**5. Discussion**

Sudden outbreak events always pose huge challenges to the countries where they occur, impacting not only on physical health but also on social and mental well-being. From this perspective, the COVID-19 pandemic will have long-term consequences, influencing international and national public health policies.

This study is part of a series of works aimed at investigating the characteristics and the psychological effects of the COVID-19 pandemic and the restrictive measures adopted by the Italian Government during the early and more severe stages of the COVID-19 outbreak [24,25]. Since the outbreak of the COVID-19 epidemic, the Italian Government imposed a lockdown in North Italy, expanding it nationwide following the exponential diffusion of the pandemic from the Northern territorial areas to both the Central and South areas. These severe limitations included the request for both people infected by the virus and healthy citizens to isolate themselves at home, prohibiting all other than indispensable activities, and making it mandatory to wear surgical masks to enter public places. Our data were collected near the infection peak (between the end of March and the beginning of April 2020) [2], and they provide an accurate snapshot of Italians' perception of this emergency.

This study delivers further information to add to the findings reported on the Chinese population that was the first to be severely affected by COVID-19 [5–8,26], indicating that the effects of this pandemic on the psychopathological conditions are similar in the Italian and Chinese populations. In both countries younger age, student status, female gender and direct contact with COVID-19 infection are associated with a greater psychological impact of the emergency, involving many psychopathological dimensions (e.g., anxiety, distress, sleep disturbance) [5–9,26].

One of the aims of the study was to analyse the psychological impact of the COVID-19 outbreak in the different Italian territorial areas. North Italy was the first area in Italy infected by the COVID-19 and in which social distancing was imposed. It continues to have the highest prevalence of contagion and deaths, with a heavy burden on the public health system. Accordingly, we expected an impact of these conditions on the psychological well-being and mental health of its inhabitants. However, although respondents from North Italy reported more sleep disturbances and a relatively higher state of anxiety compared to those from Central and South Italy, no other differences were

observed in psychopathological symptoms and PTSD risk [23]. These results would seem to underline that psychological status is not only influenced by the direct effects of a justifiable fear of contagion but also by the indirect consequences of the COVID-19 outbreak such as the restrictive measures, that equally influenced people of all the Italian regions, generating a similar psychological pattern. This assumption would be confirmed by the comparison of our results with data from the general Italian population. The differences in the selection of the sample do not allow a generalizability of these results. Most of the psychological symptoms assessed by the SCL-90 subscales are significantly higher in our sample compared to data from the general population. Only somatization and paranoid ideation resulted in being not significantly different from data on the general population. These last findings do not agree with recent data on the Chinese population [27], and they could appear incongruous because medical emergencies might induce higher somatization and intrusive and threatening thoughts. However, these results concord with those found during the SARS epidemic [28].

The high prevalence of anxiety evidenced in our sample highlights that the COVID-19 pandemic has increased alert levels and generated a high level of state anxiety in the population, confirming results of previous studies on SARS, Influenza A virus subtype H1N1 [29–31], and COVID-19 [6–8].

In our sample, 27.72% of the respondents presented PTSD symptomatology, and risk of PTSD higher than that reported in the general population, at least as regards the symptoms evaluated with the IES-R questionnaire [23]. This result should be interpreted with caution because it referred to the first weeks of the emergency when people could perceive the rapid spread of the virus and the extraordinary measures adopted by the Government as sudden stressors, and it is known that sudden stressors affect the daily lives of individuals drastically. On the other hand, this first Italian perception of the current situation would seem to give a photograph of the real impact of the COVID-19 outbreak on mental health.

Another interesting result concerns the impact of the pandemic on mood. Respondents perceived a significant change in their mood, with a sensitive decrease of positive mood (e.g., happiness, serenity) and a high increase of negative mood (e.g., sadness, preoccupation, boredom) after the COVID-19 spread and the consequent social distancing measures. From a clinical point of view, this result could suggest a possible risk of mood disorders, such as depression, as long-term consequences of a pandemic [32]. However, it must be underlined that these data are not obtained prospectively, and the causal relationship cannot be confirmed. Self-reported moods are subject to memory distortions and bias, and they should be taken with caution.

Overall, the results highlighted high levels of anxiety, psychopathological symptoms and PTSD symptoms in Italian respondents during the first critical phase of the spread of the COVID-19 pandemic and of the Government measures taken to contain it.

