Psychosocial Predictors of Sleep Disturbances during COVID-19: differential contributions of demographic, psychological, pandemic-related factors to sleep health. (preprint)

Aim: Since the declaration of COVID-19 as a Public Health Emergency of International Concern on January 30, 2020, the disease escalated into a global pandemic forcing governments around the world to impose measures that affected all aspects of life. Among other countries, Greece adopted social restriction, lockdowns, and quarantines to reduce transmission from person to person.  Subjects and Methods: This cross-sectional study aimed to investigate the impact of those measures on sleep health in a Greek adult sample. An online questionnaire collected data during from 650 participant.  Results: 60% of responders scored below the clinical cut-off on the RU-SATED, indicating they experienced poor sleep health. Better sleep health was reported with increased age and years of education. On the other hand, higher trauma-related distress, depression, anxiety and stress symptomatology were related to poorer sleep health. No gender differences were observed, and degree of compliance to pandemic restrictions did not influence sleep health. Hierarchical regression analysis indicated difficulty in securing enough/healthy food, testing positive for COVID-19, experiencing an increase in verbal arguments/conflicts at home and an increase in responsibilities were the strongest predictors of poor sleep heath.  Conclusions: Results highlight the importance of maintaining good sleep health as a pillar of general physical and mental health.

Exploring the Perspectives of Clients and Clinicians Regarding Digitally Delivered Psychotherapies Utilized for Trauma-Affected Populations. (preprint)

During the COVID-19 pandemic, many clinical sites shifted towards digital delivery of mental health services. However, there is still much to learn regarding tailoring interventions for trauma-affected populations, including military members, Veterans, and public safety personnel. This study examined perceptions of psychotherapies utilized for trauma-affected populations, as reported by Canadian military members, Veterans, and public safety personnel who completed such interventions and mental health clinicians who provided them. Specifically, we explored the shift to digital health use, what changed with this rapid shift, what needs, problems, and solutions arose, and important future considerations associated with delivering trauma-focused and adjunct treatments digitally.   Quantitative survey data were collected from 11 Canadian patients (military members, Veterans, and public safety personnel with post-traumatic stress injury) and 12 Canadian mental health clinicians. Survey questions were adapted from the Alberta Quality Matrix for Health (AQMH) and Unified Theory of Acceptance and Use of Technology (UTAUT) model. As a follow-up, participants were invited to participate in either a semi-structured qualitative interview or focus group to further explore their perspectives on digitally delivered trauma-focused and adjunct therapies. Four clients and 19 clinician participants participated in an interview or focus group.   In survey and interview/focus group results, patient and clinician participants reported that digitally delivered trauma and adjunct therapies offered similar treatment effectiveness as in-person delivery while also improving treatment access. Participants indicated unique advantages of digital delivery, including the increased accessibility of treatment, cost effectiveness, and more efficient use of resources. However, some participants struggled with using digital platforms and felt less comfortable working in a digital environment. Further research with a larger, more diverse population is required to corroborate our results and identify other avenues in which psychotherapies utilized for trauma-affected populations can be engaged with and improved upon.

Decisional procrastination and problematic mobile phone use: the mediation of anxiety and the moderation of 2019-nCoV traumatic experience (preprint)

Background Decisional procrastination (DP) has an important effect on problematic mobile phone use (PMPU); however, the potential mechanisism and boundary conditions between DP and PMPU remianed to be further explored. This essay studied the mediation of anxiety between DP and PMPU and whether 2019-nCoV traumatic experience moderated the mediation process.Methods A questionnaire was used in this study. A valid sample of 798 college students reported levels of decisional procrastination, problematic mobile phone use, anxiety, and 2019-nCoV traumatic experience.Results The results indicated that decisional procrastination is positively associated with problematic mobile phone use among college students. Anxiety served as a partial mediator in the association between decisional procrastination and problematic mobile phone use. 2019-nCoV traumatic experience would positively moderated the mediating effects of anxiety between DP and PMPU. A higher degree of 2019-nCoV traumatic experience would strengthen the mediation effects of DP to PMPU through anxiety.Conclusions This study deepens our understanding of how DP affects college students' PMPU. It was found in the study that 2019-nCoV traumatic experience positively moderated the mediation effects of anxiety between DP and PMPU. These findings provide universities with a theoretical foundation for preventing PMPU among college students.

