Our systematic review has two main objectives: (i) identify the assessment tools and psychological dimensions most used/investigated during the pandemic in Italian university students; (ii) systematize and deepen our knowledge about the impact of the pandemic on the psychological wellbeing of Italian university students. In addition, we dedicate a section to discussing the interventions implemented by university counseling services during the pandemic.

This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Page et al., 2021). On April 14^th, 2023, four electronic databases were consulted: Pubmed, Web of Science, Scopus, and EBSCOhost (APA PsycInfo). We limited our selection to scientific studies published in English and Italian languages from March 2020 to April 2023. We used words such as “Assessment,” “University,” “School,” “Psychological Counseling,” and synonyms. We adapted the syntax for the specificities of each database (see Supplementary material 5 for all the information on the literature search). Next, we used the backward (the works cited in the selected articles) and forward search (the studies that cited the selected articles) to identify any further studies. Our systematic review considered the following inclusion criteria: (i) studies concerning the Italian university student population; (ii) studies carried out during the COVID-19 pandemic period; (iii) studies that have carried out/delivered an assessment and one or more psychological intervention(s). The exclusion criteria were set as follows: (i) Scientific publications such as editorials, letters, and case reports; (ii) studies that have used only qualitative assessment methods; (iii) studies that used only unvalidated psychological scales. We focused on university students because university education is a transition period characterized by critical challenges for students (e.g., career choice, emancipation, and financial self-sufficiency; Arnett et al., 2014; Amerio et al., 2022). Furthermore, the period of university study coincides with the years in which the risk of onset of psychiatric disorders reaches its peak (75% of all lifetime mental disorders have their onset prior to the age of 24; Kessler et al., 2005). Mental disorders during this period can be associated with adverse effects on the development of young people, including worsening academic performance and dropout from university (Scott et al., 2016; Bruffaerts et al., 2018). Furthermore, we focused on the Italian context as Italy was the first in Europe to face the consequences of the pandemic and implement rigorous measures to contain the spread of the virus. The measures taken to fight the virus in countries worldwide have been different and adapted to the specific national context, which has led to important differences in programs to contain the spread of the virus in different countries (Gavosto and Romano, 2021).

The screening process was performed using the digital tool “Rayyan” (Ouzzani et al., 2016). After removing duplicates, two authors performed the screening step independently (G.S., E.T.). This first step was based on the titles and the abstracts of each record yielded by the literature search. According to the eligibility criteria presented above, irrelevant studies were excluded. Then, after the first screening step, the same investigators read the full text of the remaining articles. For the letter, the same eligibility criteria were used for the inclusion/exclusion of the articles. During both phases of the study's selection, disagreements were resolved by discussion to find a consensus. Of the 1,702 studies initially retained, 60 publications met the eligibility criteria (Figure 1).

It should be noted that nine studies (Amatori et al., 2020; Biondi et al., 2021; Busetta et al., 2021; Di Consiglio et al., 2021; Cofini et al., 2022; Marzilli et al., 2022; Quintiliani et al., 2022; Alesi et al., 2023; Bassi et al., 2023) were added after backward and forward searching methods. For articles suitable for inclusion in this systematic review, the second and the third authors extracted data related to study characteristics (the number of participants, the types of assessment, the period of data collection, the instruments used for the assessment, the interventions, and the main findings reported). See Supplementary Table 1 (studies that investigated the psychological wellbeing of the general university student population) and Supplementary Table 2 (studies that investigated the psychological wellbeing of students attending university counseling services) for a description of the studies included in this systematic review. We decided to divide the studies into two sub-groups because students requiring psychological support have a higher psychological risk profile with more significant psychological distress than the general university student population (Riva Crugnola et al., 2021). In Supplementary Tables 1, 2, we have reported the period in which the assessment was carried out, dividing the phases of the pandemic into two macro-periods: (i) lockdown period and (ii) pandemic period. The period indicated as “lockdown” goes from the closure of all non-essential commercial activities and the imposition of home confinement on the population due to the spread of COVID-19 in Italy (March 2020) up to the first easing of restrictive measures (May 2020). This period was characterized by very restrictive measures for the population and the same for the entire Italian territory. The second period, indicated as the “pandemic,” includes the second and third phases of the pandemic in Italy following the first lockdown phase. This period was characterized by less restrictive home confinement measures and the gradual reopening of non-essential commercial activities. At this stage, the restrictions were often heterogeneous between the Italian regions due to their classification into three risk scenarios. Finally, in Supplementary Table 3, we reported additional information on studies included in the systematic review.

