Work and social functioning in frontline healthcare workers during the covid-19 pandemic in Italy: role of acute post-traumatic stress, depressive and anxiety symptoms


Funzionamento socio-lavorativo negli operatori sanitari in prima linea durante
la pandemia da covid-19 in Italia: ruolo dei sintomi post-traumatici da stress acuti, depressivi e ansiosi


CLAUDIA CARMASSI1, VIRGINIA PEDRINELLI1 , VALERIO DELL’OSTE1,2,
CARLO ANTONIO BERTELLONI1, ANNALISA CORDONE1, SIHAM BOUANANI3, MARTINA CORSI4,
SIGRID BALDANZI4, PAOLO MALACARNE5, LILIANA DELL’OSSO1, RODOLFO BUSELLI4

*E-mail: virginiapedrinelli@gmail.com


1Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy

2Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Siena, Italy

3Department of Mental Health and Addictions, Azienda USL Toscana Nord-Ovest, Lucca, Italy

4 Department of Occupational Health, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy

5Anaesthesia and Intensive Care Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy


SUMMARY. Background. Evidence highlights healthcare workers (HCWs) facing outbreaks, particularly the ongoing covid-19 pandemic, are at increased risk of negative mental health outcomes, particularly post-traumatic stress symptoms (PTSS), anxiety and depression. Data from previous outbreaks highlighted the risk for a negative impact on HCWs’ social and occupational functioning, but scant data have investigated this issue in the framework of the covid-19 pandemic. A number of effective interventions have been proposed to support mental health and well-being of HCWs in emerging infectious outbreaks, but it is important to acknowledge the differential impact of mental disorders on different dimensions of functioning. Methods. The study explored the associations between work and social functioning and PTSS, depression and anxiety in a sample of 265 frontline HCWs employed at a major university hospital in Italy (Pisa), facing the first period of the covid-19 pandemic. Individuals were assessed by means of the Impact of Event Scale-Revised (IES-R) for PTSS, the Patient Health Questionnaire-9 (PHQ-9) for depressive symptoms, the General Anxiety Disorder-7 Item (GAD-7) for anxiety symptoms and the Work and Social Adjustment Scale (WSAS) to assess work and social functioning. Results. Higher levels of functioning impairment were found among individuals with moderate to severe acute PTSS, depressive and anxiety symptoms with respect to those without. Acute PTSS and depressive symptoms were predictive factors of impairment in each domain of functioning analyzed. Anxiety symptoms were associated with impairment in both work and home management activities. Frontline activity was associated with impairment in both private and social leisure activities. Conclusions. Long-term perspective studies are warranted to better investigate the psychopathological burden on HCWs’ work and social functioning and to promote adequate intervention strategies.


KEY WORDS: health care workers, work and social functioning, functioning, post-traumatic stress symptoms, post-traumatic stress reactions, stress, anxiety, depression, covid-19, SARS-CoV-2, pandemic.


RIASSUNTO. Introduzione. Gli operatori sanitari impegnati durante un’epidemia, come l’attuale pandemia da covid-19, presentano un elevato rischio di sviluppare effetti negativi sulla salute mentale, tra i quali sintomi da stress post-traumatico (Post-Traumatic Stress Symptoms - PTSS), ansia e depressione. Evidenze dai precedenti eventi epidemici hanno sottolineato un impatto negativo sul funzionamento sociale e lavorativo del personale sanitario, tuttavia i dati relativi al contesto della pandemia da covid-19 sono scarsi. Inoltre, sono stati proposti una serie di interventi a supporto della salute mentale e del benessere degli operatori sanitari durante eventi epidemici, ma a tal fine è importante riconoscere l’impatto differenziale della psicopatologia sulle specifiche dimensioni del funzionamento. Metodi. Lo studio ha indagato le associazioni tra funzionamento socio-lavorativo e PTSS, depressione e ansia in un campione di 265 operatori sanitari impegnati nella fase acuta della pandemia da covid-19 presso un ospedale universitario in Italia. I soggetti sono stati valutati mediante la Impact of Event Scale-Revised (IES-R) per i PTSS, il Patient Health Questionnaire-9 (PHQ-9) per i sintomi depressivi, la General Anxiety Disorder-7 Item (GAD-7) per i sintomi ansiosi e la Work and Social Adjustment Scale (WSAS) per valutare il funzionamento sociale e lavorativo. Risultati. Maggiore compromissione del funzionamento socio-lavorativo è stata riscontrata nei soggetti con PTSS acuti, sintomi depressivi e sintomi ansiosi di grado moderato-severo. I sintomi depressivi e i PTSS acuti si sono rivelati fattori predittivi di compromissione in ciascuno dei domini del funzionamento analizzati, mentre l’attività in prima linea è risultata associata con una compromissione delle attività ricreative sia personali che sociali. Conclusioni. Sono necessari ulteriori studi a lungo termine per valutare l’impatto della psicopatologia sul funzionamento socio-lavorativo degli operatori sanitari e per promuovere adeguate strategie di intervento.

