Assignment 1

R E V I E W

The psychological impact of COVID-19 on the mental

health in the general population G. Serafini 1,2, B. Parmigiani1,2, A. Amerio1,2, A. Aguglia1,2, L. Sher 3,4

and M. Amore1,2

From the 1Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, Genoa, Italy, 2IRCCS Ospedale Policlinico San Martino, Genoa, Italy, 3James J. Peters Veterans Administration Medical Center, 130 W. Kingsbridge Road, Bronx, NY 10468, USA and 4Department of Psychiatry, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029, USA

Address correspondence to Prof. G. Serafini, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Section of Psychiatry, University of Genoa, IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132 Genoa, Italy. email: [email protected]

Summary As a result of the emergence of coronavirus disease 2019 (COVID-19) outbreak caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in the Chinese city of Wuhan, a situation of socio-economic crisis and profound psy- chological distress rapidly occurred worldwide. Various psychological problems and important consequences in terms of mental health including stress, anxiety, depression, frustration, uncertainty during COVID-19 outbreak emerged progres- sively. This work aimed to comprehensively review the current literature about the impact of COVID-19 infection on the mental health in the general population. The psychological impact of quarantine related to COVID-19 infection has been additionally documented together with the most relevant psychological reactions in the general population related to COVID-19 outbreak. The role of risk and protective factors against the potential to develop psychiatric disorders in vulner- able individuals has been addressed as well. The main implications of the present findings have been discussed.

Introduction

As a result of the emergence of coronavirus disease 2019 (COVID-19) outbreak caused by severe acute respiratory syn- drome coronavirus 2 (SARS-CoV-2) infection in the Chinese city of Wuhan, a situation of socio-economic crisis and psychologic- al distress rapidly occurred worldwide. Although social activ- ities have been restricted in most countries, almost all not essential individual movements were prohibited due to quaran- tine, while the local hospitals received suddenly thousands of

critically ill COVID-19 patients and were forced to implement their emergency protocols. In this context, the general popula- tion as well as most of the front-line healthcare workers became vulnerable to the emotional impact of COVID-19 infection1 due to both the pandemic and its consequences worldwide.2,3

Many psychological problems and important consequences in terms of mental health including stress, anxiety, depression, frustration, uncertainty during COVID-19 outbreak emerged progressively.4 Common psychological reactions related to the mass quarantine which was imposed in order to attenuate the

VC The Author(s) 2020. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For permissions, please email: [email protected]

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COVID-19 spread are generalized fear and pervasive community anxiety which are typically associated with disease outbreaks, and increased with the escalation of new cases together with inadequate, anxiety-provoking information which was provided by media.5 The psychological reactions to COVID-19 pandemic may vary from a panic behavior or collective hysteria6 to perva- sive feelings of hopelessness and desperation which are associ- ated with negative outcomes including suicidal behavior.2

Importantly, other health measures may be compromised by abnormally elevated anxiety.7

As the general population became increasingly exposed, anxiety-provoking topics related to this emergence of the health and socio-economic crisis need to be rapidly identified to early de- tect dysfunctional processes and maladaptive lifestyle changes po- tentially leading to the onset of psychiatric conditions.8

Given this background, this work aimed to comprehensively review the current literature about the impact of the COVID-19 epidemic on the mental health in the general population.

The psychological impact of quarantine related to COVID-19 infection

The modern world in which all individuals are able to rapidly travel and communicate has been rarely forced to the current social isolation and restrictions which are linked to feelings of frustration and incertainty. This unprecedented situation related to COVID-19 outbreak is clearly demonstrating that indi- viduals are largely and emotionally unpreparated to the detri- mental effects of biological disasters that are directly showing how everyone may be frail and helpless.

Social distancing and important lockdown restrictions have been carried out first in China and later in most European coun- tries where Italy and Spain experienced a tragic growth of the number of positive cases.9 Although government regulations are necessary to maintain social balance and guarantee the safety of all individuals, a direct strategy aimed to manage the psychosocial issues related to COVID-19 crisis and its conse- quences in the community is currently lacking.