Rates of Trauma Exposure, Posttraumatic Stress Disorder (PTSD), Depressive, and Anxiety Symptoms in Primary School Children: Findings Six Months before Covid-19 Pandemic (preprint)

Studies on mental health rates among primary school children are still limited particularly related to psychological trauma and its relationship to other mental health challenges. This is the first cross-sectional study examining the rates of trauma exposure, posttraumatic stress disorder (PTSD), depressive, and anxiety symptoms in primary school children before covid-19 pandemic in Malaysia. Two hundred and twenty-one students participated in this study. They were recruited from four primary schools that volunteered to participate in the study. PTSD) Checklist for DSM-5 (PCL-5), Child PTSD Symptoms Scale-5 (CPSS-5), The Center for Epidemiologic Studies Depression Scale version (CESD) and the Spence Children's Anxiety Scale (SCAS) were used to survey psychological symptoms. Most of the students, or 54.3% of them, have experienced at least one traumatic event. Of 221 students, 39.4% reported having PTSD symptoms, 38% reported having depressive symptoms and 19% reported having anxiety symptoms. Female students were more likely to report PTSD symptoms compared to male students. The first regression analysis model showed that only depressive symptoms were significant predictors for PTSD. In the second model, religion, family income, anxiety and PTSD symptoms were significant predictors of depressive symptoms. In the third model, only depressive symptoms were significant predictors of anxiety. Findings, limitations, research future directions and recommendations were discussed.

Health professional students at the University of Illinois Chicago (HOLISTIC) Cohort study: Prevalence of mental health and lifestyle behaviors effects among health professional students during the COVID-19 pandemic (preprint)

Background The COVID-19 pandemic adversely affected the mental health of healthcare workers. The World Health Organization estimates a 25% increase in anxiety prevalence during the pandemic. The mental health of students across the health professions during the pandemic is less well understood. Objectives To better understand the impact of the COVID-19 pandemic on health professional students, a cross-sectional analysis of data collected on enrollment in a cohort study was utilized to examine the prevalence of poor mental health days in association with lifestyle behaviors in seven health sciences colleges at a large public Midwestern university during the first two years of the COVID-19 pandemic. The study recruited 890 students enrolled full- or part-time across seven health sciences colleges in 2020 and/or 2021 using convenience sampling. Methods Participants completed questionnaires which included socio-demographic questions and items from the U.S. Centers for Disease Control and Prevention’s (CDC) Behavioral Risk Factor and Surveillance System (BRFSS) 2019 survey. Results The participants reported a median of 7 days with poor mental health (IQR: 3-15 days) in the past 30 days. Female sex (OR 1.70, 95% CI [1.21, 2.38]), Asian race (OR 1.47, 95% CI [1.06, 2.06]), adverse childhood events (OR 2.01, 95 % CI [1.45-2.78]), and frequent cannabis use (OR = 2.03, 95 % CI [1.14-3.61]) were each associated with an increased risk of poor mental health during the COVID-19 pandemic. Exercise (OR 0.64, 95 % CI [0.42-0.97]) was found to be a protective factor, during COVID-19. Conclusions and Implications Results indicate the need to design, implement, and evaluate services to support mental health in health sciences students, particularly among certain subgroups. Students who are frequent cannabis users or have significant childhood trauma are more likely to have poor mental health and as such may benefit from additional mental health support. Health promotions around home-based exercise and intramural sports to health professional students along with longer open hours for the gym may be beneficial.