PAROLE CHIAVE: operatori sanitari, funzionamento sociale e lavorativo, funzionamento, sintomi post-traumatici da stress, reazioni post-traumatiche da stress, stress, ansia, depressione, covid-19, SARS-CoV-2, pandemia.


INTRODUCTION

The Coronavirus Disease-19 (covid-19) outbreak spread out rapidly and unexpectedly across countries, since the first reports of a cluster of novel viral pneumonia in Wuhan (China) in December 2019, catching off guard healthcare systems worldwide, with Italy being the first European Country being involved. In a few weeks the covid-19 infection spread, causing excessive hospital overcrowding and high workload for first line health care professionals across the great majority of countries affected1,2. Previous viral outbreaks showed that healthcare workers (HCWs) are at increased risk of infection and other physical adverse outcomes3-5. Furthermore, HCWs were shown to be at increased risk of negative mental health outcomes, reporting a wide range of psychopathological sequelae, among which post-traumatic stress symptoms (PTSS), anxiety and depression during and after the epidemics3,6-8. Likewise, some evidence has already emerged in the framework of the current covid-19 global health crisis, with HCWs involved in frontline and non-frontline activities showing several adverse psychological effects9-13.

Working during or after an outbreak of an infectious disease with a real or potential overwhelm of sanitary system may have a severe impact on the maintenance of a functional workforce and the WHO has immediately drawn attention on the high burden on HCWs due to the current emergency, calling for action to plan fast and adequate measures both to save lives and to prevent serious consequences on physical and mental health of HCWs14 and, consequently, on their impact on work and social functioning. There are many potential factors described in the current literature contributing for such high mental toll for HCWs: first of all the concern of infection for themselves and their relatives because of their frontline work with patients with high viral loads, as well as the inadequate personal protection equipments and the lack of specific guidelines for effective treatments15-18. In parallel, common psychosocial factors affecting mental health and well-being of HCWs during epidemics include changes in job routine with a heavier workload, learning new technical skills, lack of effective support in the working environment, guilt feelings, uncertainty about the future19-21.

The covid-19 pandemic suddenly disrupted HCWs daily routine forcing personnel to adapt in response to new measures and restrictions, with these changes having pervasive impact on health and wellbeing and a significant effect on every domain of human functioning22,23. Despite findings on previous coronavirus outbreaks (e.g. SARS or MERS) first highlighted the risk for a negative impact on work and social functioning in the general population with many sources reflecting the additional burden for professionals6,24, still scant data have deeply investigated this issue in the framework of the covid-19 pandemic25. First reports highlighted a major impact may be due to ethical tensions concerning inability to reach previous levels of service, dealing with management challenges, balancing exposure with social contact26,27. These burdens were described as growing over time, with female HCWs, frontline and closer to the outbreaks workers being at higher risk of psychiatric sequelae and higher functional impairment21,27,28.

Most of the cross-sectional studies on HCWs facing the covid-19 pandemic revealed a considerable proportion of participants reporting symptoms of depression, anxiety, insomnia and acute post-traumatic stress symptoms29-31. A recent meta-analysis on impact of viral epidemic outbreaks on mental health of HCWs, including covid-19 outbreak on 117 studied32, reported a pooled prevalence higher for Acute Stress Disorder (40%), followed by anxiety (30%), depression (24%) and post-traumatic stress disorder (PTSD, 13%), with some psychosocial (e.g. female gender and younger age, lack of social support, stigmatization) and occupational factors (e.g. frontline activity, working in a high risk environment, lower levels of specialized training and job experience) being associated with the likelihood of developing those problems. Irrespective of the current context, the psychological burden and overall wellness of HCWs received increasing awareness in the last decade, with research continuing to show high rates of stress, depressive and anxiety symptoms, impacting negatively on their work and social functioning abilities33-35. However, scant data are still available to understand the burden of negative mental health outcomes on work and social functioning of HCWs. Despite a number of effective interventions were indeed proposed and recommended to support mental health and well-being of HCWs and to reduce psychological distress abilities in emerging disease outbreaks (e.g. professional counselling or psychological services, clear work communication, adequate rest, peer and family support, avoidance of harmful coping strategies such as alcohol and drugs)4,23,36, it is important to acknowledge the possible differential impact of the mental illnesses on the different dimensions of functioning to identify most effective interventions.

The definitions of ‘functioning’ within the literature are diverse and a comprehensive picture is not always presented. The concept remains vague and overlapping terms are often used, such as psychosocial adjustment, social functioning and functioning impairment37-39. Bosc40 defined “social functioning” as the interaction of individuals with their environment and the ability to fulfill their role with their environment; environments with which every person daily interacts are several: work, social and leisure, marital, parental and with the extended family. We aimed at assessing functioning of HCWs employed in covid-19 inpatient wards at the peak of pandemic considering both work and social functioning as additional factors to give us a broader scope of mental state of exposed personnel.