The psychological outcomes for subjects who have been quarantined compared with those who did not, have been examined by both cross-sectional10–14 and longitudinal stud- ies.15,16 Table 1 summarized the most relevant information about the psychological impact of lockdown restrictions and quarantine included in these studies.

Other studies reported a higher prevalence of subjects with psychological symptoms,17 emotional disturbance,18 depression,19

stress,20 mood alterations and irritability, insomnia,21 post- traumatic stress symptoms,15 anger22 and emotional exhaustion5

among those who have been quarantined. Notably, fear, anger, anxiety and insomnia, confusion, grief and numbness have been identified as additional psychological responses to quarantine. Long-term behavioral changes like vigilant handwashing and avoidance of crowds as well as a delayed return to normality even after many months after the quarantine were also reported.23

Thus, the quarantine period seems to have important and dys- functional psychological consequences on the individual’s mental health not only in the short-term but even in the long-term period.

COVID-19 infection on the mental health: which are the main psychological reactions in the general population?

Existing evidence clearly showed the most relevant and pro- found psychological impact of the outbreaks on the general

population.24–27 Figure 1 summarized the most relevant psycho- logical reactions in the general population related to COVID-19 infection. Although aspecific and uncontrolled fears related to infection, pervasive anxiety, frustration and boredom, loneli- ness have been hypothesized to impair subjective wellbeing and quality of life, resilience and enhanced social support are protective factors that may help with regard to lifestyle changes and re-adaptation mechanisms.24,25

Most relevant psychological reactions to COVID-19 infection Aspecific and uncontrolled fears related to infection

This is commonly one of the most frequent psychological reac- tion to pandemics. Several existing studies demonstrated that those who have been exposed to the risk of infection may de- velop pervasive fears about their health, worries to infect others and fear infecting family members.10,23,27,28 Jeong et al.27

reported that these individuals are more vulnerable than others to manifest worries if they experienced physical symptoms po- tentially linked to the infection and fear that symptoms are dir- ectly associated to actively having the infection even several months after the exposure. Other studies reported that preg- nant women and individuals with young children are the most at risk to develop the fear of becoming infected or transmitting the virus.29

Pervasive anxiety

Social isolation related to restrictions and lockdown measures are linked to feelings of uncertainty for the future, fear of new and unknown infective agents resulting in abnormally increased anxiety.25 Anxiety may be directly related to sensorial deprivation and pervasive loneliness, in this case first insomnia but later depression and post-traumatic stress occurred. In add- ition, anxiety is closely associated with fatigue and reduced per- formance in healthcare workers while boredom and loneliness are directly related to anger, frustration and sufferings linked to quarantine restrictions.26 Furthermore, additional tragic effects associated with pervasive anxiety in a pandemic period may in- clude the perceived lower social support, separation from loved ones, loss of freedom, uncertainty and boredom.30

Frustration and boredom

Distress, boredom, social isolation and frustration are directly related to confinement, abnormally reduced social/physical contact with others, and loss of usual habits.15,19,20,23,28,29 As reported by Jeong et al.,27 frustration and pervasive loneliness seem to derive by the inhibition from daily activities, interrup- tion of social necessities, not taking part in social networking activities. Unfortunately, in this context hopelessness together with other individual characteristics such as the experience of childhood maltreatment as well as extreme sensory processing patterns may significantly and independently predict suicidal behavior31,32 but even the unbearable anger related to the im- position of quarantine may lead to negative outcomes.

Disabling loneliness

The final effect of social isolation is pervasive loneliness and boredom, which have potential dramatic effects on both physic- al and mental individual well-being. Pervasive loneliness may be significantly associated with increased depression and

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Table 1. Most relevant studies about the psychological impact of lockdown restrictions and quarantine due to global infections

Author(s) Study design Sample Main results Limitations Conclusions

Bai et al.10 Cross-sectional 338 staff members in a hospital in East Taiwan with potential contacts with SARS

Seventeen staff members (5%) reported an acute stress dis- order. The experience of quar- antine was the most relevant predictor of acute stress dis- order. Participants manifested predominantly anxiety, irrit- ability, insomnia, poorer con- centration and performance, reluctance to work due to the contact with febrile patients. Sixty-six staff members (20%) felt stigmatized and rejected in their neighborhood.