Our systematic review included several articles with different study designs. For this reason, we employed various tools to evaluate the quality of the evidence and the potential for bias. We applied the revised Cochrane Risk-of-Bias tool for randomized trials (RoB 2 – Higgins et al., 2016; Sterne et al., 2019). Furthermore, we used two different versions of the Newcastle-Ottawa Scale (NOS – Peterson et al., 2011) based on the study type: cohort studies (NOS – C) and cross-sectional studies (NOS – CS). Specifically, our systematic review included 3 randomized controlled trials (Cozzolino et al., 2021a; Celia et al., 2022a; Malighetti et al., 2023), 14 longitudinal cohort studies (Baiano et al., 2020, 2022; Bussone et al., 2020; Parola et al., 2020; Gabrielli et al., 2021; Meda et al., 2021; Pisano et al., 2021; Tinella et al., 2021; Celia et al., 2022b; Ierardi et al., 2022; Busetta et al., 2023; Cerutti et al., 2023; Conti et al., 2023; Renati et al., 2023), and 42 cross-sectional studies (Amatori et al., 2020; Cellini et al., 2020; Giusti et al., 2020, 2021; Savarese et al., 2020; Somma et al., 2020; Vitale et al., 2020; Abenavoli et al., 2021; Biondi et al., 2021; Burro et al., 2021; Busetta et al., 2021; Calandri et al., 2021; Commodari et al., 2021; De Pasquale et al., 2021a,b; Di Consiglio et al., 2021; Fornili et al., 2021; Generali et al., 2021; Marelli et al., 2021; Ranieri et al., 2021; Romeo et al., 2021; Villani et al., 2021; Viselli et al., 2021; Amerio et al., 2022; Bottaro and Faraci, 2022; Calati et al., 2022; Carletto et al., 2022; Carpi et al., 2022; Cofini et al., 2022; Comparcini et al., 2022; Concerto et al., 2022; Giangrasso et al., 2022; Guidotti et al., 2022; Loscalzo and Giannini, 2022; Manfredi, 2022; Marzilli et al., 2022; Quarta et al., 2022; Quintiliani et al., 2022; Zurlo et al., 2022a,b; Alesi et al., 2023; Bassi et al., 2023). The work conducted by Lo Moro et al. (2022) included two studies within the same article: a longitudinal cohort study and a cross-sectional one. Hence, we evaluated Lo Moro et al. (2022) twice, with the NOS – C and the NOS – CS, respectively. The evaluation of study quality was independently conducted by two authors (G.S., E.T.), who calculated percent agreement and Cohen's K (Cohen, 1960), obtaining a percentage of agreement P(a) = 97% and a Cohen's K of 0.84—an almost perfect agreement level. Any discrepancies or concerns were subsequently deliberated with the other authors. All studies obtained a satisfactory risk of bias: no concerns and high risk of bias were highlighted, and the studies were judged to be at low risk of bias. See Supplementary Tables 4, 5, and Supplementary Figure 4 for each study's risk of bias scores included in the systematic review.

The process through which the studies were included in the systematic review is described in the PRISMA flowchart (Figure 1). The initial search provided 2,889 studies potentially relevant to the present systematic review. Of these, 1,361 were identified from Pubmed, 954 from Web of Science, 155 from Scopus, and 419 from Ebscohost (APA PsycInfo). The duplicates were removed (N = 1,187), and 1,702 entries were screened. After screening the titles and abstracts, 1,587 articles were removed, leaving 115 articles to assess eligibility criteria. After reviewing the full texts, a further 64 were excluded. As shown in Figure 1, 64 articles were excluded for the following reasons: (i) no psychological assessments were performed (n = 16); (ii) no university students were assessed (n = 46); iii) the assessment was not carried out during the period of the COVID-19 pandemic (n = 2).

