key: cord-1034480-9ig34ufy authors: Medda, Emanuela; Toccaceli, Virgilia; Gigantesco, Antonella; Picardi, Angelo; Fagnani, Corrado; Stazi, Maria Antonietta title: THE COVID-19 PANDEMIC IN ITALY: DEPRESSIVE SYMPTOMS IMMEDIATELY BEFORE AND AFTER THE FIRST LOCKDOWN date: 2021-10-31 journal: J Affect Disord DOI: 10.1016/j.jad.2021.10.129 sha: cde9dfbe45724d6543aa70445562fdb41cfc17f0 doc_id: 1034480 cord_uid: 9ig34ufy BACKGROUND: Italy was one of the first countries to be heavily hit by the spread of the new Coronavirus. Longitudinal studies are needed to investigate the real effect of COVID-19 on adult mental health. The Italian Twin Registry carried out a study to investigate, over time, the course of depressive symptoms in the general population. METHODS: : The study relies on data collected just before the beginning (February 2020) and the end (June 2020) of the first lockdown. Symptoms of depression were assessed using the Patient Health Questionnaire, and total scores or categorized depression scores were considered in the analyses. RESULTS: A total of 1,690 adult twins were recruited. The study showed a mean depression score of 1.11 immediately before lockdown and 1.20 immediately after, with an overall prevalence of depressive symptoms increasing from 33.6% to 38.9%. Depressive symptoms immediately after the restriction period were associated with Covid-19 symptoms affecting households, financial problems due to the pandemic and poor social support. Independently of the baseline risk of depressive symptoms, we observed an increased risk among younger and less educated people. Compared to the pre-lockdown period, women and middle-aged people also were found to be at greater risk of developing depressive symptoms. LIMITATIONS: Possible participation bias and residual selection bias. CONCLUSIONS: The study shows that the COVID-19 pandemic was associated with an increased depressive symptomatology and that, in such health emergency times, the most vulnerable persons are young adults, women, and those living in a socially, culturally, or economically disadvantaged environment. Italy was one of the first countries worldwide to be severely afflicted by the spread of the new Coronavirus. The Covid-19 pandemic has caused in this Country a total number of 4,271,276 confirmed cases with 127,775 deaths ((Ministero della Salute, Dashboard ECDC 22 July 2021) up to July 2021. In early March 2020, the Italian Government promptly introduced strict national measures to restrain the outbreak. Thanks also to the vaccination campaign, the incidence of the infection has been continuously decreasing throughout the Country until the beginning of July 2021, but a new rise in the number of cases was observed more recently (Ministero della Salute, July 2021). Therefore, in this unpredictable scenario, the question of mental health consequences and impact remains central, as Prati and colleagues (Prati et al., 2021) have recently stated in a review on the topic "given that the Covid-19 pandemic is likely to persist through 2021, the question of the psychological impact of repeated or prolonged lockdowns will remain open". Indeed, there have been plenty of studies conducted during 2020 and the first months of 2021 that focused on the consequences of the pandemic and related lockdowns on the psychological and social well-being of people. Nonetheless, it should be noted that a high heterogeneity in terms of methods, periods of observations and populations' samples echoes on results. The findings may be, in fact, deeply influenced by differences in individual and collective attitude towards stressful extraordinary events like the unprecedented social life constraints experienced in different countries (Prati et al., 2021) . Mental health symptoms such as depression, anxiety and stress have variably been reported during the outbreak of Covid-19 all over the world by cross-sectional studies examining samples of the general population (e.g. Odriozola-Gonzalez et al., 2020a; Park et al., 2020) or specific sub-groups like students or workers (e.g. Cao et al., 2020; Odriozola-Gonzalez et al., 2020b) . The vast majority of those studies have indicated that younger age was a predictor of depressive or anxiety symptomatology during the COVID-19 outbreak (Ahmed et al., 2020; Gao et al., 2020; Gonzalez et al., 2020; Huang and Zhao, 2020; Moreira et al., 2020) . Among younger individuals, a large proportion had a student status, which was also found to be associated with higher levels of depressive symptoms and/or PTSD symptoms (Lei et al., 2020; Olagoke et al., 2020 , Samadarshi et al., 2020 Wang et al., 2020a) . Numerous studies highlighted how the pandemic has had a more negative impact on the female gender (Ahmed et al., 2020; Gao et al., 2020; Lei et al., 2020; Gonzalez et al., 2020; Qiu et al., 2020; Wang et al., 2020a) . Furthermore, individuals with chronic diseases or a history of psychiatric illness were indicated as suffering from more symptoms of anxiety and stress (Brooks et al., 2020; Mazza et al., 2020; Ozamiz-Etxebarria et al., 2020; Özdin and Özdin, 2020) . For what concerns disadvantageous socio-economic positions such as poor economic status, lower education attainment, and unemployment, they were found to be significant risk factors for developing symptoms of mental disorders, especially depressive symptoms during the pandemic period (Solomou and Constantinidou 2020; Pieh et al., 2020; Gao et al., 2020; Lei et al., 2020; Mazza et al., 2020; Olagoke et al., 2020; Wang et al., 2020b) , although a few studies showed that individuals with higher education exhibited more depressive symptoms in