(i) The preliminary na- ture of the findings; (ii) the moderate re- sponse rate; (iii) vol- untary nature of the survey (selection bias); lack of validity in the absence of face- to-face interviews.

An integrated adminis- trative and psycho- social response to the occupational and psy- chological challenges caused by outbreaks is needed

Liu et al.11 Cross-sectional 549 hospital staff Overall, 9% had higher depres- sive symptoms 3 years after quarantine. Among subjects with higher depressive symp- toms, nearly 60% had been quarantined while only 15% of the group with lower depres- sive symptoms had been imposed restrictions.

(i)the cross-sectionalna- ture of results; (ii) the absence of a true con- trol group compari- son; (iii) the use of CES-D to measure depression.

Hospital staff and sub- jects in quarantine due to infective out- breaks may be at ele- vated risk for depression, even over the long term.

Sprang and Silman12

Cross-sectional 398 adult respondents The mean post-traumatic stress scores were four times higher in children who had been quarantined relative to those who were not quarantined.

(i) Responses are poten- tially flawed by recall bias and social desir- ability; (ii) respond- ents who completed the survey represent a self-selected group.

Pandemic disasters need specific response strategies to guaran- tee behavioral health needs of both children and families.

Taylor et al.13

Cross-sectional 2760 horse owners Higher psychological distress during the outbreak was reported in >30% of horse owners quarantined for sev- eral weeks due to equine influ- enza outbreak relative to �10% of the Australian general population.

(i) Findings are difficult to be generalized as it was not possible to identify, bound or sample the target population accurately.

Younger subjects, indi- viduals with no edu- cational qualifica- tions, and subjects the main income of which was linked to a horse- related industry were more vulnerable to psychological distress.

Wu et al.16 Cross-sectional Hospital employees even 3 years after this experience

Being quarantined resulted a predictor of PTS symptoms. Symptoms related to quaran- tine were reported in 28% of parents relative to 6% of those who were not quarantined. 9% among the Hospital staff reported higher depressive symptoms 3 years after quar- antine. Among subjects with higher depressive symptoms, >50% had been quarantined than 15% of the group with lower depressive symptoms.

(i) No causal relation be- tween risk perception and PTS symptoms may be established; (ii) PTS symptoms have been measured using the IES-R.

The psychological im- pact of stressful events linked to infec- tious disease out- breaks may be mediated by individ- ual perceptions of these events. Altruism may help to protect healthcare workers against these negative impacts.

Reynolds et al.15

Cross-sectional 1912 adult individuals Of individuals who have been quarantined as in close con- tact with those who potential- ly have SARS, 20% reported fear, 18% nervousness, 18% sadness and 10% guilt. Maladaptive psychological reactions such as avoidance behaviors (e.g. minimizing

(i) The response rate was 55%; (ii) younger per- sons were under-rep- resented; (iii) Information were not collected on specific socioeconomic details.

Improvements in terms of compliance and reduced psychological distress may be per- formed by minimizing duration, revising requirements, and providing enhanced education/support.

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suicidal behavior.23 Unfortunately, the isolation is progressively enhanced by anxiety, panic or collective hysteria. Cognitive functions and decision making are firstly impaired by hyperar- ousal and anxiety and later by disabling feelings of loneliness. In addition, social isolation and loneliness are also associated with alcohol and drug abuse.14 Both frustration and pervasive loneliness seem to derive by the inhibition from daily activities, interruption of social necessities, inability to take part in social networking activities enhancing the risk of hopelessness and suicidal behavior in this specific context.33 Overall, it is well known that long periods of social isolation or quarantine for specific illnesses may have detrimental effects on mental well- being.34

Risk factors Alexithymia

The risk of related quarantine distress may be also due to the presence of alexithymic traits which may reduce psychological resilience in some subgroups of individuals.35–37 Alexithymia may be literally defined as ‘no words for mood’ and was initially identified to describe cognitive and affective features in patients with psychosomatic disorders. Alexithymic individuals may show significantly higher levels of anxiety, depression and psy- chological distress than non-alexithymics. In summary, the alexithymia construct applied to major depressive disorder

(MDD) subjects showed a significant correlation between alexi- thymia traits, MDD severity and increased risk of suicidal behavior.

