that provides an average and global representation of the patient's functioning. It is obtained from the average of the first four Kennedy Axis V scales; GAF K = Global assessment of functioning. Global functioning obtained by selecting the lowest of the scores from the first four areas; DL = Danger level, this index identifies the highest risk score among those obtained in the seven areas.

> Otherwise, the K Axis scores showed a significant main effect (F (1,6) = 9.996, *p* < 0.001; ηp <sup>2</sup> = 0.0435) and significant interaction effect of K Axis\*Session (F (1,12) = 3.157, *p* < 0.01; ηp <sup>2</sup> = 0.195). We observed significant differences in certain functional areas of the behavior measured by the K Axis between the two time points (Table 3). The comparisons revealed significant differences for violence (Area 3). Pairwise comparisons showed that the mean of T1 was lower (M = −13.333, SE = 0.09, *p* < 0.05) compared to the T2. Specifically, the patients showed a lower inclination towards violent behaviors during lockdown (higher scores indicate a lower level of criticality in this area).

> A significant difference was also observed for area 5, substance abuse. Pairwise comparisons showed higher mean difference in the T2 compared to the T1 (M = −4.861, SE = 0.265, *p* < 0.05). This functional area seemed to improve during the lockdown (higher scores indicate a lower level of criticality in this area).

> Finally, there were significant differences for medical impairment (Area 6). Pairwise comparisons showed a significant higher mean difference in the T2 compared with T1 (M = −7.917, SE = 0.004, *p* < 0.05). The physical condition of the patients improved during the lockdown (higher scores indicate a lower level of criticality in this area). No gender differences were found for any dimensions assessed.

#### **4. Discussion**

Several recent studies have demonstrated a significant impact of the COVID-19 pandemic on psychological health, particularly as a result of the lockdown [24–26], but few studies have investigated this impact on specific populations, such as psychiatric patients.

The present study compared the psychiatric symptoms and functioning in several specific areas of patients living in residential communities before and during the lockdown in Italy. An important result emerged from the comparison between the clinical evaluations from November 2019 (before the lockdown in Italy) and April 2020 (during the lockdown in Italy). According to our data, the patients did not show an increase in psychiatric symptoms; the only exception was a small increase in emotional isolation. The increased feeling of emotional isolation may have been linked to the isolation imposed by the necessary containment of COVID-19. Although social isolation is part of the symptomatology of many psychiatric disorders [27], the limitations imposed during the lockdown may have exacerbated the sense of loneliness and despair due to the imposed distance from loved

ones but also staff and other psychiatric patients in the community. In contrast, different functional areas of behavior showed improvements: there was a lower propensity for violent behaviors, lower rates of substance abuse, and better physical conditions.

These findings may seem to contrast with those of numerous studies that have indicated concerns about the pandemic or reported that a period of isolation can lead to an increase in psychopathologies, including psychotic psychopathologies [28]. Systematic reviews and specific studies have shown significant effects of the COVID-19 pandemic on the psychiatric population [29–31]. Forced quarantine to combat the spread of COVID-19 has produced forms of acute panic, anxiety, obsessive behavior, paranoia, and depression in psychiatric patients.

In the same studies, however, it was recognized that acute pathological conditions increase with concomitant causes of stressors, such as psychological vulnerability, social isolation, unemployment, relational rupture, etc. In particular, social isolation seems to be the variable that "carries the most weight" for the psychiatric population. For example, Giallonardo and colleagues [32] showed that if protracted, social isolation may increase the risk of recurrences of episodes of mental disorders beyond triggering the onset of new mental disorders in the most vulnerable people. Moreover, objective social isolation and subjective feelings of loneliness are associated with a higher risk of suicidal ideation and suicide attempts. For many persons with mental disorders, being alone is a heavy burden, far greater than that experienced by many other persons. Moesmann and colleagues [27] reported that in their nonresidential clinics, some patients went from a high level of functioning to a need for hospitalization due to the rupture of their weekly routines. In some cases, telepsychiatry and other cutting-edge technologies have been effective tools in bridging social distance and ensuring continuity in mental health assistance [33].

Research has shown the importance of ensuring social support and mental health care for patients with mental disorders [34]. In the literature, differences between psychiatric outpatients and inpatients have been reported. Outpatients have been shown to experience greater psychological impact on their mental health, with higher depression, anxiety, and stress scores than healthy controls [29,35] due to the interruption of some psychiatric services and the difficulties accessing these services due to the lockdown. Therefore, continuous monitoring of the medical and psychological health of patients receiving mental health services is essential to design and respond to problems arising from the lockdown and the spread of the virus [36]. On the other hand, inpatients have been found to experience greater confidence in being protected from virus than control groups, as they feel protected by hospital staff [37]. However, inpatient psychiatric settings have faced new challenges: close contact between staff and patients, the restriction of visitors, and the recommendation of improved hygiene [38].

In our study, the subjects were residential patients in therapeutic communities and were therefore protected from different social stressors, such as relational continuity and low exposure to mass and/or social media. During quarantine, the patients' days were spent engaging in routine activities. Twice a week, the patients could call their families to ensure their health. The peer group or community psychologists provided ongoing social support. Therefore, we believe that the patients in our study did not have worsening symptoms due to the continuity of social support and medical care.

We observed that some functional areas of behavior improved. These behavioral areas were mainly linked with containment aspects [39]. "Containment" is a broader term that includes a wide variety of strategies, including pharmacological treatment and nonpharmacological interventions or techniques, such as increased observation levels, locked wards, de-escalation techniques, the use of behavioral agreements and increased staffing levels. In this study, we refer to the conditions imposed due to COVID-19 outbreak: an inability for patients to leave the community, the use of only telephone meetings with family and friends, etc. Paradoxically, for the patients in our study, these measures likely resulted in less exposure to social stressors. Indeed, the family environment can either play a protective and detrimental role [40] and for psychiatric patients, not being embedded in

dysfunctional family dynamics (e.g., low family cohesion and low caregiver warmth) may have contributed to a stability in symptom severity.

Our hypothesis is that the lockdown condition represented a further form of containment. Daily routines, along with adequate social support, are important aspects of the stability and the level of behavioral functioning of psychiatric patients, in particular for those with anxiety, violent acts, and substance abuse. In summary, we believe that social support and continuity of care offered by psychiatric communities can be an effective safeguard against the psychological impact of the COVID-19 epidemic.

We are aware of the limitations of our research. The limited number of subjects could not ensure the external validity of our research. In addition, our investigation involved patients from a single community association. It could also be very interesting to extend our results to other residential contexts. We believe, however, that our results provide interesting insight and may be a stimulus for further research on the severe psychiatric patient population during COVID-19 and in directing further research on patients living in treatment communities.