comparison with less educated individuals (Wang et al., 2020b; Moghanibashi-Mansourieh 2020) . In addition to those risk factors, a few studies also identified factors that protected individuals against psychopathological symptoms during the pandemic (Wang et al., 2020a; Zhang et al., 2020) . For example, it was found that individuals with more social support during the pandemic had had lower stress levels (Zhang et al., 2020) . After the initial outburst, a number of longitudinal studies have tried to analyse changes in psychological health before, during, and after lockdowns, in order to identify factors possibly contributing to the onset, increase or stability of different psychological symptoms. For example, the UK Household Longitudinal Study (Pierce et al., 2020; reported that mental health deteriorated in the period April-June 2020, compared to the recorded trends of 2018-2019. Moreover, young people, women, and high income (and high education) groups were found to be at higher risk of mental health deterioration. An increase in anxiety, depression and stress during the lockdown was recorded also in Spain (Planchuelo-Gomez et al., 2020) . Moreover, a study conducted in the Netherlands ( Van der Velden et al., 2021) found that the pandemic did not seem to substantially affect the prevalence of anxiety and depression during the first four months of social life constraints (March-June 2020). In accordance with the latter findings, the Prati and Mancino (2021) review and meta-analysis of longitudinal and experimental studies on the specific topic of mental health conditions concluded that the pandemic and related lockdowns did not have the same negative effects on mental health in terms of anxiety, depression, stress, and similar constructs in all countries. Moreover, among longitudinal studies, there were a few inconsistencies regarding the factors which were found to be particularly involved in making individuals mental health more vulnerable in the pandemic situation, several weeks after the outbreak of the pandemic (Fancourt et al., 2021) . In the UK Household Longitudinal Study, for example, young people (18-34 years old), women, and individuals living with children, especially preschool aged children, were found to be at highest risk of mental health deterioration. Other longitudinal studies reaffirmed that younger adults showed particularly pronounced declines in mental health (Planchuelo-Gomez et al., 2020; Fancourt et al., 2021; Daly & Robison 2021 ) but some others found that 35-49 years old respondents were also at increased risk of declines in mental health . As regards female gender, it was found to be a consistent predictor of worse mental health by different longitudinal studies (Planchuelo-Gomez et al., 2020; Daly & Robison 2021; Fancourt et al. 2021 ). In addition, several studies found that pre-existing vulnerabilities such as ethnicity or economic inequality (lower income categories) were risk factors for mental health problems following the inception of the pandemic (Sibley et al., 2020; Kikuchi et al., 2020; Daly & Robison 2021; Fancourt et al., 2021) , whereas some other studies revealed that although rates of mental distress were higher in people who, before lockdown, were unemployed or in other economically inactive roles, such as being a full-time student, the increase in mental distress compared to previous trends was greater among those who were employed before the pandemic or had a higher education or household income Pierce et al., 2020) . Finally, individuals experiencing persistent loneliness (before and after the COVID-19 outbreak) were also found to be at increased risk of suffering from anxiety and depression symptoms during and after the outbreak ( Van der Velden et al., 2021) . In this framework, the present study provides further country-specific evidence on the extent to which mental health was actually affected by the pandemic and by the strict social measures The Italian Twin Registry is a population-based registry of voluntary twins who gave their consent to participate in the studies proposed by the ITR research group. To date, it consists of approximately 29,000 twins. In February 2020, the ITR carried out a survey to investigate the genetic and environmental contributions to chronic pain occurrence in a sample of adult twins previously enrolled in the ITR and with a known email address. Later, in June 2020, a sample of adult twins, were contacted to investigate the physical and mental health impact of Covid-19 pandemic. Some of the twins participated to both online surveys, and information of participants were linked across the two waves. Below a brief description of the two surveys: -During the first ITR survey (close to the beginning of lockdown, February 2020), in addition to questions related to chronic pain, self-perceived social support and symptoms of depression were also investigated. The three-item Oslo Social Support Scale (OSS-3) was administered to each of the participants and those who scored 3-8, 9-11 or 12-14 were classified as having "poor", "moderate" or "strong" social support, respectively (Kocalevent et al., 2018; Dalgard et al., 2006) . -In June 2020 (close to the end of the lockdown), adult ITR twins were asked to complete a questionnaire to collect information about their (or their family members') Covid-19 symptoms or positivity to SARS-Cov-2, number and characteristics of cohabitants during lockdown, households' economic problems, occupation during the lockdown, referred residency in urban or rural area, preferred means of communication during pandemic. Depressive symptoms were measured using the 9-item