Inadequate supplies

Importantly, feelings of frustration and incertainty tend to occur even in relation with inadequate basic supplies (e.g. food, water, clothes etc.) during the quarantine period which is a major source of worries, and anxiety/anger even after 4– 6 months from quarantine.27 There are studies demonstrating that supplies provided by public health authorities in order to address the outbreak may be inappropriate or their release may be carried out too late to successfully address the needs. For in- stance, thermometers or masks may be received too late while water and food were only inconsistently distributed.23

DiGiovanni et al.20 reported that during the 2003 SARS outbreak in Toronto, the government was unable to meet needs for gro- ceries and other routine supplies needed for daily living.

Inadequate information

Existing evidence20,23,29 suggest that the poor or inadequate in- formation from public health authorities may be a significant stressor because it provides inappropriate guidelines concern- ing call for actions or leads to confusion about the purpose of quarantine or the importance of measures needed to interrupt

Table 1. Continued

Author(s) Study design Sample Main results Limitations Conclusions

direct contact with patients and not reporting to work) may be really common even after quarantine.

Jeong et al.27 Longitudinal prospective

1656 South Korea resi- dents isolated for 2- week due to having contact with MERS patients

Anxiety symptoms were present in 7.6%, and feelings of anger in 16.6% during the isolation period. At 4–6 months after re- lease from isolation, anxiety symptoms were observed in 3.0. Feelings of anger were pre- sent in 6.4%. Risk factors for anxiety/anger at 4–6 months included symptoms related to MERS during isolation, inad- equate supplies, social net- working activities, history of psychiatric illnesses and fi- nancial loss.

(i) The inclusion of sub- jects with higher pri- ority in the survey; (ii) the use of self-report (GAD-7 to assess anx- iety and STAXI-2 to assess anger) measures.

Mental health problems might be prevented by providing mental health support to sub- jects with vulnerable mental health, and providing accurate in- formation together with adequate supplies.

Wu et al.16 Longitudinal prospective

549 randomly selected hospital employees

Current alcohol abuse/ depend- ence symptom counts 3 years after the outbreak were associ- ated with having been quaran- tined, or having worked in high-risk locations such as SARS wards. PTS and depres- sion were also linked to increased alcohol abuse/de- pendence. After regression analyses, hyperarousal resulted associated with alco- hol abuse/dependence.

(i) Information on the hospital employees’ pre-SARS alcohol use patterns was not available; (ii) alcohol abuse/dependence diagnoses were per- formed using a single instrument measuring levels of alcohol abuse/dependence.

Exposure to severe in- fectious disease may lead not only to PTSD but even to other psy- chiatric conditions such as alcohol abuse/ dependence.

MERS, Middle East Respiratory Syndrome; IES-R, Event Scale-Revised; PTS, post-traumatic stress; PTSD, post-traumatic stress disorder; SARS, severe acute respiratory

syndrome; CED-S, Center for Epidemiologic Studies Depression Scale; GAD-7, General Anxiety Disorder-7; STAXI-2, State-Trait Anger Expression Inventory 2.

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the pandemic spread. Confusion may be directly related to dif- ferent approaches, contradictory health messages, and poor co- ordination during the Toronto SARS epidemic as a result of the involvement of multiple jurisdictions and different levels of government.20 Braunack-Mayer et al.29 clearly referred to the perceived lack of transparency from health and government authorities concerning the severity of the outbreak. Finally, Reynolds et al.15 stated that post-traumatic stress symptoms may be related to perceived difficulties in interpreting quaran- tine protocols as well as the lack of clear rationale/guidelines.