In this regard, aim of the present study was to investigate the differential impact of acute post-traumatic stress, depressive and anxiety symptoms on dimensions of functioning in a sample of HCWs employed in a University Hospital in Italy during the acute phase of covid-19 outbreak.

METHODS

Study sample and procedures

A consecutive sample of 265 HCWs, employed at a major University Hospital in central Italy (Azienda Ospedaliero-Universitaria Pisana, AOUP, Pisa, Italy) during the covid-19 pandemic, were consecutively enrolled for the present study. The recruitment was conducted during the acute phase of the covid-19 emergency (between April 1st and May 1st 2020) at the outpatient service of the Occupational Health Department of the AOUP, specifically dedicated to assess and manage the physical and mental health of the staff in the framework of the covid-19 emergency. All HCWs enrolled experienced work-related traumatic events related to the management of patients hospitalized because of the covid-19. Inclusion criteria included being employed in the AOUP during the covid-19 pandemic and being exposed to multiple patients’ death in the framework of the outbreak emergency. Subjects with poor knowledge of the Italian language or other limits to verbal communication were excluded from the study.

The referred subjects were assessed by means of some questionnaires: the Impact of Event Scale-Revised (IES-R) for PTSS, the Patient Health Questionnaire-9 (PHQ-9) for depressive symptoms, the General Anxiety Disorder-7 Item (GAD-7) for anxiety symptoms and the Work and Social Adjustment Scale (WSAS) to assess work and social functioning.

Suitable candidates were asked to provide written informed consent after receiving a complete description of the study and they had the opportunity to ask questions. The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Area Vasta Nord-Ovest Toscana (Pisa, Italy, protocol study n° 2020/17151).

Measures

The Impact of Event Scale- Revised (IES-R)

The IES-R is a 22-item scale measuring three core symptoms of PTSD, i.e., re-experiencing of traumatic events, defensive avoidance and denial of trauma related memories and emotions41. It refers to the last week. The questionnaire has an adequate internal consistency (alpha=0.80-0.93 for the intrusion; alpha=0.73-0.84 for avoidance), and high test-retest reliability (r=0.93). A score over 24 represents a cutoff for the presence of moderate to severe PTSS. The questionnaire has adequate internal consistency, and high test-retest reliability (r=0.93). In according with the aim of the study, the items referred to the experiences in the framework of work duties during the covid-19 emergency.

The Patient Health Questionnaire (PHQ-9)

PHQ-9 is a 9-item self-administered scale measuring depressive symptoms severity in the last two weeks on a 4-point scale from 0=not at all to 3=nearly every day, with the total score ranging from 0 to 2742. A cutoff score of 10 has been shown to have a sensitivity of 88% and a specificity of 88% specificity for major depression. The test has adequate internal consistency (Cronbach’s α=0.89) and excellent test-retest reliability (r=0.84).

The Generalized Anxiety Disorder 7-Item (GAD-7)

The GAD-7 is a self-assessment questionnaire used as a tool for screening and measuring the severity of anxiety symptoms43. Particularly, it investigates the frequency of anxious symptoms in the last two weeks using 7-items with a score ranging from 0=never to 3=almost every day. The internal consistency of the GAD-7 is excellent (Cronbach’s α=.92) and test-retest reliability is also good (r=0.83). Scores over 10 suggest the presence of moderate to severe anxiety symptoms.

Work and Social Adjustment Scale (WSAS)

The WSAS is a test used to evaluate and measure the work and social adjustment44. It includes five items that assess the individual’s ability to perform the activities of everyday life and how these are affected in the week prior to the assessment. The first item investigates the work ability of the subject. The second item assesses the ability to cope with household chores such as cleaning the house, looking after the children, and doing shopping. The third item assesses private recreational activities carried out by the patient, such as going to the cinema, visiting museums, and reading. The fourth and fifth items investigate the family interaction and relationship: in particular, the fourth item investigates the social activities carried out exclusively with people who are not part of the family and includes activities such as parties, tours of pleasure, going clubbing, or going on romantic dates. The fifth item analyzes only the relations with family members with whom the person lives, and whether any problems of the subject under examination have interfered with this type of relationship. Each of the five items is rated on a nine-point scale ranging from 0 (not at all) to 8 (severe interference), so that the total scores are between 0 and 40. The internal consistency of the instrument varies from 0.70 to 0.94 (Cronbach’s alpha) and the reliability of the test-retest is 0.73.

Statistical analyses

All statistical analyses were performed using the Statistical Package for Social Science, version 25.0 (SPSS Inc.). Continuous variables were reported as mean ± standard deviation (SD), whereas categorical variables were reported as percentages. All tests were two-tailed and a p value <.05 was considered statistically significant.

Mann-Whitney test was used to correlate WSAS scores and socio-demographical characteristics of the sample and to compare WSAS scores between individuals with and without PTSS, depressive and anxiety symptoms.

Five multiple linear regression models (one for each item of WSAS questionnaire) were performed to identify strongest predictors of work and social functioning impairment among socio-demographic and clinical characteristics in the sample.

