**4. Discussion**

The present study evaluated the impact of the COVID-19 pandemic on Risk Perception, Worry, Depression, Anxiety, Stress, and Coping Strategies among Italian psychiatric patients living in a rehabilitation community, compared to healthy controls. The results showed significant differences between psychiatric patients and controls on Anxiety, Stress, Worry, and Risk Perception variables. Concerning the DASS-21, psychiatric patients scored lower on all three subscales than the comparative clinical sample studied by Bottesi et al. [24], who registered mean scores of 5.5 (*SD* = 4.6), 7.7 (*SD* = 5.6), and 8.9 (*SD* = 4.2) for the Depression, Anxiety, and Stress subscales, respectively. Although psychiatric patients in the current study generated lower DASS-21 scores, all scores were within a normal range, according to Lovibond and Lovibond's [28] version of the scale. In contrast, other studies of both non-residential psychiatric patients and the general population have identified higher DASS-21 scores during the COVID-19 lockdown [11,22].

The lower scores registered in the present study could be explained by the residential care condition of our study sample. As reported by Tansella [29], it is possible to hypothesize that residents of psychiatric rehabilitation communities, unlike psychiatric inpatients in a hospital setting, experience greater support from mental health workers and peers, present higher perceived security, and, above all, enjoy minimal coercion and maximal freedom. Moreover, unlike the population of non-residential psychiatric patients who were forced to reduce their access to psychiatric care and pharmacological and psychological support during the lockdown [30], the residential psychiatric patients in our sample were able to maintain their typical levels of care and support. This could explain their DASS-21 scores in the normal range.

Residence in a psychiatric rehabilitation community during lockdown may have been an important factor in limiting psychiatric patients' increase in depressive, anxious, and stressful symptoms. However, psychiatric patients did still show higher levels of Anxiety relative to healthy controls. While this significant difference might be explained by the impact of COVID-19 on psychopathology and mental health [31], it could also be related to psychiatric pathology. In fact, there is a higher prevalence of Anxiety disorders in people diagnosed with schizophrenia or other spectrum psychotic disorders, with 6.3% of this population presenting at least one lifetime Anxiety disorder [32–34].

In the present study, psychiatric patients presented with lower Stress compared to controls. This result could relate to their pre-existing adaptation to conditions of restricted personal freedom (i.e., limits imposed by the psychiatric community), in contrast to healthy controls, who were not accustomed to the limitations of freedom required by the lockdown. Considering that the lockdown implied separation from loved ones, loss of freedom, and boredom, higher Stress levels would be expected, as supported by research on the impact of quarantine on the general population [35].

In addition, psychiatric patients obtained a medium score on the BRCS, demonstrating a medium level of resilience [25]. Resilience and gratitude are considered protective mechanisms in conditions of trauma [36], and the resilience exhibited by the present psychiatry patients may have made them less vulnerable to COVID-19 stressors.

Furthermore, psychiatric patients scored higher than healthy controls on the Perceived Risk of getting infected with COVID-19. They received training and education on COVID-19 and its transmission by their rehabilitation community, and this might explain their higher perception of risk relative to healthy controls, as measured by the relevant survey items (e.g., "If I got COVID-19, it would be severe").

Moreover, psychiatric patients showed higher levels of Worry than the control group, particularly with respect to worries about their health and contraction of the virus [37]. Overall, the presence of a psychiatric diagnosis and higher scores on the Worry measure were found to be significant predictors of DASS-21 Anxiety and Stress. As testified by the cognitive behavioral model [38], Worry may produce negative interpretations of information. For example, Internet search results (e.g., graphic images of the surge of contagion, alarmism, fake news, conspiracy theories) could exacerbate fear, Stress, and Anxiety and, in some people, manifest nightmares and intrusive thoughts concerning COVID-19 [39].

It is worth noting that the present sample mainly consisted of younger adults (psychiatric patients: *M* = 46.61, *SD* = 12.81; healthy controls: *M* = 46.40, *SD* = 11.52). Previous studies on the COVID-19 epidemic have found a different age and gender association with Perceived Risk and Worry, with older adults demonstrating a higher risk perception and younger adults demonstrating greater Worry [40]. In the present study, both psychiatric patients and healthy controls scored higher on Worry than Risk Perception. Our results also found an association between having a psychiatric disorder and increased Anxiety and Stress.

To the best of our knowledge, the present study was the first to provide data on a population of psychiatric patients who, during the lockdown in Italy, lived within a psychiatric community that provided continuous support and care. However, the study has some limitations. First, we were limited in our ability to draw comparisons between psychiatric patients and healthy controls, due to significant differences in gender and educational level. Previous studies have investigated the impact of education level on individual responses to COVID-19, showing that, in healthy controls, a lower level of education is correlated with a lower awareness of COVID-19; this may be due to limited access to health information, reduced access to health care, and increased financial burden [41]. Furthermore, this study was conducted in only two communities in the Lazio region and may not reflect trends observed in similar contexts. The present study also used an observational design; therefore, no assumptions of causation can be made, as baseline evaluations for the psychological variables investigated were not available. Despite these limitations, this is, to the best of our knowledge, the first study to have examined the psychological impact of the threat of COVID-19 on psychiatric patients living in rehabilitation communities during the lockdown.
