**4. Discussion**

This report provides an overview of the Italian C19CRP study to investigate the psycho-social impact of the COVID-19 pandemic in the adult population. We aimed at replicating the analyses of the first two UK studies [19,20]. First, we focused on replicating the analyses by Shevlin et al. [20] about the somatic symptomatology and their relationship with anxiety. All the psychosomatic subscales showed positive correlations both with COVID-19 anxiety and general anxiety (GAD-7) (Table 1). In our regression analysis, higher COVID-19 anxiety was associated with more severe somatic symptomatology (Model 1, Table 2). Compared to the UK, in Italy the somatic symptoms showed a more linear relation between COVID-19 related anxiety and the somatic subscales and total score.

In Model 2, the individuals with higher COVID-19 anxiety displayed more severe somatic symptoms. When considering covariates, gender, health problems, GAD-7 ≥ 10, and human losses due to COVID-19 had a significant effect on somatic symptomatology. No consistent effect of region or household income were observed, with the exception of higher levels of somatic symptoms registered in the Campania region followed by the Veneto region.

In a second part of the analysis, we replicated the approach by Shevlin et al. [19]. We conducted three logistic regressions with different outcomes: presence of moderate anxiety/depression; presence of moderate traumatic stress symptoms; presence of high COVID-19-related anxiety.

When the outcome variable was the presence of moderate symptoms of anxiety and/or depression (Table 3), the factors associated with moderate symptoms of anxiety and/or depression were younger age, having children, having pre-existing precarious health conditions, mourning for COVID-19 losses, and perceiving a moderate to high risk of contracting the COVID-19 virus within one month. Regarding the regions, no significant results emerged.

If COVID-19 related anxiety is used as outcome (Table 4), being male had a protective effect, whilst living in a town and perceiving a low-moderate to high risk of getting COVID-19 within one month were associated with higher COVID-19 related anxiety.

When considering as dependent variable the presence of traumatic stress symptoms above the clinical cut-off (Table 5), younger age, having children, having pre-existing precarious health conditions, thinking about having lost someone due to COVID-19, and perceiving a low-moderate/high risk of contracting COVID-19 within one month were associated with more severe traumatic stress symptoms. Regarding, regional differences, living in Lombardia compared to Campania was associated with lower traumatic stress symptoms.

Across these models, an increase in the perceived risk to contract COVID-19 in the following month was associated with depression/anxiety, traumatic stress, and COVID-19 anxiety.

Summarizing, these results are in line with those of the UK study about anxiety, depression, and traumatic stress [19]. The UK and Italian data identify factors associated with worst psychological health: being a woman, younger age, having children, preexisting health issues of self or someone close, and the moderate to high perceived risk of contracting COVID-19 within one month. Unlike Italy, in the UK lower household incomes and having (had) the COVID-19 were associated with worst psychological health outcomes.

Despite the similar variables used in Italy and in UK, the comparison has to take into account the differences in data collection in regard to the evolution of the epidemic. The first wave in the UK was launched at the beginning of the lockdown while the Italian first wave took place two months after the end of the first lockdown, thus focusing on the adaptation to life with COVID-19. The literature shows that psychological distress symptoms can last for years [13,33–35] and data from Italy confirms that the levels of psychological distress are still considerable two months after the end of the lockdown. Moreover, the literature about other infectious respiratory diseases (IRDs) (e.g., H1N1, MERS, SARS) shows that it is important to monitor psychological health also after the peak [34–36].

Regarding the differences among Italian regions, results suggest that in July 2020 the Campania and Lazio regions suffered a strong psychological impact of the COVID-19 pandemic. In particular in Campania somatic symptoms were more severe, compared to Lombardia and Veneto (Model 2). COVID-19-related anxiety was higher in Campania than in Lombardia (Table 3). This is counterintuitive given that Lombardia had been affected earlier and to a larger extent. There were no significant regional differences between regions in term of anxiety/depression and traumatic stress. As for COVID-19 related anxiety, this result appears counterintuitive, because on the basis of the differences in infection rate and media coverage one may have expected Lombardia to have higher scores than other regions.