RESULTS

The total sample included 265 HCWs, 84 (31.7%) males and 181 (68.3%) females and it was composed by 85 (32.1%) physicians, 133 (50.2%) nurses and 47 (17.7%) healthcare assistants. Among them, 51 (19.2%) HCWs were newly employed (less than 12 months) and 117 (44.2%) had a front-line activity in the management of covid-19 patients. The mean age in the total sample was 40.43±11.20 years.

Regarding clinical characteristics, each WSAS item mean score resulted significantly higher among individuals with acute PTSS, depressive and anxiety symptoms respect to those without (Table 1).




Likewise, WSAS total mean score was significantly higher among HCWs with acute PTSS compared to those without (18.2±9.2 versus 8.5±8.6, p=<.001), as well as among those with depressive symptoms with respect to those without (23.1±8.5 versus 9.3±8.6, p=<.001) and among individuals reporting anxiety symptoms compared to those who did not report them (20.5±9.8 versus 8.9±8.3, p=<.001).

Further, the analysis of socio-demographic characteristics revealed that the mean scores of WSAS single items (except for item 5) were significantly higher among newly employed HCWs as compared to the ones with a hospital duty time over one year (Table 1). Similarly, investigating the relationships between socio-demographic characteristics and WSAS total mean score in the sample, no significant differences emerged except for hospital duty time, with subjects employed for less than one year reporting higher mean scores with respect to those hired for over one year (11.2±9.5 versus 7.3±8.4, p=.005).

Five linear regression models were performed, considering sociodemographic characteristics (age, gender, front-line activity, being newly employed, physician role), in addition to PHQ-9, GAD-7 and IES-R total scores as independent variables and the scores of each WSAS item as dependent variables. Results showed: age, IES-R, GAD-7 and PHQ-9 total scores presented a significant positive association with WSAS item 1 (working activities) (Table 2); PHQ-9, GAD-7 and IES-R total scores presented a significant positive association with WSAS item 2 (home management) (Table 3); front-line activity, IES-R and PHQ-9 total scores presented a significant positive association with WSAS item 3 (private leisure activities) (Table 4) and with WSAS item 4 (social activities) (Table 5); finally, PHQ-9 and IES-R total scores presented a significant positive association with WSAS item 5 (family relationships) (Table 6).













DISCUSSION

To the best of our knowledge, this is the first study investigating the different impact of socio-demographic and clinical variables on functional impairment in HCWs facing the acute phase of the covid-19 pandemic in Italy.

Comparing WSAS total and single item mean scores in the total sample and divided by socio-demographic characteristics, newly employed HCWs showed higher scores with respect to those with a hospital duty time over one year. Many evidences pointed out that lower levels of specialized training as well as the lack of professional experience and younger age (often combined with previous ones) were associated with higher risk of psychological effects among which higher rates of PTSS, depressive and anxiety symptoms among HCWs during previous and current disease outbreaks3,8,31,45. Despite the lack of evidence, we argue that a limited professional training – especially in a complex scenario as the one determined by a pandemic condition – may determinate a higher burden on HCWs work and social functioning, particularly for newly employed ones rather than for healthcare staff with a longer professional experience.

Our results showed clinical characteristics of the sample having the highest impact on work and social functioning. Particularly, HCWs with moderate to severe acute PTSS, depressive and anxiety symptoms reported statistically significant higher WSAS total and each item mean scores with respect to those without, revealing the burden of such psychopathological symptoms on global functioning impairment. Increasing evidence highlighted the risk for HCWs during and after disease outbreaks for negative mental health outcomes with high prevalence of PTSS, depressive and anxiety symptoms and other psychological issues, suggesting the need to establish ways to mitigate mental health risks and adjust interventions under epidemic and pandemic conditions23,34,46,47, despite little has been reported on the specific impact on work and social functioning.

Acute PTSS resulted positively correlated with impairment in all different dimensions of functioning analyzed. These findings are in line with previous research, showing acute stress reactions and PTSD were related to maladjusted work and social functioning. Most studies are focused on veterans, revealing PTSD related to negative impact on psychosocial adjustment, with an increased risk for developing subsequent global functioning impairment34,48,49. Further, it is not unusual for individuals with subthreshold post-traumatic stress reactions to demonstrate significant disability50. In a sample of over 200 of treatment-seeking psychiatric patients, Zlotnick et al.51 showed that subthreshold PTSD is associated with levels of social and work morbidity comparable to full PTSD. In two independent community surveys on more than 1600 individuals, the presence of two re-experiencing symptoms and the presence of one additional symptom of PTSD was found to be a valid limited symptom set associated to work and social impairment to profile post-traumatic functional impairment52. On a sample of HCWs working in an Emergency department of a major University Hospital in Italy, some of us reported significant correlations between PTSD symptoms and WSAS total mean score, showing that emergency workers to be at risk for both PTSD symptoms and related work and social impairment, particularly among women and non-graduated subjects53. Further, a study on 137 emergency HCWs revealed a PTSD rate of 14,3%; subjects with PTSD reported significantly higher work and social functioning impairment compared to those without54.

