This study revealed a consistent psychological burden among rheumatic patients after confinement during the COVID-19 pandemic in Italy in terms of the high impact of self-reported distress, anxiety, perceived stress, and sleep disorders. Among the identified risk factors, having female gender, younger age, living outside Lombardy, having overweight/obesity, or intestinal diseases, having a history of psychiatric symptoms (e.g. anxiety), and having to experience anxiety for financial or health issues were associated with poor mental health.
According to self-reported psychiatric symptoms and related therapy pre- and post-lockdown, we observed a worsening of symptoms and an increase in the assumption of psychiatric drugs in this vulnerable population. Our results are consistent with data reported in other cohorts of rheumatic patients during the initial stage of the COVID-19 epidemic [22, 23]. In addition, the impact of trauma was found to significantly influence the severity of stress perceived by patients in agreement with previous reports .
In particular, stress and PTSD were perceived more by females. This is not surprising as females and males react to stressful events differently in terms of coping strategies, psychological and biological mechanisms [25–27]. These results are also confirmed by data on the psychological impact of the COVID-19 pandemic on the Italian population [28–30] and Turkish RDs .
Moreover, younger adults were found to have higher levels of stress. This is in line with other Italian studies during the COVID-19 outbreak [28, 29, 31], and also with previous studies highlighting that older adults present greater self-control, emotional self-regulation, and better-coping strategies compared to younger adults [32, 33]. A further potential explanation is that younger people might experience higher stress levels because they increased the use of the Internet and social media during the lockdown period [34–36].
The current study found a significant association between overweight/obesity and higher levels of perceived stress, while the presence of intestinal diseases and anxiety disorders were related to PTSD. A recent meta-analysis reported that body mass index is directly associated with perceived stress . Thus, the COVID pandemic might have been perceived as more stressful in the light of poor outcomes associated with the infection in subjects affected by overweight or obesity . Previous studies found PTSD both in inflammatory and functional intestinal diseases [39, 40].
In the context of the COVID-19 pandemic in Italy, the first wave was much more serious in Lombardy than in the other regions. By contrast, our results showed that patients living in regions different from Lombardy had higher PSS-10 and PTSD scores after lockdown. This supports the hypothesis that psychological impact was not only related to direct COVID-19 exposure but also to the media storm that provided a general sense of threat . Furthermore, Lombardy is a highly urbanized region, while in rural areas patients may experience greater difficulty in accessing health facilities in case of emergency .
As expected, specific sources of anxiety were related to PSS-10 and PTSD scores. Notably, our data showed that worries about loss of employment and incomes had a greater impact on perceived stress levels after lockdown. These results are consistent with data reported by an Italian study assuming that higher incomes are associated with lower levels of stress , while health concern is related to psychological distress. The same sources of anxiety were reported in other studies during a pandemic [43–45]. Moreover, these results are consistent with those during quarantines showing that patients with chronic diseases perceived more stress as access to regular medical care and prescriptions were problematic .
In the context of the post lockdown phase of the pandemic, while there was a gradual restoration of outpatient services, PTSD was found in 41% of participants. This appears particularly important for the interpretation of the high rate of severe self-reported distress symptoms. Therefore, it appears to support the concern about the risk of PTSD as the second tsunami of the COVID-19 pandemic . In our data, the main PTSD cluster of symptoms (intrusion, avoidance, and hyperarousal) were balanced without prominence of none of the domains.
Moreover, sleep disturbances were a relevant concern in patients with inflammatory arthritis, with higher rates of poor sleepers compared to the general Italian population, suggesting that people affected by inflammatory arthritis are more vulnerable to COVID psychological aftermaths [7, 14].
Furthermore, our results showed that older patients who had coronavirus infection and were previously treated for psychiatric disorders were at higher risk of developing sleep disorders. Concerning age, this could be explained by age-related changes in circadian rhythms and consequent higher prevalence of insomnia among older people . The previous use of psychiatric compounds in subjects affected by insomnia during the pandemic is not surprising as sleep disturbances are generally observed in patients affected by mental disorders, particularly depression and anxiety . Besides, complaints such as difficulty falling or staying asleep, unsatisfying sleep, irritability, and nightmares are well documented in some anxiety disorders, such as generalized anxiety disorder and PTSD. Finally, our study confirmed COVID-19 infection to be an important contributing factor to the development of insomnia. Indeed, several studies proved that survivors after SARS-CoV-2 had
negative psychosocial aftermaths; notably, it seems that both immune activation towards the virus and pandemic related stressors (e.g. isolation, concerns about infecting relatives, financial difficulties) can induce detrimental effects on patients’ mental health including poor sleep quality.
It is well established that sleep disruption may worsen arthritis, leading to joint stiffness, pain, weakness, anxiety, depression, and poor outcome [8, 49]. Moreover, impaired sleep may affect work productivity, social functioning, and daily activities, proving to be a considerable psychosocial burden .
Some limitations should be considered in the interpretation of these results. First, although the number of respondents is quite large, it represents a part of the RD patients, and self-selection bias may have influenced the results. Second, the cross-sectional design of the study prevents drawing any cause-effect conclusion and the response rate cannot be calculated. Third, although the survey had nationwide dissemination, the respondents were mainly from Lombardy, probably because it was the Italian region most hit during the first wave of the pandemic.
Despite limitations, our findings may support present and post-pandemic interventions related to the COVID-19 pandemic that could be useful for mitigating the psychological impact on more vulnerable patients. Moreover, both stress and PTSD are known triggers for relapse autoimmune diseases; thus, there is a concern about potential disease flares. Besides, the present findings will be of help to patients' associations that may implement measures for psychological support.