In addition to the 51 studies obtained through this selection process, we identified and included nine studies via backward and forward reference searching methods. This selection procedure supplied 60 articles suitable for inclusion in this systematic review. The data extracted from the 60 studies are summarized in Supplementary Table 1 (summary of psychological assessment findings in general university students' population) and Supplementary Table 2 (summary of psychological assessment/intervention findings in university students attending counseling services). Supplementary Table 1 contains forty-nine studies, while Supplementary Table 2 contains eleven. All studies delivered the assessment and interventions online during the lockdown and the subsequent pandemic period. Half of the forty-three studies that reported cross-sectional data investigated the psychological condition of students during the lockdown period, while the others delivered the assessment during the subsequent pandemic period. Five of these studies also collected the data before the lockdown period, while in four studies, participants were also asked to report their psychological state before the lockdown or pandemic period investigated. Six of the fifteen longitudinal cohort studies assessed the psychological wellbeing of Italian university students before and during the pandemic. Differently, four studies assessed it before and during the lockdown. The others (5 studies) delivered at least one psychological intervention during the pandemic.

Two randomized controlled trials provided at least one psychological intervention during the pandemic, while the other was during the lockdown period. 47.8% of the universities involved in the studies included in this review are from northern Italy (see Supplementary Table 3). Consistently, students from northern universities are the most represented (50.2%), followed by those studying in central Italy (34.71%), and finally, students from southern and island universities are the least numerous (15.04%). In almost all studies, the participants are mainly women. Of the six studies in which there are more male participants (Amatori et al., 2020; Baiano et al., 2020; Parola et al., 2020; Amerio et al., 2022; Concerto et al., 2022; Manfredi, 2022), only one (Concerto et al., 2022) have a percentage of women lower than 40%, while the remaining five have percentages of men only slightly higher than women. Most studies assess students from multiple departments. Instead, eight studies focus only on medical and nursing students (see Supplementary Table 3).

As shown in Figure 2, the psychological dimensions most investigated by studies during the pandemic are anxiety (16.9%), depression (14%), stress (8%), aspects related to COVID-19 (e.g., fear and stress related to the pandemic), emotions (7%), social aspects (7%), and quality of life in general (6%). The “other” category contains 33% of all assessments considered in this review. This category includes studies that focused on psychological distress (5.16%), psychiatric symptoms other than depression and anxiety (e.g., symptoms of eating disorders, suicidal tendencies, smartphone, and internet addiction, 4.76%), and the quality of sleep (3.76%). Other psychological dimensions investigated, such as resilience, self-efficacy, self-esteem, metacognition, attitude to the future, coping, attachment, and personality traits, were explored by < 3% of the total assessment tools used in the studies. Finally, the most assessment instruments used are reported in Figure 3 (Beck Depression Inventory-II, BDI- II, 5.63%; State-Trait Anxiety Inventory, STAI-Y, 5.16%; Perceived Stress Scale, PSS, 5.16%; Symptom Check-List Item Revised, SCL-90-R, 3.92%; Depression, Anxiety and Stress Scale-21, DASS-21, 2.94%; Positive and Negative Affect Schedule, PANAS, 2.45%; Patient Health Questionnaire 9, PHQ-9, 2.45%; Beck Anxiety Inventory, BAI, 1.96%; Pittsburg Sleep Quality Index, PSQI, 1.96%; Seven-Item Generalized Anxiety Disorder, GAD-7; 1.96%; General Health Questionnaire, GH-12; 1.47%; Mental Health Continuum-Short Form, MHC-SF, 1.47%; Fear of COVID-19, FCV-19S, 1.47%).

This literature review shows an adverse effect of the COVID-19 pandemic on the psychological wellbeing of Italian university students (i.e., Bussone et al., 2020; Commodari et al., 2021; Pisano et al., 2021; Viselli et al., 2021; Alesi et al., 2023). Studies mainly report increases in levels of depression (i.e., Conti et al., 2023), anxiety (i.e., Abenavoli et al., 2021), and stress (i.e., Lo Moro et al., 2022), both during the period of more significant lockdown restrictions and in the subsequent phase of the pandemic. Some longitudinal studies report an additive increase in the adverse effects on psychological wellbeing as the weeks pass during lockdown (Giusti et al., 2020; Parola et al., 2020; Zurlo et al., 2022a). However, during the subsequent pandemic phase, some psychological dimensions (i.e., depression) may improve compared to the lockdown's previous and more restrictive phase (Di Consiglio et al., 2021; Meda et al., 2021). Another result that emerges is that the students who have suffered most from the measures imposed by the pandemic are women students (Vitale et al., 2020; Busetta et al., 2021, 2023; Romeo et al., 2021; Villani et al., 2021; Viselli et al., 2021; Amerio et al., 2022; Carletto et al., 2022), and younger students (Fornili et al., 2021; Ranieri et al., 2021; Concerto et al., 2022). Although no studies included in this review directly compared students who sought university counseling services with Italian university students in general (but see Riva Crugnola et al., 2021), some studies (Baiano et al., 2020; Cellini et al., 2020; Busetta et al., 2021) reported a greater negative effect of the COVID-19 pandemic on fragile students (i.e., students with high levels of depression and anxiety). Finally, Ierardi et al. (2022) reported that students who sought college counseling services before the pandemic had similar levels of psychological distress as those who did so during the pandemic.

