The impact of COVID-19 on psychologists' practice: An Italian experience.

Introduction

The World Health Organization (WHO) has declared the Coronavirus Disease 2019 (CoViD-19) outbreak a public health emergency of international concern on Jan 30, 2020. It is well-known COVID-19 not only affects physical health, but also mental health and psychological well-being throughout the population, especially for vulnerable groups (WHO 2020). The socio-economic impact, quarantine, and isolation measures urgently adopted to control the COVID-19 pandemic affected psychological and social health (Brooks et al., 2020). Several cross-sectional and longitudinal studies have detected an increased risk of experiencing symptoms of psychological distress during the outbreak associated with various factors, including gender, social support, specific experiences with COVID-19 infection, length of isolation, and amount of exposure to the media (Brooks et al., 2020; Prati and Mancini, 2021). A recent systematic literature review (Xiong et al., 2021) reported the presence of high rates of symptoms of anxiety (6.33% to 50.9%), depression (14.6% to 48.3%), post-traumatic stress disorder (7% to 53.8%), psychological distress (34.43% to 38%), and stress (8.1% to 81.9%) in the general population during the COVID-19 pandemic in China, Spain, Italy, Iran, the US, Turkey, Nepal, and Denmark. Psychological distress has also been reported in other parts of the world, including Canada, Brazil, Singapore, India, and Japan (Rajkumar 2020). All these findings indicate that the pandemic and quarantine measures related to COVID-19 are seriously inducing adverse effects on mental health.

This overwhelmed many countries’ healthcare systems, and, of course, has affected healthcare providers such as physicians and nurses fighting on the frontlines to safeguard the lives of everyone affected (Lal et al., 2021). However, accumulating evidence suggests the COVID‐19 pandemic has indirect effects on psychological well‐being due to the trauma and stress of coping with the disease, bereavement, and the national and local measures employed to contain the infection (Brooks et al., 2020). When COVID-19 first hit, health professionals as psychologists and psychotherapists were not deemed "essential services". This meant that psychologists were not allowed to see clients face-to-face, and all sessions had to be shifted to telehealth platforms. Thus, the COVID-19 pandemic has halted or modified psychological support services as reported by WHO data. On the other hand, the observed increase in mental health problems during the COVID-19 outbreak additionally enhanced the general need for mental health care during and after the COVID-19 pandemic. In this context, as reported by APA, most psychologists have provided remote treatment for anxiety and depressive disorders, trauma and stress-related disorders, and sleep-wake disorders. Similarly, Sammons and collaborators (2020) surveyed over 3000 psychologists about the impact of the COVID-19 health crisis on their clinical practices. The findings showed the almost “overnight” transition from in-office practice to online practice. Telepsychology practice went from 29% of users employing online platforms for a portion of their practice to over 80% conducting almost all their practice online. This is an amazing practice transformation that occurred in just 1–2 weeks. However, in the absence of evidence‐based guidance to point these efforts in any direction, professionals and services have taken largely spontaneous steps to respond to the situation. Thus, more information is needed about how the pandemic upended the work of psychologists and psychotherapists, how they have interacted with patients, and how health psychology may help to tackle COVID-19 on many levels.

Until now, there are no studies investigating the influence of COVID-19 on psychologists’ practice which are one the main clinical category involved in the directly (infected) or indirectly (massive mass-media pressure, long-term social isolation) management of patients. For this reason, we performed, for the first time, a preliminary evaluation on how COVID-19 pandemic is changing the clinical practice of psychologists - in terms of way of delivering interventions (e.g., in-office vs. online practice), increase/decrease in the number of patients, sociodemographic characteristics of the new category of patients and relative mostly reported clinical symptoms

Materials and methods

Participants

The current study is intended to be an explorative study. Participants were recruited via an advertisement in national newspapers and on the Internet, including text- and video-based posts on social media websites, in relevant Internet forums, and on a website promoting participation in scientific studies (www. http://www.psicologicalabria.it/). Data were collected using an anonymous online survey from January 2021 to May 2021. In filling this survey, we required participants to refer to the time window starting from the first total national lockdown (8 March 2020). A snowball sampling strategy was employed, wherein the participants were initially recruited via online advertisements and were encouraged to pass the survey link to others. Before starting, participants were encouraged to read all verbal instructions, which stressed that all responses were anonymous and confidential, and that participation was voluntary. Participants that did not complete the final set of questionnaires were sent up to four reminder notifications, after which they were considered to have withdrawn.

We enroled only psychologists who fulfilled the following criteria: (i) having a specialist training in clinical psychologist for at least 3 years; (ii) employed in public or private practice in psychotherapy; (iii) joined the Register of Psychologists. All the participants gave written informed consent. The study was approved by the Ethical Committee of the University of Calabria (n° 571 28/01/2021), according to the Helsinki Declaration.