Understanding, Measuring, and Ameliorating Workplace Violence in Healthcare: A Canadian Systematic Framework to Address a Global Healthcare Phenomenon (preprint)

Background: Globally, healthcare institutions have seen a marked rise in workplace violence (WPV), especially since the Covid-19 pandemic began, affecting primarily acute care and emergency departments (EDs). At the University Health Network (UHN) in Toronto, Canada, WPV incidents in EDs jumped 169% from 0.43 to 1.15 events per 1000 visits (p<.0001). In response, UHN initiated a comprehensive quality improvement (QI) project to address WPV. This study presents the project's design, implementation, results, and key takeaways, aiming to showcase effective and trauma-informed strategies for mitigating WPV in healthcare settings. Methods: Our multi-intervention QI initiative was guided by the Systems Engineering Initiative for Patient Safety (SEIPS) 3.0 framework. We also leveraged the SEIPS 101 tools to aid in crafting each QI intervention. This approach amalgamated various methodologies to approach WPV, incorporating literature reviews, a modified Delphi method, qualitative interviews, surveys, quantitative data gathering and pragmatic interventions. Results: Our complex intervention contained a total of 12 subprojects. We reviewed existing literature (n=84) pertaining to WPV in healthcare. N = 229 quality indicators utilized to measure WPV in healthcare were extracted from the literature and underwent a Delphi process which yielded 17 quality indicators for a new organizational WPV dashboard. WPV theories were critically reviewed in the context of intervention development. Educational initiatives (n=2) were implemented including ad-hoc point of care training, as well as rollout of a comprehensive trauma-informed training program for WPV prevention, verbal de-escalation and management of escalated responsive behaviour. Further changes involved establishing a Code White Governance Committee, enhancing WPV reporting and addressing underreporting. Debriefing was structured into hot and cold debriefing models. Additionally, environmental indicators promoting mutual respect were introduced, alongside security enhancements including wearable video devices for all security guards and a 100% increase in ED security guards. Outreach initiatives were implemented including qualitative interviews with ED staff (n=75) and the development of a patient partner and community outreach group. Conclusions: WPV in healthcare is a complex phenomenon that urgently requires effective solutions. We developed a 13-step framework that offers guidance for healthcare institutions seeking to develop a systemic approach in addressing WPV tailored to their organization’s needs.

Psychometric Properties and Validity of Inventory of Symptoms of Professional Traumatic Grief and Relevance to Clinical Practice. (preprint)

Background Traumatic grief can exert a considerable influence on the mental and physical well-being of nurses, potentially altering their ability to provide high quality care. This impact is most pronounced in specific contexts such as health emergencies, palliative care and paediatric intensive care units. In the context of the Covid-19 pandemic, health professionals have faced an unprecedented increase in loss and trauma, and this situation is seen as an exacerbating factor in complicated bereavement. Despite the availability of instruments for the assessment of prolonged or pathological grief, there is a pressing need for additional studies that allow for a more accurate understanding and measurement of this phenomenon, filling certain existing methodological gaps. The main purpose of this research is to evaluate the psychometric properties of the Inventory of Symptoms of Professional Traumatic Grief (ISDUTYP), with a view to improving assessment tools in this field.Method Construct validity, reliability, criterion validity, convergent validity and discriminant validity were assessed. The scale's psychometric properties were tested with 930 nursing professionals. The data were collected between September 2022 and January 2023.Results A total of 930 people took part in the study. The factorial analysis of ISDUTYP showed that, according to eigenvalues and the scree plot, the optimal number of factors was 2. These factors consisted of 13 and 12 items, respectively, and had clinical significance. Factor 1 could be termed "Behavioural Symptoms," while Factor 2 could be termed "Emotional Symptoms." Cronbach's alpha values demonstrated excellent reliability for all scores. In particular, Cronbach's alpha was 0.964 for the overall score, 0.950 for the behavioural symptoms subscale, and 0.950 for the emotional symptoms subscale. Regarding criterion validity, all expected correlations were statistically significant. Finally, almost all hypotheses defined of convergent and discriminant validity were fulfilled.Conclusions The high reliability and validity of the scale supports its use in research and clinical practice to assess the impact of professional traumatic grief and enhance its treatment. The validated scale for measuring nurses' grief has significant implications in clinical practice, allowing for the identification and management of nurses' grief, fostering a healthy work environment, and improving patient care quality.