It has been suggested that medical students are more likely than students of other faculties to experience higher levels of anxiety regarding COVID-19 (Busetta et al., 2023). However, not all data confirm this view (e.g., Manfredi, 2022; Bassi et al., 2023). These inconsistent results could depend on the fact that the studies that include healthcare students are heterogeneous by year of course and type of specialization taken into consideration. University students have reported significant difficulties related to distance learning during the pandemic, such as reduced concentration ability and problems completing the thesis and internship activities (Generali et al., 2021; Giusti et al., 2021). More severe psychological symptomatology was positively correlated with worse academic performance (Amerio et al., 2022). The inability to attend university, distance from colleagues, and career uncertainty were associated with increased anxiety (Villani et al., 2021; Comparcini et al., 2022; Busetta et al., 2023). Furthermore, Calandri et al. (2021) reported that the worsening of learning abilities was related to depressive symptoms through the mediating effect of academic self-efficacy (Calandri et al., 2021). Fear of COVID-19 and worry about contracting the virus appear to be important factors in determining higher levels of anxiety and negative changes in mood and eating behavior, both during the lockdown and during the pandemic (De Pasquale et al., 2021a,b; Generali et al., 2021). Lastly, internalizing personality traits and immature defense mechanisms were both risk factors for depression, anxiety, and stress symptoms during the lockdown (Biondi et al., 2021).

On the contrary, a healthy lifestyle (i.e. doing physical activity, healthy nutrition) (Amatori et al., 2020; Fornili et al., 2021; Villani et al., 2021), a healthy relational environment (family, peer, and university) (Calandri et al., 2021; Carletto et al., 2022), satisfaction with the quality of e-learning (Giusti et al., 2021; Cofini et al., 2022), and the possibility of benefiting from external spaces and contact with nature (Busetta et al., 2021; Quarta et al., 2022), are all factors reported as positive for mental health both during the lockdown and during the pandemic. Adaptive coping strategies were protective factors for managing COVID-19 stressors (Zurlo et al., 2022b), and high levels of resilience predicted lower levels of psychological distress after a year of the pandemic (Renati et al., 2023). Furthermore, the study by Giangrasso et al. (2022) reported that high levels of mattering and self-esteem are crucial for adequate life satisfaction during the lockdown.

Almost all studies conducted on students who requested psychological counseling from university services have focused on the effectiveness of online psychological intervention (see Supplementary Table 2). These works show that five sessions of online psychological interventions (Tinella et al., 2021) with psychodynamic (Ierardi et al., 2022; Cerutti et al., 2023) and strategic (Celia et al., 2022b) approaches, and the Brain Wave Modulation Technique (BWM -T) (Cozzolino et al., 2021b; Celia et al., 2022a), are effective in reducing perceived stress, negative affects, depressive and anxious symptoms, and in improving different aspects of students' psychological and emotional wellbeing (i.e., self-efficacy, emotional regulation, positive affect) both during the lockdown and the pandemic. Furthermore, Gabrielli et al. (2021) and Malighetti et al. (2023) report decreases in levels of anxiety and perceived stress using a healthy coping chatbot (“Atena,” 4 weeks of use) and improvements in psychological wellbeing through self-help virtual reality interventions (six sessions for 3 weeks), respectively. However, Ierardi et al. (2022) reported that the face-to-face intervention delivered before the pandemic was more effective than the online intervention delivered during the pandemic. While the online intervention improved levels of depression, anxiety, and obsessive-compulsive symptoms, differently from face-to-face intervention, it was not effective in improving levels of life satisfaction (Ierardi et al., 2022). Although none of these studies directly investigated the effects of university psychological counseling on academic performance, worse psychological symptomatology has been reported to be a strong predictor of poor academic performance (Giusti et al., 2021). Finally, it is important to note that some university psychological counseling services have integrated specific interventions to improve academic performance (e.g., workshops on study methodologies in small groups of students in Savarese et al., 2020).