The trajectories of anxiety and depression during the COVID-19 pandemic and the protective role of psychological flexibility: A four-wave longitudinal study
Open accessAbstract
Background Published reports on the adverse mental health impacts of the initial phase of the COVID-19 pandemic suggest an emerging global mental health crisis. However, the trajectories of these mental health impacts over multiple COVID-19 peaks and corresponding lockdowns are unknown. This study explored the trajectories of anxiety and depression over two consecutive lockdowns during the first nine months of the pandemic in Europe (April 2020-January 2021) and examined whether they varied as a function of different psychological flexibility and inflexibility profiles.Methods A total of 569 Italians completed online surveys at four assessment points. Trajectories of anxiety and depression were examined with latent growth modeling and according to different psychological flexibility and inflexibility profiles.Results Anxiety increased linearly throughout the study period, whereas depression displayed a quadratic trajectory evidencing a decrease with the easing of the first lockdown followed by an increase during the second lockdown. Furthermore, two profiles were identified that displayed different anxiety and depression trajectories. Compared to the psychologically flexible profile, the psychologically inflexible profile reported significantly higher anxiety and depression which remained higher across the study period.Limitations A reliance on self-report measures and convenience sampling constitute key study limitations.Conclusions Results suggest that high psychological inflexibility is a risk factor for prolonged elevated anxiety and depression during the COVID-19 pandemic, whereas high psychological flexibility is a protective factor. Psychological flexibility and inflexibility should be targeted by preventive public health interventions that harness evidence-based strategies shown to effectively target these factors.
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The findings support earlier research that lower psychological flexibility is linked with greater psychological distress among nursing students.
“Our findings support earlier research by indicating that lower levels of flexibility are linked with greater psychological distress among nursing students”
From Associations of psychological flexibility, mindfulness, and valued living with psychological distress among nursing students (2025) · cites this paper as [43]
The Discussion reports that participants with a psychologically inflexible profile had higher anxiety and depression throughout the study. But the Methods describe a heterogeneous sample of Italian adults, not nursing students; the source does not establish the association for that population. Page numbers are unavailable in our copy. (LLM, conf=0.88)
Experimental — accuracy not yet measuredLimited psychological flexibility may heighten vulnerability to emotional challenges in high-pressure academic and clinical environments.
“This suggests that limited flexibility may heighten vulnerability to emotional challenges in high-pressure academic and clinical environments.”
From Associations of psychological flexibility, mindfulness, and valued living with psychological distress among nursing students (2025) · cites this paper as [43]
The Discussion reports that participants with a psychologically inflexible profile had higher anxiety and depression throughout the pandemic study period than those with a flexible profile. This supports the suggested link between limited flexibility and emotional vulnerability, but the study does not establish that link specifically in high-pressure academic or clinical environments. (LLM, conf=0.86)
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- Authors
- Landi, G., Pakenham, K. I., Crocetti, E., Tossani, E., & Grandi, S.
- Affiliations
- University of Bologna (IT)
- The University of Queensland (AU)
- Corresponding author
- Landi, Giulia
- Venue
- Journal of Affective Disorders
- Publisher
- Elsevier BV
- Published
- 2022-06
- Volume
- 307
- Pages
- 69-78
- ISSN
- 0165-0327 (ISSN-L)
- PMC
- PMC8972980
- OpenAlex
- W4220798147
- Cited by
- 74
- References
- 82
- Citations by year
- 2026: 12 · 2025: 18 · 2024: 19 · 2023: 19 · 2022: 6
- FWCI
- 14.14
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Licence
- Locations
- Journal of Affective Disorders (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Archivio istituzionale della ricerca (Alma Mater Studiorum Università di Bologna) (submittedVersion, cc-by-nc-nd)
- Topics
- Social Sciences › Psychology › Clinical Psychology › COVID-19 and Mental Health
- Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Maternal Mental Health During Pregnancy and Postpartum
- Keywords
- COVID-19 pandemic, anxiety trajectories, depression trajectories, psychological flexibility, psychological inflexibility, lockdown, mental health, protective factors, public health interventions
- MeSH terms
- COVID-19, SARS-CoV-2, Anxiety, Communicable Disease Control, Depression, Humans, Longitudinal Studies, Pandemics
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