Hoist missions and seasonal influences on air rescue service helicopters: A descriptive study based on three German helicopters (preprint)

Background In the German emergency medical services, 67 rescue helicopters and 12 helicopters for rescue and intensive care transport missions provide their services mostly under visual flight conditions. Of these, 10 helicopters are equipped with a rescue hoist. There is limited data on the frequency of hoist operations, tracer diagnoses, and influences such as weather and vacation periods. This study examines hoist deployment frequencies, tracer diagnostics, and the influence of vacation season at three German helicopter sites.Methods In the period from 01 Feb. 2018 to 31 Dec. 2021, a total of 1340 hoist missions were retrospectively examined descriptively for the helicopters Christoph 15 (n = 196), Christoph 1 (n = 316), and Christoph Murnau (n = 828) using their electronic mission documentation.Results 56.89% of the hoist missions were flown during the summer months, with vacation periods having a small effect on Christoph 1 only. Traumatological diagnoses clearly predominated on all three helicopters, with 75.0% on Christoph 15, 78.8% on Christoph 1, and 52.17% on Christoph Murnau. Among the traumatological indications, extremity trauma (39.29%) was the most frequent, followed by spinal injuries (10.71%), traumatic brain injuries (8.67%), and polytrauma (4.59%). Among internal medicine emergencies, collapse/syncope (5.61%) and cardiovascular arrest (3.06%) were the most common, followed by acute coronary syndromes, anaphylaxis, and hypothermia (2.55% each).Conclusions Despite the predominance of extremity injuries and syncope/collapse, where risk stratification was the primary concern and complex medical care was usually not required, there were also dynamic and complex emergency events, e.g., cardiovascular arrests, traumatic brain injuries, and anaphylaxis. Not even the Covid-19 pandemic led to a significant shift in distribution. Surprisingly, the influence of vacation periods on the frequency of operations was less pronounced even in tourism-oriented regions. For future research, other aspects need to be studied, such as the impact of severe weather on helicopter operations in the context of climate change, as well as personnel strategy (e.g., 3-person vs. 4-person crews).

Pandemic-Related Post-traumatic Stress Symptomatology in COVID-19 Patients with and without Post-COVID Conditions (preprint)

Trauma and stressor-related symptoms have been frequently reported during the COVID-19 pandemic. Few studies compare post-traumatic stress symptoms (PTSS) between patients and non-infected controls. Using data from an ongoing natural history study of COVID-19, this study compared PTSS between patients infected with SARS-CoV-2 during the first year of the pandemic and controls. Within the COVID-19 patient cohort, we also compared PTSS between patients with and without post-COVID conditions, also known as post-acute sequelae of SARS-CoV-2 infection (PASC). This study also examined the association of PTSS with trait resilience and prior trauma exposure. PTSS were assessed using the Impact of Event Scaled-Revised (IES-R), which has a validated probable PTSD cutoff (score [≥]33). The results showed that patients (n=131) reported significantly higher IES-R scores than controls (n=82) and had significantly higher odds of having scores indicative of PTSD [AOR: 4.17 p: 0.029]. IES-R scores among PASC patients (n=68) were significantly elevated compared to patients without PASC (n=63) and PASC patients did not have higher odds for probable PTSD [AOR: 2.60; p: 0.14]. Trait resilience was associated with lower PTSS. These findings help characterize the mental health impact of the COVID-19 illness experience and highlight elevated PTSS in patients with persistent post-COVID conditions.

Beyond for Better and for Worse: Expanding Environmental Sensitivity into a Post-Traumatic Growth perspective (preprint)

People differ in their responses to experiences with some showing a heightened Environmental Sensitivity (ES) for better and for worse. Highly sensitive people tend to get easily overwhelmed in adverse conditions but also to flourish in enriched environments. Yet, no studies have investigated whether people with a heightened ES may experience a positive outcome as well, in terms of Post-traumatic Growth (PTG), when a traumatic event occurs. This study provided a first empirical evidence regarding the relationship between ES and PTG on a general population of 2387 adults (age range: 18-88yy) surveyed online during the first Covid-19 lockdown. Correlations showed that ES was positively associated with PTG, though with a small effect size. Interaction effects from regression analyses provided evidence that the ES-PTG association was stronger when the individuals experienced anxiety to some extent, and not too much depression. To conclude, findings suggested highly sensitive people as not only more susceptible to adversities, but also more open to experience a growth when faced with challenging events. Identifying potential paths of growth in individuals who are more prone to negative feelings can have important implications for clinical practice as well as for theory by broadening our understanding of the concept of environmental sensitivity.