Results also showed the burden of depressive symptoms on HCWs functioning, the latter being predictive factors of impairment in every dimension of functioning analyzed. Depression is a very common mental illness that diminishes quality of life and in which emotional, somatic and functional impairments are included among the main features of Major Depressive Disorder55. Functional impairment related to depression results in both occupational and social impairments that upset working abilities, social and private leisure activities, family life and responsibilities and interpersonal relationships56,57. Many studies highlighted the effect of exposure to extreme stress on hospital personnel with a considerable proportion of HCWs experiencing mood disturbances and stressing the need to establish ways to mitigate mental health risks among this working class29,47,58,59, but studies that investigated the impact of depressive symptoms on functioning among HCWs are scarce60. In a repeated cross-sectional study, for instance, Ben-Ezra et al.61 compared depressive and PTSS and psychosocial functioning among exposed and non-exposed HCWs during the Gaza war and six months later finding that compared to unexposed hospital personnel, exposed hospital personnel had significantly higher level of depressive and post-traumatic stress symptoms and higher psychosocial functioning impairment. Xiao et al.62, investigating over 900 HCWs at the peak of covid-19 pandemic in China, revealed that more than 53% of professionals had symptoms of depression, with independent risk factors represented by gender, different job titles, protective support and contact history, suggesting interventions to prevent work and social functioning impairment in this working class.

The finding of the present study indicating anxiety symptoms as predictive factors for functioning impairment of HCWs, with a positive association with WSAS total mean score and with impairment in both working and home management activities, was in line with the literature. Among clinical and community samples, anxiety disorders were in general associated with a significant dissatisfaction in work and overall social adjustment of individuals affected, with a significant impact on functioning, occupational role and work productivity, poor interpersonal relations, family and social life related to a lower quality of life than any non-anxious control sample63-65. Evidence from previous outbreaks, along with evidence from the current covid-19 pandemic, pointed out high rates of anxiety symptoms among HCWs and many target interventions have been proposed to support mental health of frontline health professionals, but there is little data in literature about the burden of anxiety symptoms on psychosocial functioning among healthcare staff. Korkmaz et al.66 in a sample of 140 HCWs involved in covid-19 patients care found that 33% of the participants reported clinically significant anxiety symptoms: anxiety levels were negatively correlated to quality of life and problem-solving skills, showing that such symptoms could affect the problem-solving skills of HCWs with an impairment of their working and social abilities to cope with such crisis and cause a deterioration of their quality of life.

Noteworthy, in the present study frontline activity was positively associated with impairment in social functioning, with reported impairment in both private and social leisure activities. Frontline HCWs, being employed in high-risk departments, such as Intensive Care Units and respiratory wards, have the highest exposure risk and most studies evidenced direct exposure to covid-19 patients as one of the most common risk factor for negative mental health outcomes among health personnel in the current pandemic29,67, with significantly higher levels of post-traumatic stress, depression and anxiety symptoms and other psychological issues among frontline HCWs with respect to non-frontline HCWs11,29,68. Reasons for such high toll may be several: first, frontline HCWs, beyond having the most exposure risk, directly see the effects of covid-19 on patients and the reported unpredictable nature of deterioration and the high mortality and morbidity associated with the disease, increasing their worrying of being infected themselves and transmitting to their colleagues, friends and family, with common experiencing of feelings of fear and helplessness67. Further, heavy and uncomfortable protective gear must be worn for several hours and, in parallel, in the case of Personal Protective Equipment shortages (as happened in the first phase of the epidemic), the risk of infection dramatically increases67. Social distancing measures, greatly practiced in the current pandemic as an important tackle to limit the disease outbreak, is greatly required to frontline HCWs. Thus, the need of HCWs to maintain distance from their family members, friends and colleagues, can result in lack of emotional support from the significant others and adds to emotional stress and impairment in social and private leisure activities15,69. Moreover, some authors reported HCWs in general and frontline HCWs in particular, to be at risk of lack of control over their lives, especially during periods of isolation and quarantine and revealed perceived stigma to be a major mediator for psychiatric problems associated with higher distress and negative consequences on frontline HCWs’ wellbeing with negative effect on leisure time and ability to relax15,70-72.

However, when discussing the present study, some limitations should be taken into account. First, the sample size was relatively small. Second, the cross-sectional study design. Third, the use of self-administered assessments.

CONCLUSIONS

Among HCWs facing the first period of the covid-19 pandemic, clinical characteristics demonstrated a stronger association with both work and social functioning than socio-demographic characteristics: higher levels of functioning impairment were found, indeed, among individuals with moderate to severe acute PTSS, depressive and anxiety symptoms with respect to those without. Particularly, acute PTSS and depressive symptoms were predictive factors of impairment in each domain of functioning analyzed. Anxiety symptoms were associated with impairment in both working and home management activities. Further, frontline activity was associated with impairment in both private and social leisure activities. Therefore, further longer-term perspective studies are needed to better investigate the psychopathological burden on HCWs’ work and social functioning and to promote adequate intervention strategies for the current and future healthcare crises. Exploring such burden may prevent HCWs to develop negative coping strategies as well as absenteeism at the workplace and help to address tailored intervention strategies.