Responses of 204 participants were included in the final data set. Considering the impact of COVID-19 on their life, participants were asked to provide sociodemographic information about their patients and themselves.

Results

All data analysis is descriptive due to the explorative study design. Many respondents (mostly working in private practice, 67.7%) and reported a substantial increase of new patients during the pandemic (58.7%). Delivering of psychological therapies was mainly made employing online internet (84.8%) tools (skype, zoom, teams), which was judged an effective option (64.7%). The majority of respondents affirmed that the COVID-19 pandemic has not compromised their clinical relationships (59.3%), although it has affected their mental (56.2%) more than physical (42.8%) health (Table 1 ).

Table 1

Sociodemographic information about respondents

	Questions	Frequency
Employment settings and Covid-19 effects onPsychologist's work/health	1. Where do you conduct your clinical work?
	• Hospitals/Clinics	10.9%
	• Private practice	67.7%
	• Both Hospitals/Clinics and private practice	17.4%
	• Social Services settings	4%
	2. Is the number of patients requiring treatment increased or diminished during COVID-19?
	• Increased	58.7%
	• Diminished	16.9%
	• Stable	24.4%
	3. Have you delivered online psychological therapies and interventions from the beginning of pandemic to now?
	• Yes	84.8%
	• No	15.2%
	3.1 If you answered Yes to question 3, how often?
	• Rarely	4.6%
	• Sometimes	32.4%
	• Often	43.9%
	• Very Often	19.1%
	3.2 If you answered Yes to question 3, do you judge the online delivery of psychological therapies and interventions an effective option?
	• Yes	64.7%
	• No	2.9%
	• Only during lockdown periods	32.4%
	4. Has lockdown influenced your physical health?
	• Yes	42.8%
	• No	57.2%
	5. Has lockdown influenced your mental health?
	• Yes	56.2%
	• No	43.8%
	6. Has lockdown influenced your clinical relationships?
	• Yes	40.7%
	• No	59.3%
	6.1 If you answered Yes to question 6, which was the main emotion felt during therapy?
	• Stress	34.9%
	• Discomfort	20.9%
	• Fear	10.5%
	• Anxiety	8.1%
	• Optimism	5.2%
	• Pleasure	4.1%
	• Joy	1.2%

Patients were mainly from the South of Italy (70.7%) since most respondents worked in this area. Concerning the demographic characteristics, patients were mainly female (75.7%), unmarried (47.3%) and of middle age (58.7% ranged between 26 and 69 years). The majority of patients were employees (27.9%) or students (26.7%) (Table 2 ).

Table 2

Sociodemographic information about patients

Sociodemographic information about patients	7. Age range?
	• 1-6 years	2.2%
	• 7-13 years	5.3%
	• 14-18 years	14.1%
	• 19-25 years	21.3%
	• 26-45 years	41.3%
	• 46-69 years	15.6%
	• > 70 years	2.5%
	8. Regions of Origin
	• North	23.4%
	• Centre	16.3%
	• South/Islands	70.7%
	9. Education
	• 0-5 years	5%
	• 5-8 years	14.8%
	• 8-13 years	37.9%
	• 14-18 years	30.2%
	• > 19 years	12.1%
	10. Marital status
	• Unmarried	47.3%
	• Married	35.8%
	• Cohabitant	16.8%
	11. Job
	• Unemployed	16.4%
	• Employed	27.9%
	• Freelance professional	20.6%
	• Artisan	2.2%
	• Trader	6.1%
	• Students	26.5%
	• Other (i.e., Director)	0.3%

The questions about the clinical characteristics of the patients revealed that, during the pandemic, patients showed new clinical symptoms of moderate (76.8%) degree, mainly related to anxiety (19.7%), mood (14.2%), sleep (13.7%), and stress (13.7%) disorders. These symptoms were indirectly related to COVID-19 (78.6%), that is occurring in patients who were not infected by the virus. Moreover, respondents also reported the remitting of old symptomatologies, which would seem to be solved. Similarly, to new symptomatologies, patients showed a re-emersion of anxiety (19.9%), mood (14.2%), sleep (13.9%), and stress (12.7%) disorders of moderate degree (67.1%) and indirectly related to COVID-19 (81.2%) (Table 3 ).