Radiation Overuse in Intensive Care Units: A Cause for Concern (preprint)

Radiological imaging is essential for acute patient management in Intensive Care Units (ICUs); however, it introduces the risk of exposure to ionizing radiation. This review synthesizes research on radiation exposure in intensive care unit (ICU) settings, highlighting its rise during the COVID-19 pandemic and repetitive imaging. Our analysis extends to radiation safety thresholds, revealing that some ICU patients exceed annual occupational limits, emphasizing the need to balance diagnostic utility against potential long-term risks, such as cancer. Prospective studies have demonstrated an increase in the median Cumulative Effective Dose (CED) in patients with trauma over time, prompting calls for improved awareness and monitoring. Moreover, innovative dose-reduction strategies and optimized protocols, especially in neuro-ICU units, promise to mitigate these risks. This review highlights the essential but risky role of radiological imaging in critical care. It advocates rigorous radiation management protocols to safeguard patient health, while ensuring the continuity of high-quality medical care.

Supporting young people through the COVID-19 pandemic and beyond: A multi-site qualitative longitudinal study (preprint)

Throughout the COVID-19 pandemic, youth have experienced substantial stress due to abrupt changes in education, finances, and social life, compounding pre-existing stressors. With youth (ages 15-26) often at critical points in development, they are vulnerable to long-term mental health challenges brought on by pandemic trauma. To identify youth experiences throughout the pandemic and examine changes over time, we conducted semi-structured interviews among n=141 youth in two Canadian provinces (Ontario and British Columbia) and across the country of Ireland at three time points over the course of more than one year (August 2020-October 2021). We conducted a qualitative longitudinal analysis using an inductive content approach. Categories identified were (1) coping with hardship; (2) opportunities for growth; (3) adapting to new ways of accessing services; (4) mixed views on the pandemic: attitudes, behaviour, and perception of policy response; (5) navigating COVID-19 information; (6) transitioning to life after the pandemic; and (7) youth-led recommendations for government and service response. The findings also reveal trends in health and wellness in accordance with prolonged periods of lockdown, changes in weather, and return to normalcy after the availability of COVID-19 vaccines. Key recommendations from youth include incorporating youth voice into decision making, communicating public health information effectively to youth, enhancing service delivery post-pandemic, and planning for future pandemics. These results provide insights into the extensive longitudinal impacts of the COVID-19 pandemic on young people across three geographical locations. Including youth in decision making for future pandemics or public health emergencies is critical.

The Influence Of Covid-19 On Patient Mobilization And Injury Attributes In The ICU: A Retrospective Analysis Of A Level II Trauma Center (preprint)

The objectives of this study were to determine the effect of COVID-19 on physical therapy (PT) mobilization of traumatically-injured patients and to determine if mobilization affected patient course in the ICU. This retrospective study included patients who were admitted to the ICU of a level II trauma center. The patients were divided into two groups, i.e., those admitted before (n=378) and after (n=499) April 1, 2020 when Georgia's COVID-19 Shelter-in-place order was mandated. The two groups were contrasted on nominal and ratio variables using Chi-square and Student's t-tests. A secondary analysis focused specifically on the after COVID patients examined the extent to which mobilization (n=328) or lack of mobilization (n=171) influenced ICU outcomes (e.g., mortality, readmission). The two groups were contrasted on nominal and ratio variables using Chi-square and Student's -tests. The after COVID patients had higher injury severity as a greater proportion was classified as severely injured (i.e., >15 on Injury Severity Score) compared to the before COVID patients. After COVID patients also had greater cumulative number of comorbidities and experienced greater complications in the ICU. Despite this, there was no difference between patients in receiving a PT consultation or day-to-mobilization. Within the after COVID cohort, those that were mobilized were older, a higher proportion were female, they had greater Glasgow Coma Scale scores, had longer total hospital days, and a lesser mortality rate. Despite shifting patient injury attributes post-COVID-19, a communicable disease, mobilization care remained consistent and effective.