Conflict of interests: the authors have no conflict of interests to declare.

references

1. Armocida B, Formenti B, Ussai S. The Italian health system and the covid-19 challenge. Lancet Public Health 2020; 5: e253.

2. Ferrara P, Albano L. Covid-19 and healthcare systems: what should we do next? Public Health 2020; 185:1-2.

3. Lancee WJ, Maunder RG, Goldbloom DS. Prevalence of psychiatric disorders among Toronto hospital workers one to two years after the SARS outbreak. Psychiatr Serv 2008; 59: 91-5.

4. Khalid I, Khalid TJ, Qabajah MR, Barnard AG, Qushmaq IA. Healthcare workers emotions, perceived stressors and coping strategies during a MERS-CoV outbreak. Clin Med Res 2016; 14: 7-14.

5. Xiao J, Fang M, Chen Q. SARS, MERS and COVID-19 among healthcare workers: a narrative review. J Infect Public Health 2020; 13: 843-8.

6. Chan AO, Huak CY. Psychological impact of the 2003 severe acute respiratory syndrome outbreak on health care workers in a medium size regional general hospital in Singapore. Occup Med (Lond) 2004; 54: 190-6.

7. Maunder RG, Lancee WJ, Balderson KE. Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak. Emerg Infect Dis 2006; 12: 1924-32.

8. Carmassi C, Foghi C, Dell’Oste V, et al. PTSD symptoms in healthcare workers facing the three coronavirus outbreaks: what can we expect after the covid-19 pandemic. Psychiatry Res 2020; 292: 113312.

9. Giallonardo V, Sampogna G, Del Vecchio V, et al. The impact of quarantine and physical distancing following covid-19 on mental health: study protocol of a multicentric Italian population trial. Front Psychiatry 2020; 11: 533.

10. Huang JZ, Han MF, Luo TD. Mental health survey of 230 medical staff in a tertiary infectious disease hospital for covid-19. Chin J Ind Hyg Occup Dis 2020; 38: e001.

11. Liu Q, Luo D, Haase JE, et al. The experiences of health-care providers during the covid-19 crisis in China: a qualitative study. Lancet Glob Health 2020; 8: e790-8.

12. Muller AE, Hafstad EV, Himmels JPW, et al. The mental health impact of the covid-19 pandemic on healthcare workers, and interventions to help them: a rapid systematic review. Psychiatry Res 2020; 293: 113441.

13. Talevi D, Socci V, Carai M, et al. Mental health outcomes of the covid-19 pandemic. Riv Psichiatr 2020; 55: 137-44.

14. World Health Organization (WHO). Covid-19 Public Health Emergency of International Concern (PHEIC) Global Research and Innovation Forum: towards a research roadmap (pp. 1-7). Geneva: R&D Blueprint, 2020.

15. Gupta S, Sahoo S. Pandemic and mental health of the front-line healthcare workers: a review and implications in the Indian context amidst covid-19. Gen Psychiatr 2020; 33: e100284.

16. Huang LG, Lin L, Tang L, Yu L, Zhou Z. Special attention to nurses’ protection during the covid-19 epidemic. Crit Care 2020; 24: 120.

17. Salazar de Pablo G, Vaquerizo-Serrano J, Catalan A, et al. Impact of coronavirus syndromes on physical and mental health of health care workers: systematic review and meta-analysis. J Affect Disord 2020; 275: 48-57.

18. Carmassi C, Cerveri G, Bui E, Gesi C, Dell’Osso L. Defining effective strategies to prevent post-traumatic stress in healthcare emergency workers facing the covid-19 pandemic in Italy. CNS Spectrums 2020; 1-2.

19. Styra R, Hawryluck L, Robinson S, Kasapinovic S, Fones C, Gold WL. Impact on health care workers employed in high-risk areas during the Toronto SARS outbreak. J Psychosom Res 2008; 64: 177-83.

20. Lee SM, Kang WS, Cho A, Kim T, Park JK. Psychological impact of the 2015 MERS outbreak on hospital workers and quarantined hemodialysis patients. Compr Psychiatry 2018; 87: 123-7.

21. Shanafelt T, Ripp J, Trockel M. Understanding and addressing sources of anxiety among health care professionals during the covid-19 pandemic. JAMA 2020; 323: 2133-4.

22. Hitch D, Cramer E, Adcock E, et al. The functional impacts of the covid-19 pandemic: a rapid review. 27 May 2020, PREPRINT (Version 1), available at Research Square.

23. Pollock A, Campbell P, Cheyne J, et al. Interventions to support the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic: a mixed methods systematic review. Cochrane Database Syst Rev 2020; 11: CD013779.