Table 3

Clinical characteristics of patients during the COVID-related pandemic

Clinical characteristics	12. Which are the NEW clinical symptoms that emerged during the pandemic?
	• Anxiety	19.7%
	• Mood Disorders	14.2%
	• Sleep Disorders	13.7%
	• Stress Disorders	13.7%
	• Obsessive-Compulsive Disorders	6%
	• Social Network Addiction	6.5%
	• Internet Addiction	5.8%
	• Gaming Addiction	4.5%
	• PTSD	4%
	• Eating Disorders	4.2%
	• Alcohol Abuse	2.9%
	• Suicide/auto-lesionism	2.9%
	• Drug Addiction	1.8%
	13. Define the degree of this NEW symptomatology
	• Severe	8.5%
	• Moderate	76.8%
	• Mild	14.7%
	14. Is this NEW symptomatology directly or indirectly related to the COVID-19 pandemic?
	• Directly	11.5%
	• Indirectly	78.6%
	• I don't know	9.9%
	15. Which are the OLD clinical symptoms that re-emerged during the pandemic?
	• Anxiety	19.9%
	• Mood Disorders	14.2%
	• Sleep Disorders	13.9%
	• Stress Disorders	12.7%
	• Obsessive-Compulsive Disorders	7.6%
	• Social Network Addiction	6.4%
	• Internet Addiction	5.7%
	• Gaming Addiction	3.4%
	• PTSD	4.7%
	• Eating Disorders	3.4%
	• Alcohol Abuse	3.2%
	• Suicide/auto-lesionism	2.8%
	• Drug Addiction	1.7%
	16. Define the degree of this OLD symptomatology
	• Severe	7.9%
	• Moderate	67.1%
	• Mild	25%
	17. Is this OLD symptomatology directly or indirectly related to COVID-19 pandemic?
	• Directly	13%
	• Indirectly	81.2%
	• I Don't know	5.8%

Discussion

COVID-19 is having a dramatic worldwide impact on well-being and public mental health. The psychological consequences of this pandemic have been related to the direct infection as well as to indirect effects of fear (being infected) and social isolation. In the first case, it has widely been demonstrated that anxiety/depression disorders and insomnia are the main symptoms persisting from some weeks until 6 months after diagnosis of COVID-19 (Taquet et al., 2021; Huang et al., 2021). Otherwise, some authors demonstrated that in the general population the presence of the COVID-19 pandemic has an indirect effect on mental health, influencing the occurrence of stress disorders (Lee et al., 2020; Castelli et al., 2020).

While politicians are involved in the definition of social restrictions to contain the spread of COVID-19, psychiatrists try to face off against the spread of COVID-related mental symptoms. However, there is another first-line clinical category engaged as gatekeepers of the healthcare system: psychologists. In this study, we provide preliminary evidence on how psychologists are facing the psychological snowball effect of COVID-19.

First, COVID-19 had a significant impact on psychologists’ way of delivering interventions and health. Concerning the first point, indeed, we found that most respondents (84.8%) delivered psychological therapies and interventions through online platforms. This percentage is like that reported in other studies (see Sammons et al., 2020). Again, the respondents judged the online delivery of psychological therapies and interventions an effective option. This transition from in-office practice to online practice due to the pandemic has the potential to make mental health services accessible and more affordable for many people. However, evidence-based guidelines for the different conditions are necessary to offer the best care to patients since, so far, psychologists have taken largely spontaneous steps to deliver online therapies. Concerning the second point, as already demonstrated for medical doctors and general practitioners (Castelli et al., 2021), our study suggests that the stressful conditions imposed by COVID-19 might also induce health problems in psychologists. Indeed, mostly respondents reported an increased distress condition (56.2%).

As concerns patients, we found that the vast majority of psychologists reported an increased number of new (mainly unmarried female of middle age) patients who are characterized by new (or old) symptomatologies directly (11.5%) or indirectly (78.6%) related to the COVID-19 pandemic. The main symptoms described are the emergence (or remitting) of anxiety, mood, sleep, and stress disorders, perfectly in agreement with those reported in long-term patients directly affected by COVID-19 (Taquet et al., 2021; Huang et al., 2021)

Limitations

Despite these new and interesting results, some limits should be mentioned. First, our sample included mainly psychologists working in the South of Italy. Secondly, respondents were asked to provide sociodemographic information and to fill a specific clinical questionnaire, but future studies should collect data using also specific assessment tools, such as State-Trait Anxiety Inventory and Beck Depression Inventory.

Conclusion

The results from this descriptive study suggest the need to implement prompt psychological interventions to develop timely screening programs aimed at identifying people (i.e., female, unmarried) being at a higher risk to develop psychopathological symptoms, which could dramatically increase direct/indirect costs for health care system

Declaration of Competing Interest

All authors have participated in (a) conception and design, or analysis and interpretation of the data; (b) drafting the article or revising it critically for important intellectual content; and (c) approval of the final version.