However, the results of the present study also suggested which people are most vulnerable to the psychological consequences of the COVID-19 outbreak. This unexpected situation seems to have had a higher impact on females and people under 50 years. Moreover, to have had direct contact with people infected by the virus, and to know people more or less severely infected by the COVID-19 (i.e., people hospitalized in an intensive care unit or people dying as consequences of COVID-19 infection) emerged as other relevant risk factors for psychological well-being. All these characteristics would make people more vulnerable to developing anxiety, psychopathological symptoms, and PTSD-related symptoms, confirming results observed in previous studies [8,33]. These risk factors may depend on different aspects of the COVID-19 pandemic. The high psychopathological risk related to direct experience with the COVID-19 infection could depend on the fear of contagion, while being younger could be a risk factor due to the sense of constraint caused by social distancing and the other measures taken by the Italian Government [3].

Our study reports that COVID-19 infected 0.4% of the sample. This result is higher than the data on the general Italian population (0.22%), updated on the 30 March 2020 [2], but it indicates the high rate of healthy individuals in the sample. Both this consideration and the data on risk factors would confirm that, even without real exposure to the COVID-19 and an actual infection, fighting against an invisible enemy could affect mental health. Uncertainty, fear about infection and social consequences of a pandemic could be triggers for psychopathological symptoms, and they should be considered in further studies.

Although some psychological characteristics are linked to medical conditions [34–37], psychological consequences of at-risk people are often overlooked during an epidemic emergency as reported for SARS and H1N1 [29,30,33]. Once again, the importance of not disregarding mental health and intervening during and after the pandemic emergency in the most affected psychological dimensions appear relevant in a long-term perspective.

This study gives a picture of the psychological well-being of the Italian population at the beginning of the COVID-19 emergency. However, some limitations must be considered. Despite the large sample size, it is not possible to overcome the limitation of a cross-sectional study, which does not allow us to determine a causal relationship between the variables. Also, the use of an online survey presents other limitations. Selection bias of participant recruitment is a consequence of this methodological choice. This bias is expressed by some characteristics of our sample, such as the higher number of respondents younger than 30 years, and the high number of females and people from South Italy. Another limit related to the online survey can be associated with convenience sampling that may have induced the collection of responses primarily from people who feel strongly about the considered issue. These limitations reduce the representativeness of our findings and may have influenced the results of the study. Therefore, they must be considered. However, the adoption of an online survey was the best solution in this emergency in which social distancing measures limit data collection.

In conclusion, a global response is desperately needed to prepare health systems to face the new challenge of the COVID-19 outbreak. Despite the underlined limitations, these preliminary findings, in line with the results of previous studies, evidenced that the diffusion of this pandemic can be related to anxiety, changes in mood, high psychopathological symptomatology, and could be associated with the development of PTSD. Moreover, similarly to the results of other studies on the COVID-19 pandemic, these findings should be considered preliminary, but they can be useful to predispose interventions aimed at improving the psychological conditions of the population. Generally, there is still a lack of relevant research on psychological aspects during the COVID-19 epidemic. It would be essential to analyse further psychological dimensions related to the COVID-19 outcomes, such as lifestyle changes, fear, and perception of the emergency, to assess their role in influencing the psychological status of the Italian population.

We hope that these preliminary data can be useful to other researchers in analysing the impact of the infection and social isolation due to COVID-19 diffusion. It is our desire that COVID-19 be defeated but also that the research on this topic grows so that we can start thinking about the mental health of those involved in this severe emergency.

**Author Contributions:** Conceptualization, G.F., M.C., F.F., R.T.; Methodology, G.F., M.C., F.F.; Formal Analysis, G.F., F.F.; Investigation, G.F., M.C., F.F., R.T.; Resources, M.C., R.T.; Data Curation, F.F., G.F.; Writing—Original Draft Preparation, M.C., F.F., G.F.; Writing—Review & Editing, M.C., G.F., F.F., R.T.; Supervision, M.C., R.T. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no specific grant from any funding agency, commercial or not-for-profit sectors.

**Acknowledgments:** There is no funding support for this survey. We would like to thank Gianluca Pistore and all the people who helped in the data collection by sharing our survey on various social media.

**Conflicts of Interest:** The authors declare no conflict of interest.

### **References**


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