24. Mohammed A, Sheikh TL, Poggensee G, et al. Mental health in emergency response: lessons from Ebola. Lancet Psychiatry 2015; 2: 955-7.

25. Carmassi C, Cerveri G, Bertelloni CA, et al. Mental health of frontline help-seeking healthcare workers during the covid-19 outbreak in the first affected hospital in Lombardy, Italy. Psychiatry Res 2021; 298: 113763.

26. Boldrini P, Kiekens C, Bargellesi S, et al. First impact on services and their preparation. “Instant paper from the eld” on rehabilitation answers to the covid-19 emergency. Eur J Phys Rehab Med 2020; 56: 319-22.

27. Griffin KM, Karas MG, Ivascu NS, Lief L. Hospital preparedness for covid-19: a practical guide from a critical care perspective. Am J Resp Crit Care Med 2020; 201: 1337-44.

28. Buselli R, Baldanzi S, Corsi M, et al. Psychological care of health workers during the covid-19 outbreak in Italy: preliminary report of an Occupational Health Department (AOUP) responsible for monitoring hospital staff condition. Sustainability 2020; 12: 5039.

29. Lai J, Ma S, Wang Y, et al. Factors associated with mental health outcomes among health care workers exposed to Coronavirus Disease 2019. JAMA Netw Open 2020; 3: e203976.

30. Chew NWS, Lee GKH, Tan BYQ, et al. A multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during covid-19 outbreak. Brain Behav Immun 2020; 88: 559-65.

31. Wang Y, Ma S, Yang C, et al. Acute psychological effects of Coronavirus Disease 2019 outbreak among healthcare workers in China: a cross-sectional study. Transl Psychiatry 2002; 10: 348.

32. Serrano-Ripoll MJ, Meneses-Echavez JF, Ricci-Cabello I, et al. Impact of viral epidemic outbreaks on mental health of healthcare workers: a rapid systematic review and meta-analysis. J Affect Disord 2020; 277: 347-57.

33. Carmassi C, Gesi C, Corsi M, et al. Exploring PTSD in emergency operators of a major University Hospital in Italy: a preliminary report on the role of gender, age, and education. Ann Gen Psychiatry 2018; 17: 17.

34. Sheffler JL, Rushing NC, Stanley IH, Sachs-Ericsson NJ. The long-term impact of combat exposure on health, interpersonal, and economic domains of functioning. Aging Ment Health 2016; 20: 1202-12.

35. Dell’Osso L, Carmassi C, Musetti L, et al. Lifetime mood symptoms and adult separation anxiety in patients with complicated grief and/or post-traumatic stress disorder: a preliminary report. Psychiatry Res 2012; 198: 436-40.

36. Kisely S, Warren N, McMahon L, Dalais C, Henry I, Siskind D. Occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis. BMJ 2020; 369: m1642.

37. Campbell SB, Renshaw KD. PTSD symptoms, disclosure, and relationship distress: explorations of mediation and associations over time. J Anxiety Disord 2013; 27: 494-502.

38. Flanaghan JC, Fischer MS, Badour CL, Ornan G, Killeen TK, Back SE. The role of relationship adjustment in an integrated individual treatment for PTSD and substance use disorders among veteran: an exploratory study. J Dual Diagn 2017; 13: 213-8.

39. Reich K, Nemeth LS, Mueller M, Sternke LM, Acierno R. Psychosocial functioning in veterans with combat‐related PTSD: an evolutionary concept analysis. Nursing Forum 2021; 56: 194-201.

40. Bosc M. Assessment of social functioning in depression. Compr Psychiatry 2000; 41: 63-9.

41. Weiss DS, Marmar CR. The impact of Event Scale-Revised. In: Wilson JP, Keane TM (eds). Assessing psychological trauma and PTSD. New York City, NY: Guilford Press, 1997.

42. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001; 16: 606‐13.

43. Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder. The GAD-7. Arch Intern Med 2006; 166: 1092-7.

44. Mundt JC, Marks IM, Shear M, Greist JM. The Work and Social Adjustment Scale: a simple measure of impairment in functioning. Br J Psychiatry 2002; 180: 461-4.

45. Lin CY, Peng YC, Wu YH, Chang J, Chan CH, Yang DY. The psychological effect of severe acute respiratory syndrome on emergency department staff. Emerg Med J 2007; 24: 12-7.

46. Gesi C, Carmassi C, Cerveri G, Carpita B, Cremone IM, Dell’Osso L. Complicated grief: what to expect after the coronavirus pandemic. Front Psychiatry 2020; 11: 489.

47. Pappa S, Ntella V, Giannakas T. Prevalence of depression, anxiety, and insomnia among healthcare workers during the covid-19 pandemic: a systematic review and meta-analysis. Brain Behav Immun 2020; 88: 901-7.

48. Ruger W, Wilson S, Waddoups S. Warfare and welfare: military service, combat, and marital dissolution. Armed Forces & Society 2002; 29: 85-107.