There are a few factors that may have affected these results. As always, findings should be contextualized with respect to the time and circumstances of data collection. Lombardia and Veneto experienced COVID-19 issues for a longer period and had more contagions than Lazio and Campania. Resilience may have increased over time [37]. Another possible explanation concerns the role of media in transmission of threatening information, when the data was gathered people in areas with higher infection rates (e.g., north vs. south; Italy vs. UK) already received more threatening information, thus increasing their risk perception but also their strength. A second factor is that in July 2020 attention was focused on the central and southern regions because of seasonal tourism. This may be related to the higher anxiety and somatic issues in the Campania region at this point in time. Finally, as discussed in the introduction, one reason both Lombardia and Veneto were included in our study is because they are geographically contiguous but had been differentially affected by the pandemic. If differences reflect geography rather than extent of the health emergency, these may also relate to differences in attitudes or approach to the survey in different regions. Further investigations are necessary to clarify similarities and differences between regions.

These findings from the Italian general population suggest that two months after the end of lockdown the psychological distress was still present, and it was high for certain categories of the population, such as women, the younger, and those with children. Our results are in line with the current literature about the impact of COVID-19 in Italy [10,38–40] and worldwide [41] both in clinical and general population as well. To date, most of studies focused on the negative consequences of COVID-19. An Italian study in general population showed the COVID-19 massive effects with rates of psychological issues ranging around 41.8% for high distress, 32.1% for high anxiety, and 7.6% for PTSD symptomatology linked to the virus [38]. Other Italian studies focused on the mental health of specific categories, as parents [40] at higher risk of experiencing distress and young adults [39] who showed an increase in internalizing and externalizing problems, anxiety, depression, somatic complaints, and aggressive and rule-breaking behaviors.

The anxiety related to COVID-19 was associated with somatic symptomatology beyond general anxiety, thus suggesting that COVID-related issues (e.g., degree and type of exposure to COVID-19) deserve clinical consideration. Moreover, results highlighted the socio-demographic risk-factors associated with more severe psychological outcomes. These indicators are useful to identify at-risk groups in the population which may need targeted psychological interventions. Noteworthy, the perceived risk of contracting COVID-19 was considerable in the population. This may influence a number of outcomes ranging from psychological issues, hygiene practices, precautionary behavior, attitudes toward vaccine, trust in institutions, and beliefs in conspiracy theories. Future studies will focus on the role of other aspects that are relevant for adaptation to living with the COVID-19 in the Italian context.

The limitations of this study should be acknowledged. An online administration methodology was used, this may bias the results because there may be differences between the paper-pen administration and the online version. Self-report measures were used, with potential well-known biases related to social desirability and misleading answers. When the study was launched in UK, a broad number of measurement tools were used, including already validated measures and tools developed ad hoc in order to reflect the current psychological issues related to the COVID-19 emergency. Given that the same measures were administered in Italy, socio-cultural differences suggest caution in interpretation and in the direct comparison [20].

An observational cross-sectional study design was used, whilst a longitudinal design would be desirable to monitor the evolution of the COVID-19 impact. Future waves of the survey would provide valuable information. Our analyses can only show association and not causation. Finally, despite the well-balanced sample, a larger sample would better capture and represent minorities.

The Italian C19PRC can contribute to ongoing research on health issues such as: the factors hindering resilience, the relationship between conspiracy theories and denial, the link between trust in Institutions and compliance, the burden and clinical characteristics of psychological issues, and the psychological heath of specific subgroups at higher risk for adverse psychophysical outcomes. Moreover, comparing results in a broader international framework allows cross-cultural comparisons. In addition to Italy and the UK, the international consortium now includes the Republic of Ireland (from March 2020), Spain (from April 2020), the United Arab Emirates (from April 2020), and Saudi Arabia (from May 2020).

Regarding the strengths of this research, respondents were recruited by using an online research panel with stratified quota sampling to ensure that the sample would meet the characteristics of sex, age, household income of the Italian population. Moreover, the C19PRC Study was designed drawing from studies that investigated previous IRDs epidemics and their psychosocial impact (e.g., H1N1, MERS, SARS). To do so, several factors were assessed to capture the complexity of the phenomenon from an ecological perspective, taking into account the demographic, social, political, economic, and psychological influences. The findings of this project may be useful to understand and manage the psycho-social implications of the COVID-19 pandemic.