Protective factors Resilience

Psychological resilience may be generally defined as the ability to support or retrieve psychological well-being during or after addressing stressful disabling conditions. Although the inter- connectedness increased dramatically over the past decades, similarly the vulnerability of billions of individuals across the world to existing or novel pathogens tragically increased with- out a corresponding enhancement in coping abilities.24

Historically, different indices have been adopted to measure re- silience and individual ability to react to social, economic and political threats, including public health emergencies. Unfortunately, being less resilient to social threats, such as pan- demics, may enhance the risk of developing psychiatric condi- tions.25 Notably, a general message of hope and social protection given by healthcare regulatory authorities and scien- tists not only about the risk of being infected but even about the existence of containment measurements that may be imple- mented in the hospitals and in the community as a whole may enhance resilience and individual abilities to successfully react to social threats.30

Social support

A higher and significant perception of social support is associ- ated with a reduced likelihood to develop psychological distress and psychiatric conditions. Conversely, according to a recent

online survey conducted in South Korea,30 most (72.0%) of the respondents reported they could get someone else’s support if they were isolated due to COVID-19, and 28.0% clearly reported they would not have social support. Adequate social support for the general population with regard to specific at risk popula- tions (e.g. infected patients, quarantined individuals and medic- al professionals) should be provided by offering targeted, tailored messages according to the most reliable scientific evi- dence. Relevantly, a variety of mental health supporting strat- egies are required in pandemic areas in order to facilitate lifestyle changes and re-adaptation activities required after the occurrence of invalidating outbreaks.1,24

Preventive strategies

Specific preventive strategies at the community level such as (i) implementing effective communication and (ii) providing ad- equate psychological services should be carried out in order to attenuate the psychological and psychosocial impact of COVID- 19 outbreak. Health education needs to be enhanced using online platforms, social fear related to COVID-19 needs to be correctly addressed while stigma and discrimination need to be recognized as major challenges able to reinforce the feelings of uncertainty in a period of social crisis. Hospitals protocols linked to the early and effective management of health emer- gency need to be implemented while healthcare professionals need to be supplied by adequate protective facilities.

Scientific community should provide appropriate informa- tion to attenuate the impact of anxiety, frustration, and all the negative emotions which represent important barriers to the correct management of social crisis and psychological conse- quences related to pandemic. Unmet needs should be rapidly identified by medical staff who need to communicate frequent- ly and in a timely manner with most of patients to understand the risk to develop new symptoms or worsen a preexisting psy- chological distress. Furthermore, telephones helplines, Internet access, active social networks, dedicated blogs and forums should be implemented in order to reduce social isolation and loneliness as well as allow to specific populations (e.g. infected subjects in hospitals or quarantine settings) the successful com- munication with their loved ones.

Marginalized populations such as elderly individuals or those with psychological problems should be able to actively consult with clinical psychotherapists to rapidly detect warning signs. Finally, telemedicine should be really implemented espe- cially in areas where mental health services are poorly repre- sented or severely impaired by the rapid spread of pandemic and lockdown restrictions. Importantly, symptoms related to initial psychological crisis together with the need to perform ef- fective interventions using personalization and monitoring of adverse drug reactions related to psychoactive medications should be detected by psychiatrists.24

Conclusion

Implementing community-based strategies to support resili- ence and psychologically vulnerable individuals during the COVID-19 crisis is fundamental for any community.38 The psy- chological impact of fear and anxiety induced by the rapid spread of pandemic needs to be clearly recognized as a public health priority for both authorities and policy makers who should rapidly adopt clear behavioral strategies to reduce the burden of disease and the dramatic mental health consequen- ces of this outbreak.

Figure 1. Summary of the most relevant psychological reactions in the general

population related to COVID-19 infection.

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Funding

This work was developed within the framework of the DINOGMI Department of Excellence of MIUR 2018-2022 (law 232/2016).

Conflict of interest: None declared.

References 1. Xiang YT, Yang Y, Li W, Zhang L, Zhang Q, Cheung T, et al.

Timely mental health care for the 2019 novel Coronavirus outbreak is urgently needed. Lancet Psychiatry 2020; 7:228–9.