49. Richardson L, Frueh B, Acierno R. Prevalence estimates of combat-related post-traumatic stress disorder: critical review. Aust N J Psychiatry 2010; 44: 4-19.

50. Carmassi C, Corsi M, Bertelloni CA, et al. Mothers and fathers of children with epilepsy: gender differences in post-traumatic stress symptoms and correlations with mood spectrum symptoms. Neuropsychiatr Dis Treat 2018; 14: 1371-9.

51. Zlotnick C, Franklin CL, Zimmerman M. Does “subthreshold” post-traumatic stress disorder have any clinical relevance? Compr Psychiatry 2002; 43: 413-9.

52. Norman SB, Stein MB, Davidson JR. Profiling post-traumatic functional impairment. J Nerv Ment Dis 2007; 195: 48-53.

53. Carmassi C, Gesi C, Simoncini M, et al. DSM-5 PTSD and post-traumatic stress spectrum in Italian emergency personnel: correlations with work and social adjustment. Neuropsychiatr Dis Treat 2016; 12: 375-81.

54. Carmassi C, Malacarne P, Dell’Oste V, et al. Post-traumatic stress disorder, burnout and their impact on global functioning in Italian emergency healthcare workers. Minerva Anestesiol 2021; 87: 556-66.

55. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC: APA Press, 2013.

56. Dell’Osso L, Carmassi C, Rucci P, et al. Lifetime subthreshold mania is related to suicidality in posttraumatic stress disorder. CNS Spectr 2009; 14: 262-6.

57. Sheehan DV, Nakagome K, Asami Y, Pappadopulos EA, Boucher M. Restoring function in major depressive disorder: a systematic review. J Affect Disord 2017; 215: 299-313.

58. Palgi Y, Ben-Ezra M, Langer S, Essar N. The effect of prolonged exposure to war stress on the comorbidity of PTSD and depression among hospital personnel. Psychiatry Res 2009; 168: 262-4.

59. Ben-Ezra M, Soffer CY. Hospital personnel reactions to Haiti’s earthquake: a preliminary matching study. J Clin Psychiatry 2010; 71: 1700-1.

60. Buselli R, Corsi M, Baldanzi S, et al. Professional quality of life and mental health outcomes among health care workers exposed to Sars-Cov-2 (covid-19). Int J Environ Res Public Health 2020; 17: 6180.

61. Ben-Ezra M, Palgi Y, Wolf JJ, Shrira A. Psychiatric symptoms and psychosocial functioning among hospital personnel during the Gaza War: a repeated cross-sectional study. Psychiatry Res 2011; 189: 392-5.

62. Xiao X, Zhu X, Fu S, Hu Y, Li X, Xiao J. Psychological impact of healthcare workers in China during covid-19 pneumonia epidemic: a multi-center cross-sectional survey investigation. J Affect Disord 2020; 274: 405-10.

63. Stein D, Kean YM. Disability and quality of life in social phobia: epidemiologic findings. Am J Psychiatry 2000; 157: 1606-13.

64. Olatunji BO, Cisler JM, Tolin DF. Quality of life in the anxiety disorders: a meta-analytic review. Clin Psychol Review 2007; 27: 572-81.

65. Sudhir PM, Sharma MP, Mariamma P, Subbakrishna DK. Quality of life in anxiety disorders: its relation to work and social functioning and dysfunctional cognitions: an exploratory study from India. Asian J Psychiatr 2012; 5: 309-14.

66. Korkmaz S, Kazgan A, Çekiç S, Tartar AS, Balcı HN, Atmaca M. The anxiety levels, quality of sleep and life and problem-solving skills in healthcare workers employed in covid-19 services. J Clin Neurosci 2020; 80: 131-6.

67. Sanghera J, Pattani N, Hashmi Y, et al. The impact of SARS-CoV-2 on the mental health of healthcare workers in a hospital setting: a systematic review. J Occup Health 2020; 62: e12175.

68. Lu W, Wang H, Lin Y, Li L. Psychological status of medical workforce during the covid‐19 pandemic: a cross‐sectional study. Psychiatry Res 2020; 288: 112936.

69. Robertson E, Hershenfield K, Grace SL, et al. The psychosocial effects of being quarantined following exposure to SARS: a qualitative study of Toronto health care workers. Can J Psychiatry 2004; 49: 403-7.

70. Fiorillo A, Sampogna G, Giallonardo V, et al. Effects of the lockdown on the mental health of the general population during the covid-19 pandemic in Italy: results from the COMET collaborative network. Eur Psychiatry 2020; 63: e87.

71. Koh D, Lim MK, Chia SE, et al. Risk perception and impact of severe acute respiratory syndrome (SARS) on work and personal lives of healthcare workers in Singapore: what can we learn? Med Care 2005; 43:676-82.

72. Park J-S, Lee E-H, Park N-R, et al. Mental health of nurses working at a government-designated hospital during a MERS-CoV outbreak: a cross-sectional study. Arch Psychiatr Nurs 2018; 32: 2-6.