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Digital archive of theses discussed at the University of Pisa


Thesis etd-07302020-164655

Thesis type
Tesi di specializzazione (4 anni)
Thesis title
Acute mental health impact of the COVID-19 pandemic on 514 frontline healthcare workers: a multicenter study in three Italian regions at different exposure levels
Course of study
relatore Dott.ssa Carmassi, Claudia
  • mental health
  • healthcare workers
  • funzionamento
  • functioning
  • disturbo post-traumatico da stress
  • depressione
  • depression
  • COVID-19
  • Coronavirus 2019
  • anxiety
  • ansia
  • operatori sanitari
  • pandemia
  • pandemic
  • Post-traumatic stress disorder
  • PTSD
  • salute mentale
Graduation session start date
Release date
Background: Post-Traumatic Stress Disorder (PTSD) is a severe psychiatric disorder typically occurring after exposure to a traumatic event, often causing a chronic psychological suffering and invalid course. Healthcare workers (HCWs) employed in emergency are frequently exposed to high stressful situations, which can influence physical and mental well-being, leading to PTSD onset, as well as to anxiety and depressive disorders. The current spread of COronaVIrus Disease 2019 (COVID-19) pandemic has shed new light on the need of paying special attention to the mental health of firstline HCWs. HCWs directly involved in the treatment of COVID-19 patients are under an ever-increasing number of confirmed and suspected cases, overwhelming workload, depletion of personal protective equipment (PPE), lack of specific drugs, challenging expectations and feelings of being inadequately supported, that may contribute to hopelessness feelings and to their mental burden. The first aim of the present thesis was to investigate PTSD, anxiety and depressive symptoms in a sample of frontline HCWs from three of the most affected Italian regions at different exposure levels to COVID-19 pandemic. The second aim was to detect the impairment of functioning, analyzing possible correlations between this variable and PTSD, anxiety and depressive symptoms, with particular attention to possible regional, environmental and occupational differences.
Material and method: The study sample included 514 healthcare workers (physicians, nurses and other hospital healthcare workers) from five major hospitals of three Italian regions (Tuscany, Emilia-Romagna and Lombardy). Subjects were consecutively recruited from April 2020 to June 2020 in Emergency Departments (EDs), Intensive Care Units (ICUs) and other various Medical/Surgical Units exposed to COVID-19 patients. The assessment was performed by using the Impact of Event Scale-Revised (IES-R), to investigate the acute post-traumatic stress reaction, the Generalized Anxiety Disorder 7-item (GAD-7), to investigate the anxiety symptoms, the Patient Health Questionnaire (PHQ-9), to detect the depressive symptoms and the Work and Social Adjustment Scale (WSAS), to examine the impact of post-traumatic stress, anxiety and depressive symptoms on global functioning.
Results: One-hundred twenty-one subjects (23.5%) reported a probable PTSD diagnosis, while 163 (31.7%) presented clinically significant PTSD symptoms. One hundred fifteen subjects (22.4%) reported moderate-severe anxiety symptoms, 99 (19.3%) moderate-severe depressive symptoms, 117 (22.8%) a clinically significant functioning impairment. In Lombardy and Emilia Romagna the mean values of IES-R scores were statistically significantly higher than those of Tuscany. In Lombardy the GAD-7 mean scores were statistically significantly higher than in Tuscany and Emilia Romagna, and in Emilia Romagna were statistically significantly higher than in Tuscany. In Lombardy and Emilia-Romagna the PHQ-9 mean values were statistically significantly higher than those in Tuscany. In Lombardy and in Emilia Romagna the WSAS mean values were statistically significantly higher than in Tuscany.
In EDs IES-R and WSAS mean values were statistically significantly higher than those of ICUs and Medical/Surgical Units. In Medical/Surgical Units the WSAS mean values were statistically significantly higher than in ICUs.
In nurses IES-R and PHQ-9 mean scores were statistically significantly higher than those of other HCWs. In a linear regression model, the IES-R, GAD-7 and PHQ-9 total scores presented a significant positive association with the WSAS scores. The mediation analysis showed that total and direct effect of PHQ-9 total score on WSAS total score were statistically significant. PHQ-9 total score also showed a significant indirect effect on WSAS total score through IES-R total score.
Conclusions: This work underlines a positive correlation between levels of exposure to COVID-19 infected patients and PTSD, anxiety and depressive symptoms, and highlights the high risk of mental disturbances in frontline HCWs exposed to COVID-19 pandemic. The most important factor associated to a reduction in global functioning were the depressive symptoms, but this effect was partly direct and partly indirect, through PTSD symptoms. A deeper assessment of work-related trauma and post-traumatic stress reactions in these subjects, including PTSD, anxiety and depression, could be clinically beneficial, in terms of planning prevention strategies and therapeutic interventions.