Patterns in Domestic Injuries and how COVID-19 Lockdown Measures Changed Their Incidence in Mexico (preprint)

Domestic accidents occur worldwide. From small burns and bruises to significant wounds and injuries from dangerous falls, not all of them reach clinical care; so to measure the toll of these hardships on society, we surveyed three major cities in Mexico to better understand the problem and how coronavirus disease 2019 (COVID-19) lockdown measures changed the incidence rate. We conducted an analytical cross-sectional study using Microsoft Forms, with a digital survey distributed among the Mexican population from October 2021 to November 2021, during lockdown. The incidence of all injuries surveyed increasedduring the first year of the COVID-19 pandemic. A comparison of the time spent inside the house before and during the pandemic showed that only burns increased. The number of wounds and musculoskeletal injuries decreased as people spent more time at home. Women were shown to be the most vulnerable group. This study offers an unprecedented perspective on home-related trauma, as past literature has mainly examined trauma injuries treated in hospitals. The types of wounds have morphed depending on the percentage of time spent in the house, which has undergone a remarkable transformation since the lockdown was enacted.

Racial/Ethnic Differences in COVID-19-Traumatic Symptoms, Sleep, Coping Outcomes in a Group of New-Yorkers (preprint)

Background: Little research has examined within/between group predictors and mediators of race/ethnic differences or disparities in mental and sleep health outcomes arising from the experience of the COVID-19 pandemic. Objectives: This study sought to evaluate the effect of COVID-19 experiences on trauma-related symptoms and sleep quality among a multiracial/ethnic sample in New York. Method: This is a cross-sectional study conducted online among multiethnic adults (n=541) who experienced the pandemic in New York from September to November 2020. Comparisons of characteristics and mean scores by race/ethnicity status were conducted using one-way ANOVA and independent samples t-tests for continuous variables and chi-square tests for categorical variables. Multilinear regression was used for associations between social determinants of health and/or SES, trauma-related symptoms, coping, and sleep. Results: Compared to Whites [Mean (SD)= (24.1(7.6)] and other group [Mean (SD)=24.9(8.2), Blacks [Mean (SD)=(26.3(6.4)] and Hispanics [Mean(SD)=(27.2(8.2)] reported higher level of peritraumatic distress [ df= 3; F=4273; p=0.005). The prevalence of clinically significant PTSD symptoms was 21.4%(n=113): [Whites=31(16.3%); Blacks=28(25.7%); Hispanics=24(25%); and other groups=30(22.4%); x2 =4.93; p=0.177]. This rate doubled [48.3%(257)] when it comes to the overall clinically significant depression level. Compared to all subcategories, [Blacks=52(47.7%); Hispanics =62(64.6%); other group=66(49.3%)], depression symptoms were lower among Whites [77(39.9%; x2 =15.71; p=0.001]. We found a prevalence of insufficient sleep <6 hours of 41%(198): [Whites=69(39.4%); Blacks=43(41.7%); Hispanics=46(52.3%); other groups=40(34.2%); x2=12.21; p=0.057]. Several unique demographic predictors of PTSD emerged for distinct racial/ethnic groups. Among Blacks, sex [{beta} = -0.22; p < .01] and employment [{beta} = -0.159; p < .05] emerged as significant predictors for PTSD, but for no other racial/ethnic group. Interestingly, among Hispanics [{beta} = -0.144; p = .064] and Blacks [{beta} = -0.174; p = .0.076], coping strategies did not mitigate PTSD or depressive symptoms. Conclusion: As New York and the rest of the world are trying to bounce back from the COVID-19 consequences, mental health outcomes are devastating, particularly among historically marginalized communities. This study provides insight into the emergency for policymakers to invest in racial justice programs and provide free access to culturally responsive mental health care for the most vulnerable groups.

