4. Discussion
To date, the mental health impacts of the COVID-19 outbreak is still under-reported. Individual emotional responses during the massive infectious disease outbreaks are likely to include feelings of extensive fear and uncertainty that, along with social and economic consequences, may eventually cause a dramatic mental health burden [27]. For this reason, we conducted a survey to investigate the occurrence of depressive symptoms among the Italian general population during the early phase of the pandemic. We also went further, by hypothesizing that distinct psychopathological risk factors may conjointly predict depression severity. The results provide additional support for societal concerns of the stressful impact of COVID-19 on mental health.
Our findings indicated, in fact, that nearly 25% of our sample displayed a relevant depressive symptomatology according to BDI-II cutoff scores. Similar rates of depressive symptoms were reported by cross-sectional studies conducted among the general population of worst-hit countries during the initial stage of the pandemic [28,29]. Of note, the majority of individuals in our sample reported no depressive symptomatology. This might be due to the still relatively short exposure to the pandemic or to possible interindividual protective factors promoting mental health [30,31]. Our results also suggested that women and younger individuals were, to a certain degree, more likely to experience significant symptoms of depression in response to the COVID-19 outbreak. These findings may in part be due to the fact that women represent a greater percentage of the workforce that has been negatively affected by the COVID-19 outbreak, including retail, service industry, and healthcare, in addition to biological factors. Similarly, work loss and unpredictability that derived from the COVID-19 pandemic may be particularly stressful among younger age groups [15].
The present findings highlighted that direct exposure to confirmed cases ofCOVID-19 may significantly account for the determination of depression severity. The COVID-19 pandemic may embody a number of negative emotional states and overwhelming stressors. A few of these include loss of employment; deaths of family members, friends, or colleagues; financial insecurity; isolation from others; as well as risk of exposure to contagious individuals. The fact that COVID-19 is human-to-human transmissible, associated with high morbidity, as well as being potentially fatal, may intensify depressive feelings, particularly among those who reported contacts with confirmed cases [32]. In line with our results, a recent population-based study among the community of Wuhan, China identified close contact with individuals with COVID-19 as a risk factor for depression during the first month of lockdown [33].
Decreased emotion regulation abilities as well as anhedonia significantly predicted depression severity in our sample. Sustained negative affects and stressors tend to deplete one’s energy and ability to adaptively cope with situational challenges, which in turn may exacerbate the experience of negative affects, including depressive symptoms [34].
An important issue pertaining to emotion regulation concerns the interindividual variability in experiencing negative or positive affects, as well as the habitual tendency to prefer some regulatory strategies over others to control distressful affects. On the one hand, depression has long been associated with increased levels of negative and stressful affects [35]. On the other hand, one of the key components of emotion dysregulation is the inability to regulate negative emotion and to decrease the duration of negative affect once it arises [36]. Consistently with this conceptual framework, there is evidence linking impaired emotion regulation mechanisms with depressive symptoms, also at a neurobiological level. Indeed, depression has been repeatedly associated with dysfunction in brain regions that are normally implicated in emotion regulation, including prefrontal cortex, (PFC), amygdala, and hippocampus. Intriguingly, these regions have been implicated in the regulation of stress and coping, with the PFC and the hippocampus providing inhibitory control over stress responses, whereas the amygdala has been implicated in potentiating stress-related behaviors [5].
A growing body of evidence suggests that acute stressors may also adversely affect sensitivity to hedonic stimuli [7]. Similarly, anhedonic symptoms have long been conceptualized in terms of blunted response to positive reinforcement, which in turn represents a biological endophenotype of increased depression vulnerability [37]. Taken together, emotion dysregulation and anhedonia may therefore reflect a more general individual incapacity to regulate adaptive responses when facing stressful events, which may ultimately lead to depression. The findings reported here may have practical implications, as the effect of emotion dysregulation and impaired hedonic tone on depressive symptoms is actionable and modifiable through specific interventions on emotion regulation mechanisms. The emerging fields of emotion research and affective neuroscience have, in fact, paved the way for new potential therapeutic venues [38]. This literature points to mutually inhibitory relationships among neural regions implicated in emotion regulation, and a wide network of cortical areas that are involved in downregulating early reactivity to emotionally salient stimuli [11,39].
We understand that the choice of an online survey is not free from methodological risks [40]. However, this was necessary in order to reach a sizeable percentage of the Italian population in a short time during an early phase of the outbreak, when face-to-face contacts are forbidden [41].
Before drawing a study conclusion, we must acknowledge some issues that might mitigate the generalizability of our results. First, the study was carried out throughout four days and lacks longitudinal follow-up. Indeed, the mental health impact of the COVID-19 outbreak on the Italian general population might become more stressful over time. Second, the survey design involved a non-probabilistic sampling method which relied upon the capacity of participants to forward online invitations to others, so that each participant’s suitability may be not controlled for once sample increases in size. Third, people not using network devices, as well as non-Italian language speakers, were excluded. This might represent a selection bias, as there is evidence that COVID-19 disproportionately affects minority groups as well as those living in socially disadvantaged contexts [42]. Fourth, it was not possible to calculate the participation rate, since it is unclear how many individuals received the link for the survey. Finally, the reliability of self-administered questionnaires may be partially biased.