version of the Patient Health Questionnaire (PHQ-9). Answers to the first two items of this scale were extrapolated to define the presence of depression symptoms as done in the first survey. Living abroad during the Italian lockdown was the only exclusion criterion for this study. Subjects underwent an informed consent procedure to participate in the study. The research was approved by the Ethical committee of the Istituto Superiore di Sanità (May 2020). PHQ-2 data were first summarised using means and standard deviations for the continuous total scale scores, or percentages for the dichotomous depression symptoms (cut-off score of 2), and were then compared between the two waves using the paired Student's t test of means (on the logtransformed total scores to reduce asymmetry) or the McNemar's test of proportions. The strength of the association (expressed as odds ratio, OR and 95% Confidence Intervals, 95% CI) between the presence of depressive symptoms (dependent variable) and participants' sociodemographic characteristics was estimated by a logistic regression model. The extent to which the independent variables affect the dependent variable was estimated immediately before (Model 1, PHQ-2 in February 2020) and after lockdown (Model 2, PHQ-2 in June 2020). The effects of those characteristics in the first and the second survey were then compared to highlight differences between the two observation periods. A third logistic regression model to assess the impact of the lockdown on the occurrence of depression symptoms immediately after the first Italian lockdown was then fitted (Model 3). The possible determinants were: Covid-19 symptoms among respondents and/or their family members, economic problems, perceived social support. The model took also into account previous depression condition, age, gender, and educational level. A multiple linear regression approach (Model 4) was also applied using log transformed PHQ-2 total score as dependent continuous variable, with the aforementioned covariates. In all regression models, p values and standard errors were adjusted for the non-independence of observations because of twin relatedness. All analyses were performed using Stata software version 16 (Stata Corporation, College Station, TX, USA). About 7,000 adult twins, enrolled in the ITR, were invited by email to join the chronic pain online survey and later to participate to the Covid-19 survey. The response rate was about 30% in both surveys and in line with other studies conducted by the ITR. Given the relatively low response rate, to exclude major selection biases in terms of depression vulnerability, depression scores and socio-demographic characteristics were compared between subjects participating in both waves and those taking part in the baseline assessment only. Mean PHQ2 scores were not different between either the two groups considered overall [3.18 (subjects at both waves), 3.26 (subjects at baseline only), p=0.09) or in the socio-demographic variables subgroups. A total of 1,806 twins responded to both surveys, and 1,690 subjects, not in pharmacological or psychological treatment for mental health disorders and informative for the PHQ-2 scales, were considered in the analyses. Mean age was 45 years (range 18-93), with the majority of participants (63%) being women. Characteristics of the study sample are shown in Table 1 . The absolute and relative frequencies of subjects with or without depressive symptoms immediately before and after lockdown are showed in Table 2 . During the observation period, the development of depressive symptoms was observed in about 19% of the sample whereas, up to 65% of the subjects were stable (without or with depressive symptoms, 47.5% and 19.9% respectively). Subjects who increased depressive symptoms were slightly younger compared to those who were stable without symptoms, while among subjects who meliorated their depressive state there were relatively more males than in the other subgroups. Mean PHQ-2 total score was 1.11 before lockdown and 1.20 during lockdown (8% mean percent increase, P<0.001), while the proportions of subjects with a score of 2 or above were 33.6% and 38.9% immediately before and after lockdown respectively (P<0.001) ( Table 3 ). Figure 1 shows the results of the two logistic regression models for the occurrence of depressive symptoms immediately before (Model 1) and after lockdown (Model 2). Significant odds ratios were found in both models for younger age, low educational level, Southern Italian area of residence, and poor social support, which suggests a relevant role of these features as risk factors for depressive symptoms both before and after lockdown. In addition, the odds ratios estimated by Model 2 indicate that the chance of developing depressive symptoms during lockdown increases significantly also in middle age and in women. Moreover, the OR achieves statistical significance in subjects with a moderate social support. Table 4 (Model 3), a threefold increase of risk of depression symptoms due to the lockdown was observed in those subjects with previous depression conditions. Independently of the effect of depression symptomatology at baseline, the logistic model showed that Covid symptoms in family members of twins and households' economic problems due to Covid pandemic were risk factors significantly associated to depressive symptoms after the restriction period. The occurrence of Covid-19 symptoms among the responding subjects did not seem to increase the probability of developing depressive symptoms. Younger age (≤34, OR=4.12 and 35-49, OR=2.17), female gender (OR=1.42), low educational level (