Assessment of Children Suicide Attempts Frequency in the Peripandemic Period (preprint)

Objectives: The aim of our study was to evaluate patients after suicide attempts treated at the Department of Trauma Surgery for Children before and after the outbreak of the Covid-19 pandemic. Material and methods: Retrospective review of the medical database at equal time intervals of 24 months to identify patients treated before and after the COVID-19 was done. Thorough analysis including injury mechanism, medical procedures, history of previous mental disorders or suicidal behavior was performed. Furthermore, results were compared with the Polish police suicide statistics. Results: Based on our retrospective review we found 4 patients treated in our department before the pandemic and 10 patients treated after COVID-19 outbreak. The group before SARS-Cov-2 era consisted of three girls and one boy with a mean age of 14.97 (12.7-17.6). The group treated in the pandemic crisis consisted of 8 boys and 2 girls, the mean age was 15.49 (10.8-17.2). In the pre-COVID-19 group, 2 out of 4 patients had received psychiatric treatment before, but none had attempted suicide before. In the COVID-19 group, 6 out of 10 patients had previously received psychiatric treatment, moreover 3 of them attempted suicide before. Based on our analysis, the number of individuals who displayed suicidal attempts has raised. Between 2018 and 2021 the largest number of suicides concerned the 13-18 y.o. group, both for the Silesian Voivodeship (H=9.374; p=0.0092) and for the whole country (H= 10.203; p=0.0061). Conclusions: 1. Results of our study indicate that the pandemic may have caused a wide range of negative mental health consequences for young individuals; 2. During the SARS-Cov-2 era, we observed an alarming 2.5-fold increase in the number of patients treated after suicide attempts at the children's orthopedic trauma department; 3. Suicide attempts in children are often related with high energy trauma.

Exploring Emotions Related to the COVID-19 Pandemic through Death Education: A Qualitative Study in Italian Primary Schools (preprint)

Background: The Covid-19 pandemic has globally impacted the lives of individuals, families, and children. In Italy, measures such as lockdowns and distance learning were implemented in schools, which affected the mental health of children and families. Methods: This article employs qualitative methodology to explore the experiences of children, parents, and teachers during the pandemic and lockdown, as well as the implementation of a death education project aimed at primary school children to help them process emotions and losses experienced during this period. Results: Distance learning posed challenges to the learning process and exacerbated social inequalities. Children suffered from limited social contact with friends and experienced negative emotions, including anger, fear, and concern for the health of their loved ones. The death education project provided a safe space for emotional expression and facilitated the acquisition of coping strategies. Open communication between adults and children about illness and death proved effective in mitigating the psychological impacts of loss and preventing traumatic bereavement. Conclusions: The findings highlight the utility of death education in enhancing children's ability to express their emotions and approach the topic of death morefrankly.

Working through multiple crises: the experience of psychotherapists and psychoanalysts in Lebanon (preprint)

Background This research explores the impact of the COVID-19 pandemic on psychotherapists' practices and their ability to maintain a framework despite a shared reality with their patients. The specific focus in this article is on the Lebanese context, which is characterized by a series of crises including economic collapse, the COVID-19 pandemic, and the Beirut blast. The objective of this study was to examine how the destabilization of the meta-frame due to crises necessitates adaptations in theoretical knowledge, practice, and setting.Methods We conducted a qualitative study among a population consisting of mental health professionals, which were recruited in multiple countries through associations and societies of psychologists, psychotherapists, and psychoanalysts. Data was collected using semi-structured individual interviews. The interviews were analyzed using interpretative phenomenological analysis (IPA), which allowed for a dynamic exploration of the participants' experiences. A total of 44 participants were interviewed, with 15 interviews specifically focusing on Lebanese psychoanalysts and psychotherapists.Results Our study revealed four superordinate themes: (1) the strained frontiers; (2) the cumulative traumatic reality and its impact; (3) A challenged professional identity; (4) The creativity stemming from collective trauma.Conclusions Our results highlight the insecurity caused by external reality infiltrating the therapeutic setting. Online therapy allowed for continued work, but uncertainty about the online environment's impact on therapeutic relationships was observed. The study underscores the importance of adaptability, containment, and support for therapists navigating crises, particularly in the online setting.