2. Thakur V, Jain A. COVID 2019-suicides: a global psychological pandemic. Brain Behavior Immun 2020; S0889-1591:30643–7.

3. Zhai Y, Du X. Loss and grief amidst COVID-19: a path to adap- tation and resilience. Brain Behavior Immun 2020; S0889-1591: 30632.

4. Duan L, Zhu G. Psychological interventions for people affected by the COVID-19 epidemic. Lancet Psychiatry 2020; 7: 300–2.

5. Maunder R, Hunter J, Vicent L, Bennett J, Peladeau N, Leszcz M, et al. The immediate psychological and occupational im- pact of the 2003 SARS outbreak in a teaching hospital. CMAJ 2003; 168:1245–51.

6. Barbisch D, Koenig KL, Shih FY. Is there a case for quarantine? Perspectives from to Ebola. Disaster Med Public Health Prep 2015; 9:547–53.

7. Rubin GJ, Wessely S. Coronavirus: the psychological effects of quarantining a city. BMJ Opinion 2020; 368:m313.

8. Sa L. How much “Thinking” about COVID-19 is clinically dys- functional? Brain Behavior Immun 2020; S0889-1591:30682–6.

9. https://covid19.who.int/ (18 May 2020, date last accessed). 10. Bai Y, Lin C-C, Lin C-Y, Chen J-Y, Chue C-M, Chou P. Survey of

stress reactions among health care workers involved with the SARS outbreak. Psychiatr Serv 2004; 55:1055–7.

11. Liu X, Kakade M, Fuller CJ, Fan B, Fang Y, Kong J, et al. Depression after exposure to stressful events: lessons learn- ed from the severe acute respiratory syndrome epidemic. Compr Psychiatry 2012; 53:15–23.

12. Sprang G, Silman M. Posttraumatic stress disorder in parents and youth after health-related disasters. Disaster Med Public Health Prep 2013; 7:105–10.

13. Taylor MR, Agho KE, Stevens GJ, Raphael B. Factors influenc- ing psychological distress during a disease epidemic: data from Australia’s first outbreak of equine influenza. BMC Public Health 2008; 8:347.

14. Wu P, Fang Y, Guan Z, Fan B, Kong J, Yao Z, et al. The psycho- logical impact of the SARS epidemic on hospital employees in China: exposure, risk perception, and altruistic acceptance of risk. Can J Psychiatry 2009; 54:302–11.

15. Reynolds DL, Garay JR, Deamond SL, Moran MK, Gold W, Styra R. Understanding, compliance and psychological im- pact of the SARS quarantine experience. Epidemiol Infect 2008; 136:997–1007.

16. Wu P, Liu X, Fang Y, Fan B, Fuller CJ, Guan Z, et al. Alcohol abuse/dependence symptoms among hospital employees exposed to a SARS outbreak. Alcohol Alcohol 2008; 43:706–12.

17. Mihashi M, Otsubo Y, Yinjuan X, Nagatomi K, Hoshiko M, Ishitake T. Predictive factors of psychological disorder devel- opment during recovery following SARS outbreak. Health Psychol 2009; 28:91–100.

18. Yoon MK, Kim SY, Ko HS, Lee MS. System effectiveness of de- tection, brief intervention and refer to treatment for the

people with post-traumatic emotional distress by MERS: a case report of community-based proactive intervention in South Korea. Int J Ment Health Syst 2016; 10:51.

19. Hawryluck L, Gold WL, Robinson S, Pogorski S, Galea S, Styra R. SARS control and psychological effects of quar- antine, Toronto, Canada. Emerg Infect Dis 2004; 10: 1206–12.

20. DiGiovanni C, Conley J, Chiu D, Zaborski J. Factors influencing compliance with quarantine in Toronto during the 2003 SARS outbreak. Biosecur Bioterror 2004; 2:265–72.

21. Lee S, Chan LY, Chau AM, Kwok KP, Kleinman A. The experi- ence of SARS-related stigma at Amoy Gardens. Soc Sci Med 2005; 61:2038–46.

22. Marjanovic Z, Greenglass ER, Coffey S. The relevance of psy- chosocial variables and working conditions in predicting nurses’ coping strategies during the SARS crisis: an online questionnaire survey. Int J Nurs Stud 2007; 44:991–98.

23. Cava MA, Fay KE, Beanlands HJ, McCay EA, Wignall R. The ex- perience of quarantine for individuals affected by SARS in Toronto. Public Health Nurs 2005; 22:398–406.

24. Wang J, Wang JX, Yang GS. The Psychological Impact of COVID-19 on Chinese Individuals. Yonsei Med J 2020; 61: 438–40.

25. Khan S, Siddique R, Li H, Ali A, Shereen MA, Bashir N, et al. Impact of coronavirus outbreak on psychological health. J Glob Health 2020; 10:010331.

26. Torales J, O’Higgins M, Castaldelli-Maia JM, Ventriglio A. The outbreak of COVID-19 coronavirus and its impact on global mental health. Int J Soc Psychiatry 2020; 66:317–320.

27. Jeong H, Yim HW, Song Y-J, Ki M, Min JA, Cho J, et al. Mental health status of people isolated due to Middle East respiratory syndrome. Epidemiol Health 2016; 38:e2016048.

28. Desclaux A, Badji D, Ndione AG, Sow K. Accepted monitoring or endured quarantine? Ebola contacts’ perceptions in Senegal. Soc Sci Med 2017; 178:38–45.

29. Braunack-Mayer A, Tooher R, Collins JE, Street JM, Marshall H. Understanding the school community’s response to school closures during the H1N1 2009 influenza pandemic. BMC Public Health 2013; 13:344.

30. Lee M, You M. Psychological and behavioral responses in South Korea during the early stages of coronavirus dis- ease 2019 (COVID-19). Int J Environ Res Public Health 2020; 17:2977.

31. Pompili M, Innamorati M, Lamis DA, Erbuto D, Venturini P, Ricci F, et al. The associations among childhood maltreat- ment, “male depression” and suicide risk in psychiatric patients. Psychiatry Res 2014; 220:571–578.

32. Engel-Yeger B, Muzio C, Rinosi G, Solano P, Geoffroy PA, Pompili M, et al. Extreme sensory processing patterns and their relation with clinical conditions among individuals with major affective disorders. Psychiatry Res 2016; 236:112–8.

33. Orsolini L, Latini R, Pompili M, Serafini G, Volpe U, Vellante F, et al. Understanding the complex of suicide in depression: from research to clinics. Psychiatry Investig 2020; 17:207–21.

34. Stickley A, Koyanagi A. Loneliness, common mental disor- ders and suicidal behavior: findings from a general popula- tion survey. J Affect Disord 2016; 197:81–7.

35. De Berardis D, Fornaro M, Valchera A, Rapini G, Di Natale S, De Lauretis I, et al. Alexithymia, resilience, somatic sensa- tions and their relationships with suicide ideation in drug naı̈ve patients with first-episode major depression: an ex- ploratory study in the “real world” everyday clinical practice. Early Interv Psychiatry 2020; 14:336–42.

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nloaded from https://academ

ic.oup.com /qjm

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ashington user on 28 S eptem

ber 2020

36. De Berardis D, Vellante F, Fornaro M, Anastasia A, Olivieri L, Rapini G, et al. Alexithymia, suicide ideation, affective tempera- ments and homocysteine levels in drug naı̈ve patients with post- traumatic stress disorder: an exploratory study in the everyday ‘real world’ clinical practice. Int J Psychiatry Clin Pract 2020; 24:83–7.

37. De Berardis D, Fornaro M, Orsolini L, Valchera A, Carano A, Vellante F, et al. Alexithymia and suicide risk in

psychiatric disorders: a mini-review. Front Psychiatry 2017; 8:148.

38. Amerio A, Bianchi D, Santi F, Costantini L, Odone A, Signorelli C, et al. Covid-19 pandemic impact on mental health: a web-based cross-sectional survey on a sample of Italian general practitioners. Acta Biomed 2020; 91: 83–8.

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