Prolonged grief during and beyond the pandemic: Factors associated with levels of grief in a four time-point longitudinal survey of people bereaved in the first year of the COVID-19 pandemic (preprint)

BackgroundThe COVID-19 pandemic has been a devastating and enduring mass-bereavement event, with uniquely difficult sets of circumstances experienced by people bereaved at this time. However, little is known about the long-term consequences of these experiences, including the prevalence of Prolonged Grief Disorder (PGD) and other conditions in pandemic-bereaved populations. MethodsA longitudinal survey of people bereaved in the UK between 16 March 2020 and 2 January 2021, with data collected at baseline (n=711), c. 8 (n=383), 13 (n=295) and 25 (n=185) months post- bereavement. Using measures of Prolonged Grief Disorder (PGD) (Traumatic Grief Inventory), grief vulnerability (Adult Attitude to Grief Scale), and social support (Inventory of Social Support), this analysis examines how participant characteristics, characteristics of the deceased and pandemic- related circumstances (e.g. restricted visiting, social isolation, social support) are associated with grief outcomes, with a focus on levels of PGD. ResultsAt baseline, 628 (88.6%) of participants were female, with a mean age of 49.5 (SD 12.9). 311 (43.8%) deaths were from confirmed/suspected COVID-19. Sample demographics were relatively stable across time points 34.6% of participants met the cut-off for indicated PGD at c. 13 months bereaved and 28.6% at final follow-up. Social isolation and loneliness in early bereavement and lack of social support over time strongly contributed to higher levels of PGD, whilst feeling well supported by healthcare professionals following the death was associated with reduced levels of PGD. Characteristics of the deceased most strongly associated with lower PGD scores, were a more distant relationship (e.g. death of a grandparent), an expected death and death occurring in a care- home. Participant characteristics associated with higher levels of PGD included low level of formal education and existence of medical conditions. ConclusionResults suggest higher than expected levels of PGD compared with pre-pandemic times, with important implications for bereavement policy, provision and practice now (e.g. strengthening of social and specialist support) and in preparedness for future pandemics and mass-bereavement events (e.g. guidance on infection control measures and rapid support responses).

Post-traumatic Stress and Depressive Sequelae in ICU Hospitalized COVID-19 Patients 6 Months after Discharge: A Comparison with Non-COVID ICU Patients (preprint)

The Coronavirus Disease 2019 (COVID-19) pandemic has had a major impact on the mental and physical health of hospitalized patients. In our study we focused on the onset of symptoms correlated with Post-traumatic stress disorder (PTSD), depression and physical disabilities in patients admitted to the Intensive Care Unit (ICU) because of a severe respiratory distress related to COVID-19 (COVID Group) compared with patients admitted to the same ICU for trauma and other medical conditions than COVID-19 (No-COVID Group). The physical symptoms and the level of disability were evaluated with the Glasgow Outcome Scale-Extended (GOS-E), the Quality of Life after Brain Injury (QOLIBRI) and the 3 levels version of EQ-5D (EQ-5D-3L) questionnaire; psychiatric symptoms were investigated using the Impact of Event Scale-Revised 22-item (IES-R), the Patient Health Questionnaire, 9-Item Version (PHQ-9) and the Generalized Anxiety Disorder Assessment, 7-items version (GAD-7). These questionnaires were administered 6 months after discharge. Patients in the No-COVID Group showed statistically significant more severe scores in all the physical assessments while similar relevant PTSD and depressive symptoms were reported in both groups. The results of the present study underline the psychopathological impact of being hospitalized in ICU because of COVID-19 even after 6 months from discharge ,suggesting the importance of assessing the psychiatric effects of COVID-19 in the long term in order to create supportive measures.